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
Introduction: A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute... Show moreIntroduction: A semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one. Methods: A systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure. Results: Three trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45 degrees bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45 degrees elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of mechanically ventilated patients to a 20 to 45 degrees position and preferably to a >= 30 degrees position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes. Conclusions: Although the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions. Show less
Introduction: Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and... Show moreIntroduction: Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and cost-effectiveness of this practice have been criticized. This study aimed to evaluate clinical characteristics and the biomarker procalcitonin (PCT) as an aid in predicting bacteremia. Methods: A prospective observational multicenter cohort study included consecutive adults with febrile UTI in 35 primary care units and 8 emergency departments of 7 regional hospitals. Clinical and microbiological data were collected and PCT and time to positivity (TTP) of blood culture were measured. Results: Of 581 evaluable patients, 136 (23%) had bacteremia. The median age was 66 years (interquartile range 46 to 78 years) and 219 (38%) were male. We evaluated three different models: a clinical model including seven bedside characteristics, the clinical model plus PCT, and a PCT only model. The diagnostic abilities of these models as reflected by area under the curve of the receiver operating characteristic were 0.71 (95% confidence interval (CI): 0.66 to 0.76), 0.79 (95% CI: 0.75 to 0.83) and 0.73 (95% CI: 0.68 to 0.77) respectively. Calculating corresponding sensitivity and specificity for the presence of bacteremia after each step of adding a significant predictor in the model yielded that the PCT > 0.25 mu g/l only model had the best diagnostic performance (sensitivity 0.95; 95% CI: 0.89 to 0.98, specificity 0.50; 95% CI: 0.46 to 0.55). Using PCT as a single decision tool, this would result in 40% fewer blood cultures being taken, while still identifying 94 to 99% of patients with bacteremia. The TTP of E. coli positive blood cultures was linearly correlated with the PCT log value; the higher the PCT the shorter the TTP (R-2 = 0.278, P = 0.007). Conclusions: PCT accurately predicts the presence of bacteremia and bacterial load in patients with febrile UTI. This may be a helpful biomarker to limit use of blood culture resources. Show less
Nieuwkoop, C. van; Bonten, T.N.; van't Wout, J.W.; Kuijper, E.J.; Groeneveld, G.H.; Becker, M.J.; ... ; Dissel, J.T. van 2010
INTRODUCTION Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and... Show moreINTRODUCTION Guidelines recommend that two blood cultures be performed in patients with febrile urinary tract infection (UTI), to detect bacteremia and help diagnose urosepsis. The usefulness and cost-effectiveness of this practice have been criticized. This study aimed to evaluate clinical characteristics and the biomarker procalcitonin (PCT) as an aid in predicting bacteremia. METHODS A prospective observational multicenter cohort study included consecutive adults with febrile UTI in 35 primary care units and 8 emergency departments of 7 regional hospitals. Clinical and microbiological data were collected and PCT and time to positivity (TTP) of blood culture were measured. RESULTS Of 581 evaluable patients, 136 (23%) had bacteremia. The median age was 66 years (interquartile range 46 to 78 years) and 219 (38%) were male. We evaluated three different models: a clinical model including seven bed-side characteristics, the clinical model plus PCT, and a PCT only model. The diagnostic abilities of these models as reflected by area under the curve of the receiver operating characteristic were 0.71 (95% confidence interval (CI): 0.66 to 0.76), 0.79 (95% CI: 0.75 to 0.83) and 0.73 (95% CI: 0.68 to 0.77) respectively. Calculating corresponding sensitivity and specificity for the presence of bacteremia after each step of adding a significant predictor in the model yielded that the PCT > 0.25 μg/l only model had the best diagnostic performance (sensitivity 0.95; 95% CI: 0.89 to 0.98, specificity 0.50; 95% CI: 0.46 to 0.55). Using PCT as a single decision tool, this would result in 40% fewer blood cultures being taken, while still identifying 94 to 99% of patients with bacteremia.The TTP of E. coli positive blood cultures was linearly correlated with the PCT log value; the higher the PCT the shorter the TTP (R(2) = 0.278, P = 0.007). CONCLUSIONS PCT accurately predicts the presence of bacteremia and bacterial load in patients with febrile UTI. This may be a helpful biomarker to limit use of blood culture resources. Show less
