Intensive Care Society State of the Art (SOA) 2022 Abstracts

4816

Informing local policy through an audit of the assessment, management and outcomes of intermediate and high risk patients with pulmonary embolism

Julia Harrington¹, Danielle Hannah¹, Jun Ki Jeon¹, Karwai Tsang¹, Lara Roberts¹, Tasneem Pirani²

¹ Kings College Hospital

² Kings college hospital

Kings College Hospital, [e-mail]

Abstract

Introduction: In the assessment and management of patients with acute pulmonary embolism (PE), risk stratification can provide information that helps guide therapeutic decision-making and detection of deterioration. There is substantial heterogeneity in risk assessment and management recommendations from national practice guidelines¹ and non-high risk are often not monitored for deterioration.² PE response teams (PERTs) have been introduced to facilitate multidisciplinary and timely management of this patient group.

Objectives: We aimed to audit the initial risk assessment, management and outcomes of inpatients diagnosed with an ‘intermediate-high risk’ PE. We aimed to use this data to guide local policy change through a structured pathway for managing intermediate risk PE patients, and formation of a local PERT team.

Methods: Data was analysed for all patients diagnosed with a PE on CTPA from 1/7/2021 to 30/9/2021. Three domains of care were analysed on patients who were stratified as intermediate or high risk (PESI ≥1): initial management; assessment of severity of risk using biomarkers (troponin, BNP, persistent lactate), imaging (right heart strain on echo, ECG or CT) and clinical factors (syncope); and monitoring for/management of deterioration.

Results: 63 inpatients were diagnosed with a PE over a 3 month period (63% male, mean age 56 years). For all patients, median time to anticoagulation was 120 minutes (IQR 54–285 mins) from diagnosis on scan or anticoagulation. 47/63 (74.6%) received the correct dose of anticoagulation as per body weight.

Of those patients who were intermediate or high risk (PESI ≥1), we used markers of severity to stratify patients into an ‘Intermediate low’ risk group (≤1 marker of severity) vs ‘intermediate high’ risk group ((≥2 markers of severity). 40/63 (63.5%) were Intermediate or high risk (PESI ≥1). Of these, 32/40 (80%) had a troponin measured, 15/40 (37.5%) had a BNP measured, 27/40 (67.5%) had an echo. In only 11/27 cases (40.7%) was the echo completed within 24 hrs. Median time to echo for all intermediate patients was 26 hrs (IQR 14-48 hrs), with only 7/20 intermediate-high risk patients having a bedside echo (35%).

The majority of intermediate high risk patients were managed in a ward based setting (12/20; 60%). The patients managed on wards had some additions to their care, such as more frequent observation monitoring (4/12, 33.3%), cardiac monitoring (5/12, 41.7% ) or critical care outreach consultations (4/12, 33.3%). 7/11 (63.6%) of the patients with intermediate high risk PE managed in a non-critical care environment were consulted at a later stage by a member of the intensive care team due to deterioration. 2 of these patients had a cardiac arrest (18.1%), and 1 was later thrombolysed (9.1%).

Conclusions: Management of intermediate-high risk patients is heterogenous, with varying practice in severity risk assessment and monitoring for deterioration despite a 5.6% risk of death/haemodynamic decompensation.² Currently the majority of these patients are managed in a non-high dependency environment without cardiovascular monitoring yet many deteriorate or require additional critical care outreach. A PERT team and PE pathway offering systematic management and escalation of care has been established in our trust.

References

1. European Society of Cardiology (2019) Guidelines on Acute Pulmonary Embolism (Diagnosis and Management of). https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Pulmonary-Embolism-Diagnosis-and-Management-of

2. Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10; 370(15):1402-11.

4813

An initial exploration into the use of a novel virtual reality system to aid rehabilitation in Intensive Care

Nicholas Aveyard¹, Rebecca Johnson¹, Summer Ashbury², James Bruce¹, Nicholas Peres¹, Jacqueline Rees-Lee¹, Tod Guest¹

¹ Torbay & South Devon NHS Foundation Trust

² The University of Plymouth

Torbay & South Devon NHS Foundation Trust, [e-mail]

Abstract

Introduction: Patients in the intensive care unit commonly suffer from delirium, disrupted sleep, memory loss and anxiety. Overcoming the cognitive, psychological and physical impairments that result from critical illness is vital to full functional recovery.¹ Strategies to minimise the psychological impact of being on an intensive care unit can reduce the incidence of post-traumatic distress, whilst enhancing quality of life.²

To date, virtual reality software has been used effectively in a number of clinical settings and patient populations to minimise pain, anxiety, and depression.³ Its use in intensive care and rehabilitation is a rapidly expanding field that has potential to improve patient outcomes.⁴ However, whilst other studies have evaluated the use of commercially available virtual reality software in the intensive care environment, our group has designed and produced a custom-built system based on patient and staff input.

Methods: By assembling a collaborative team of clinicians, therapists, psychologists, and digital designers, we have produced a novel digital platform prototype suitable for a range of patients at various stages of their rehabilitation journey. The design process has been guided by investigative methods including workshops, interviews and focus groups with a range of patients, previous patients, and staff, incorporating this key feedback and data to produce a prototype that is integrally co-designed and patient-led in practice.

The prototype consists of a three-dimensional (3D) virtual-reality (VR) based environment that operates via head-mounted device and optional handheld input. It can be adapted for flat-screen based integration where practical. Consideration has been given to the differing capabilities of ICU patients, and compatibility with the intensive care environment. The function of this platform ranges from a basic format intended to orientate and promote normal circadian rhythm by displaying live data (date, time and weather), to an interactive virtual reality interface capable of providing escapism and storing patient-specific rehabilitation goals, family communication and mindfulness exercises. The 3D environment is visually inspired by local areas of natural beauty and utilises a combination of diegetic sounds, natural sounds, and ambient music, alongside engaging and calming visuals.

The project aims to investigate the extent to which virtual reality technology provides benefit to patient wellbeing and rehabilitation. The prototype will be trialled with patients admitted to the ICU and on their rehabilitation pathway. Its effectiveness will be measured through patient and family feedback regarding quality of life and psychological wellbeing.

Discussion: This project aims to demonstrate both the potential for virtual reality to improve patient outcomes and the benefit of collaborative working between clinical staff and digital designers. Designing a virtual reality interface based on input from the multidisciplinary intensive care team streamlines the process of development and ensures it meets the varied and complex needs of patients.

References

1. Hatch R, Young D, Barber V, Griffiths J, Harrison DA, Watkinson P. Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study. Crit Care dec. 2018; 22(1):310.

2. Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bienvenu OJ, Needham DM. Posttraumatic stress disorder in critical illness survivors: a metaanalysis. Crit Care Med. mai. 2015;43(5):1121–9

3. Yeung AWK, Tosevska A, Klager E, Eibensteiner F, Laxar D, Stoyanov J, Glisic M, Zeiner S, Kulnik ST, Crutzen R, Kimberger O, Kletecka-Pulker M, Atanasov AG, Willschke H. Virtual and Augmented Reality Applications in Medicine: Analysis of the Scientific Literature. J Med Internet Res. 2021 Feb 10;23(2):e25499.

4. Hill JE, Twamley J, Breed H, Kenyon R, Casey R, Zhang J, Clegg A. Scoping review of the use of virtual reality in intensive care units. Nurs Crit Care. 2021 Nov 15.

4812

Surprising chest radiograph- air in mediastinum

Avinash Kumar Jha, Edward Denison-Davies

Lancashire Teaching Hospitals

Lancashire Teaching Hospitals, [e-mail]

Abstract

Case Report: A young Asthmatic male presented with Chest tightness and Shortness of breath on evaluation had wheeze on auscultation of lung fields. His inflammatory markers and saturation were normal, and a chest X-ray showed no significant features initially. He was given salbutamol nebulization and discharged home. Twenty-four hours later, he called the ambulance for persistent breathlessness along with swelling over his face, chest and arms. Paramedics on arrival treated him for hypersensitivity by administering adrenaline. On re-evaluation at the hospital, subcutaneous emphysema over the thorax, neck and arms were evident. A repeat chest-X-ray revealed features of subcutaneous emphysema and a thin rim around the left cardiac silhouette (Figure 1), and because of these findings, a CT chest was performed, which showed evidence of extensive pneumomediastinum (Figure 2).

A detailed history was elicited, and the patient mentioned having phlegm and vigorous cough in the past 24 hours and feeling a pop in his chest. He was requiring 4 litres/minute of oxygen and was hemodynamically stable.

The CT was discussed with the cardiothoracic team, who mentioned that given the stability he would be for conservative management along with monitoring of hemodynamic status.

Otorhinolaryngologist evaluated the patient at beside and performed an endoscopy that did not reveal any leak from the upper pharyngeal/oesophageal areas.

Analgesia was provided with morphine patient-controlled analgesia. Point of care echocardiogram (subcostal window) showed good biventricular function and absence of features of tamponade. Over the next 48 hours, he remained hemodynamically stable. A repeat Chest-Xray showed significant resolution of pneumomediastinum (Figure 3) and subcutaneous emphysema. Hence, he was transferred to the ward for further management and was discharged home after 72 hours.

Discussion: Pneumomediastinum is the presence of air in the pericardial space and can be a life-threatening condition hence needing early recognition and management. It was first described in 1827.¹ Over a century later, the mechanism as air leak from alveolar rupture pressures tracking into the mediastinal cavity via peribronchial and perivascular sheaths.²

Figure 1.

Chest Xray showing pneumomediastinum-covering left cardiac border.

Figure 2.

CT chest showing pneumomediastinum.

Figure 3.

Repeat Chest Xray showing resolving pneumomediastinum.

Depending on the presentation, it can be visualized on a chest X-ray or CT scan. It is classified as primary- with no identifiable cause and secondary- associated with asthma, infections, trauma and oesophageal perforation. The course can be either self-resolving or have associated complications like hemodynamic collapse, neurological manifestations and cardiac arrest.³

In our case, the patient correlated the events after he had returned from a body massage, but a detailed history pointed towards a chest infection in the past week, which had led to vigorous coughing and the subsequent pneumomediastinum and the pneumothorax.

Management of pneumomediastinum depends on the clinical condition; therefore, it may range from a conservative approach to surgical intervention.

No doubt it is a less common entity. A specific subset of patients (young, asthmatic, history of trauma) presenting with chest tightness should be suspected to have pneumomediastinum once the other common causes have been ruled out.

References

1. McNicholl B. Pneumomediastinum and Subcutaneous Emphysema in Status Asthmaticus, requiring Surgical Decompression. Archives of Disease in Childhood. 1960 Aug 1;35(182):389–92.

2. Macklin MT, Macklin CC. malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of the clinical literature in the light of laboratory experiment. Medicine. 1944 Dec 1;23(4):281–358.

3. Paluszkiewicz P, Bartosinski J, Rajewska-Durda K, Krupinska-Paluszkiewicz K. Cardiac Arrest Caused by Tension Pneumomediastinum in a Boerhaave Syndrome Patient. The Annals of Thoracic Surgery. 2009 Apr 1;87(4):1257–8.

4811

#RehabIsCritical – A continuous improvement journey to develop an occupational therapy step down pathway from critical care to acute medical wards

Jenny Henry, Rebecca Gaunt, Rowena Currie

Lancashire Teaching Hospitals NHS Trust

Lancashire Teaching Hospitals NHS Trust, [e-mail]

Abstract

Introduction: Occupational therapists in acute settings experience significant pressure to support discharge pathways, which can often impact on the clinical time spent supporting rehabilitation of patients, including critical care patients. Despite national guidelines and a growing evidence base that demonstrates the effectiveness of early intervention on patient outcomes; cultural pressures limit the maximum contribution of occupational therapists towards local and national objectives. Occupational therapists have the skills and knowledge to deal with the myriad of motor, cognitive, psychosocial and sensory challenges which these patients may present with.

Objectives:

• To identify the drivers for change and evidence for developing the pathway

• To present a variety of analytical tools to increase understanding of the current pathway and need for change

• To present the impact of developing the pathway

Methods: A continuous improvement methodology.

Results and Conclusion: The acute phase of rehabilitation for critical care patients is a feasible and valuable role for occupational therapists in critical care and acute medical wards. A continuous improvement methodology can be used to support a change in practice to prioritise the professions involvement with this patient cohort. Reflecting on and boldly challenging cultural norms will not only enable quality care services, improve job satisfaction but also support the financial position of the Trust.

References

1. Faculty of Intensive Care Medicine (2019) Guidelines for the Provision of Intensive Care Services (GPICS) second edition. Available at: https://www.ficm.ac.uk/standards-research-revalidation/guidelines-provision-intensive-care-services-v2.

2. National Institute of Clinical Excellence (2017) Rehabilitation after Critical Illness in Adults Quality Standard.

3. White, C. et al (2021) Rehabilitation after critical illness. British Medical Journal. 373:n910.

4809

Exploring tissue donation as part of end-of-life wishes- a duty of care following death on ICU?

Kate Tizard, Tariq Trussell, Rebecca Gallagher

Countess of Chester Hospital NHS Foundation Trust

Countess of Chester Hospital NHS Foundation Trust, [e-mail]

Abstract

Introduction: Deceased tissue donation can be life-changing for transplant recipients. Almost anyone can be considered for donation of tissue following death and there aren’t the same logistical constraints as there are with organ donation.¹ However, donation needs to occur within 24-48 hours of death and therefore early referral to tissue services, to ensure the donated tissues are safe and to discuss donation with the next-of-kin, is required. With the new legislative changes to an opt-out system for organ donation,² people may assume their end-of-life wishes around tissue donation will be automatically undertaken at the time of their death, but an automatic referral process is currently not available to our Trust.

Objectives: To clarify the current practice and referral rate of deceased ICU patients to the tissue donation services and identify any barriers to referral practice.

To establish our duty of care as a Trust to pursue an automatic referral process for tissue donation following death, in order to ensure end-of-life wishes are respected.

To create a robust and effective tissue donation referral process, delivered by engaged and motivated staff to ensure facilitation of our patients’ end-of-life wishes.

Methods: We audited current practice by completing a retrospective case note review over a 6-month period (February 2021- August 2021), reviewing all patients who had died on the ICU during this period, noting any exclusion criteria for referral. We also submitted a clinical question for debate at the hospital’s ethics committee to more clearly define our ethical responsibility as a Trust on this subject.

Results: 47 patients died on the ICU during the audit period, 21 met exclusion criteria for tissue donation leaving 26 possible referrals following death. Only 5 of these potentially eligible patients were referred for consideration of tissue donation, 4 as part of SNOD involvement and one by an ICU staff nurse with a special interest in tissue donation. This equates to an 81% missed referral rate.

The conclusion from ethics committee reported “the moral arguments arising from beneficence and respect for persons/autonomy would support an improvement in trust processes/policy that resulted in the offer of a referral for tissue donation to the bereaved families of all eligible patients, when referral represents part of the patient’s wishes for their death (e.g., the patient was on the organ donation register) . . . . . . However, the moral imperative to avoid/minimise harm (arising from the principle of non-maleficence) also requires the mitigation of the possible harm of causing distress to families if these conversations were to be handled poorly”.

Conclusions: To improve the process, a Trust policy for referral of a deceased patients to the tissue services has been written, including an easy-to-follow flow-chart and guide with suggested wording for approaching families about referral to tissue services. We have recruited “tissue-donation” nurse advocates for education roll-out and have a rapid-access tissue donation folder kept with the bereavement information on the ICU. The referral practices will be re-audited to measure the impact of interventions and resources will be refined in response to results, to continue to streamline efficiency and engagement across the Trust.

References

1. NHS Blood and Transplant: Tissue Donation. https://www.organdonation.nhs.uk/helping-you-to-decide/about-organ-donation/tissue-donation/ (accessed 06 March 2022).

2. The Organ Donation (Deemed Consent) Act 2019 (Commencement No. 3) Regulations 2020. https://www.legislation.gov.uk/uksi/2020/520/made (2020, accessed 06 March 2022).

4808

The impact of deprivation on Respiratory Support Unit outcomes in COVID-19 patients, and highlights from wave 2 data in Portsmouth

Christopher O’Hagan

Portsmouth Hospital University Trust

Portsmouth Hospital University Trust, [e-mail]

Abstract

Background: The second wave of the COVID-19 pandemic caused significant demand for beds capable of delivering enhanced respiratory support. NHS England recommended the use of CPAP for patients with COVID-19 respiratory failure, a treatment which can be offered outside of a critical care facility, and on a Respiratory High Care/ Support Unit (RSU).

The enhancement of Portsmouth’s RSU provided CPAP and NIV for patients with COVID-19 respiratory failure. With our intensive care facilities at 300% their normal capacity, this greatly alleviated bed pressures on critical care.

Varied levels of deprivation exist in Portsmouth’s dense population. Deprivation has an impact on overall health, however the effect of postcode on outcomes for people going onto support for COVID-19 respiratory failure, is unknown.

Methods: Retrospective cohort analysis of consecutive patients admitted to Respiratory Support Unit during the second wave of the COVID-19 pandemic, from 02/11/2020 to 31/01/2021.

227 patients were included in the study with 8 removed due to incomplete data, all of the patients received respiratory support in the form of CPAP or NIV. We collected multivariate data including biochemical markers, demographics, oxygenation status, co-morbidities and outcomes. Outcomes measured were: 1) Death in RSU, 2) Discharge from RSU or 3) Intubation and Ventilation.

To measure deprivation, we linked a persons postcode to an area called an LSOA (Lower-layer Super Output Area). These are small areas of similar population size, each of which has a deprivation score (ie. top 10%, to the lowest 10% areas of deprivation in the UK). This is measured using an ‘index of multiple deprivation’. An individual’s outcome from the RSU was then analysed in relation to the deprivation score allocated to their postcode.

Results: We observed a significant number of patients discharged from RSU, without needing invasive mechanical ventilation. 80/219 were discharged directly. 45/219 died in RSU, and 94 were eventually admitted to ITU. The average stay on CPAP or NIV before needing admission to ITU was 3 days.

Some biochemical markers which stood out in relation to the outcomes described were as follows: average LDH, D-dimer and Troponin levels were higher in those who were admitted to intensive care. In patients who died, the PCT was significantly higher on average when compared to the other two groups. In the group who were discharged, mean lymphocyte count was >1, in the other two groups this was <1.

From our observations in Portsmouth, there is a negative correlation between deprivation and lower aged individuals admitted for COVID-19 related respiratory support. Overall, we also saw disproportionate representation of those from the most deprived 50% of the UK in our respiratory support unit.

Conclusions: CPAP and NIV can effectively be used in an RSU during a spike of COVID-19, to safely minimise demand on critical care services.

Deprivation may have an impact on outcomes in patients needing respiratory support related to COVID-19. Deprivation levels may help predict risk of needing enhanced respiratory support in certain age groups.

Multiple biochemical markers may be of prognostic value in COVID-19.

4807

Survey of attitudes towards end of life care as a tool in identifying areas for improvement

Robert Maher, John Donaghy, Thomas Baxter Baxter, Jonathan Betteridge, Benjamin Hardy, Ritwik Mungara, Emily Collis, Anna Petsas, Timothy Bonnici, Veronica Marsh

University College Hospital (London) - London, Greater London

University College Hospital (London) - London, Greater London, [e-mail]

Abstract

Introduction: Unfortunately, up to 20% of patients who are admitted to an intensive care unit (ICU) in England will pass away despite our best efforts.¹ Whilst not all of these deaths can be predicted or prepared for, a proportion of them can be. This makes good end of life care an invaluable process in any ICU. As part of a wider initiative to improve end of life care on the unit, we undertook a survey to help identify any staff groups that felt more support was required. This would then be used to help formulate a strategy to improve our practice.

Objectives: To survey staff members of the ICU to see where support should be targeted in an effort to improve end of life care.

Methods: We registered our survey in accordance with our trust protocol. Our data was collected over a two week period. Throughout this process, we have maintained the highest ethical standards.

An anonymised survey consisting of eight questions was disseminated amongst various staff members via an online questionnaire. Staffing groups included; medical, nursing and allied health professionals. The questions enquired into; individuals roles, how confident they felt in identifying patients at the end of life and how involved they felt in the decision making process. The survey contained a free text section to suggest any areas for improvement.

Findings: The results were collated and in total we had 59 respondents; medical had 12, nursing had 40, and allied health professional had 7.

In the nursing group, 90% rated themselves between somewhat to extremely confident in the recognition of a dying patient. Within the same group, 50% felt little to no involvement in the multidisciplinary team (MDT) discussion on end of life care. In the free text section there was an aspiration to avoid “false hope”. In the medical grouping 100% of respondents felt somewhat to very confident that they could recognise a dying patient. In contrast to the nursing group, 92% felt somewhat to very involved in the MDT discussion in end of life care. The free text section highlighted a drive towards a “unit philosophy”. The allied health professional group had 86% who felt somewhat to very confident that they could recognise a dying patient. 86% of the same group felt somewhat to reasonably involved in the MDT discussion on end of life care.

Conclusion: Not all of the of staffing groups surveyed felt involved in the decision making process. The survey allowed us to identify what staff groups needed more support. This in turn allowed us to formulate an effective strategy to target our efforts appropriately. We are working on processes that seeks to elicit the opinions of all members of the MDT. We aim to perform this survey again after the implementation of these process and close the loop. This survey has deeply impacted our work and we would advocate a similar strategy in other units seeking to improve the quality of their end of life care.

Reference

1. Faculty of Intensive care medicine Care at the end of life 2016.

4804

A quality improvement project regarding family communication within critical care

Rebecca Lewis¹, Tom Georgiou², Andy Jones², Rosalinde Tilley², Andy Retter³, Rebecca Lewis²

¹ Guy’s and St Thomas’

² Guys and St Thomas’ NHS Foundation Trust

³ Guys ans St Thomas’ NHS Foundation Trust

Guy’s and St Thomas’, [e-mail]

Abstract

Introduction: Communication is central to high quality critical care (CC)¹ and caring for family members is integral to the care of critically ill patients. Communication within the CC frequently does not meet families’ needs,² impacts informed decisions making³ and can result in psychological morbidity for patients and their families.⁴ During the COVID-19 pandemic communication was challenging with restricted family visiting. As part of our recovery strategy we aim to ensure that frequent, high quality communication remains a key aspect of critical care. There is currently no guidance relating to the frequency of family communication within critical care.

Objective: Our aim was to review the frequency of family communication during CC admissions admission and to develop our own internal standards.

Methods: A retrospective audit was conducted of 110 admissions to Guys and St Thomas’ CC from November 2021 – February 202. We reviewed all routine family discussions documented in the medical notes. Data regarding the patient’s length of stay, time to first communication from admission, frequency of communication throughout admission and grade of clinician leading the communication was collected. Family discussion regarding adverse incidents and admissions less than 24hrs were excluded. If multiple communications occurred on the same day, the most senior communication was included. To complement the audit a short survey of the consultants, regarding expectations and standards of practice of family communication was completed.

Results: 99 patients were included within the audit and 13 responses to the survey (34% response). The mean length of stay for all patients was 14 days for survivors and 16.5 days for those who died. 32% of patients received a document family communication within 24hrs of admission, 34% did not have a documented communication within 72 hours of admission. 58.3% of consultants felt a family update should happen within 24hrs of admission and 84.7% of consultants reported that families should be updated once every 3 days. On average families received a documented family communication every 5.5 days of a CC admission. When focusing just on patients who died there was an increase in the frequency of communication to once every 3 days. 23% of all documented family discussions were consultant led with the number rising to 44% in non-survivors. The audit also showed that the longer a patient stayed within critical care the less frequently a family communication became. The survey indicated that the two biggest barriers to family communication is time pressures and appropriate space.

Conclusions: We demonstrated that documented family communication was less frequent than expected. To ensure that family commination remains a key component of CC within our department we have adopted or own internal standard of providing families with an update once every 3 days. We are exploring the role of communication facilitators⁵ and seeking patient/family feedback also to improve family communication further.

References

1. Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. American journal of respiratory and critical care medicine. 2005;171(8):844-9.

2. Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, et al. Half the families of intensive care unit patients experience inadequate communication with physicians. Crit Care Med. 2000;28(8): 3044-9.

3. Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(4): 835-43.

4. Jacobowski NL, Girard TD, Mulder JA, Ely EW. Communication in critical care: family rounds in the intensive care unit. Am J Crit Care. 2010;19(5): 421-30.

5. Curtis JR, Treece PD, Nielsen EL, Gold J, Ciechanowski PS, Shannon SE, et al. Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care. American journal of respiratory and critical care medicine. 2016;193(2):154-62.

4803

Sleep Promotion in a Busy Inner City High Dependency Unit

Bethan O’Brien, Richard Hay, Maia Graham

Liverpool University Foundation Trust

Liverpool University Foundation Trust, [e-mail]

Abstract

Introduction: Critical care patients commonly have disrupted sleep patterns, with reduction of REM sleep, duration of sleep, increased fragmentation and loss of circadian rhythm.¹ Causes include the patients’ pathophysiology, medications administered and the busy critical care environment. Data collection showed that our patients were sleeping, on average, for a single block of sleep of 3.5 hours. Delirium rates and its known deleterious effects are highly associated with poor sleep, as well as an impairment of psychomotor performance and neurocognitive dysfunction. Sleep deprivation in the healthy population impairs lymphocyte action, cytokine production and pro-inflammatory balance, as well as a reduction in respiratory function and prolongation of respiratory support.²

Objectives: To firstly measure the sleep quality and explore the reasons behind poor sleep from the patients themselves and to gauge the MDT knowledge and interest in sleep, as a fundamental component of patient management. Then using the results we aimed to improve the duration and quality of the patients sleep on high dependency unit.

Methods: The Adapted Richard Campbell Sleep Questionnaire was given to all patients in the HDU over a 4 week period. Results were analysed, then stored for post intervention comparison. The duration of sleep was documented for all patients and a staff questionnaire was done to assess knowledge and concern of staff.

Interventions included a staff sleep awareness week with education and prompts attached to the charting tables promoting sleep. Face masks and ear plugs were freely available to be distributed at the evening ward round. The critical care pharmacist identified medications that could alter the patients ability to achieve REM sleep – e.g. evening administered PPIs, and melatonin was commenced early when sleep was troublesome. Estates fixed soft close doors and soft closed bins supplied for clinical areas. After interventions, there was a further 4 week study period where the above factors were repeated. The need for natural light was highlighted and thus this was optimized in the ward environment and those physiologically able were offered trips outdoors to facilitate normal day night wake cycle. With the COVID pandemic ongoing we also endeavored to limit movement overnight of venerable patients.

Results: The original data collection was of 45 patients with multiple data points, and the second of 27 patients with multiple data points.

Results from the Adapted Richard Campbell Sleep Questionnaire were compared using a one tailed students t test. There were significant increases in the subjective quality of sleep (p=0.046) and quantity of sleep (p=0.00018). Reasons given as to improvement of sleep were reduction in discomfort from monitoring and the bed (p=0.026), reduced ambient light (p=0.031) and reduced impact from the presence of other patients (p=0.002).

Conclusion: There was marked improvement in the awareness of the importance of sleep within the critical care team after education promoting a change in attitude and culture towards sleep. We are planning a second iteration targeting sedation, noise from monitors and staff and overnight interventions. Although this has been done with level 2 patients, extension to level 3 areas would be beneficial.

References

1. Matthews E. Sleep disturbances and fatigue in critically ill patients. AACN Advance Critical Care 2011;22(3):204-224.

2. Medrzycka-Dabrowska W, Lewendowska K, Kwiecien-Jagus K et al. Sleep deprivation in Intensive Care Unit – systemic review. Open Med (Wars), 2018;13:284-393.

4799

Findings from a regional survey of critical care nursing staff focusing on retention and factors that influence wellbeing

Roxanne Burns¹, Catherine Ridgewell¹, Kujan Paramanantham¹, Gillian Leaver¹, Stephen Wimbush¹, Mike Carraretto², Sue Herson²

¹ Thames Valley and Wessex Adult Critical Care ODN

² Kent, Surrey and Sussex Adult Critical Care ODN

Thames Valley and Wessex Adult Critical Care ODN, [e-mail]

Abstract

Introduction: The Covid-19 pandemic has put unprecedented pressures on the National Health Service (NHS) with adult critical care being one of the key specialties that has been affected. NHS staff have been working relentlessly throughout the pandemic and adult critical care teams were at the forefront of that.

Thames Valley & Wessex and Kent, Surrey & Sussex Adult Critical Care Operational Delivery Networks had heard from our unit matrons and clinical leads around their concerns for the wellbeing of their staff. We had also heard of the number of critical care nurses who have either left their roles or are planning to leave.

Objectives: As Networks our main objective was to gain a better understanding on some of the factors that locally might be influencing the wellbeing of our staff and any intentions to leave, and to see if this aligns with the published research. The Networks also planned to develop a series of recommendations based on the results from the data.

Methods: A survey was developed as a method of gathering both qualitative and quantitative self-reported data from nurses currently working on adult critical care units. All survey data collected was anonymous. This was circulated, via the unit Matrons and Nurse Leads, to nursing staff within their critical care department.

Results: The survey produced a large amount of data, with 427 responses (approximately 15% of nurses) from 33 units across 24 questions. The data found that 51% of nurses report that Covid-19 has made them less likely to stay in their current roles. 7 in 10 reported high levels of stress because of their work with the most common cause of stress being “staff shortages” and “being asked to work on other wards”. The results also showed within the next 3 years, 50% of nurses are planning on leaving their current roles in their adult critical care unit with 47% of nurses feeling they do not get adequate salary. On a positive note, 87% of nurses feel they are having a positive impact on patient care with 74% reporting that they would recommend adult critical care nursing to other nurses. Following this analysis of the data, the networks developed six recommendations that looked at repeating and sharing the report, wellbeing, salary, contributing factors for stress and dedicated time for education and development. Alongside a formal report, individual units with more than five participants were provided with an infographic, personalised to them with their results.

Conclusions: The data showed points of significant interest for the networks and units and has generated interest from the wider critical care community, with the desire to replicate this survey Nationally.

It is clear that despite 87% of nurses feeling they have a positive impact on patient care and 74% recommending critical care nursing to others, 50% of nurses are looking to leave. We need to understand this aspect in more detail along with the two key reasons for stress, moving to the wards and staff shortages.

4797

HLH: The sepsis mimic

Kate O’Donnell, Andrew Westbrook, Liam Smyth

St Vincent’s University Hospital

St Vincent’s University Hospital, [e-mail]

Abstract

Introduction: Haemophagocytic Lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome induced by aberrantly activated macrophages and cytotoxic T-cells. Paediatric HLH is most often due to genetic factors but in adults inflammatory triggers tend to play a greater role. Patients may present with a sepsis-like syndrome and can progress to terminal multiple organ failure without appropriate treatment. Mortality is high for these patients, reported to be between 40 to 68%.¹

Case Presentation: We present a 24 year old male who presented with fevers, lymphadenopathy and rash. His background was significant for psoriatic arthritis and had recently been started on sulfasalazine. He was treated with broad spectrum antibiotics but on day 4 became tachypnoeic and hypotensive, requiring admission to the intensive care unit for vasopressor support and later mechanical ventilation. He had a leukocytosis, high lactate dehydrogenase, high ferritin level and deranged liver function tests. A bone marrow aspirate (BMA) showed evidence of haemophagocytic activity and amasticytes which was suggestive of HLH possibly secondary to leishmaniasis. This was confirmed when Leishmania Donovani complex DNA was detected on PCR. Amphotericin was commenced with the cessation of other antibiotics and he was immunosuppresed with steroids and ciclosporin. His care ultimately involved the multidisciplinary input of haematology, hepatology, dermatology, intensive care medicine, infectious disease, rheumatology and hepatobiliary surgeons and he was discharged well on continued antifungal therapy, ciclosporin and tapering steroids following a 29 day admission.

Conclusion: This case highlights the importance of a multidisciplinary approach to critical illness and the need to continually re-evaluate diagnoses based on response to therapy. Haemophagocytic Lymphohistiocytosis is a syndrome of pathologic immune activation with both genetic and environmental contributing factors. It is the immune response itself that drives much of the pathology as opposed to the trigger. HLH has no unique identifying features to distinguish it from other inflammatory syndromes such as severe sepsis or haematological malignancies. The HScore is a validated scoring system for use in adults to help diagnose HLH. It consists of 3 clinical (known immunosuppression, pyrexia, organomegaly), 5 laboratory (triglyceride, ferritin, serum glutamic oxaloacetic transaminase, fibrinogen, cytopenia) and 1 cytologic (haemophagocytosis on BMA) variables which combined give a probability of having HLH.²

This patient had risk factors for HLH associated with both a rheumatological condition and immune compromise due to the recent starting of sulfasalazine. It was the unexpected finding of amasticytes on bone marrow biopsy that informed further investigations and later confirmation of visceral Leishmaniasis. This illustrates the necessity of a thorough work up and exclusion of potential aetiologies in the diagnosis HLH as this will affect treatment modalities. Liver disease, catastrophic antiphospholipid antibody syndrome, sepsis and DRESS are all HLH mimics and there is considerable overlap, particularly in this patient’s case.

A multidisciplinary approach is key to the appropriate and prompt recognition and management of such cases. Every critical care physician should maintain an index of suspicion for HLH in patients with fevers, cytopenias and organomegaly.

References

1. Ramos-Casals M, Brito-Zerón P, López-Guillermo A, Khamashta MA, Bosch X. Adult haemophagocytic syndrome. Lancet. 2014;383(9927):1503-16.

2. Fardet L, Galicier L, Lambotte O, Marzac C, Aumont C, Chahwan D, et al. Development and Validation of the HScore, a Score for the Diagnosis of Reactive Hemophagocytic Syndrome. Arthritis & Rheumatology. 2014;66(9):2613-20.

4792

Tracking functional recovery post critical illness

James Bruce¹, Kieran Miller², Greg Warren²

¹ Torbay & South Devon Healthcare Nhs Foundation Trust

² Torbay & South Devon NHS Foundation Trust

Torbay & South Devon Healthcare NHS Foundation Trust, [e-mail]

Abstract

Tracking functional recovery post critical illness

Introduction: Intensive Care Unit (ICU) survivors may experience long-term impairment of their functional and physical capabilities.¹ Exercise limitation, physical and psychological sequelae, decreased quality of life, and increased costs and use of health care services have been observed 5 years post ICU survival.² Certain patient groups are at a higher risk of poor functional recovery from critical illness.³ Early rehabilitation therapy has been shown to improve outcomes.⁴

Torbay intensive care unit employs a specialist critical care multi-disciplinary rehabilitation team led by a band 7 occupational therapist. This team commences early rehabilitation on ICU, sets goals for the wards and implements appropriate discharge plans for the community. Following discharge, the same team follow up all high-risk patients to track functional and psychological recovery.

The Functional Independence Measure (FIM) and the Functional Independence Measure + Functional Assessment Measure (FIM+FAM) have been used to track functional change at specific time lines of patient recovery.

Objectives: To describe the physical and non-physical impairment of patients post-critical illness. To observe the outcomes of the two functional measures to see which to adopt.

Methods: All admitted ICU patients were screened by the rehabilitation team and classified as having high or low rehabilitation need. For all high need patients, routine measurement of FIM or FIM+FAM scores were taken at specific time points of the patient journey. 54 patients were randomly allocated into each group of outcome measure score. Descriptive statistics plotted in Microsoft Excel show recovery trajectories using both outcome measures.

Results and Discussion: While patients may have significant functional limitation at the time of ICU discharge, early, targeted, goal-driven and ongoing rehabilitation therapy allow for marked recovery in many by the time of discharge from hospital and at review in follow-up clinic.

Physical and psychological baselines are not met by many by the time of hospital discharge, highlighting the need for continuing follow-up care in the community.

FIM+FAM appears to be a more sensitive discriminator particularly of mental health recovery at the time of acute hospital discharge.

Conclusion: Critical illness requiring ICU admission leads to multifaceted functional deterioration. Significant recovery can be seen in high-risk individuals by time of follow up. A wider variability in functional recovery is observed during hospital admission phase. The FIM+FAM is observed to be more sensitive to the issue’s patients present with at follow up in both physical and non-physical areas of recovery and future need. At the point of hospital discharge, there remains a functional deficit which can be recovered via targeted rehabilitation in the outpatient setting. This shows the importance of on-going rehab during the time between discharge and follow up. The FIM+FAM would be the recommended tool to monitor patient recovery from illness to follow up.

References

1. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from intensive care unit. Critical Care Medicine. 2012 Feb;40(2):502–9.

2. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional Disability 5 Years after Acute Respiratory Distress Syndrome. New England Journal of Medicine [Internet]. 2011 Apr 7;364(14):1293–304.

3. Rehabilitation after critical illness [Internet]. Available from: https://www.nice.org.uk/guidance/cg83/evidence/full-guideline-pdf-242292349

4. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet (London, England). 2009 May 30;373(9678):1874-8.

4789

Piloting pharmacist medicines reconciliation on step down from adult critical care

David Sapsford, Victoria Bowles

Cambridge University Hospitals NHSFT

Cambridge University Hospitals NHSFT, [e-mail]

Abstract

Introduction: On admission to the ICU, focus of care is directed towards preservation of life and medicines for chronic conditions are often not required or may be inappropriate in this context. At the point of step down to a general ward, the respective decreasing resource gradient may present a risk of adverse drug events (ADEs) either by inappropriate continuation of ICU specific treatments or by failure to restart pre-admission medicines which may be appropriate. These transitions of care are extremely complex.

Clinical pharmacists are integral to the ICU multidisciplinary team and in delivering high quality medicines reconciliation (MR), a useful tool in reducing adverse drug events¹ and a practice which is recommended widely on admission to and step down from ICU.^2–4 Additionally a recent systematic review and meta-analysis found that medication review and MR were very effective and reduced potential ADEs in patients transitioning from ICU⁵.

During August 2021, a pilot was undertaken to identify and actively complete MR and pharmaceutical review, by an ICU trained pharmacist, upon step down to the ward.

Objectives: To develop a pharmacist-led medicines review service for patients discharged from ICU to ward based care.

Methods: Patients discharged from ICU were identified via a report on the electronic patient record (EPR). All pharmacists undertaking the review were either ICU trained or supported by an ICU pharmacist.

A local SOP was developed to standardise the process and ‘smart-phrase’ created on the EPR to ensure consistency of review.

Pharmaceutical recommendations were actioned by the pharmacist (if an independent prescriber) or communicated to the ward pharmacist if a medical team review was required.

Data collection was prospective and included ICU area, discharge ward, time taken for review, number of pharmaceutical contributions to care, number of non-prescribing prescription amendments and clinical importance of the review, categorised subjectively as high, medium or low.

Results: Over a 2-week period, 61 patients were identified with complete records available for 32. The table below provides data for the 32 records analysed.

	Pharmaceutical interventions (prescribing activities)	Non-prescribing prescription amendments	Total	Time taken for review (mins)	Severity (per review)
					High	Medium	Low	n/a or blank
Total	125	88	213		9	18	2	3
Mean per patient	3.9	2.8	6.7	24	-	-	-	-

Non-prescribing prescription amendments included:

• Discontinuation of concentrated PRN electrolyte prescriptions

• Discontinuation of arterial line flushes

• Switching from NG to PO administration route

Pharmaceutical interventions included:

• Discontinuation of PPIs commenced as stress ulcer prophylaxis

• Restart of long-term inhaled medications for asthma and COPD

• Weaning of antipsychotic medications commenced for critical care related delirium

• Restart of long-term antiplatelet and statin medication for secondary prevention of cardiovascular events

Conclusions: EPR systems no longer require drug charts to be re-written on transitioning from the ICU. This may result in inappropriate continuation or failure to recommence appropriate prescriptions for the management of long-term conditions. Pharmacist medication reviews following ICU discharge are clinically significant and benefit patients in terms of both morbidity and mortality. They also provide a cost-saving to the NHS through reduction in polypharmacy. This may also reduce re-admission rate.

References

1. Shulman R, McKenzie CA, Landa J, Bourne RS, Jones A, Borthwick M et al. Pharmacists Review and Outcomes: Treatment Enhancing Contributions Tallied, Evaluated and Documented (PROTECTED-UK). J Crit Care. 2015;30:808-13

2. Faculty of Intensive Care Medicine and the Intensive Care Society. Guidelines for the Provision of Intensive Care Services (2) https://www.ics.ac.uk/ICS/GuidelinesAndStandards/GPICS_2nd_Edition.aspx (2019, accessed 3^rd March 2022)

3. NHS England. Adult Critical Care service specifications, https://www.england.nhs.uk/wp-content/uploads/2019/05/Adult-Critical-Care-Service-Specification-FINAL.pdf (2019 [updated January 2021], accessed 3^rd March 2022

4. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical Care Medicine 2021; 49: 1063-1143 doi: 10.1097/CCM.0000000000005337

5. 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 [Internet]. 2022 Jan 17;bmjqs-2021-013760. Available from: http://qualitysafety.bmj.com/content/early/2022/01/17/bmjqs-2021-013760.abstract

4784

Delirium in the intensive care unit: a survey of the knowledge, attitudes and practice of United Kingdom nurses and doctors

Kate Godfrey¹, Jane Harden², Clare Bennett²

¹ University of Wolverhampton

² Cardiff University

University of Wolverhampton, [e-mail]

Abstract

Delirium in the intensive care unit: a survey of the knowledge, attitudes and practice of United Kingdom nurses and doctors

Introduction: Delirium in the Intensive Care Unit (ICU) is a prevalent condition, recognised to have negative implications for patient experience and outcomes.¹ It is therefore vital that ICU nursing and medical staff have an understanding of delirium in their patients, so that it can be appropriately detected, responded to and where possible, prevented. There is a paucity of research in the UK that has evaluated this. This has included: one large survey of 681 consultant doctors;² a survey of 76 ICU nurses and doctors in Scotland³ and a focus group study with 12 nurses form a single ICU in England.⁴

Objectives: The study aimed to address the above gap in the literature by carrying out a survey of ICU nurses and doctors in the UK, investigating their knowledge of and attitudes toward delirium and its assessment.

Methods: The survey was carried out online using the ‘Survey Monkey’ software package. The previously validated tool from a published survey on the topic³ was adapted with permission, for use online. Analysis of data was carried out using SPSS. For the main survey questions Chi² analysis was carried out to assess for difference between groups. Comparisons were carried out relating to profession, length of service in ICU and time and type of last education on delirium. Comments in free text boxes were summarised and evaluated for key themes. A link to the survey was distributed by the ICS in a newsletter and by the Critical Care Networks National Nurse Leads (CC3N) via the critical care network. The approach to recruitment aimed to maximise reach to the target population. The survey was part of a larger study investigating potential influencing factors on how ICU staff think about delirium.

Results: A total of 650 ICU nurses (302) and doctors (348) participated in the survey; representing all four UK countries, with England being the most strongly represented, accounting for 84.2% (547) of participants. The majority of doctors (72.7%) were of consultant grade, with nurse participants being more evenly spread across grade banding, overall 58.1% of participants had greater than 10 years’ experience in ICU.

Seventeen questions relating to knowledge, assessment practice and education and training were completed. Data demonstrated that staff had a good knowledge of defining features of delirium and recognise it to have a number of serious complications. However, there is a lack of understanding as to the form most likely to be present and potentially related to this, a lack of appreciation of the importance of a valid screening tool. Whilst the majority of participants were aware ICU delirium fluctuates in presentation, the corresponding appreciation for the needed frequent and regular screening was not apparent. A positive impact of education was seen with a suggestion that bedside teaching was less effective than some other methods.

Conclusion: The survey has identified gaps in knowledge, and practice in relation delirium in the ICU, as well as potential variance in preference and efficacy of differing forms of education on the topic. These insights could help inform future educational developments on delirium in the ICU.

References

1. Ely EW. every deep drawn breath. Scribe: London

2. Mac Sweeney R, Barber V, Page V, Ely EW, Perkins GD, Young JD, McAuley DF. A national survey of the management of delirium in UK intensive care units. QJM: An International Journal of Medicine. 2010 Apr 1;103(4):243-51.

3. Elliott SR. ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive and Critical Care Nursing. 2014 Dec 1;30(6):333-8.

4. Zamoscik K, Godbold R, Freeman P. Intensive care nurses’ experiences and perceptions of delirium and delirium care. Intensive and Critical Care Nursing. 2017 Jun 1;40:94-100.

4782

Accidental colchicine overdose: a highly lethal drug in minimal overdose with unpredictable dose-related outcomes in an otherwise healthy adult

Charlotte Spiers, Michael McGinlay, Maeve Durand

Regional Intensive Care Unit, Royal Victoria Hospital, Belfast

Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, [e-mail]

Abstract

Introduction: Colchicine toxicity is a rare but potentially life-threatening condition which can rapidly lead to multi-organ failure and death. It is important to recognise the potential lethality of this drug early in overdose with early treatment and referral to enhanced care areas to optimise outcomes.

Case: A 47 year old male (SL) who was suffering from severe symptomatic gout presented to our emergency department with abdominal pain following an impulsive colchicine overdose. He ingested approximately 7mg.

Past medical history includes gout, mild asthma and type two diabetes mellitus. Prescribed medications include colchicine 500mcg twice daily and allopurinol 200mg daily.

Initial bloods and observations were normal. Over 24 hours SL developed worsening abdominal discomfort, distension and lower GI bleeding. CT abdomen demonstrated non-specific findings of sigmoid colitis. Hypotension and hyperlactaemia developed becoming refractory to aggressive volume resuscitation. An oliguric AKI and metabolic acidosis (pH 7.23, BE -10.4, HCO3 15.4) ensued.

An ICU referral was made at 36 hours. High flow oxygen was commenced. Invasive lines were inserted. Noradrenaline and adrenaline infusions were required to achieve a mean arterial pressure of 65mmHg. IV sodium bicarbonate was administered whilst being established on continuous renal replacement therapy (CVVHDF). Empiric broad-spectrum antimicrobial cover was commenced.

An echocardiogram demonstrated severe bi-ventricular failure. A pulmonary artery catheter was placed to reveal a cardiac output of 1.3L/min. Levosimendan was added and lead to a transient improvement in cardiac output to 5.8L/min. Extracorporeal support was explored but declined. Worsening hypoxic respiratory failure necessitated invasive ventilation. Hepatic and bone marrow failure became apparent and was managed with Filgrastim, platelets and tranexamic acid. Rapidly progressive multi-organ failure ensued with death occurring at 89 hours.

Discussion: Colchicine has a narrow therapeutic index and dose related fatality is extremely variable.¹ Colchicine is readily absorbed after oral ingestion binding to intracellular tubulin, thereby preventing the formation of microtubules which are essential for vital cellular functions.^2–3 Metabolism is primary hepatic via CYP3A4 and glucuronidation with significant enterohepatic re-circulation.^1–2

Peak concentrations are seen within 2 hours. Within 24 hours patients classically develop gastrointestinal disturbance.⁵ Diarrhoea may be profuse and bloody resulting in electrolyte derangement and hypovolaemic shock. Classically a progressive decline over the subsequent 24 hours to 7 days ensues leading to multi-organ dysfunction. Features of cardiovascular collapse, renal, hepatic and bone marrow failure are well described. Multi-organ failure and sepsis culminating in intractable hypotension and asystole are common modalities of death, occurring within 8-72 hours.^2,5

The mainstay of treatment consists of early and aggressive GI decontamination with activated charcoal to reduce colchicine absorption. Given colchicine’s propensity for enterohepatic recirculation, delaying gastrointestinal decontamination can result in ongoing toxicity.

Supportive management including administration of granulocyte colony-stimulating factor are the mainstay of ICU treatment.² Colchicine specific Fab fragment antibodies are not commercially available.⁴

Clinicians should be alert to the significance of colchicine in overdose and associated high mortality despite aggressive intensive care therapies. Patients may initially be asymptomatic before developing irreversible cardiovascular collapse. Early recognition and gastrointestinal decontamination are paramount.

References

1. Colchicine: Drug information. www.uptodate.com/contents/colchicine-drug-information?search=colchicine%20toxicity&topicRef=1672&source=see_link (accessed 23 February 2022).

2. Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571.

