BACCN Conference 2015 Abstract Book

Abstracts

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Biography

Ruth Kleinpell PhD RN FAANP is currently the Director of the Center for Clinical Research and Scholarship at Rush University Medical Center and a Professor at Rush University College of Nursing in Chicago Illinois, USA. She is certified as an Acute Care Nurse Practitioner and maintains active practice. She presents and publishes on a variety of clinical topics and is a board member of the Society of Critical Care Medicine; the Commission on Collegiate Nursing Education; the American Academy of Nursing; and the Institute of Medicine of Chicago. She is a fellow in the American College of Critical Care Medicine; American Academy of Nursing; American Association of Nurse Practitioners; and the Institute of Medicine of Chicago. She is completing a second two-year term as President of the World Federation of Critical Care Nurses, an international organization with 40 country members representing over 500,000 critical care nurses worldwide

Abstract

It is well acknowledged that improving quality and safety in healthcare is an international priority. The theme of the 5th International BACCN Conference - Delivering High Quality and Safe Critical Care Services: A Global Ambition - identifies that a general goal for critical care is ensuring that high quality and safe care practices are being provided. However, during criti-cal illness, patients are at increased risk for experiencing adverse complications due to their severity of illness, challenging the ability of clinicians to provide high quality care. Additionally, the focus on costs of care, patient outcomes, and patient satisfaction has been identified as priority areas for healthcare. This session will review strategies for redesigning critical care to promote care that is focused on quality and safety, taking into consideration competing priority areas for improving health-care. Clinical exemplars will be highlighted to showcase how improvements in ICU care can be achieved to optimally meet global healthcare goals for critical care.

Keynote Speakers

S01: Delivering quality and safety - have we got the right ambitions?

Professor Ruth Kleinpell

Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing, USA

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Biography

Building on a career of Nursing posts in acute care, and Higher Education, Jane’s roles within the past eight years include Nurse Advisor to the NPSA, President of the Association for Perioperative Practice (AfPP), Intervention Lead Patient Safety First, Nurse Advisor WHO 2nd Global Challenge Safe Surgery Saves Lives (Geneva), Associate Dean (Nursing and Allied Health Professions) Bournemouth University and Dean Somerset Academy.

Jane’s current portfolio includes Researcher Queen Mary, University of London, Nurse Advisor NQB Human Factors Group, Co-Chair Learning to be Safer Expert Group at Health Education England, Clinical Lead Wessex Patient Safety Collaborative, Regional Lead (South of England) for Sign up to Safety, and Non-Executive Director Dorset County Hospital NHS Foundation Trust.

Special interests include, professionalism, human factors, patient safety, continuous quality improvement, healthcare ethics and law. In 2013 Jane was recognised by the HSJ in association with Barclays and the NHS Leadership Academy, as one of the most inspirational women leaders, in healthcare.

Abstract

Short cuts and work-arounds, are a feature of daily life domestically and professionally, such as failing to separate household waste for recycling or wearing scrubs to the hospital canteen.

Amalberti et al (2006) describe such acts, as violations because they occur as deliberate digressions from standard practices and in the case of our professional lives, deviations from established organisational procedures, processes and protocols. Our collective challenge is that depending upon the context violations can also be justified, as creative ways of managing difficult situations; while this can prove true, in the majority of cases, violations are unconscious acts of deviance, that are extremely seductive, because they ‘appear’ easier to execute and offer a range of perceived immediate benefits, including time savings. Unless the circumstances, surrounding any and all deviations from desired practice, are properly examined through a safety science lens (Emanuel et al 2008) the situation can rarely be rectified, or improved upon, because the underlying reasons/justifications are rarely properly surfaced.

Objectives - this session will:

1. Discuss the concept of violation and migration in clinical practice 2. Identify common violations and migrations in critical care environments3. Consider the importance of identifying and owning routine violations to determine tolerances and thresholds of service

quality 4. Explore and debate the challenges faced by nurse leaders in upholding clinical and professional standards 5. Propose a range of strategies for critical care leaders to adopt

ReferencesAmalberti R., Vincent C., Auroy Y., de Saint Maurice G. (2006) Violations and migrations in health care: a framework for understanding and management. Quality and Safety Health Care. December; 15(Suppl 1): i66–i71. doi: 10.1136/qshc.2005.015982Emanuel, L., Berwick D,. Conway J,. Combes J,.Hatlie M,. Leape L., Reason, J., Schyve P,., Vincent C,. Walton M,. (2008) What Exactly Is Patient Safety? in Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Agency for Healthcare Research and Quality. Available at : http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/index.html

S02: Human Factors Understanding in Critical Care

Prof Jane ReidRegional Lead (South) Sign up to Safety, Clinical Lead Wessex Patient Safety Collaborative, UK

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Keynote Speakers

S03: Factors affecting safe care-how can we be the safest healthcare system in the world?

Dr Suzette WoodwardCampaign Director, Sign up to Safety, UK

Biography

Suzette Woodward is the national Campaign Director for Sign up to Safety, a campaign for the NHS in England to save lives and reduce avoidable harm. Previously Suzette was Executive Director of Safety, Learning and People at the NHS Litigation Authority and before that Director of Patient Safety at the National Patient Safety Agency.

A paediatric intensive care nurse by background she has worked for over 20 years in patient safety at a national and international level. Suzette has a Doctorate in Patient Safety and an MSc in Clinical Risk from UCL.

Abstract

Suzette will inform delegates about the new campaign for patient safety; Sign up to Safety. Suzette will also describe the lessons learnt over the last 15 years in patient safety and the top ten things you can do tomorrow to reduce avoidable harm and save lives.

1. Creating a’ just culture’ to support staff when things go wrong and to help learn2. Stopping the spread of infections by improving hand hygiene compliance, continuously reinforcing the right barrier

precautions and implementing care bundles to prevent ventilator-associated pneumonia linked to intubation and central line-associated bloodstream infections

3. Use real-time ultrasonography when placing invasive lines or tubes such as central lines or nasogastric tubes4. Designing systems based approach which constantly monitors invasive lines and tube; catheter-related urinary tract infections

for example are the most common type of health care-associated infection5. Checklists to reduce surgical complications. The WHO surgical safety checklist has been shown to cut mortality rates and

reduce complication rates6. Improving communication, information sharing and handover among team members and between teams, units or care settings7. Improved administration of prophylaxis e.g. for sepsis and VTE8. Improved detection of the deteriorating patient together with a faster response9. Avoid hazardous acronyms and drug abbreviations which cause significant number of medication errors a year such as using

abbreviations like “u” for “unit”10. Use multicomponent interventions to prevent pressure ulcers; such as continual assessment of the skin of at-risk patients,

regular turning of these patients, management of incontinence to prevent soiling that can contribute to bedsores, and nutritional assessment for malnourishment that can enable the ulcers

This talk will present the main findings and recommendations from the report which is due for publication on the 13th June 2014.

Dr Suzette Woodward

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Biography

Dr. Sandra Goldsworthy is a recognized critical care expert, having worked in this field for more than 25 years. As an Associate Professor in the Faculty of Nursing at the University of Calgary, with a Research Professorship in Simulation Education, she is also an accomplished practitioner, researcher and author. Sandra holds two national CNA credentials in Critical Care and Medical Surgical Nursing. Her research focus is simulation and transfer of learning, job readiness and transition of new graduates. Sandra has conducted and published research involving the use of simulation and technology in nursing education. Her recent publications and national and international presentations have concentrated on critical care and technology in nursing. Sandra is the co-editor of all three editions of Medical Surgical Nursing in Canada texts. She recently co-authored ‘Simulation Simplified: a practical guide for nurse educators’, ‘Simulation Simplified: Student lab manual for critical care nursing’ and The Compact Clinical Guide for Mechanical Ventilation.

Abstract

Intensive Care Units have been shown to have the highest turnover rates and there is currently limited scientific evidence on how to retain critical care nurses.

Studies have shown that one of the most commonly listed incentives for this group of nurses is organizational support in the form of access to educational opportunities and career development. Strategies are urgently needed to stabilize the critical care nurse workforce and ensure healthy workplace environments. Findings will be presented from a Canadian study that examined how a specific professional development intervention, which included human simulation, influenced intent to stay among critical care nurses. In addition, essential elements of healthy nurse work environments will be discussed and implications for managers, education and policy.

S04: Stabilizing the Critical Care Nurse Workforce: Focus on retention

Dr Sandra GoldsworthyAssociate Professor, University of Calgary, Canada

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Keynote Speakers

Biography - Jane Woollard

Jane has worked for 24 years as a Registered Nurse across a wide range of specialities based within large tertiary referral hospitals within the UK and Australia. Jane is passionate about supporting and developing Registered Nurses to reach their full potential and is the Course Director for the University of Greenwich accredited Royal Free Adult Intensive Care and Accident and Emergency Course. Jane, in collaboration with the ICU and HLIU team ensured that ICU nurses were available to support the needs of the critically unwell Ebola patients.

