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ObjectivesClinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators.DesignA 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process.ParticipantsThirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process.Measurements and main resultsThe final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization.ConclusionsThese recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should

OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recom

OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recom

Full Text, Thesis (PhD Doctorate), Doctor of Philosophy (PhD), School of Nursing & Midwifery, Griffith Health, Background: There is minimal evidence to inform blood flow rate (BFR) during continuous renal replacement therapy (CRRT). Aims: We aimed to assess the effect of BFR on circuit life and solute maintenance during CRRT. Design: A prospective randomised controlled trial. Setting: Twenty-four bed, single-centre, tertiary-level intensive care unit. Participants: Critically ill patients with acute kidney injury treated with CRRT (continuous venovenous haemofiltration [CVVH] or continuous venovenous haemodiafiltration [CVVHDF]). Interventions: Patients were randomised to receive one of two BFRs: 150 mL/min or 250 mL/min. Main outcome measures: The primary outcome was circuit life measured in hours. The secondary outcome was changes in urea and creatinine concentrations (changes from baseline), and delivered treatment for each 12 h period was used to assess solute maintenance. Results: One hundred patients were randomised, with 96 completing the study (150 mL/min, n = 49; 250 mL/min, n = 47) using 462 circuits (245 runs at 150 mL/min and 217 runs at 250 mL/min). Primary outcome: Circuit and patient data were collected until each circuit clotted or was ceased electively for non-clotting reasons. Data for clotted circuits were presented as median (interquartile range [IQR]) and compared using the Mann–Whitney U test. Survival probability for clotted circuits was compared using a log-rank test. Circuit clotting data were analysed for repeated events using hazard ratio (HR). Median circuit life for the first circuit (clotted) was similar for both groups (150 mL/min: 9.1 [5.5, 26] h vs. 10 [4.2, 17] h, p = 0.37). CRRT using a BFR set at 250 mL/min was not more likely to cause clotting compared with 150 mL/min (HR 1.00, 95% CI 0.60–1.69; p = 0.68). Gender, body mass index, weight, vascular access type, length, site, mode of CRRT and international normalised ratio had no effect on clotting risk. CRRT without anticoagulation was more likely to cause clotting compared with use of hep

Background: Interventions to support psychological recovery after critical illness, including information provision via an intensive care unit (ICU) diary or discharge summary, have been widely adopted in some regions, albeit without strong empirical evidence. Objective: The objective of this study was to examine the feasibility and acceptability, for patients, family members, and clinicians, of information provision via an ICU diary or discharge summary to support psychological recovery for critical illness survivors. Methods: This was a pilot, partially randomised patient preference study in a mixed ICU in a tertiary hospital in Australia. Eligible patients were those in the ICU for >24 h and who were able to converse in English. Interventions were ICU diary or discharge summary compared with usual care. Feasibility was assessed throughout the study process, and acceptability assessed 3 and 6 months after hospital discharge, with data analysed descriptively and thematically. Results: Sixty-one patients were recruited; 45 completed 3-month follow-up (74%), and 37 (61%), 6-month follow-up. Participants were medical (39%), surgical (30%), and trauma (31%) patients; aged 55 [interquartile range (IQR): 36–67] years; and stayed in the ICU for 7 [IQR: 3–13] days and hospital for 23 [IQR: 14–32] days. Within the partially randomised framework, 34 patients chose their intervention – four chose usual care, 10 ICU diary, and 20 discharge summary. The remaining 27 patients were randomised – nine usual care, 10 ICU diary, and seven discharge summary. The majority (>90%) considered each intervention helpful during recovery; however, a significant proportion of patients reported distress associated with reading the ICU diary (42%) or discharge summary (15%). Clinicians reported they were hesitant to make diary entries. Conclusions: When given a choice, more patients chose a discharge summary over the ICU diary or usual care. Participants considered both interventions acceptable.

