OBJECTIONS: Development of acute lung injury after cardiac surgery is associated with an unfavourable outcome. Acute respiratory distress syndrome in general is, besides cytokine and interleukin... Show moreOBJECTIONS: Development of acute lung injury after cardiac surgery is associated with an unfavourable outcome. Acute respiratory distress syndrome in general is, besides cytokine and interleukin activation, associated with activation of platelets, monocytes and neutrophils. In relation to pulmonary outcome after cardiac surgery, leucocyte and platelet activation is described in animal studies only. Therefore, we explored the perioperative time course of platelet and leucocyte activation in cardiac surgery and related these findings to acute lung injury assessed via PaO2/FiO(2) (P/F) ratio measurements. METHODS: A prospective cohort study was performed, including 80 cardiac surgery patients. At five time points, blood samples were directly assessed by flow cytometry. For time course analyses in low (< 200) versus high (>200) P/F ratio groups, repeated measurement techniques with linear mixed models were used. RESULTS: Already before the start of the operation, platelet activatability (P = 0.003 for thrombin receptor-activator peptide and P = 0.017 for adenosine diphosphate) was higher, and the expression of neutrophil activation markers was lower (CD18/CD11; P = 0.001, CD62L; P = 0.013) in the low P/F group. After correction for these baseline differences, the peri- and postoperative thrombin receptor-activator peptide-induced thrombocyte activatability was decreased in the low P/F ratio group (P = 0.008), and a changed pattern of neutrophil activation markers was observed. CONCLUSIONS: Prior to surgery, an upregulated inflammatory state with higher platelet activatability and indications for higher neutrophil turnover were demonstrated in cardiac surgery patients who developed lung injury. It is difficult to distinguish whether these factors are mediators or are also aetiologically related to the development of lung injury after cardiac surgery. Further research is warranted. Show less
Berkhout-Byrne, N.C.; Voorend, C.G.N.; Meuleman, Y.; Mooijaart, S.P.; Brunsveld-Reinders, A.H.; Bos, W.J.W.; Buren, M. van 2023
BackgroundDialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the... Show moreBackgroundDialysis might not benefit all older patients with kidney failure, particularly those with multimorbid conditions and frailty. Patients' and healthcare professionals' awareness of the presence of geriatric impairments could improve outcomes by tailoring treatment plans and decisions for individual patients. ObjectiveWe aimed to explore the perspectives of patients and healthcare professionals on nephrology-tailored geriatric assessment to fuel decision-making for treatment choices in older patients with kidney failure. DesignIn an exploratory qualitative study using focus groups, participants discussed perspectives on the use and value of nephrology-tailored geriatric assessment for the decision-making process to start or forego dialysis. Participants and MeasurementsPatients (n = 18) with kidney failure, caregivers (n = 4), and professionals (n = 25) were purposively sampled from 10 hospitals. Interviews were audio-recorded, transcribed verbatim and inductively analysed using thematic analysis. ResultsThree main themes emerged that supported or impeded decision-making in kidney failure: (1) patient psycho-social situation; (2) patient-related factors on modality choice; (3) organisation of health care. Patients reported feeling vulnerable due to multiple chronic conditions, old age, experienced losses in life and their willingness to trade longevity for quality of life. Professionals recognised the added value of nephrology-tailored geriatric assessment in three major themes: (i) facilitating continual holistic assessment, (ii) filling the knowledge gap, and (iii) uncovering important patient characteristics. Conclusionsnephrology-tailored geriatric assessment was perceived as a valuable tool to identify geriatric impairments in older patients with kidney failure. Integration of its outcomes can facilitate a more holistic approach to inform choices and decisions about kidney replacement therapy. Show less
Nollen, J.M.; Brunsveld-Reinders, A.H.; Peul, W.C.; Furth, W.R. van 2023
Objectives To explore the perceptions and experiences of patients who underwent transsphenoidal pituitary gland and (para)sellar tumour surgery regarding indwelling urinary catheters (IDUCs) and... Show moreObjectives To explore the perceptions and experiences of patients who underwent transsphenoidal pituitary gland and (para)sellar tumour surgery regarding indwelling urinary catheters (IDUCs) and the postoperative fluid balance.Design Qualitative study using semistructured interviews based on the attitudes, social influence and self-efficacy model and expert knowledge.Participants Twelve patients who underwent transsphenoidal pituitary gland tumour surgery and received an IDUC during or after surgery.Setting One patient was interviewed in the endocrinology outpatient clinic and 11 patients were interviewed on the neurosurgery ward.Results Five major themes emerged: (1) conflicting information and preoperative expectations, (2) IDUCs perceived as patient-friendly during bedrest, particularly for women, (3) little room for patients' opinions, (4) physical and emotional limitations and (5) fluid balance causes confusion. Information regarding IDUC placement and fluid balance given to patients both preoperatively and postoperatively did not meet their expectations, which led to confusion and uncertainty. The IDUC was perceived as preferable if bedrest was mandatory, preferred particularly by women. Patient could not mobilise freely due to the IDUC and felt ashamed, judged by others and dependent on nurses.Conclusions This study provides insight into the challenges patients experience in relation to the IDUC and fluid balance. Perceptions on the necessity of an IDUC varied among patients and were influenced by both physical and emotional impediments. A clear, frequent and daily communication between healthcare professionals and patients to evaluate IDUC and fluid balance use is necessary to increase patient satisfaction. Show less