Breda Athan

Senior Matron for Infection and Immunity, Lead for the High Level Isolation Unit (HLIU) The Royal Free NHS London Foundation Trust, UK

Biography - Breda Athan

Breda has worked at the Royal Free London Foundation Trust for over 25 years. Within this time Breda has worked in the area of Infectious and Tropical Diseases, setting up one of the first nurse led travel clinics. Breda has previously been a member of the Committee for Emergency Planning for Viral Haemorrhagic Fevers. This was particularly relevant in 2014 when the Ebola outbreak in West Africa meant the HLIU, the only unit in the UK, admitted three positive patients with Ebola, resulting in a 100% success rate of survival. Breda was paramount in ensuring nursing staff were trained and available as short notice for such a unit and involved in the coordination of the multi-disciplinary team. Breda, along with NHS England, amongst others, was involved in the development and implementation of a Surge Contingency Plan and programme of training for health care workers throughout the UK.

S05: Delivering World Class Care to critically ill Ebola Patients, What can we do and what are our limits?

Jane WoollardHead of Nursing Emergency and Critical Care, Royal Free London NHS Foundation Trust

Biography - Will Pooley

Having qualified in early 2013 Will studied for a Tropical Nursing diploma at LSHTM whilst working as a ward nurse in Southampton General. In early 2014 Will took a post with a small healthcare charity operating in Sierra Leone. Whilst there the West African Ebola epidemic took hold in the East of the country where Will went on to volunteer in an Ebola Treatment Unit. After infection with EVD Will was repatriated to the UK and was successfully treated at the Royal Free Hospital. He returned to Sierra Leone shortly afterwards with King’s Health Partnership Sierra Leone as an Ebola nurse volunteer before coming back to the UK to work in Accident and Emergency at the Royal Free Hospital.

Will PooleyStaff Nurse, The Royal Free London NHS Foundation Trust, UK

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Biography - Oliver Carpenter

Oliver is the clinical practice educator for the infectious diseases ward and the high level isolation unit at the royal free hospital. He has worked in these areas since qualifying in 2001 as a staff nurse. He developed an interest in educating nurses and became a clinical practice educator in 2007. He is one of the senior nurses that runs the HLIU when open. When the HLIU is not open, he carries out training for staff interested in working there. He has given presentations about ebola and HLIU to the Ambulance Service and the RCN Critical Care Forum. He recently qualified as a practice teacher and is also an honorary lecturer in nursing studies at Middlesex University.

Oliver CarpenterClinical Practice Educator, Infectious Diseases and HLIU, The Royal Free London NHS Foundation Trust , UK

Abstract

In 2014 the Ebola Virus continued to spread across Western Africa and as more health care workers were deployed to support, manage and prevent the spread of Ebola, it became a reality that health care workers were at risk of contracting the Ebola Virus themselves. In August 2014 the first of three confirmed Ebola patients arrived at the Royal Free NHS London Foundation Trust. All three of the patients were Registered Nurses and all required different levels of critical care support.

The key note speech will focus on “how” the critical care team supported and worked with the infectious diseases team to provide world class care to the critically unwell Ebola patients. There will be an overview of what is a High Level Isolation Unit, clinical manifestations and management of Ebola and an informative discussion with regard to “out of the ordinary” operational issues. During the presentation you will also hear a direct account from Will Pooley with regard to what it felt like to be a healthcare worker and patient with Ebola and also what the staff experience was of caring for an Ebola patient. Key themes identified include the “need to think differently all of the time” and the constant question “what can we do now, what are our limits?”

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Workshop AbstractsW01: Care of the Proned Patient John Bell, UHB NHS Foundation Trust, UK & Andrew Freeman-Fielding, University Hospital Bristol, UK

SPONSORED BY:

ICU Bristol prone approximately 150 ventilated patients a year. This session will introduce why you would prone a patient, the pathophysiology involved, as well as looking at the care of the ventilated prone patient. The Trust have made changes to their guidelines which have had an impact on patient’s pressure area care, giving near zero incidence of harm. The results they have achieved and the improvements to patient care and safety in relation to prone ventilation will be presented.

W02: Continuous Renal Replacement Therapy Workshop using Citrate

Hayley Gilbrook, Andrew Mizen, West Suffolk Hospital, UK

Acute Kidney Injury (AKI) is now recognised as an important syndrome alongside acute coronary syndrome, acute lung injury, severe sepsis and septic shock, leading to specific treatment recommendations in the management of this disease (KDIGO 2012).

Early recognition and treatment of AKI is paramount using approved assessment criteria. Once established management of haemodynamic instability and Renal Replacement Therapy (RRT) is recommended for the critically ill patient. RRT is now common place in Critical Care, with units devising their own individualised protocols and guidelines according to the types of machines they are using and their experience. There are different modes to choose from and various ways to anti-coagulate the machine/patient to ensure continuous treatment.

Anticoagulation of the circuit is required in continuous renal replacement therapy (CRRT) and heparin has always been the first choice of anticoagulant despite the increased risk of bleeding associated with its use. Regional anticoagulation using citrate is fast becoming the anticoagulation therapy of choice in CRRT due to the reduced risk of bleeding (Wu et al 2012).

This workshop aims to follow the path of a patient presenting with AKI. It will be an interactive workshop with the audience assisting to make the decisions for the treatment of the patient. We will cover:

Setting up CRRT• Discussions surrounding the different modes

• Exploring the use of Citrate for anticoagulation therapy• Adjusting therapy according to results

The interactive workshop and discussion will hopefully lead to a successful patient outcome.

ReferencesKDIGO (2012) KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. Vol 2 Issue 1 Wu, M et al (2012) Regional Citrate Versus Heparin Anticoagulation for Continuous Renal Replacement Therapy: A Meta-Analysis of Randomised Controlled Trials. American Journal of Kidney Disease, 59(6); 810-818

W03: Going off the MAP: Using arterial pressure and cardiac output efficiently and effectively

Barbara McLean, Grady Hospital, USA

Objectives: Learner Objectives:

1. Review the rationale for stoke volume, Starling curve and tissue endpoint monitoring for critically ill patients.

2. Identify the patient at risk and the value of their therapy in simulated case studies

Abstract: The management of hemodynamically unstable patients presents one of the most challenging experiences for critical care providers and incorrect treatment or delay in appropriate treatment results in markedly increased morbidity and mortality. Cardiac output (stroke volume) is regarded as one of the most important variables to be monitored in patients with acute circulatory failure, including septic, cardiac, and hypovolemic shock. With an increased focus on the dynamic interpretation criteria of the arterial bed, understanding the evaluation and generating endpoint for resuscitation requires significant knowledge and practice. How do we prepare for this shift and are we up to the challenge?

In clinicians’ quest to achieve optimal oxygen delivery (DO2) they are often faced with imprecise, non-specific information in which to guide their therapy. Traditional hemodynamic monitoring parameters (HR, MAP, CVP, and PAOP) are often insensitive and sometimes misleading in the assessment of circulating blood volume. Volume is one of the first therapeutic interventions clinicians turn to when optimizing DO2. The questions“ Can we use fluid to improve hemodynamics?” or “Is it the appropriate intervention?” are difficult to answer and often based on incomplete data.

Evidence supports that pressure measures are often insensitive and sometimes misleading in the assessment of circulating blood

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volume. In recent years, alternative minimally invasive technologies have become available utilizing the arterial pulse contour, allowing beat-to-beat cardiac output monitoring and facilitating dynamic volumetric measures as well as assessing heart–lung interactions in mechanically ventilated patients. Analysis using arterial pressure waveform, pulsatile perfusion indicators and evaluative ABG/VBG is based on the physiological principle that stroke volume and CO2 clearance is of significant benefit when determining resuscitation endpoints. In addition, Stroke volume variation and its comparable measurement, pulse pressure variation (PPV), are not indicators of actual preload but of relative preload responsiveness. SVV has been shown to have a very high sensitivity and specificity when compared to traditional indicators of volume status (HR, MAP, CVP, PAD, PAOP), and their ability to determine fluid responsiveness. The transition from PA monitoring to arterial wave calculation has been well discussed and supported in the literature, however, the unique method of provider driven evaluation is less so. When used within its limitations SVV is a sensitive tool that can be used to guide the appropriate management of the patient’s preload to achieve optimal DO2 and answer the question “Can we use fluid to improve hemodynamics?”, “ What should we do next?” and “When is enough, enough!”

Marrying a preload or volume responsiveness to a full tissue oxygenation panel, creates a rich critical care platform for communicating effectively with colleagues and determining both treatment and evaluation. The critical pathway will assist the provider to organize the data in such a way that the science and practice will become very clear. Combined with central venous oximetry and appropriate arterial blood gas measures, this platform of dynamic reporting may change current practice.

Further validation and research is required to further the science of fluid, vasopressor and inotropic administration in shock states. The platform discussed here is in current evaluation and testing.