3. Harris R.D. and Gillett M.J. Colchicine poisoning—overview and new directions. Emergency Medicine, 1997; 10: 161-167.

4. Baud FJ, Sabouraud A, Vicaut E, P Taboulet, Lang J, Bismuth C, et al. Treatment of severe Colchicine overdose with colchicine-specific Fab fragments. N Engl J Med 1995; 332:642-645

5. Colchicine – pharmaceutical, www.toxbase.org/poisons-index-a-z/c-products/colchicine-pharmaceutical/ (2017, accessed 23 February 2022).

4779

Planning for a potential paediatric bronchiolitis surge: how Inter-Professional Education (IPE) was used to build a practice-ready clinical team

Fiona Frame, Michael Raffles, Heather Prowse, Princy Suresh, Suzanne Webb, Abigail Goodwin, Filipa Monteiro, Emma Nebi

Royal Berkshire NHS Foundation Trust

Royal Berkshire NHS Foundation Trust, [e-mail]

Abstract

Introduction: Bronchiolitis is the most common cause for paediatric respiratory hospital admissions in young children in the UK.¹ Following the relaxation of international SARS-Cov-2 lockdown measures a potential national surge in cases was predicted, highlighting a need for more collaborative working across core specialities.² This prompted the use of the principles of Inter-Professional Education (IPE) to prepare and deliver an intervention to improve outcomes for these patients.³

Objectives:

• To plan, deliver and evaluate an educational intervention focussed on improving the knowledge, skills and attitudes needed to care for a sick child with bronchiolitis

• To utilise the principles of IPE to improve competence and confidence across core specialities involved in the care of a sick child with bronchiolitis

Methods: A team from the Adult Intensive Care Unit (AICU) and the Paediatric High Dependency Unit (PHDU) from the Royal Berkshire Hospital in Reading delivered an inter-professional teaching session focussed on caring for the sick child with bronchiolitis. The patient journey was utilised as a framework to teach the core knowledge, skills and attitudes needed to clinically manage a child from the Emergency Department (ED) to the Intensive Care Unit (ICU). Each session included a lecture about bronchiolitis – describing pathophysiology and how to recognise the deteriorating child; a skills and drills tutorial - highlighting the need for weight-based calculations for high flow nasal oxygen, intravenous fluids and drugs; and a practical simulation scenario – focussing on the stabilisation and management of a sick child awaiting retrieval to the Paediatric Intensive Care Unit (PICU).

Results: 135 healthcare professionals from a range of adult and paediatric disciplines involved in the care of children across the patient journey attended one of fourteen teaching sessions delivered between September to December 2021. Attendees completed a feedback questionnaire. One hundred and twenty-two (90%) reported an extremely high degree of satisfaction overall, with many saying they would recommend the teaching sessions to others. Areas of personal and professional development were highlighted across the following main themes: gaining theoretical knowledge; understanding key equipment; performing drug calculations; preparing for intubation and ventilation; assessing the need for chest physiotherapy techniques; and more collaborative team-working. Free text comments demonstrated that the attendees felt the teaching sessions: built confidence through the sharing of new or improved knowledge and skills; facilitated a safe space to practice using simulation; and provided the opportunity to learn about and from each other. Many of the attendees also commented on areas they wanted to reinforce and further develop in daily clinical practice as a direct result of the sessions.

Conclusions: On-going evaluation is taking place as the teaching sessions continue throughout the year, facilitating the inclusion of additional inter-professional groups from across core specialities. These sessions have been used as a template for the development of further planned IPE with a more varied range of paediatric clinical cases and presentations. These will continue to build on the transferable knowledge and skills that increase competence and confidence in caring for the sick child whilst developing a more collaborative practice-ready workforce.

References

1. Friedman JN, Rieder MJ and Walton JM. Bronchiolitis: recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health 2014: 19(9): 485-491.

2. Limb M. RSV: the year the respiratory infection “took its gloves off”. BMJ 2021; 374(2078):1-2.

3. Guraya SY and Barr H. The effectiveness of inter-professional education in healthcare: a systematic review and meta-analysis. Science Direct 2018; 34(3): 160-165.

4778

Emergency re-intubation plans on the Intensive Care Unit: improving clarity and patient safety

Jamie Gibson, Neil Botting

Worthing Hospital

Worthing Hospital, [e-mail]

Abstract

Introduction: NAP4 highlighted that nearly 20% of all major airway complications occurred on the ICU with 70% of events involving tracheostomies.¹ It is recommended that plans for inadvertent tracheal tube or tracheostomy displacement should be available, high-risk patients should be identified and a plan for these patients should be made and documented. It was noted that these recommendations are not routinely put into practice in our institution.

Objectives:

1. Identify current practice in terms of documentation of emergency re-intubation plans for patients with tracheostomies.

2. Design, implement and assess the utility of an emergency re-intubation plan proforma which can be completed for every patient with an endotracheal tube (ETT) or tracheostomy tube (TT) and is easily visible on the electronic patient record

Methods: To address objective one, a retrospective audit was carried out, reviewing all patients with a TT admitted to ICU over the previous three years. The medical notes were reviewed for the presence of a documented emergency re-intubation plan, as well as documentation of the grade of intubation.

To address objective two, we randomised trainees with airway management competence and experience with the ICU electronic patient record system (ICCA) into two groups.

• Group A were asked to review the electronic notes of a real life ICU patient with a TT and verbalise an airway management plan which was likely to be successful, based on the index technique

• Group B were asked to review the electronic notes of a simulated ICU patient which included the new emergency re-intubation proforma and verbalise an airway management plan.

The average time difference between groups A and B would then be assessed.

Following implementation of the new emergency re-intubation proforma, a repeat audit would be carried out to assess improvement across the department.

Results: The baseline audit demonstrated that there were 62 patients cared for on our unit with tracheostomies over the period February 2019 – January 2022. Of these, zero patients had an emergency re-intubation documented in the medical notes. The grade of oral intubation was documented in 64.5% of patients.

The results related to objective two are pending, with the project currently ongoing.

Conclusions: NAP4 identified a high rate of airway complications occurring on the ICU. A simple way to avoid unanticipated airway complications, as well as minimise stress for on call teams, includes identifying high risk patients and utilising an emergency re-intubation plan which is clearly documented in the medical notes and can be simply followed in the event of an airway emergency.

Reference

1. Cook, T. National Audit Project 4 of the Royal College of Anaesthetists and the Difficult Airway Society. Major Complications of Airway Management in the UK. March 2011.

4777

Oxygen flow: How much do we know?

Sharique Anwar¹, Nitin Arora¹, Noor Alhamamy², Hanan Ibrahim¹

¹ University Hospitals Birmingham

² Sandwell and West Birmingham NHS trust

University Hospitals Birmingham, [e-mail]

Abstract

Introduction: Since the advent of Covid, oxygen has been the centre of discussion despite being the most important entity for the survival of human life. As various modes of its delivery has been in practice for a long time, using the non-rebreather mask has been a part of most guidelines for emergencies and hypoxia. This requires a higher flowrate of up to 15 l/min. Most flowmeters can deliver upto 75 l/min over the maximum calibrated mark.¹ What may appear as a small rise from the maximum labelled mark can deliver more oxygen than required and result in wastage of oxygen or hide the severity of the patient’s condition. Using this audit/ QIP we are trying to determine if the flowrates delivered are as per the prescription/protocol.

Aim: To find out if the oxygen administration when it is prescribed at 15L/min is at the prescribed value and therefore quantify the amount of oxygen that is being wasted.

Methods: Data was collected randomly, observing the flow rates that the patients were receiving as prescribed or over the prescribed rate for those on non rebreather mask.

Result: 54 observations were recorded from ED, ITU, AMU and theatre recovery across two hospitals. It was found that 57.4% of the patients were on flowrates more than the prescribed value.

Conclusion & Discussion: More than half the patients requiring high flow rate of oxygen were on rates more than prescribed. This is potentially due to the lack of understanding of the calibration of the flowmeter. This results in the wastage of oxygen causing significant financial loss and an increase in the carbon dioxide emission impacting the environmental pollution. We plan to run an educational intervention for staff in these departments to emphasise the importance of administering drugs (including oxygen) as they are prescribed, and how easy it is to over administer oxygen.

Reference

1. N. Arora, A. Dennis, J.Willson, J. Norrie, M.Tunstall. Delivery of oxygen by standard oxygen flowmeters. Anaesthesia 2021; 76: 1546-7.

4776

Ondansetron and Hypothermia induced Cardiac Arrest in a 97 year-old Female: A Case Report

Keith Sai Kit Leung¹, Faareaha Ahmad², Amun Mahmood², Yuki Ka Ling Shum², Ekta Punj³, Riad Hosein³, Azam Majeed³, Muzaffar Hashmi³, Anna Hong³

¹ Aston University / University Hospitals Birmingham NHS Foundation Trust

² Aston University

³ University Hospitals Birmingham NHS Foundation Trust

Aston University / University Hospitals Birmingham NHS Foundation Trust, [e-mail]

Abstract

Background: Ondansetron and hypothermia are both known to induce bradycardia or QT interval prolongation, which put affected patients at risk of cardiac arrest.

Case: A 97-year-old female initially presented with confusion and hypothermia, with past medical history of heart failure with preserved ejection fraction, previous neck of femur fracture, gout, folate and vitamin B12 deficiency anaemia, and no known family history of sudden cardiac death or long QT syndrome. Pre-arrest ECG showed a borderline prolonged QTc of 466ms. Shortly following a 4mg intravenous ondansetron bolus injection, she was seen cyanotic and suffered a severe bradycardia, subsequentally an asystolic cardiac arrest. ROSC was achieved after 2 cycles of CPR, with maximum downtime of eight minutes. She made satisfactory progress clinically and was discharged to a community hospital for further rehabilitation thirteen days after the arrest.

Proposed Mechanisms: Bradycardia and QT interval prolongation is an uncommon and a rare side effect of ondansetron, a 5HT-3 receptor antagonist, with an incidence of >1 in 1000 to <1 in 100, and >1 in 10000 to 1 in 1000 respectively.¹ Interestingly, our patient was also found to have hypothermia with a temperature of 33.8°C on initial examination prior to the arrest. Changes in electrocardiographic parameters is a well-known phenomenon in hypothermic patients, in particular bradycardia and prolonged QT interval.² Therefore, we hypothesise two possible mechanisms for the arrest in our patient as a result of both hypothermia and ondansetron use, resulting in 1.) severe bradycardia and subsequent asystole, or 2.) exacerbation of QTc prolongation resulting in Torsades de Pointes.

Clinical Significance: To the best of our knowledge, this is the first case report in the United Kingdom to describe such outcome. Ondansetron is associated with both bradycardia and QTc prolongation, these can be further exacerbated by hypothermia. Clinicians should be aware of administering ondansetron in patients with hypothermia, which may further augment such risk leading to adverse cardiac events and eventual cardiac arrest.

Consent: Patient family consent obtained.

References

1. Zofran Injection - Summary of Product Characteristics (SmPC) - (emc) [Internet]. Medicines.org.uk. 2022 [cited 27 February 2022]. Available from: https://www.medicines.org.uk/emc/product/7873/smpc#UNDESIRABLE_EFFECTS

2. Mattu A, Brady W, Perron A. Electrocardiographic manifestations of hypothermia. The American Journal of Emergency Medicine. 2002;20(4):314-326.

4775

Pericardial Decompression Syndrome: A rare, but often fatal, complication of pericardial drainage

Conor Steele¹, Tom Beach¹, Vinoth Sankar²

¹ Countess of Chester Hospital

² Royal Liverpool University Hospital

Countess of Chester Hospital, [e-mail]

Abstract

Background: Cardiac tamponade is a life-threatening condition. Urgent pericardial drainage is required to restore haemodynamic stability and prevent cardiac arrest.¹

While haemodynamic improvement is often immediate, some patients develop a paradoxical worsening of cardiac function following uncomplicated pericardial drainage without the development of an additional pathology to explain the deterioration. This rare, potentially fatal complication is known as pericardial decompression syndrome (PDS).

The exact incidence of PDS is unknown but it is estimated to be around 5% of procedures.² However, the condition carries a high mortality at around 30%.³ Various pathological mechanisms have been suggested to explain this deterioration, including haemodynamic, ischaemic and autonomic imbalance hypotheses³.

Case: We present the case of a 65-year-old female with a background of type 2 diabetes mellitus and multiple sclerosis. She attended the emergency department with acute dyspnoea on a background of breathlessness, cough, and 6kg weight loss over 6 months. She was tachycardic and tachypnoeic. ECG showed sinus tachycardia, CXR demonstrated cardiomegaly and left-sided consolidation. An initial diagnosis of chest sepsis was made, and antibiotics and IV fluids were prescribed.

The patient deteriorated with worsening hypoxia and persistent hypotension despite fluid resuscitation.

A CT Thorax revealed left lower lobe malignancy and pericardial effusion, but no evidence of PE.

The patient was intubated and transferred to the ICU. A bedside echocardiogram was performed and showed cardiac tamponade (Figure 2).

A pericardial drain was inserted, draining 650ml of blood-stained fluid. There was an immediate clinical improvement, with echocardiological evidence of improved RV and LV function.

Within hours haemodynamic instability recurred. Repeat echocardiogram showed a severely impaired RV, and significantly impaired LV.

The patient continued to deteriorate over the next day with escalating doses of multiple inotropes and vasopressors. Multi-organ failure ensued, and the decision was made to withdraw life-sustaining treatment.

Discussion: PDS is an underdiagnosed and underreported syndrome. We suggest clinicians maintain a high degree of clinical suspicion in patients who experience a paradoxical deterioration in haemodynamics following pericardial drainage.

Several potential risk factors have been identified: malignancy-associated effusions, female sex, the volume and rate of drainage, and procedure (pericardiostomy > pericardiocentesis)¹.

Presentation is variable. About 40% of patients have left ventricular failure, 29% have pulmonary oedema without shock, 20% have shock associated with biventricular failure and 11% with shock associated with RV failure and non-cardiogenic pulmonary oedema.³

Treatment is essentially supportive.² Patients will require close monitoring in a critical care setting, inotropic support and aggressive heart failure treatments.

While there are no clear guidelines on the prevention of PDS, a proposed approach is to only remove enough fluid to resolve haemodynamic instability, then removing the remaining fluid in small volumes over subsequent days until the effusion is resolved.³

Conclusion: PDS is a rare complication of pericardial drainage with a high associated mortality. As early recognition and supportive care are the only treatments, identification of those at risk and prevention is key. It is, therefore, essential that clinicians caring for patients following pericardial drainage are aware of this complication.

References

1. Amro A, Mansoor K, Amro M, Sobeih A, Suliman M, Okoro K et al. A Comprehensive Systemic Literature Review of Pericardial Decompression Syndrome: Often Unrecognized and Potentially Fatal Syndrome. Current Cardiology Reviews. 2021; 17(1):101-110.

2. Imazio M. Pericardial decompression syndrome: A rare but potentially fatal complication of pericardial drainage to be recognized and prevented. European Heart Journal: Acute Cardiovascular Care. 2014;4(2): 121-123.

3. Prabhakar Y, Goyal A, Khalid N, Sharma N, Nayyar R, Spodick D et al. Pericardial decompression syndrome: A comprehensive review. World Journal of Cardiology. 2019;11(12):282-291.

Figure 1.

Pathophysiology of Pericardial Decompression Syndrome.¹

Figure 2.

Subcostal views on bedside echo showing cardiac tamponade.

Figure 3.

Presentation of Pericardial Decompression Syndrome.²

4774

Immunosuppression and Covid-19: Risk factor or treatment?

Madeleine Gray, James Rivett, Gayathri Perera, Jagdish Sokhi

Chelsea & Westminster Hospitals NHS Foundation Trust

Chelsea & Westminster Hospitals NHS Foundation Trust, [e-mail]

Abstract

Introduction: During the Covid-19 pandemic, 540,895 people were identified as immunosuppressed and believed to be at increased risk of severe disease.¹ As the pandemic evolved, biologic immunosuppression became a treatment of severe Covid-19.² The true impact of immunosuppression on disease severity remains unclear.

Objectives:

1. Identify the incidence of immunosuppressed patients admitted to the ICU.

2. Analyse the mortality of those who are immunocompetent and immunosuppressed.

3. Examine the differences in mortality and level of care required between sub groups of patients on immunosuppression; those on biologics, non-biologics, and a combination of both.

Methods: A retrospective search of all Covid-19 positive admissions from March 2020 to November 2021 across two adult ICUs at Chelsea & Westminster NHS Trust was performed, using the EPR system. We identified those on immunosuppressive drugs, the level of care they required, and 28 day mortality. We categorised different types of immunosuppression, vaccination status, if applicable and co-morbidities. The exclusion criteria were primarily those with false positive swabs or incomplete data.

Results: Baseline characteristics were median age (56 vs 56), and APCHE II score (20.08 in the immunosuppressed group vs 14.0 in immunocompetent).

Thirteen immunosuppressed patients were identified. Reasons for drug immunosuppression in this group included solid organ transplant (6/13), and autoimmune conditions (7/13). Two patients were on biologic drugs alone, 8 were on non-biologics, and 3 were on a combination. Four of this group had received at least 2 doses of a Covid-19 vaccine.

Mortality was 61.54% (8/13) in the immunosuppressed group vs 36.65% (199/543) in the immunocompetent group.

Conclusion: Despite similar demographics, patients on immunosuppression had a significantly higher mortality than the immunocompetent group. Interestingly, those on targeted biological immunosuppression had the lowest incidence of requiring level 3 care, and no deaths. It is a possibility that biologics dampen the hyper-inflammation seen in severe Covid-19 pneumonitis, raising the question of a possible protective benefit from severe disease. This reflects the findings of the REMAP-CAP investigators,³ who showed that the IL-6 inhibiting biologics Tocilizumab and Sarilumab are efficacious against the most severe disease following admission to ICU with Covid-19 pneumonitis.

The single centre and retrospective observational design, combined with small numbers on immunosuppression, despite a large inclusion criterion, mean it is not possible to make statistical conclusions.

Confounding factors include the effects of vaccination, shielding and the change in SARS-CoV-2 variant prevalent during different times during the pandemic.

References

1. COVID-19 vaccine surveillance report - Week 49. Report, UK Health Security Agency, UK, 9 December 2021.

2. RECOVERY Collaborative Group. Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet, 2021; 397(10285): 1637-1645.

3. The REMAP-CAP Investigators. Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19. N Engl J Med, 2021; 384:1491-1502.

4773

Type 1 Respiratory Failure – An unusual presentation of Weil’s disease: A case report

Ifsa Mahmood, Thaventhran Prabhahar

North Middlesex University Hospital

North Middlesex University Hospital, [e-mail]

Abstract

Background: Leptospirosis is a zoonotic disease prevalent in tropical and subtropical areas.¹ 55 confirmed cases of Leptospirosis were reported in England in 2021, cases included exposure linked to animals or contact with contaminated water sources.² In most cases, the disease course is mild with non-specific symptoms. Weil’s disease is the severe form of Leptospirosis occurring secondary to systemic spread and involvement of multiple organs.³

Case: We report the case of a 21-year-old male with no previous medical history presenting to the emergency department with a one-week history of myalgia, fever, cough, dyspnoea and haemoptysis. The patient had a 5-pack year history of cigarette smoking and use of marijuana. In terms of the epidemiological context, patient denied any recent travel or exposure to contaminated water or animal sources.

Observations in the emergency department revealed a temperature of 39.5°C, pulse of 124 beats/min and blood pressure of 85/64 mm/Hg. Saturations on room air were 83%. Auscultation of the lungs revealed widespread bilateral crackles and patient continued to have episodes of haemoptysis. The abdomen and calves were soft, there were no rashes, joint swelling or jaundice.

Initial laboratory results were notable for a CRP of > 300 mg/L (0–5 mg/L), WCC 18.34 ×10^9 (3–10 ×10^9), NEU 16.56 ×10^9 (2–7.5 ×10^9). All other routine blood investigations were normal. Chest X-ray (CXR) revealed multiple ill-defined nodules throughout the poorly expanded lung. Subsequent CT pulmonary angiogram reported no filling defect in the main, lobar, segmental or subsegmental pulmonary arteries to suggest the presence of a pulmonary embolus. Extensive parenchymal shadowing bilaterally with ground-glass element was also reported.

Initial diagnosis of chest sepsis resulted in patient being admitted to critical care for respiratory and inotropic support. Empiric antibiotics (Linezolid, Tazocin and Clarithromycin) were commenced. On day 2 of admission patient was intubated due to worsening Type 1 Respiratory Failure. Bronchoalveolar lavage showed moderate volume of blood-tinged secretions and blood clots.

On day 4 of admission Clarithromycin was empirically switched to Doxycycline. Over the next 3 days, FIO2 and vasopressor requirements started to show a down trending pattern and patient was extubated on day 7. CXR revealed improvement of the diffuse pulmonary opacities seen on admission.

On day 8 of admission PHE RIPL reported positive serological tests for Leptopira immunoglobulin M. Antibiotics were narrowed to Doxycycline and Ceftriaxone.

Patient was discharged from critical care on day 10 of admission and discharged home on day 13.

Retrospectively, when the patient was questioned about occupational or recreational risk factors that may have placed him at risk of infection, he admitted to being in close contact with homeless individuals and would regularly dwell in alleyways.

Conclusion: In our case the disease evolved in a classic biphasic manner leading to the more severe form of leptospirosis; Weil’s disease. This case illustrates that a high index of suspicion is required for timely initiation of antibiotic treatment which can prevent progression of disease and lead to favourable outcomes as demonstrated by this case.

References

1. Public Health England. Leptospirosis. https://www.gov.uk/guidance/leptospirosis ( 2013, Last accessed 20 February 2022).

2. UK Health Security Agency. Common animal- associated infections: 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1052425/hpr2021-zoos-q4-2021.pdf (2021, accessed 20 February 2022).

3. Leptospirosis. https://www.amboss.com/us/knowledge/Leptospirosis (2021, Last accessed 5 February, 2022).

4770

Helping Hands

Samuel Cooke, Mattew Powell

Leeds Teaching Hospitals

Leeds Teaching Hospitals, [e-mail]

Abstract

Introduction: We work in a large, tertiary Teaching Hospital Critical Care unit. As such we have a sizeable and diverse workforce from multiple professional backgrounds. We noted both anecdotally, and from the formal process of Exit Interviews that the changes imposed by the Covid-19 pandemic were impacting on team relationships. Physical barriers enforced by social distancing, as well as the burden of increased patient numbers and changes to job roles had driven apart nursing and medical teams.

Critical care appeals to many staff because of the MDT and the chance to work with highly qualified, ambitious colleagues with varying skill sets. Nurturing this positive working relationship between different teams requires a commitment from all to share the burden of increased pressures wherever possible.

Objectives: The aims for this project are to identify specific areas within the working relationship between the medical team and the nursing team that can be improved. More than this, we want to open wider conversation about how teams can work more collaboratively for the benefit of the working environment, staff mental health and ultimately the patient.

Methods: We created an e-survey with input from the critical care matrons and psychologists before distributing amongst nursing staff. Questions focused on communication, practical support and the general working relationship. Each section contained MCQ’s and white space questions to allow us to collect both quantitative and qualitative data. Following collection of responses we identified common themes that could be addressed and created an eye-catching poster with specific suggestions for the medical team.

Results: Communication: Common themes were more presence on the unit with more regular walk-rounds and that STAT medications are often prescribed but not communicated to the nurse at the bedside and are therefore delayed.

Practical support: Common suggestions were helping with repositioning patients and relieving breaks. Others included, pulling blood gases, printing off blood request forms and working in pairs for lines so that the nurse doesn’t have to be engaged.

Working relationship: suggestions mainly focused around introducing ourselves and level of training as well as social integration of the two teams. A few said that improving the communication and assisting with tasks would feed into improving the relationship. A few also said that the survey itself was a good start.

Discussion: The survey generated many useful suggestions as well as demonstrating an open and receptive attitude. Responses were used to create a poster that gives clear and practical advice to the medical team. This method is easily reproducible and we believe that we have already seen positive changes that have been widely well received. We plan also to send a follow up survey once changes have become ingrained into the culture of the workforce.

Acknowledgements

Matthew Powell

Jane Atkins

Nathan Shearman

Helen Horton

4765

Is there an increased incidence of bacteraemia among COVID-19 patients requiring critical care admission who have received IL-6 inhibitors?

Matthew Packer, Pankaj Lal, Ingeborg Welters, Barbara Borgatta, Emma Fadden, Clare Sales, Matthew Packer

Liverpool University Hospitals NHS Foundation Trust

Liverpool University Hospitals NHS Foundation Trust, [e-mail]

Abstract

Is there an increased incidence of bacteraemia among COVID-19 patients requiring critical care admission who have received IL-6 inhibitors?

Introduction: Interleukin-6 (IL-6) inhibitors have been shown to reduce mortality in hospitalised COVID-19 patients. There is, however, concern that induced immunosuppression may increase the risk of secondary nosocomial infection.

Objectives: Our primary aim was to determine if there was increased incidence of bacteraemia in COVID-19 patients requiring critical care admission who had received IL-6 inhibitors compared to those who had not.

Methods: A retrospective review of all COVID-19 admissions to two critical care units in Liverpool from 4th March 2020 to 31st October 2021. Patients were divided into those who received an IL-6 inhibitor (sarilumab or tociluzimab) and those who did not. Hospital antimicrobial policy was to administer a five day prophylactic course of co-amoxiclav and clarithromycin for patients with severe COVID-19 during the study period. Blood culture results from 14 days before admission to critical care and 90 days after admission were included. The blood culture results comprised cultures taken in both critical care and on the wards. Data were linked and analysed using Stata V15.1 (StataCorp, Stata Statistical Software: Release 15, College Station, Texas, USA).

Results: 894 patients were included in the study. 134 patients had at least one positive blood culture result. The most commonly identified pathogens were Coliforms (23/134, 17.2%), Enterobacter (22/134, 16.4%) and Escherichia coli (16/134, 11.9%). Of patients administered an IL-6 antagonist, 16.8% (114/565) developed a positive blood culture compared to 11.6% (20/172) who did not, p=0.096. We did not observe an increased frequency of antimicrobial resistant culture in the IL-6 administered group 22.8% (26/114) vs. 20.0% (4/20) in this cohort, p=0.781. Data have not been adjusted for demographic and clinical factors in this preliminary analysis.

Conclusions: We observed a trend toward increased frequency of blood culture positivity in patients administered an IL-6 antagonist within this COVID-19 positive cohort but this was not statistically significant. Further analysis is required to adjust for relevant demographic and clinical factors.

4764

Communication with patient’s relatives in ICU: how can we improve the process?

Marrion Abong, Sandra Gelvez-zapata

East and north Hertfordshire NHS Trust, Lister Hospital

East and north Hertfordshire NHS Trust, Lister Hospital, [e-mail]

Abstract

Introduction: The unanticipated admission of a patient to the intensive care unit (ICU) can be particularly frightening and stressful for their family members. The most important need identified by the family members is the need for assurance, followed by information, proximity, comfort, and support.

The family members of patients admitted to ICU have elevated levels of needs in the assurance, proximity, and information dimensions that require to be addressed. This should guide the development of connection, effective communication, and beneficial cooperation toward offering the best possible care and support to ICU patients and their relatives. We conducted this audit to evaluate the communication process in our ICU.

Objectives:

• To determine how often we give updates to patients’ families and how soon we give the update from the time they were admitted to ICU

• To make some improvements surrounding communication with patients and their families – avoid misinformation and misunderstanding

• To minimize complaints received regarding poor communication

• To improve the overall standard of care that we deliver

Methods: 15 patients’ notes were reviewed. Only patients were admitted for more than 10 days in ICU from March to April 2021. We collected date and time of admission, date and time of the first update, date and time of succeeding updates until the 10th day of admission, and who has done the update.

Results: For the first update: 9 were done by nurses, 2 by consultants, 2 by registrars, and 2 by SHO’s. In terms of time from admission to the first update: 9 were done within the first 6 hours of admission, 3 between 6 to 12 hours of admission, 2 between 12 and 24 hours of admission, and 1 after 24 hours of admission.

67.57% of all updates were done by nurses, 16.22% by consultants, 8.11% by registrars, and 8.11% by SHO’s.

Assessing the quality assessment/ details of the updates, most of the updates done by the consultants and registrars happened when the patient has significantly deteriorated, ended up intubated, or when the patient was imminently dying. On a regular basis, the nurses do most of the family updates – which is acceptable.

Conclusion: The vast majority of the updates were done in the first 6 hours of admission which was acceptable but not ideal. Based on this, we proposed to include a family update as part of the plan when the patient is admitted (write in the admission clerking) to do it in the first 6 hours after admission, to include a tick box in the ward round proforma about family update to remind the doctors about it, document in the ward round notes the specifics of what to discuss with the relatives, for very ill patients, schedule the routine phone calls to avoid missing it and ensure that all discussions/updates are documented in the green communication sheets. We are in the process of changing the ward round proforma but in the meantime, the communication with the relatives has subjectively improved. We will re-audit 4 months after the proforma will be updated.

References

1. TAlsharari AF. The needs of family members of patients admitted to the intensive care unit. Patient Prefer Adherence. 2019;13:465–73.

2. Azoulay E, Kentish-Barnes N. A 5-point strategy for improved connection with relatives of critically ill patients with COVID-19. Lancet Respir Med. (2020) 8:e52. 10.1016/S2213-2600(20)30223

4761

QR cure

Kevin Scott¹, Luke Dornan¹, Kevin Gervin¹, Linda-Jayne Mottram²

¹ NHS

² Belfast Health and Social Care Trust

NHS, [e-mail]

Abstract

Introduction: Clinical protocols contain a wealth of information regarding the recognition and management of commonly encountered clinical emergencies in critical care. However, staff may not be aware of departmental emergency protocols or be aware how to access this information in a timely manner when reviewing critically unwell patients at the bedside. This may in turn contribute to extraneous cognitive load in already high stress, high stakes scenarios.

Quick Response (QR) codes have become an increasingly popular and familiar way to access specific information on mobile devices. Their use has become widespread in recent years. We present a novel and innovative way of using QR codes to increase awareness and improve accessibility of clinical protocols for all members of staff.

Objectives: To investigate the effectiveness of Quick Response codes as a means of improving awareness of and access to departmental clinical protocols.

Methods: Quick Response codes were generated for emergency protocols used in the Regional Intensive Care Unit in Belfast Royal Victoria Hospital. These QR codes were then organised on to a poster categorised by body system and displayed in high traffic areas within the clinical environment for use by all members of the multi-disciplinary team. Clinical staff were surveyed with a pre and post intervention questionnaire on their awareness of emergency protocols in the intensive care unit and their accessibility.

Results: Preliminary analysis suggests the use of the QR codes has improved awareness and accessibility of time critical protocols across the multi-disciplinary team including medical, nursing and physiotherapy staff. We conclude that with improved accessibility to departmental standardised protocols, emergency interventions were able to be undertaken more quickly and thus we would expect improved patient outcomes.

4760

Implementation of Neuron Specific Enolase (NSE) for multimodal prognostication after cardiac arrest

Maximillian Balogac, Olivia Don, James Williams, Olivia Hayward

NHS Wales

NHS Wales, [e-mail]

Abstract

Introduction: Approximately 2/3 of patients surviving critical care admission and experiencing coma following an out of hospital cardiac arrest (OHCA) will die of hypoxic-ischaemic brain injury. Withdrawal of life sustaining treatment following poor neurological outcome occurs in >66% of OHCA and 25% of in-hospital cardiac arrests. Prognostication is complex, using a multimodal approach of clinical, biochemical, radiographical and neurophysiological tests.

The 2021 guidelines from the European Resuscitation Council and European Society of Intensive Care surrounding post resuscitation care highlight the role of NSE as part of this process.

NSE is a protein biomarker released from neurons following injury, with high levels suggestive of neuronal cell damage. It has been recommended as a predictor of poor neurological outcome following cardiac arrest.

The adoption of this recommendation was the focus of this QI project.

Objective: Agreeing a local protocol for the use of NSE in neuro-prognostication, and auditing adherence via plan-do-study-act (PDSA) cycling in a South Wales ICU.

Method: A literature review and discussion and agreement with local biochemistry services were the first steps in the production of a NSE neuro-prognostication protocol. A proforma was introduced, with testing recommended at 48 and 72 hours post return of spontaneous circulation (ROSC). It was presented at a departmental quality and safety (Q&S) meeting and agreed upon prior to its implementation.

As part of the first PDSA cycle, ICNARC data was used to identify all post-cardiac arrest patients admitted to ICU in the previous 30 days. A notes and electronic blood results system review was performed to assess time of ROSC, NSE sample times and results, and patient outcomes. Compliance with NSE protocol and proforma completion were reviewed.

Results: In this first PDSA cycle, 8 sets of patient’s records were examined. In 3, NSE was not sent due to early neurological recovery, or resuscitation being ceased. Of the remaining 5; NSE was sent correctly at 48 hours in one case and none at 72 hours. In 2 of 5, the proforma had been filled out, although these patients died before the first sample was taken. 2 patients had samples rejected by the laboratory; one patient had 6 samples taken at variable timepoints and the other experienced sample haemolysis, from failure to alert the laboratory of sample taking.

Conclusion: This PDSA cycle revealed that NSE sampling compliance was increasing but had not achieved a satisfactory standard. This was likely due to a lack of awareness of the new protocols and proformas. Barriers identified to the implementation are the dissemination of information to a large unit with changing work force and the time lag to feedback audit cycles.

The results were presented at a departmental Q&S meeting and feedback distributed via nursing and trainee social media/WhatsApp groups.

Educational resources (see below) were produced and distributed to all staff groups. Further work on improving PDSA feedback is ongoing via the employment of a data manager to improve methods. A second cycle is in progress to assess if these interventions have improved awareness and accuracy of NSE sampling.

4759

Nurses’ knowledge, perceptions, and challenges of caring for intubated adults with light sedation: A Qualitative Approach

Muna Al-Tamimi¹, Tony Long², Lyvonne N Tume³

¹ University of Salford Manchester UK, School of Health & Society

² University of Salford, SALFORD M6 6PU, School of Health & Society

³ University of Salford, Manchester UK, School of Health & Society

University of Salford Manchester UK, School of Health & Society, [e-mail]

Abstract

Background/Introduction: The move to having intubated patients less sedated has led to better outcomes: shorter length of intensive care stay, lower mortality, and less delirium.^1–2 However, for nurses, safely managing more awake patients can be challenging may impact on nursing workload and adverse events.^3–4 Few studies, and none in the United Arab Emirates (UAE) have explored nurses’ experiences of caring for lightly sedated adults.

Objective: To explore nurses’ knowledge, perceptions, and challenges of caring for mechanically ventilated patients with light sedation in adult ICUs in the United Arab Emirates (UAE) where the fixed RN to patient ratio is 1:2.

Method: A pragmatic qualitative approach was conducted using semi-structured, individual face-to-face interviews in four different intensive care units at the United Arab Emirates (UAE). Registered nurses who had cared for lightly sedated mechanically ventilated adults were invited to take part in the study. Interviews were audio-recorded and transcribed verbatim by the research team. Data were coded and analyzed thematically.

Results: Sixteen nurses participated from four adult ICUs in the UAE. Preliminary analysis highlights an overarching theme “the impact of light sedation on nurses and patients” Most nurses believed that light sedation had positive effects on patients, such as faster recovery, shorter length of stay. Nurses described caring for intubated, lightly sedated patients in terms of higher workload and possible adverse events. Patient distress, unplanned removal of lines and self-extubation were major concerns that were perceived to have a negative impact on patient safety. In addition, nurses cited concerns over ‘missed nursing care’ for the other assigned patient that increased the nurses’ feelings of frustration and dissatisfaction. Effective team working during the shift appears to have a vital role in managing stressful moments that nurses encounter when unintendedly missing the care of other assigned patients. Communication barriers formed another challenge in increasing nurses’ and patient’s frustrations. Most nurses emphasized the need for a 1:1 RN: patient ratio to allow them to adequately care for lightly sedated patients. Many nurses described how family involvement in a patient’s care was beneficial in lessening the patient’s anxiety. However good family education and more liberal visiting hours was required for the family to effectively support the patient.

Conclusion: This study revealed some challenges of caring for lightly sedated intubated patients in the UAE context with limited family visiting hours and a lower than 1:1 RN patient ratio. This requires some in the current ICU family policy, and that the nurse-to-patient ratio need to be reconsidered. Education about managing lightly sedated patients might also be beneficial as few had received any training on this. Further research is required to ascertain the impact on this on nursing workload in the UAE context.

Declarations

This is a self-funded PhD being undertaken at the University of Salford, Manchester UK.

References

1. Groetzinger LM, Rivosecchi RM, McVerry BJ, Smithburger PL, Lamberty PE, Donahoe MP, et al. A Quality Improvement Evaluation of a Primary As-Needed Light Sedation Protocol in Mechanically Ventilated Adults. Crit Care Explor. 2020;2(12): e0264.

2. Ranzani OT, Simpson ES, Augusto TB, Cappi SB, Noritomi DT, Vicente E, et al. Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: A quality improvement multicenter project. Crit Care. 2014;18(5).

3. Tingsvik C, Bexell E, Andersson AC, Henricson M. Meeting the challenge: ICU-nurses’ experiences of lightly sedated patients. Aust Crit Care [Internet]. 2013;26(3):124–9. Available from: http://dx.doi.org/10.1016/j.aucc.2012.12.005

4. Bäcklund K, Persson K, Hadziabdic E. Intensive Care Nurses’ Experiences of Caring for Intubated Patients under Light Sedation: A Qualitative Study. Open J Nurs. 2018;08(07):473–84.

4757

Implementing an extubation checklist in critical care

Jamie Hooker, Rachael Robertson

NHS Ayrshire and Arran

NHS Ayrshire and Arran, [e-mail]

Abstract

Introduction: Extubation and the peri-extubation period represent a time of high-risk for patients within their critical care journey. Complicated by factors such as critical illness myopathy, airway oedema and impaired conscious levels, rates of failure and the need for re-intubation within 48-hours are as high as 25%.¹ In order to improve patient safety, the Faculty of Intensive Care Medicine recommends the use of extubation checklist.² Prior to this quality improvement project, no formal extubation checklist was in use in the intensive care unit (ICU) at University Hospital Crosshouse.

Methods: Planned extubations were audited over a period of one week to assess for use of an extubation checklist and for any post extubation complications, including failure. A literature search was used to identify any existing extubation checklists for use in ICU which were adapted for use within University Hospital Crosshouse. Following the introduction of an extubation checklist, planned extubations were re-audited over a period of a week using the same criteria as initial audit.

Results: A checklist was used in 0% of six planned extubations at initial audit. We introduced an extubation checklist which was attached to airway trolleys within the ICU, and raised awareness at the weekly departmental multidisciplinary team meeting. Following this, 75% of extubations at repeat audit were performed using the extubation checklist.

Conclusions: Prior to implementing an extubation checklist in the ICU at University Hospital Crosshouse the failure rate was double that typically quoted. This improved by 50% post intervention. Both pre and post intervention results highlight incomplete documentation of NG aspiration prior to extubation, suggesting the need for further quality improvement to address this.

References

1. Glover, Glossop (2017) Managing Extubation and the Post Extubation Period in the Intensive Care Unit. Respir. 2017;5[1]:85-91.

2. FICM (2019) Guidelines for the Provision of Intensive Care Services. (Online). Available at: https://www.ficm.ac.uk/standardssafetyguidelinesstandards/guidelines-for-the-provision-of-intensive-care-services (Accessed 20/02/2022).

4756

Evaluation of local sedation hold practice and Creation of Sedation Hold Improvement Pathway (SHIP)

Rachel Saunders¹, Alison Evans¹, Clare Smedley²

¹ Countess of Chester

² Whiston

Countess of Chester, [e-mail]

Abstract

Introduction: The majority of critically ill patients admitted to Intensive Care require sedation and analgesia to facilitate the management of their underlying acute illness, however as their condition stabilises it is common to hold sedation agents. Sedation holds have been demonstrated to decrease ITU length of stay, number of days mechanically ventilated¹ and risk of pneumonia.² Practising daily sedation holds is consequently recommended across the literature and has been incorporated into the ventilator care bundle,³ with 90% of Intensive care units reporting using a daily sedation hold.⁴

A 2008 National Survey⁵ demonstrated that 80% of the surveyed units used a sedation guideline and 88% used a sedation score to guide this, such as the Richmond Agitation Sedation Scale (RASS) or the Ramsay Sedation Scale. These guidelines and scores focus on choice of sedation agent, scoring of the level of sedation and timing of sedation hold, but not the process itself. An overlooked element of the sedation hold is a holistic examination of the patient to ensure there are no underlying signs or symptoms of conditions, or new diagnoses that may be inhibiting progression. On literature review there are no utilised tools available to provide a method of examining the patient during a hold and documenting progress to facilitate comparisons between earlier sedation holds.

Objectives: To review the current sedation practices of our ITU including sedation break frequency and the assessment made of the patient on each sedation hold. Based on the results of the review and a review of the current literature, we aimed to create a sedation hold proforma to guide this process.

Methods: We retrospectively audited 30 sedation holds on the Intensive care unit in Countess of Chester between 10th August - 10th September 2020. Collected data included length of sedation hold, evaluation of documentation process, examination performed and outcome of the hold.

We reviewed the literature published between 2000- 2021 to guide the creation of our Sedation Hold Proforma.

Results: On our unit 11 patients accounted for the 30 sedation holds audited across the 1 month period (Table 1). In general we found that documentation of the examination process itself was poor with many areas of improvement possible.

Conclusions: The detrimental effects of oversedation has been demonstrated across the literature, however a consensus regarding the best way to assess and wean from sedation has not been achieved. Our audit of the current sedation hold process demonstrated a lack of documentation of assessment or examination performed, and often it was unclear if a sedation hold had occurred. The reasons identified are multifactorial including unclear sedation hold instructions or assessment given on ward round, juniors unsure how best to assess the patient and sometimes no doctor is present when the sedation hold occurs. This reinforces the need to create a proforma to guide this process and facilitate sedation hold practice. Based on the results of the audit and our review of the literature, we devised a Sedation Hold Proforma.

References

1. Rowe K and Fletcher S. Sedation in the Intensive Care Unit. Continuing Education in Anaesthesia Critical Care & Pain 2008; 8: pp. 50–55.

2. Jackson DL, Proudfoot CW, Cann KF and Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care 2010; 14: pp. R59.

3. Department of Health. Saving lives: reducing Infection, delivering clean and safe care. London: Department of Health; 21 June 2007.

4. Richards-Belle A, Canter RR, Power SG, Robinson EJ, Reschreiter H, Wunsch H, Harvey SE. National survey and point prevalence study of sedation practice in UK critical care. Crit Care 2016; 20: Article number 355.

5. Reschreiter H, Maiden M and Kapila A. Sedation practice in the intensive care unit: a UK national survey. Crit Care. 2008; 12(6): pp. R152.

4755

Displaced mandibular reconstruction plate: Challenging the airway

Gayan Dissanayake¹, Ashani Ratnayake²

¹ University Hospitals of Northamtonshire, Kettering, United Kingdom

² Dental Hospital (Teaching), Peradeniya, Sri lanka

University Hospitals of Northamtonshire, Kettering, United Kingdom, [e-mail]

Abstract

Displaced mandibular reconstruction plate: Challenging the airway

Gayan Lakmal Dissanayake⁽¹⁾, Ashani Ratnayake⁽²⁾

⁽¹⁾Trust grade registrar in Anaesthesia and ICU, University hospitals of Northamptonshire, Kettering, United Kingdom

⁽²⁾Consultant Anaesthetist, Dental Hospital (Teaching), Peradeniya, Sri Lanka

Introduction: Difficult airway situations are common in Oro-maxillary facial (OMF) surgeries. Primary oral pathology and treatment like radiotherapy (RT) contributes to have a difficult airway. They may need repeated surgeries with implants. This is a case report of a patient who presented for an OMF surgery with a displaced mandibular plate challenging the airway.

Case report: A 55 year old lady presented with a displaced mandibular reconstruction plate. She had undergone removal of floor of the mouth squamous cell carcinoma with partial mandibulectomy followed by staged reconstruction with humeral graft and mandibular reconstruction plate. Patient had a tracheostomy and was decannulated before undergoing RT to the neck. 6 months later she presented with displaced mandibular reconstruction plate, limiting mouth opening and swallowing (figure 1 ) with limited neck extension (figure 2) A surgery was planned for plate removal and tracheostomy till a definitive procedure is performed.

Figure 1.

Front view of displaced mandibular plate.

Figure 2.

Side view showing the displaced mandibular plate and neck scarring.

On airway assessment patient had limited mouth opening due to fixed immobile plate with limited neck extension. She was drooling as she was unable to swallow increasing risk of aspiration. As conventional intubation was impossible an awake fibre optic intubation was planned. Plan B was the surgeon to cut the plate and try awake videolaryngoscopy. Awake tracheostomy under local anaesthesia was not considered as the first line due to anticipated technical difficulty and increased risk of bleeding with previous tracheostomy and neck RT.

The patient had an awake fibre optic intubation with routine preparations, high flow nasal oxygen and sedation with TCI remifentanil with some difficulty due to secretions. Planned surgery was performed uneventfully.

Discussion: Prevalence of difficult airway can be as high as 15-16,7% in OMF surgeries.¹ The use of awake tracheal intubation has changed this picture as it is one of the first line of airway management plans in difficult OMF surgeries.² Following the new guidelines³ with adequate airway topicalisation, using high flow nasal oxygen and titrated sedation with TCI remifentanil will increase the success rate of the procedure in experienced hands. However alternative plans for the airway management should be drawn prior to attempting awake tracheal intubation. In most of the situations, the back up plan would be to perform tracheotomy under local anaesthesia. However in our patient awake tracheostomy would have been difficult. Therefore we needed to have an alternative plan for the airway. After the discussion with OMF surgeons a plan was made to cut the mandibular plate allowing insertion of the video laryngoscope.

Conclusion: Difficult airway scenarios are common in OMF surgeries and most have become possible due to awake tracheal intubation techniques. Backup plans has to be drawn before hand in patients with challenging airways to avoid unexpected complications.

References

1. Tuzuner-Oncul AM, Kucukyavuz Z. Prevalence and prediction of difficult intubation in maxillofacial surgery patients. J Oral Maxillofac Surg. 2008;66: 1652–1658. doi: 10.1016/j.joms.2008.01.062.

2. Jaisani MR, Pradhan L, Bhattarai B, Sagtani A. Intubation techniques: preferences of maxillofacial trauma surgeons. J Maxillofac Oral Surg. 2015;14(2):501-505. doi:10.1007/s12663-014-0679-8

3. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/abs/10.1111/anae.14904

4754

Inter-Hospital Transfers of Critically Ill Patients: Next-of-Kin communication & documentation of reason for transfer: An observational Audit

Oliver Williams

William Harvey Hospital ITU (Ashford, Kent)

William Harvey Hospital ITU (Ashford, Kent), [e-mail]

Abstract

Introduction: Transfer of critically ill patients between hospitals is very common, with over 70 taking place at a 16-bed district-general-hospital ITU in 2021. This usually is required when a patient needs to receive more specialist care or is returning from an area where specialist care has been carried out. Interhospital transfers carry with them a certain risk, either in the form or physiological deterioration during transit or potential equipment failure. It is therefore important that reasons for transfer and proper evaluation of risks and benefits are clearly documented in the patient notes. This information should also be discussed with the patient or the patient’s next of kin prior to transfer.

Guidelines for the provision of Intensive Care Services (GPICS) recommend the following:

• GPICS recommendation 3.10.2:

The reason for any transfer should be documented in the patient’s notes. This should include an assessment of potential benefits against risks. Transfer decisions should only be made by consultant intensive care team members, and this information should also be documented.

• GPICS recommendation 3.10.8:

The patient, where possible, and their next-of-kin should be informed of the decision to transfer, and an explanation given to them of the need for transfer. This discussion should be documented.

Objectives: To observe the number of patients transferring from a 16-bed ITU in 2021 who’s notes where compliant with GPICS recommendations.

Methods: Patient notes were checked for all patients who were discharged from the ITU in 2021 from January to October. This included patients on both non-clinical and clinical transfers. There were no exclusion criteria. Documentation was verified from daily review sheets and discharge summaries. If the relevant documentation was included in at least one of these, a positive result was logged.

