The intensive care unit (ICU) is a dynamic, complex and, at times, highly stressful work environment that involves ongoing exposure to the complexities of interprofessional team functioning. Failures ...of communication, considered examples of poor collaboration among health care professionals, are the leading cause of inadvertent harm across all health care settings. Evidence suggests effective interprofessional collaboration results in improved outcomes for critically ill patients. One recent study demonstrated a link between low standardized mortality ratios and self‐identified levels of collaboration. The aim of this paper is to discuss determinants and complexities of interprofessional collaboration, the evidence supporting its impact on outcomes in the ICU, and interventions designed to foster better interprofessional team functioning. Elements of effective interprofessional collaboration include shared goals and partnerships including explicit, complementary and interdependent roles; mutual respect; and power sharing. In the ICU setting, teams continually alter due to large staff numbers, shift work and staff rotations through the institution. Therefore, the ideal ‘unified’ team working together to provide better care and improve patient outcomes may be difficult to sustain. Power sharing is one of the most complex aspects of interprofessional collaboration. Ownership of specialized knowledge, technical skills, clinical territory, or even the patient, may produce interprofessional conflict when ownership is not acknowledged. Collaboration by definition implies interdependency as opposed to autonomy. Yet, much nursing literature focuses on achievement of autonomy in clinical decision‐making, cited to improve job satisfaction, retention and patient outcomes. Autonomy of health care professionals may be an inappropriate goal when striving to foster interprofessional collaboration. Tools such as checklists, guidelines and protocols are advocated, by some, as ways for nurses to gain influence and autonomy in clinical decision‐making. Protocols to guide ICU practices such as sedation and weaning reduce the duration of mechanical ventilation in some studies, while others have failed to demonstrate this advantage. Existing organizational strategies that facilitate effective collaboration between health care professionals may contribute to this lack of effect.
Nutritional status differs between infants and young children living in slum and non-slum conditions-infants and young children living in City Corporation slums are likely to have worse nutritional ...status compared to those from non-slums. Furthermore, families in slums tend to engage female labor in cash-earning activities as a survival strategy; hence, a higher percentage of mothers stay at work. However, little is known about feeding practices for infants and young children in families with working mothers in slums. This study aims to understand the factors that determine feeding practices for infants and young children living in families with working mothers in Dhaka slums.
This study adopted a qualitative approach. Sixteen In-depth Interviews, five Key Informant Interviews, and Focused Group Discussions were conducted with family members, community leaders, and program staff. Method triangulation and thematic analyses were conducted.
Feeding practices for infants and young children in families with working mothers are broadly determined by mothers' occupation, basis civic facilities, and limited family buying capacity. Although mothers have good nutritional knowledge, they negotiate between work and feeding their infants and young children. Household composition, access to cooking facilities, and poverty level were also found to be significant determining factors.
The results suggest a trade-off between mothers' work and childcare. The absence of alternative care support in homes and/or work places along with societal factors outweighs full benefits of project interventions. Improving alternative childcare support could reduce the burden of feeding practice experienced by working mothers and may improve nutritional outcomes.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose
To compare the effects of prevention interventions on delirium occurrence in critically ill adults.
Methods
MEDLINE, Embase, PsychINFO, CINAHL, Web of Science, Cochrane Library, Prospero, and ...WHO international clinical trial registry were searched from inception to April 8, 2021. Randomized controlled trials of pharmacological, sedation, non-pharmacological, and multi-component interventions enrolling adult critically ill patients were included. We performed conventional pairwise meta-analyses, NMA within Bayesian random effects modeling, and determined surface under the cumulative ranking curve values and mean rank. Reviewer pairs independently extracted data, assessed bias using Cochrane Risk of Bias tool and evidence certainty with GRADE. The primary outcome was delirium occurrence; secondary outcomes were durations of delirium and mechanical ventilation, length of stay, mortality, and adverse effects.
Results
Eighty trials met eligibility criteria: 67.5% pharmacological, 31.3% non-pharmacological and 1.2% mixed pharmacological and non-pharmacological interventions. For delirium occurrence, 11 pharmacological interventions (38 trials,
N
= 11,993) connected to the evidence network. Compared to placebo, only dexmedetomidine (21/22 alpha
2
agonist trials were dexmedetomidine) probably reduces delirium occurrence (odds ratio (OR) 0.43, 95% Credible Interval (CrI) 0.21–0.85; moderate certainty). Compared to benzodiazepines, dexmedetomidine (OR 0.21, 95% CrI 0.08–0.51; low certainty), sedation interruption (OR 0.21, 95% CrI 0.06–0.69; very low certainty), opioid plus benzodiazepine (OR 0.27, 95% CrI 0.10–0.76; very low certainty), and protocolized sedation (OR 0.27, 95% CrI 0.09–0.80; very low certainty) may reduce delirium occurrence but the evidence is very uncertain. Dexmedetomidine probably reduces ICU length of stay compared to placebo (Ratio of Means (RoM) 0.78, CrI 0.64–0.95; moderate certainty) and compared to antipsychotics (RoM 0.76, CrI 0.61–0.98; low certainty). Sedative interruption, protocolized sedation and opioids may reduce hospital length of stay compared to placebo, but the evidence is very uncertain. No intervention influenced mechanical ventilation duration, mortality, or arrhythmia. Single and multi-component non-pharmacological interventions did not connect to any evidence networks to allow for ranking and comparisons as planned; pairwise comparisons did not detect differences compared to standard care.