ReferencesVieillard-Baron A , Loubieres Y , Schmitt JM , Page B , Dubourg O ,Jardin F . Cyclic changes in right ventricular output impedance during mechanical ventilation . J Appl Physiol . 1999; 87 (5): 1644 - 1650.Guervilly C, Forel JM, Hraiech S, et al. Right ventricular function during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome. Crit Care Med. 2012; 40 (5): 1539 - 1545.Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F. Echo-Doppler demonstration of acute cor pulmonale at the bedside in the medical intensive care unit. Am J Respir Crit Care Med. 2002; 166 (10): 1310 - 1319.

W04: Creating the right environment to successfully implement the National Critical Care Competency Framework

Melanie Kynaston, Julie Platten, National Critical Care Education Review Forum, UK

The ‘National standards for Critical Care Nurse Education’ and the ‘National Competency Framework for Adult Critical Care Nurses’ provides robust assessment of the registered nurses’ competence in practice, ensuring that the nursing workforce is fit for purpose and holds the right skills. However, implementing these standards will create challenges for critical care service providers and Higher Educational Institutes offering post graduate critical care programmes.

Learning outcomes for the workshop:1. Overview of framework and recent revisions2. Understanding the challenges with implementing the framework operationally

Quality assurance in the learning environment and with assessment processTime constraintsLearners taking ownership of development3. Insight into models of implementation that have been successful elsewhere4. Lessons learnt from those who would do things differently Implementing the competency framework has created challenges at unit level and successful implementation has in some cases required additional resource to support local educational infrastructure and strategy. It has identified gaps in the knowledge and skills of the existing workforce and reinforced the need for a national suite of critical care competencies to underpin registered nurses professional development. Taking a structured approach to implementation, following an initial scoping exercise of local requirements will enable units to implement the competency framework successfully and take advantages of the benefits it has to offer.

Workshop format:1. Initial short presentation and overview2. Group work: What you need to consider before implementing the framework 3. Group work: Implementation strategies used locally 4. Agree set of standardised principles to successfully implement framework (with a view to participants being acknowledge and these being published with the framework) ReferencesNational Competency Framework for Adult Critical Care Nurses: Support Information (2013) Critical Care Nurse Education Review Forum on behalf of the Critical Care National Network Lead Nurse Forum (CC3N) National Standards for Critical Care Nurse Education: A framework to improve educational outcomes and quality (2011) Critical Care Nurse Education Review Forum on behalf of the Critical Care National Network Lead Nurse Forum (CC3N)

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W05: Exploring a holistic approach to patient care- the use of multi-modal delirium care bundles to deliver real improvements in care

John Owen-Bell, Dr Sanjoy Shah, Bristol Royal Infirmary, UK

SPONSORED BY:

Delirium is associated with increased mortality, prolonged ICU stays and thedevelopment of post-ICU cognitive impairment.1

It is estimated that up to 80% of ICU patients will suffer from it and it can be acutely distressing for them.2,3

Whilst also leading to increased inpatient length of stay, mortality, morbidity and significant long-term health and social care consequences, some of the latest evidence suggests delirium is in fact a health care emergency and is a sensitive clinical sign for potentially huge long-term care costs to society.3,4,6

Meanwhile there is growing evidence of the true impact of delirium on long-term prognosis and cognitive function months and years after delirium episode.4,6,7

Risk factors include pre-existing dementia, history of hypertension and oralcoholism and a high severity of illness at admission.1

In addition to environmental factors such as noise, sleep disturbances, sensory overload and sensory deprivation, patient specific factors such as pain, anxiety and stress may all play a huge role in the development of delirium in critical care.8,9 The delirium project work and scholarship presented in this workshop on the multi-modal care bundle approach for the prevention and management of delirium has found some interesting and thought provoking outcomes in terms of patient’s pain and anxiety levels and the quantities of sedative and opiate infusions required for patients in critical care. This has obvious health economic implications.

Benzodiazepine use may also be a risk factor for the development of deliriumin ICU patients.1,2,5,8

At Bristol Royal Infirmary a multi-disciplinary multi-modal approach has been used towards the prevention, reduction and treatment of patient delirium with results that have potential applications world-wide. This session is presented by John Owen-Bell Charge Nurse, Adult Critical Care Unit and Dr Sanjoy Shah ICU consultant from Bristol

Royal Infirmary and will explore how the results and positive impact of a multi-modal approach can be achieved through both holistic and drug-regimen modifications and how choice of sedative can be used effectively as a part of this multi-modal approach.

References1 Barr J. et al. Crit Care Med, Jan 13; 41(1):263-3062. Pandharipande P et al. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006; 104:21–26.2. Lin SM et al. Crit Care Med. 2004;32(11):2254-9.3. Ely EW et al. JAMA. 2004;291(14):1753-62.4. McAvay GJ et al. Older adults discharged from the hospital with delirium: 1 year outcomes. J Am Geriatr Soc 2006; 54:1245–1250.5. Schieman A, et al. (2011) Managing ICU Delirium, current opinion in critical care volume 17: 131-1406. Hopkins R.O and Jackson J.C. (2006) Assessing neurocognitive outcomes of critical illness: are delirium and long-term cognitive impairment related, Current Opinon Critical Care 2006, volume 12: 388-3947. P.P. Pandharipande et al. for the BRAIN-ICU Study Investigators* (2013) Long-Term Cognitive Impairment after Critical Illnessn engl j med 369;14 nejm.1306 org october 3, 20138. Jorge I Salluh1*et al.The DECCA (Delirium Epidemiology in Critical Care) Study Group, Delirium epidemiology in critical care (DECCA):an international study, Critical Care 2010, 14:R2109. J. Patel, (2013) The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients, Anaesthesia 2014, 69, 540–549

W06: Deprivation of Liberty Safeguards post Cheshire West: Is this relevant to Critical Care?

Dr Tim Collins, East Kent Hospitals University NHS Foundation Trust, UK, Nicola Credland, University of Hull, UK

The Deprivation of Liberty Safeguards (DOLS) scheme was introduced in 2009 as an addendum to the 2005 Mental Capacity Act, with the aim to provide protection for the human rights of vulnerable people who lack capacity to decide their care and treatment (Ministry of Justice 2008). In 2014, the Supreme Court generated an “acid test” following the cases of “Cheshire West” and “MIG & MEG”. This acid test stated that “if a person is under continuous supervision & control and is not free to leave, then this constitutes an objective deprivation of liberty” (P v Cheshire West and Chester Council 2014). This acid test was not decided within critical care but the law states that DOLS is not context specific. Following this Supreme Court judgement, there has been uncertainty relating to application of this acid test to critical care practice, which has led to many Trusts advocating DOLS assessments are completed for patients fulfilling the acid test (Crews et al 2014). This has generated considerable debate amongst the acute care community with many lawyers stating that at present the context is uncertain due to no test case being undertaken specifically within critical care.

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This interactive workshop will aim to generate professional discussion and debate relating to the application of the acid test to critical care. The workshop will initially provide an overview of current DOLS legislation and the process of how the acid test was generated in terms of developing case law. The workshop will involve using interactive voting keypads to allow participants to vote in decision making relating to patient case studies that will generate discussion and opinion. The presentation of critical care case studies and their application to current case law will facilitate debate and interaction amongst delegates. The workshop will provide opportunity to share how the BACCN, ICS & other professional organisations are attempting to gain clarity following this Supreme Court ruling and recommendations on how to best apply DOLS assessments to critical care practice.

ReferencesCrews M, Garry D, Phillips C et al (2014) Deprivation of Liberty in Intensive Care. JICS,4:320-324. Ministry of Justice (2008) Mental Capacity Act 2005: Deprivation of liberty safeguards – Code of Practice to supplement the main Mental Capacity Act 2005 Code of Practice. London: The Stationery Office. P v Cheshire West and Chester Council and another. P and Q v Surrey County Council (2014) UKSC 19. On appeal from: [2011] EWCA Civ1257; (2011)EWCA Civ 190.

W07: The Role of Targeted Temperature Management in Cardiac and Neuro ICUs

Suman Shrestha, Frimley Park Hospital NHS, UK Foundation Trust, Abigail Beane, Royal London Hospital, UK

SPONSORED BY:

The TTM study by Niklas Nielsen and his group was published in 2013.

This study has raised a lot of questions as to whether patients should be temperature managed and as to which temperature we should be controlling the Sudden Cardiac Arrest patients. Suman will be sharing his experience and protocol on how patients are temperature managed at Frimley Park Hospital.

Abigail will be sharing her experience on how cooling and fever management is achieved at the Royal London Hospital.

Both these presentations will reiterate the importance of Targeted temperature Management focusing on its key elements : Control, Precision and Results.

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Concurrent AbstractsC01: Treating obesity hypoventilation with Assured Volumes and Auto Epap

Iain Wheatley, Elizabeth Spillan-Ind, Frimley Health NHS Foundation Trust, UK

Aim: To demonstrate through case studies the place for assured volume assist pressure support (AVAPS) and auto EPAP (AVAPS-AE) in treating patients with Obesity hypoventilation syndrome (OHS) and obstructive sleep apnoea (OSA).