Data was collected considering the criteria listed below: -

GPICS3.10.2:

1. Reason for transfer documented in the patient’s notes.

2. Assessment of potential benefits against risks

3. Transfer decision made by a consultant ICU team member and this information documented.

GPICS3.10.8:

1. The patient informed of the decision to transfer

2. The next of kin informed of the decision to transfer

3. Explanation given to the patient of the need to transfer

4. Explanation given to the next of kin of the need to transfer

Results:

Total number of transfers	65
Non-Clinical transfers	22
Clinical transfers	43

Conclusion:

The observational data demonstrates the GPICS recommendation 3.10.2 was only achieved in 28% of cases. The most common reason for this was that risks and benefits of the transfer were very rarely documented (only 30% of the time). If this factor were removed the standard would have been met in 79% of cases.

GPICS recommendation 3.10.8 was achieved in 52% of the cases. It is possible that this is underestimated, and that communication is taking place but not being documented.

The proposed solution to improving adherence to these standards introducing a proforma to be completed prior to each transfer that would ensure each of the above elements is being documented.

4753

Biomarkers of Mitochondrial Dysfunction and Acute Respiratory Distress Syndrome: Systematic review and meta-analysis

Catherine McClintock, Niamh Mulholland, Bronwen Connolly, Cecilia O’Kane, Danny McAuley, Anna Krasnodembskaya

Queen’s University Belfast

Queen’s University Belfast, [e-mail]

Abstract

Introduction: Acute respiratory distress syndrome (ARDS) is a principal cause of Intensive care unit (ICU) morbidity and mortality. Metabolic biomarkers of mitochondrial dysfunction are correlated with disease development and high mortality in many respiratory conditions, however it is not known if they can be used to assess risk of mortality in patients with ARDS.

Objectives: The aim of this systematic review is to examine the link between recorded biomarkers of mitochondrial dysfunction in ARDS and mortality.

Methods: A systematic review of CINAHL, EMBASE, MEDLINE, and Cochrane databases was performed, following Cochrane methodology. Studies had to include critically ill ARDS patients with reported biomarkers of mitochondrial dysfunction and mortality. Information on the levels of biomarkers reflective of energy metabolism and mitochondrial respiratory function, mitochondrial metabolites, coenzymes and mitochondrial deoxyribonucleic acid (mtDNA) copy number was recorded.

No exclusions were applied to study design, cohorts ranging from 1-800 patients. RevMan5.4 software random effects model was used to analyse data significance and heterogeneity. Cochrane risk of bias tool and Newcastle-Ottawa scale were used to evaluate publication bias. (Prospero protocol registration: CRD42022288262)

Results: Twenty-three studies were included in the systematic review and seven had raw data available for follow up meta-analysis. Biomarkers of mitochondrial dysfunction included mtDNA (eight studies), lactate (four studies), glutathione (four studies), Nox2 (one study), HMOX2 (one study), Glycolysis protein expression (one study), hydrogen peroxide and lipid peroxidation markers (nine studies). High levels of mtDNA in patient plasma/ BAL were associated with higher risk of mortality (p<0.00001) (Fig1A). Elevations in mtDNA were also associated with the severity of patient ARDS, but not to levels of significance (p<0.07) (Fig1B). Remaining biomarkers demonstrated positive correlation of biomarker concentration with ARDS disease severity in study figures; however, raw data was not available for our own statistical analysis. Publication bias for key biomarker mtDNA remained low across the spectrum of studies included.

Conclusions: Increased levels of biomarkers of mitochondrial dysfunction are positively associated with ARDS disease. Plasma mtDNA levels are most often used as a biomarker of mitochondrial dysfunction.

Figure 1.

A) Significant association of higher mtDNA levels in ARDS patients compared to Healthy patients. b) Significant association of higher mtDNA levels in ARDS patients survivors compared to ARDS patient non-survivors. A forest plot meta-analysis of the levels of mtDNA in ARDS patients and healthy controls. Three studies provided data available for analysis. Data analysis generated on RevMan 5.4. Significance standard mean difference concluded was retrospectively; P<0.00001 and P<0.07.

4752

‘Critical Concepts’: Development of an online Introduction to Intensive Care lecture series

Christopher Pennington, Ben Evans

Health Education North East

Health Education North East, [e-mail]

Abstract

Introduction:

Background: Intensive Care Learning in the North East is a group of intensive care doctors in the North East of England, passionate about education in ICM.¹ The SARS-CoV-2 pandemic has necessitated social distancing and disrupted traditional in-person courses. However, this has borne opportunities for virtual courses delivered to a national audience.²

Course content: We describe the second iteration of an eight-part online and interactive lecture series entitled ‘Critical Concepts: An Introduction to Intensive Care’. The lectures focus on the A-E management of the critically ill patient, with additional sessions on ‘Return of Spontaneous Circulation’, and ‘Applications and Careers in ICM.’ The lectures were delivered fortnightly via Zoom,³ and consist of a 45-minute lecture followed by a 45-minute break-out room to discuss interactive cases with a facilitator and four participants. The lectures were available for two weeks on YouTube⁴ via private link, to enable participants to catch-up if not able to attend.

Objectives: We wished to examine the effectiveness and quality of our lecture series through a pre-course and a post-course questionnaire. We designed the questionnaire to elicit qualitative and quantitative feedback from the participants.

Methods: We invited the 60 course participants to fill in a pre- and post-course questionnaire, and received 28 and 51 responses respectively.

Results:

Participant demographics:

25% of delegates were in FY1, 75% were in FY2. 50% had no prior experience of working in an ICU, 21.4% had worked in an ICU during FY, 28.6% had undertaken a Taster Week in ICU.

Quantitative results:

• ‘How would you rate your current apprehension regarding redeployment to ICU?’ (1 - very apprehensive; 5 - not apprehensive), the mean self-rating prior to the course was 2.54, and following completion of the course was 3.51.

• ‘How would you rate your understanding of what happens in an ICU?’ (1 - very poor understanding; 5 - very good understanding), the mean self-rating prior to the course was 2.75, and following completion of the course was 4.00.

• ‘How confident do you feel in discussing escalation of care with critical care staff?’ (1 - not confident at all; 5 - very confident), the mean self-rating prior to the course was 3.00, and following completion of the course was 4.04.

YouTube catch-up

The mean number of weeks that participants were able to attend in real-time was 4. 4 participants were able to attend all weeks, 78.8% of participants missing at least 1 week were able to catch-up on all weeks using YouTube, 21.2% were able to catch-up on some weeks, and no participants did not use this facility.

Conclusions: We have demonstrated that our online teaching course has improved understanding of the care delivered on ICU, and reduced apprehension surrounding working in ICU and discussing patients with colleagues. We have demonstrated that YouTube is a free and well utilised method to enable to enable participants to catch-up on lecture content they were unable to attend in real-time. We believe that courses such as this will remain as Covid-19 restrictions are lifted.

References

1. https://www.a-line.org.uk/i-line/

2. Dost S, Hossain A, Shehab M, et al. Perceptions of medical students towards online teaching during the COVID-19 pandemic: a national cross-sectional survey of 2721 UK medical students. BMJ Open 2020; 10:e042378. doi: 10.1136/bmjopen-2020-042378

3. https://www.zoom.us/

4. https://www.youtube.com/

4750

Improving safety of doctor to doctor handover in the emergency department using a standardised electronic tool

Mohamed Ramadan, Emily Reid, Christine Loughran, Laura Wilson, Emma Greenwood

Belfast Health and Social Care Trust

Belfast Health and Social Care Trust, [e-mail]

Abstract

Introduction: Effective handover is crucial to patient safety, and breakdowns in communication are well known contributing factors to adverse events in hospitals.¹ It is well recognised that there is a lack of formal training and standardisation of the format and structure of handover in healthcare.² This leads to a lack of confidence amongst staff, and a potential vulnerability in patient safety. Utilising a standardised tool has been shown to improve physician confidence and efficiency at handover in similar quality improvement projects.^3–4

Objective: To improve the safety of doctor-to-doctor handover within the Emergency Department, and the confidence of the clinicians involved.

Methods: All medical staff working in the Royal Victoria Hospital (Belfast) Emergency Department were invited to partake in qualitative research, employing an online questionnaire for data collection. Participants were asked to comment on any handover formats they were aware of, their confidence in the current handover format and the safety of doctor-to-doctor handovers in the Emergency Department. Responses were collected using Likert-type questions and free text comments.

Results: 50 responses were collected, ranging from consultant level (28% of responses) to foundation doctors (18% of responses). There was a variety of experience amongst participants, with 54% having greater than five years experience working in Emergency Medicine, and 24% having no previous experience. 28% of participants did not feel confident receiving a safe and effective handover. The majority of participants (40%) reported handing over a patient every two to three shifts and 6% reported handing over a patient less than once a month. The latter commented that they would rather stay late than handover unfinished tasks due to their concerns about handover safety. When asked to comment on what makes a handover unsatisfactory, common responses included; poor communication, inadequate documentation and non-specific plans. These results were presented locally at the ED Consultants’ business meeting, and there was unanimous support for the inclusion of a handover tab to the patient tracking electronic application (Symphony) used in the department.

Conclusion: 96% of participants agreed that the handover process between doctors in the Emergency Department could be improved. Our team have designed a handover tab to add to the electronic patient tracking system (Symphony), which will aim to provide structure and format to the handover process. This will be implemented and further audit will take place to assess its suitability as a safe handover tool within the Emergency Department. Should the results be positive and the project successful, this handover tab will be included in the new regional electronic patient record (Encompass) which is to be introduced in Northern Ireland.

References

1. The Joint Commission. Sentinel Event Data: root causes by event type 2004-2014 (Accessed 25/2/2022).

2. Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J. 2012;29(12):941-946. doi:10.1136/emermed-2011-200199.

3. Sykes M, Garnham J, Kostelec PM, Hall H, Mitra A. Assessment and improvement of junior doctor handover in the emergency department. BMJ Open Qual. 2020 Aug;9(3):e001032. doi: 10.1136/bmjoq-2020-001032.

4. Kwok ESH, Clapham G, White S, Austin M, Calder LA. Development and implementation of a standardised emergency department intershift handover tool to improve physician communication. BMJ Open Qual. 2020 Feb;9(1):e000780. doi: 10.1136/bmjoq-2019-000780.

4749

Burnout and Wellbeing During the Second Covid-19 Wave: Are There Differences Between Medical Specialties?

Laura Kyle¹, Stephanie Edmunds¹, Luke Rutter¹, Tariq Ali², Richard Innes¹

¹ Somerset NHS foundation trust

² Somerset NHS foundation Trust

Somerset NHS foundation trust, [e-mail]

Abstract

Introduction: Burnout is common amongst clinical staff. Critical Care is widely accepted to have amongst the highest rates, with an incidence of >38%.¹ The Covid-19 pandemic placed unprecedented pressures on staff, making them vulnerable to burnout.² Although stressors were similar across medical teams, we suspected there were differences in burnout between medical specialties.

Objectives: This study aimed to examine burnout amongst the hospital MDT, focussing on three higher care clinical areas: Coronary Care (CCU), Respiratory (RSU) and Critical Care (ICU) and identify recurring positive and negative experiences.

Methods: Between March and April 2021 staff were invited to complete a two-part survey. Part one investigated demographic data and free text answers on feelings towards Covid-19. Part two questioned recipients on the 22 questions of the MBI –HSS (Maslach Burnout Index- Human Services Survey).³ This survey assesses burn-out in three domains: Emotional Exhaustion (EE), Depersonalisation (DP), and lack of Personal Accomplishment (PA). MBI-HSS results were analysed and a previously used ‘high-risk’ cut-off was used to calculate percentages per domain and overall. Free text analysis was conducted by two researchers to identify common themes, protective factors and negative factors which may increase burnout.

Results: 148 staff members responded to the survey: 53% of respondents met the criteria for burnout in at least one domain. 58% of ICU staff, 42% of RSU staff and 44% of CCU staff were burnt out in one domain or more. ICU had the highest percentage of staff at high risk of EE and lack of PA. RSU had the highest percentage of staff scoring highly for DP.

Free text analysis demonstrated some positive experiences from the Covid-19 pandemic: teamwork, communication, resilience, and opportunities to learn new skills were highlighted by staff across all areas.

All areas found staffing and workload a negative factor. In ICU, workspace organisation and long shifts in PPE were key stressors which made communication and taking breaks safely difficult. Managing stress and uncertainty were highlighted by the ICU teams. In RSU, a significant proportion of staff found the lack of established treatments and poor outcomes difficult to manage, potentially highlighting the differences in Covid-19 management compared with ICU. As nursing staff work with higher ratios in RSU, some found managing patients’ needs difficult: “Not having enough time to care for patients’ basic needs . . . patients in side-rooms were left feeling isolated and scared”.

In CCU, there was a shift towards fear of catching the virus, PPE provision and poor infection control guidance, possibly arising from lower exposure to Covid-19: “It felt like the trust didn’t give a s**t about their staff with regard to PPE and vaccinations.”

Conclusion: All clinical areas highlighted increased teamwork as a positive outcome of the Covid-19 pandemic, and good relationships have been built, a known protective factor against burnout. Many negative factors have impacted the rate of burnout, including high workload, staffing issues, redeployment and managing death and uncertainty. We hope to resurvey the same areas to assess wellbeing one year on, and address key factors to improve wellbeing.

References

1. Vincent, L., Brindley, P. G., Highfield, J., Innes, R., Greig, P. & Suntharalingam, G. 2019. 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, 20, 363-369.

2. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic BMJ 2020; 368 :m1211.

3. Maslach C, Jackson SE and Leiter MP. Maslach burnout inventory manual. 4th edn. Menlo Park, CA: Mind Garden, Inc.,

4748

Management of tracheostomy emergencies in the Intensive Care Unit

Ultan Watson, Barbara Philips

University Hospitals Sussex NHS Foundation Trust

University Hospitals Sussex NHS Foundation Trust, [e-mail]

Abstract

Introduction: In the UK, 10-20% of Intensive Care Unit (ICU) patients undergo a tracheostomy, with a median admission duration of 23 days.^1–2 Tracheostomy tube displacement is the commonest adverse event associated with tracheostomies.³ It is more common than the ‘can’t intubate, can’t ventilate’ scenario.³ Half of airway-related deaths in ICU are reportedly due to tracheostomy tube displacement.³ Other complications include haemorrhage, tube occlusion and pneumothorax.⁴ Protocols for managing tracheostomy complications and appropriate staff training are recommended.^1–3 The National Tracheostomy Safety Project’s (NTSP) emergency algorithms are freely available, designed to be used for any patient inside or outside of the ICU, and by anyone, airway specialist or not.⁵ ICU patients ventilated via a tracheostomy are, however, a recognised subset of this population. They may be ventilator-dependent with high oxygen requirements, needing significant ventilatory support with diminished intrinsic respiratory drive. Consequently, the generic algorithm may not always be suitable for them.

Objectives: The aim of this study was to ascertain how confident and competent the ICU staff at University Hospitals Sussex (UHSx East sites), perceived themselves to be at managing tracheostomy emergencies and to propose an ICU-specific algorithm.

Methods: UHSx (East) has 43 Level 2 and 3 beds caring for 1,700 patients annually, including tertiary ENT and Neurosurgical referrals. On 10 days between April–November 2021, 20 adult patients with tracheostomies were reviewed to see whether the appropriate bedside equipment and protocols were present in case of a tracheostomy emergency.

An online questionnaire was emailed to the UHSx (East) ICU nursing body, Advanced Critical Care Practitioners, and doctors (of all grades). This sought to obtain qualitative and quantitative data regarding their experiences with these emergencies and whether an ICU-specific algorithm would be beneficial to their practice.

We adapted the NTSP’s ‘Emergency tracheostomy management’ algorithm to be ICU-specific.⁵

Results: Of the 20 patients reviewed, 17 (85%) had an individualised NTSP tracheostomy bedhead visible. 19/20 (95%) patients had a bedside ‘blue box’ (a self-contained box found at the bedside with replacement tracheostomies, a smaller size tracheostomy and inner tubes). 2/20 (10%) patients had the NTSP emergency algorithm visible.

65 staff responded to the survey. Graph 1 displays the breakdown of staff members. 46/65 (71%) had >12 months experience working in ICU; 43/65 (67%) had been directly involved in a tracheostomy emergency. The mean confidence of staff members in managing tracheostomy emergencies between 1 (Not confident at all) – 5 (Very confident) was 3.5. 42/42 (100%; Table 1 ) of staff stated that the presence of an ICU-specific tracheostomy emergency algorithm, alongside the standard patient-specific information about their tracheostomy and spare tracheostomy equipment at their bedside, would be beneficial in an emergency; 59/63 (91%; Table 2 ) reported it would improve their competence.

Figure 1 outlines the proposed ICU-specific tracheostomy emergency algorithm.

Conclusions: Tracheostomy care is common in the ICU; staff should be trained and supported to manage associated complications. This study suggests that an ICU-specific algorithm for tracheostomy emergencies may improve staff confidence and competence managing them. We plan to evaluate this ICU-specific algorithm and implement tracheostomy emergency management simulation training.

Graph 1.

Table 1.

Do you think having an emergency algorithm in addition to patient specific information about their tracheostomy and spare tracheostomy equipment at their bedside, would be beneficial in an emergency situation?
Yes	65/65 (100%)
No	0/65 (0%)

Table 2.

Do you think having an emergency algorithm in addition to patient specific information about their tracheostomy and spare tracheostomy equipment at their bedside, would improve your confidence and competence in an emergency situation?
Yes	59/65 (91%)
No	6/65 (9%)

References

1. UK National Tracheostomy Safety Project. Guidance For: Tracheostomy Care. 2020.

2. McGrath BA, Wallace S, Lynch J, Bonvento B, Coe B, Owen A, et al. Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. Br J Anaesth. 2020;125(1):e119–29. https://doi.org/10.1016/j.bja.2020.04.064

3. Cook TM, Woodall N, Frerk C. Major Complications of Airway management in the United Kingdom. Report and Findings. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. 2011. Available from: https://www.nationalauditprojects.org.uk/downloads/NAP4FullReport.pdf

4. McGrath BA, Wilkinson K. The NCEPOD study: On the right trach? lessons for the anaesthetist. Br J Anaesth. 2015;115(2):155–8. http://dx.doi.org/10.1093/bja/aev147

5. National Tracheostomy Project Resources. [cited 2022 Jan 16]. Available from: https://www.tracheostomy.org.uk/resources/documents

Figure 1.

4746

Evaluating a novel communication device for tracheostomy patients in the intensive care unit: a mixed methods feasibility study

Fiona Howroyd, Ruth Capewell, Charlotte Small, Catherine Snelson

University Hospitals Birmingham NHS Foundation Trust

University Hospitals Birmingham NHS Foundation Trust, [e-mail]

Abstract

Introduction: Communication with voiceless tracheostomy patients in the intensive care unit (ICU) is a well-recognised challenge.¹ Although there are Augmentative and Alternative Communication (AAC) devices available, there are a number of limitations to their effectiveness in the ICU, often causing further distress and frustration for both patients and staff.

To address this problem, a critical care survivor has developed a novel ‘high-tech’ AAC, named ICU-CHAT. ‘ICU Communication witH Acute Tracheostomy: ICU-CHAT’ is the first prototype version of a novel high-tech AAC device, developed for voiceless tracheostomy patients in the ICU. The device uses the integrated camera of a laptop monitor to track head movements in order to direct a mouse-pointer on the screen. The program interface has icons with common phrases that speak the written content; when clicked by hovering over the symbol using the head-tracking pointer (Figure 1). As the first prototype, the design elements are relatively simple to allow early evaluation of the ICU-CHAT in the clinical setting before further complexity can be incorporated.

Objectives: This preliminary study aimed to assess the usability and user acceptance of ICU-CHAT.

Methods: A mixed-methods feasibility design was used; recruiting alert, voiceless, tracheostomy patients, their communication partners and staff from an adult intensive care unit. In stage one patients completed a usability assessment with ICU-CHAT and all participants completed questionnaires. In stage two, once patients had return of voice, patients and communication partners were invited to complete a semi-structured interview. Thematic analysis of qualitative data was integrated with quantitative data to enrich understanding and inform design of future iterations.

Results: Over a six-month period, 24 tracheostomy patients met the inclusion criteria. Of those eligible, eleven patients (45.8%) were recruited, with ten nurses and nine communication partners also enrolled.

Ten out of the eleven patients were able to use the ICU-CHAT with some degree of success; defined as being able to select icons on the dashboard to provide a vocal output. Staff and communication partners were supportive of using AAC in the ICU. However, staff had concerns that ICU-CHAT may not be usable amongst a wider patient population and some patients found the head-tracker frustrating. Qualitative data revealed emotive responses and implications associated with impaired communication. No adverse events were reported.

Conclusions: ICU-CHAT was safe and feasible to introduce to the ICU amongst a small number of tracheostomy patients; offering a method of communication for alert tracheostomized patients who were unable to tolerate cuff deflation for the use of standard speaking valves. Although qualitative feedback was variable, ICU-CHAT was considered usable by most patients. The emotional reactions caused by communication impairments support the need for further development of AAC in the ICU to optimise communication.

Figure 1.

The ICU-CHAT dashboard.

Reference

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

4745

Peripartum Covid 19 admissions in an intensive care unit – Case series

Alex Fonseca, Sudhindra Kulkarni

Lancashire Teaching Hospitals NHS Foundation Trust

Lancashire Teaching Hospitals NHS Foundation Trust, [e-mail]

Abstract

Introduction: Peripartum women are at increased risk for severe illness with coronavirus disease (Covid-19) infection. Recent medical literature has drawn attention to the possible influence of COVID-19 on the course of pregnancies and its long-term effects.^1–5

Objective: This case series aimed to observe the clinical course of peripartum women with confirmed Covid-19 admitted to a critical care unit in the North-west of England.

Methods: Since the start of the pandemic, all pregnant women with Covid-19 infection admitted to the critical care unit were monitored and followed up. Demographic profile, medical co-morbidities, treatment received, respiratory support and vaccination status were noted.

Results: From March 2020 until February 2022, 8 women in our practice were shifted to the critical care unit post-partum in view of worsening work of breathing & increasing oxygen requirement after initial management in the delivery suite. All admissions were during the 3^rd wave of the pandemic in the UK, between June to October 2021. 5 patients underwent Caesarean section under spinal anesthesia & 3 were shifted post normal vaginal delivery. Mean age in the study population was 33.25 years (SD +/− 3.99) and mean length of stay in the ICU was 6.62 days (SD +/− 3.99). Only one woman required intubation & mechanical ventilation for 10 days and the rest were managed on High Flow Nasal Cannula (HFNC) or Continuous Positive Airway Pressure (CPAP) hood and self-proning manoeuvres. 50% of the patients received Tocilizumab. All women were discharged home and there were no maternal deaths. Pre- admission none of the women were vaccinated, but on follow up 5 out of the 8 had completed their vaccination. All women were emotionally distraught due to being isolated from their family and new born. When reviewed at 12 weeks, one patient experienced post traumatic stress disorder (PTSD) and one had features of long Covid syndrome. On follow up, all new born babies were doing well.

Conclusions: From the limited amount of data available, psychological stress was common to all patients. Being isolated from their new-born and family was the most difficult emotional aspect for the mothers in addition to finding it difficult to breathe and uncertainty about the future. Most mothers and new-born babies were discharged from the hospital without any serious complications. However, further observation and long term follow up is imperative. Use of guidelines in peripartum patients will aid in appropriate escalation of care.

Key words: COVID-19, Pregnancy, Peri-partum, Long Covid syndrome.

References

1. Vizheh M, Muhidin S, Aghajani F, et al. Characteristics and outcomes of COVID-19 pneumonia in pregnancy compared with infected nonpregnant women. Int J Gynaecol Obstet. 2021;153(3):462-468.

2. Wang CL, Liu YY, Wu CH, Wang CY, Wang CH, Long CY. Impact of COVID-19 on Pregnancy. Int J Med Sci. 2021;18(3):763-767.

3. Elsaddig M, Khalil A. Effects of the COVID pandemic on pregnancy outcomes. Best Pract Res Clin Obstet Gynaecol. 2021;73:125-136.

4. Fox NS, Melka S. COVID-19 in Pregnant Women: Case Series from One Large New York City Obstetrical Practice. Am J Perinatol. 2020;37(10):1002-1004.

5. Taribagil P, Creer D, Tahir H. ‘Long COVID’ syndrome. BMJ Case Rep. 2021;14(4):e241485.

4744

Specifically designed family communication booklet to help staff to communicate effectively with Intensive Care Unit patients’ next of kin

Kate Goodchild, Abigail Mann, William Laing, Amanda King, Marghanita Jenkins, Caroline Ficke, Rowan Hardy, Fiona E Kelly

Department of Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK

Department of Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK, [e-mail]

Abstract

Introduction: Families of patients admitted to the Intensive Care Unit (ICU) experience significant emotional distress.¹ Visiting restrictions mandated during the COVID-19 pandemic presented new barriers to family communication, including a shift from regular bedside nursing updates and in-person family meetings to scheduled, clinician-led telephone calls and video calls.² This resulted in loss of non-verbal clues and feedback during family discussions, difficulties establishing rapport with families and risked inconsistent messages and moral injury to staff.³

Objectives: We aimed to design a system where all ICU family discussions were documented in one place in a standardised format, thereby clarifying information given to families to date and helping staff give families a consistent message. In addition, we aimed to provide practical advice for the staff making family update telephone calls and strategies for managing difficult telephone conversations.

Methods: We designed and implemented an ICU family communication booklet: this was colour-coded blue; separate to other ICU documentation within the patient notes; and included communication aids and schematics to help staff optimise and structure a telephone update. Using Quality Improvement methodology, we completed four Plan-Do-Study-Act (PDSA) cycles and gathered qualitative and quantitative feedback: this occurred prior to the project and at one,12,18 and 21 months post introduction. We implemented suggested changes at each stage. We designed staff surveys with questions in a 5-point Likert scale format plus opportunity for free comments. Twenty-one months post implementation, we designed and delivered an MDT awareness campaign using the ‘tea-trolley training’ method,⁴ departmental induction sessions for new ICU doctors and nurses and a ‘Message of the Week’ initiative. An updated version of the booklet was introduced in February 2022 (Figure 1).

Results: Staff survey results are shown in Table 1. Forty-six staff participated in tea trolley training, feedback form return rate 100%. Following feedback, the family communication booklet was updated to include the following: a prompt to set up a password; a new communication checklist at the front, including documentation of next of kin contact details, a prompt to confirm details for video calls, confirm primary contact and whether the next of kin would like updates during the night; consent (if the patient is awake) for video calls while sedated; information regarding patient property; prompt to give families our designated ICU email address to allow relatives to send in photographs to display next to patients’ beds; prompts to encourage MDT documentation and patient diary entry.

Conclusions: During unprecedented visiting restrictions in the COVID-19 pandemic, we implemented an ICU family communication booklet which has been so successful that we plan to use it indefinitely. We plan to further develop this tool by encouraging MDT involvement, seek further staff feedback in six months’ time, incorporate this structure into our electronic patient information system when introduced and collect feedback from patients and their next of kin at our ICU follow up clinic. This communication booklet would potentially be reproducible and transferable to other ICUs and could be used as part of a national ICU family communication initiative.

References

1. Auerbach S, Kiesler D, Wartella J et al. Optimism, satisfaction with needs met, interpersonal perceptions of the healthcare team, and emotional distress in patients’ family members during critical care hospitalisation. American Journal of Critical Care 2005; 14: 202-210.

2. Rose L, Yu L, Casey J et al. Communication and Virtual Visiting for Families of Patients in Intensive Care during COVID-19: A UK National Survey. Annals of the American Thoracic Society 2021; 18: 1685-1692.

3. Davidson J, Powers K, Heydayal K et al. Clinical practice guidelines for support of the family in the patient-centred intensive care unit. American College of Critical Care Medicine Task Force 2007; 35: 605-622.

4. O’Farrell G, McDonald M, Kelly FE. “Tea trolley” difficult airway training. Anaesthesia 2015; 70:104.

Figure 1.

Updated MDT family communication booklet.

4743

ICU without walls = ICU without Data? The Covid-19 deficit

Mairead Murnin, Mark Brannigan, Christopher Cullen, Andrew McCleane, Rhonda Marks, Padraig Headley, Christopher Gowers

South Eastern Health and Social Care Trust

South Eastern Health and Social Care Trust, [e-mail]

Abstract

Introduction: Northern Ireland (NI) has 5.5 ICU beds/100 000 population,¹ amongst the lowest in Western Europe.² Alongside ICU bed expansion the Covid-19 response required delivery of advanced Respiratory support (Continuous Positive Airway Pressure (CPAP) and High Flow Nasal Oxygen (HFNO)) outside ICU.

ICNARC provides robust data for patients within ICU but this is unavailable for those receiving ‘critical care’ elsewhere.

Objectives: To evaluate delivery of CPAP/HFNO outside of ICU to Covid-19 patients - focusing on demographics and outcomes including ICU admission and mortality.

Methods: Ward-CPAP for acute hypoxaemic respiratory failure (AHRF) was not previously utilised.³ It was introduced for Covid-19 to Medical wards.

Data was analysed using the NI Electronic Care Record, ward electronic note system (EDAMS) and ICU system (ICCA, Koninklijke Philips N.V.). Data was compared between Wave 1 (01/03/2020 – 12/12/2020) and Wave 2 (13/12/2020 - 01/04/2021).

Results: 215 patients received CPAP/HFNO/Invasive Mechanical Ventilation (IMV) for Covid-19: 103 in Wave 1 and 112 in Wave 2. 75 Covid-19 patients were admitted to the ICU itself (comprising 44 of the study cohort, 11 direct from ED and 20 transferred from other Trusts).

Table 1 shows demographics. Fewer patients were female as seen elsewhere,⁴ there were more young patients in Wave 2. The majority of patients would likely have been ICU candidates pre-pandemic,³ but a subset of 25% were deemed for a ward ceiling-of-care on admission by a Consultant and the proportion of elderly patients was higher than described by ICNARC.⁴ Comorbidities and obesity were common.

Outcomes are shown in Table 2 and Figures 1–3. Close co-operation with ICU saw 61% of patients with a documented ICU review. Overall 20% of patients were admitted to ICU, and 15% received IMV. Mortality was 37%, but 22% if patients with an admission ward ceiling-of-care decision were excluded. Mortality correlated with frailty and age (fig 2&3). Outcomes were generally better in Wave 2.

Conclusions: This Evaluation documents the huge contribution to the critical care Covid-19 response made by our Medical teams, not captured by ICNARC. Most patients avoided ICU admission and IMV and outcomes were likely at least comparable which undoubtedly freed up vital ICU beds. We thank the teams involved and believe it is vital to evaluate the outcome of all critically ill Covid-19 patients irrespective of their location.

Table 1.

Demographics.

Domain	Wave 1	Wave 2	Overall
Number of patients	103	112	215
Age <60	28	45	57
Age 60-69	32	30	62
Age >70	43	36	79
Female	47	41	88
Clinical Frailty Score 0-3	64	56	120
BMI>30	53	57	110
≥1 Co-morbidities	90	97	187
Admitted from home	94	109	203
DNACPR at admission	23	22	45
Ward ceiling of care at admission	27	26	53

Table 2.

Outcomes.

Domain	Wave 1	Wave 2	Overall
Admitted to ICU – IMV (%)	21	10	15
Mortality at hospital discharge (%)	47	28	37
Mortality (excluding not for escalation at admission) (%)	34	13	22
Discharged home no care package (%)	40	66	53

Figure 3.

Patient flow and ICU utilisation.

References

1. AgendaNi. Critical care capacity. Published December 2020. Available from Critical care capacity - agendaNi (accessed 26^th February 2022).

2. Anandaciva, S. Critical care services in the English NHS. The King’s Fund. Published April 2020 and updated November 2020. Available from https://www.kingsfund.org.uk/publications/critical-care-services-nhs#the-number-of-beds (accessed 26^th February 2022).

3. British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax. 2002;57(3):192-211. doi:10.1136/thorax.57.3.192.

4. ICNARC report on COVID-19 in critical care England, Wales and Northern Ireland 6^th July 2021, available from https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports. (accessed 26^th February 2022).

4742

Analysis of Maternal Critical Care at The Mid Yorkshire Hospitals NHS Trust

Lauren Tye, Ahmed Atewah

Mid Yorkshire Hospitals NHS Trust

Mid Yorkshire Hospitals NHS Trust, [e-mail]

Abstract

Introduction: Perinatal admissions to Critical Care are increasing due to rising maternal age, obesity, and comorbid disease.¹ The MBRRACE Report 2021 stated that of 191 maternal deaths in 2017-2019, only 17% had good care.² Since the COVID-19 pandemic, there was a subjective increase in perinatal admissions to Mid Yorkshire Hospitals Critical Care.

Objectives: To investigate whether MYH Critical Care maternal admissions have increased, if there has been a change in admission trends and to evaluate the care of critically ill pregnant and postpartum women compared to FICM standards.³

Methods: Retrospective audit of notes of all pregnant and up to 6 weeks postpartum women admitted to critical care between 24/02/2019 and 05/09/2021. Data collected included gestation, duration of admission, organ support, days reviewed by obstetrics and mortality outcomes.

Results:

• There was 1 maternal death and 3 fetal deaths during the study period

• 50% of the admissions were antenatal and 50% were postnatal

• During the COVID-19 pandemic we have seen a 47% increased rate of admissions from 1 per 29 critical care bed days to 1 per 19 critical care bed days

• 50% of patients were supported with ventilation and CPAP during admission, 13% with CPAP only. Prior to the COVID pandemic, no maternal admission required CPAP on our Critical Care unit during the data collection period

• 63% of patients were reviewed by obstetrics at least one during their admission, but obstetric review was documented on only 37 of 112 patient days

• There is no critical care SOP for perimortem Caesarean section

• There is no specialist neonatal resuscitation equipment available on ICU

• There is no named ICM consultant responsible for Maternal Critical Care

• There is no SOP for support of maternal contact with baby

• There is no critical care/obstetric services MDT follow-up

Conclusions: This study shows that Critical Care admissions have increased, and that care does not follow all the FICM recommendations. Considering this, the following recommendations have been made:

• Introduce an SOP and simulation training for peri-mortem section

• Introduce neonatal resuscitation equipment box

• Nomination of a named ICM Consultant lead for Maternal Critical Care to ensure quality of care and act as liaison

• Train critical care staff in supporting contact between a mother and baby, with support from midwifery services

• Introduction of Obstetric and Critical Care MDT follow-up

References

1. Quinn A, Waldmann C. Care of the critically ill woman in childbirth; enhanced maternal care [Internet]. Royal College of Anaesthetists; 2018 [cited 27 February 2022]. Available from: https://www.rcoa.ac.uk/sites/default/files/documents/2019-09/EMC-Guidelines2018.pdf

2. Knight M, Bunch K, Tuffnell D, Patel R, Shakespeare J, Kotnis R et al. Saving Lives, Improving Mothers’ Care [Internet]. MBRRACE-UK; 2021 [cited 27 February 2022]. Available from: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf

3. Quinn A, Vincent L. Guidelines For The Provision Of Intensive Care Services [Internet]. 2nd ed. The Faculty Of Intensive Care Medicine; 2019 [cited 27 February 2022]. Available from: https://ficm.ac.uk/sites/ficm/files/documents/2021-10/gpics-v2.pdf

4738

Fire and fluid: The turning tide of burns fluid resuscitation over a decade

Lois Nunn, Madeleine Gray, Marcela Vizcaychipi, Michelle Hayes, James Rivett

Chelsea and Westminster NHS Foundation Trust

Chelsea and Westminster NHS Foundation Trust, [e-mail]

Abstract

Introduction: Patients with severe burn injuries require early resuscitation with large fluid volumes. Current practice is guided by the Parkland formula with careful titration to avoid fluid creep and the associated morbidity.^1–2 Avoiding excessive fluid administration has become more challenging following the cessation of synthetic colloid use as a resuscitation fluid, due to safety concerns.³

Objectives: To review the changes in initial fluid resuscitation for patients with severe burns over a decade, in accordance with guidelines and to review the possible improvements and learning.

Methods: A retrospective cohort study was conducted comparing the fluid administered to patients admitted to a regional burns centre, with a total body surface area (TBSA) burn of equal to or more than 15%, during years 2010 and 2020. Data was collected on patient demographics, fluid input and output, type of fluid administered over 72 hours from the time of burn injury, inhalational injury and survival to ICU discharge. Statistical analysis was carried out using the Mann-Whitney U Test. The study was performed in accordance with local ethical and governance standards.

Results: There were no demographic differences between the groups except for the admission lactate which was significantly higher in the 2020 cohort (Table 1). The median volume administered in the first 24 hours, in excess of the Parkland formula, reduced significantly from 5.5ml/kg/%TBSA in 2010 to 3.98ml/kg/%TBSA in 2020 (Table 2). There was no significant difference in the amount of fluid administered from 24-72 hours. Synthetic colloid use had completely ceased by 2020 however there was an increase in the use of albumin, which was predominantly following the initial 24-hour resuscitation phase. The median urine output was not significantly different between the two cohorts.

Conclusions: This retrospective review at a regional burns centre demonstrates successful reduction in the amount of crystalloid fluid administered to patients in the first 24 hours following a severe burn injury from 2010 to 2020, despite the avoidance of synthetic colloids. Urine output was unaffected by the reduction in fluid administered in the first 24 hours. The use of albumin increased following the initial 24 hours. Despite there being limited evidence for the use of albumin in major burns,⁴ its use has led to a reduction in crystalloid administered in one centre.⁵ Increased use as part of a rescue or hybrid protocol in the first 24 hours may help to further reduce the administered volumes.

Table 1.

Demographics.

	2020	2010	p-value
Number(N)	14	12
Age(years)	38(35-59)	38.5(32-45)	0.625
Weight(kg)	83(75-91)	82(66-92)	0.396
%TBSA	43(31-49)	31(28-36)	0.353
Inhalational injury(N)	1	3	-
Admission base deficit	-4.5(-8.3- -0.8)	-6.6(-8.1- -4.6)	0.662
Admission lactate	3.6(2.3-4.0)	2.05(1.2-2.8)	0.016
Survival to ICU discharge	79%	75%

Data: Median(IQR)

Table 2.

Fluid data.

	2020	2010	p-value
24hr Total fluid input(ml/kg/%TBSA)	3.98(3.24-4.53)	5.5(3.8-7.9)	0.033
24hr Urine output(ml/kg/hr)	1.09(0.86-1.80)	1.0(0.8-1.5)	0.419
Colloid (% of total volume)	2	18
Inhalational injury(N)	1	3
24hr total fluid(ml/kg/%TBSA)	3.29	6.43(4.9-8.4)

Data: Median(IQR).

References

1. Pruitt BA Jr. Protection from excessive resuscitation: ‘pushing the pendulum back’. J Trauma. 2000; 49: 567–568.

2. Cartotto R, Zhou A. Fluid creep: the pendulum hasn’t swung back yet! J Burn Care Res. 2010;31:551–558.

3. Guilabert P, Usua G, Martin N, Abarca L, Barret JP, Colomina MJ. Fluid Resuscitation management in patients with burns : update. BJA. 2016; 117(3): 284-96.

4. Navickis RJ, Greenhalgh DG, Wilkes MW. Albumin in burn shock resuscitation: A meta-analysis of controlled clinical studies. J Burn Care Res, 2016; 37: 268-278.

5. Hunter JE, Drew PJ, Potokar TS, Dickson W, Hemington-Gorse SJ, Albumin resuscitation in burns: a hybrid regime to mitigate fluid creep. Scars, Burns and Healing 2016 ; 2:1-5.

4736

Disseminated Mucormycosis in a patient on long term immunosuppression: Severe fungal infections as multi-system disorders

Kaja Koksa¹, Rebecca Acres¹, Mark Studley², Jennifer Briggs¹

¹ Leicester Royal Infirmary

² Queen’s Hospital Burton

Leicester Royal Infirmary, [e-mail]

Abstract

Introduction: Mucormycosis is a rare, severe fungal infection with an incidence of 0.005 to 0.17 per million.¹ but incidence has risen recently, particularly in the Asian subcontinent, due to use of immunosuppression for Covid19.² Presentations can vary and are classified into: rhino-orbito-cerebral, pulmonary, cutaneous, disseminated, renal and gastrointestinal. Risk factors include diabetes, immunosuppression, iron overload, malnutrition, and prematurity.^1,3 Although mucormycosis has an extremely high mortality rate and disseminated infection is usually fatal, treatment options exist if diagnosed early and surgical debridement may be curative.

Objectives: We present a case of mucormycois in a female patient in her 40s who was immunosuppressed with methotrexate for rheumatoid disease. This case is discussed to increase awareness of critical illness caused by opportunistic invasive fungal infections in immunosuppressed patients and promote timely identification and management.

Methods: We detail the clinical context and management of a patient with mucormycosis and discuss relevant literature.

Results: A female patient in her 40s who had been experiencing upper respiratory tract symptoms for several weeks, including cough and brown sputum, was admitted with a presumptive diagnosis of methotrexate toxicity after a full blood count performed by the general practitioner demonstrated pancytopenia.

Initially, National Early Warning System 2 score (NEWS2) was 2 but became intensely hypertensive during blood transfusion and then profoundly shocked with an escalating NEWS2.

Broad-spectrum antibiotics and fluconazole were commenced for neutropenic sepsis and the patient was referred to critical care in multiple organ failure. Computerised tomography (CT) scan of the chest, abdomen and pelvis showed “left upper lobe consolidation, which with neutropenia might represent an angioinvasive aspergillosis”. She had multiple areas of skin discolouration and desquamation. Haematology and Infectious Diseases opinions were sought, and a bone marrow biopsy was performed which showed severe toxic effects consistent with sepsis/life threatening infection.

Progressive proptosis was noted, and CT scan of her head was requested. Sadly, she was never stable enough for CT transfer.

Beta D Glucan and aspergillus antigen serology was negative. Broncho-alveolar lavage demonstrated Candida albicans and then, later, Rhizopus arrhizus was isolated and anti-fungal treatment changed to voriconazole and then amphotericin B.

Upon reviewing the notes in light of the positive culture for Rhizopus, the patient had likely been exhibiting symptomatic Mucormycosis sinus infection for some time prior to this admission with disseminated infection. The patient’s condition continued to deteriorate and she sadly died.

Conclusions:

• The Early Warning Score significantly underestimated how unwell the patient was upon arrival in ED, a systems-based assessment would have demonstrated that the patient had multiple system dysfunction and significant potential to deteriorate suddenly despite having stable observations

• The methotrexate level has no clinical value in diagnosing or refuting a diagnosis of methotrexate toxicity

• A full examination of the immunosuppressed patient including ENT is a necessity when searching for a source of infection

• Invasive fungal infections can cause multi-system symptoms and atypical presentations

• As a greater proportion of patients have received systemic immunosuppression for Covid-19, vigilance for more unusual pathogens, including Mucormycosis by clinicians is advised.⁴

References

1. Rachana M. Palnitkar MS. BMJ Best Practice Mucormycosis [Internet]. BMJ Best Practice; Available from: https://bestpractice.bmj.com/topics/en-gb/921/pdf/921/Mucormycosis.pdf (Accessed February 2022)

2. Sen M, Honavar SG, Bansal R, et al. Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbitalcerebral mucormycosis in 2826 patients in India – collaborative OPAI-IJO study on Mucormycosis in COVID-19 (COSMIC), report 1. Indian J Ophthalmol 2021; 69(7): 1670– 1692.

3. Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European confederation of medical mycology in cooperation with the mycoses study group education and research consortium. Lancet Infect Dis 2019; 19(12): e405.21.

4. World Health Organisation. Covid-19: What can we do to keep safe?: Mucormycosis https://www.who.int/india/emergencies/coronavirus-disease-(covid-19)/mucormycosis (Accessed February 2022).

4735

Comparative evaluation of analgo-sedative effects of oral ketamine and oral morphine for wound dressing in adult burns patient

Adeniyi Tobun

Nottingham University Hospital

Nottingham University Hospital, [e-mail]

Abstract

COMPARATIVE EVALUATION OF ANALGO-SEDATIVE EFFECTS OF ORAL KETAMINE AND ORAL MORPHINE FOR WOUND DRESSING IN ADULT BURNS PATIENT

Adeniyi Tobun

Fellow, Intensive Care Medicine

Queen’s Medical Centre

Nottingham University Hospital

Introduction: The provision of adequate analgesia during wound care and dressing in burns patient has been reported to be an important determinant of the outcome of therapy, especially recovery time and length of hospital stay. Options for analgesia are limited by availability of potent analgesic agents, risk of respiratory depression, availability of routine monitoring, and difficulty in securing venous access.

Objectives: The aim of this study was to compare the analgesic and sedative effects of oral ketamine (6mg/kg) with that of oral morphine (25mg) used during wound dressing in burns patient on admission at Lagos State University Teaching Hospital, Nigeria.

Methods: This was a crossover study involving 50 American Society of Anaesthesiology I and II patients between the ages of 18-50 years with Total Burn Surface Area (TBSA) of 15-30%. The patients were assessed clinically in the morning after an overnight fast to determine eligibility for the study. The rule of nines was used to calculate TBSA. Informed consent was signed by all participants.

The study was in two phases. In phase one, burns patients were randomly selected into two groups of 25-participants using computer-generated random numbers; group M received oral morphine (25mg) and group K received oral ketamine (6mg/kg). In phase two of the study, the patients in group M were switched to group K, and vice versa. Pain and sedation scores were assessed at different time intervals using Verbal descriptive scale (VDRS) and Ramsay Sedation scale (RSS) respectively.

Data were analysed using Statistical Package for the Social Sciences.

Results: A total of 50 adult burns patient were recruited into this study.

The mean ± SD intraprocedural pain score at 0min (30minutes after administration of study drug) was significantly lower with Oral Ketamine (OK) (mean = 1.04 ± 0.53) when compared to Oral Morphine (OM) (mean = 1.30 ± 0.50), p = 0.021. At 15-minutes ,it was 1.16 ± 0.58 (OK) and 1.58 ± 0.54(OM), p < 0.001. At 30-minutes, pain score was 1.19 ± 0.50 (OK) and 1.33 ± 0.47 (OM), p = 0.016.

Intra-procedural mean sedation score, at 0-minutes (30-minutes after administration of study drug) was 2.70 ± 0.61(OK) and 1.60 ± 0.57(OM), p < 0.001. At 15-minutes was 2.22 ± 0.62 (OK) and 1.26 ± 0.44 (OM), p < 0.0001. At 30 minutes was 2.09 ± 0.48 (OK) and 1.13 ± 0.33 (OM), p < 0.001.

Post-procedural sedation score at 0minute; was significantly higher with Oral Ketamine (mean = 2.00 ± 0.49) than Oral morphine (mean = 1.08 ± 0.28), p < 0.001. At 30minutes sedation score was 1.96 ± 0.53 (OK) and 1.06 ± 0.24 (OM), p = 0.001, at 1hour was 1.64 ± 0.60 (OK) and 1.04 ± 0.20 (OM), p < 0.001 while at 2-hours, sedation score was 1.20 ± 0.40 (OK) and 1.00 ± 0.00 (OM), p = 0.001.

As regards complications, 15% and 12% of the patients in OK-group developed hallucinations and hyperventilation respectively. None of these side effects were reported in OM-group.

More than half (58%) of the participants preferred oral morphine.

Conclusions: The study showed Oral ketamine and Oral Morphine produced good analgesia and sedation during wound dressing sessions. It’s not surprising that participants were more satisfied with Oral morphine which had reduced side-effect. This will need to be considered when determining the choice of analgesic during wound dressing in burns patent.

References

1. Abdi S, McPeek B. Pain in Burn Patients in the Massachusetts General Hospital handbook of Pain Management. 2009; 317-322. 3rd ed. Lippincott Williams & Wilkins press.

2. Patterson DR, Hofland HW, Espey K, Sharar S. Nursing committee of the international society for burn injuries. Pain Management. Burns 2004; 30(8): A10-A15.

3. Ezike HA, Odiakosa MC. Oral ketamine for wound care procedures in adult patients with burns. South Afr J Anaesth analg 2011;17(3):242-248.