Tresfon, J.; Langeveld, K.; Brunsveld-Reinders, A.H.; Hamming, J. 2023
Physical restraints are viewed as potentially dangerous objects for patient safety. Contemporary efforts mainly focus on preventing bad outcomes in restraint use, while little attention is paid... Show morePhysical restraints are viewed as potentially dangerous objects for patient safety. Contemporary efforts mainly focus on preventing bad outcomes in restraint use, while little attention is paid under what circumstances physical restraints are applied harmlessly. The aim of this research was to understand how physical restraints are used by neurology/neurosurgery ward nurses in relation to the protocol. In ethnographic action research, the Functional Resonance Analysis Method (FRAM) was used to map and compare physical restraints as part of daily ward care against the protocol of physical restraints. Comparison between protocol and actual practice revealed that dealing with restlessness and confusion is a collective nursing skill vital in dealing with physical restraints, while the protocol failed to account for these aspects. Supporting and maintaining this skillset throughout this and similar nursing teams can prevent future misguided application physical restraints, offering valuable starting point in managing patient safety for these potentially dangerous objects. Show less
Tresfon, J.; Brunsveld-Reinders, A.H.; Valkenburg, D. van; Langeveld, K.; Hamming, J. 2022
Introduction: Modern safety approaches in healthcare differentiate between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined) as a means to further develop... Show moreIntroduction: Modern safety approaches in healthcare differentiate between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined) as a means to further develop patient safety. Research in this area has shown case study examples, but to date lacks hooking points as to how results can be embedded within the studied context. This study uses Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with the work-as-done. The aim of this study is to show how FRAM can effectively be applied to identify the gap between work prescriptions and practice, while subsequently showing how such findings can be transferred back to, and embedded in, the daily ward care process of nurses. Methods: This study was part of an action research performed among ward nurses on a 38 bed neurological and neurosurgical ward within a tertiary referral centre. Data was collected through document analysis, in-field observations, interviews and group discussions. FRAM was used as an analysis tool to model the prescribed working methods, actual practice and the gap between those two in the use of physical restraints on the ward. Results This study was conducted in four parts. In the exploration phase, work-as-imagined and work-as-done were mapped. Next, a gap between the concerns named in the protocol and the actual employed methods of dealing with physical restraint on the ward was identified. Subsequently, alignment efforts led to the co-construction of a new working method with the ward nurses, which was later embedded in quality efforts by a restraint working group on the ward. Conclusion The use of FRAM proved to be very effective in comparing work-as-done with work-as-imagined, contributing to a better understanding, evaluation and support of everyday performance in a ward care setting. Show less
Background Indwelling urinary catheters (IDUCs) are associated with complications and early removal is therefore essential. Currently, it is unknown what the effect of a specific removal time is... Show moreBackground Indwelling urinary catheters (IDUCs) are associated with complications and early removal is therefore essential. Currently, it is unknown what the effect of a specific removal time is and what the consequences of this removal time are. Research question To present an overview of the available evidence to determine the effects of three postoperative IDUC removal times (after a certain number of hours, at a specific time of day and flexible removal time) on the development of complications in hospital. Methods PubMed, Medline, Embase, Emcare and Cochrane Central Register of Controlled Trials were searched till 6 June, 2021. Studies were included that described the effect of the removal time in relation to re-catheterisation, urinary tract infections (UTIs), ambulation time, time of first voiding and hospital stay. The quality of the studies was assessed with the Newcastle-Ottawa Scale and the Cochrane Effective Practice and Organisation of Care. A narrative descriptive analysis was performed. PRISMA guidelines were followed in reporting this review. Results Twenty studies were included from which 18 compared removal after a number of hours, 1 reported on a specific removal