Background: Non-invasive ventilation (NIV) has been traditionally used in patients with acute respiratory failure using spontaneous timed (S/T) modes where an inspiratory (IPAP) and an expiratory (EPAP) pressure is set. In obese patients the level of IPAP necessary to achieve a sufficient tidal volume sometimes causes issues with mask leak and compliance (Antonelli et al 2003). Claudett et al (2013) found that patients who received AVAPS quickly reached IPAP levels needed for maintaining assured tidal volume, and hypoventilation was corrected. However is AVAPS alone enough for patients with OHS as they also frequently have increased airway resistance resulting in OSA?

Method: Two case reviews will be described: The first patient, BMi 55 admitted with hypercapnic respiratory failure due to OHS commenced on S/T NIV and then changed to AVAPS.

The second case, BMi 78 commenced on standard S/T NIV. Changed to AVAPS due to compliance issues and difficulty reducing the CO2. Airway resistance proved an obstacle and auto EPAP was introduced.

Results: The first case study showed that through the use of AVAPS, compliance can be improved by a reduction in IPAP. The second patient continued to have high airway resistance, enough to impede the effect of the set EPAP. By changing to auto EPAP the device overcame airway resistance with the effect of reducing the sleep related events, and improving sleep quality.

Conclusion: In patients with OHS and OHSOSA using AVAPS-AE provides a number of benefits including improved patient compliance, less leak at the mask interface and reduced IPAP. Auto EPAP provides an extra automated approach to tackling airway resistance and reduc-ing sleep related events.

ReferencesAntonelli M, Pennisi MA, Conti G: (2003) New advances in the use of noninvasive ventilation for acute hypoxaemic respiratory failure. European Respiratory Journal Supplement, 42:65s-71s. Claudett K H B, Claudett B M, Wong M C S, Martinez, Espinoza RS, Montalvo M, Rodriguez A E, Diaz G G , Andrade M G (2013) Non-invasive Mechanical Ventilation With Average Volume Assured Pressure Support (AVAPS) in Patients With Chronic Obstructive Pulmonary Disease and Hypercapnic Encephalopathy BMC Pulm Med;13(12)

C02: Intraosseous vascular access in adults

Joanne Garside, Stephen Prescott, University of Huddersfield, UK

Introduction: From 2010 Resuscitation Guidelines included an in-creased recommendation for the use of the intraosseous (IO) route for administration of drugs and fluids if intravenous (IV) access could not be established (Resuscitation Council, United Kingdom (RCUK), 2010). Although not new, IO as an alternative to IV access suggests a higher profile for its use in adult resuscitation yet a paucity of evidence exists regarding effectiveness and actual implementation of the practice.

Learning outcomes: Following a detailed review of the literature recently published in Nursing in Critical Care (Garside et al. 2015). This oral paper intends to present the evidence base in order to promote awareness of contemporary practices of IO vascular access in adults. The paper will further suggest and debate implications and recom-mendations for critical care practices. The final section will present further research proposals submitted as a result of the literature review publication.

Study design: An exploratory literature review was undertaken using five electronic search engines. The search terms were ‘intraosseous’ and ‘adult’ which were purposely limited because of the exploratory nature of the review. Studies that met the inclusion criteria of primary research articles with an adult focus were included. Further research proposals have been developed.

Results: IO is considered an alternative vascular access route although debate on preferred anatomical site exists; documented practices are only established in pre-hospital and specialist ED settings however vari-ety exists in policy and actual practice. Achieving insertion competence is relatively uncomplicated following minimal preparation although ongoing skill maintenance is less clear. IO is associated with minimal complications although pain is a significant issue for the conscious patient especially when administering fluids.

Conclusions: The evidence base demonstrated that IO route is clearly a valuable alternative to problematic intravascular access. However, further research, including cost effectiveness reviews, is required to gain clarity of whole emergency and critical care approaches.

ReferencesGarside J., Prescott S., & Shaw S (2015) Intraosseous vascular access in critically ill adults – a review of the literature. Nursing in Critical Care. ISSN 13621017 RCUK (Resuscitation Council, UK) (2010) 2010 Resuscitation Guidelines. Resuscitation Council, UK, London. Available at http://www.resus.org.uk/pages/GL2010.pdf

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C03: Factors Influencing Intensive Care Physicians’ Decisions to Intubate and Ventilate Patients with Chronic Obstructive Pulmonary Disease (COPD)

Maria Toshack, Calderdale and Huddersfield NHS Foundation Trust, UK, Moira Tyas, University of Huddersfield, UK, Dr Andrew Breen, Leeds Teaching Hospitals, UK

Background: Chronic Obstructive Pulmonary Disease (COPD) is a progressive, respiratory condition, characterised by partially irreversible airflow obstruction [1, 2], deteriorating lung function, acute exacerbations and worsening quality of life [3]. A wide variation in practice exists regarding decisions to intubate and ventilate patients with COPD, with some physicians considering intubation more readily than others [3]. This causes inconsistencies in the healthcare provided to patients, which can have a significant impact on the equity of patient care.

Introduction: This presentation will discuss the effect of five specific factors on the influence of intensive care physicians’ decisions to intubate and ventilate patients with COPD and explore the perceived and actual variance within those decisions.

Participants: 40 Consultant physicians working in intensive care units within Yorkshire.

Methods: An experimental survey design was used where five variables were manipulated within hypothetical patient scenarios across two versions of a questionnaire. Physicians were asked to decide whether the patients would be suitable candidates from invasive ventilation on ICU.

Results/Conclusions: Four out of the five variables investigated: exercise tolerance / functional status; age; recovery following previous intensive care admissions; and congestive cardiac failure as a co-morbidity significantly influenced intubation decisions. No significant association between long term oxygen therapy and intubation decisions was established. Variability in intubation decisions exists, but not to the extent to which it is perceived to exist by physicians’.

Clinical Implications: If the variability observed in this study occurs in clinical practice, then patient outcomes become affected by physician’s confidence in their decisions. This has significant implications within critical care regarding the equity of patient care. Because of this variability and the potential for an unpredictable assessment, clear national guidance is needed to advise intensive care physicians on which patients are suitable candidates for intubation and ventilation.

References

1. Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2014) Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease [online] Available at: http://www.goldcopd.org/guidelines-global-strat-egy-for-diagnosis-management.html [Accessed 10th January 2014).

2. National Institute for Health and Clinical Excellence (2010a) Chronic Obstructive Pulmonary Disease (Update) Full Guidance: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care [online] Available at: http://www.nice.org.uk/nicemedia/live/13029/49425/49425.pdf [Accessed 13th October 2013].

3. Perrin, F., Renshaw, M., Turton, M. (2003) ‘Clinical Decision-Making and Mechanical Ventilation in Patients with Respiratory Failure due to an Exacerbation of COPD’ Clinical Medicine 3 (5) pp.56-59. [online] Available from: Summon http://library.hud.ac.uk/summon [Accessed 11th November 2012].

4. Saure, E.W., Eagan, T.M.L., Jenson, R.L., Voll-Aanerud, M., Aukrust, P., Bakke,S. and Hardie, J.A. (2011) ‘Explained Variance for Blood Gases in a Population with COPD’ The Clinical Respiratory Journal 6 (2) pp.72-80 [online] Available from: Summon http://library.hud.ac.uk/summon [Accessed 6th February 2014]

5. Wildman, M.J., Sanderson, C.F.B., Groves, J., Reeves, B.C., Ayres, J.G., Harrison, D., Young, D. and Rowan, K. (2008) ‘Survival and Quality of Life for Patients with COPD or Asthma Admitted to Intensive Care in a UK Multicentre Cohort: The COPD and Asthma Outcome Study (CAOS)’ Thorax 64 (2) pp.128-132 [online] Available from: Summon http://library.hud.ac.uk/summon [Accessed 8th November 2012].

6. O’Shea Forbes, M. (2007) ‘Prolonged Ventilator Dependence: Perspective of the Chronic Obstructive Pulmonary Disease Patient’ Clinical Nursing Research 16 (3) pp.231-250 [online] Available from: Summon http://library.hud.ac.uk/summon [Accessed 12th December 2013].

C04: Small Steps = Big Wins

Norah Noel, Natalie Wilson, NHSBT, UK, Paul Glover, BHSCT, UK

Introduction: Organ donation and transplantation is recognised as the only life-saving treatment available for many patients suffering from end stage organ failure and is seen as ‘the modern day success story’1. The Organ Donation Taskforce Report (2008)2 highlighted elements of the donation pathway that required development in order to increase the number of deceased organ donors. Donor identification and referral was one key step identified. The report aimed to make donation usual, not unusual, and establish donation as a routine component of end of life care.

Since 2008, referral rates for deceased organ donation have increased. However, in our Intensive Care Unit, we recognised that

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not all patients who met the criteria as a potential DCD donor were being discussed with the Specialist Nurse for Organ Donation (SN-OD). This was despite NICE recommendations (2011)3 on the use of specific clinical triggers to initiate referrals of potential donors to the SN-OD.