4. Kundra P., Velayudhan S., Krishnamachari S., Gupta L. S. Oral ketamine and dexmedetomidine in adults’ burns wound dressing- A randomised double blind crossover study. Burns 2013; 39:1150-1156

4734

Analysis of Quality Metrics Relating to the Intubation of Covid-19 patients on a General ICU

Anne Frawley, James Lavers, Lucy Hoade, James Williams

Cardiff and Vale University Health Board

Cardiff and Vale University Health Board, [e-mail]

Abstract

Introduction: Most modern healthcare systems are striving to improve patient outcomes in an evidence-based manner. Increasingly, performance metrics are seen as key tools for accurately measuring and improving patient outcomes and healthcare value.¹ However, in order to achieve better outcomes, process measures need to be identified. Process measures are evidence-based, best practices metrics that can be measured and thus, used to identify if outcomes are being met. Good process measures can improve patient outcomes by reducing the amount of variation in care delivery. During the Covid-19 pandemic, vast quantities of data were generated while managing ARDS (Acute Respiratory Distress Syndrome) on the ICU. Furthermore, there was as a concomitant evolution of treatment strategies, which made it exceedingly difficult to identify processes that were actually improving patient outcomes.

Objectives: The aim of our quality improvement project was to promote standardised high quality care for intubated Covid-19 patients by identifying potential quality indicators and trends in their management. It is our intention to expand on this work to report metrics on all severe acute respiratory failure patients.

Methods: 15 process metrics surrounding the early care of intubated of Covid-19 patients were selected via a consultant led review process and a literature review in an effort to identify markers of quality surrounding intubation on our ITU. The variables selected included: - P/F ratio 24 hours pre-intubation, CPAP (continuous positive airway pressure) duration prior to intubation, Recording intubation location, Enhanced thromboprophylaxis prescribed, Permissive hypercapnia, Driving pressure documented, prone position and paralysis initiated if P/F ratio was less than 20 kPa, Echo post intubation.

Results: Data surrounding the intubation of Covid-19 patients was collected over an 11 week period between September and November 2021. The data was collected in a standardised fashion from patient notes and nursing notes, then stored in an excel file. Our data showed more than half the patients admitted were either intubated on the ward or immediately following arrival onto our ICU, possible indicating a delay in admitting Covid-19 patients. Our data also demonstrated heterogeneity of duration in CPAP prior to intubation which may also indicate delayed intubation for these patients.²

Conclusions: Our data demonstrated a reasonable degree of heterogeneity in our approach to the early care of intubated Covid-19 Patients. Areas of concern highlighted were the number of patients intubated on the ward or immediately upon arrival to ITU, rather than admitting prior to deterioration (most likely due to bed pressure) and variation in post intubation respiratory sampling between invasive and non-invasive broncheoalveolar lavage. Ongoing PDSA (plan-do-study-act) cycling are in progress to refine the data collection processes and reporting for all severe acute respiratory failure patients.

References

1. Shah A. Using data for improvement. BMJ [Internet]. 2019;364:189. Available from: http://www.bmj.com/permissionsSubscribe:http://www.bmj.com/subscribehttp://www.bmj.com/

2. Vaschetto R, Barone-Adesi F, Racca F, Pissaia C, Maestrone C, Colombo D, et al. Outcomes of COVID-19 patients treated with continuous positive airway pressure outside the intensive care unit. ERJ Open Res [Internet]. 2021 Jan 1 [cited 2022 Feb24];7(1):00541–2020. Available from: https://openres.ersjournals.com/content/7/1/00541-2020

4732

“Working in the dark but expected to be an expert”: reflecting on critical care preparations for COVID-19

Naomi Cochrane¹, Stephanie Harper², Sara Mistry³, Cliff Shelton⁴

¹ North West Schools of Anaesthesia and Intensive Care Medicine

² North West School of Anaesthetics

³ Department of Anaesthesia, Wythenshawe Hospital

⁴ Department of Anaesthesia, Wythenshawe Hospital

North West Schools of Anaesthesia and Intensive Care Medicine, [e-mail]

Abstract

Introduction: Before spring 2020, many healthcare organisations did not possess detailed plans for the expansion and delivery of critical care during a pandemic. Furthermore, there was little directly-relevant individual or institutional experience to draw upon. Local, national and international guidance was drawn up rapidly and subject to frequent revision.¹ Reflecting on these challenges, we designed a study to explore critical care and anaesthetic doctors’ experiences of preparation for the provision of critical care services in the first wave of COVID-19.

Objectives:

1. To establish what factors facilitated and hindered the expansion and delivery of critical care services.

2. To identify important learning points for the provision of critical care during future pandemics.

Methods: We conducted semi-structured interviews with medical staff from the anaesthesia and critical care departments of our hospital, a tertiary centre with general and cardiothoracic intensive care units, including an ECMO service.

We classified participants into two groups;

1. Decision makers – individuals instrumental in shaping the critical care response, e.g., clinical directors and college tutors.

2. Staff members – clinicians working within the departments, including consultants and trainees.

Thirteen interviews were conducted with 15 participants: eight decision makers and seven staff members. The interviews were recorded, transcribed and anonymised. We manually coded transcripts, and carried out an inductive thematic analysis.²

Results: Eight themes were generated from our analysis:

• Problem solving with simulation: simulation exercises allowed experienced clinicians to troubleshoot practical issues and helped staff to prepare for unfamiliar tasks.

• A sense of togetherness: staff reported that the “all hands-on deck” ethos was protective against fatigue, although this was short-lived.

• Delayed and changing guidance: frequent guideline changes created confusion and anxiety.

• Leading from the front: leaders with a clinical role were perceived more positively than those operating at a distance from the “shop-floor”.

• Coordination, collaboration and compromise: departments that accommodated each other’s needs fostered productive inter-departmental relationships.

• Insecure supply chains: staff took their own measures to ensure PPE availability, including acquisition of items outside NHS supply chains.

• Constant communication: rapid methods of personal communication, e.g., WhatsApp were effective, although “WhatsApp fatigue” was endemic.

• Balancing skill mix and fatigue: flux in workload required dynamic staff allocation. Underutilised staff groups created frustration and low morale in overworked colleagues.

Conclusions: The threat to health and society from pandemic events is expected to increase over time.³ We should take this opportunity to gather experiences from those involved in the COVID-19 pandemic to guide future preparations. In early 2020, decision makes in local hospitals were operating with unclear guidance from external agencies. Our data, obtained in the summer of 2021 demonstrates that individual and departmental reflections had already resulted in processes being refined in later waves of COVID-19. Whilst the exact nature of future pandemics will vary, some elements of preparation will remain consistent. We recommend that plans for pandemic management should aim to reduce workload and target the most effective interventions, including by addressing the themes outlined above.

References

1. Baraza W, Shelton C. No doctor is an island: the ‘social distancing’ of guidelines during the COVID-19 pandemic. British Journal of Surgery 2020; 107: e389.

2. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3: 77–101.

3. Kain T, Fowler R. Preparing intensive care for the next pandemic influenza. Critical Care; 23. Epub ahead of print October 30, 2019. DOI: 10.1186/s13054-019-2616-1.

4731

Caesarean section in critically unwell peri-partum patients with COVID-19: a tertiary centre’s experience

Michael Wylie¹, Kyle Gibson², Jennifer Service¹, Arlene Wise¹

¹ NHS Lothian

² University College London Hospitals NHS Foundation Trust

NHS Lothian, [e-mail]

Abstract

Introduction: The COVID-19 pandemic has required clinical teams to function with an unprecedented amount of uncertainty, balancing complex risks and benefits in a highly fluid environment. This is especially the case when considering the delivery of a pregnant woman critically unwell with COVID-19. This is one maternal critical care team’s reflections on establishing best practice and a shared mental model when undertaking a Caesarean section in critically unwell patients with COVID-19.

Objectives: We describe our experience of balancing the risks and streamlining the process of this high-risk intervention.

Methods: We used our standard clinical governance forums across four specialties (Obstetrics, Intensive care, Anaesthetics and Neonatology) to identify key challenges and learning points. We developed a working group to combine our learning and develop a shared mental model across the involved teams.

Results:

1. The decision to deliver must be multidisciplinary involving Obstetrics, Intensive care, Anaesthetics, Neonatology and the patient according to their capacity to participate. The existing structure of twice daily ITU ward rounds could be leveraged as a ‘pause’ moment to consider the need for imminent delivery and review the risk-benefit balance of continued enhanced pharmacological thromboprophylaxis.

2. We identified a range of scenarios that our teams might be exposed to:

3. Perimortem Caesarean section

4. Critically unwell – unsafe to move to theatre

5. Critically unwell – safe to move to theatre

6. Recreating an obstetric theatre in the ICU

Advantages

Avoids moving a critically unstable patient, although our experience is increasing moving patients for ECMO.

Some forms of maximal non-invasive therapy such as High Flow Nasal Oxygen may require interruption to move to theatre with resultant risk of harm or be difficult to continue in transport mode through a bulky ICU ventilator e.g. CPAP

Disadvantages

Significant logistics and coordination burden: multiple items of specialist equipment needing to be brought to the ICU.

Human factors burden: performing a caesarean section in an unfamiliar environment is a significant increase in cognitive load for participating teams.

Environmental factors: ICU side rooms may offer limited space vs the need to control the space if performed on an open unit.

Delivering a Neonate into a COVID bubble.

Conclusions: Developing a shared mental model across the key teams involved in delivering an emergency caesarean section in this cohort of critically unwell patients has enabled our group to own a common understanding of the key decisions and risks involved.

We recommend a patient centred MDT decision making model, with a structure for regular reassessment by senior members of the teams involved. In most circumstances the human factors and logistical burden of recreating an operating theatre in the ICU outweighs the risk of transport to theatre. Pre-defined checklists and action cards mitigate the cognitive and logistical burden when multiple teams do perform an operative delivery in ICU. Action cards highlight key aspects of routine obstetric care to be replicated in the ICU environment.

4729

Occupational Therapy in Northern Ireland’s Regional ICU: understanding the demand and acceptability

Aisling Durkin¹, Catherine Gillan¹, Karen Ross²

¹ Belfast Health and Social Care Trust

² Royal Hospital Belfast

Belfast Health and Social Care Trust, [e-mail]

Abstract

Introduction: Survival of critically ill patients has improved in recent years, however, many experience ongoing physical, psychosocial and cognitive impairment.¹ These patients require specialist multidisciplinary assessment and treatment to minimise the risk of further deterioration, to promote recovery and improve long term outcomes.² The importance of Occupational Therapy (OT) for critically ill patients is recognised in current national standards of practice in the UK.³ To date there is no funded OT service in the Regional Intensive Care Unit (RICU) in Northern Ireland. On average the OT Service currently receives one referral per month from RICU.

Objective: To identify the demand for an OT service in the RICU and the satisfaction and acceptability of the service amongst the multidisciplinary team.

Methods: From May to July 2021, a pilot OT service was funded in the RICU (1× Band 7 full-time, 5 days per week). Referrals were generated by the OT or by members of the MDT and OT input was provided to patients in line with inclusion/exclusion criteria and staff capacity. Education sessions on the role of the OT were completed with ICU staff. Data collection included level of patient therapy input including number of treatment sessions, duration of session and staff required. Staff perceived understanding of the role of OT and satisfaction with the OT service in RICU via online questionnaire (pre/post pilot). Referral data was compared to the last previous three years. Level of therapy input and data from staff questionnaires were analysed and summarised descriptively.

Results: 66 patients were referred to the OT service during the 3 month duration, an increase of 1850%. Referrals were generated by all MDT members; OT (51%), Physiotherapist (21%), Nursing (17%) and Medical staff (11%). A total of 37 patients received Occupational Therapy input during the pilot. On average patients were seen 6 times per month, ranging from one session to twenty fours across the caseload. The occupational therapy service had approximately 77 direct patient contacts per month.

There was an 84% increase in staff satisfaction with the OT service following the pilot. A significant proportion of staff felt the OT service provided was efficient; with 81% reporting patients were seen in a timely manner and 71.2% felt the duration and frequency of input was appropriate to the patient needs. 76% of staff felt an Occupational Therapist was valuable for MDT. High proportions of staff felt OT had a positive impact on patient related outcomes; improving patients’ independence during their ICU stay (76%), promotion of their psychological wellbeing (81%) and optimisation of their physical recovery (81%). 90% of staff states they would support a dedicated OT service in ICU.

Conclusion: During the pilot there was a significant increase (>1850%) in the referral rate to OT indicating a demand for the service within RICU. MDT staff reported an increased understanding and satisfaction with the role of OT the RICU. Future business cases should include the provision of OT in RICU.

References

1. Rabiee A, Nikayin S, Hashem MD, Huang M, Dinglas VD, Bienvenu OJ, Turnbull AE, Needham DM. Depressive symptoms after critical illness: a systematic review and meta-analysis. Critical care medicine. 2016 Sep;44(9):1744.

2. Simpson R, Robinson L. Rehabilitation after critical illness in people with COVID-19 infection. American journal of physical medicine & rehabilitation. 2020 Jun;99(6):470.

3. Faculty of Intensive Care Medicine and Intensive Care Society (2019), available at: https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/gpics-v2.pdf (acessed 27th February 2022).

4728

Improving Outcomes in Oesophagectomy Patients

William Smy¹, Shayanthan Nanthakumaran², Douglas Coventry²

¹ NHS grampian

² NHS Grampian

NHS grampian, [e-mail]

Abstract

Introduction: Aberdeen Royal Infirmary is a low volume centre carrying out approximately 13 oesophagectomies per annum. Due to minimal exposure to post-operative oesophagectomy patients, staff had low perceived confidence in their management within the Intensive Care Unit (ICU). After an initial pause due to the COVID-19 pandemic, oesophagectomy service provision restarted in June 2020. Prior to this project, no standardised care pathway existed for post-operative oesophagectomy patients. A protocol driven management pathway was implemented within the ICU setting in October 2020.

Objectives:

1. Standardise the first 5 days of post-operative care for oesophagectamies

2. Improve 30 day mortality rate

3. Reduce opiate use on step down to High Dependency Unit (HDU)

4. Improve ICU Medical and Nursing staff perceived confidence in the management of oesophagectomy patients.

Methods: A multi-disciplinary approach was taken, with input from ICU, Surgical, Anaesthetic, Physiotherapy, Nursing, Pain and HDU teams. Standards of care for post-operative oesophagectomy patients were identified and a protocol was subsequently produced for use within ICU with reference to current Enhanced Recovery After Surgery (ERAS) guidelines.¹

The protocol covered the first 5 days of post-operative care. It identified tasks to be completed each day and highlighted which staff group was responsible for performing each task. Additionally, an information sheet was distributed to Medical and Nursing ICU staff to educate them on oesophagectomy patients and recognition of potential complications that arise when caring for this patient group.

Data on 30 day mortality and opiate use at step down to HDU was collected from electronic notes. This was collected retrospectively prior to implementation of the protocol from January 2019 - July 2020 and prospectively following its implementation, from October 2020 - December 2021.

ICU staff perceived confidence in managing post-operative oesophagectomy patients was measured using a combined quiz and survey. It was completed by staff prior to introduction of the protocol. Following implementation of the protocol and distribution of the information sheet, the quiz and survey was repeated to evaluate improvement in staff confidence.

Results: A total of 38 oesophagectomy cases were identified.

21 cases were reviewed prior to implementation of the protocol, with 1 mortality at 30 days.

17 cases were reviewed following implementation of the protocol, with 0 mortalities at 30 days.

Qualitative scoring showed a 20% increase in staff confidence to manage this patient group. Review of drug prescription charts revealed a reduction in dose of modified release opiates at step down to HDU.

Conclusions: Oesophagectomy is major surgery and causes significant staff anxiety in low volume centres. This protocol has successfully standardised care for this patient group and allowed continuation of this essential service provision during the COVID-19 pandemic. This protocol improved 30 day mortality, reduced opiate use at step down to HDU and improved ICU staff perceived confidence in caring for post-operative oseophagectomy patients.

Reference

1. Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS. Guidelines for perioperative care in esophagectomy: enhanced recovery after surgery (ERAS®) society recommendations. World journal of surgery. 2019 Feb;43(2):299-330.

4727

Paediatric Emergency Quick Reference Cards – a cognitive aid to improve intensive care staff performance in high pressure situations

John Wright¹, Andrew J Gilroy², Oliver Crowther², Amanda Varey², Jonathan Price², Fiona E Kelly²

¹ Department of Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK

² Department of Intensive Care Medicine, Royal united Hospitals Bath NHS Foundation Trust, Bath, UK

Department of Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK, [e-mail]

Abstract

Introduction: Caring for critically unwell children brings unique challenges due to their varying age and size.¹ In our District General Hospital (DGH), we are responsible for stabilising and resuscitating critically ill children prior to transfer to a tertiary Paediatric Intensive Care Unit (PICU). Many staff members are not familiar with calculating paediatric drug doses or selecting paediatric equipment, and report that cognitive overload is common in high pressure situations² such as caring for a sick child. We currently calculate paediatric drug doses using our local PICU’s on-line weight-dependent spreadsheet,³ but this requires access to a computer and can take time to print.

Objectives: We aimed to design and implement hard-copy Paediatric Emergency Quick Reference Cards for selected ages/weights that can be printed, laminated, immediately available in an emergency and easy to use. In addition, we aimed to provide multi-departmental training in the use of these cards for the multi-disciplinary team (MDT) across the hospital.

Methods: Paediatric Emergency Quick Reference Cards were designed and developed by an ICU consultant and pharmacist, including important drug doses and equipment sizes for neonates to near adult. These were checked by our local PICU team. Hard copies of these Quick Reference Cards were printed, laminated and placed in our ICU paediatric emergency ‘grab bag’ and ICU paediatric trolley. We organised a multi-department MDT training programme, using the ‘tea trolley training’ method.⁴ Feedback was collected using a post-training survey, with questions in multiple choice and 5-point Likert scale format and an opportunity for free text comments. Respondents completed the survey immediately after the teaching by scanning a QR code. Data were analysed using Microsoft Excel.

Results: Fifty-seven MDT staff participated in the teaching: ICU/anaesthetics (45); paediatrics (6); emergency department (ED) (6). Survey response rate 100%, results as follows: 93% respondents had cared for <4 critically unwell children in the previous year; 44% reported feeling very anxious about looking after critically unwell children; 89% reported that the Quick Reference cards will be helpful/very helpful in preparing equipment and drug doses; 89% reported that the Quick Reference cards will reduce cognitive load. All participants reported that the Quick Reference cards are likely/very likely to improve patient safety and all participants recommended them to other hospitals. Three free text responses requested that these are made available in the ED, emergency operating theatres and paediatric ward.

Conclusions: Our survey demonstrated that there is significant anxiety around caring for critically unwell paediatric patients, with concerns around decision making for drug doses and equipment sizes. The majority of respondents reported that our readily available Paediatric Emergency Quick Reference Cards will be helpful in decision-making, and would reduce errors and cognitive load in high pressure situations. We plan to run paediatric simulation sessions using these cards and implement them in the ED paediatric resus bay, anaesthetic paediatric trolleys in theatre and on the paediatric ward. Such Quick Reference Cards could be transferable to other DGHs and included in future Advanced Paediatric Life Support manuals and courses.

Figure 1.

Examples of Bath Emergency Paediatric Quick Reference cards for neonate, one year and five years of age.

Figure 2.

‘Tea trolley training’ to raise awareness of the Quick Reference cards and collect MDT staff feedback

References

1. Luten R, Wears RL, Broselow et al. Managing the Unique Size-related Issues of Pediatric Resuscitation: Reducing Cognitive Load with Resuscitation Aids. Acad Emerg Med 2002; 9: 840-7.

2. Szulewski A, Howes D, van Merriënboer JJ et al. From theory to practice: the application of cognitive load theory to the practice of medicine. Acad Med. 2020; 96: 24-30

3. Wales and West Acute Transport for Children. Drug Sheet. https://www.watch.nhs.uk/drug-sheet (2021, accessed 10^th February 2022)

4. O’Farrell G, McDonald M, Kelly FE. “Tea trolley” difficult airway training. Anaesthesia 2015; 70: 104.

4725

Hyperferritinaemia causes inflammasome-driven inflammation in acute respiratory distress syndrome

Thea Mawhinney, Chloe McKee, Wei Wang, Daniel McAuley, Rebecca Coll

Queens University Belfast

Queens University Belfast, [e-mail]

Abstract

Introduction: Elevated serum ferritin (hyperferritinaemia) is associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). Inflammasomes are intracellular complexes which drive inflammation. Increased levels of inflammatory cytokines in ARDS including interleukin (IL)-1β and IL-18 are related to increased inflammasome activity. Inflammasomes are activated by a ‘priming’ signal such as lipopolysaccharide (LPS) and an ‘activation’ signal such as adenosine triphosphate (ATP) or nigericin.¹ Measures of inflammasome activation include quantification of ‘ASC specks’, pyroptosis (inflammatory cell death) and the production of IL-1β and IL-18 cytokines.^2–3 We hypothesise that in ARDS serum ferritin is released from macrophages during pyroptosis, priming inflammasomes and leading to a damaging inflammatory positive feedback mechanism.

Objectives: To examine if ferritin can cause inflammasome activation by nigericin and ATP in a clinically relevant in vitro human macrophage model.

Methods: Human monocytes were isolated from buffy coats and differentiated into macrophages. Macrophages were stimulated with LPS and ferritin, before the addition of ATP or nigericin. LPS with ATP or nigericin treatment is known to activate inflammasomes and serves as a positive control. The NLRP3 inhibitor, MCC950, was employed to prevent inflammasome formation and serves as an additional negative control. Immunofluorescence was used to quantify ASC speck formation by inflammasomes. Cell free supernatants were analysed by ELISA for ferritin, IL-1β and IL-18 concentrations.

Results: The highest numbers of ASC specks were observed in macrophages primed with LPS or ferritin, and stimulated with nigericin (Figure 1). ASC specks were also elevated in cells primed with LPS or ferritin, and stimulated with ATP. There was a reduction in ASC specks in cells treated with MCC950. LPS and nigericin triggered IL-18 secretion and enhanced ferritin secretion. Ferritin secretion was reduced in the presence of MCC950 (Figure 2A). IL-1β secretion and IL-18 secretion were increased when cells were treated with ferritin with ATP or nigericin (Figure 2B and 2C).

Conclusions: We have identified a novel inflammatory process driven by inflammasomes and hyperferritinaemia. Serum ferritin primes inflammasomes leading to a positive feedback mechanism of inflammation.

References

1. Moreira AC, Mesquita G, Gomes MS. Ferritin: an inflammatory player keeping iron at the core of pathogen-host interactions. Microorganisms. 2020 Apr;8(4):589.

2. McKee CM, Coll RC. NLRP3 inflammasome priming: A riddle wrapped in a mystery inside an enigma. Journal of Leukocyte Biology. 2020 Sep;108(3): 937-52.

3. Shi J, Zhao Y, Wang K, Shi X, Wang Y, Huang H, Zhuang Y, Cai T, Wang F, Shao F. Cleavage of GSDMD by inflammatory caspases determines pyroptotic cell death. Nature. 2015 Oct;526(7575):660-5.

Figure 1.

Representative fluorescent micrographs indicating inflammasome activation causing formation of ASC specks. No ASC specks are visualised in unstimulated, nigericin, LPS and ferritin panels. ASC specks are located intra- and extracellularly in LPS + nigericin and ferritin + nigericin panels indicating inflammasome activation. ASC specks indicated by white arrowheads. Scale bar = 100 µm. Created with BioRender.com.

Figure 2.

Inflammasome activation drives ferritin release and ferritin primes inflammasome activation. Donors indicated by individual symbols. Data are median, IQR and 5-95% range from n=6 (A, B) or n=4 (C, D) individual donors. (*p < 0.05, **p < 0.01).

4722

A case of Acute Fatty Liver of Pregnancy in Intensive Care. But also, Sheehan’s Syndrome?

Emma Wilson, Sarah McCann

South Eastern Health and Social Care Trust

South Eastern Health and Social Care Trust, [e-mail]

Abstract

Introduction: Acute fatty liver of pregnancy (AFLP) is thought to be a variant of pre-eclampsia/HELLP syndrome and generally presents in the third trimester. Its prevalence is estimated as 1 to 3 cases per 10,000 deliveries.¹ The estimated maternal mortality is 5 deaths per 100,000 cases and estimated foetal mortality is between 20% and 50%.²

The presenting symptoms are often nonspecific and include malaise, fatigue, nausea and anorexia.¹ Renal impairment occurs in 90% of cases.² Fulminant liver failure manifesting as encephalopathy, coagulopathy and hypoglycaemia can also develop.² Clinical features, particularly renal and liver dysfunction, often deteriorate in the postpartum period. Therefore, patients with AFLP frequently require management in a high dependency setting.²

Sheehan’s syndrome results from necrosis of the anterior pituitary gland following significant post-partum hypovolaemia or shock.³ Pituitary hormone synthesis is consequently affected, causing multiple physiological effects.

The case: A 39 year old lady presented acutely unwell at 38 weeks’ gestation. On arrival, she was found to be jaundiced and the cardiotocograph demonstrated signs of foetal distress.

She underwent an emergency Caesarean section under general anaesthetic. She was hypoglycaemic (blood glucose 2.7mmol/L) and had a metabolic acidosis (pH 7.23, BE -14.8, bicarbonate 13.8mmol/L, pCO2 4.2kPa). Her blood pressure was labile, despite a blood loss of only 500mls, requiring beta-blockade and later, pressors. She delivered a male infant who also had significant metabolic derangement (pH 6.8, Lactate 15mmol/L, glucose 2.9mmol/L).

Postoperatively, extubation failed due to respiratory decompensation and possible encephalopathy. The patient also had persistent hypoglycaemia, lactaemia, consumptive coagulopathy and deranged liver function (Bilirubin 209µmol/L, AST 107 U/L). A diagnosis of AFLP was made after fatty infiltration of the liver was seen on a CT scan. In the context of ongoing hypoglycaemia, mildly deranged LFTs and a persistent pressor requirement, a random cortisol level was measured on day 5 of admission and returned a value of 49nmol/L. This prompted an MRI of pituitary which showed subtle changes in the gland in keeping with Sheehan’s syndrome and the patient was commenced on corticosteroid replacement. Following this she began to wean from invasive therapies. Renal replacement was successfully withdrawn on day 7 followed by extubation on day 8 of admission. She was discharged from ICU on day ten.

Discussion: This lady showed multiple features diagnostic of AFLP. However, she was slow to improve compared to the usual expectation of clinical recovery at 3-4 days postpartum,¹ which prompted a search for additional pathology. Whilst her eventual improvement and recovery could, arguably, have simply represented the natural course of her acute liver disease, it is difficult to dismiss the role of a severely reduced serum cortisol, corresponding changes on pituitary imaging and improvement after introduction of steroids. In hindsight, she did have a number of fluctuations in blood pressure perioperatively which may well have contributed to a Sheehan’s syndrome.

Conclusion: This case serves as a reminder that multiple pathologies can exist in postpartum patients, and indeed, in any critically unwell patient, and should be actively sought, especially if the patient does not respond as expected.

References

1. Naoum E., Leffert L., Chitilian H. et al. Acute fatty liver of pregnancy: pathophysiology, anesthetic implications, and obstetrical management. Anesthesiology 2019; 130: 446-461.

2. Griffiths S., Nicholson C. Anaesthetic implications for liver disease in pregnancy. BJA Educ 2016; 16(1): 21–25.

3. Karaca Z., Laway B., Dokmetas H. et al. Sheehan syndrome. Nat Rev Dis Primers 2016; 2: 16092.

4721

Similar symptoms at 3 months post discharge in ICU, COVID-19 ICU, and COVID-19 patients that received non-invasive ventilation in high dependency areas

Melissa Brown¹, Sarah Sanders²

¹ University hospitals Bristol and Weston

² University Hospitals Bristol and Weston NHS Foundation Trust

University hospitals Bristol and Weston, [e-mail]

Abstract

Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge from ICU [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston (UHBW) had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Spare clinic spaces were used for non COVID ICU patients.

Objectives: To review symptoms reported by patients in the following 3 groups, COVID-19 patients treated in ICU (COVID ICU), COVID-19 patients treated with continuous positive airway pressure ventilation in high dependency areas (COVID CPAP) and non COVID-19 ICU patients (ICU), at 2-3 months post discharge from UHBW.

Methods: Referred patients had an initial phone call at 8 weeks post discharge. The call identified both physical and psychological symptoms. Advice regarding recovery, signposting to resources and onwards referrals to appropriate specialities were provided.

If symptoms indicated, patients would then be referred into the multidisciplinary team follow up clinic. Here they met with an intensivist, clinical psychologist, physiotherapist, occupational therapist, speech and language therapist and dietitian.

Results: As Graph 1 shows all 3 patient groups had a wide variety of ongoing symptoms at 2-3 months post discharge. Fatigue was the most common symptom reported in all 3 groups.

Breathlessness was the second most common symptom reported by COVID patients but was less frequently reported in the ICU population who had a variety of non-respiratory related reasons for admission.

COVID ICU patients more commonly reported ongoing problems with their swallowing, voice and communication compared to the COVID CPAP group, most probably due to invasive ventilation.

Psychological burden post critical illness was high in all 3 groups. More than 20% of all patients scored ≥10 on a PHQ-9 depression scale showing moderate to severe depression. More than 15% of all patients scored ≥10 on a GAD-7 showing moderately severe to severe anxiety.

COVID ICU group had the highest incidence of post-traumatic stress disorder (PTSD). This may be linked to the higher level of delirium we saw in this group, as a result of change in practice, such as full PPE and absence of visiting during the pandemic.

ICU patients presented with a significantly higher percentage of physiotherapy needs. This is likely because patients with the longest and most complex ICU admissions were selected for the clinic.

Sleep likely goes under reported in these results as we only began questioning specifically about this later on in the clinic.

Conclusions: This data goes some way in supporting current literature that the rehabilitation needs of COVID ICU patients equal that of ICU patients (Puthucheary et al 2021). It also shows the need to follow up patients who receive advanced respiratory support outside of the ICU environment, as their symptoms, and therefore rehabilitation needs are very similar to ICU patients at 2-3 months post discharge.

References

1. NICE, Rehabilitation after critical illness in adults. https://www.nice.org.uk/Guidance/CG83 (2009, accessed 24^th February 2022)

2. Puthucheary Z, Brown C, Corner E, et al. The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part II: clinical engagement and future directions for the national Post-Intensive Care Rehabilitation Collaborative. J Intensive Care Soc 2021;1751143720988708

Graph 1

4720

1 year outcomes after lower tidal volume ventilation, facilitated by extracorporeal carbon dioxide removal, in adults with acute hypoxaemic respiratory failure

Andrew Boyle¹, Cliona McDowell², Ashley Agus², Danielle Logan², Jonathan Stewart¹, Colette Jackson², Jeanette Mills², James McNamee³, Daniel McAuley¹

¹ Queen’s University Belfast

² Northern Ireland Clinical Trials Unit

³ Belfast Health and Social Care Trust

Queen’s University Belfast, [e-mail]

Abstract

Introduction: The protective ventilation with veno-venous lung assist in respiratory failure (REST) trial demonstrated that lower tidal volume ventilation, facilitated by veno-venous extracorporeal carbon dioxide removal (vv-ECCO₂R), did not improve 90-day mortality in patients with acute hypoxaemic respiratory failure (AHRF) when compared to standard care.¹ Given that adherence to a lung-protective ventilation strategy is associated with improved long-term outcomes in the acute respiratory distress syndrome,² it is feasible that analysis of long-term outcomes from the REST trial demonstrate a benefit from lower tidal volume ventilation.

Objectives: To evaluate the effect of lower tidal volume ventilation, facilitated by v-ECCO₂R, on outcomes at 1 year, and identify if there was benefit in clinical and functional outcomes in patients that had a meaningful reduction in tidal volume in the intervention study arm.

Methods: This was a pre-specified analysis of the REST trial. Mortality to 1-year was analysed, whilst standardised questionnaires were used to assess respiratory function (St George’s Respiratory Questionnaire (SGRQ)), post-traumatic stress disorder (post-traumatic stress symptoms (PTSS)-14 questionnaire), cognitive function (Montreal Cognitive Assessment (MoCA)-BLIND scoring system or AD8 score) and health-related quality of life (EuroQol Five Dimension 5 level (EQ-5D-5L) questionnaire) were evaluated in survivors at 1 year.

An exploratory analysis of patients who had a reduction in tidal volume (defined as a change from baseline to day 3 of at least 2ml / kg predicted body weight (PBW)), compared to patients in standard care that had no reduction (defined as a change in tidal volume from baseline to day 3 <2ml / kg PBW) was also performed.

Results: 401 of 412 (97%) patients enrolled in the REST trial had 1-year mortality outcome data available, and this was similar between patients allocated to intervention (43.9%) and standard care (42.9%; p = 0.83). 161 patients alive at 1 year provided at least one questionnaire response. There was no difference in SGRQ score (intervention 40.9 [27.1] vs. standard care 40.9 [26.4]; p = 1.00), or PTSS-14 score (intervention (34.3 [19.8]) vs. standard care 38.8 [22.2]; p = 0.25), between treatment groups. Furthermore, there was no significant difference in the proportion of patients that had mild (intervention 33.3% vs. standard care 41.1%), moderate (16.7% vs. 8.9%) or severe (0% vs. 1.8%) cognitive impairment (p = 0.41), whilst health-related quality of life was similar between treatment groups (Table 1).

In an exploratory analysis evaluating the effect of meaningful tidal volume reduction (≥ 2 ml / kg PBW) in patients allocated to intervention, there was no benefit identified in long-term clinical or functional outcomes when compared with patients in standard care with no meaningful tidal volume reduction (Table 2).

Conclusion: Lower-tidal volume ventilation, facilitated by vv-ECCO₂R, does not affect 1-year mortality in patients with moderate-to-severe AHRF, and there was no treatment effect on long term respiratory function, post-traumatic stress disorder, cognitive dysfunction or health-related quality of life.

References

1. McNamee JJ et al. Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure: The REST Randomized Clinical Trial. JAMA. 2021;326:1013–23.

2. Needham DM et al. Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study. BMJ. 2012;344:e2124.

Table 1.

Questionnaires at 1-year following randomization.

	Intervention	Standard care	P-value
St George’s Respiratory Questionnaire score	40.9 (27.1) n=53	40.9 (26.4) n=63	1.00
Post-traumatic stress symptoms-14 score	34.3 (19.8) n=60	38.8 (22.2) n=56	0.25
Normal cognition	30 (50.0%)	27 (48.2%)	0.41
Mild cognitive impairment	20 (33.3%)	23 (41.1%)
Moderate cognitive impairment	10 (16.7%)	5 (8.9%)
Severe cognitive impairment	0 (0.0%)	1 (1.8%)
EQ-5D-5L utility score	0.56 (0.36) n=63	0.56 (0.34) n=67	0.95

Data presented as mean (standard deviation) and analysed using independent samples t-test.

Table 2.

Exploratory analysis evaluating the effect of tidal volume reduction.

	Intervention (tidal volume reduction ≥2 ml / kg PBW)	Standard Care (tidal volume reduction <2 ml / kg PBW)	p-value
St George’s Respiratory Questionnaire score	38.9 (27.2) n=33	42.6 (26.5) n=54	0.53
Post-traumatic stress symptoms-14 score	30.4 (19.6) n=32	39.8 (22.3) n=48	0.06
MoCA-BLIND score	17.4 (3.6) n=32	17.8 (3.1) n=48	0.62
EQ-5D-5L utility score	0.58 (0.35) n=39	0.53 (0.34) n=58	0.52

Data presented as mean (SD) and analysed using independent samples t-test.

4716

Subphenotypes are present in acute hypoxaemic respiratory failure and may respond differently to lower tidal volume ventilation facilitated by ECCO2R

Kiran Reddy¹, Andrew Boyle², John Conlon², David Antcliffe³, Pratik Sinha⁴, Carolyn Calfee⁵, James McNamee⁶, Danny McAuley²

¹ Queen’s University Belfast - WWIEM

² Queen’s University Belfast

³ Imperial College London

⁴ Washington University at St. Louis

⁵ University of California San Francisco

⁶ Royal Victoria Hospital Belfast

Queen’s University Belfast - WWIEM, [e-mail]

Title page

Subphenotypes are present in acute hypoxaemic respiratory failure and may respond differently to lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal

Reddy, K¹, Boyle AJ^1,2, Conlon J¹, Antcliffe DB^3,4, Sinha P⁵, Calfee CS^6,7, McNamee JJ^1,2, O’Kane CM¹, McAuley DF^1,2

¹Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Queen’s University Belfast, 97 Lisburn Rd, Belfast BT9 7B

²Regional Intensive Care Unit, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA

³Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK

⁴Department of Critical Care, Imperial College Healthcare NHS Trust, London, UK

⁵Washington University in St Louis, 7548, St Louis, Missouri, United States

⁶Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine; University of California, San Francisco, San Francisco, CA

⁷Department of Anesthesia; University of California, San Francisco, San Francisco, CA

Abstract

Introduction: Hyperinflammatory and hypoinflammatory subphenotypes in ARDS have consistently different mortality rates, biomarker profiles, and clinical characteristics, and may respond differently to treatment. Simplified models using a limited set of biomarkers and clinical variables have been proposed to identify these subphenotypes. Subphenotypes may be present in a broader population of patients with acute hypoxaemic respiratory failure (AHRF) and may be targetable by precision medicine approaches.

Objectives: To identify ARDS subphenotypes in a critically ill population with AHRF and assess heterogeneity of treatment effect (HTE) based on subphenotype allocation in a trial population.

Methods: This study was a secondary analysis of a subset of patients recruited to the REST trial which randomised patients with AHRF to lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal (ECCO₂R) or standard care and showed no overall treatment benefit. In this subset, the inflammatory cytokines interleukin-8 (IL-8) and soluble tumour necrosis factor receptor-1 (sTNFR-1) were measured by ELISA from plasma samples taken at the time of trial enrolment. These data were used in a regression model that also incorporated bicarbonate and vasopressor use to identify hyperinflammatory and hypoinflammatory subphenotypes. Clinical outcomes were compared between subphenotypes using Fisher’s exact test for categorical variables and Wilcoxin signed-rank test for continuous variables. HTE was examined using logistic regression for mortality and Poisson regression for ventilator-free days (VFDs).

Results: Data were available to classify 75 patients and of these 21 (28%) were allocated to the hyperinflammatory subphenotype. As compared to the hypoinflammatory subphenotype, hyperinflammatory patients had significantly increased driving pressure, more renal dysfunction, more coagulopathy, higher APACHE II scores, and higher SOFA scores. Patients with AHRF with a hyperinflammatory subphenotype had higher 90-day mortality (52% versus 24% for the hypoinflammatory subphenotype; p = 0.18) and fewer median VFDs (5 [IQR 0 – 18] versus 9 [IQR 0 – 18] for the hypoinflammatory subphenotype; p = 0.72) although these differences were not statistically significant. Multivariate regression analysis demonstrated a significant interaction between treatment group and subphenotype for VFDs (p < 0.001) (Figure 1).

Conclusions: This study identified subphenotypes which were previously defined in patients with ARDS in a population of patients with AHRF. Hyperinflammatory patients had improved outcomes when allocated to the treatment group, in contrast to the hypoinflammatory patients who had improved outcome in the control group. Further prospective clinical studies investigating lower tidal volume ventilation with ECCO₂R in patients with a hyperinflammatory subphenotype may be warranted.

Figure 1.

Effect size plot for treatment interaction in multivariate Poisson regression.

4715

QI Project - Improving safety for patients receiving high flow nasal oxygen (HFNO) in the emergency department

Ellen Thompson, Max Zammit-Maempel, Stuart Lutton, Emma Greenwood

Belfast Health and Social Care Trust

Belfast Health and Social Care Trust, [e-mail]

Abstract

Introduction: Most high flow nasal oxygen (HFNO) delivery devices require mains power and will not deliver oxygen during transfer unless attached to a compatible uninterruptible power supply. On 1st April 2020 a National Patient Safety Alert (NatPSA/2020/002/NHSPS)¹ was issued, titled ‘Interruption of high flow nasal oxygen during transfer’. Four deaths were identified over a two year period relating to transfer, with further reports of hypoxia, cyanosis, collapse and respiratory arrest. One of the recommendations (2b) from the alert states - ‘do not start HFNO in any emergency department or short stay unit without a plan for how to transfer the patient onwards’.

In June 2021 ‘Learning Matters’ issue 17² from HSC Public Health Agency detailed a serious adverse incident involving the death of a patient following a transfer from the emergency department to the ward whilst on Airvo2, and it highlights that this is against the manufacturer’s advice as there is no supplemental oxygen supply when the machine is disconnected from the mains power.

After this incident an audit was carried out to review the safety of HFNO use in the emergency department. Followed by a quality improvement initiative to focus on safety and how patients requiring HFNO should be transferred onward.

Objectives: To Improve safety for patients receiving high flow nasal oxygen (HFNO) in the Emergency Department through use of a standardised proforma.

This includes appropriate indications, determining escalation status and a plan for therapy failure, accurate recording of device settings, considerations for transfer onward from the Emergency Department.

Methods: The department computer system ‘Symphony’ was used to identify patients and review data.

Outcome measure - Proforma use

Process measures - Individual proforma elements completed - Indication, Escalation status, Device settings, Transfer documentation

Balancing measures - Any adverse incidents reported

PSDA Cycles

• Baseline Data collected (January - October 21)

• Staff survey (October 21)

• Introduction of paper proforma (November 21)

• Staff education week and competition (January 21)

• Staff survey repeated (February 21)

• Proforma added to ‘Symphony’ system (in progress)

• Introduction of a Standardise Operating Procedure for transfer (in progress)

Results: Baseline data January to October 2021

• None of the former department proformas were used

• The escalation plan was only clear in 46% cases

• Device settings were only recorded in 54% cases

• Transfer was documented in 23% cases

Data for November/December 2021

• Proforma use 50%

• Clear escalation plan 100%

• Settings recorded 75%

• Transfer documentation 50%

Paper proformas received positive feedback from staff so will be uploaded to the ‘Symphony’ system to facilitate ease of use. This will aide with data collection and any future audit.

The repeated staff survey following the education week showed an overall improvement in confidence for setting up, adjusting and managing HFNO.

Conclusions: Safety considerations for patients must be taken into account before starting any therapy. This is an ongoing project which focuses on proforma use to standardise care for patients receiving HFNO in the emergency department, as well as an emphasis on staff education.

References

1. NHS England. Interruption of high flow nasal oxygen during transfer. National Patient Safety Alert NatPSA/2020/002/NHSPS; 1 April 2020.

2. HSC Public Health Agency. Interruption of high flow nasal oxygen (AIRVO 2™) during transfer. Learning Matters; June 2021. 17, p4.

4713

TL;DR - Improving handover through the use of an integrated electronic discharge proforma in neurocritical care

Alexander Davison¹, William Woodward¹, Florence Bell², Manprit Waraich¹

¹ National Hospital for Neurology & Neurosurgery

² Evelina Children’s Hospital

National Hospital for Neurology & Neurosurgery, [e-mail]

Abstract

Introduction: Effective handover between treating clinical teams is an important part of communication in the care of patients leaving the intensive care environment.¹ This can be even more vital in neurocritical care, where patients may be unable to communicate their own history due to neurological deficits and whose families are unable to visit due to COVID. These patients often have had complex neurosurgical interventions and ongoing complex MDT discussion due to the nature of their illness. Handover needs to represent this.

Furthermore, as a specialist tertiary centre, many patients leave the unit as repatriations to other intensive care units. In these situations, it is even more important for good handover to contain the relevant and succinct information for ongoing care.

Objective: We aim to improve the quality of handover from the intensive care team to ward teams at a specialist neurocritical care centre through the use of an electronic discharge proforma integrated into the electronic patient record (EpicCare Epic Systems Corporation). This is a system that has only recently been introduced locally and has required modification for the intensive care environment.

Methods: We performed a retrospective cohort study of documented transfer of care (TOC) summaries for patients entering the ICU in a month-long period. 67 patient admissions were identified as possible candidates with 11 cases excluded as not meeting criteria. The TOC summaries of suitable cases were compared to standards set by the Faculty of Intensive Care Medicine and Intensive Care Society and criteria tailored to the neuro-intensive care environment.

Following this, we implemented a curated discharge proforma for all patients leaving intensive care. Through the use of smart lists and specific prompts, we aim to improve compliance with the guidelines and improve the quality of TOC.

The project is currently ongoing and we aim to repeat the analysis in March 2022 to review if there has been improved compliance.

Results: Compliance for the first round of discharges was variable. There was generally good quality information on the summary of stay of the patient (96%) and ongoing plan for the care of the patient (88%). However, documentation of the rehabilitation needs (32%), psychological needs (14%), communication needs (16%), safeguarding issues (4%), and resuscitation and escalation status of the patient was suboptimal (4%). Documentation of verbal handover to the parent team (25%) and critical care outreach team (45%) was mixed.

Conclusion: Here we present the use of an electronic discharge proforma to improve the quality of handover in patients leaving the intensive care environment. While the study is ongoing, we show that currently local patient handover is often incomplete with a lack of detail in the TOC summary and poor verbal communication between teams. Through the use of this proforma, we aim to improve the quality of this handover and improve the continuity of care for patients leaving the neuro-intensive care unit.

Reference

1. The Faculty of Intensive Care Medicine and Intensive Care Society. Guidelines for the Provision of Intensive Care Services, Edition 2. FICM, June 2019.

Figure 1.

Electronic discharge proforma.

4711

Smartphone App-Based Videolaryngoscopy Data for Adult Intensive Care and Emergency Department Intubations

Kate Goodchild¹, Robert Penders¹, Fiona E Kelly¹, Timothy M Cook²

¹ Royal United Hospitals Bath NHS Foundation Trust, Bath, UK

² University of Bristol, University of Bristol, Bristol, UK

Royal United Hospitals Bath NHS Foundation Trust, Bath, UK, [e-mail]

Abstract

Introduction: Airway management in critically unwell patients outside of the operating room is well recognised to be high risk, with increased unanticipated difficulty, increased life-threatening complications^1–2 and >25% of major airway events reported to NAP4 occurring in ICU or ED.² First pass success (FPS) at tracheal intubation of critically ill patients is associated with reduced major adverse peri-intubation events.³ The importance of maximising FPS and consideration of videolaryngoscopy (VL) is emphasised in Difficult Airway Society guidance.⁴

Objectives: An accessible smartphone intubation app was designed and introduced to enable recording of intubations in our hospital’s VL database following implementation of universal VL. We report data collected for ICU and ED adult intubations occurring from the app launch on 9 March 2020 to 2 February 2022.

Methods: Storz videolaryngoscopes were used for all intubations recorded in the app-based VL database. Grade of intubation is classified as Easy (grade 1 and 2a), Restricted (grade 2b and 3a) or Difficult (grade 3b and 4),⁵ and cases reported as straightforward or difficult. Criteria for difficult intubation includes any of >2 attempts, change in device or operator, or any complications.

Results: Of 123 recorded intubations in ICU and ED (82 male, 41 female), 96% were rapid sequence intubations. Forty-six (37.4%) patients were obese. Intubation was undertaken by 21 junior trainees, 67 senior trainees and 35 consultants: 66% of users were experienced with >50 prior uses of that blade. The FPS rate was 88.6%. First choice blade was a Macintosh-shaped blade in 116 cases and a hyperangulated blade in 7 cases (all 7 cases predicted to be difficult intubations). In 75 cases with a Macintosh-shaped blade, both direct and videolaryngoscopy grades of view were recorded: VL improved the view by one grade in 15 (20%) cases and in no cases was it worse. Forty-five (36.6%) cases were predicted to be difficult for anatomical, physiological or logistical reasons: of these, 39 (87%) cases were straightforward and six (13%) were difficult. Among nine difficult cases (six anticipated, three unanticipated), this included >2 attempts in two cases, a change in device in two, a change in operator in three and six complications. Number of attempts in difficult cases was 1 in four cases, 2 in three cases, 3 in two cases and there were no failed intubations. Complications occurred in 6/123 (4.9%) of cases: profound hypoxaemia (Sp0₂ <60%, three cases); severe hypoxaemia (Sp0₂ <75%, one case with pre-existing hypoxaemia); tachyarrhythmia (one case); recognised oesophageal intubation (one case, 0.8%).