time and 1 reported on both topics. The results were contradicting regarding the hypothesis that later removal increases the incidence of UTIs. Earlier removal does not lead to a higher re-catheterisation rate while immediate removal is beneficial for reducing the time to first ambulation and shortening the hospital stay. Studies reporting on specific removal times did not find differences in outcomes. No study addressed flexible removal time. Conclusions There is inconclusive evidence that earlier removal results in less UTIs, despite the incidence of UTIs increasing if the IDUC is removed >= 24 h. Immediate or after 1-2 day(s) removal does not lead to higher re-catheterisation rates while immediate removal results in earlier ambulation and shorter length of hospital stay. Implications of key findings Nurses should focus on early IDUC removal while being aware of urinary retention. Show less
Rietbergen, T.; Spoon, D.; Brunsveld-Reinders, A.H.; Schoones, J.W.; Huis, A.; Heinen, M.; ... ; Bodegom-Vos, L. van 2020
Background In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for... Show moreBackground In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. Methods PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the 'Cochrane Effective Practice and Organisation of Care' (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel-Haenszel risk ratios (95% CI) were calculated using a random effects model. Results Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). Conclusions The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. Show less
Healthcare systems have become more effective but are also more complex with greater use of new technologies and interventions. This can result in incidents and life threatening events during... Show moreHealthcare systems have become more effective but are also more complex with greater use of new technologies and interventions. This can result in incidents and life threatening events during patients’ hospitalization and affect the quality of care and patient safety. The objective of the investigations was to assess the tools that are available to measure and monitor quality of care in critically ill patients and the effect of implementing some of these tools on quality of care. Show less
Brunsveld-Reinders, A.H.; Ludikhuize, J.; Dijkgraaf, M.G.W.; Arbous, M.S.; Jonge, E. de; COMET Study Grp 2016
Purpose: We performed a systematic review to assess (1) to what extent Incident Reporting Systems (IRS) on the adult ICU meet the criteria of the WHO Draft Guidelines for Adverse Event Reporting... Show morePurpose: We performed a systematic review to assess (1) to what extent Incident Reporting Systems (IRS) on the adult ICU meet the criteria of the WHO Draft Guidelines for Adverse Event Reporting and Learning Systems, (2) to what extent the IRSs comply with the four aspects of the iterative quality loop and (3) whether IRSs have led to improvement measures in clinical practice. Data sources: The authors searched multiple electronic databases from 1966 until June 26th 2014. Study Selection: Studies were included if they reported incident reporting systems on the adult ICU. Data Extraction: Data on study design, characteristics of the incident reporting system, implementation, feedback and improvement measures were collected using structured data extraction forms. Results of data synthesis: A total of 2098 studies were identified and 36 studies reported IRSs on the adult ICU. Studies were divided into: ICU specific IRSs and general IRSs. Items of the WHO checklist were assessed and categorized into the four phases of the iterative quality loop. Conclusion: None of the IRSs completely fulfilled the WHO checklist criteria. With respect to the iterative loop, data input and data collection are well established but not much attention was given to analyzing incidents and to give feedback. This resulted in an administrative report system, rather than the much desired instrument for change of practice and increase of quality as an IRS can only effectively contribute to improve patient safety and quality of care if more attention is given to analyzing incidents and feedback. Show less
Broek, J.M. van den; Brunsveld-Reinders, A.H.; Zedlitz, A.M.E.E.; Girbes, A.R.J.; Jonge, E. de; Arbous, M.S. 2015
Objectives: To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview... Show moreObjectives: To perform a systematic review of the literature to determine which questionnaires are currently available to measure family satisfaction with care on the ICU and to provide an overview of their quality by evaluating their psychometric properties. Data Sources: We searchedPubMed, Embase, The Cochrane Library, Web of Science, PsycINFO and CINAHL from inception until October 30, 2013. Study Selection: Experimental and observational research articles reporting on questionnaires on family satisfaction and/or needs in the ICU were included. Two reviewers determined eligibility. Data Extraction: Design, application mode, language and the number of studies of the tools were registered. With this information the tools were globally categorized according to validity and reliability: level I (well established quality), II (approaching well-established quality), III (promising quality) or IV (unconfirmed quality). The quality of the highest level (I) tools was assessed by further examination of the psychometric properties and sample size of the studies. Data Synthesis: The search detected 3,655 references, from which 135 articles were included. We found 27 different tools that