Purpose: To examine whether in-bed cycling assists critically ill adults to reduce acute muscle wasting, improve function and improve quality of life following a period of critical illness. Materials and methods: A single-centre, two-group, randomised controlled trial with blinded assessment of the primary outcome was conducted in a tertiary ICU. Critically ill patients expected to be mechanically ventilated for at least 48 h were randomised to 30 min daily in-bed cycling in addition to usual-care physiotherapy (n = 37) or usual-care physiotherapy (n = 37). The primary outcome was muscle atrophy of rectus femoris cross-sectional area (RFCSA) measured by ultrasound at Day 10 following study enrolment. Secondary outcomes included manual muscle strength, handgrip strength, ICU mobility score, six-minute walk test distance and health-related quality of life up to six-months following hospital admission. Results: Analysis included the 72 participants (mean age, 56-years; male, 68%) who completed the study. There were no significant between-group differences in muscle atrophy of RFCSA at Day 10 (mean difference 3.4, 95% CI -6.9% to 13.6%; p =.52), or for secondary outcomes (p-values ranged p =.11 to p =.95). Conclusions and relevance: In-bed cycling did not reduce muscle wasting in critically ill adults, but this study provides useful effect estimates for large-scale clinical trials. Trial registration: anzctr.org.au Identifier: ACTRN12616000948493.

Background: There is minimal evidence to inform blood flow rate (BFR) during continuous renal replacement therapy (CRRT). Aims: We aimed to assess the effect of BFR on circuit life and solute maintenance during CRRT. Design: A prospective randomised controlled trial. Setting: Twenty-four bed, single-centre, tertiary-level intensive care unit. Participants: Critically ill patients with acute kidney injury treated with CRRT (continuous venovenous haemofiltration [CVVH] or continuous venovenous haemodiafiltration [CVVHDF]). Interventions: Patients were randomised to receive one of two BFRs: 150 mL/min or 250 mL/min. Main outcome measures: The primary outcome was circuit life measured in hours. The secondary outcome was changes in urea and creatinine concentrations (changes from baseline), and delivered treatment for each 12 h period was used to assess solute maintenance. Results: One hundred patients were randomised, with 96 completing the study (150 mL/min, n = 49; 250 mL/min, n = 47) using 462 circuits (245 runs at 150 mL/min and 217 runs at 250 mL/min). Primary outcome: Circuit and patient data were collected until each circuit clotted or was ceased electively for non-clotting reasons. Data for clotted circuits were presented as median (interquartile range [IQR]) and compared using the Mann–Whitney U test. Survival probability for clotted circuits was compared using a log-rank test. Circuit clotting data were analysed for repeated events using hazard ratio (HR). Median circuit life for the first circuit (clotted) was similar for both groups (150 mL/min: 9.1 [5.5, 26] h vs. 10 [4.2, 17] h, p = 0.37). CRRT using a BFR set at 250 mL/min was not more likely to cause clotting compared with 150 mL/min (HR 1.00, 95% CI 0.60–1.69; p = 0.68). Gender, body mass index, weight, vascular access type, length, site, mode of CRRT and international normalised ratio had no effect on clotting risk. CRRT without anticoagulation was more likely to cause clotting compared with use of hep, Thesis (PhD Doctorate), Doctor of Philosophy (PhD), School of Nursing & Midwifery, Griffith Health, Full Text