Conclusions: A smartphone app-based approach for recording intubation data enables audit of performance and analysis of difficult cases and complications. Our 88.6% FPS rate, 4.9% complication rate and 0.8% oesophageal intubation rate all compare favourably to a recent large study which used a predominantly direct laryngoscopy approach (79.8% FPS, 45.2% peri-intubation adverse events, 5.6% oesophageal intubation rate).³ Larger database and registries may provide useful information to support or refute the value of videolaryngoscopy as a primary tool for tracheal intubation in the critically unwell population.⁴

References

1. Nolan JP, Kelly FE. Airway Challenges in Critical Care. Anaesthesia 2011; 66: 81-92

2. Cook TM, Woodall N, Harper J et al. Major Complications of Airway Management in the United Kingdom: results of the 4^th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia 2011; 106: 632-642

3. 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: 1164–172

4. Kelly FE, Cook TM. Seeing is Believing: getting the best out of videolaryngoscopy. British Journal of Anaesthesia 2016; 117: i9-i13

5. Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000; 55 (3): 274-9

4710

ICU follow-up clinic provides the opportunity to recognise and address symptoms post critical illness, which may otherwise have been missed

Melissa Brown¹, Susan Calvert², Olivia James³

¹ University hospitals Bristol and Weston

² University Hospitals Bristol and Weston

³ University Hospitals Bristol and Weston NHS Foundation Trust

University hospitals Bristol and Weston, [e-mail]

Abstract

Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors.

Objectives: To provide a service that supports and empowers patients with their recovery from critical illness. Improving quality of life, speed of recovery and reducing longer term health care needs.

Methods: Referral criteria for the clinic included COVID-19 patients who received advanced respiratory support within intensive care and the high dependence unit. 8 weeks post discharge patients had a telephone appointment where ongoing symptoms could be identified. Advice around recovery, signposting to resources and onward referrals to appropriate specialities were provided. At 10 weeks post discharge patients had lung function tests and a chest X-ray which were reviewed by respiratory consultants. Based on the combination of these assessments, patients would be discharged or referred into the multidisciplinary team (MDT) follow-up clinic.

The face to face clinic consisted of appointments with an intensivist, clinical psychologist, physiotherapist, and occupational therapist. Where needed patients would also be seen by a speech and language therapist or dietitian. Patients were seen only once in follow up clinic but again would be referred onto appropriate services within trust or the community, including but not exclusively community therapy services, secondary care services, SALT, dietetic or psychology clinics.

Results: One of the key outcomes was the need for 147 onward referrals (an average of 1.13 referrals per patient). This included, 31 referrals to musculoskeletal physiotherapy outpatients for problems originating or made worse by their admission. 20 referrals to secondary care, including cardiology and ENT. 16 referrals to community occupational therapy, for provision of equipment, home adaptations and support in accessing the community.

Subjectively, patient feedback was excellent. When asked what they felt was the most valuable thing they had taken from the clinic they reported: “Reassurance”; “To know I’m not alone, others feel like this”; “They listened to me and gave advice”; “The ability to ask anything I wanted and the obvious kindness and support from all the clinicians I saw”.

Conclusions: Onward referral rates made by the follow-up clinic highlight the many issues faced by patients following discharge from ICU and hospital. With timely recognition and management, we can prevent a majority of these symptoms manifesting into chronic problems. This has the potential to lower the long-term burden on health care and improve quality of life for patients in both the short and long term. Without the follow-up clinic, these issues may have been missed or delayed. This reinforces the importance of the follow-up clinic and the need for ongoing investment.

Reference

1. NICE, Rehabilitation after critical illness in adults. https://www.nice.org.uk/Guidance/CG83 (2009, accessed 24^th February 2022)

4708

Establishing an Intensive Care follow up clinic for patients in Belfast, Northern Ireland

Aoife Deeny, Helen Lindsay, Rosalind O’Reilly, Rachel Irwin

Belfast HSCT

Belfast HSCT, [e-mail]

Abstract

Introduction: National guidance states that follow up should be offered to all patients who have spent more than four days in intensive care¹ with specific guidance for the follow up of COVID patients released in May 2020.² Prior to the pandemic, in the Belfast trust, there was no follow-up service provided for intensive care patients. The pandemic presented many new challenges to intensive care, with a high number of patients requiring follow up after discharge. It also presented a unique problem in that follow up clinics could not be delivered in the traditional face to face manner.

Objective: To set up a follow up service that assessed patient recovery from COVID 19 and offered rehabilitation, in a manner that could be delivered safely during a national lockdown.

Method: A database was collated of all the patients who had been treated in intensive care, during the first wave of the pandemic with a confirmed positive COVID-19 sample. A follow up pathway (Figure 1) was designed for the clinic based on the BTS and FICM guidelines.^2–3 The multidisciplinary team used Microsoft Teams to complete clinic proformas for each patient, share files and perform virtual appointments. Patient questionnaires were collated using the forms app within MS Teams. Patients filled in various objective health questionnaires at both their 6 and 12 week appointments to allow the team to assess their rehabilitation. Once the appointments were completed the proformas were entered into their permanent medical record on the Northern Ireland Electronic Care Record (NIECR).

Results: There were 42 patients treated in the pandemic’s first wave, 40 were reviewed at 6 weeks and 39 at 12 weeks post hospital discharge. Anonymous feedback was gathered electronically from patients about their experience of the clinic. The feedback from the patients was overwhelmingly positive. To date the clinic has offered follow up to nearly 300 patients and is still in use. It has grown in size and has received input from the Belfast trust for further staffing and resources. The project recently received joint first prize in the innovation and transformation in care category for the Health and Social Care Quality Improvement (HSCQI) awards in the trust.

Conclusion: This project highlights the essential requirement for follow-up after an intensive care admission with significant ongoing morbidity demonstrated in this patient cohort. It is currently still the only service with this breadth of MDT input in Northern Ireland. The initial use of MS Teams has allowed this service to run safely during a pandemic but it has since been adapted as the pandemic has evolved and is now offered to all Intensive care patients. Its collaborative platform allows for immediate communication throughout the whole team, and the ability for the team to be flexible. In essence, we have set up a unique and robust system that can be easily used to offer excellent follow up to Intensive care patients within the Belfast trust.

References

1. NICE Guidance. Rehabilitation after critical illness in adults. https://www.nice.org.uk/guidance/cg83( 2017 accessed April 2020).

2. British Thoracic Society. Guidance on Respiratory Follow Up of Patients with a Clinico-Radiological Diagnosis of COVID-19 Pneumonia. https://www.brit-thoracic.org.uk/document-library/qualityimprovement/covid-19/resp-follow-up-guidance-post-covid-pneumonia (May 2020 accessed May 2020).

3. The Faculty of Intensive Care Medicine. Recovery and Rehabilitation for Patients Following the Pandemic. https://www.ficm.ac.uk/sites/ficm/files/documents/2021-10/ficm_recovery_and_rehab_provisional_guidance.pdf(May 2020 accessed May 2020).

Figure 1.

Belfast Trust ICU Follow Up Clinic Pathway.

4707

Comparing effects of invasive versus non-invasive ventilation on P/F ratio, CRP and respiratory rate of COVID patients, a retrospective observational study

Nabeel Amiruddin, Tarek Hassan

Russells Hall Hospital

Russells Hall Hospital, [e-mail]

Abstract

Introduction: Some of the COVID pneumonitis patients are happily hypoxic and not showing signs of severe respiratory distress despite being significantly hypoxic,¹ leading to a delay to start a timely treatment and may worsen the prognosis.² Studies have shown that non-invasive ventilation could be used in severe COVID pneumonitis and could avoid intubation in some of those patients.³ Effects of different modalities of ventilation on the oxygenation of COVID-19 patients and on the inflammatory process accompanying COVID-19 pneumonitis need thorough investigation in a trial to reach to an understanding of the pathophysiological process and may be a guide to formulate the optimum protocol to ventilate COVID-19 patients.

Objectives: Comparing the effects of invasive versus non-invasive ventilation on P/F ratio, CRP and respiratory rate of COVID-19 patients.

Methods: In this retrospective observational study, we compared the effect of NIV on the P/F ratio, CRP trends and Respiratory rates of COVID patients during their ITU admission in comparison with intubated ventilated patients. The study was carried out in a single center in England before introduction of the Tocilizumab in the guidelines of COVID treatment and included 74 COVID patients divided in to two groups, group A which included 15 patients who were non-invasively ventilated and avoided intubation during their ITU admission while group B included 59 patients who were intubated at certain point of their course of admission.

Patients` Respiratory rate, modality of ventilation, time of intubation (if any), modes of ventilation, FIO2, P/F ratio and CRP trends were followed during their admission. The collected data of 3 variable (CRP, RR and P/F ratio) has been blotted and a summative means were calculated. The least square means of the linear models of the ventilated and non-ventilated patients were used to compare both groups.

Results: 36.4 % of intubations was done before or during the first 20 hours of the ITU admissions and 50% during the first 40 hours. The study also has shown the probabilities in the difference between slopes as following.

Firstly, regarding P/F ratio the probability was 0.058 in favor of non-invasive ventilation. Secondly, RR probability was <0.0001 significantly in favor of non-invasive ventilation. Lastly, CRP probability was 0.024 significantly in favor of non-invasively ventilated patients.

Conclusion: CRP and respiratory rate were significantly less in non-invasively ventilated COVID pneumonitis patients in comparison with ventilated patients while there was no significant difference in P/F ratio trends between both groups.

References

1. Wilkerson RG, Adler JD, Shah NG, Brown R. Silent hypoxia: a harbinger of clinical deterioration in patients with COVID-19. Am J Emerg Med. 2020; W. B. Saunders; [cited 2020 May 31]; Available from: https://linkinghub.elsevier.com/retrieve/pii/S0735675720303909.

2. Xie J, Covassin N, Fan Z, Singh P, Gao W, Li G, et al. Association between hypoxemia and mortality in patients with COVID-19. Mayo Clin Proc. 2020; Elsevier; [cited 2020 Apr 19];0. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0025619620303670.

3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054-62.

4704

Scope in the wind: Videolaryngoscopy outside the operating theatre setting

Jan Hansel¹, Andrew Rogers²

¹ Manchester University NHS Foundation Trust

² Royal United Hospitals Bath NHS Foundation Trust

Manchester University NHS Foundation Trust, [e-mail]

Abstract

Introduction: The role of videolaryngoscopy (VL) for tracheal intubation in settings outside of the operating theatre is not clear, with evidence to date suggesting possible benefits and harms when compared to direct laryngoscopy (DL).^1–3

Methods: Data from a recent Cochrane systematic review of randomized controlled trials comparing VL to DL for tracheal intubation in adults was used to conduct post hoc subgroup analyses looking specifically at intubations performed outside the operating theatre setting.¹ We looked at four critical outcomes: failed intubation, hypoxaemia, successful first attempt and oesophageal intubation. We combined all videolaryngoscope designs for our comparisons. We used risk of bias assessments from the full review. We report effect estimates for dichotomous outcomes as risk ratios (RR) with 95% confidence intervals (CI), using random-effects models for meta-analysis. We used Review Manager 5 software for data synthesis.

Results: We found 21 studies (with 4261 participants) conducted in the emergency department (ED), intensive care unit (ICU) or prehospital setting. All studies were at high risk of bias in at least one domain. The most commonly reported outcome in these studies was successful first attempt, with approximately half of the studies reporting using a hyperangulated VL design. We found little or no difference in rates of failed intubation (RR 0.80, 95% CI 0.34 to 1.90; I2 = 84%; favours VL; 11 studies, 2059 participants), hypoxaemia (RR 0.73, 95% CI 0.53 to 1.02; I2 = 34%; favours VL; 6 studies, 1095 participants), successful first attempt (RR 1.07, 95% CI 0.98 to 1.16; I2 = 87%; favours VL; 18 studies, 3793 participants), or oesophageal intubation (RR 0.57, 95% CI 0.27 to 1.20; I2 = 34%; favours VL; 11 studies, 2422 participants). When analysing success on the first attempt by setting, we noted the effect estimate for prehospital studies favouring DL (RR 0.83, 95% CI 0.62 to 1.12; I2 = 95%; favours DL), and statistically significantly improved rates of successful first attempt in ICU when a VL was used (RR 1.19, 95% CI 1.04 to 1.36; I2 = 71%; favours VL) (Figure 1). This was, however, associated with considerable heterogeneity and few studies contributed data overall. The possible reasons for the discrepancy are explored to some extent in the prehospital trial manuscripts, and range from factors such as intubators’ differential expertise with the two devices, patient factors (e.g. airway soiling, suboptimal positioning), and environmental factors, such as unfavourable weather conditions (e.g. sunlight causing glare, rain obscuring the screen).^4–5

Conclusion: This post hoc subgroup analysis highlights the need to further explore the role of VL in the prehospital setting, where harms may outweigh benefits, while providing additional support for the use of VL in ED and ICU.

Figure 1.

Forest plot comparing successful first attempt with videolaryngoscopy versus direct laryngoscopy by setting (ED, ICU, prehospital).

References

1. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis. Cochrane Database of Systematic Reviews. Forthcoming 2022.

2. Griesdale DE, Chau A, Isac G, Ayas N, Foster D, Irwin C, Choi P, Canadian Critical Care Trials G: Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial. Canadian Journal of Anaesthesia 2012; 59(11): 1032-9.

3. Janz DR, Semler MW, Lentz RJ, Matthews DT, Assad TR, Norman BC, Keriwala RD, Ferrell BA, Noto MJ, Shaver CM, et al. Randomized trial of video laryngoscopy for endotracheal intubation of critically ill adults. Critical Care Medicine 2016; 44(11): 1980-7.

4. Arima T, Nagata O, Miura T, Ikeda K, Mizushima T, Takahashi A. Comparative analysis of airway scope and Macintosh laryngoscope for intubation primarily for cardiac arrest in prehospital setting. American Journal of Emergency Medicine 2014; 32: 40-3.

5. Trimmel H, Kreutziger J, Fertsak G, Fitzka R, Dittrich M, Voelckel WG. Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: a randomized control trial. Critical Care Medicine 2011; 39: 489-93.

4703

Follow-up after critical illness: A service evaluation of a therapy-led virtual triage assessment

Katie Johnson, Huw Woodbridge, Vicky Newey, Alice Harrison, Maribel Manikon, Stephen Brett

Imperial College Healthcare NHS Trust

Imperial College Healthcare NHS Trust, [e-mail]

Abstract

Introduction: Patients who have been discharged from an intensive care unit (ICU) can have long-lasting complications including unresolved medical issues and physical, cognitive and psychological disability, all impacting on quality of life.¹ Addressing these substantial needs is vital, however, currently there is uncertainty over the optimal way to achieve this to enhance survivorship from critical care.² At Imperial College Healthcare NHS Trust, a UK hospital group with ICUs on three acute hospital sites, a critical illness follow up pathway has been established with a key component of an initial virtual follow up screening call. This follow up call is implemented six weeks after hospital discharge for all ICU survivors who had an ICU length of stay of four days or more. It is a therapist-led assessment, identifying any unmet patient needs and initiating early management and onward referrals. Patients are then triaged and those with ongoing needs are discussed at a multidisciplinary team meeting (MDT), with subsequent onward referral being made to a face to face consultant-led clinic as appropriate.

Objectives: To describe a service evaluation of a novel pathway of virtual critical illness follow up and how it facilitates identification of critical illness survivor unmet needs and appropriate initiation of early management and onward referrals.

Methods: Over a three month period after initiation of the virtual triage appointment, a service evaluation was carried out to describe the following outcomes:

1. The number of eligible ICU survivors who took part in the follow-up appointment.

2. Number of unmet health needs identified.

3. Number of patients discussed in an MDT and number followed up in a consultant-led clinic.

4. Number of patients issued with self-management advice.

5. Number of patients where a new onward referral was initiated.

6. Patient satisfaction ratings on a five-point Likert scale.

Results: Over a three month period, 66% of eligible patients took part in a virtual ICU follow up appointment. Of these 123 patients, a median of 6 (IQR 4-8, mode 4) unmet needs were identified per patient. 52 patients (42%) were then discussed in an MDT and 44 (35%) referred to a consultant-led clinic. For each patient, a median of 1 (IQR 1-2, mode 1) type of self-management advice (such as breathlessness or fatigue management) was given and a median of 2 (IQR 1-3, mode 2) onward referrals were made (such as for community physiotherapy or social services). 89% of patients asked (n=54) rated the appointment as ‘very useful’.

Conclusions: A virtual critical illness follow up triage assessment was found to be accessible for service users, facilitating the screening of a large number of survivors. The assessment facilitated early holistic identification of the needs of ICU survivors, initiation of appropriate management and appropriate triage to a face to face consultant-led clinic for those with outstanding needs. Providing an initial virtual appointment was highly rated by service users.

Funding

HRW receives funding from the NIHR Imperial BRC.

References

1. Iwashyna, T. J. & Netzer, G. 2012. The burdens of survivorship: an approach to thinking about long-term outcomes after critical illness. Semin Respir Crit Care Med, 33, 327-38.

2. Schofield-Robinson OJ, Lewis SR, Smith AF, McPeake J, Alderson P. Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database of Systematic Reviews 2018, Issue 11. Art. No.: CD012701.

4702

Diffuse Idiopathic Skeletal Hyperostosis: An Unusual cause of Recurrent Airway Obstruction

Shane o Keeffe¹, Donal O Croinin²

¹ HSE

² Mercy University Hospital

HSE, [e-mail]

Abstract

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is a condition characterised by the ossification and calcification of ligaments and entheses.¹ We report an unusual case of recurrent acute upper airway obstruction resulting in respiratory failure secondary to DISH. This was successfully treated by cervical osteophytectomy.

Case Presentation: A 75 year-old man with a past medical history of COPD was admitted to hospital for management of self-neglect. Chlordiazepoxide was prescribed for alcohol withdrawal. That evening nursing staff witnessed an acute desaturation event while he was eating and felt it likely he had aspirated. He was designated NPO. A few hours later he collapsed following apparent respiratory arrest so his trachea was intubated. Laryngoscopy with a McGrath laryngoscope revealed a view consistent with Cormack-Lehane grade one. Upon transfer to the ICU arterial blood gas analysis was normal and the patient required minimal supplementary oxygen. The working diagnosis was respiratory arrest secondary to over-sedation. The following morning the patient’s trachea was extubated and the chlordiazepoxide discontinued. GCS was 15/15 and he had minimal oxygen requirement. That night he had another respiratory arrest leading to tracheal intubation with rapid subsequent normalisation of arterial blood gas analysis. Documentation pertaining to his past medical history was obtained and revealed he had previously been investigated for dysphagia at a different hospital. At that time he was diagnosed with DISH affecting the cervical spine with osteophyte protrusion into the mid pharynx and upper oesophagus. We did not believe DISH to be the primary cause of his recurrent deterioration due to the non-obstructive images on previous MRI and normal views on laryngoscopy

Clinically, the patient had a rapidly progressing myopathy believed to be due in part to his poor baseline nutritional status. It was decided to trial extubation to non-invasive ventilation (BiPAP) as there was concern that prolonged invasive ventilation might lead to a worsening of the myopathy. The patient had 48 hours off invasive ventilation before once again having an episode of profound desaturation resulting in intubation.

CT scan of the neck was performed. This showed severe diffuse idiopathic skeletal hyperostosis with a fused anterior osteophyte formation from C3-C7 level with a pseudoarticulation of the most prominent osteophyte at C3 vertebral level extending anteriorly and causing airway compression. Neurosurgical and otolaryngological consultations led to planned anterior cervical osteophytectomy, decompression of the oropharynx and tracheostomy insertion. Following an uneventful recovery he was de-cannulated six weeks later when the considerable post-operative haematoma and oedema of the airway had resolved.

Discussion: DISH is a not uncommon condition and should be included in the differential for airway obstruction in patients who have a history of dysphagia or suspected recurrent aspiration. There are some case reports in the literature detailing DISH causing airway obstruction but these generally present with chronic slowly deteriorating symptoms or acute deterioration of chronic airway obstruction provoked by respiratory infection.^2–3 As tracheal intubation was easy on all occasions in this case airway obstruction seemed relatively unlikely. This dramatic presentation of apparently unprovoked recurrent acute airway obstruction resulting in respiratory arrest due to DISH is rare and is not well documented in the literature.

Figure 1.

Axial view of CT neck at C3 vertebral level showing osteophyte protrusion causing airway obstruction.

Figure 2.

Sagittal view of CT neck showing fused anterior osteophyte formation from C3-C7 with a pseudoarticulation of the most prominent osteophytes at C3 vertebral level extending 1.8cm anteriorly and causing airway obstruction.

Figure 3.

Sagittal view of CT neck post op showing surgical excision of large parts of anterior osteophyte complex previously spanning vertebral levels C2-C4.

References

1. Mader R, Verlaan J-J, Buskila D. Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms. Nat Rev Rheumatol 2013; 9: 741–750.

2. Hoey AW, Dusu K, Gane S. Diffuse idiopathic skeletal hyperostosis (DISH): an unusual cause of airway obstruction. BMJ Case Rep; 2017. Epub ahead of print 15 March 2017. DOI: 10.1136/bcr-2017-219635.

3. Yoshimatsu Y, Tobino K, Maeda K, et al. Management of Airway Obstruction due to Diffuse Idiopathic Skeletal Hyperostosis in the Cervical Spine: A Case Report and Literature Review. Intern Med 2019; 58: 271–276.

4701

Introduction of a multidisciplinary rehabilitation assistant in to an intensive care setting

Rebeca Romain, Emma Brereton, Menke Wiersma, Naomi Fisher, Hannah Parsons, Siobhan Moore

Cardiff and Vale University Health Board

Cardiff and Vale University Health Board, [e-mail]

Abstract

Introduction of a multidisciplinary rehabilitation assistant in to an intensive care setting

Rebeca Romain, Emma Brereton, Menke Wiersma, Naomi Fisher, Hannah Parsons, Siobhan Moore

Cardiff and Vale University Health Board, Cardiff

Introduction: This abstract provides an overview of introducing a multidisciplinary rehabilitation assistant (RA) into the University Hospital of Wales Intensive Care Unit (ICU) following receiving funding from the directorate. We will discuss benefits, challenges and future development aims for the role.

Objectives: From the outset, the aim was to work collaboratively to establish an interdisciplinary role and enhance rehabilitation along the ICU pathway. Our vision was to provide training and skill development across all professional areas, thus enabling holistic input to patients, with multiple therapeutic aims met at each patient contact.

Methods: A lead from each allied health professional (AHP) was identified (occupational therapy; speech and language therapy; dietetics; physiotherapy; psychology). The group used experiences from services that already had an established RA e.g. Major Trauma. A decision was made to follow a task-based approach to developing competencies and agreeing upon a job plan. A structured induction and training timetable was developed for the first three months. The RA had a designated supervisor and named contact from each speciality with regular supervision and progress meetings arranged. A test of change questionnaire was developed for pre/post training with the aim of evaluating knowledge and effectiveness of training.

Results: The most significant benefit of this role to date has been enhanced patient wellbeing and maximisation of therapist’s time. This has been achieved through improved multi-disciplinary team (MDT) communication and AHP role promotion, thus allowing for more timely identification of patient needs and onward referrals to relevant professionals. A holistic and therapeutic approach to patient care has maximised the impact and value of every contact. This role has also created an enriched environment, improved access to various resources and enhanced MDT data collection and documentation.

Due to the scope of the role, significant time investment and planning was required pre/post recruitment to facilitate integration, training and communication across all AHPs. The unpredictability of workload and variability of patients alongside awareness of the role and ensuring it remained appropriate for band 3 level were challenges in implementation.

A test of change questionnaire has shown improvement in confidence scores and depth of knowledge, demonstrating successful training and induction. However quantifying the value of the role has not yet been achieved.

Conclusions: The introduction of the RA has been an overwhelmingly positive addition to the service, however as with integration of all new roles we have met challenges along the way as discussed above. Our aspirations for this role’s development are to build on the foundations established, by expanding competencies in a broader variety of tasks across the professions and optimising communication to streamline workload. Additionally, aiming to utilise the role across the whole ICU patient journey including ward step down and follow up post discharge. Ongoing evaluation will be vital to ensure the role meets the complex needs of the ICU patient cohort and is utilised to its full potential. This will require development of a robust method of demonstrating the value of the RA, with the longer-term aim of expanding the RA workforce.

4698

An innovative digital care pathway supporting intensive care survivor recovery: preliminary data from a service innovation project

Kate Brooks¹, Chloe Apps¹, Ella Terblanche², Nicholas Hart¹, Joel Meyer¹, Louise Rose²

¹ Guy’s and St Thomas’ NHS Foundation Trust

² King’s College London

Guy’s and St Thomas’ NHS Foundation Trust, [e-mail]

Abstract

Introduction: Survivors of critical illness experience prolonged physical, cognitive and psychological challenges impeding recovery. Healthcare fragmentation following in-patient setting transfers and hospital discharge is common. This fragmentation can result in information loss, treatment omissions, and poor patient and family experience. Bridging transitions with virtual care and telemedicine can ameliorate these issues and enable individualised patient and family-centred support. Therefore, we created a digital ICU recovery pathway delivered via an e-health platform (aTouchaway, Aetonix, Canada), supported by a dedicated ICU recovery co-ordinator.

Objectives: To develop, implement, and evaluate the digital ICU recovery pathway in a single tertiary centre.

Methods: We co-designed the pathway using a series of consultation meetings with healthcare professionals representing ICU multidisciplinary team members, clinical academics (UK and international), patients and family members, in collaboration with our e-health partner Aetonix. We iteratively designed clinical workflows (similar to automated protocols) for in-hospital and at-home recovery phases. The pathway central component is individualised patient recovery goal-setting in collaboration with the recovery co-ordinator. Goal achievement is self-reported based on Goal Attainment Scaling. The pathway includes e-forms to assess baseline status and recovery barriers, e-resources tailored to individualised recovery barriers, recovery e-diary, tailored activity reminders, two way-digitally secure text, audio and video communication, and note functions. We launched the pathway in June 2021. Evaluation methods comprise quantitative (acceptability, feasibility, appropriateness measures [AIM, FIM, IAM]) and qualitative assessment of participant engagement with and acceptability of the digital pathway.

Results: To-date, we have enrolled 50 ICU survivors with 39 (78%) actively engaged in goal setting and rating via the digital platform. Of the 39 patients, 30 (77%) required 107 onward speciality referrals, mean (SD) of 5.2 (2.5) referrals/patient; 32 (82%) required occupational therapist specialist care and advice including vocational rehabilitation, upper limb assessment, cognitive rehabilitation, and fatigue management. In terms of individualised recovery goal achievement, 39 patients set 126 weekly goals and achieved 77 (61%); 39 set 96 monthly goals and achieved 43 (45%); 36 set 50 aspirational goals and achieved 18 (36%). Of the 39 active patients, 10 have completed the pathway.

Eight patients to-date rated on the AIM, FIM, IAM with mean (SD) scores of 4.4 (0.71), 4.4 (0.62), and 4.3 (0.80) respectively, indicating agreement that the recovery pathway is acceptable, feasible, and appropriate.

Qualitative interviews with 8 participants identified initial themes of ‘promoting recovery through individualised advice’, ‘accessibility to recovery coordinator for emotional support’ and ‘positive impact of goal monitoring’

“One of the most important things to me has been jointly setting goals with the recovery co-ordinator. At first, I couldn’t even brush my teeth by myself, so this became a goal. We still do medium and long term goal setting now, and it was and still is incredibly invaluable to stay focused and positive” Participant 1.

Conclusion: In this cohort of 50 ICU survivors enrolled into a novel co-designed digital ICU recovery pathway, most required specialty referrals and occupational therapist management and advice once discharged home. Preliminary results demonstrate good acceptability, feasibility and engagement in the digital ICU recovery pathway.

4696

Outcomes of cancer patients with Covid-19 admitted to the Intensive Care Unit: a retrospective study

Jigeeshu Divatia¹, Shilpushp Bhosale², Nirmalyo Lodh¹, Sheila Myatra¹, Amol Kothekar¹, Vijaya Patil¹, Atul Kulkarni¹

¹ Tata Memorial Hospital

² Tata memorial Hospital

Tata Memorial Hospital, [e-mail]

Abstract

Introduction: Active cancer increases the odds of death among patients with COVID-19.¹ Cancer patients may be at increased risk of complications and mortality from COVID-19 owing to the systemic effects of malignancy, immune suppression after chemotherapy, treatment-related complications and presence of co-morbidities.² They may develop serious complications necessitating ICU admission. In a meta-analysis, the pooled mortality in cancer patients with COVID-19 admitted to an ICU was 60.2%.³ Our hospital is a tertiary referral cancer centre, and the ICU admitted cancer patients with Covid-19 throughout the pandemic.

Objectives: To determine the 30-day in-hospital mortality of adult cancer patients with Covid-19 admitted to the ICU. We also aimed to determine the factors associated with mortality in cancer patients with Covid-19.

Methods: After approval from the Institutional Ethics Committee, data of all cancer patients (age ≥ 16 years) with Covid-19 admitted to the ICU between March 2020 and March 2021 were retrieved from the hospital records. In case of multiple ICU admissions, data from the first admission was recorded. Data recorded included demographic details, type of cancer (solid, haematological), surgical status, APACHE-II and SOFA scores, C-reactive protein, and interventions in ICU. The primary outcome was 30-day in-hospital mortality. Data were analysed using Man-Whitney test and chi-square test. A multivariable regression analysis was carried out to determine factors associated with mortality.

Results: Data of 127 cancer patients with Covid-19 was analysed. The median [interquartile range, IQR] age was 55 (43-62) years, and there were 50 females (39.3%). Comorbidities were present in 46 (36%) patients, the commonest being diabetes (29 patients) and hypertension (31 patients). The median [IQR] APACHE-II and SOFA scores were 15[8-20] and 4[2-7], respectively. Overall, 62/127 patients died, and 30-day hospital mortality was 49%. There were 30 patients with haematological malignancy and 97 with solid tumours with 30-day in-hospital mortality rates of 46.7% and 49.5%, respectively; p = 0.84). Amongst patients with solid tumours, there was no difference in mortality in surgical patients compared to non-surgical patients (43.3% vs. 52.2%; p = 0.42). Table 1 summarises the parameters and interventions in survivors and non-survivors. On multivariable analysis, only the change in SOFA score from Day 1 to Day 3 was independently associated with outcome (Odds ratio 1.36 (95% confidence interval 1.01-1.84, p-0.04).

Conclusions: In patients with cancer and Covid-19 and age ≥16 years admitted to our ICU, the crude 30-day hospital mortality was 47%. There was no association of mortality with cancer type or surgical status. The only independent predictor of mortality was progression of organ failure. Cancer patients with Covid-19 have a reasonable outcome and should be given a trial of intensive care.

References

1. Gupta S, Hayek SS, Wang W, et al. Factors associated with death in critically ill patients with coronavirus disease 2019 in the us. JAMA Intern Med. 2020;180:1436-1447

2. Disis ML. Oncology and COVID-19. JAMA. 2020; 324:1141

3. Nadkarni AR, Vijayakumaran SC, Gupta S, Divatia JV. Mortality in Cancer Patients With COVID-19 Who Are Admitted to an ICU or Who Have Severe COVID-19: A Systematic Review and Meta-Analysis. JCO Glob Oncol. 2021 Aug;7:1286-1305.

Table 1.

Severity of illness and interventions.

Parameter	Survivors	Non-survivors	p
APACHE II Score*	10 [5-16]	17 [11-22.25]	<0.01
SOFA score (Highest)*	3 [2 - 6]	7 [4-12]	<0.001
Day3 SOFA-Day1SOFA*	0 [-1 to 1]	1 [0-3]	0.003
C-reactive protein (highest, mg/L)*	14.1 [8.0-25.3]	19.6 [12.6-26.9]	0.08
Mechanical ventilation	21 (33.3%)	42 (66.7%)	<0.001
Corticosteroids	39 (47%)	44 (53%)	0.19
Vasopressors	21 (33.3%)	42 (66.7%)	<0.001
Dialysis	6 (27.3%)	16 (72.7%)	0.01

*

:Median[IQR]

4695

Management of raised blood glucose within a critical care unit – would a point-of-care ketone meter be of benefit?

Jenny Heath, Laura Medhurst, Chian Chyn Leo Khoo, Elizabeth Flockton

Royal Liverpool University Hospital

Royal Liverpool University Hospital, [e-mail]

Abstract

Introduction: Diabetic Ketoacidosis (DKA) is a common cause of admission to a critical care unit.¹ Management relies on regular monitoring of parameters including serum ketones, glucose, and pH. National Diabetes UK guidance states that measurement of serum ketones with a point-of-care ketone meter is gold standard to guide DKA management.² In our critical care department ketones were measured via serum samples that were sent to the lab. We aimed to assess if a busy inner city critical care unit were adhering to local guidance in measuring serum ketones when serum blood glucose was measured over 16mmol/l. We also questioned whether there is a role for a point-of-care ketone meter within a critical care setting given the intensity of measurements required when treating patients with DKA.

Objectives: To measure the adherence to local protocols for serum glucose and ketone monitoring, whereby serum ketones should be obtained when blood glucose measurements are over 16mmol/l. To investigate problems that may lead to delay or failure to obtain timely serum ketone results. To consider if a point-of-care ketone meter would be an appropriate implementation within the critical care unit.

Methods: Over a two-week period in November 2020, we measured (1) the number of patients in the High Dependency and Intensive Care Units who had blood glucose measurements above 16mmol/l; (2) the total number of blood glucose readings over 16mmol/l; and (3) how many serum ketone measurements were sent. We retrospectively analysed patient notes to investigate any events surrounding the raised serum glucose and any factors that may have influenced serum ketone measurement.

Results: In total there were 78 patients treated in the critical care units in the two-week period under investigation. Of these, 11 patients (14%) had a recorded blood glucose of above 16mmol/l on at least one occasion, and one of these patients was admitted with DKA. There was a total of 70 individual raised blood glucose events that - according to local protocol - would require a serum ketone measurement. In total 5 (7%) serum ketone measurements were sent. Of ketone samples sent, one sample was deemed invalid as it arrived at the lab over 30 minutes from collection. No urinary ketones were measured.

Anecdotally, reasons for poor adherence to serum ketone measurement included: patient’s having no IV access for regular serum blood sampling; the burden of repetitive, laborious blood sampling on nursing staff time; and the clinical team not requesting serum ketone measurements when reviewing high blood glucose results.

Conclusions: Our project highlighted that the critical care unit were not adhering to local protocol. We identified barriers than could be overcome by the implementation of a point-of-care ketone meter. We presented the data at a directorate audit meeting and as a result of the quality improvement project a point-of-care ketone meter has been introduced into the department. We are now providing gold standard of care for patients admitted with DKA to our critical care unit.

References

1. Dhatariya K, Nunney I, Higgins K, Sampson M, Iceton G. National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014. Diabetic Medicine. 2015;33(2):252-260.

2. Joint British Diabetes Societies for Inpatient Care. The Management of Diabetic Ketoacidosis in Adults. Rev ed. [Internet]. 2021 [cited 2022 February 24]. Available from: https://www.diabetes.org.uk/professionals/position-statements-reports/specialist-care-for-children-and-adults-and-complications/the-management-of-diabetic-ketoacidosis-in-adults

4694

Salt steps and sugar checks - making arterial line use safer in our trust

Emma Wilkinson, Aoibhin Hutchinson, Simon Marcus, Jack Gamble, David Kean, Sharon O’Donnell, Matthew Jasztal, Joanne Coates, Eric Byrne, Mark Eccles

Belfast Health and Social Care Trust

Belfast Health and Social Care Trust, [e-mail]

Abstract

Introduction: Arterial lines are used within our intensive care unit to allow invasive blood pressure monitoring and regular blood gas analysis. Inadvertent use of dextrose containing fluids in the flush have been associated with falsely high glucose readings. When these are acted on with insulin, it can cause devastating hypoglycaemic brain injury.

There have been a number of deaths and other incidents relating to the wrong fluid being used in arterial line set up reported within the UK in recent years. In 2014 the AAGBI released a safety guideline on the use of arterial lines specifically to reduce to the risk of hypoglycaemic brain injury.

Objectives: Our objective was to ensure that 100% of arterial lines in use within Royal Victoria Hospital’s intensive care unit were compliant with our trust policy on the management of arterial lines.

Methods: We audited our intensive care unit’s compliance with our trust policy and found that we were 80% compliant. We formed a multi-disciplinary arterial line working group in order to tackle the problem.

Our quality improvement project consisted of two main approaches:

1. To educate staff on how to manage arterial lines correctly.

We divided the management of arterial lines into S.A.L.T steps (a 7 step bundle on “Setting up an Arterial Line Transducer”) and SUGAR checks ( a series of red flag moments to prompt staff to review the patient prior to starting or increasing insulin administration).We developed educational posters for key areas in ICU and presented our findings at departmental meetings.

• 2. To change the system, in order to make it easier to do the right thing.

We developed a Universal Adult Arterial Pack (UAAP) containing key components in the setup of an arterial line. This also included aide memoires for the S.A.L.T steps and SUGAR checks.

In order to measure the effect of these changes, we:

1. Audited compliance on a regular basis.

2. Monitored serious bundle breaches ( for example no label, wrong fluid used)

3. Assessed usage of the UAAP.

Results:

1. Bundle compliance improved during the first half of 2021, however then reduced in the second half with the number of serious bundle breaches increasing. This coincided with COVID surge 4 – associated with reduced nursing ratios and staff redeployment.

2. UAAP usage increased throughout the project, from an average of 6 to 9 per day. 86% of staff found the packs useful and 85% thought that they reduced the potential for error.

Conclusions: The presence of a policy does not ensure that staff will know about it or adhere to it. Although we have not yet achieved our target of 100% compliance, we have seen evidence of how our project has the potential to do so in the near future. We aim to roll out our new e-learning module for staff education, manufacture our UAAP on a bigger scale, and disseminate the project to other departments within the trust.

Reference

1. Association of Anaesthetists of Great Britain and Ireland. Arterial line blood sampling: preventing hypoglycaemic brain injury 2014. Anaesthesia 2014, 69: pages 380–385

4693

A novel approach to an evolving cohort of critical care patients

Paul Twose, Emma Brereton, Gemma Jones, Julie Highfield, Jason Nunn, Jack Parry-Jones, Rebeca Romain, Gareth Scholey

Cardiff and Vale UHB

Cardiff and Vale UHB, [e-mail]

Abstract

Introduction: As the population of patients accessing critical care continues to evolve, so too does the processes in which care is delivered.¹ Over the past few years there has been increasing recognition of the ‘chronic critical illness’ cohort, which refers to those with significant ongoing physical and non-physical symptoms resulting in prolonged length of stay, increase cost and far greater rehabilitation requirements.² Whilst this cohort of patients may be small in percentage terms, they occupy significant proportions of bed days both within critical care and acute care. These challenges were further heightened during the pandemic with the vast increase in patient numbers, including an increasing proportion of patients having multi-organ failure and increased length of stay.³

At the start of the pandemic, we undertook a quality improvement project and developed a novel approach to providing care for this cohort. This including developing a ‘blue’ zone within critical care, specifically for those patients with chronic critical illness.

Methods: A Plan-Do-Study-Act approach was adopted with initial focus on cohort identification and methods of working (including existing examples). The ‘blue’ zone was opened in May 2020 and remains in existence. The focus was to deliver a patient centred approach with greater consistency from the whole MDT (including a Monday-Friday ICM consultant), increased AHP presence, weekly MDT meetings, holistic outcome measures (PICUPS) and greater focus on ongoing rehabilitation requirements including discharge destination. Further PDSA cycles included refinement of patient cohorts, introduction of MDT meetings and rehabilitation prescriptions.

Data presented was collected between November 2020 and February 2022.

Results: A total of 102 patients were transferred to the ‘blue’ zone during the data collection period, accounting for only 6.8% of all critical admissions but 31.4% (4865 days) of the entire critical care units bed days and 34.0% (4287 days) of ventilator days. As expected, critical care length of stay for this cohort was longer than those not requiring transfer to ‘blue zone’ (50.7 days v 7.7 days), were slightly older (55.5 years v 55.0 years) and had higher APACHE II scores on admission (14 v 12). Whilst no control data was available (due to concerns around who would have been transferred), post critical care was lower than expected (17.8 days), with reductions in post critical care mortality (2.3% v 4.2% for blue zone and critical care population respectively). Patient and staff feedback was extremely positive specifically on consistency and patient involvement in decision making.

Conclusion: Within this QI project we developed a novel approach to caring for those with chronic critical illness. This focus on patient centred care, increased AHP involvement and shared decision making. The findings suggest despite prolonged critical care admissions, patients had similar post critical care lengths of stay to those with significant shorter critical care stays, had lower post critical care mortality and high levels of patient satisfaction.

References

1. Pugh, R.J., et al., Long-term trends in critical care admissions in Wales**. Anaesthesia, 2021. 76(10): p. 1316-1325.

2. Harrison, D.A., B.C. Creagh-Brown, and K.M. Rowan, Timing and burden of persistent critical illnessin UK intensive care units: An observational cohort study. Journal of the Intensive Care Society. 0(0): p. 17511437211047180.

3. Doidge, J.C., et al., Trends in Intensive Care for Patients with COVID-19 in England, Wales, and Northern Ireland. Am J Respir Crit Care Med, 2021. 203(5): p. 565-574.

4692

Developing and evaluating the Digitally Enhanced Liberation from VEntilation (DELVE) system: A study of feasibility and user acceptance

Charlotte Small¹, Fiona Howroyd², Karl Hewson³, Ben Crundwell³, Jason Mashinchi³, Stephanie Ward³, David McWilliams⁴, Ben Attwood⁵, Ben Strutt³, Catherine Snelson²

¹ Wye Valley NHS Trust

² NIHR Surgical Reconstruction and Microbiological Research Centre

³ Cambridge Design Partnership

⁴ University Hospitals Coventry and Warwickshire NHS Foundation Trust

⁵ South Warwickshire NHS Foundation Trust

Wye Valley NHS Trust, [e-mail]

Abstract

Introduction: In common with many aspects of critical illness recovery, there is no universally accepted formula for “weaning,” the term used to describe the process of liberating patients from mechanical ventilation.^1–3 Understanding a patient’s progress during a prolonged wean can be difficult and requires integration of various datasets. Therefore, it is good practice to ensure that weaning prescriptions are clear, easy to follow and adhered to and that weaning-associated data and meta data are recorded accurately and are easy to interpret. The prototype Digitally Enhanced Liberation from VEntilation (DELVE) system has been designed to be used in combination with the Puritan Bennett^(™) 980 (PB980) ventilator (Covidien, USA). DELVE is an open-loop system which provides an interactive weaning chart, combining the weaning prescription entered by the clinical staff, with actual settings recorded from the ventilator in order to display compliance with the prescription (Figure 1). DELVE also collects measured data from the ventilator which could be used to display respiratory performance, both real-time and historical.

Figure 1.

DELVE set up with the PB980 ventilator (in the simulation suite).

Objectives: This feasibility study was designed to inform development of the first DELVE prototype and a future clinical trial to determine clinical effectiveness and usefulness. The study objectives were to determine whether DELVE could:

1. Present a digital weaning chart that staff could use effectively and would be superior to the current paper version.

2. Record and display the patients’ ventilatory performance, both real time and historical, during liberation from mechanical ventilation.

Methods: This was a mixed-methods, prospective feasibility study of a complex intervention.⁴ Ventilated patients with a tracheostomy, commencing the weaning process, were recruited from an adult intensive care unit. DELVE was used alongside the current paper-based system for weaning planning and data collection. Patients remained in the study until they no longer required the support of the PB980 ventilator.

Results: Twenty patients were enrolled for between 25 and 270 hours each. There were no safety incidents or data breaches. DELVE was successfully operated by staff, who were able to connect DELVE to the ventilator, prescribe weaning plans and analyse adherence. The digital weaning chart user interface was intuitive and easy to navigate. It was clearer, more complete and easier to interpret when compared to the paper weaning charts (Figure 2). DELVE reliably collected data every ten seconds and safely stored over six million items of measured data and 25000 events, such as alarm triggers and setting changes, in a form that could allow analysis and pictorial or graphical presentation.

Conclusions: This study supported the feasibility of this and future versions of DELVE to present both a digital weaning chart and to facilitate visual and numerical data presentation. Future iterations of the system could include a user-friendly dashboard representing patient progress during the weaning process. Assimilation of large volumes of data could be used to enhance understanding and inform decision making around the prolonged wean.

Figure 2.

Comparison of paper and DELVE weaning charts.

References

1. Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007; 29: 1033-1056.

2. Perren A, Brochard L. Managing the apparent and hidden difficulties of weaning from mechanical ventilation. Intensive Care Med. 2013; 39: 1885-1895.

3. Blackwood B, Alderdice F, Burns KE, Cardwell CR, Lavery G, O’Halloran P. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2010; CD006904. Published 2010 May 12.

4. Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008; 337: a1655.

4691

Immersive Technologies - the future for tracheostomy education?

Paul Twose, Jason Nunn, Gemma Jones, Sara-Catrin Cook

Cardiff and Vale UHB

Cardiff and Vale UHB, [e-mail]

Abstract

Introduction: The need for standardised education on tracheostomy care is well recognised.¹ Staff frequently report a lack of confidence in caring for those with tracheostomies, as well as the management of adverse events as they occur.² Over the past decade, healthcare providers have developed strategies to educate staff, however, the covid-19 pandemic has severely hampered the ability to provide this necessary training due to restrictions on access to training rooms, the need for social distancing and the significant clinical demands placed on both trainers and trainees.³

The potential for immersive technologies to augment healthcare training is gaining interest exponentially.⁴ However, its effectiveness is yet to be clearly understood and as such it is not yet common within healthcare education.⁵

Based on the above, we aimed to explore the potential of these immersive technologies to overcome the current challenges of tracheostomy education, and to develop future strategies to use immersive technology in healthcare education.

Methods: We received a £400,000 grant from Cardiff Capital Region (CCR) to undertake a rapid innovation project overseen by the SBRI centre of excellence. The project consisted of 3 main phases: 1) feasibility; 2) development; and 3) testing. The project was officially launched in April 2021 and lasted 12 months.

Project governance was provided via the SBRI for clinical excellence, a project board with representation from Welsh Government, Cardiff University and Cardiff and Vale UHB, and a project team with clinical expertise in both the delivery of tracheostomy education and the provision of simulation training in healthcare.

Results:

Phase 1:

During phase one 4 industries were successful and received up to £30,000 to explore the feasibility of immersive technology to support tracheostomy education. The industries were Rescape, TruCorp, Aspire2Be and Nudge Reality. During the feasibility phase all industries focused on the emergency management process utilising existing NHS Wales tracheostomy education resources and the national tracheostomy safety programme.

Phase 2:

For phase 2, Rescape and Nudge Reality were chosen to develop the technology. These industries continued to work in conjunction with the project team to capture the core elements of tracheostomy care, including multi-user emergency management scenarios. Additional content was also added for bronchoscopy and insertion of intercostal drains.

Phase 3:

Testing of both solutions was undertaken over an 8-week period, across 6 Health Boards in NHS Wales. The results of the testing will be analysed and available for presentation in due course. Provision findings demonstrate good face and content validity with high levels of user satisfaction.

Discussion / Conclusion: The provision of essential tracheostomy education has been severely affected by the covid-19 pandemic. Evolving immersive technologies have the potential to overcome these challenges and improve the effectiveness and efficiency of education packages in tracheostomy care and wider. Through this CCR grant, in conjunction with industry, we have developed two solutions with the potential for widescale procurement and future research on the use of immersive technologies within healthcare.

References

1. McGrath, B.A., et al., Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals. British Journal of Anaesthesia, 2020. 125(1): p. e119-e129.

2. Brenner, M.J., et al., Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth, 2020. 125(1): p. e104-e118.

3. Sneyd, J.R., et al., Impact of the COVID-19 pandemic on anaesthesia trainees and their training. British Journal of Anaesthesia, 2020. 125(4): p. 450-455.