Aim: Improve the referral rates of potential DCD donors to the SN-OD resulting in an increase in the number of organs available for transplantation.

Methods: In response to an EU Joint Action: Achieving Comprehensive Coordination in Organ Donation (ACCORD) (2013) a number of small interventions were introduced into our clinical area. A model for improvement - Plan, Do, Study, Act (PDSA) provided a framework for developing, testing and implementing changes to referral practice in our ICU.

Over a six month period data relating to deaths due to brain-related injuries was collected in ICUs across Europe using an audit tool provided by ACCORD. This data was analysed and each hospital participating in the study was required to identify an outstanding issue and develop a plan to address it. We used the Ishikawa fish bone model to identify barriers to referral of potential DCD donors in our ICU. Following this, a number of interventions were introduced and subsequent referral rates of potential DCD donors to the SNOD were measured.

Results: The referral rates of potential DCD donors to the SNOD have increased from 57% to 89% in our ICU. There is an increased readiness of medical and nursing staff to discuss the possibility of donation with the SNOD, and these conversations are more relaxed and seen as part of routine end-of-life care.

Conclusions: The PDSA approach to problem solving provides a simple framework for addressing identified issues and has proven to be effective in modifying practice in our ICU. The use of the Ishikawa diagram helped to define the problem as it revealed key relationships among the variables and possible factors causing the overall effect. This facilitated the introduction of a number of changes which have had a positive impact on the referral rate of potential DCD donors to the SNOD, resulting in an increase in the number of organs available for transplantation from DCD donors.

ReferencesFrancis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery office.

1. Organ Donation Taskforce (2008) Organs for Transplant: a re-port from the Organ Donation Taskforce, London; Department of Health.

2. Simpson, P.J. (2012) What are the issues in organ donation in 2012? British Journal of Anaesthesia 108(S1);13-6 3. National Institute for Health and Clinical Excellence (NICE) (2011) Organ Donation for transplantation: improving donor identification and consent rates for deceased organ donation. NICE clinical guideline 135.

C05: Tracheostomy Care: Meeting The National Standards

Valerie Poole, Lindsay Harvey, Stockport NHS Foundation Trust, UK

The NCEPOD report ‘On the Right Trach’ Wilkinson, Martin, Freeth, Kelly, & Mason, (2014), reported 25.2% complication rate in tra-cheostomy patients with measurable harm occurring in 60-70% patients. The report identified the scale of tracheostomy related problems and highlighted potential for improvement Rangasami, & Higgs, (2015).

To assess the standard of tracheostomy care within our trust we conducted an audit, which involved 300 members of nursing staff. The results highlighted inconsistencies in staff confidence and knowledge alongside worrying variations in clinical practices that represented a threat to patient safety.

To address these inconsistencies and improve safety, a multi-disciplinary steering group was formed to manage multiple quality improvement interventions on a Trust-wide scale. These included reviewing and rewriting the current tracheostomy policy, organi-sational restructure of designated tracheostomy wards; mandatory tracheostomy training for designated nursing, physiotherapists and junior doctors using high fidelity simulation, emergency tracheosto-my/laryngectomy airway algorithms, workshops and lecture based teaching methods. We have recently introduced tracheostomy link nurses for each of the designated tracheostomy wards, who will play a key part in cascading training and ensuring best practice is adhered to by ward staff.

Furthermore, there are plans to introduce a multidisciplinary tra-cheostomy ward round consisting of Ear, Nose & Throat Consultant, Speech and Language therapist, Head and Neck nurse specialist and respiratory physiotherapist.

The Trust has joined the Global Tracheostomy Collaborative (Ena-mandram, Peltz, Arora, Narula, Roberson, & Hettige, 2014) as part of the SHINE project, an award winning project (McGrath, & Lynch 2014). The SHINE project collects tracheostomy related data which has shown a (Fishers exact two tailed p=0.5708) reduction in the rate of incidents resulting in the most severe types of harm (12.91 vs. 4.96 incidents per 1000 tracheostomy days) across four Trusts. By implementing sustainable interventions (as discussed earlier in the abstract) we aim to reduce tracheostomy related patient incidents and also improve staff knowledge and competence through training and education.

ReferencesEnamandram SS, Peltz A, Arora A, Narula AA, Roberson DW, & Hettige, R. (2014). Global Tracheostomy Collaborative: The Future of Quality Improvement Strategies. Current Otorhinolaryngology Reports, 2 (1), 13-19. McGrath BA, Lynch SJ. (2014) Implementing the Global Tracheos-tomy Collaborative quality improvement project. Retrieved February 6, 2015 from http://www.health.org.uk/areas-of-work/programmes/shine-2014/related-projects/university-hospital-of-south-manches-

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ter Rangasami J, & Higgs A. (2015). Tracheostomy care in 2015: Are we on the right trach?. Journal of the Intensive Care Society, 1751143714567038.

C06: Intra-Abdominal Hypertension - Where Has All The Fluid Gone?

Marcia Bixby, Consultant, USA

Many patients in our critical care, emergency departments and stepdown units have Intra-Abdominal Hypertension (IAH)) that is under recognized and undiagnosed. IAH that is left untreated can lead to Abdominal Compartment Syndrome (ACS)and Multiple Organ Dysfunction Syndrome (MODS). Nurses who understand the physiologic phenomena of cellular dysfunction that leads to movement of fluid to the interstitial space will be better at identifying patients at risk of developing IAH.. This presentation will discuss pathophysiolgy and risk factors of IAH, identification based on measurement of Intra-Abdominal Pressure (IAP) and treatment based on guidelines developed by the World Society of Abdominal Compartment Syndrome (WSACS). Early identification and initiation of evidence based interventions is crucial to preventing multiple organ dysfunction that leads to increased mortality and morbidity.

References Intra-abdominal Hypertension and Abdominal Compartment Syndrome: A Comprehensive Overview Rosemary Koehl Lee, DNP, ARNP, CNS, ACNP-BC, CCNS, CCRNtra- CriticalCareNurse Vol ( 2012) 32, No. 1, Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Medicine. (2013) Volume 39, Issue 7,

C07: Delirium recognition in critical care - an education intervention and evaluation

Shaun Mawhinney, Calderdale & Huddersfield NHS Foundation Trust, UK, Joanne Garside, Andrew Sutton University of Huddersfield, UK

Introduction: Delirium is a syndrome characterised by disturbed consciousness, altered cognitive function or perception which can have many negative outcomes. Delirium is a common yet serious condition affecting a vast proportion of critically ill patients. Incidence rates range from 26% to as high as 81% (Van Den Boogaard et al., 2012; Page et al., 2009; Ely et al., 2004a). Delirium has many serious negative outcomes for patients including lengthening of Intensive Care Unit (ICU) and hospital stays, increased need for intubation, increased length of time spent on a ventilator but significantly associated with the subsequent development of long term dementia (Ely et al., 2001a; Ely et al., 2004a; Jackson et al., 2004; Ouimet et al., 2007). Recognition of the signs and symptoms of delirium is poor despite the critical care nurse being in a unique position to recognise the subtle behavioural and cognitive changes.

Learning outcomes: To promote awareness of delirium recognition and management; therefore this oral paper will discuss an educational strategy and evaluation implemented to support the development of delirium knowledge and skills with a group of critical care nurses.

Methods: The educational intervention focused on the concept of delirium, risk factors, prevention, management and use of the Confusion Assessment Method for the Intensive Care Unit. Educational approaches incorporated a variety of didactic teaching and interactive exercises and application of script concordance theory. Throughout a detailed evaluation using Kirkpatrick’s four stage model was undertaken.

Findings: Although a relatively small sample, evaluation results demonstrated that prior to the educational intervention critical care nurses displayed a significantly lack of knowledge of delirium and the use of assessment tools. Following the educational intervention a significant increase and sustained level of knowledge with application was displayed. In conclusion a multi-factorial educational intervention on delirium can improve the ability of critical care nurses to understand and recognise patients with delirium within critical care.

References Ely W, Gautam S, Margolin R, Francis J, May L, Speroff T, Truman B, Dittus R, Bernard G, and Inouye S (2001) ‘The impact of delirium in the intensive care unit on hospital length of stay’. Intensive Care medicine. 27 pp.1892-1900 Ely W, Shintani A, Truman B, Speroff T, Gordon S, Harrell F, Inouye S, Bernard G, and Dittus R (2004) ‘Delirium as a predictor of mortality in mechanically ventilated patients in the Intensive Care Unit’. The Journal of the American Medical Association. 291 (14) pp.1753-1762 Jackson J, Gordon S, Hart R, Hopkins R, and Ely E (2004) ‘The association between delirium and cognitive decline: A review of the empirical literature’. Neuropsychology Review. 14 (2) pp. 87-98 Ouimet S, Kavanagh B, Gottfried S, and Skrobik Y (2007) ‘Incidence, risk factors and consequences of ICU delirium’. Intensive Care Med. 33 pp.66-73 Page V, Navarange S, Gama S and McAuley D (2009) ‘Routine delirium monitoring in a UK critical care unit’. Critical Care. 13 (R16) pp.1-6Van Den Boogaard M, Schoonhoven L, Van Der Hoeven J, Van Achterberg T and Pickkers P (2012) ‘Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study’. International Journal of Nursing Studies. 49 pp. 775-783

C08: Implementation of ‘Protected Sleep Time’ in Adult Critical Care Units across Lancashire and South Cumbria

Claire Horsfield, Lancashire and South Cumbria Critical Care Unit, UK, Jackie Baldwin, Lancashire Teaching Hospitals NHS Trust, UK

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Background: Patients frequently report disturbed sleep as one of the negative experiences of being in hospital. This is especially the case in the highly technical critical care environment, where noise/light levels and interruptions to patients can remain high overnight due to the intensive monitoring and treatment required by severely ill patients.