Introduction: In-bed cycling for critically ill patients is a rehabilitative exercise that may help improve patients’ functional status at hospital discharge. In-bed cycling is not currently implemented early during a patients’ critical illness. Objectives: To identify if early in-bed cycling could be safely implemented following a patients’ admission to ICU and to identify the barriers and facilitators to implementation of in-bed cycling within ICU. Methods: A randomised controlled trial comparing usual care physio-therapy with additional in-bed cycling within a tertiary mixed medical, surgical, trauma ICU was conducted. Number of sessions of in-bed cycling planned, conducted, distance and duration cycled, haemodynamic parameters and occurrence of pre-defined adverse events were recorded. A diary of intervention implementation processes and outcomes was kept to identify barriers and facilitators to implementation of in-bed cycling. Results: Thirty-seven participants completed 276 of 304 (90.8%) planned in-bed cycling interventions. Participants completed a median (IQR) of 6 (4,8) in-bed cycling sessions. Participants commenced in-bed cycling a median (IQR) of 2.3 (1.8,3.1) days following ICU admission. Participants cycled a mean (SD) 27.7 (5.2) minutes per session and mean (SD) 3.23km (1.63km) per session and maintained haemodynamic stability. Two minor adverse events (0.7% of sessions) occurred that required clinician intervention (increased respiratory rate and oxygen desaturation). These events required adjustment to ventilator settings without any long-term consequences. The main barriers to the implementation of in-bed cycling sessions were patient fatigue (n = 9), delirium (n = 5) and haemodynamic instability (n = 4). Timing of initiation of the intervention following morning chest x-ray round with independent implementation by a physiotherapist were identified as the main facilitators to the in-bed cycling intervention. Conclusions: In-bed cycling commencing

Learning Objectives: Critically ill patients lose large amounts of skeletal muscle early during their ICU admission. This muscle loss is associated with the development of weakness and functional impairments. In-bed cycling initiated early in an ICU admission may reduce muscle atrophy, maintain muscle strength and promote recovery of mobility. Methods: A two-arm (blinded assessment) randomized controlled trial (RCT) compared usual care versus early in-bed cycling (in addition to usual care). The setting was a tertiary mixed medical, surgical, trauma ICU. Participants included adult patients with expected duration of mechanical ventilation >48 hours. All participants received usual care while patients randomized to the intervention group received an additional daily intervention of 30 minutes of in-bed cycling. In-bed cycling participants were encouraged to cycle actively whenever possible whilst pre-specified safety parameters were observed. The in-bed cycling sessions could be passive, machine-assisted or active. The primary outcome was rectus femoris cross sectional area (RFCSA) measured by ultrasound (blinded ultrasonographers) at: Baseline, Days 3, 7, 10 (primary) post-study enrollment, as well as 7 days post-discharge from ICU. Other outcomes included manual muscle strength assessed by the Medical Research Council (MRC) Sum Score and distance in meters walked during the 6-minute walk test (6MWT) 7 days post-discharge from ICU. Results: Seventy-four participants (mean (SD) age = 56 (17), 69% male) were recruited. There was a difference of 4% in median RFCSA atrophy at Day 10 (primary outcome) favoring the intervention group. Participants in the in-bed cycling group (n = 37) had a median (IQR) percent of RFCSA atrophy of -9.4% (-23.2%, 0.8%) in comparison to usual care participants (n = 37) -13.2% (-26.4%, -2.9%). During the 6MWT the in-bed cycling group walked median (IQR) 258 meters (30, 326) versus usual care participants median (IQR) 210 met

Background: Interruptions during handover may compromise continuity of care and patient safety. Local Problem: Interruptions occur frequently during handovers in the intensive care unit. Methods: A quality improvement study was undertaken to improve nursing team leader handover processes. The frequency, source, and reason interruptions occurred were recorded before and after a handover intervention. Interventions: The intervention involved relocating handover from the desk to bedside and using a printed version of an evidence-based electronic minimum data set. These strategies were supported by education, champions, reminders, and audit and feedback. Results: Forty handovers were audiotaped before, and 49 were observed 3 months following the intervention. Sixty-four interruptions occurred before and 52 after the intervention, but this difference was not statistically significant. Team leaders were frequently interrupted by nurses discussing personal or work-specific matters before and after the intervention. Conclusions: Further work is required to reduce interruptions that do not benefit patient care.