4. Pottle, J., Virtual reality and the transformation of medical education. Future healthcare journal, 2019. 6(3): p. 181-185.

5. Chen, F.-Q., et al., Effectiveness of Virtual Reality in Nursing Education: Meta-Analysis. Journal of medical Internet research, 2020. 22(9): p. e18290-e18290.

4688

Developing a sustainable Speciality trainee-led Intensive Care Medicine teaching programme for non-speciality doctors rotating in ICU

ABEER UL AMNA¹, Joanna Shak²

¹ KETTERING GENERAL HOSPITAL

² Kettering General Hospital

KETTERING GENERAL HOSPITAL, [e-mail]

Abstract

Introduction: Intensive Care Medicine (ICM) is growing as a standalone training field, the incorporation of ICU placement in the new training curriculum for foundation and Internal medicine trainees (IMT) has provided the opportunity to inspire junior doctors and improve their learning outcomes from these rotations.^1–2 The Intensive Care Unit is unanimously viewed as an intimidating environment; thus, it is easy for non-speciality trainees to diligently complete ward tasks, without maximising the learning potential an Intensive Care placement can provide. This project aims to improve the learning experience of non-speciality doctors at our District General Hospital Intensive Care Unit by establishing a sustainable and replicable teaching programme.

Objective: The objective of our quality improvement project was to seek learning needs from current and past non-speciality trainees and develop a trainee-focused and trainee-led teaching programme. We used a pragmatic approach to increase trainee attendance and create sustainable and replicable teaching to increase interest and recruitment to ICM.

Methods: We conducted focus group discussions and distributed a departmental survey to past and current trainees to identify challenges to teaching and learning in our ICU. After assessing the feedback, we established a teaching programme covering the common equipment and system-based interventions used in ICU. Presentations were made keeping non-specialist doctors in mind and these targeted the fundamental ICU interventions. A quick-reference guide was also created to ensure easy access to frequently used medications and terminologies in ICU, as well as a list of recommended topics for discussions and supervised learning events, this booklet was provided on induction to junior doctors. Presentations and resources were stored on a cloud drive, shared with each new rotation, to ensure the sustainability of this teaching project. Teaching sessions were scheduled according to non-speciality trainee rota, rather than a set time each week thereby maximising their attendance. The trainee-led approach also provided the speciality doctors to improve their teaching skills. Questionnaires were created to collect feedback to assess the quality of teaching as well as end of placement satisfaction after each cycle.

Results: A significant deficit was identified for formal teaching in ITU specific interventions see figure 1. Challenges to teaching included lack of time to devise teaching sessions, unpredictable clinical commitments, scheduling teaching days when non-speciality trainees were present and frequent doctor rotations. However, the use of cloud drive turned out to be imperative for the sustainability of this project, speciality doctors were able to continue the teaching programme even after rotations. Through self-assessed feedback before and after the programme, we demonstrated considerable increases in the confidence of junior doctors and overall ICU placement satisfaction see figure 2.

Conclusion: Survey results after two rotations show that the programme has been well received, with positive feedback on teaching and a tangible improvement in team cohesion. It is hoped that by setting up the cloud drive, future speciality doctors can continue this teaching project in our department and all future junior doctors rotating in ICU shall benefit from this teaching project.

References

1. Joint Royal Colleges of Physicians Training Board. Rough guide to internal medicine training—guidance for training programme directors, supervisors and trainees.

2. Higher Education England [HEE] 2019. Foundation Programme Review Recommendation- Foundation Educational and clinical supervisor modules. https://www.hee.nhs.uk/our-work/foundation-medical-training/foundation-review

Figure 1 Figure 2

4685

The ‘Life after ICU’ mobile application- a process in creating an accessible patient-centred platform for Intensive Care rehabilitation resources

Laura MacDonnell, William Allingham, Peter O’Brien

NHS Aryshire & Arran

NHS Aryshire & Arran, [e-mail]

Abstract

Introduction: InS:PIRE (Intensive Care Syndrome: Promoting Independence and REcovery) is a multidisciplinary programme whose role is to assist patients in the identification of, and subsequent rehabilitation from the sequelae of an admission to the Intensive Care Unit (ICU). In NHS Aryshire and Arran (NHSAA) InS:PIRE has traditionally consisted of in-person rehabilitation and support meetings to help manage common post-ICU issues. COVID-19 forced all InS:PIRE activities online, and has required services to redesign their delivery of supporting resources to be readily accessible remotely.

Thus, the ‘Life after ICU’ app was created.

Objectives: The role of this application was to help better-provide accessible information to former ICU patients and their relatives, as well as, improve connectivity between medical professionals and patients.

Methods: The app platform was developed by Piota. Resources were chosen for inclusion through surveying InS:PIRE attendees, who identified their main areas of concern. These areas included: physical problems, emotional issues, social issues, family support, COVID specific support, and physiotherapy. The multidisciplinary InS:PIRE team co-ordinated the identification and collation of the appropriate resources. Additionally, the app serves as a platform for InS:PIRE to disseminate information about the on-going programmes as well as allowing attendees to contact the InS:PIRE team.

Results: A trial version of the ‘Life After ICU’ app has now been launched. This app will allow patients and their families to readily access the resources they require. Following a trial period, feedback from app users will be collected and further adaptations made.

Conclusions: Launching the app recognises the wider view of the importance of eHealth, and its role in modernising service-delivery. Indeed, the Scottish National Clinical Strategy recognises this as an area for future development. The efficacy of eHealth interventions for rehabilitation have been acknowledged,^1–2 and thus translating them to the ICU context can be considered as a means of improving the holistic rehabilitation of this complex patient group. Furthermore, through providing services easily accessible by patients, this app allows InS:PIRE to realise NHSAA’s ‘Caring for Ayshire’ strategy, whose aim is to provide care closer to home.

References

1. Su JJ, Yu DSF, Paguio JT Effect of eHealth cardiac rehabilitation on health outcomes of coronary heart disease patients A systematic review & metaanalysis J Adv Nurs 2020 Mar 1;76(3):754–72 https://pubmed.ncbi.nlm.nih.gov/31769527/

2. Kraaijkamp JJM, van Dam van Isselt EF, Persoon A, Versluis A, Chavannes NH, Achterberg WP eHealth in Geriatric Rehabilitation: Systematic Review of Effectiveness, Feasibility & Usability J Med Internet Res 2021;23(8)e24015.

4683

Using the “Omnicell” automatic drug dispensing cabinet to monitor sedative drugs in a critical care unit

Anthony Thomas¹, Emma Boxall¹, Eleanor Fidler²

¹ Salford Royal Hospital

² University of Manchester

Salford Royal Hospital, [e-mail]

Abstract

Introduction: Automatic drug dispensers are now widely used in critical care.^1–2 They can provide information about dispensed drugs. Good practice in sedation restricts the use of sedatives and titrates doses to defined responses.^3–4

Objectives: To extract drug dispenser issuing records for sedatives and link these to patient records to evaluate sedative use.

Methods: in October 2019, we introduced two Omnicell XT automated dispensing cabinets (Omnicell inc. CA, USA) into a 42 bedded general/neurological unit. ICNARC (Intensive care national audit and research centre) and CCMDS (Critical care minimum data set) data was collected using the Ward Watcher program. Dispenser issuing records for alfentanil, propofol and midazolam were obtained as Excel files for 13 months from January 2020. Output time stamps were converted to dates and times.

Outputs were linked to outputs of the ICNARC and CCMDS records for the patients that the drugs were issued to. All the outputs had patients identified by their unique hospital numbers. These were used in Excel “power queries” to produce a spread sheet with a single row per patient. Multiple admissions used the first diagnosis, the final outcome and the total length of stay. The total dose of sedatives was calculated from ampoule dose and number. The duration of treatment was calculated from the first and last issues of the drug. ICNARC codes were used to identify the primary system in the admission diagnostic code and those patients admitted for COVID-19. Variables were compared using Chi Squared, Mann-Whitney U and Kruskal Wallis Tests. The significance of associations was established using Spearman’s Rho. Linear regression was used to define relationships more clearly.

Results: Table one summarises the patient characteristics with respect to all admissions during the study period and for patients who had had the studied drugs issued to them. Midazolam was used in fewer patients, they were more likely to be male, heavier (p>0001) and to die than patients receiving Propofol or Alfentanil (p>0.001). With respect to diagnostic groups, all the sedatives, particularly Midazolam (p<0.001), were more likely to be used in patients with COVID-19.

The relationship between the dose of sedative drugs and patient age and weight was explored using the dose per advanced respiratory day. All three drugs had a significant but weak negative relationship with age, lower doses being given to older people (Propofol r² = 0.02, p=0.01. Alfentanil r² = 0.04, p=0.00. Midazolam r² = 0.07, p=0.00.). There was also a weak but significant relationship between increasing dose of Propofol with patient weight (r² = 0.02, p=0.01), but there was no relation between weight and doses of the other drugs.

Conclusions: Information from automatic drug dispensers can be interpreted and combined with other datasets to produce clinically relevant information. The limited weak relationships between drug dose and age and weight suggests that sedative drugs could have been better titrated to response.

References

1. Chapuis C, Bedouch P, Detavernier M. Automated drug dispensing systems in the intensive care unit: a financial analysis. Crit Care 2015. 19.318.

2. Craswell A, Bennett K, Dalgliesh B. The impact of automated medicine dispensing units on nursing workflow: A cross-sectional study. Int J Nurs Stud 2020; 111.

3. Devlin JW, Skrobik Y, Gelinas C. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018. 46. 825-873.

4. Ranzani OT, Simpson ES, Augusto TB, Cappi SB, Noritomi DT. Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project. Crit Care. 2014 18.580.

4682

Preventing unrecognised oesophageal intubation in the Intensive Care Unit using a multidisciplinary capnography training package

James McCulloch, Olivia Burke, Tobin Osicki, Robert Penders, Victoria Poyntz, Fiona Kelly

Royal United Hospital

Royal United Hospital, [e-mail]

Abstract

Introduction: The death of Glenda Logsdail in 2020 following an unrecognised oesophageal intubation highlighted the importance of the whole intubation team being able to recognise and interpret capnography waveforms, and the need to actively exclude oesophageal intubation when a flat capnograph trace is seen.¹ This was previously described by the Royal College of Anaesthetists’/Difficult Airway Society “No trace = Wrong place” Campaign² in 2018. The importance of a flat team hierarchy and team members feeling able to speak up and be listened to was also highlighted by the coroner.¹ Airway management in the Intensive care Unit (ICU) is known to be high risk³ and the lessons identified in the Logsdail case are very relevant to ICU airway management.

Objectives: We designed and delivered a capnography training package based on the ‘hats and caps’ capnography training tool.⁴ We aimed to improve the ability of the multidisciplinary team (MDT) to interpret capnography waveforms and stress the significance of an absent capnography trace. In addition, we aimed to empower the MDT to speak up and act on concerning capnography waveforms.

Methods: We delivered capnography teaching in the ICU during normal working shifts using the Bath ‘Tea Trolley Training’ method.⁵ Our training package included the following: a capnography training sheet, describing four different capnography waveforms, simplifying them into ‘good’ and ‘bad’ categories (Figure 1);⁴ top hats, ‘Ascot hats’ and dunce hats (Figure 2) to reinforce the capnography shapes and make the teaching fun and engaging; a flashcard quiz of the capnography traces to help consolidate knowledge; handout to facilitate reflective learning; ‘capnography cupcakes’ in the coffee room. We designed a feedback form, using a 5-point Likert scale and opportunity for free comments, to be completed immediately after training.

Results: Fifty-two staff participated in training over a one-month period: 3 consultants, 14 junior doctors, 3 ACCPs, 26 ICU nurses, 3 physios, 2 HCAs, 1 medical student. Feedback form response rate 81%. Results as follows: participant self-rated confidence in ability to interpret a capnography waveform was 45% pre-training and 97% post-training; 100% reported that the training would improve their ability to assist with intubations and improve their ability to detect an airway problem; 100% reported that the teaching was extremely useful/useful; 100% reported that they would recommend the teaching was repeated in our ICU; 100% would recommend to other ICUs. Free comments included: “I like the use of hats - I’m much more likely to remember now”; “Fantastic teaching- great props, excellent explanation”; “Encourages nurses to speak up in a non-confrontational way”.

Conclusions: This simple, non-threatening, easy to deliver and fun capnography training package was well received by our ICU MDT. Participants reported improved confidence in the interpretation of capnography waveforms and detection of airway issues, with many reporting that they felt more empowered to speak up after training. This training package would be easily transferable and reproducible to other ICUs. We plan to upload the training package to our department webpage, and free to download, to facilitate this.

References

1. https://www.judiciary.uk/publications/glenda-logsdail-prevention-of-future-deaths-report/ (Accessed 19/2/22).

2. https://www.rcoa.ac.uk/news/rcoa-das-response-glenda-logsdail-ruling (Accessed 19/2/22).

3. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the United Kingdom: results of the 4^th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part II: Intensive Care and Emergency Departments. Br J Anaesth 2011; 106: 632-42.

4. Cook TM, Kelly FE, Goswami A . ‘Hats and Caps’ capnography training on intensive care. Anaesthesia 2013; 68: 421-421.

5. O’Farrell G, McDonald M, Kelly FE. ‘Tea trolley’ difficult airway training. Anaesthesia 2015; 70: 104.

Figure 1.

Capnography training teaching sheet.

Figure 2.

‘Hats and caps’ capnography training in progress.

4681

Post arrest imaging - “consider” it done! CTPA is highly valuable after cardiac arrest

James Winchester, Charlotte Jenkinss

Buckinghamshire Healthcare NHS Trust

Buckinghamshire Healthcare NHS Trust, [e-mail]

Abstract

Introduction: Where there is not sufficient evidence to suggest a cardiac cause of cardiac arrest, European Resuscitation Council guidelines state “Consider CT Brain +/− CTPA”. Published data shows a high rate of major intracranial and intrathoracic pathologies in these patients.

Objectives: We wanted to identify the frequency with which we were carrying out CT Head and CT Pulmonary Angiogram scans in survivors of cardiac arrest (in or out of hospital) admitted to our intensive care units, and to establish how often these detected major, treatment-altering pathologies.

Methods: We reviewed requests and results of CT scans in 171 survivors of cardiac arrest who were admitted to Buckinghamshire ICUs between 2016 and 2020, excluding those with a known cardiac cause of arrest. We looked for major new diagnoses which may have precipitated the arrest, and complications of cardiopulmonary resuscitation excluding simple rib fractures.

Results: CT Head was performed in 55% of survivors, but CT Pulmonary Angiogram in fewer than 30%. Pulmonary embolism was identified in 21% of CTPAs, and subarachnoid haemorrhage was identified in 3% of CT Heads. Major chest trauma e.g. haemopneumothorax was seen in less than 5%.

Conclusions: CTPA in particular, whilst uncommonly performed, was a highly valuable investigation in this group of patients. The incidence of major complications of cardiopulmonary rescuscitation was lower than we expected, but the rate of pulmonary embolism was high. There is a small but important rate of occult subarachnoid haemorrhage in patients presenting with arrest. These diagnoses create opposing priorities when considering prophylactic or therapeutic anticoagulation; early identification is extremely important. As part of the creation of a local post arrest ICU guideline, we have agreed a CT Head and CTPA pathway for all of these patients with our local radiology department. We advocate performing these scans as soon as is safely possible following successful resuscitation.

References

1. Nolan JP et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med. 2021 Apr;47(4):369-421.

2. Hwang CW et al. A descriptive analysis of cross-sectional imaging findings in patients after non-traumatic sudden cardiac arrest. Resusc Plus. 2021 Jan 28;5:100077.

4679

Rehabilitation needs after critical illness: Referral outcomes from a ICU follow up clinic in Northern Ireland

Kirsty Jerrard, Rosalind O’Reilly, Ann McQueen, Catriona Irvine

Belfast Health and Social Care Trust

Belfast Health and Social Care Trust, [e-mail]

Abstract

Introduction: In 2019/20 a total of 171,900 people were admitted to adult general intensive care units (ICU) across England, Wales and Northern Ireland, with a survival rate of 79.6% at hospital discharge.¹ Patients who survive critical illness and admission to ICU often experience ICU-related long-term physical and non-physical impairments and disability following hospital discharge.² National guidance advocates multidisciplinary team (MDT) follow up to identify and manage the unmet health needs of this patient population.^3–4 The UK has seen an increase in the number of follow up services available in the last 7 years.² The Covid-19 pandemic further highlighted the need to provide this service, locally resulting in the establishment of the Belfast Health and Social Care Trust (BHSCT) ICU follow up clinic in July 2020.

The follow up clinic is offered to patients aged ≥ 18 years, an ICU length of stay of ≥ 4 days, who have been discharged from an inpatient setting within the last 12 weeks and do not receive follow up from any other established care pathway. The clinic consists of an ICU Nurse, Doctor, Clinical Psychologist and Physiotherapist. Patients are offered either a virtual, face-to-face or telephone appointment.

Objective: To identify unmet rehabilitation needs and onward referral requirements of patients presenting at an ICU follow-up clinic in Northern Ireland.

Methods: Data was gathered retrospectively using an excel database detailing patient demographics, appointment details and onward referrals generated from the clinic. Data was analysed for a set time period between the 01/12/2021 – 09/02/2022. The type of referral and the profession responsible were captured.

Results: During the time period eight post ICU follow up clinics were completed. A total of 36 patient’s attended (14 male and 22 female). Six appointments were attended virtually via MS Teams, 12 via telephone and 18 face-to-face.

Twenty-three (64%) of the patients required at least one onward health referral. A total of 61 onward health referrals were generated from this population. Table 1 details the number of onwards referrals by speciality.

Table 1.

Number of onwards health referrals by speciality.

Speciality	No of referrals
Clinical psychology and mental health services	14
General Practitioner	10
Commissioned MDT rehabilitation services	9
Outpatient Physiotherapy services	8
Voluntary services for physical exercise	3
ENT	3
Occupational Therapy	2
Speech and Language Therapy	2
Respiratory medicine	2
Other	8

Conclusion: Approximately 64% of patients who attended the post ICU follow up clinic, during a 10 week period, demonstrated unmet rehabilitation needs resulting in onward health referrals. This data supports the need for a post ICU follow up clinic at BHSCT to identify ongoing need, ensure transition of care to relevant services and optimise patient’s physical and psychological outcomes. One limitation of this study is that not all recommended allied health professionals are commissioned for the clinic which may impact on the health needs identified. Future work should consider the impact of this and discussions regarding the need for a commissioned post ICU follow up clinic which is truly MDT for this patient population should be considered.

References

1. Key statistics from the Case Mix Programme — adult, general critical care units. 1 April 2019 to 31 March 2020. London. 2020.

2. Connolly B, Milton-Cole R, Adams C, Battle C, McPeake J, Quasim T et al. Recovery, rehabilitation and follow-up services following critical illness: an updated UK national cross-sectional survey and progress report. BMJ Open. 2021;11(10):e052214.

3. Clinical guideline 83 Rehabilitation after critical illness. London: National Institute for Health and Clinical Excellence; 2009.

4. FICM and ICS. Guidelines for the Provision of Intensive Care Services - Edition 2. London: Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS); 2019.

4678

Improving interdisciplinary communication within the regional ICU, Royal Victoria Hospital, Belfast

Max Zammit-Maempel, Gavin Smith, Jenna Adamson, Kevin Scott

NHS

NHS, [e-mail]

Abstract

This quality improvement project aims to improve interdisciplinary communication in the Regional Intensive Care Unit (RICU) in the Royal Victoria Hospital, Belfast. Lack of effective interdisciplinary communication has numerous negative repercussions; adversely affecting patient safety, patient outcomes and prolonging patient journey.^1–2 Improving communication between nursing and medical staff strengthens working relationships and promotes a safer environment for both staff and patients.^3–4 Due to the size and structure of the unit, communication in RICU is primarily achieved through a mobile telecom -Voicera. This system primarily relies on the user knowing the full name of the person to establish contact, however high turnover of both medical and nursing staff has resulted in personnel not knowing their colleagues. Most importantly nursing staff may not know which member of the medical team to contact or have difficulty in achieving this communication in critical emergency scenarios.

This project aims to improve interdisciplinary communication and patient safety by streamlining and improving the ease for nursing staff to gain contact with the appropriate doctor. We aim for 70% of nursing staff to have >80% confidence in contacting the relevant doctor.

To achieve this objective, a questionnaire was conducted for nursing staff of all grades (newly qualified, agency, deputy sisters, full time, re-deployed) to assess confidence in contacting doctors of differing grades (SHO, airway doctor, consultant) and charge nurses. After this data was collected, a system of whiteboards were implemented for each area, on which each staff member designated to that area can write their full name under an appropriate heading; ‘Airway Doctor’, ‘Consultant’, ‘Charge Nurse’, ‘SHOs’, ‘Ward Clerk’, or ‘Pharmacist’. Photographs with names and grades of all doctors were also displayed in each area. The questionnaire was repeated after the intervention among all grades of nursing staff. 46 nurses took part in the initial questionnaire with 19 nurses taking part in the second questionnaire.

Results showed, after the intervention, there was significant improvement in the ease and knowledge of how to gain contact in with the appropriate doctor. Confidence in contact to the SHO improved from 46% to 89%, Airway Doctor from 54% to 84% and consultant from 65% to 84%. Prior to the intervention, 37%, 46% and 65% of nursing staff had >80% confidence in contacting SHO, airway doctor and consultant respectively. Contrasting with 74% of nursing staff having >80% confidence to contact all respective doctors after the project.

To conclude, these methods of intervention in communication have increased confidence in interdisciplinary communication and contact throughout and between the wider nursing and medical staff in the RICU.

We aim to further this project by conversing with the Voicera company to create generic commands of few words, for example ‘Airway Doctor’, to aid critical communication in emergency scenarios. We aim to display posters of these commands as aids on how to utilise it, hopefully further decreasing time and cognitive burden to contact the necessary personnel. We will conduct briefing sessions on whiteboard and Voicera-command use with senior nursing staff who will dissipate the information to new staff.

References

1. Dingley C, Daugherty K, Derieg MK, Persing R. Improving Patient Safety Through Provider Communication Strategy Enhancements [Internet]. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Agency for Healthcare Research and Quality (US); 2008 [cited 2022 Feb 27]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21249923

2. 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 [Internet]. 2004 Oct [cited 2022 Feb 27];13 Suppl 1(Suppl 1):i85-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15465961

3. Reader TW, Flin R, Mearns K, Cuthbertson BH. Interdisciplinary communication in the intensive care unit. Br J Anaesth [Internet]. 2007 Mar 1 [cited 2022 Feb 27];98(3):347–52. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0007091217348766

4. Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Qual Saf Health Care [Internet]. 2004 Oct 1 [cited 2022 Feb 27];13 Suppl 1(suppl 1):i96-104. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15465963

4676

Improving human factors aspects of displaced tracheostomy emergency management by encouraging algorithm use during simulation training

Layla Guscoth, Olivia Burke, Kate Goodchild, Fiona Kelly

Royal United Hospitals Bath

Royal United Hospitals Bath, [e-mail]

Abstract

Introduction: Emergency situations in the Intensive Care Unit (ICU) can lead to cognitive overload.¹ Human Factors and Ergonomics (HFE) is a scientific discipline which aims to optimise system performance² and recommends the use of algorithms to reduce errors and increase speed and fluidity of performance.³ We proposed that running displaced tracheostomy simulation training, with the team directly referring to an emergency tracheostomy algorithm during the scenario, would improve adherence to the algorithm steps and improve teamwork and communication.

Objectives: We designed and delivered an ICU multidisciplinary team (MDT) tracheostomy simulation training programme. Our aims were: provide MDT education, emphasising HFE aspects of tracheostomy emergency management; rehearse a displaced tracheostomy scenario with and without direct access to an algorithm; observe whether direct reference to the algorithm conferred benefits for teamwork, communication and confidence.

Methods: We devised a scoresheet to assess the key steps of our Trust tracheostomy emergency algorithm, including calling for help, applying oxygen, checking capnography, assessing tracheostomy patency and declaring an emergency (maximum score 18). We ran simulation training sessions using a “Trachy-Tracey” model,⁴ the ‘tea trolley’ training method⁵ and a displaced tracheostomy scenario: in alternate scenarios, staff had no access to the algorithm, and in the remainder staff referred to the algorithm while performing the scenario. Each group was scored by an independent assessor. We designed a post-training questionnaire using a Linkert 5-point scale plus opportunity for free comments. Scoresheet data were not normally distributed, therefore the median(IQR) was calculated and Mann-Whitney-U test was performed to compare the two groups. Results were analysed using SPSSv.28.

Results: Forty-two staff participated:16 doctors, 14 nurses, 3 ACCPs, 7 physios, 2 medical students. We ran 26 scenarios: 13 with direct reference to the algorithm (Group 1) and 13 without (Group 2) (Table 1). The total scores were 145/234 (62%) for Group 1 and 203/234 (86%) for Group 2. The median (IQR) score for Group 1 was 12(4) compared to 16(5) for Group 2 (p=0.002). The biggest improvement in adherence to algorithm steps was seen for identification of red flag signs, applying capnography monitoring and declaring an emergency. The independent observers reported that direct reference to the algorithm improved qualitative assessment of teamwork, delegation of tasks and communication. Questionnaire response rate was 100% (Fig.1). Free comments included: “using the algorithm empowers us to do the right thing”, “very helpful especially if someone is reading the algorithm out loud”.

Conclusions: One team member reading out a tracheostomy algorithm during a simulated tracheostomy emergency improved adherence to the algorithm and improved independent qualitative assessment of performance, team working and communication. This highlights the importance of displaying emergency algorithms at the bed space for all ICU tracheostomy patients, to enable use in an emergency and regular MDT simulation training. New national tracheostomy algorithms should include prompts for staff to directly refer to algorithms in an emergency, nominate a team leader and nominate another team member to read out the algorithm.

References

1. Bion JF, Abrusci T, Hibbert P. Human factors in the management of the critically ill patient. Br J Anaesth 2010;105:26–33.

2. The International Ergonomics Association. What is Ergonomics? https://iea.cc/what-is-ergonomics/ (accessed 11th February 2022).

3. Marshall S. The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg.2013;117:1162-1171.

4. Riley E, Payne S, Jones J, et al. ‘Trachy Tracey’ - an education tool for tracheostomy training. Anaesthesia. 2018;73:1044-1045.

5. O’Farrell G, McDonald M, Kelly FE. ‘Tea trolley’ difficult airway training. Anaesthesia.2015;7:104.

Algorithm Steps/observed actions	Group 1: Scenario run without reference to the tracheostomy algorithm [Total score(%)]	Group 2: Scenario run with reference to the tracheostomy algorithm [Total score(%)]
Identifies red flags (3): Airway Breathing Circulation (max score 3)	21/39 (53.8%)	36/39 (92.3%)
Calls for help Bleeps 7333 (max score 2)	17/26 (65.4%)	25/26 (96.2%)
Applies 100% oxygen: To face To tracheostomy (max score 2)	23/25 (88.5%)	24/26 (92.3%)
Checks capnography Identifies normal/abnormal trace (max score 2)	14/26 (53.8%)	24/26 (92.3%)
Calls for difficult airway trolley (max score 1)	2/13 (15.4%)	12/13 (92.3%)
Removes inner tube (max score 1)	11/13 (84.6%)	13/13 (100%)
Attempts to pass suction catheter (max score 1)	12/13 (92.3%)	13/13 (100%)
Applies: Water circuit Two breaths Checks: Capnography Chest moving Neck swelling (max score 5)	38/65 (58.5%)	44/65 (66.7%)
Identifies and declares correct outcome (max score 1)	7/13 (53.8%)	12/13 (92.3%)
TOTAL	145/234 (62%)	203/234 (86.8%)

4675

Isoflurane Provides Cardioprotection from Metaraminol induced Cardiac Injury

Sophie Walker¹, Ana Gutierrez-del-Arroyo², Gareth Ackland²

¹ Broomfield Hospital, Chelmsford, UK

² Queen Mary University of London, UK

Broomfield Hospital, Chelmsford, UK, [e-mail]

Abstract

Introduction: Metaraminol is a alpha-adrenoreceptor agonist commonly used in perioperative practice. It stimulates alpha-adrenoreceptors in peripheral vasculature leading to vasoconstriction as well as cardiac alpha-adrenoreceptors directly. Preclinical studies have shown to a single dose of alpha-agonist will induce cardiac injury in mice.¹ Volatile anaesthetic agents have been shown to provide some levels of cardiac protection in cardiac and non-cardiac surgery reducing ischaemia and reperfusion injury.²

Objectives: This study examines the cardiac dysfunction following metarmainol injections, and the influence of isoflurane anaesthetic on this cardiac injury.

Methods: C57B6 mice underwent baseline echocardiography (Vevo3100, Visualsonics) 1 week prior to any intervention. Metaraminol (10mg/kg) was given via a single dose intraperitoneal injection either awake, or anaesthetised with 2% isoflurane. 36 hours later, repeat echocardiography was performed under anaesthesia followed by tissue harvest and cardiac tissue enzymatic digestion (collagenase type IA and XI, Deoxyribonuclease I, Hyaluronidase IV). Cells from the cardiac digestion were stained (CD45 FITC, Miltenyi Biotech) and analysed using flow cytometry (LSRFortessa, BD Biosciences). Tail cuff volume pressure recording (Coda NIBP Monitor, Kent Scientific) was used to serially measure systolic blood pressure in awake and anaesthetised mice injected with metaraminol.

Results: Mice injected with metaraminol whilst awake showed a significant infiltration of immune cells into cardiac tissue compared to saline injected (p=0.002). Those injected with metaraminol whilst anaesthetised with isoflurane demonstrated no rise in immune cell infiltration compared with saline injected (p=0.934) (Figure 1A, B). There was no significant elevation in systolic blood pressure in awake (p=0.942) or anaesthetised (p=0.119) mice compared to baseline within 10 minutes of a metaraminol injection (Figure 1C). There was, however, a significant decline in cardiac ejection fraction 36 hours after a metaraminol injection in awake mice (p=0.002). In those injected whilst under isoflurane, no such decline in cardiac function was seen (p=0.695).

Conclusion: This study demonstrates a single dose of metaraminol (10mg/kg) induces an infiltration of immune cells into cardiac tissue along with a decline in cardiac function. If this metaraminol is administered whilst under isoflurane anaesthetic, the effect is attenuated. This cardiac injury appears to be not exclusively related to sustained uncontrolled hypertension, as there was no significant increase in systolic blood pressure in awake or anaesthetised mice. Further research into the pathophysiology of this cardioprotective mechanism and the role of the immune system is required.

References

1. Navarro-Sobrino M, Lorita J, Soley M, Ramirez I. Catecholamine-induced heart injury in mice: differential effects of isoproterenol and phenylephrine. Histol Histopathol. 2010;25(5):589-97.

2. Van Allen NR, Krafft PR, Leitzke AS, Applegate RL, 2nd, Tang J, Zhang JH. The role of Volatile Anesthetics in Cardioprotection: a systematic review. Med Gas Res. 2012;2(1):22.

Figure 1.

A: CD45+ immune cell infiltration of cardiac tissue (% of events run). Saline 1.1±0.7 n=6. Awake 7.5±4.6, n=5, p=0.002. Isoflurane 1.6±1.1 n=7, p=0.9. B: Example of Flow Cytometry demonstrating influx of CD45+ immune cells into cardiac tissue C: Systolic blood pressure (mmHg) Awake: Baseline 125±15 10 mins 123±15, n=4, p=0.942. Isoflurane: Baseline 83±7 10 mins 100±14, n=3, p=0.119 D: Ejection Fraction (%) Awake: Baseline 67.1±8.2, 36 hours 62.4±5.3, n=5, p=0.002. Isoflurane: Baseline 62.6±8.6, 36 hours 64.9±5.4, n=5, p=0.70.

4670

The impact of a dedicated critical illness rehabilitation team on mobility levels in survivors of critical illness on step down to the ward

David McWilliams, Emma Stuart-Thomas

University Hospitals Coventry and Warwickshire

University Hospitals Coventry and Warwickshire, [e-mail]

Abstract

Introduction: Early and structured rehabilitation is recommended to improve outcomes for patients admitted to the intensive care unit (ICU).¹ Despite this increased focus on rehabilitation, only limited data is available to evaluate whether this level of rehabilitation is maintained on ward step down. A study by Hopkins et al (2012) demonstrated activity levels to decrease in 56% of patients on the first full ward day in comparison to highest levels achieved in the ICU,² with sub-optimal rehabilitation identified as a common factor for those patients who die on the ward following ICU discharge.³ Within our trust we have created a dedicated critical illness rehabilitation team (CIRT) to support ongoing rehabilitation and patient transition from ICU to the ward.

Objective: To evaluate whether the presence of a dedicated critical illness rehabilitation team helps to maintain or improve mobility level on the first full ward day after step down from ICU.

Method: Patients admitted to ICU for ≥ 4 days between 4^th October 2021 and 11^th February 2022 and surviving to ICU discharge were eligible for inclusion in the analysis. Inclusion criteria were patients who achieved a Manchester Mobility Score of ≤ 5 at ICU discharge but who had been independently mobile prior to ICU admission. Patients were excluded if they had contraindications to mobilise (e.g. major trauma or neurological injury). The critical illness rehabilitation team supported rehabilitation in critical care prior to ward step down, and then continued for up to 2 additional weeks on the ward. Primary outcome was change in activity level, defined as change in Manchester Mobility Score on day 1 on the ward vs the highest level achieved before ICU discharge.

Results: During the trial period 78 patients met the inclusion criteria and were seen by the critical illness rehabilitation team. Just over half of the patients were mechanically ventilated in ICU and the average length of stay was 13.2 days (see table. 1). Mobility levels were maintained in 33 (42%) or increased in 35 (45%) of patients, with only 10 (13%) showing a reduction (see Figure. 1). Median Manchester mobility scores were significantly higher on day 1 on the ward in comparison to ICU discharge levels (5 vs 4, p=0.01828). Patients received an average of 5 additional rehabilitation sessions from the CIRT on the ward.

Table 1.

Age – years (mean +/-sd)	55 +/-13.9
Gender (male)	48 (62%)
ICU length of Stay – days (mean +/-sd)	13.2 +/- 12.6
Ventilated	44 (56%)
Ventilation days (n=44) (mean +/- sd)	12.5 +/- 11.1
Manchester Mobility Score - ICU discharge (Med (IQR))	4 (2-5)
Manchester Mobility Score - Ward day 1 (Med (IQR)	5 (2.5-6)
Ward length of stay – days (mean +/- sd)	15.9 +/- 16.2

Conclusion: The presence of a dedicated critical illness rehabilitation team was effective in maintaining or improving mobility levels on the first day of ward transfer. This could provide a useful framework to support ward step down and ongoing rehabilitation in survivors of critical illness.

References

1. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018; 46(9):e825-e873.

2. Hopkins RO, Miller RR, Rodriguez L, et al. Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit, Physical Therapy, 2012. 92(12):pp 1518–1523.

3. Vollam, S., Gustafson, O., Young, J.D. et al. Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study. Crit Care 25, 10 (2021).

4669

An international survey exploring the adoption and utility of diagnostic lung ultrasound by physiotherapists and respiratory therapists in intensive care

Fion Lau¹, Simon Hayward², George Ntoumenopoulos³

¹ Royal Perth Bentley Group

² Blackpool Teaching Hospitals NHS Foundation Trust

³ St Vincent’s Hospital

Royal Perth Bentley Group, [e-mail]

Abstract

Introduction: Lung ultrasound (LUS) is an emerging assessment tool for intensive care unit (ICU) therapists (physiotherapists, physical therapists, and respiratory therapists) to aid pathology identification, intervention selection, clinical reasoning and as an outcome measure to assess intervention efficacy. However, the extent of LUS adoption and use by ICU therapists internationally has not been described in the literature.

Objectives: This surveyed explored how widespread the interest in LUS is amongst ICU therapists internationally. In addition, LUS training, use in clinical practice and barriers to implementation were also explored. The survey findings were used to facilitate recommendations for future adoption.

Methods: International ICU therapists were invited to answer a thirty-seven-question cross-sectional survey, distributed using the online survey tool Redcap®. The exact sample size of eligible ICU therapists from around the world is unknown, therefore the participant responses received were a representative convenience sample of the international ICU therapist population. Survey links were posted on the relevant web pages and social media forums utilised by various ICU therapist associations and professional organisations worldwide. A snowballing technique was used to encourage survey participants to forward the survey link within their professional networks. The survey was open on Redcap® for an eight-week period between March and May 2021.

Results: Three hundred and twenty ICU therapists from 30 countries responded with most respondents coming from either the United Kingdom (n=94) or Australia (n=87).

89 of the ICU therapist respondents (30%) reported being users of LUS, however, 40 of those 89 respondents reported having no formal accreditation. The top indications to perform a LUS scan were changes on chest radiograph, altered findings on auscultation and a low partial pressure of arterial oxygen/fraction of inspired oxygen ratio.

71% of LUS users reported that their ICU does not have a local policy in place to guide ICU therapists’ use of LUS. Most LUS users (82%) only document their LUS findings in the patient’s medical notes and (73%) only store the LUS clips locally on the ICU’s ultrasound machine.

85% of respondents see LUS becoming an increasing part of their objective assessment in the future and 96% report that they have one or more ICU therapist colleagues interested in adopting LUS. Main reasons why respondents believe that ICU therapists are not adopting LUS in their ICU are a difficulty in accessing appropriate training, mentorship, and a lack of local governance policy guiding their use of LUS.

Conclusions: To our knowledge this is the first study to explore the international adoption and utility of LUS by ICU therapists. LUS is a growing technique with widespread interest from ICU therapists internationally with a desire to adopt LUS into their assessments and upskill their practice. ICU therapists’ use of LUS could allow more targeted and appropriate treatment for patients on ICU. Barriers to LUS adoption could be mitigated by having access to quality training programmes and mentorship. Development of profession specific guidance and policies within local infrastructure should facilitate growth and ensure robust quality assurance and governance processes.

4668

Tracheostomy care and outcomes during the COVID-19 pandemic- an observational cohort perspective from Cardiff

Jason Nunn¹, Paul Twose², Gemma Jones¹, Jennifer Lowes¹, Paul Morgan¹

¹ Cardiff and Vale University Health Board

² Cardiff and Vale University Health Board and Cardiff University

Cardiff and Vale University Health Board, [e-mail]

Abstract

Introduction: Prior to the COVID-19 pandemic an estimated 5000 surgical and 12000 percutaneous tracheostomies were completed in the UK each year.¹ A UK study looking at COVID-19 tracheostomy outcomes found 1605 tracheostomy cases from 126 hospital, median time from intubation to tracheostomy was 15 days while 285 (18%) patients died following the procedure.² COVID-19 patients also typically spend longer in critical care with prolonged time receiving organ support when compared to patients diagnosed with other viral pneumonias.³ Incidence of laryngeal pathologies are also higher in COVID-19 patients post tracheostomy.⁴

Objectives: The aim of this observational study was to review the outcomes of patients post tracheostomy insertion during the COVID-19 pandemic compared to non-COVID patients.

Methods: A service evaluation was completed including all patients requiring a tracheostomy since the beginning of the COVID-19 pandemic in March 2020 within University Hospital Wales, Cardiff. Data was captured from local tracheostomy databases.

Patients were grouped into either COVID or non-COVID based on their clinical history. The key outcomes evaluated were number of tracheostomies, average time to cuff deflation and decannulation, critical care and hospital length of stay, occurrence of adverse events and time from critical care admission to tracheostomy insertion.

Data was evaluated using descriptive statistics using Microsoft Excel^TM.

Results: During the review period 58 patients with COVID-19 and 158 without required a tracheostomy.

In the COVID-19 group cuff deflation occurred at a median of 10 days post insertion compared to 7 days. Decannulation occurred at a median of 16 days in patients with COVID-19 compared to 18 days. The rate of decannulation was also higher in the COVID-19 group at 74.1% compared to 67.1%. Critical care length of stay was 37 days in the COVID-19 compared to 25 days. Time from intubation to tracheostomy was comparable between groups at a median of 16 days for our COVID-19 cohort compared to 15 days.

The incidence of clinical incidents was higher in the non-COVID-19 group at 10.1% compared to 5.2%.

Conclusion: This internal service evaluation has shown that COVID-19 patients typically spend longer in critical care but their time to decannulation was shorter and their rate of decannulation was higher in our cohort then in the comparison group. This could be due to the tertiary neuroscience and major trauma specialities within our Health Board. Both with groups of patients that, due to the nature of their injuries may require prolonged periods of tracheostomy insertion even after critical care discharge.

COVID-19	Non-COVID-19
Total no Tracheostomy	58	158
Cuff deflation completed (n, %)	47 (81%)	125 (79.1%)
Time to cuff deflation (days)	10	7
Downsize completed (n, %)	10 (17.2%)	30 (18.9%)
Time to downsize (days)	18	18
Decannulation completed (n, %)	43 (74.1%)	106 (67.1%)
Time to decannulation (days)	16	18
Critical Care Admission to Tracheostomy Length (days)	16	15
Hospital Length of Stay (days)	48	48
Critical Care Length of Stay (days)	37	25
Adverse Events (n, %)	3 (5.2%)	16 (10.1%)
No of Deaths (n, %)	13 (22.4%)	29 (18.4%)

References

1. McGrath BA, Lynch J, Bonvento B, Wallace S, Poole V, Farrell A, et al. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ Quality Improvement Reports. 2017;6(1):bmjqir.u220636.w7996.

2. collaborative CO, Hamilton NJI, Schilder AGM, Jacob T, Ambler G, Singer M, et al. COVIDTrach; a prospective cohort study of mechanically ventilated COVID-19 patients undergoing tracheostomy in the UK. medRxiv. 2020:2020.10.20.20216085.

3. Richards-Belle A, Orzechowska I, Gould DW, Thomas K, Doidge JC, Mouncey PR, et al. COVID-19 in critical care: epidemiology of the first epidemic wave across England, Wales and Northern Ireland. Intensive Care Medicine. 2020;46(11):2035-47.

4. Boggiano S, Williams T, Gill SE, Alexander PDG, Khwaja S, Wallace S, et al. Multidisciplinary management of laryngeal pathology identified in patients with COVID-19 following trans-laryngeal intubation and tracheostomy. Journal of the Intensive Care Society. 2021:17511437211034699.

4667

FUSIC-SY: Developing online educational material for critical care ultrasound

Ben Stoney¹, James Sylvester¹, Steve Lobaz², Simon Chau², Max Broadbent³

¹ Sheffield Teaching Hospitals

² Barnsley Hospital

³ Max Broadbent Design

Sheffield Teaching Hospitals, [e-mail]

Abstract

Introduction: Focused Ultrasound in Intensive Care (FUSIC) accreditation has been particularly challenging during the pandemic with a lack of courses and an increase in workload leading to less time for training and mentorship. This has caused a change to more independent learning where the FUSIC trainee is more autonomous, and separated from their mentor by space and time.¹ With technology advances online learning is becoming a way to facilitate learner education at their own pace, from any location, leading to a more learner-centric experience.² In regards to FUSIC training, online learning would help make logbook progression and ongoing mentoring a more blended learning experience. Studies suggest that blended learning through online and face-to-face sessions stimulate more effective learning and knowledge outcomes for postgraduate healthcare professionals compared to traditional teaching methods.^2–3

Objectives: Our current aim is to develop online educational material for critical care ultrasound training, that is concise and freely accessible.

Method: A website is uniquely situated to provide ultrasound education:

• It is freely accessible with an internet connection and can be accessed on phone/tablets/desktop. (Fig.1)

• It can provide written and visual information.

• It can be edited to remain up to date with current practices and developed over time.

Online education isn’t without its barriers which include time constraints, poor technical skills, inadequate infrastructure, absence of institutional support and negative attitudes.⁴ To avoid these we needed buy in from local FUSIC mentors and critical care departments, and help with the technical aspects of producing the content.

The main areas we needed to consider to produce the website were:

• Website build with aid of a graphic designer

• Producing the educational material

• Acquiring ultrasound images

• Clinical governance guidance and patient consent

• Copyright issues

• Cost

Results: The website can be visited at fusic-sy.co.uk.⁵ The homepage gives an overview of our ultimate goals of improving trainee motivation, confidence and enthusiasm for ultrasound training by providing educational material, courses and mentorship.

The educational material is found under the education tab and covers the FUSIC modules. The educational style used is a mixture of text, images and ultrasound clips. (Fig.2) This is to appeal to read/write and visual learners from the VARK styles of learning. Our consideration for aural and kinaesthetic learners was that they were more likely to benefit from mentorship and hands-on experience.

Ultrasound training in general is difficult to convey in an aural fashion such as with a podcast, and our use of educational videos was limited to only short clips. This was to help maintain interest and make it easier for trainees to find relevant information on the webpage.

Conclusion: Our initial project was setting up the FUSIC educational material, but there is scope to expand the resources to include case reports, blog posts, webinars by local/national experts and develop a more connected regional mentorship program. Overall, we hope this project helps grow the critical care ultrasound community within South Yorkshire.

Figure 1.

Compatibility on phone/tablet/desktop.

Figure 2.

Abdomen education page layout with text/image/US clips.

References

1. Moore, M. Toward a theory of independent learning and teaching. Journal of Higher Education. 1973 December; 44(9): 661-680.

2. Westerlaken, M. et al. Blended learning for postgraduates; an interactive experience. BMC Medical Education. 2019 July; 19(289).

3. Vallée, A. et al. Blended learning compared to traditional learning in medical education: Systematic review and meta-analysis. Journal Medical Internet Research. 2020 August; 22(8).

4. O’Doherty, D. et al. Barriers and solutions to online learning in medical education - an integrative review. BMC Medical Education. 2018 June; 18(130).

5. Stoney, B. Broadbent, M. et al. FUSIC-South Yorkshire. [Online].; 2022 [cited 2022 February 22. Available from: fusic-sy.co.uk.

4666

Physiotherapy-led lung ultrasound in critical care: a service evaluation

Deirdre O’Dowd

Hse

Hse, [e-mail]

Abstract

Introduction

Physiotherapists across Ireland and the United Kingdom (UK) are gaining momentum as they incorporate point-of-care lung ultrasound (LUS) into their clinical practice in critical care.¹ Auscultation and interpretation of chest radiographs (CXR), assessment tools traditionally used by physiotherapists in critical care, are known to have diagnostic limitations.² LUS however, when compared to CXR, has been shown to have a higher diagnostic accuracy in identifying consolidation, pleural effusion, pneumothorax and interstitial syndrome.³ Consequently, LUS offers physiotherapists an advanced respiratory assessment skill and an opportunity to extend their roles beyond traditional practice in critical care. The aim of this service evaluation was to explore the use of LUS by physiotherapy in a critical care unit in a Model 4 Irish hospital.

Methods: A retrospective chart review was performed. All adult critical care patients who were assessed by physiotherapy using LUS as part of a physiotherapy respiratory assessment, between May 2021 and January 2022, were included. The critical care unit at the hospital site, a supra-regional centre, consisted of an adult intensive care unit (ICU; 11 beds), high dependency unit (HDU; 6 beds), cardiothoracic ICU (CTICU; up to 5 beds), and post anaesthetic care unit (PACU; 4 beds). Descriptive statistics were used to analyse the data.

The physiotherapist performing the LUS scans had gained accreditation to perform LUS through the Intensive Care Society (UK) Focused Ultrasound in Intensive Care (FUSIC) programme and had one year’s experience of performing LUS.

Data collected included: the patient’s ventilation status at the time of physiotherapy assessment, documented reason for undertaking LUS, and recommendations made based on the findings of the LUS scan.

Results: In total, between May 2021 and January 2022, 35 patients were assessed by physiotherapy with LUS. At the time of the physiotherapy assessment 74% of patients were mechanically ventilated.

The primary reason the physiotherapist used LUS was to guide appropriate physiotherapy treatment (29/35, 83%). This was achieved by supporting clinical reasoning (10/35; 29%) and accurately identifying lung pathology (19/35; 54%). In these cases, based on the findings of LUS, a recommendation for airway clearance was made for 17 patients (17/29, 59%). 34% of patients were deemed not to require physiotherapy respiratory intervention (10/29).