Aims and Objectives: A sleep improvement research study, conducted in a large teaching hospital in Spring 2012 (Patel et.al 2014), introduced a bundle of simple, low-cost interventions which improved the quality of patient sleep and halved the incidence of delirium in critical care patients. This project aimed to establish this intervention as best practice across critical care units in the region by promoting the Protected Sleep Time concept.

Methods: A novel implementation toolkit was developed to establish protected sleep time into practice. An animated infographic was developed to educate staff about protected sleep time and an interactive poster designed which played video instructions of the interventions when triggered by smartphones/ipads. To measure the effectiveness of the protected sleep time bundle a programme of audit was developed for use in critical care units across the region.

Results: This toolkit of interventions is being used in 7 critical care units across 4 trusts in Lancashire and South Cumbria. The impact of the “Protected Sleep Time” bundle is currently being evaluated using audit data, including patient experience of sleep and incidence of delirium in critically ill patients.

Conclusion: Through application of a bundle of interventions, there is potential to improve patients’ experience of sleep in adult critical care environments. This can significantly reduce their risks of developing delirium.

NB. The original study (Patel at al, 2014) was presented as a poster at last year’s BACCN conference in Cardiff and this proposal is about roll out across the Network and sustainability.

References Patel, Baldwin, Bunting and Laha (2014). The effect of a multicomponent, multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia. Vol. 69. Pg 540-549 NICE (National Institute for Health and Care Excellence CG 103, 2010). Delirium: diagnosis, prevention and management. https://www.nice.org.uk/guidance/cg103

C09: Audit as a post-registration intensive care nursing course assignment

Heather Baid, University of Brighton, UK

Background: The Intensive Care Pathway is a post-registration, degree level, nursing course with a poster presentation as one of the university assignments. Previously, students designed an educational poster and presented this to a panel of lecturers, nurses, practice educators, managers and doctors. In 2014, students were

given a new option to present a poster based upon an audit they had conducted themselves. The rationale was to link the university assignment with local initiatives for improving patient safety and quality of care and to encourage junior nurses to take a more active role in audits. Aim: The purpose of this presentation is to explore the implications of post-registration intensive care nursing students conducting an audit for a university assignment. The course leader will be the main presenter and other relevant people will be available to answer questions including past students, practice educators and an audit nurse.

Methods: The Plan-Do-Study-Act (PDSA) model (Taylor et al. 2013) was used to systematically prepare, introduce and evaluate the new audit option for intensive care nurses completing a degree level, university poster presentation assignment. Within the ‘Study’ stage of this model, the course leader evaluated the audit option by gathering feedback from students, practice educators, audit nurses, clinical nurses, doctors and managers in addition to her own personal reflection. The ‘Act’ stage involved making changes for the next group of students before initiating another PDSA cycle.

Conclusions: An audit option for a post-registration intensive care nursing assignment provides students with the opportunity to promote patient safety and quality initiatives and to develop auditing skills. However, a significant amount of teaching and guidance on how to conduct an audit and to present audit findings is needed. Recommendations will be made for providing this support from the perspective of students, lecturers, practice educators and audit nurses.

ReferencesTaylor, M.J. et al. 2013. Systematic review of the application of the plan-do-study-act model to improve quality in healthcare. BMJ Quality and Safety 0:1–9. doi:10.1136/bmjqs-2013-001862

C10: Non Invasive Ventilation A safe cluster of care 2 years on our results

John Bell, Chris Summers, UHB NHS Foundation Trust, UK

Working on a 21 bedded adult critical care unit- mixed ICU and HDU we were experiencing very high levels of NIV and CPAP related facial pressure ulcers.

As a result of these incidence we developed a NIV/ CPAP “cluster of care” prescribing a standard of care we expected for all our patients to receive whilst delivering Non Invasive Ventilation. The cluster of care has been running for 18 months now and whilst in 2012

During a period of 8 months in 2012 ,pre cluster of care, there were 1105 hours of NIV/CPAP :97 patients treated. (4 grade 3 pu’s and 6 grade 2 pu’s) circa 9-10% of our patients were developing facial pressure ulcers.

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What we did about this: PDSA cycles, Root Cause Analysis and Clinical Governance led us to belive that we had to remove all facial contact with the patients bridge of nose and distribute the surface contact pressure around the face more evenly.

Now in it’s 5th version the NIV cluster of care has been instrumental in ensuring the following results.

Post the cluster of care during 18 months there has been 5159 hours of NIV/CPAP (314 patients). We have had zero incidence of pu’s associated with NIV/CPAP delivered with our Cluster of Care.

I would like to share these experiences with the BACCN and provide a strong argument for the following

Thorough review of incidentsPEER reviewThink big- we aimed to deliver zero harm for all our patients on NIV and CPAP and have done so consistently for the last 18 monthsInnoviation- use technology to help support effective practice- use of plasma screens and IPODS to indicate when facial pressure area care is required or indicated

ReferencesReferences RCA’s- September 2012 Plymouth hospitals NIV guide 2012 found at: www.plymouthhospitals.nhs.uk/.../vent_Non-Invasive%20Ventilation RCN NIV report 2011- found at: www.rcjournal.com/contents/02.09/02.09.0246.pdf ICS guideline when and how to wean 2007 Found at: www.ics.ac.uk/professional/...guidelines/weaning_guidelines_2007_

C11: How nurses in a cardiothoracic ITU display Courage in response to the 6Cs of Nursing

Esther Pierce, Felicia Cox, Peter Doyle, Royal Brompton & Harefield Foundation Trust, UK

Background: The 6Cs of Nursing (Cummings, 2012) were introduced to raise the standard of patient care in advance of the Francis Report (2013) which reported the patient neglect. The aim of the project was to investigate the responses of the nurses working in the Cardiothoracic critical care unit to different situations in relation to Courage as part of a trust wide initiative to imbed the 6Cs.

Methodology: Following institutional approval this project a postal questionnaire was developed and piloted locally prior to administration and a qualitative focus group was conducted. Responses to individual questions in the postal tool were categorised by Band.

Results: Completed questionnaires (12 questions) were received from 98 out of 122 nurses (80% response rate). Responses related to a consultant being bare below the elbow, highlighting good practice to peers and challenging dangerous practice were statistically significantly different between at least two Bands.Band 7 nurses identified peer support (33.3%) and adverse event reporting (20%) as the most useful tools to challenge practice,

in contrast only 2.3% of Band 5 nurses would report an adverse event. Nurses used a variety of tools to help them act as advocates including training, mentorship, unit culture and the NMC Code of Conduct. Four themes emerged from the thematic analysis of the focus group discussion; Challenging, Practice, Rewarding and Change.

Discussion: Many changes have occurred in response to these results including providing staff with education to better manage challenging situations, the introduction of bay leaders and safety huddles.

Summary: The project highlights the importance of unit culture and bidirectional colleague support to enable nurse to act with courage. Further exploration and promotion or peer support is ongoing.

ReferencesCummings, J. (2012) Compassion in Practice Nursing, Midwifery and Care Staff Our Vision and Strategy. London, Department of Health. Francis, R. (2013) THE MID STAFFORDSHIRE NHS FOUNDATION TRUST PUBLIC INQUIRY - Chaired by Robert Francis. London, The Stationary Office. Report number 2535334

C12: Comprehensive Oral Care Program for Intubated Intensive Care Unit Patients

Abdul-Monim Batiha, Philadelphia University, Jordan Ventilator-associated pneumonia is among the most widespread intensive care unit nosocomial infection; it can be prevented by oral care.

Aim:To explore the impact of implementing American Association of Critical Care Nurses Endotracheal Tube and Oral Care procedure (AACN ETT& OC) on the rate of VAP development in Jordanian mechanically ventilated patients.

Methods: A quasi-experimental design with control group was used.

Results: VAP was found significantly greater among the control group, in comparison to the intervention group (12.5% and 4% respectively, P <0.01). In the intervention group, the VAP rates decreased by 50% and the mean length of mechanical ventilator usage decreased from 7.3 to 5 days. The mean time to start VAP was extended from 2.3 days (in the intervention group) to 4.9 days (in the control group). A significant decrease was found in mortality rates; from 20% (15/72) in the control group to 13.9% (10/75) in the intervention group, P <0.01.