Background: Miscommunication during handover has been linked to adverse patient events and is an international patient safety priority. Despite the development of handover resources, standardized handover tools for nursing team leaders (TLs) in intensive care are limited. Aims: The study aim was to implement and evaluate an evidence-based electronic minimum data set for nursing TL shift-to-shift handover in the intensive care unit using the knowledge-to-action (KTA) framework. Methods: This study was conducted in a 21-bed medical-surgical intensive care unit in Queensland, Australia. Senior registered nurses involved in TL handover were recruited. Three phases of the KTA framework (select, tailor, and implement interventions; monitor knowledge use; and evaluate outcomes) guided the implementation and evaluation process. A postimplementation practice audit and survey were carried out to determine nursing TL use and perceptions of the electronic minimum data set 3 months after implementation. Results are presented using descriptive statistics (median, IQR, frequency, and percentage). Results: Overall (86%, n = 49), TLs’ use of the electronic minimum data set for handover and communication regarding patient plan increased. Key content items, however, were absent from handovers and additional documentation was required alongside the minimum data set to conduct handover. Of the TLs surveyed (n = 35), those receiving handover perceived the electronic minimum data set more positively than TLs giving handover (n = 35). Benefits to using the electronic minimum data set included the patient content (48%), suitability for short-stay patients (16%), decreased time updating (12%), and printing the tool (12%). Almost half of the participants, however, found the minimum data set contained irrelevant information, reported difficulties navigating and locating relevant information, and pertinent information was missing. Suggestions for improvement focused on modifications to the e

Introduction: There is widespread use of clinical information systems in intensive care units however, the evidence to support electronic handover is limited. Objectives: The study aim was to assess the barriers and facilitators to use of an electronic minimum dataset for nursing team leader shift-to-shift handover in the intensive care unit prior to its implementation. Methods: The study was conducted in a 21-bed medical/surgical intensive care unit, specialising in cardiothoracic surgery at a tertiary referral hospital, in Queensland, Australia. An established tool was modified to the intensive care nursing handover context and a survey of all 63 nursing team leaders was undertaken. Survey statements were rated using a 6-point Likert scale with selections from ‘strongly disagree’ to ‘strongly agree’ and open-ended questions. Descriptive statistics were used to summarise results. Results and discussion: A total of 39 team leaders responded to the survey (62%). Team leaders used general intensive care work unit guidelines to inform practice however they were less familiar with the intensive care handover work unit guideline. Barriers to minimum dataset uptake included: a tool that was not user friendly, time consuming and contained too much information. Facilitators to minimum dataset adoption included: a tool that was user friendly, saved time and contained relevant information. Identifying the complexities of a healthcare setting prior to the implementation of an intervention assists researchers and clinicians to integrate new knowledge into healthcare settings. Conclusion: Barriers and facilitators to knowledge use focused on usability, content and efficiency of the electronic minimum dataset and can be used to inform tailored strategies to optimise team leaders’ adoption of a minimum dataset for handover.

Background Despite increasing demand for structured processes to guide clinical handover, nursing handover tools are limited in the intensive care unit. Objectives The study aim was to identify key items to include in a minimum dataset for intensive care nursing team leader shift-to-shift handover. Methods This focus group study was conducted in a 21-bed medical/surgical intensive care unit in Australia. Senior registered nurses involved in team leader handovers were recruited. Focus groups were conducted using a nominal group technique to generate and prioritise minimum dataset items. Nurses were presented with content from previous team leader handovers and asked to select which content items to include in a minimum dataset. Participant responses were summarised as frequencies and percentages. Results Seventeen senior nurses participated in three focus groups. Participants agreed that ISBAR (Identify-Situation-Background-Assessment-Recommendations) was a useful tool to guide clinical handover. Items recommended to be included in the minimum dataset (≥65% agreement) included Identify (name, age, days in intensive care), Situation (diagnosis, surgical procedure), Background (significant event(s), management of significant event(s)) and Recommendations (patient plan for next shift, tasks to follow up for next shift). Overall, 30 of the 67 (45%) items in the Assessment category were considered important to include in the minimum dataset and focused on relevant observations and treatment within each body system. Other non-ISBAR items considered important to include related to the ICU (admissions to ICU, staffing/skill mix, theatre cases) and patients (infectious status, site of infection, end of life plan). Items were further categorised into those to include in all handovers and those to discuss only when relevant to the patient. Conclusions The findings suggest a minimum dataset for intensive care nursing team leader shift-to-shift handover should contain items wi