Four patients were triaged using LUS (4/35; 11%) with 75% of patients identified as not requiring respiratory treatment at that time (3/4; 75%). Physiotherapy-led LUS was also used to track the response to physiotherapy treatment (2/35; 6%) however there were no cases of LUS used to assist in the weaning of mechanically ventilated patients.

Conclusions: Appropriate physiotherapy treatment is dependent on an accurate physiotherapy assessment. This evaluation highlights how LUS can support physiotherapists’ diagnostic abilities in critical care and directly inform clinical decision making. LUS offers physiotherapists a tool to guide, monitor and evaluate respiratory physiotherapy intervention. It is important, however, in order to continue the momentum of change that the impact of physiotherapy-led LUS is further explored.

References

1. Hayward S, Smith M, Innes S. Diagnostic thorax ultrasound imaging - an exploration of respiratory physiotherapists’ interest and use in clinical practice: A national survey. Ultrasound. 2020; 28(1):14-22.

2. Leech M, Bissett B, Kot M, Ntoumenopoulos G. Lung ultrasound for critical care physiotherapists: a narrative review. Physiother Res Int. 2015; 20(2): 69-76.

3. Xirouchaki N, Magkanas E, Vaporidi K, Kondili E, Plataki M, Patrianakos A, Akoumianaki E, Georgopoulos D. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011;37(9): 1488-1493.

4665

The fragility index in randomised controlled trials of interventions for aneurysmal subarachnoid haemorrhage: a systematic review

Aravind Ramesh, Henry Munby, Matt Thomas

Southmead Hospital, North Bristol NHS Trust

Southmead Hospital, North Bristol NHS Trust, [e-mail]

Abstract

Introduction: Crossing the arbitrarily defined threshold for statistical significance, usually taken to be a p-value of less than 0.05, may rest on as few as one or two actual events even in high quality randomised trials.^1–2 If the threshold for statistical significance is not met it is unlikely that the intervention studied will be adopted by clinicians.³

The number of events that need to change groups to render a statistically significant result non-significant is an indicator of the fragility of that result.⁴ Fragility analysis supplements the p-value and risk of bias assessment in the interpretation of results of randomised controlled trials.

Application of fragility analysis to the field of neurocritical care has been limited. A review of cerebrovascular studies limited by date and database showed the median fragility index of seven randomised controlled trials in aneurysmal subarachnoid haemorrhage to be 5.⁵

Objectives: The primary objective is to present Fragility Index for randomised controlled trials of interventions in aneurysmal subarachnoid haemorrhage that report a statistically significant patient centred primary outcome. Secondary objectives are to analyse the risk of bias, to compare the Fragility Index with the number of participants lost to follow up in the trial, and to calculate the Fragility Quotient.

Methods: This is a systematic review registered with PROSPERO (ID: CRD42020173604). Randomised controlled trials in adults with aneurysmal subarachnoid haemorrhage were analysed if they reported a statistically significant primary outcome of mortality, function (e.g. modified Rankin Scale), vasospasm or delayed neurological deterioration.

Results: We identified 3809 records with 17 randomized trials selected for analysis (Figure 1). The median fragility index was 3 (inter-quartile range 0-5) and the median fragility quotient was 0.012 (IQR 0-0.034) (Table 1). Six of nineteen trial outcomes (31.6%) had a fragility index of 0 (Figure 2). In seven trials (36.8%), the number of participants lost to follow-up was greater than or equal to the fragility index. Only 17.6% of trials are at low risk of bias (Table 2).

Conclusions: Randomised controlled trial evidence supporting management of aneurysmal subarachnoid haemorrhage is weaker than indicated by conventional analysis using p-values alone. Increased use of fragility analysis by clinicians and researchers could improve the translation of evidence to practice.

References

1. Ridgeon EE, Young PJ, Bellomo R, et al. The fragility index in multicenter randomized controlled critical care trials. Crit Care Med 2016;44:1278–84. doi: 10.1097/CCM.0000000000001670

2. Khan MS, Ochani RK, Shaikh A, et al. Fragility Index in Cardiovascular Randomized Controlled Trials. Circ Cardiovasc Qual Outcomes 2019;12:e005755. doi:10.1161/CIRCOUTCOMES.119.005755

3. Pocock SJ, Stone GW. The Primary Outcome Fails — What Next? N Engl J Med 2016;375:861–70. doi:10.1056/nejmra1510064

4. Walsh M, Srinathan SK, McAuley DF, et al. The statistical significance of randomized controlled trial results is frequently fragile: A case for a Fragility Index. J Clin Epidemiol 2014;67:622–8. doi:10.1016/j.jclinepi.2013.10.019

5. Adeeb N, Terrell DL, Whipple SG, et al. The Reproducibility of Cerebrovascular Randomized Controlled Trials. World Neurosurg 2020;140: e46–52. doi:10.1016/j.wneu.2020.04.106

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram showing study selection for inclusion in Fragility analysis.

Figure 2.

Distribution of fragility index of randomized controlled trials in aneurysmal subarachnoid haemorrhage reporting significant effects of an intervention on a prespecified patient-centred outcome

4664

Outcome of a quality improvement project to prevent unnecessary red blood cell transfusion in an intensive care unit in Bangladesh

Kazi Bodruddoza¹, Eshita Majumder²

¹ Square Hospitals Limited

² James Cook University Hospital - Middlesbrough, Cleveland

Square Hospitals Limited, [e-mail]

Abstract

Introduction: Although anaemia is a common finding in critically ill patients, overzealous transfusion to correct the mere haemoglobin (Hb) numbers to normal value may lead to transfusion-associated health hazards and increase mortality rates among ICU patients.¹ Several randomized multicentre trials established that restrictive transfusion with target Hb 7 gm/L has better patient outcomes except for the patients with active haemorrhage, traumatic brain injury (TBI) and acute coronary syndrome. Moreover, the supply of RBC is scarce compared to the demand. So, prevention of inappropriate transfusion will also be cost-effective in a resource-poor country like Bangladesh.

Objectives: As there are no national guidelines for blood transfusion in our country, we follow the guidelines of the British Committee for Standards in Haematology (BCSH) for the management of anaemia and red cell transfusion in adult critically ill patients in our institution. The aims of this quality improvement project (QIP) are to collect the background RBC transfusion data in our hospital critical care setting, determine the percentage of deviation from the recommended guideline and after implementation of interventions to assess the improvement from the initial practice.

Methods: During the initial audit, RBC transfusions over two months were recorded (n = 67). The patients with active bleeding, traumatic brain injury, acute coronary syndrome, and acute sepsis (within the first 12 hours) were excluded (n = 11). The percentage of patients who received transfusion despite Hb level > 70 gm/L were calculated. A teaching session was delivered to increase awareness among critical care physicians and nurses regarding the restrictive threshold of RBC transfusion. After 3 months, 2nds set of data was collected. Despite the significant change of transfusion practice, to reinforce the change posters depicting an algorithm aiding the clinical decision of RBC transfusion was inserted at the doctor-nurse working areas. 2nd Plan-Do-Study-Act (PDSA) cycle was conducted after 3 months of this intervention.

Results: On the initial audit, it was found that 43 patients had RBC transfusion over the study period despite Hb level >7 gm/L (7.3−8.1) which was 76.78% of total transfusion. After 1st intervention, the inappropriate transfusion rate reduced to 37.39% whereas 2^nd PDSA showed a reduction to 4.43%.

Conclusion: A well-thought quality improvement project can bring positive changes in transfusion practice in critically ill patients.

References

1. Hebert, P.C., Wells, G., Blajchman, M.A., Marshall, J., Martin, C., Pagliarello, G., et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. The New England Journal of Medicine 1999; 340:409-17

2. Retter, A., Wyncoll, D., Pearse, R., Carson, D., McKechnie, S., Stanworth, S., et al for the British Committee for Standards in Haematology. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. British Journal of Haematology 2013;160:445–64.

4662

What limits mobilisation of critically ill patients: An observational study

Agatha Poole¹, David McWilliams²

¹ University Hospitals Coventry and Warwickshire NHS Trust

² University Hospitals Coventry & Warwickshire NHS Trust

University Hospitals Coventry and Warwickshire NHS Trust, [e-mail]

Abstract

Introduction: Intensive care acquired weakness is a common risk factor of extended intensive care unit (ICU) stays and has been found to be more prevalent when sedation and neuromuscular blocking agents are used, as well as when a patient experiences multiple organ failure and long periods of immobility.¹ Early mobilisation has been found to be safe and feasible in acute phases of illness, resulting in a higher level of mobility at point of discharge from ICU in turn, reducing hospital length of stay.² Despite this, a previous point prevalence survey showed rehabilitation levels in ICU in the United Kingdom were low, particularly in patients receiving mechanical ventilation and organ support.³

Objectives:

1. To determine mobilisation rates within ICU in a large UK based acute hospital trust

2. To identify limiting factors to mobilisation in ICU and any potentially modifiable factors

Methods: We conducted a survey of physiotherapy treatment for two separate five day periods (20/12/2021-24/12/2021; 10/01/2022-14/01/2022) in a UK based 30 bedded ICU. Rehabilitation data was collected for all patients, excluding those with specific contraindications to mobilise (e.g. spinal injuries). Data was collected daily using a pre-designed tool establishing mode of ventilation, sedation use, inotropic support, Continuous Veno-Venous Hemofiltration (CVVH) requirement and mobilisation levels. When mobilisation (defined as sitting on the edge of the bed, transferring to a chair, standing or walking) was not completed, the primary reason for this was collected from the therapy notes. Statistical analysis was carried out using Fisher’s exact tests.

Results: A total of 164 physiotherapy treatments were administered over the study period, of which 39 (24%) included mobilisation. Levels of mobilisation were significantly lower in patients receiving mechanical ventilation (10% vs 41%, p<0.00001) and those receiving inotropic or vasopressor support (6% vs 33%). Whilst patients receiving continuous renal support mobilised less frequently, this was not statistically significant (12% vs 26%, p=0.1356). Whilst no patients who were receiving sedation mobilised, once sedation had been stopped conscious level and the ability to follow commands was not a barrier for mobilisation (38% vs 37%, p=1.00). For patients who were mechanically ventilated and not receiving sedation, mobilisation rates increased to 26%.

The largest barriers to mobilisation were sedation +/− paralysis (42%) and cardiac or respiratory instability (23%). A number of potentially modifiable factors were identified, with up to 32% of limitations being potentially modifiable. The largest of these were awaiting neurosurgeon documentation of mobility status (10%) and reason not stated (6%) where no apparent limitation could be identified.

Conclusions: This observational study demonstrated that despite the proven benefits of early mobilisation, a number of barriers to delivery still exist. The ability to mobilise were significantly affected by the presence of sedation, invasive ventilation and inotropes / vasopressors. Promisingly, approximately a third of limitations to mobilise were potentially modifiable. Improved education, better management of agitated patients and a more patient centred approach to rehabilitation planning may help to improve overall mobilisation rates.

References

1. Kress J and Hall J. ICU-Acquired Weakness and Recovery from Critical Illness. N Engl J Med 2014; 370: 1626-1635.

2. McWilliams D, Weblin J, Atkins G, et al. Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project. J Crit Care 2015; 30: 12-18.

3. McWilliams D, Duffy L, Snelson C. Current rehabilitation practices for patients admitted to critical care in the UK: a 5 day point prevalence survey of 12 adult general intensive care units. Journal of ACPRC. 2016. 48. 4-13.

4661

Minimum standards of clinical practice for physiotherapists working in critical care units in Ireland: a modified Delphi technique

Niamh O’Malley¹, Brenda O’Neill²

¹ University Hospital Galway

² Ulster University

University Hospital Galway, [e-mail]

Abstract

Introduction: Physiotherapists in Irish hospitals with critical care units deliver physiotherapy services 24 hours a day, 7 days a week. There is a perceived lack of consistency in the level of clinical competence, required skills and content of training between hospitals, compounded by the absence of a national policy, procedure or clinical framework for physiotherapists working in critical care. The study aimed to identify the minimum standards of clinical practice expected of physiotherapists working in critical care settings in Ireland.

Objectives: The objectives of this study were to gain a professional consensus of the minimum standards of clinical practice for physiotherapists working in critical care in Ireland, to understand the clinical skills expected of a physiotherapist to work independently in a critical care setting in Ireland and to compare the minimum Irish standards with those of Australia and New Zealand, the UK and Japan.^1–3

Methods: A modified Delphi technique was used to survey a panel of senior and clinical specialist physiotherapists working in critical care units in Ireland to obtain consensus of items. The 214 questionnaire items were comprised of common critical care clinical conditions, physiotherapy assessments and treatments in a critical care setting. The questionnaire was completed over three rounds. Items were determined ‘Essential/Not Essential/Unsure’ by participants. Items that did not reach consensus were included in the subsequent round with additional items suggested by participants.

Results: 25/46(54%) physiotherapists completed the first round, with 17 and 13 completing round 2 and round 3 respectively. A total of 220 items were included, 120 of which were deemed essential for a minimum standards of independent clinical practice in Irish critical care units. 56 items were considered not essential while consensus was not reached on 44 items.

Conclusions: This study identified 120 items of knowledge and clinical skills considered essential as a minimum standard by physiotherapists working in Irish critical care units. Further discussion is required to determine how these results can be applied to guide clinical practice and education for physiotherapists working in critical care in Ireland.

References

1. Skinner EH, Thomas P, Reeve JC, Patman S. Minimum standards of clinical practice for physiotherapists working in critical care settings in Australia and New Zealand: a modified Delphi technique. Physiotherapy theory and practice. 2016;32(6):468-82.

2. Twose P, Jones U, Cornell G. Minimum standards of clinical practice for physiotherapists working in critical care settings in the United Kingdom: a modified Delphi technique. Journal of the Intensive Care Society. 2019; 20(2):118-31.

3. Takahashi T, Kato M, Obata K, Kozu R, Fujimoto T, Yamashita K, Ando M, Kawai Y, Kojima N, Komatsu H, Nakamura K. Minimum standards of clinical practice for physical therapists working in intensive care units in Japan. Physical Therapy Research. 2020:E10060.

4660

Judicious use of the Critical Care Outreach Team: A QIP to reduce the inappropriate use of Early Warning Scores through targeted communication

Urwah Ahmed, Clara Green, Rahul Mukherjee

University Hospitals Birmingham

University Hospitals Birmingham, [e-mail]

Abstract

Introduction: Early Warning Scores (EWS) use physiological parameters to create an aggregate score alerting medical teams to patient deterioration. Although vital tools for triggering referrals to critical care services in appropriate patients, the score does not take account of patients with persistently altered physiology or patients who are not deemed suitable for escalation to critical care. In these instances, EWS can result in the over-monitoring of patients and inappropriate contact of already strained critical care outreach services.^1–2 Guidelines state that in such circumstances routine recording of EWS may be stopped.¹

The COVID-19 pandemic has placed unprecedented demands on already overstretched resources in the critical care services,³ in particular on the Critical Care Outreach Team (CCOT). This makes their judicious use, and this QIP, ever more pertinent.

Objectives: In our trust, it was found that despite documented decisions not to escalate patients to critical care, these patients were still being monitored according to EWS, resulting in the inappropriate call out of the CCOT.

We introduced measures to improve the proportion of inpatients with treatment limitations in place that had these limitations documented on their EWS charts, with the overall aim of reducing the number of inappropriate call-out of the CCOT.

Methods: We performed two snapshot audits on acute medical (control) and general medical wards (intervention) in a large district general hospital between the years 2018-2019. We obtained the percentage of patients with treatment limitations in place who had this documented on their EWS charts before and after improvement measures. Firstly, a paper prompt on the EWS chart was used in both control and intervention wards. Secondly, targeted communication interventions to general medical wards only. Targeted communication was not repeated after the second audit. A third snapshot audit was completed a year after improvement measures (2020) to identify whether improvements were sustained.

Results: There was no significant difference in EWS amendment in the acute medical ward, where only a paper prompt was used. However, where targeted communication was used (general medical ward), there was a statistically significant improvement in review and amendment of EWS scores between the first and second audit in the intervention ward (37.2% vs 59.1%, p=0.017). However, this improvement was not sustained when the audit was repeated a year later.

Conclusions: The proportion of inpatients with treatment escalation limitation decisions in place that have EWS amended can be improved by targeted communication, but paper prompts alone are not sufficient. However, these improvements are not sustained without repeated communication. The importance of appropriate amendment of EWS has two key benefits. Firstly, it reduces inappropriate and futile monitoring of end-of-life patients, allowing them to have a more dignified death. Secondly, instead of performing repeated observations (nursing staff) or patient reviews (CCOT) that will not alter management, nursing staff can better utilise their time in providing palliative support where appropriate (particularly considering current visiting restrictions), and the ever- stretched CCOT can be used more judiciously.

Figure 1.

Patients with treatment limitations in place on general medical wards who had their EWS modified/stopped in 2018, 2019 and 2020. There was a significant difference in the percentage of patients with EWS amendment across the 3 audits. Significantly more patients with limitations in place had their EWS amended in 2019 in comparison with 2018 and 2020. * = p.

References

1. RCP, 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. . 2017: London: RCP.

2. Hope, J., et al., A fundamental conflict of care: Nurses’ accounts of balancing patients’ sleep with taking vital sign observations at night. J Clin Nurs, 2018. 27(9-10): p. 1860-1871.

3. Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z et al. Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China. Annals of Intensive Care. 2020;10(1).

4659

Liver Function Tests in the Intensive Care Unit - are we testing appropriately?

Kit Morris, David Slessor

Portsmouth Hospital University Trust

Portsmouth Hospital University Trust, [e-mail]

Abstract

Introduction: Liver Function Tests (LFTs) are performed to assess hepatic function and to investigate the undifferentiated, unwell patient.^1–4 The British Gastroenterology Society have published guidelines on LFTs.¹ Acknowledging that LFTs are neither sensitive nor specific, they recommend criteria for an acute liver screen being performed and for a low threshold for Gastroenterology referral.¹ It is unclear how often LFTs should be performed on patients in intensive care.^1–4

Background: Our Intensive Care Unit (ICU) has often requested daily LFTs even when previous results were normal. We were concerned that we were over testing LFTs, whilst simultaneously not referring patients with deranged LFTs to Gastroenterology on discharge from ICU.

Methods: We reviewed every patient admitted between 1/10/21 and 31/10/21 whose admission was longer than 96 hours. We noted the number of liver function tests requested for each patient and the frequency of LFTs performed. Patients who we felt warranted daily LFT monitoring included those with deranged LFTs (defined as Bilirubin > 40, ALT > 200, ALP > 200), high vasopressor requirement (or severe hypotension), overdose, receiving TPN, research purposes or at the consultant’s discretion. We then investigated to find that if the frequency of those blood tests were reduced, if we would have missed a change in management.

Results: A total of 50 patients met the inclusion criteria. Of these 50, we found 12 of these patients needed daily LFTs due to initially deranged LFTs. A further 7 met criteria for daily LFT testing as stated above. However, 39 (of 50) had their LFTs checked daily for the duration of their ICU stay. Of the remaining 11 patients, 5 had their LFTs checked > 90% of the days they were admitted, 4 had their LFTs checked > 80% of the time, and 2 > 70%.

3 patients had previously had an acute liver screen performed prior to their ICU admission. 0 patients with deranged LFTs had a full liver screen performed whilst on ICU, regardless of the suspected aetiology of the derangement. 0 patients admitted with deranged LFTs were referred to outpatient Gastroenterology by ICU on discharge from ICU.

We found that 31 of 50 patients had their liver function tested inappropriately frequently. A total of 227 unnecessary liver function tests were run on these patients. Had all patients had their LFTs checked by the standards above (i.e. twice weekly excepting the criteria for daily tests listed above), not a single patients LFT derangement would have been missed.

Conclusions: When requesting bloods, ICE requests prepopulate boxes for daily blood tests for ICU, for which LFTs featured on each day. After discussion with the ICU department, practice will change to a default of twice weekly LFTs, unless otherwise indicated. This will change on ICE. There will be a small cost saving associated with this. More importantly, we hope this will reduce the unnecessary testing burden on our patients, our laboratory and our intensive care unit.

References

1. Newsome PN, Cramb R, Davison SM et al, Guidelines on the management of abnormal liver blood tests, Gut, 2017;0:1–14. doi:10.1136/gutjnl-2017-314924

2. Lang T, Croal B, National minimum retesting intervals in pathology: A final report detailing consensus recommendations for minimum retesting intervals for use in pathology. The Royal College of Pathologists, The Association for Clinical Biochemistry and Laboratory Medicine, The Institute of Biomedical Science; 2015.

3. Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS One. 2013;8:e78962.

4. Thomson SJ, Cowan ML, Johnston I, Musa S, Grounds M, Rahman TM. “Liver function tests” on the intensive care unit: a prospective, observational study. Intensive Care Med. 2009;35:1406-1411.

4658

High-Dose Steroids in COVID-19 Related Acute Respiratory Distress Syndrome: A Proposed Protocol

Tom Beach

BCUHB

BCUHB, [e-mail]

Abstract

Introduction: The introduction of dexamethasone in the treatment of COVID-19 began in late 2020 after evidence emerged demonstrating that treatment with corticosteroids reduced mortality in those infected with severe COVID-19.¹ Current guidelines suggest the use of Dexamethasone 6mg OD for 7-10 days for those requiring oxygen.

A small proportion of patients in the intensive care unit do not respond to the usual dosing of dexamethasone. A treatment often advocated following discussion with the regional ECMO centre was high-dose steroid therapy.^2–3

No guidance existed regarding the use of high-dose steroids in ARDS secondary to COVID-19. We believed there was inconsistency in patient selection, screening, dosing and monitoring. A protocol was needed to simplify this process.

Objectives: To develop a simple protocol for the use of high-dose steroids in COVID-19 related ARDS that provided the user with information on:

1. When to consider high-dose steroids

2. The precautions that should be taken to exclude infection prior to commencing high-dose steroids

3. The monitoring required while receiving high-dose steroids

4. A proposed treatment regimen

Methodology and Results: A literature review of treatment regimens for high-dose steroids in COVID-19 ARDS was undertaken. We also included trials involving non-COVID-19 ARDS.^3–4 A local evidence-based protocol for the use of high-dose steroids in COVID-19 related ARDS was designed.

Following peer review by the wider MDT the protocol was first trialled, reviewed, and then adopted. An extended guideline with scientific context together with a quick reference bedside poster were launched.

Conclusion: The protocol provided a user-friendly summary of the information required to safely use high-dose steroids for the treatment of COVID-19 related ARDS.

The algorithm has now been adopted in several units and has been submitted for consideration as a network wide resource.

Feedback from users has been positive and we will seek to review and update this guidance as further evidence emerges in this evolving condition.

References

1. Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al. The recovery Collaborative Group. Dexamethasone in hospitalized patients with COVID-19. N Engl J Med. 2021; 384:693-704.

2. Piccica M, Lagi F, Trotta M, Spinicci M, Zammarchi L, Bartoloni A, for the COCORA working group. High-dose steroids for the treatment of severe COVID-19. Intern Emerg Med. 2021; 16(5):1395-1399.

3. Taboada M, Rodriguez N, Varela PM, Rodriguez MT, Abelleira R, Gonzalez A, et al. Effect of high versus low dose of dexamethasone on clinical worsening in patients hospitalised with moderate or severe COVID-19 Pneumonia: an open-label, randomised clinical trial. Eur Respir J. Published online December 16, 2021. doi:10.1183/13993003.02518-2021.

4. Villar J, Ferrando C, Martinez D, Ambros A, Munoz T, Soler JA, et al. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Respir Med. 2020; 8(3):267-276.

4654

‘Bug Off Week 2021’: a multidisciplinary Intensive Care Unit quality improvement project to improve the management of Clostridium Difficile and Staphylococcus

Victoria Gilmartin, Jennifer Nash, Marghanita Jenkins, Sandra Jameson, Sophie Legg, Alice Rossiter, Barbara Sowatey, Jaz Grant, Alaina Blachford, Fiona Kelly

Royal United Hospital NHS Foundation Trust, Bath

Royal United Hospital NHS Foundation Trust, Bath, [e-mail]

Abstract

Introduction: Clostridium Difficile (C.Diff) and Staphylococcus infections are a challenge in our Intensive Care Unit (ICU). We therefore designed and delivered a multidisciplinary team (MDT) quality improvement project focussing on our Trust C.Diff management policies¹ and Aseptic No-Touch Technique (ANTT):² ‘Bug Off Week 2021’.

Objectives:

1. Improve knowledge/management of C.Diff and stool chart documentation

2. Improve ANTT practice and knowledge for intravenous drug administration

3. To make infection prevention and control education fun!

Methods: We completed pre-intervention audits of ANTT checklist compliance during IV drug administration and stool chart completion compliance, and carried out staff surveys regarding C.Diff management and ANTT knowledge. ‘Bug Off Week’ involved three ‘tea trolley training’ programmes,³ providing non-threatening MDT education in the workplace during the normal working day:

1. Ice cream stool chart education programme – interactive station using ice cream cones decorated with different shaped chocolates (Maltesers, Wispa Bites, Nutella) to represent different stool types. The aims were to illustrate the Bristol Stool chart⁴, explain the recommended actions for new onset of type 5-7 stool and improve stool chart documentation. In addition, chocolate sauce in a flexiseal was used to demonstrate how to sample stool from the side port (and also decorate the ice cream cones!)

2. C Diff card game – staff were asked to identify and split 30 statement cards on the management of C.Diff into true or false piles

3. ANTT step card game – staff were asked to place 8 cards representing stages of ANTT for intravenous drug administration in the correct order and answer three bonus questions.

In addition, an ANTT steps video was filmed and distributed and two MDT competitions were organised: a ‘poop the potato’ competition, involving answering C.Diff related multiple-choice questions by carrying and dropping a potato into the correct bucket, and a staff ‘Bug Off Bake Off’ cake competition. ICU staff worked in their development teams to win prizes for each training programme and competition. Following feedback, a new ‘diarrhoea flow chart’ was designed. A post ‘Bug Off Week’ questionnaire was designed to collect feedback.

Results: There were 127 entries across all training stations and games: ice cream stool chart education (43 staff); C.Diff card game (24 staff); ANTT step card game (39 staff); poop the potato (13 staff); Bug Off Bake off (8 staff). The results of the two audits and two surveys are shown in Table 1. The post ‘Bug Off Week’ questionnaire was completed by 38 staff: 100% reported that they felt their practice had improved as a result.

Conclusions: Our ‘Bug Off Week’ project resulted in improvements in all aspects of measured ANTT and C.Diff management, including appropriate and timely sending of stool samples, completion of stool charts and compliance with ANTT for intravenous drug administration. The project brought the MDT together to work collaboratively whilst having fun in refreshing their knowledge. We plan to re-audit in three months to look for evidence of sustained change in practice. ‘Bug Off Week’ is potentially transferrable and reproducible to other ICUs.

Figure 1.

Bug off week activities.

References

1. Royal United Hospital NHS Foundation Trust. Clostridium Difficile Trust Policy, https://webserver.ruh-bath.nhs.uk/staff_resources/governance/policies/documents/clinical_policies/yellow_infection_control/Yellow_617_Clostridium_Difficile_policy.pdf?t=52003.88 (2019, Accessed 24 February 2022).

2. Royal United Hospital NHS Foundation Trust. Aseptic Non-Touch Technique Trust Policy, https://webserver.ruh-bath.nhs.uk/staff_resources/governance/policies/documents/clinical_policies/blue_clinical/Blue_764_Aseptic_Non_Touch_Technique_ANTT_Policy.pdf?t=52003.88 (2019, Accessed 24 February 2022).

3. O’Farrell G, McDonald M, Kelly FE. ‘Tea trolley’ difficult airway training. Anaesthesia 2015; 70: 104.

4. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scandanavian Journal of Gastroentorology 1997; 32: 920-24.

4649

Creating a smart classroom on intensive care using assisted reality technology

Charlotte Willis, Jessica Dawe, Christopher Leng, Rosie Warren

Northampton General Hospital

Northampton General Hospital, [e-mail]

Abstract

Introduction: Medical students receive relatively little exposure to intensive care medicine throughout their undergraduate training in comparison to other specialties. The COVID-19 pandemic further hindered students’ exposure with entrance to intensive care units (ICU) limited to conserve personal protective equipment (PPE) and reduce the risk of virus spread. To address this problem, this study explored the use of assisted reality technology to create a smart classroom whereby medical students can experience intensive care medicine with the COVID-19 risks mitigated. There is existing literature describing the use of live streaming ward rounds using wearable technology to teach medical students, however, we believe this is the first time assisted reality technology has been harnessed to develop a teaching curriculum on intensive care.¹

Objectives: This study aimed to assess the feasibility of using a wearable headset with assisted reality technology to live stream intensive care teaching to remotely based medical students.

Methods: Three intensive care teaching sessions were live streamed to three groups of medical students using the AMA XpertEye wearable glasses. The teaching session focused on the intensive care bed space and equipment as well as the assessment of a critically unwell intensive care patient. Two educators were required to facilitate the optimum learning environment. One educator wore the assisted reality technology glasses on the ICU whilst the other educator remained with the students to facilitate group discussion. The educators had the means to communicate via inbuilt technology on the glasses. Feedback from students was collected using the evaluation of technology-enhanced learning materials (ETELM).²

Results: The response rate for the ETELM survey was 100%. Students strongly agreed that the session was well organised, relevant and that the navigation of technology-based components was logical and efficient. ‘There was a strong instructor presence and personal touch to the session’ returned the strongest positive response. ‘This session will change my practice’ received the most varied response from students, potentially due to their stage in undergraduate training and distance from actual clinical practice. Students strongly disagreed that their learning was affected by technology issues. Educators reported problems with securing a patient appropriate to be involved alongside the busy clinical demands of the ICU. Facilitation by trained educators was crucial to ensure the teaching sessions were high quality.

Conclusions: The use of smart classrooms on intensive care using assisted reality technology was very well received by medical students and educators. The main limitations included the necessity to balance the delivery of teaching alongside the clinical demands of the unit, however this is arguably the case with most forms of clinical teaching. There is the potential to continue using smart classrooms in the post-pandemic period, as they provide an open and safe platform for students to explore intensive care medicine and to ask questions that they may feel less able to raise in the busy clinical environment.

References

1. Mill T, Parikh S, Allen A, Dart G, Lee D, Richardson C, et al. Live streaming ward rounds using wearable technology to teach medical students: a pilot study. BMJ Simulation and Technology Enhanced Learning. 2021;7(6):494-500.

2. Cook DA, Ellaway RH. Evaluating technology-enhanced learning: A comprehensive framework. Med Teach. 2015;37(10):961-70.

4648

Developing a transfer risk assessment tool for the Midlands Critical Care Network

Alexander Nottingham¹, Robert Watson², Jonathan Birks¹

¹ Northampton General Hospital

² Kettering General Hospital

Northampton General Hospital, [e-mail]

Abstract

Introduction: Inter-facility critical care transfers are a high-risk activity, with a significant reported critical incident rate.¹ The 2019 ICS Transfer of the Critically Ill Adult Patient guideline² recommends a consultant-led risk assessment is performed in order to provide a rationale for the make-up of the transfer team. Prior to our project, there was no formalised risk assessment process at our unit.

Objectives: We wished to assess whether any ‘informal’ risk assessment process was already being performed prior to transfers. We then aimed to implement a clear assessment process, initially for our unit but ultimately for our critical care network.

Methods: We performed a baseline audit of adult inter-facility critical care transfers undertaken by a team from our unit between 1^st December 2019 and 28^th February 2020. Notes were analysed for evidence of any risk assessment performed in discussion with the responsible consultant

We then locally piloted a new risk assessment tool for our Critical Care Network’s transfer documentation. It included the required elements from ICS guidance, and followed a systems-based approach to facilitate completion in time-critical situations. Colour coding enabled easy identification of potential high-risk transfers and guided team formation.

Initial re-audit of the new tool was performed between 16^th September and 16^th October 2020, after which it was implemented across the network.

A further re-audit was performed between 1^st October and 31^st December 2021.

Results: Fifteen transfers occurred during the initial audit period. All were clinical. No risk assessments were documented (0% compliance), although all were accompanied by a transfer-trained, airway competent doctor and all but one by an ODP.

Our second audit cycle identified 10 transfers, of which 4 had risk assessments completed (40% compliance). All transfers had been undertaken with a dual doctor/ODP team.

We identified that there was limited knowledge of the risk assessment process among clinicians, so introduced the topic into our unit’s transfer training programme. Assessment completion was made a key performance indicator, fed back to team members following each transfer.

Our final cycle covered 14 clinical transfers. Eight had a fully completed risk assessment (57% compliance), 2 had partially completed risk assessments (14% partial compliance), 4 had no risk assessment and 2 cases were excluded due to incomplete data.

Conclusions: Our tool is now used for all inter-hospital transfers across the Midlands Critical Care Network. It enabled risk assessments to be performed appropriately for transfers originating from our unit. Introduction was initially hampered by limited training for clinicians during the first wave of the Covid pandemic, and compliance improved once this was implemented.

The recent introduction of a regional critical care transfer service means that the majority of transfers undertaken by our unit’s staff are now time-critical clinical transfers. This may contribute to the failure to complete risk assessments in some cases, however these assessments are likely to be of higher importance since such transfers may be higher risk. We now aim to collect feedback from transferring staff to identify any barriers to correct completion.

References

1. Grier S, Brant G, Gould TH, Vopelius-Feldt J von, Thompson J. Critical care transfer in an English critical care network: Analysis of 1124 transfers delivered by an ad-hoc system: Journal of the Intensive Care Society [Internet]. 2019 Mar 4 [cited 2020 Oct 19]; Available from: https://journals.sagepub.com/doi/10.1177/1751143719832175

2. Intensive Care Society, Faculty of Intensive Care Medicine. Guidance On The Transfer Of The Critically Ill Adult. 2019.

4638

Lip recognition software in critically ill patients

Mathew Musalia¹, Shondipon Laha²

¹ Royal Preston Hospital - Preston, Lancashire

² Lancashire teaching Hospital NHS trust

Royal Preston Hospital - Preston, Lancashire, [e-mail]

Abstract

Introduction: Communication is important for critically ill patients, whose pathologies and medical interventions may lead to acute or progressive impediments of speech. This includes patients with neurological pathologies, vocal cord injury, laryngectomies, head and neck tumours and more commonly tracheostomies. This can lead to loss of autonomy and frustration for patients as well as those caring for them.

Objectives: We sought to evaluate the effectiveness of incorporating lip reading technology that utilizes two different phrase recognition approaches, i.e dynamic time warping (DTW) and deep neural networks (DNN), into everyday handheld devices by use of a mobile application called SRAVI (Speech Recognition App for the Voice Impaired). The Trial was a collaborative process by Lancashire Teaching Hospitals NHS Foundation Trust, Liopa and the Queens University Belfast. It was funded by the UKRI Innovate UK Digital health technology catalyst round 3 feasibility studies process.

Methods: An evaluation of SRAVI was carried out by medical staff at Lancashire Teaching Hospitals NHS Foundation Trust (LTHTr). Appropriate patients were identified, assessed and consented to take part. Eligibility criteria included recent admission to the critical care unit, underlying pathology or interventions that impaired speech, understanding of english, absence of cognitive impairment that would hinder ability to use the application ,and ability to follow commands. Exclusion criteria included patients on sedation, those with cognitive impairment, delirium and those who were deemed top unwell/unstable. Using SRAVI, patients attempted mouthing various supported phrases with recordings evaluated by both DNN and DTW processing methods. Then a trio of potential recognition phrases were displayed on the screen, ranked from first to third in order of likelihood. The user would then select the correct phrase and text to speech conversion would be used to audibly output the phrase.

Results: 14 patients were deemed appropriate and recruited into the study. A total of 657 videos were recorded: patient recordings 616, staff tests 37 and 4 invalid recordings made. The overall results revealed a total recognition accuracy across all three ranks of 86% using the DNN method. The rank 1 recognition accuracy of the DNN method was 75%. The DTW method had a total recognition accuracy of 74% with a rank 1 accuracy of 48%. Of the 14 participants 3 were female and 11 male. Age distribution: 3 were young, 6 were middle aged and 5 were elderly. 79% of patients were male and 93% were caucasian. Accuracy was improved as patients continued to use SRAVI.

Conclusion: This pilot study of a novel lip-reading app (SRAVI) demonstrated a good correlation between spoken phrases and app recognition, LTHTr staff captured a large number of samples from a variable group of patients. Various challenges have been identified with patient, environmental and technical parameters playing a part. With good feedback and recommendations there is room to improve. The SRAVI pilot study will hopefully pave the way for further efforts to develop the effectiveness of the lip-reading technology. The next steps will include efforts to improve the robustness against illuminations and pose changes, reducing latency for the end user, formal training of staff, recruitment of more patients to the SRAVI trial and assessing the possibility of moving the processing to the mobile handset.

References

1. Radtke, Jill & Baumann, Brooke & Garrett, Kathryn & Happ, Mary. (2011). Listening to the Voiceless Patient: Case Reports in Assisted Communication in the Intensive Care Unit. Journal of palliative medicine. 14. 791-5. 10.1089/jpm.2010.0313.

2. Hurtig RR, Alper RM, Berkowitz B. The cost of not addressing the communication barriers faced by hospitalized patients. Perspect ASHA Spec Interest Groups. 2018 Jan;3(12):99-112. doi: 10.1044/persp3.SIG12.99. PMID: 30854467; PMCID: PMC6402813.

3. Ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR. Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Crit Care. 2016 Oct 19;20(1):333. doi: 10.1186/s13054-016-1483-2. PMID: 27756433; PMCID: PMC5070186.

4. Carroll, Stacey. (2007). Silent, Slow Lifeworld: The Communication Experience of Nonvocal Ventilated Patients. Qualitative health research. 17. 1165-77. 10.1177/1049732307307334.

4633

Burden of decision making and cognitive function amongst high consequence decision-makers in Intensive Care

Nada Khalil¹, Jeremy Chui², Pooja Shah², Payal Kotecha², Michael O’Connor², Vivian Sathianathan²

¹ London North West Health Care NHS Trust

² London North West Healthcare NHS Trust

London North West Health Care NHS Trust, [e-mail]

Abstract

Introduction: Decision fatigue is a crucial concept in the intensive care unit (ICU) setting; it is the idea that after making many decisions, a person’s ability to make additional decisions becomes worse. ICU consultants make numerous high consequence decisions on patients with complex pathology in time-critical scenarios. The aim of the study was to identify the density of decision making and its consequences on the quality of the decisions made by ICU consultants in our unit.

Methods: This study took place across four twenty-four-hour on-call periods. Each consultant was monitored by a dedicated ICU trainee who recorded the daytime data. Demographic variables included the age, seniority of the ICU consultants, acuity of patients on the unit and staffing gaps. Baseline measurements included the number of days the consultant had been on the unit, their decision fatigue scale (DFS) score¹ and their reaction times. Real-time measurements of the number of decisions and interruptions during the on-call period were documented.

Results: Our study demonstrated increased reaction times and DFS scores for all consultants post-on-call compared with their baseline measurements (Table 1).

Table 1.

Overall findings from Decision Fatigue Study

Consultant number	1	2	3	4
Change in DFS score	+23	+32	+24	N/A
Change in reaction time	+133%	+100%	+24%	+14.6%
Morning decisions	218	250	321	158
Morning interruptions	48	60	33	20
Afternoon decisions	123	92	63	85
Afternoon interruptions	14	13	5	11

Figure 1.

Example of burden of referrals, decision making and interuptions with time of day.

Conclusion: This study highlighted the number of decisions and interruptions consultants experience throughout their day. Signs of decision fatigue and reduced confidence in decision making were evident. Strategies to help reduce this could include moving non-urgent decisions to an alternative time of the day and a ‘silent cockpit’ rule to reduce non-urgent interruptions during ward rounds.

Reference

1. Hickman R, Pignatiello G, Tahir S. Evaluation of the Decisional Fatigue Scale Among Surrogate Decision Makers of the Critically Ill. Western Journal of Nursing Research. 2017;40(2):191-208. Available from: doi:10.1177/0193945917723828

Oral Presentations

4783

Outcomes of a Pilot Contribution Database for the ICU Pharmacy Team at the University Hospitals of Leicester NHS Trust

Sarah Cooke

University Hospitals of Leicester

University Hospitals of Leicester, [e-mail]

Abstract

Introduction

It has long been felt that many contributions made by the ICU Pharmacy team, are not well showcased by the yearly regional network multi-speciality contributions audit. Themes specific to ICU are diluted amongst Trust and region wide data, and valuable learning for the multi-disciplinary team (MDT) is subsequently overlooked.

Objectives: The aims of this project were to:

• Develop and pilot a Microsoft™ Access© database for the ICU pharmacy team to record significant contributions.

• Enable the production of reports to the ICU Quality & Safety board, to raise awareness, disseminate concerns, and influence future quality improvement projects.

• Provide examples to contribute to the training of the whole MDT.

• Generate evidence of team effectiveness and encourage further investment.

• Provide team members with a means to recall contributions, for revalidation, appraisal, prescribing re-affirmation and framework mapping.

Methods:

• A database was built with a user-friendly data-entry form to prevent overwriting. Fields were agreed with peers who would be using the database.

• The team were invited to voluntarily enter their contributions which they thought added value and provided useful learning.

• The pilot phase ceased with the emergence of the Omicron SARS-CoV-2 variant, due to staffing pressures and surge planning.

Results:

• Between 12/07/2021 and 25/11/2021, a total of 211 contributions were recorded.

• Pharmacists entered 88.6% and a single technician entered 11.4% of these.

• Independent Prescribing was utilised in 52.13% of contributions, and deprescribing in 25.12%.

• Figure 1 demonstrates the contributions by drug group

Figure 1.

Clinical Contributions by Drug Group.

• The top 5 drugs associated with contributions were:

• Vancomycin

• Voriconazole

• Meropenem

• Co-trimoxazole

Treatment optimisation was an outcome for 76.3% of all contributions. Figure 2 stratifies these by type.

Figure 2.

Treatment Optimisation Contributions.

• Drug suitability was a cause for intervention in 12.8% of all contributions, encompassing allergies, contraindications, cautions and interactions and routes.

• Medicines reconciliation accounted for 17.54% of all contributions, which almost half were Technician led. Admission was the most common stage to intervene (81.08%), followed by transcription.

• Of all contributions, 37.91% were classified as patient safety incidents. Reassuringly 76.25% of these were prevented by the Pharmacy team. Themes have been extracted from these incidents and are presented in Table 1 .

Conclusions: PROTECTED-UK¹ demonstrated the value pharmacists contribute to the quality and safety of patient care on ICU. Studies of similar quality and scale including Pharmacy Technicians are lacking, but even in this pilot study, it is evident how important their input is.

Independent prescribing is a fundamental and well utilised part of our ICU Pharmacist skillset, supporting the GPICS² recommendation that ICU pharmacists should be encouraged to become prescribers.

Compiling a team interventions database is a useful tool to highlight local priority areas for guideline development; training; and ensuring that appropriate decision support is built into electronic prescribing systems.

To improve the usefulness of the data, further stratification of contributions according to the Eadon Criteria³ may be worthwhile, to expand its use as a medication safety thermometer for ICU.

References

1. Rudall N, McKenzie C, Landa J, Bourne R, Bates I, Shulman R. 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. 2016; 25(4):311-319.

2. Faculty of Intensive Care Medicine / Intensive Care Society. Guidelines for the Provision of Intensive Care Services: 2^nd Edition (2019).

3. Eadon H. Assessing the quality of ward pharmacists’ interventions. International Journal of Pharmacy Practice. 1992;1(3):145-147.

4741

Can eye movement desensitisation and reprocessing improve psychological recovery following COVID-19 related critical illness? The CovEMERALD feasibility trial

Andrew Bates¹, Rebecca Cusack¹, Sophie Rushbrook², Elan Shapiro³, Hannah Golding¹, Natalie Pattison⁴, David Baldwin⁵, Mike Grocott⁶

¹ University Hospital Southampton

² Intensive Psychological Therapies Service, Dorset Healthcare University NHSFT

³ EMDR Europe

⁴ East and North Herts University NHS Trust and University of Hertfordshire

⁵ University of Southampton

⁶ Univeristy of Southampton and University Hospital Southampton

University Hospital Southampton, [e-mail]

Abstract

Introduction: Over 200,000 patients survive an intensive care admission each year in the United Kingdom (UK). For patients, survival is frequently beset by a range of chronic disabilities. Approximately 50% must navigate an often complex convalescence, while suffering serious and persistent symptoms of post-traumatic stress disorder (PTSD), anxiety and/or depression.¹ Eye-movement desensitisation and reprocessing (EMDR) is a trauma-focussed psychological therapy, recommended for treating PTSD by the International Society for Traumatic Stress Studies² and NICE.³ However, EMDR has never been systematically investigated for patient benefit following intensive care admission.

Objectives: CovEMERALD⁴ evaluated the feasibility of delivering a randomised controlled trial (RCT), testing the effect of EMDR on the psychological health of intensive care survivors, following COVID-19 related critical illness. We also provide preliminary evidence of the effect on clinically relevant outcomes. Findings will inform the design of a subsequent fully-powered RCT.

Methods: This feasibility RCT was conducted at a single-centre, teaching hospital in the UK (University Hospital Southampton). Patients were eligible if they were admitted to intensive care for over 24-hours with confirmed COVID-19, were above 18 years of age, were recruited within 3-months of hospital discharge, and had no cognitive impairment or pre-existing psychotic diagnosis. Participants were randomised (1:1) to receive either up to 8 sessions of remotely-delivered EMDR (Recent traumatic events protocol) or standard care alone as the control group (CG). Psychometric evaluation was undertaken at Baseline and 6-months after hospital discharge.

Results: Seventy-five consecutive patients were screened at hospital discharge, from October 2020 to April 2021. 51 eligible patients approached. 26 (51%) provided consent. Reasons for declining participation were; no psychological distress (n=16), no internet access (n=7) and being physically unready (n=2). Demographic variables were balanced between groups. Of the 13 patients randomised to EMDR, one withdrew prior to intervention: the remaining attended all sessions recommended by the psychological therapists (mean of 3-4 sessions per patient), giving an overall adherence of 93%. One patient from each group declined the 6-month follow-up evaluation, so trial completion was possible in 23 of 26 (88%) participants. No reasons for trial withdrawal were given. There were no attributable adverse events. Mean change in PTSD score (PTSD Checklist-Civilian) from Baseline to 6-months, was -8 (SD=10.49) in the EMDR group vs. +0.75 (SD=15.17) in CG (p=0.126). Mean change in anxiety (Hospital Anxiety and Depression Scale-Anxiety) was −0.45 (SD=2.3) following EMDR vs. -0.83 (SD=4.0) in the CG (p=0.787), and median change in depression (HADS-D) was −2(IQR:-3.0,1.0) following EMDR vs. +1(IQR-1.5,2.0) in the CG (p=0.263).

Figure 1.

Box-plot of change in PTSD symptoms (PCL-C) from baseline to 6-months post-hospital discharge for control group and EMDR intervention group.

Conclusions: EMDR can improve psychological recovery following an intensive care admission for COVID-19, and appeared feasible and safe. Although not powered to determine clinical effectiveness, this single-centre feasibility study returned a positive signal, in reducing PTSD and depressive symptoms. A full results manuscript will be submitted prior to congress. CovEMERALD has supported a successful NIHR doctoral fellowship application, during which protocol refinements will be tested, within existing, and recommended rehabilitation pathways. Trial activity and progression will be consistent with the Medical Research Council framework for developing and evaluating complex healthcare interventions.⁵

References

1. Hatch R, Young D, Barber V, Griffiths J, Harrison DA, Watkinson P. Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study. Crit Care. 2018;22(1): 310.

2. Forbes D, Bisson JI, Monson CM, Berliner L. Effective treatments for PTSD: practice guidelines from the international society for traumatic stress studies. 3^rd ed: Guilford Press, UK. 2020.

3. National Institute for Health and Care Excellence (NICE). Post-traumatic stress disorder: NICE guideline. NICE Guidance. 2018.

4. Bates A, Rushbrook S, Shapiro E, Grocott M, Cusack R. CovEMERALD: Assessing the feasibility and preliminary effectiveness of remotely delivered Eye Movement Desensitisation and Reprocessing following Covid-19 related critical illness: A structured summary of a study protocol for a randomised controlled trial. Trials. 2020 Dec 17;21(1):929.

5. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374(n2061).

4739

Feasibility and Metabolic Analysis of the Use of Alternative Substrates in the Critically Ill Subject (ASICS)

Anne Langan¹, Angela McNelly², Danielle Bear³, Kieron Rooney⁴, Simon Eaton⁵, Simon Heales⁶, Philip Atherton⁷, Daniel Wilkinson⁷, Rupert Pearse⁸, Hugh Montgomery⁹, Zudin Puthucheary⁸

¹ Barts Health NHS Trust

² William Harvey Research Institute

³ Guys and St.Thomas’ NHS Foundation Trust

⁴ Department of Critical Care, Bristol Royal Infirmary, Bristol

⁵ Developmental Biology & Cancer, UCL Great Ormond Street Institute of Child Health

⁶UCL Great Ormond Street Institute of Child Health Health, ⁷University of Nottingham

⁸ William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London

⁹ UCL Hospitals NHS Foundation Trust (UCLH), National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), London

Barts Health NHS Trust, [e-mail]

Abstract

Introduction: Ketogenic feeding (KF) may enhance muscle performance and prevent muscle wasting under physiological stress in healthy individuals. Critically ill patients suffer substantial and rapid muscle loss in the face of metabolic and physiological stress, and so might in theory benefit from KF. In preparation for an appropriately powered trial, we performed a randomised controlled feasibility study to test this hypothesis ClinicalTrials.gov NCT04101071.¹ We sought to determine whether Intensive Care Unit (ICU) patients can be recruited into a study of enteral KF; if feed can be prepared, administered, and tolerated; and if it alters concentrations of plasma and urine ketone bodies and other metabolites. We also sought to perform metabolomic analysis of plasma and urine samples to identify the impact of KF on nutritional metabolic pathways.

Methods: We recruited adult (>18 years old) patients within 48 hours of admission to one of two UK ICUs, who were (i) prescribed enteral feed (ii) likely to have mechanical ventilation >48 hours, and to be on ICU ≥5 days surviving ≥10 days and (iii) had multi-organ failure (SOFA score >2 in >2 areas). Participants were randomised 1:1 to 10 days dietitian-prescribed enteral KF or standard feed (SF) to ensure adequate nutritional delivery. Data were collected for feasibility of recruitment, retention (receipt of 10 days randomised feed and those on ICU ≥5 days if <10 days feed), and provision of feed (via questionnaires to research and nursing staff); Adverse Events (AEs); blood glucose concentration; urine and plasma ketone body concentrations. Untargeted metabolomic analysis of plasma and urine was performed using ultra-high performance liquid chromatography (UHPLC) coupled to a high-resolution mass spectrometer, to identify potential differential metabolite signatures enabling biological insight into the effects of the intervention.

Results: Of 286 patients screened, 29 were recruited and 24 were retained (12/14: SF; 12/15 KF). It was feasible but labour-intensive to calculate and prepare feed constituents to meet patients’ daily nutritional needs, and for bedside nurses to administer KF. No related or unexpected serious AEs were found. AE rates for episodes of daily vomiting and high gastric residual volume (GRV; >350mls) were similar in SF and KF arms; episodes of diarrhoea (3 days in a row) were more prevalent with KF than SF (76.92% vs. 52.33%, respectively). Daily blood glucose concentration remained ≥3.9mmol/L in all KF patients but was ≥10mmol/L in a greater proportion of SF than KF patients (57.48% vs. 26.85%, respectively). KF was associated with mild plasma ketosis (up to 2.7 mmol/L) and a greater urinary ketosis (up to 8 mmol/L). Metabolomics data highlighted alterations in key groups of metabolites associated with KF.

Conclusions: Enteral KF in ICU patients is safe and well tolerated and does induce ketone body production. The availability of ready-made feed would improve feasibility of administration for bedside nurses. Using the impartial approach of metabolomic analysis may suggest novel approaches to future interventional nutritional research.

Grant acknowledgement

National Institute for Health Research: Research for Patient Benefit Grant PB-PG-0317-20006.

Reference

1. Langan, A et al. (2020). Intensive Care Med. Exp. 8(S2):43

4726

Defining a core outcome set for dysphagia intervention trials in intensive care

Sallyanne Duncan¹, Margaret Walshe², Daniel F. McAuley³, Bronwen Connolly³, Patrick Zuercher⁴, Bronagh Blackwood³

¹ Belfast Health & Social Care Trust and Queen’s University Belfast

² Department of Clinical Speech and Language Studies, Trinity College Dublin

³ Queen’s University Belfast

⁴ Bern University Hospital, Switzerland

Belfast Health & Social Care Trust and Queen’s University Belfast, [e-mail]

Abstract

Introduction: Dysphagia is common following critical illness. Our systematic review of dysphagia interventions reported a small but rising trend of trials in critical care patients.¹ Reported outcomes had wide variability in outcome choice, measures and time points, thus emphasising the need to develop a core outcome set in this field.

Objectives: This study aimed to develop an international core outcome set for dysphagia intervention trials for adult patients in intensive care.

Methods: The study adhered to standardised guidance on core outcome set development.² A consensus methodology approach was used, which included a 2-round online Delphi study and 3 virtual meetings. Participants were recruited from three stakeholder groups: multi-disciplinary clinicians; ex-ICU patients who experienced dysphagia and critical care researchers. Various information sources were used to gather outcomes: published trials and observational studies, patient focus group findings and a national survey of critical care Speech and Language Therapy clinicians. During the Delphi study, each outcome was ranked on a 9-point likert scale from one (least important) to nine (most important). Outcomes were included if ≥70% of responses from each stakeholder group had scored an outcome as 7 or higher (i.e. ‘critical’ to include in a core set) and ≤15% of responses from each group had scored an outcome as 3 or less (i.e. ‘not important to include in a core set’). Three consensus meetings followed with the aim of agreeing measures and time points for each outcome identified in the Delphi study.

Results: The study was conducted from November 2020 to June 2021 with 181 participants from 22 countries across 6 continents. Participants included 18 ex- patients who had all experienced dysphagia during their intensive care stay, 36 intensive care researchers and 127 intensive care clinicians from five professional groups (intensivists, nursing, physiotherapy, speech and language therapy and clinical nutrition). In the online Delphi study, 181 participants rated 28 outcomes in round 1. Participant feedback added two outcomes to round 2. 160 participants rated 30 outcomes in round 2. Six outcomes met consensus criteria: aspiration; severity of aspiration; swallow function; efficiency of cough; pneumonia and mortality as detailed in Table 1. Twenty seven participants (ex-patients, clinicians, clinical trials groups and core outcome set developers from the field of intensive care) engaged in consensus meetings. Definitions for all core outcomes and minimum measures and time points for five of the six outcomes (except pneumonia) were agreed.

Conclusion: Six core outcomes are recommended for trialists, to provide consistency in outcomes in all future dysphagia intervention trials in intensive care. Adoption of this core set would enhance comparability in outcomes across trials and ultimately strengthen conclusions about the effectiveness of dysphagia treatments in intensive care.

Grant received: Public Health Agency Northern Ireland: Doctoral Fellowship Award Ref EAT 5382/17 awarded to first author to complete PhD.

References

1. Duncan S, Mc Auley, DF, Walshe M, McGaughey J, Anand R, Fallis R, Blackwood B. Interventions for oropharyngeal dysphagia in acute and critical care: a systematic review and meta-analysis. Intensive Care Medicine 2020; 47(3): 1326-1338. https://doi.org/10.1007/s00134-020-06126-y

2. Kirkham J, Gorst S, Altman D, Blazeby J, Clarke M, Tunis S, Williamson. Core Outcome Set-STAndardised Protocol Items: COS-STAP Statement. Trials 2019; 20: 1-7.

Table 1.

Number and percentage of participants rating outcomes as ‘critical’ to include in a core outcome set (i.e. score 7 or higher during Delphi study).

Outcome	Clinicians (n=106)	Researchers n=36)	Patients (n=18)
Aspiration	104 (98%)	33 (92%)	14 (77%)
Severity of aspiration	102 (96%)	29 (81%)	15 (83%)
Swallow function	102 (96%)	35 (97%)	17 (94%)
Efficiency of cough	97 (92%)	27 (75%)	17 (94%)
Pneumonia	88 (83%)	30 (83%)	14 (77%)
Mortality	77 (73%)	27 (75%)	13 (72%)

4718

Baseline plasma interleukin-18 may allow identification of patients with the acute respiratory distress syndrome that benefit from simvastatin therapy

Andrew Boyle¹, Peter Ferris¹, Ian Bradbury², John Conlon¹, Manu Shankar-Hari³, Angela Rogers⁴, Cecilia O’Kane¹, Daniel McAuley¹

¹ Queen’s University Belfast

² N/a

³ University of Edinburgh

⁴ Stanford University

Queen’s University Belfast, [e-mail]

Abstract

Introduction: Interleukin (IL)-18 is a marker of inflammasome activation, and high baseline plasma IL-18 was associated with increased mortality in patients with sepsis-induced acute respiratory distress syndrome (ARDS) recruited to the SAILS trial. Interestingly, patients allocated to rosuvastatin had a temporal increase in plasma IL-18, and patients with increasing plasma IL-18 had an increased risk of death.¹ Previous studies have demonstrated that simvastatin, but not rosuvastatin, is associated with reduced mortality in patients with the hyperinflammatory subphenotype of ARDS.^2–3 Therefore, it is plausible that, compared with rosuvastatin, simvastatin may have a different effect on inflammasome activity, and that there is a beneficial effect of simvastatin on outcomes for patients with ARDS who have higher inflammasome activity.

Objectives: To determine if simvastatin was associated with benefit in patients with ARDS and high plasma IL-18.

Methods: A secondary analysis of the HARP-2 clinical trial was performed, comparing 28-day mortality and response to simvastatin according to baseline plasma IL-18 using cox proportional hazards analysis. Furthermore, monocyte-derived macrophages from healthy volunteers were pre-incubated with simvastatin or rosuvastatin before stimulation with ATP and LPS, and the effect on secreted IL-18 and IL-1β compared using Kruskal-Wallis test with Dunn’s multiple comparison test.

Results: 511 patients from HARP-2 with available data were evaluated. High baseline plasma IL-18 (≥ 800 pg/ml) was associated with increased 28-day mortality (high IL-18 30.6% vs. low IL-18 17.5%; HR 1.89 [95% CI 1.30 – 2.73]; p = 0.001) (Figure 1). Allocation to simvastatin in patients with high baseline plasma IL-18 was associated with a lower probability of 28-day mortality compared with placebo (24.0% vs 36.8%; p = 0.01) (Figure 2). Finally, simvastatin, but not rosuvastatin, reduced stimulated macrophage secretion of both IL-18 and IL-1β (Figure 3).

Conclusions: In patients with high baseline plasma IL-18, simvastatin is associated with a higher probability of survival, an effect that may be due to reduced macrophage inflammasome activation. These data suggest that baseline plasma IL-18 may allow a personalised treatment approach by identifying patients with ARDS who could benefit from simvastatin therapy.

Figure 1.

28-day survival dichotomised by baseline plasma IL-18. Kaplan-meier curve of survival from enrolment to day 28. Survival was higher in patients with low plasma IL-18 at baseline (HR 1.89 [1.30 − 2.73]; log-rank test p = 0.001).

Figure 2.

28-day survival stratified by baseline IL-18 and treatment simvastatin vs. placebo). Kaplan-meier curve of survival from enrolment to day 28. Overall p-value <0.001. Patients with high baseline IL-18 (=800 pg/ml) treated with simvastatin vs placebo p = 0.01; patients with low baseline IL-18 (<800 pg/ml) treated with simvastatin vs. placebo p = 0.75. Interaction of simvastatin and high baseline IL-18 p = 0.19.

References

1. Rogers AJ, Guan J, Trtchounian A, Hunninghake GM, Kaimal R, Desai M, et al. Association of Elevated Plasma Interleukin-18 Level With Increased Mortality in a Clinical Trial of Statin Treatment for Acute Respiratory Distress Syndrome*: Crit Care Med. 2019;47:1089–96.

2. Sinha P, Delucchi KL, Thompson BT, McAuley DF, Matthay MA, Calfee CS, et al. Latent class analysis of ARDS subphenotypes: a secondary analysis of the statins for acutely injured lungs from sepsis (SAILS) study. Intensive Care Med. 2018;44:1859–69.

3. Calfee CS, Delucchi KL, Sinha P, Matthay MA, Hackett J, Shankar-Hari M, et al. Acute respiratory distress syndrome subphenotypes and differential response to simvastatin: secondary analysis of a randomised controlled trial. Lancet Respir Med. 2018;6:691–8.

Figure 3.

Effect of statin pre-treatment on monocyte-derived macrophage inflammasome activation. Monocyte-derived macrophages were pre-treated with either 50μM simvastatin or 50μM rosuvastatin for 4 hours before stimulation with 100ng / ml LPS and 2mM ATP. In contrast to rosuvastatin, simvastatin significantly reduced the production of both (A) IL-18 and (B) IL-1β by MDMs (p < 0.05). when compared to the unstimulated control, rosuvastatin pre-treatment was associated with significantly higher IL-1β production (p < 0.05). Data analysed using Kruskal-Wallis test with Dunn’s multiple comparison test for between group differences. * = p < 0.05. N = 6 for all groups.

The Cauldron

4758

Intensive Care Consultant: Superhero or normal human being but more capable!

Sandra Gelvez Zapata

Lister Hospital - Stevenage, Hertfordshire

Lister Hospital - Stevenage, Hertfordshire [e-mail]

Submission content

Introduction: Intensive care medicine has become an admired, loved, hated, and definitely more interesting Specialty due to a special situation (COVID-19) that exposed the training process to numerous criticisms, positives, and negatives, and this is how I believe we could improve our beloved world.

Proposal:

1. Ideal training program from medical school to Certificate of Completion of Training (CCT):

2. Stage 1: there should be a core surgical training of at least 6 months

3. Stage 2: there should be a rotation on Psychiatry of at least 4 weeks with on calls in ICU and 2 weeks in Palliative Care

4. Stage 3: acting as a consultant for the last six months on ST7 with backup from a formal consultant, and

5. Surgical training should be included in the possible dual or triple CCT

How would we be assessed?

I agree with the Faculty of Intensive Care Medicine (FICM) staging program assessment, with some modifications:

As ST7 the trainee should act as a consultant with back support at least 50% of the stage and need to be evaluated by a Multi-Source Feedback (MSF).

Clinical Fellows should have a consultant as a Certificate of Eligibility for Specialist Registration (CESR) guide who establishes the equivalent stage of training supporting them and assessing them under the same model.

Changing the way, the General Medical Council (GMC) conducts the CESR application and making it really equivalent to the ICM training with the FFICM curriculum.

What do we need to be taught?

Hot topics for ICU (academic),

Overseas talks to share experiences,

Ultrasound (FUSIC),

Wellbeing strategies,

Leadership training

Psychiatric and physiological effects post ICU for patients and staff,

The administrative and political model of the National Health Service (NHS), and

Communication skills to establish excellent relationships with the other specialties.

What would our working life look like?

Normal day: 8 am to 3 pm

Midday shift: 1 pm to 8:30 pm

Night shift: 8 pm to 8:30 am

A rolling rota of 12 weeks with 2 weekends during this time

How would you produce Intensive Care Medicine (ICM) Consultants of the future who both love their job and their life:

Starting with less intense shifts,

More cordial relationships between the teams,

Supporting ICM trainees and Fellows going through their CESR pathway,

Making the training more attractive to either male-female doctors getting them involved in as many different specialties as ICM can cover,

Conclusion: Having full-time ICM Consultants should be welcome in all ICUs in the country, which is not at the moment. This will definitely attract a lot of excellent doctors who are 100% focused on ICM.

4674

How I would train the ICM leaders of the future: patchwork quilting and French plaits

Cathy Challifour

Royal United Hospital, Bath

Royal United Hospital, Bath [e-mail]

Submission content

Introduction: Don’t panic, you haven’t stumbled into an arts and crafts seminar – I’m about to convince you that the future of ICM training is in patchwork quilts and French plaiting.

Main Body: My first ICM post was in a unit led by an eclectic mix of Consultants. Towards the end I told them that “taken individually you’re all slightly odd and unusual, but when you’re brought together you make a joyful and comforting thing of beauty”. Thus evolved my theory of the ICU Consultant body as a patchwork quilt.

You may all recognise your place in the quilt (your juniors and colleagues definitely will): the innovator, the educator, the nurturer, the knob twiddler. The complex needs of critical care patients can only be met by this intoxicating blend of personalities and skills and the job of training is to encourage this diversity rather than to produce a heterogenous Consultant body.

Which brings us to French plaits. The technique involves beginning a plait with three or four sections of hair and smaller strands are incorporated along the way resulting in a strong and stable structure. Importantly, no two plaits are ever the same. To extend the analogy to training the three strands are your core ICM clinical skills, your clinical special interest and your non-clinical special interest - a fourth strand represents your dual specialty if you are that way inclined!

Throughout training many experiences will be woven in, changing and enhancing your training as it progresses but at CCT you should not be expected to excel beyond those three (or four) key areas. We are not aiming to train jacks of all trades, masters of none. I am no academic – or even a particularly good knob twiddler – but I am a passionate educator and communicator. It’s taken 13 years and some career coaching to realise I’m a potentially valuable scrap of fabric in the ICU’s patchwork quilt and to finally stop worrying that I will never be published in the Lancet!

Training must recognise that diversity of personalities and skills are key to a highly functioning and happy ICU. We need to capture the imaginations of trainees early and to help them identify their unique strengths by offering career coaching to all – not just those perceived to be ‘trainees in trouble’. We need to encourage excellence in the interests of the individual rather than forcing trainees to engage in tick box energy-sapping forays into every possible endeavour. Time must be built into training to enable us to pursue those interests in a meaningful way without detriment to our families, friends and sanity. And maybe whilst we’re at it we’ll introduce a limit on non-clinical achievements? I’ve long dreamt of a ceasefire in the CV arms race!

Conclusion: Critically ill patients are coming in greater numbers, with ever greater complexity: they deserve a joyful, high functioning patchwork team of Intensivists who are happy in their work because their individual qualities have been recognised, nurtured and not exhausted during the years of training.

4656

Training the Intensive Care Medicine leaders of the future: Another brick in the wall?

Zoe Brummell

Royal London Hospital

Royal London Hospital [e-mail]

Submission content

Introduction: Intensive Care Medicine (ICM) is at crisis point. Staff shortages in combination with a growing, ageing, complex population, make the long-term safety and sustainability of ICM unfeasible.¹ There is no single solution to the increased pressures facing us. However, substantially increasing our workforce numbers is the starting point and properly looking after and advocating for our trainees is the game-changer. We need to plan for and implement the best recruitment, support, education and training strategies for both the current and future ICM workforce. Our ability to do this for trainee doctors is hampered by limitations on National Training Numbers, restrictions placed on us with regards to assessment and problematic intermediary communication. We can circumvent these limitations, enabling full control and oversight by developing and managing ‘Training Schemes’ jointly overseen by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS), through the Certificate of Eligibility for Specialist Registration (CESR) route.² Providing ICM alternative training schemes will bring order, certainty and truly individualised training for trainees.

FICM/ICS CESR Programme:

• ICM training through the FICM/ICS CESR programme will start at ST3 level

• Applications will be managed by the ICS

• FICM/ICS will negotiate placement funding from the Department of Health and Social Care through tariffs in line with current HEE arrangements³

• FICM/ICS CESR trainees will train within one of the 42 Integrated Care Systems (InCS) thus reducing large geographical areas for placements⁴

• Administrative medical staffing and statutory training burdens will be reduced through a lead provider model

Annual appraisals will be undertaken in person, involving the trainee, their allocated Consultant mentor and the InCS Training Programme Director to discuss trainee experience and ongoing training requirements

Multi-Source Feedback will stay, but all other assessments will be done informally, and units of training will be signed off by Educational Supervisors

FICM/ICS will lobby the General Medical Council to ensure that Trainees who start a training programme on one curriculum will finish on that curriculum

Education and training within the programme will focus on multidisciplinary working

Trainees will be assisted in working Less Than Full Time through personal choice, enabled to take time out of training if requested and to attend significant life events

As a trainee at the end of my training I say please review the current training system, make it less complex, improve trainer/trainee communication, enable us to be treated like real people with real lives and understand that being a trainee currently isn’t easy (perhaps it never was). We love ICM, that’s why we are here, why we turn up and get involved.

Conclusion: We need to attract, train and retain individuals who want to do ICM and have the potential to enhance and lead our specialty for future generations. Taking control of training programmes is the first step to setting us all free (trainers and trainees) of the current dogmatic restrictions imposed upon us.

References

1. Centre for Workforce Intelligence 2015. In-depth review of the anaesthetics and intensive care medicine workforce. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/507348/CfWI_Anaesthetics_ICM_main_report.pdf [Accessed 12th February 2022].

2. General Medical Council 2022. Specialty specific guidance for CESR and CEGPR. Available from: https://www.gmc-uk.org/registration-and-licensing/join-the-register/registration-applications/specialty-specific-guidance-for-cesr-and-cegpr [Accessed 12th February 2022].

3. Department of Health and Social Care 2021. Education and training tariff guidance and prices for 2021 to 2022 financial year. Available from: https://www.gov.uk/government/publications/healthcare-education-and-training-tariffs-2021-to-2022/education-and-training-tariff-guidance-and-prices-for-2021-to-2022-financial-year#annex-a [Accessed 12th February 2022].

4. National Health Service 2021. Working together at scale: guidance on provider collaboratives. Available from: https://www.england.nhs.uk/wp-content/uploads/2021/06/B0754-working-together-at-scale-guidance-on-provider-collaboratives.pdf [Accessed 12th February 2022].

4632

What I’ve learnt from Netflix

Rachel Jones

Musgrove Park Hospital

Musgrove Park Hospital [e-mail]

Submission content

Introduction: 100’s MAMILs, a lack of diversity and large consultant gaps. ICU is broken but the answer to fix it lies within our television box. If we take inspiration from three major television programs, we can fix ICU training.

Main Body: Call The Midwife is based in Poplar in the East End of London. This series has a better understanding of health inequalities than any medical training program. This is the big topic which no one has been able to address since the Marmot inquiry,¹ yet on BBC1 every Sunday the answer is clear to see.

We need to get into the community (bicycle optional) and see how our patients recover and their families. Only then can we then properly advocate for our patients. We need to see recovery to more than just “discharge from ICU”. This, coupled with ICU rehab clinic, in a MDT approach, we can appreciate the burden of ICU but also the gift of recovery. For those patients who can’t attend clinic we need to visit them at home. This will give an additional insight into life outside Waitrose.

WBPA are not worth the paper they’re written on and should switch to a Cake-Based Discussion. The Great British Bake off is a defining text. Baking would offer more educational value than any DOPS on arterial line placement. Baking through recipes enables assessment of instructions and will reward attention to detail (a vital ICU skill). It also facilitates a discussion on nutrition and could be combined with the dieticians. Nutrition currently is a topic that our curriculum glosses over. The versatility continues as it will also be a wellbeing event. An opportunity to meet in a nonclinical environment lowering hierarchy and making bonds. A team that eats cake together stays together.

We also need to stop defensive medicine. We are increasing embracing transparency and duty of candour, so the obvious next step is to replicate Love Island on the units. Less debauchery but an accurate documentation which can be reviewed for assessment purposes. Cameras in our units will get rid of simulation-based medicine and Resus Annie and focus what you really did. With it we can look at our technical and non-technical skills. This is how we can examine trainees, FFICM is more contentious than the royal family and there is so much controversy about single point high stake examination. We need assessment that is real time, accurate. So why not make it constant assessment and accept that more is more.

Conclusion: We all agree we need to reflect society that we represent. Society in the UK spends over 3h per day watching Television.² So why don’t we look at what society values when creating a new training program. So really, if we spent more time watching the Telly and less time cycling, we can all fix ICU training for the future.

References

1. Marmot, M. Fair society, healthy lives : the Marmot Review : strategic review of health inequalities in England post-2010. (2010) ISBN 9780956487001

2. https://cybercrew.uk/blog/tv-statistics-uk/

MDT Diaries

4791

Would you mind putting my out of office notification on

Emma Jackson

Blackpool Victoria Hospital

Blackpool Victoria Hospital [e-mail]

Submission content

A day that changed my practice.

I read a book that I hoped would change my practice. A book that I knew I really appreciated and changed how I thought about death. But I didn’t appreciate how much I needed to read until I put it into practice.

I had heard a lot about ‘With the end in mind’ by Kathryn Mannix. It was on my list to read but not up at the top, if I’m brutally honest I thought I was pretty good at end of life conversations. I’m an Intensive Care Doctor, death and the associated conversations are something we deal with regularly.

So I read a book. I hoped it had changed my practice and continued with my daily practice.

3 weeks later I was on the ITU and we had a patient who was conscious and dying. We referred to palliative care and awaited the next steps.

For my daily review I stuck my head in a quick hello, make sure he wasn’t in any pain or distress and pass on my way to continue to let palliative care manage his end of life treatment. I said is there anything that is worrying you that I can help with and he said I’m worried about what dying is going to be like and what it will look like to my family.

Normally I would have at this point just said well, the palliative care team will be around tomorrow to answer your questions. But this man was frightened and worried. I couldn’t let him wait till the following day. Off the back of Kathryn’s book I knew I could do this conversation. It would be uncomfortable, I didn’t really want to but it was the right thing to do. So I put my big girl pants on, pulled up a chair and using a lot of the phrases that Kathryn uses throughout her book I explained.

I watched as my patient visibly relaxed, the fear of what was coming, the worry about the distress he might cause his family rolled away and he turned to me and said ‘Thankyou, would you explain what you have said to me to my wife’. Which I did. I’m not ashamed to say he cried, his wife cried and I cried. But some of that fear had gone.

1 week later on a night shift my patient buzzed the nurse, he was a little confused. He asked the nurse to put his out of office email on, for a cup of tea, to wake his wife up who was sleeping at his bedside and held her hand as he died. It was exactly the ending he wanted.

So perhaps I was adequate at end of life conversations before I read the book. But what I know now is I have a much deeper confidence to talk about death, to reassure and to comprehend some of the fears that my patients are facing. I am a much better doctor for ‘reading with the end in mind’.

References

With the End in Mind - Kathryn Mannix

4714

Born with resilience

Ellen Thompson

Belfast Health and Social Care Trust

Belfast Health and Social Care Trust [e-mail]

Submission content

Introduction: It has been a tough few years for everyone. All of our professional and personal lives have been upended and we have had to adapt to new ways of working and living. How do we keep going on?

I am an emergency medicine and intensive care dual trainee, we are a minority in ICM. Burnout is huge in both of these specialties, and resilience is key to longevity.

Main Body: 7am in the ED is tough, survival mode, waiting for the 8am relief to arrive. Decision fatigue has set in many hours before and every new question is a difficult process of weighing risk and benefit. New patients are picked up on a life or limb threatening basis, and the red phone is the last sound you want to hear.

On this particular morning “you need to come and see this” was the call. I stumbled into a cubicle to find a concealed baby crowning from a somewhat un-expectant mother. I summoned my colleagues and in one push baby and placenta were delivered together. It was tiny but fully formed, however it was grey and lifeless. I scanned my brain for the teaching session I had delivered to my junior colleagues the previous year on neonatal life support. I gave inflation breaths, then continued ventilation, then started CPR.

I vividly remember a colleague, who was with the mother, asking if it was a boy or a girl. All I could think was - it’s dead. I mentally began to figure out how I would tell the mother her baby was dead, how the team would cope, how I could even speak to lead a debrief on this. I was just waiting for the paeds team to arrive to tell me to stop resuscitation.

After around 3 minutes, her colour changed, we had a heart beat. At 20 minutes she opened her eyes and began to move. At 6 hours she was extubated. At 4 days she was discharged home.

This was my first time delivering a baby.

Conclusion: Despite working in emergency medicine and intensive care, and being surrounded by life saving equipment, I rarely get that feeling at the end of a shift that my actions have saved a life. We are surrounded by so much sorrow and stress that the days when we leave work with a big smile on our faces are rare.

This extreme case has shown me that we are born with resilience, but sometimes we just need a little help to get through the difficult times. I cannot explain how fantastic my colleagues were, the team within the chaos was one that I am proud to be a part of. The best part of that morning was the breakfast debrief, a safe space to deal with the emotions we had all been through. We need to acknowledge these small moments of greatness in our work and hold onto those feelings so we can keep coming back tomorrow and the next day.

4663

Re-humanisation; recognising the person behind the patient

Naomi Watson

Homerton University Hospital

Homerton University Hospital [e-mail]

Submission content

Introduction: At the end of a particularly hectic night shift on the intensive care unit (ICU) I found myself sitting in the relatives’ room with the mother and aunt of a young patient, listening to their stories of her hopes and aspirations as she grew up. She had been diagnosed with lymphoma aged 14 and received a bone marrow transplant from her younger sister. Fighting through treatment cycles interposed with school studies, she eventually achieved remission and a portfolio of A-levels. Acceptance into university marked the start of a new era, away from her cancer label, where she studied forensic science and took up netball. Halfway through her first year she relapsed.

Main body: When I met this bright, ambitious 20-year-old, none of this history was conveyed. She had been admitted to ICU overnight and rapidly intubated for type-1 respiratory failure. The notes contained a clinical list of her various diagnoses and treatments, with dates but no sense of the context. Rules regarding visitation meant her family were not allowed onto the unit, with next-of-kin updates carried out by designated non-ICU consultants to reduce pressures on ICU staff. No photos or personal items surrounded her bedside, nothing to signify a life outside of hospital. She remained in a medically-induced coma from admission onwards, while various organ systems faltered and failed in turn.

Sitting in that relatives’ room I had the uncomfortable realisation that I barely saw this girl as a person. Having looked after her for some weeks, I could list the positive microbiology samples and antibiotic choices, the trends in noradrenaline requirements and ventilatory settings. I had recognised the appropriate point in her clinical decline to call the family in before it was too late, without recognising anything about the person they knew and loved. She died hours later, with her mother singing ‘Somewhere Over the Rainbow’ at her bedside. Poignant as this was, the concept of this patient as more than her unfortunate diagnosis and level of organ failure had not entered my consciousness. Perhaps a coping mechanism, but dehumanisation none-the-less.

Conclusion: Striking a balance between emotional investment and detachment is of course vital when working in a clinical environment like the ICU, where trauma is commonplace and worst-case-scenarios have a habit of playing out. At the start of my medical career, I assumed I would need to consciously take a step back, that I would struggle to switch off from the emotional aspects of Medicine. However, forgetting the person behind the patient became all too easy during the peaks of Covid-19, where relatives were barred and communication out-sourced. While this level of detachment may be understandable and necessary to an extent, the potential for this attitude to contribute to the already dehumanising experience of ICU patients should not be ignored. I always thought I was more interested in people and their stories than I was in medical science; this experience reminded me of that, and of the richness you lose out on when those stories are forgotten.

4651

A breath of fresh air

Christopher Marsh

Liverpool University Hospitals NHS Foundation Trust

Liverpool University Hospitals NHS Foundation Trust [e-mail]

Submission content

Introduction: This is a story about the day I wheeled a patient outside.

I know, it sounds somewhat underwhelming. But little did I know that this short trip down a hospital corridor and beyond the entrance foyer would mark a profound shift in perspective both for me and my patient, which I hope will influence me for the rest of my career.

Main Body: “Paul” was in his 50s and severely afflicted by COVID-19, resulting in a protracted ICU admission with a slow and arduous ventilator wean. Throughout his time on the unit, Paul had seen no daylight; no view of the outside world. He was struggling to make progress and was becoming exasperated. His deteriorating mood in turn affected his sleep, which further undermined his progress. Due to COVID-19, visiting was not permitted and Paul’s cuffed tracheostomy meant that he couldn’t speak to his family.

One day, witnessing Paul’s psychological decline, I asked him if he fancied a trip outside. Despite initial reluctance, he eventually gave in to some gentle persuasion from the staff nurse, with whom he had developed a close bond.

So there we went; Paul, his nurse and me. And as we wheeled his bed through the door into open air, Paul’s whole demeanour suddenly changed. He appeared as though the weight of the world had been lifted from his shoulders and his face lit up with awe, a tear emerging in the corner of his eye.

In that moment he rediscovered life. Not as a hospital patient, but as a person. Watching the world go by, he remembered what it was like to be a member of the human race, not the subject of endless tests and treatments. He tasted freedom.

Conclusion: Awakened by his experience of the forgotten outside world, when we eventually returned to the ICU Paul was an entirely different man. To Paul, the trip outside symbolised progress. After weeks of frustration and despair, he finally had a purpose; a motivation to get better.

Meanwhile, I was having my own quiet realisation. I now understood what it truly meant to deliver holistic care. It can become all too easy to focus on the clinical aspects; to obsess about the numbers. But in fact, often what matter most to patients are the ‘little things’, to which no amount of medication is the solution. I now try to consider during my daily review: what matters to this patient? How are they feeling? What are they thinking? What else can I do to help their psychological recovery?

And as for me personally? Having witnessed Paul’s reaction to the outside world, I suddenly became aware of how little attention I normally pay to the world around me. How little I appreciate the simple ability to walk outside, and the fundamental things we take for granted. Now, when I’m feeling annoyed or frustrated about something trivial, I stop and think of Paul. I then thank my lucky stars for what I have to be grateful for.

Ultrasound Ninja

4815

Acute or chronic? Failing left ventricle in a 34 year old

James Winchester

Buckinghamshire Healthcare NHS Trust

Buckinghamshire Healthcare NHS Trust [e-mail]

Submission content

Introduction: An unusual case of a very young patient without previously known cardiac disease presenting with severe left ventricular failure, detected by a point of care echocardiogram.

Main Body: A 34 year old previously well man was brought to hospital after seeing his general practitioner with one month of progressive shortness of breath on exertion. This began around the time the patient received his second covid-19 vaccination. He was sleeping in a chair as he was unable to lie flat. Abnormal observations led the GP to call an ambulance.

In the emergency department, the patient required oxygen 5L/min to maintain SpO2 >94%, but he was not in respiratory distress at rest. Blood pressure was 92/53mmHg, mean 67mmHg. Point of care testing for COVID-19 was negative. He was alert, with warm peripheries. Lactate was 1.0mmol/L and he was producing more than 0.5ml/kg/hr of urine. There was no ankle swelling. ECG showed sinus tachycardia. He underwent CT pulmonary angiography which demonstrated no pulmonary embolus, but there was bilateral pulmonary edema. Troponin was 17ng/l, BNP was 2700pg/ml.

Furosemide 40mg was given intravenously by the general medical team. Critical care outreach asked for an urgent intensivist review given the highly unusual diagnosis of pulmonary edema in a man of this age.

An immediate FUSIC Heart scan identified a dilated left ventricle with end diastolic diameter 7cm and severe global systolic impairment. The right ventricle was not severely impaired, with TAPSE 18mm. There was no significant pericardial effusion. Multiple B lines and trace pulmonary effusions were identified at the lung bases.

The patient was urgently discussed with the regional cardiac unit in case of further deterioration, basic images were shared via a cloud system. A potential diagnosis of vaccination-associated myocarditis was considered,¹ but in view of the low troponin, the presentation was felt most likely to represent decompensated chronic dilated cardiomyopathy. The patient disclosed a family history of early cardiac death in males.

Aggressive diuresis was commenced. The patient was admitted to a monitored bed given the potential risk of arrhythmia or further haemodynamic deterioration. Advice was given that in the event of worsening hypotension, fluids should not be administered but the cardiac centre should be contacted immediately. Formal echocardiography confirmed the POCUS findings, with ejection fraction <35%. He was initiated on ACE inhibitors and beta adrenergic blockade. His symptoms improved and he was able to return home and to work, and is currently undergoing further investigations to establish the etiology of his condition.

Conclusion: Early echocardiography provided early evidence of a cardiac cause for the patient’s presentation and highlighted the severity of the underlying pathology. This directed early aggressive diuresis and safety-netting by virtue of discussion with a tertiary cardiac centre whilst it was established whether this was an acute or decompensated chronic pathology.

Ultrasound findings: PLAX, PSAX and A4Ch views demonstrating a severely dilated (7cm end diastolic diameter) left ventricle with global severe systolic impairment.

Reference

1. Bozkurt B, Kamat I, Hotez PJ. Myocarditis With COVID-19 mRNA Vaccines. Circulation. 2021 Aug 10;144(6):471-484.

4801

Pregnancy, major haemorrhage and massive pulmonary embolus – the echocardiogram-guided management

Bruno Fernandes, Chris Gough

University Hospital of Wales

University Hospital of Wales [e-mail]

Submission content

Introduction: A pregnant lady who had cardiac arrest immediately after baby delivery suffered both major haemorrhage and massive PE. Echocardiogram (echos)-guided management led to thrombolysis, but further echos guided her therapy as her right ventricle (RV) first deteriorated and then improved.

Main body: A young lady, who had a previous DVT, but whom had stopped treatment, suffered PEA cardiac arrest shortly after successful vaginal twin delivery. After 3 cycles of CPR and adrenaline boluses, she had return of spontaneous circulation, but remained unstable with significant vaginal bleeding. A major haemorrhage protocol was commenced, and she was transferred to theatre. Despite extensive blood product replacement, she remained unstable, and an intravaginal balloon was inserted. Following this, she underwent a CTPA on-route to ICU.

On arrival to ICU she had a pH of 6.9, an FiO2 of 1.0, and was on Noradrenaline 0.8microgramg/kg/min, and Adrenaline 0.2mcg/kg/min. Renal replacement therapy was commenced. The CTPA report confirmed a large pulmonary embolus (PE) with evidence of right heart strain.

An echo was performed to help assess which component of her shock was the main contributor at that time. The echo showed a dilated and impaired RV, with compression into the LV cavity. It was felt that her main problem was obstructive shock due to the PE, and that she would die without aggressive treatment. She underwent thrombolysis simultaneous with aggressive coagulopathy correction.

She remained profoundly sick although ongoing blood loss was minimal. A repeat echo showed further deterioration of the RV systolic function. This finding led to aggressive RV support, and referral for VA ECMO. Her management at this time included:

• Inhaled NO at 20 ppm.

• Enoximone 5micrograms/kg/min

• Vasopressin 2.5 UI/kg/min

• Sodium bicarbonate 8.4% boluses

• CVVHDF

• Calcium chloride 10% boluses

• Adrenaline (0.2mcg/kg/min) and noradrenaline (1.0mcg/kg/min) infusions being weaned.

A further echo was performed, to guide a decision regarding ECMO transfer. Approx. 12 hours after cardiac arrest, she began to show signs of improvement, with an RV, despite still dilated and impaired, showing some improvement in contractility.

For the next 48 hours, she gradually improved. Another echo was performed which gave confidence to further weaning of the inotropes. Her vasopressin and inhaled NO were also weaned.

On the third day of ICU, as she continued to improve, it was postulated that aiming for a positive fluid balance could improve her haemodynamics. An echo was performed while a passive leg raise was undertaken. This showed a detrimental response, and so a negative fluid balance was achieved instead, which led to further improvement in her haemodynamics, and the noradrenaline was weaned off.

Conclusion: Regular echos were essential in this case, with a rapidly changing clinical course that necessitated multiple echos in the first 24 hours. The clinical team feel that the echo-guided management was a key factor in this young lady’s survival.

Ultrasound video description: Images throughout this case are available, including good views of the RV, and measurements including fractional area change, and its response to our management.

4798

To give fluids or not? Let the ultrasound decide!

Amol Kothekar, Atul Kulkarni

TATA MEMORIAL CENTRE

TATA MEMORIAL CENTRE [e-mail]

Submission content

Introduction: Point of care ultrasound (POCUS) can be useful for bedside hemodynamic management of patients in shock.¹ Cardiac ultrasound (echocardiography) is of particular use in patients undergoing major pulmonary resections like pneumonectomy due to the possibility of acute right ventricular (RV) dysfunction secondary to the sudden increase in RV afterload.² We describe a case of post-pneumonectomy circulatory shock where POCUS helped in the diagnosis of acute RV dysfunction and precise management.

Main Body: A 59-year-old male with recent-onset hypertension was diagnosed to have a non-metastatic primary carinal Adenocarcinoma extending into left main bronchus He underwent carinal resection with left pneumonectomy. Intraoperatively, the patient sustained Ventricular Fibrillation cardiac arrest during manual cardiac retraction which was successfully revived after internal defibrillation of 20 Jules and internal chest compressions for 90 seconds. Further, he required norepinephrine up to 0.1 µg/kg/min to maintain mean blood pressure of more than 70 mm Hg. He was electively ventilated with low tidal volume (4ml/kg) and Positive end-expiratory pressure (PEEP) of 5 cm H2O.

Post-operatively patient had further hypotension requiring higher doses of norepinephrine (0.3 µg /kg/min). CVP of 10mm Hg (on mechanical ventilation) indicated possible benefits from further fluid boluses. However, the POCUS revealed grossly dilated right ventricle with the paradoxical movement of septum during diastole impairing LV filling. (Fig) indicating RV volume overload. The further fluid infusion was stopped and the patient was given diuretics (Inj furosemide 20mg) to relieve RV volume overload. This lead to improvement in the patient’s hemodynamic parameters.

Conclusion: POCUS can help in the diagnosis of RV volume overload and can help in precision hemodynamic management in major pulmonary resections like pneumonectomy.

Brief description of ultrasound video: dilated right ventricle (RV) with flattening of intraventricular septum during diastole indicating RV volume overload.

References

1. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010;28:29. doi:10.1016/j.emc.2009.09.010

2. Kowalewski J, Brocki M, Dryjański T, Kaproń K, Barcikowski S. Right ventricular morphology and function after pulmonary resection. Eur J Cardiothorac Surg. 1999;15(4):444-448. doi:10.1016/s1010-7940(99)00032-9

4730

More than meets the eye - Ocular Ultrasound

Alex Fonseca, Sudhindra Kulkarni

Lancashire Teaching Hospitals NHS Foundation Trust

Lancashire Teaching Hospitals NHS Foundation Trust [e-mail]

Submission content

Introduction: Invasive Intra Cranial Pressure (ICP) monitors are the gold standard for measuring ICP which requires neurosurgical tools & expertise. At a tertiary neurosurgical centre, there can be situations when the neurosurgical teams are very stretched and a time critical insertion of an ICP monitor could be delayed. Ultrasonic measurement of optic nerve sheath diameter (ONSD) can reflect the relative real-time changes in intracranial pressure and can aid in improving patient care.^1–2

Main body: A male patient in his late forties, developed sudden onset aphasia, right sided weakness, facial droop & gaze deviation at a referral district general hospital. CT scan revealed hyperdense left middle cerebral artery (MCA) ischemic stroke with left internal carotid artery (ICA) dissection. An hour and a half post thrombolysis there was no improvement in his clinical condition and he was transferred to our specialist neuro centre for thrombectomy of left MCA clot and stenting of left ICA under general anesthesia.

Post procedure he was noted to have low sensorium a nd was admitted to the critical care unit, sedated & ventilated. Repeat CT brain post thrombectomy revealed hyperacute changes in left hemisphere with acute infarct in the left caudate head with no mid line shift.

The treatment plan according to the primary team was to commence Clopidogrel after repeating a CT scan 4- 6 hours later with an aim to stop sedation and extubate the next day.

While awaiting CT scan an ONSD assessment was performed which prompted us to get the CT scan expedited. Additional pharmacological measures to control ICP were initiated prior to the scan.

Repeat scan showed massive left sided infarct with mass effect & midline shift and patient was scheduled for decompressive craniectomy under platelet cover. Prior to being shifted to the theatres, patient had developed anisocoria (Right pupil: 3mm, sluggishly reactive. Left pupil 8mm, unreactive) and surgical management was accelerated.

Conclusion: This case report highlights the potential of swiftly identifying raised ICP using a rapid, bedside, non-invasive, point of care method. The observations by this handheld device preceded clinical findings and resulted in early diagnosis and treatment in the critically ill neurosurgical patient.

Image findings: Measurements were made 3mm posterior to the point at which the optic nerve enters the globe. ONSD was 6.0mm in the right eye & 6.3mm in the left eye.

References

1. Fernando SM, Tran A, Cheng W, Rochwerg B, et al. Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis. BMJ 2019; 366: l422.

2. Chen, Li-Min et al. Ultrasonic measurement of optic nerve sheath diameter: a non-invasive surrogate approach for dynamic, real-time evaluation of intracranial pressure. British Journal of ophthalmology 2019; 103: 437-441.

4673

Physiotherapist use of Point of Care lung Ultrasound (PoCUS) in Critical Care patients with acute respiratory deterioration - Case studies

Susan Calvert

University Hospitals Bristol & Weston

University Hospitals Bristol & Weston [e-mail]

Submission content

Introduction: Point of care lung ultrasound (PoCUS) is building momentum within the field of Critical Care Physiotherapy with now over 50 accredited clinicians within the United Kingdom & Ireland. It can be used to aid diagnosis as well as provide an outcome measure of effectiveness of physiotherapy interventions (Le Neindre et al. 2016).

Main Body: Within a 2 week period, PoCUS was able to expedite physiotherapy treatment and resolution of acute respiratory deterioration in 2 patients in the critical care environment.

Case Study 1: The patient was 3 days post Aortic dissection repair and on a sedation hold in preparation for extubation when he acutely deteriorated. He was known to have a small right-sided pneumothorax conservatively managed on an earlier x-ray. On initial physiotherapy assessment FiO2 was 0.9 with SpO2 90%. PoCUS was performed to exclude pneumothorax and identified worsening left lung base collapse/consolidation. Having been able to confidently exclude a pneumothorax, physiotherapy intervention including positioning, Ventilator Hyperinflation (VHI) and PEEP recruitment were performed immediately. The patient was successfully extubated the following day. Feedback from the consultant caring for the patient described how: ‘Having a senior member of the physiotherapy team who is equipped with the skills to reliably undertake PoCUS in order to confirm a clinical diagnosis is a ‘game-changer’ in Cardiac ICU. To then act on the diagnosis and pursue an appropriate course of therapy is clearly of benefit to both the patient and the organisation as a whole.’

Case Study 2: The 2^nd patient was extubated 18 days after an Out of hospital cardiac arrest. He almost immediately deteriorated and required reintubation which did not resolve the respiratory compromise. On physiotherapy assessment he was on FiO2 1.0 with SpO2 72% and not moving the left side of his chest. PoCUS was performed and identified an almost complete collapse/consolidation of the left lung. Whilst awaiting a post intubation x-ray, physiotherapy intervention consisting of positioning, VHI and Mechanical insufflation:exsufflation via ETT (as patient did not have an effective cough on suction). Copious amounts of secretions were cleared and SpO2 improved >90% with O2 weaned to <50%. The chest x-ray further assisted the clinical reasoning as the ETT was very close to the carina and this may have further contributed to the L side collapse. Following ETT withdrawal by 2cm and further physiotherapy input, the patient was stable on FiO2.24. Repeat PoCUS and CXR demonstrated resolution of the collapse. Feedback from the consultant caring for the patient was again positive: “This quick, simple, bedside diagnostic tool was incredibly helpful and enabled rapid correct management to be instituted immediately. Thank you!”

Conclusion: PoCUS performed by physiotherapists in the critical care is an invaluable tool in the assessment and treatment of acute respiratory deterioration. It should be noted that it should be used in combination with other assessment tools (e.g. x-ray) in order to provide a full & detailed assessment. It can also provide beneficial and timely feedback into the effectiveness of the intervention.

Brief description of ultrasound video: Due to the acute nature of the situations & limited storage on the unit devices, images were not captured. If required, similar images to demonstrate the pattern of collapse/consolidation observed in these cases could be provided. Chest x-rays demonstrating a ‘white out’ in case study 2 with resolution post physiotherapy intervention are also available.

Reference

1. Le Neindre, A., Mongodi, S., Philippart, F., & Bouhemad, B. (2016). Thoracic ultrasound: Potential new tool for physiotherapists in respiratory management. A narrative review. Journal of Critical Care, 31(1), 101–109. https://doi.org/10.1016/j.jcrc.2015.10.014