Conclusion: Implementation of this procedure reduces hospitalization, morbidity, mortality and improves quality of care.

Implications for nursing and health policy: The implementation of an AACN ETT& OC can significantly reduce VAP rates, and encourages health policy makers to adapt evidence-based oral and ETT care.

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Keywords: educational program, endotracheal tube, intensive care units, Jordan, oral care, ventilator-associated pneumonia

ReferencesBatiha, A, Bashaireh, I, Albashtawy, M, & Shennaq, S 2012, ‘Exploring the competency of the Jordanian intensive care nurses towards endotracheal tube and oral care practices for mechanically ventilated patients: an observational study’, Global Journal Of Health Science, 5, 1, pp. 203-213. McLellan, B, Kravutske, M, Halash, C, Patten, S, Colpaert, N, Phillips, L, Price, N, & Digiovine, B 2007, ‘A stringent oral care protocol and its effect on VAP in a medical intensive care unit’, American Journal Of Critical Care, 16, 3, p. 306.Soh, K, Ghazali, S, Soh, K, Raman, R, Abdullah, S, & Ong, S 2012, ‘Oral care practice for the ventilated patients in intensive care units: a pilot survey’, Journal Of Infection In Developing Countries, 6, 4, pp. 333-339.

C13: How the use of a clinical information system can facilitate fully automated collection of ICNARC data: improving data accuracy, patient safety and service quality

Nicola Warburton, The Christie NHS Foundation Trust, UK

The collection of data for ICNARC’s (Intensive Care National Audit and Research Centre) Case Mix Programme (CMP) submissions can be a laborious exercise, often retrospectively looking at paper notes and charts. Depending on the size of the Critical Care Unit (CCU), dedicated members of staff are employed to collect and submit the audit information; this may be a mixture of both clerical and nursing staff.

The implementation of clinical information systems (CIS) enhances the potential to streamline and automate the task of collecting such data (Donati et al., 2008).

Through the implementation of MetaVision (CIS) and its accompanying ICNARC module, the CCU has achieved fully electronic, automated and prospective capturing of all data required for ICNARC submissions. Patient information is fed via interfaces from the hospitals electronic patient record (EPR), laboratory systems, electronic noting, e-prescribing and medical devices into MetaVision and then exported to the ICNARC module via intelligent mapping of the required data items. The day-to-day impact on CCU is negligible, with nursing staff often unaware that they are contributing to the national audit. All data is recorded electronically within the CCU CIS, with no paper charting or noting for care or audit purposes.

The implementation of a CIS represents a huge potential time and resource saving for units employing dedicated staff to collect this information, with the further potential for improvements in patient safety, care quality and service improvement as the data is easily accessible for local auditing and benchmarking (Morrison, Jones, &

Bracken, 2013).

Since the implementation of the CIS and ICNARC module, a marked decrease in the number of Data Validation Report (DVR) checks has been evidenced; from 106 checks per 100 admissions in quarter 1 of 2012, to 45 checks per 100 admissions in the most recent DVR, quarter 4 of 2014.

ReferencesDonati, A., Gabbanelli, V., Pantanetti, S., Carletti, P., Principi, T., Marini, B., et al. (2008). The impact of a clinical information system in an intensive care unit. Journal of Clinical Monitoring and Computing, 22(1), 31–36. doi:10.1007/s10877-007-9104-x Morrison, C., Jones, M. R., & Bracken, J. (2013). Clinical Information Systems in Critical Care. Cambridge: Cambridge University Press. doi:10.1017/cbo9781139192729

C14: Utilising Safety Crosses To Reduce Accidental Medical Device Displacements

Dawn Stephenson, Claire Wilcox, Royal Preston Hospital, UK

Introduction: Harm Free Care (HFC) can only be delivered through implementation of measuring systems prompting frontline teams to think differently and develop a safe culture (NHS Safety Thermometer 2014). Accidental displacement of any medical device results in some degree of patient harm. As there was no measuring system in place to capture these incidents, Lancashire Teaching Hospitals Trust implemented the use of a ‘Safety Cross’ to measure Accidental Medical Device Displacement (AMDD).

Aims and Objectives: Safety crosses are part of our performance board review. They are visual tool that allows a real time reflection of patient harms at a glance. It also enables us to examine the incidence of AMDD, discover which measures and actions were required to reduce occurrence and recognise the barriers to change. ‘The devices include intracranial pressure probes (ICP), chest drains (CD), central venous catheters (CVC) and nasogastric tubes (NGT) (this list is not exhausted).

Methodology: Data collection commenced in April 2014. Staff was asked to complete an incident form and the safety cross. Each incident was reviewed by the clinical lead to determine level of harm, duty of candour and appropriate actions post incident. The results were displayed in graph format to aid visual compliance whilst highlighting the most popular device displaced.

Results: The data collated showed varied levels of incidence which is thought to be partly due to the need to drive awareness, the measures implemented and increased compliance. The incidences peaked at 17 per month but have been reduced to 10. The most common devices to be displaced are NGT and CVC.

Conclusion: A Root Cause Analysis form has been developed to aid more detail gathering to determine the cause of the device displacement, level of harm and if delirium was a contributing factor. We are working to encourage all Trusts within our Critical

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Care Network to follow suit so that we can identify common themes with AMDD and to develop further strategies to reduce the risk of further incidents.

References NHS Safety Thermometer, Harm Free Care – A New Mind-set in Patient Safety Improvement, 2010-2015, retrieved from http://harmfreecare.org/measurement, on 8th January 2015

C15: Safer ICU handover

Denise Hinge, Rachael Grimaldi, Brighton and Sussex University Hospitals Trust, UK Introduction: Transfer and admission of a critically ill patient to an ICU environment is a complex process. It requires skilful coordination to ensure the process is managed safely and all key aspects of the patients care are communicated between teams.

This handover is further complicated as teams do not work together regularly. Anaesthetic trainees reported that handover was often chaotic. ICU incident reporting analysis revealed that 13 % of reports were related to communication.

Learning from Catchpole et al. (2007) and the WHO safety checklist (2008) we were inspired to review the patient admission and handover process to ICU and develop a standard operating procedure (SOP).

Methodology: We used a multi-professional team (Outreach, Anaesthestics , Intensivists, Emergency care) to develop a 7 step standard operating procedure including a structured summary of care for handover:

1. Prepare (Transfer checklist)2. Arrival on ICU / HDU (request ICU team at bedside)3. ICU Ventilation established4. Moment of silence : Team member introductions5. Verbal handover: Lead assigns roles for transfer6. Transfer of patient takes place7. Review of observations

An educational film was created to support the implementation of the SOP.

Link: (password = brightonicu) http://vimeo.com/77773303

ICU, ED, anaesthetic and theatre staff were trained and the SOP modified based on feedback. The SOP was launched 2013 on one hospital site and has now been implemented trust wide.

Summary: A structured handover tool improves safety and quality of patient care. It increases staff confidence and satisfaction. The use of simulation is invaluable for testing practical application of a new process and is a powerful education aid.

Successful implementation of a new process requires multi professional engagement, frequent updates (as medical and nursing

staff change) and management support.

“Why haven’t we done it like this all along?” (ICU Nurse feedback)

References 1. Catchpole, K et al. (2007). Patient Handover from Surgery to Intensive Care: Using Formula 1 and Aviation Models to Improve Safety and Quality. Pediatric Anesthesia. 17(5), p. 470-478. 2. .Intensive Care Society (2011) Guidelines for the transport of the critically ill adult (3rd Edition) http://www.ics.ac.uk/ics-homepage/guidelines-and-standards/ [Accessed 5th March 2015] 3.WHO safety checklist (2008) World alliance for patient safety. http://www.who.int/patientsafety/safesurgery/ss_checklist/en/ [Accessed 5th March 2015]

C16: The Role of the Critical Care Network in Delivering High Quality and Safe Critical Care Services

Graham Brant, South West Critical Care Network, UK

Critical Care Networks were established as regionally based collaborative partnerships, enabling clinical services to work together to promote the highest quality critical care services for the regions. The main focus of the Network is adult critical care but links are now being forged with specialised areas providing critical care including cancer, cardiac, neurosciences and renal and paediatric intensive care.

The Network takes a whole system approach to ensuring the delivery of quality, safe and effective services across the regional health community in order to provide valuable expertise, advice and facilitation. This single unified structure has further enabled effective engagement with the clinical pathway groups based on patient flow rather than administrative boundaries, providing a cost effective, safe and sustainable structure throughout England and Wales.

Networks will support the activity of Provider Trusts’ in service delivery, improvement and delivery of a commissioned pathway, with a key focus on the quality and equity of access to service provision. A key role is to act as an advisory body in the development, setting, maintenance and dissemination of, high quality evidence based standards of critical care across the region. This is achieved by use of peer review, quality dashboards and network group meetings and visits. The role of the Critical Care Network has an essential role in ensuring the delivery of high quality and safe critical care services.