Conclusion
Compared to placebo and benzodiazepines, we found dexmedetomidine likely reduced the occurrence of delirium in critically ill adults. Compared to benzodiazepines, sedation-minimization strategies may also reduce delirium occurrence, but the evidence is uncertain.
Investigators evaluated the caregivers of patients who had received mechanical ventilation for at least 7 days in an ICU. Although there was a large burden of depressive symptoms soon after ...discharge, the burden diminished in magnitude, in most caregivers, during the subsequent year.
Unpaid caregivers (typically family or close friends) are essential to the sustainability of North American health care systems, because their unpaid labor annually accounts for $27 billion in Canada and $642 billion in the United States.
1
,
2
More than half the patients who have received prolonged mechanical ventilation during a stay in the intensive care unit (ICU) and have survived to discharge continue to require assistance from a caregiver 1 year after ICU discharge.
3
Although caregiver assistance can be beneficial for patients, such care may have negative consequences for caregivers, including poor health-related quality of life,
4
emotional distress,
4
–
8
a . . .
Purpose
Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of ...chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients.
Methods
A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors.
Results
A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio aOR, 1.13; 95% confidence interval CI 0.82 to 1.54;
P
= 0.46). Time to IVACs (adjusted hazard ratio aHR, 1.06; 95% CI 0.44 to 2.57;
P
= 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23;
P
= 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10;
P
= 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17;
P
= 0.02) improved in the intervention period.
Conclusion
Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health.
In this study, a report of dietitian-led nutrition interventions for patients with COVID-19 during ICU and ward-based rehabilitation is provided. As knowledge of COVID-19 and its medical treatments ...evolved through the course of the pandemic, dietetic-led interventions were compared between surge 1 (S1) and surge 2 (S2).
A prospective observational study was conducted of patients admitted to the ICU service in a large academic hospital (London, UK). Clinical and nutrition data were collected during the first surge (March-June 2020;
= 200) and the second surge (November 2020-March 2021;
= 253) of COVID-19.
A total of 453 patients were recruited. All required individualized dietetic-led interventions during ICU admission as the ICU nutrition protocol did not meet nutritional needs. Feed adjustments for deranged renal function (
= 0.001) and propofol calories (
= 0.001) were more common in S1, whereas adjustment for gastrointestinal dysfunction was more common in S2 (
= 0.001). One-third of all patients were malnourished on ICU admission, and all lost weight in ICU, with a mean (SD) total percentage loss of 8.8% (6.9%). Further weight loss was prevented over the remaining hospital stay with continued dietetic-led interventions.
COVID-19 patients have complex nutritional needs due to malnutrition on admission and ongoing weight loss. Disease complexity and evolving nature of medical management required multifaceted dietetic-led nutritional strategies, which differed between surges.
In a recent case-control study with matching using the duration of mechanical ventilation, physically restrained patients were 5 times more likely to experience unplanned extubation 6. Because of the ...low event rate of unplanned extubation and corresponding large sample size of a randomized controlled trial to evaluate this causal relationship, we anticipate it is unlikely that trials to evaluate the effectiveness of interventions to reduce physical restraint will use unplanned extubation as the primary outcome.
Background
There are various reasons why weaning and extubation failure occur, but ineffective cough and secretion retention can play a significant role. Cough augmentation techniques, such as lung ...volume recruitment or manually‐ and mechanically‐assisted cough, are used to prevent and manage respiratory complications associated with chronic conditions, particularly neuromuscular disease, and may improve short‐ and long‐term outcomes for people with acute respiratory failure. However, the role of cough augmentation to facilitate extubation and prevent post‐extubation respiratory failure is unclear.
Objectives
Our primary objective was to determine extubation success using cough augmentation techniques compared to no cough augmentation for critically‐ill adults and children with acute respiratory failure admitted to a high‐intensity care setting capable of managing mechanically‐ventilated people (such as an intensive care unit, specialized weaning centre, respiratory intermediate care unit, or high‐dependency unit).