Purpose: Recalibration and determining discriminative power, internationally, of the existing delirium prediction model (PRE-DELIRIC) for intensive care patients. Methods: A prospective multicenter cohort study was performed in eight intensive care units

This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of protocol directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated ICU patients. We will look at various outcomes, conduct subgroup and sensitivity analyses and examine the role of bias in order to examine the level of evidence for this intervention.

Purpose: Communication is integral to effective trauma care provision. This presentation will report on barriers to meaningful information transfer for multi-trauma patients upon discharge from the Emergency Department (ED) to the care areas of Intensive Care Unit, High Dependency Unit, and Perioperative Services. This is an ongoing study at one tertiary level hospital in Queensland. Method: This is a multi-phase, mixed method study. In Phase 1 data were collected about information transfer. This Phase was initially informed by a comprehensive literature review, then via focus groups, chart audit, staff survey and review of national and international trauma forms. Results: The barriers identified related to nursing handover, documented information, time inefficiency, patient complexity and stability and time of transfer. Specifically this included differences in staff expectations and variation in the nursing handover processes, no agreed minimum dataset of information handed over, missing, illegible or difficult to find information in documentation (both medical and nursing), low compliance with some forms used for documentation. Handover of these patients is complex with information coming from many sources, dealing with issues is more difficult for these patients when transferred out of hours. Conclusions and further directions: This study investigated the current communication processes and standards of information transfer to identify barriers and issues. The barriers identified were the structure used for documentation, processes used (e.g. handover), patient acuity and time. This information is informing the development, implementation and evaluation of strategies to ameliorate the issues identified.

Background: Injury is a leading cause of preventable mortality and morbidity in Australia and the world. Despite this there is little research examining the health related quality of life of adults following general trauma. Methods: A prospective cohort design was used to study adults who presented to hospital following injury. Data regarding injury and demographic details was collected through the routine operation of the Queensland Trauma Registry (QTR). In addition, the short form 36 (SF-36) was mailed to patients approximately 3 months following injury. Results: Participants included 339 injured patients who were hospitalised for ≥24 h in March-June 2003. A secondary group of 145 patients completed the SF-36, but did not have QTR data collected due to hospitalisation being <24 h. Both groups of participants reported significantly lower scores on all subscales of the SF-36 when compared to Australian norms. Conclusions: Health related quality of life of injured survivors is markedly reduced 3 months after injury. Ongoing treatment and support is necessary to improve these health outcomes.

Existing trauma registries in Australia and New Zealand play an important role in monitoring the management of injured patients. Over the past decade, such monitoring has been translated into changes in clinical processes and practices. Monitoring and changes have been ad hoc, as there are currently no Australasian benchmarks for “optimal” injury management. A binational trauma registry is urgently needed to benchmark injury management to improve outcomes for injured patients.

Many patients admitted to acute care areas of a hospital experience cardiovascular compromise due to conditions such as acute myocardial infarction (AMI), acute coronary syndrome or exacerbations of chronic heart failure. Additionally, patients can experience cardiovascular collapse due to bleeding or cardiac arrhythmias postoperatively. As a consequence, nurses in acute care settings need to be competent in assessing the cardiovascular status of adult patients. The authors provide a framework for assessing the cardiovascular status of patients in acute care settings using the determinants of cardiac output. They provide a brief review of the determinants of cardiac output before discussing both the aims of cardiovascular assessment and how to perform, such an assessment. (non- author abstract)