assessed overall or circumscribed aspects of family satisfaction with ICU care. Only four questionnaires were categorized as level I: the CCFNI, the SCCMFNA, the CCFSS and the FS-ICU. Studies on these questionnaires were of good sample size (>n=100) and showed adequate data on face/content validity and internal consistency. Studies on the CCFNI, the FS-ICU also contained sufficient data on inter-rater/test-retest reliability, responsiveness and feasibility. Generally, data on measures of central tendency and sensitivity to change were scarce. Conclusions: Of all the questionnaires found, the CCFNI and the FS-ICU were the most reliable and valid in relation to their psychometric properties. However, a universal “best questionnaire” is indefinable because it depends on the specific goal, context and population used in the inquiry. Show less
Brunsveld-Reinders, A.H.; Arbous, M.S.; Kuiper, S.G.; Jonge, E. de 2015
Introduction: Transport of critically ill patients from the Intensive Care Unit (ICU) to other departments for diagnostic or therapeutic procedures is often a necessary part of the critical care... Show moreIntroduction: Transport of critically ill patients from the Intensive Care Unit (ICU) to other departments for diagnostic or therapeutic procedures is often a necessary part of the critical care process. Transport of critically ill patients is potentially dangerous with up to 70% adverse events occurring. The aim of this study was to develop a checklist to increase safety of intra-hospital transport (IHT) in critically ill patients.Method: A three-step approach was used to develop an IHT checklist. First, various databases were searched for published IHT guidelines and checklists. Secondly, prospectively collected IHT incidents in the LUMC ICU were analyzed. Thirdly, interviews were held with physicians and nurses over their experiences of IHT incidents. Following this approach a checklist was developed and discussed with experts in the field. Finally, feasibility and usability of the checklist was tested.Results: Eleven existing guidelines and five checklists were found. Only one checklist covered all three phases: pre-, during- and post-transport. Recommendations and checklist items mostly focused on the pre-transport phase. Documented incidents most frequently related to patient physiology and equipment malfunction and occurred most often during transport. Discussing the incidents with ICU physicians and ICU nurses resulted in important recommendations such as the introduction of a standard checklist and improved communication with the other departments. This approach resulted in a generally applicable checklist, adaptable for local circumstances. Feedback from nurses using the checklist were positive, the fill in time was 4.5 minutes per phase.Conclusion: A comprehensive way to develop an intra-hospital checklist for safe transport of ICU patients to another department is described. This resulted in a checklist which is a framework to guide physicians and nurses through intra-hospital transports and provides a continuity of care to enhance patient safety. Other hospitals can customize this checklist to their own situation using the methods proposed in this paper. Show less
Brunsveld-Reinders, A.H.; Arbous, M.S.; Kuiper, S.G.; Jonge, E. de 2015
Objective: To describe the effect of implementation of a Rapid Response System (RRS) on the composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death. Design: Pragmatic... Show moreObjective: To describe the effect of implementation of a Rapid Response System (RRS) on the composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death. Design: Pragmatic prospective Dutch multi-center before-after trial, Cost and Outcomes analysis of Medical Emergency Teams (COMET) trial. Setting: Twelve hospitals participated, each including two surgical and two non-surgical wards between April 2009 and November 2011. The Modified Early Warning Score (MEWS) and Situation-Background-Assessment-Recommendation (SBAR) instruments were implemented over seven months. The Rapid Response Team (RRT) was then implemented during the following 17 months. The effects of implementing the RRT were measured in the last 5 months of this period. Patients: All patients 18 years and older admitted to the study wards were included. Measurements and main results: In total 166,569 patients were included in the study representing 1,031,172 hospital admission days. No differences were observed in patient demographics between periods. The composite endpoint of cardiopulmonary arrest, unplanned ICU admission, or death per 1000 admissions was significantly reduced in the RRT versus the before phase, adjusted odds ratio (OR) 0.847 (95% CI 0.725-0.989, p=0.036). Cardiopulmonary arrests and in hospital mortality were also significantly reduced, OR 0.607 (95 CI 0.393-0.937, p=0.018) and OR 0.802 (95% CI 0.644-1.0, p=0.05) respectively. Unplanned ICU admissions showed a declining trend, OR 0.878 (95% CI 0.755-1.021, p=0.092) whereas severity of illness at the moment of ICU admission was not different between periods. Conclusions: In this study, introduction of nationwide implementation of RRSs was associated with a decrease in the composite endpoint of cardiopulmonary arrests, unplanned ICU admissions and mortality in patients on general hospital wards. These findings support the implementation of RRSs in hospitals to reduce severe adverse events. Show less
Van den Broek, J.M.; Brunsveld-Reinders, A.H.; Zedlitz, A.M.; Girbes, A.R.; De Jonge, E.; Sesmu Arbous, M. 2015