Secondary objectives were to determine the effect of cough augmentation techniques on reintubation, weaning success, mechanical ventilation and weaning duration, length of stay (high‐intensity care setting and hospital), pneumonia, tracheostomy placement and tracheostomy decannulation, and mortality (high‐intensity care setting, hospital, and after hospital discharge). We evaluated harms associated with use of cough augmentation techniques when applied via an artificial airway (or non‐invasive mask once extubated/decannulated), including haemodynamic compromise, arrhythmias, pneumothorax, haemoptysis, and mucus plugging requiring airway change and the type of person (such as those with neuromuscular disorders or weakness and spinal cord injury) for whom these techniques may be efficacious.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 4, 2016), MEDLINE (OvidSP) (1946 to April 2016), Embase (OvidSP) (1980 to April 2016), CINAHL (EBSCOhost) (1982 to April 2016), and ISI Web of Science and Conference Proceedings. We searched the PROSPERO and Joanna Briggs Institute databases, websites of relevant professional societies, and conference s from five professional society annual congresses (2011 to 2015). We did not impose language or other restrictions. We performed a citation search using PubMed and examined reference lists of relevant studies and reviews. We contacted corresponding authors for details of additional published or unpublished work. We searched for unpublished studies and ongoing trials on the International Clinical Trials Registry Platform (apps.who.int/trialsearch) (April 2016).
Selection criteria
We included randomized and quasi‐randomized controlled trials that evaluated cough augmentation compared to a control group without this intervention. We included non‐randomized studies for assessment of harms. We included studies of adults and of children aged four weeks or older, receiving invasive mechanical ventilation in a high‐intensity care setting.
Data collection and analysis
Two review authors independently screened titles and s identified by our search methods. Two review authors independently evaluated full‐text versions, independently extracted data and assessed risks of bias.
Main results
We screened 2686 citations and included two trials enrolling 95 participants and one cohort study enrolling 17 participants. We assessed one randomized controlled trial as being at unclear risk of bias, and the other at high risk of bias; we assessed the non‐randomized study as being at high risk of bias. We were unable to pool data due to the small number of studies meeting our inclusion criteria and therefore present narrative results rather than meta‐analyses. One trial of 75 participants reported that extubation success (defined as no need for reintubation within 48 hours) was higher in the mechanical insufflation‐exsufflation (MI‐E) group (82.9% versus 52.5%, P < 0.05) (risk ratio (RR) 1.58, 95% confidence interval (CI) 1.13 to 2.20, very low‐quality evidence). No study reported weaning success or reintubation as distinct from extubation success. One trial reported a statistically significant reduction in mechanical ventilation duration favouring MI‐E (mean difference ‐6.1 days, 95% CI ‐8.4 to ‐3.8, very low‐quality evidence). One trial reported mortality, with no participant dying in either study group. Adverse events (reported by two trials) included one participant receiving the MI‐E protocol experiencing haemodynamic compromise. Nine (22.5%) of the control group compared to two (6%) MI‐E participants experienced secretion encumbrance with severe hypoxaemia requiring reintubation (RR 0.25, 95% CI 0.06 to 1.10). In the lung volume recruitment trial, one participant experienced an elevated blood pressure for more than 30 minutes. No participant experienced new‐onset arrhythmias, heart rate increased by more than 25%, or a pneumothorax.
For outcomes assessed using GRADE, we based our downgrading decisions on unclear risk of bias, inability to assess consistency or publication bias, and uncertainty about the estimate of effect due to the limited number of studies contributing outcome data.
Authors' conclusions
The overall quality of evidence on the efficacy of cough augmentation techniques for critically‐ill people is very low. Cough augmentation techniques when used in mechanically‐ventilated critically‐ill people appear to result in few adverse events.
Population trends of disease prevalence and incidence over time measure burden of disease and inform healthcare planning. Neuromuscular disorders (NMD) affect muscle and nerve function with varying ...degrees of severity and disease progression.
Using health administrative databases we described trends in incidence, prevalence, and mortality of adults and children with NMD. We also explored place of death and use of palliative care.
Population-based (Ontario, Canada) cohort study (2003 to 2014) of adults and children with NMD identified using International Classification of Disease and health insurance billing codes within administrative health databases.
Adult disease prevalence increased on average per year by 8% (95% confidence interval (CI) 6% to 10%, P <.001), with the largest increase in adults18-39 years. Childhood disease prevalence increased by 10% (95% CI 8% to 11%, P <.0001) per year, with the largest increase in children 0 to 5 years. Prevalence increased across all diagnoses except amyotrophic lateral sclerosis and spinal muscular atrophy for adults and all diagnoses for children. Adult incidence decreased by 3% (95% CI -4% to -2%, P <.0001) but incidence remained stable in children. Death occurred in 34,336 (18.5%) adults; 21,236 (61.8%) of whom received palliative care. Death occurred in 1,009 (5.6%) children; 507 (50.2%) of whom received palliative care. Mortality decreased over time in adults (odds ratio (OR) 0.86, 95% CI 0.86-0.87, P <.0001) and children (OR 0.79, 95% CI 0.76-0.82, P <.0001). Use of palliative care over time increased for adults (OR 1.18, 95% CI 1.09 to 1.28, P <.0001) and children (OR 1.22, 95% CI 1.20 to 1.23, P <.0001).
In both adults and children, NMD prevalence is rising and mortality rates are declining. In adults incidence is decreasing while in children it remains stable. This confirms on a population-based level the increased survival of children and adults with NMD.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
PDF