C17: Implementation of Intensive Care Outreach: Nurses and Junior Doctors’ knowledge, attitude and practice in risk assessment and responses to deteriorating patients

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Dr. Salizar Mohamed Ludin, Syuhada Fatihah Razali, Kulliyyah of Nursing, International Islamic University, Malaysia

Introduction: Studies shows increasing trends of patients with complex condition and are more likely to be or become seriously ill during hospitalization. Early identification of deterioration warning signs and effective resuscitation during hospitalization are important in ensuring patients’ safety and reduces admission to intensive care setting. This paper is part of a bigger study that aims to examine general ward healthcare providers’ need of ICU outreach services in general wards.

Problem Statement: Over 35.7% of total Malaysian ICU admissions are from the wards and medical wards being the highest in referring cases to ICU (47.4%) in 2013. Nevertheless, the status of healthcare providers’ knowledge in assessing and responding to acutely ill patients in Malaysia is unknown.

Objective: This study aim to determine nurses and junior doctors’ knowledge, attitude and practice (KAP) towards the assessment of patient at risk and their responses prior, during and after the deterioration including knowledge on the emergency pharmacotherapy provided in the medical ward setting.

Methodology: This mixed method study will explore nurses’ and junior doctors’ KAP using survey questionnaire, followed by retrospective case-note analysis on risk assessment prior, responses during and after the acutely ill patients deteriorated. Finally, they will be individually interviewed for experience in care of the deteriorated patients. Purposive sampling will be used to recruit ICU nurses and junior doctors’ from the population (300 nurses and 50 doctors) in three tertiary hospitals. SPSS Version22 will be used for descriptive and inferential data analysis and subsequently interpretation of data for emerging themes using Nvivo10.

Expected Outcome and conclusion: The result will inform us on nurses’ and junior doctors’ KAP on assessment of patients at risk, responses during and after the acute deterioration. Their need on ICU outreach services in general wards will be distinguished to ensure safety and quality in general wards

ReferencesBright , D., Walker , W., & Bion , J. (2004). Clinical review: Outreach - a strategy for improving the care of the acutely ill hospitalized patient. Critical Care, 8:33-40. Carberry, M., & headley, E. (2014). How helpful are early warning scores? Nursing Times, 110(1):12-14. McGloin, H., Adam, S., & Singer, M. (1997). The quality of pre-ICU care influences outcome of patients admitted from the ward. Clinical Intensive Care , 8:104. Oliver, C. M., Hunter, S. A., Ikeda, T., & Galletly, D. C. (2012). Junior doctor skill in the art of physical examination: a retrospective study of the medical admission note over four decades. British Medical Journal, 3:e002257. Patient Safety Alliance. (2010). Aims of the Scottish Patient Safety Programme: NHS Quality Improvement Scotland Year. Retrieved from Patient Safety Alliance: http://www.patientsafetyalliance.scot.nhs.uk/programme/about/aims.

Salizar , M., Noor Azizah , M., Azrina , M., & Basri, M. (2013). The Needs for implementation of ICU Outreach Services at hospitals in East Coast Malaysia: Comparison between ICU and Ward Nurses’ Knowledge, Attitude and Perception. Unpublished Undergraduate Thesis

C18: The challenges of incorporating the ‘National Competency Framework for Critical Care Nurses’ into a ‘Critical Care Nursing’ Course in Northern Ireland

Michelle Scallon, Queen’s University Belfast, UK

In 2012, the National Standards for Critical Care Nurse Education’ were published (CC3N). These standards set out a nationally agreed core curriculum to underpin critical care nurse education and made clear recommendations to support the development of a competent and academically educated nursing workforce. In order to ensure equity of care delivery, essential competencies required for a critical care nurse were identified and set out in a National Competency Framework for Critical Care Nurses ( CC3N, 2013) . This framework identifies three ‘Steps of Competence’ in a progressive pathway. Step 1 competencies should be commenced when a nurse begins working in critical care and should be completed within 12 months. Steps 2 and 3 competencies should be completed as part of an academic critical care programme. The competencies are system based and are designed to mirror the core curriculum outlined in the National Standards for Critical Care Nurse Education.

In Northern Ireland, the School of Nursing and Midwifery at Queen’s University, Belfast offers three academic and practice based education programmes for practitioners working in critical care areas. This presentation will share the experience of developing andimplementing a new ‘Critical Care Nursing’ course which was designed to meet the National Standards for Critical Care Education and incorporate Steps 2 and 3 of the Competency Framework. The first cohort of students will complete the course in June 2015. Studentsand mentors will be surveyed to ascertain their views and experience of the new programme and the results from their evaluations will be presented. It is hoped to use this information to improve the delivery of the programme for the next intake of students on the course and to assist when incorporating Step 1 competencies into a Clinical Skills module designed for those new to critical care nursing.

ReferencesCritical Care Networks National Nurse Leads Group (CC3N) (2012) National Standards for Critical Care Nurse Education; A framework to improve educational outcomes and quality of care. Critical Care Networks National Nurse Leads Group (CC3N) (2013) National Competency Framework for Critical Care Nurses.

C19: The In-house ICU Course Sean Carroll, Cariona Flaherty, Royal Free and Barnet NHS Foundation Trust, UK

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The majority of ICU’s currently have a high vacancy factor at the Band 6 level, the Royal Free ICU team did a route cause analysis of this and found the major factor being a lack of ICU courses to enable Band 5’s to progress to Band 6 on completion and consolidation of the ICU course. We have approx 75 band 5’s all wishing to develop into expert ICU nurses and both funding and availability of the University based ICU course could not fill our demand. Our education team headed by our Head of Nursing investigated the possibility of developing and running a fully accredited (level 6 30 Credits) in house ICU course. A working party was set up and within a 3-4 month time- frame our course was accredited by Greenwich University. The huge task of setting up the programme started, a course curriculum document, course hand book, pre course study work books, study work books, the ICU document work book, reading list, speakers, examination papers, room bookings and not forgetting candidate interviews all needed to take place for the start of the first cohort in May 2015. We have achieved all of the above and have 20 Band 5’s from our ICU’s in Barnet and the Royal Free starting with a considerable amount of excitement from both units.

As a team, we would like to share our achievements with the BACCN at its forth coming conference in London in September as a oral presentation. We would share our curriculum along with hand books and workbooks etc.... We feel this is an exciting development in the world of ICU and others could gain valuable information and follow our lead in setting up in-house courses accredited to local Universities.

ReferencesMay 2014 (NHS Employer) NHS Qualified Nurse supply and Demand findings.

C20: Pedagogic strategies to support practice learning in specialised clinical learning environments: A Grounded Theory Approach Allan Seraj, Royal Brompton & Harefield NHS Foundation Trust, UK Dr Lauren Griffith ARRC, Buckinghamshire New University, UK, Peter Doyle, Royal Brompton & Harefield NHS Foundation Trust, UK

Background: I am a nurse educator working in an Intensive Care Unit (ICU) and I am interested in exploring and understanding the actual or potential impact that learning strategies used in practice will have on the relationship between mentees and mentors, particularly within specialised clinical learning environments.

Methodology: I have used a qualitative, social constructivist, grounded theory (GT) methodology in this doctoral study as it fits with the study’s interpretative perspective and philosophical assumptions.

Method: After obtaining ethical approval, gatekeepers were engaged to gain access, and consent was obtained from

participants who met the study’s inclusion criteria. I conducted semi structured, in-depth taped interviews with 17 mentors and mentees, working in Intensive Care Units and Midwifery areas.

In keeping with the tenets of GT, I systematically coded the interview scripts after each interview using NVivo. Constant comparison enabled me to develop my interview skills and recruit participants until I achieved data saturation (no new properties or any further theoretical insights emerge). I also kept memos through the data collection period to maintain reflexivity, aid with the development of the emerging codes and augment the understanding of the context of the research process.

Data Analysis: GT data handling of the interviews scripts produced five axial codes: two (2) major codes and three (3) minor codes.

Study Outcome: A substantial pedagogical theory has emerged from this study related to the mentoring relationship in specialised clinical learning environments.

Impact of Study: The GT concepts of ‘Fit’, ‘Relevance’, ‘Workability’ and ‘Modifiability’ have been applied in my reflection on the theory’s impact on clinical practice, teaching & learning, epistemology, society, policy development and economics.

The challenges of being an insider researcher, power relations and validity have augmented my development as a reflexive practitioner. I was also able to ‘find my voice’ in the research journey.

ReferencesGlaser, B. (1978). Theoretical Sensitivity, Mill Valley, CA: Sociology Press. Ritchie, J., & Lewis, J. (2010) Qualtative Research Practice. In: A guide for Social Science Students and Researchers. London: Sage Publication, pp.66-69, 73-74. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage Publications, Inc.

C21: Sunshine therapy: an innovative approach to improving the experience of long term ITU patients

Peter Doyle, Agnesia Nikiel, John Hickman, Ana Hurtado, Royal Brompton and Harefield NHS Foundation Trust, UK

Setting: Harefield Hospital is a 150 bed cardiothoracic hospital with transplantation, artificial heart, ECMO and PCI services. Our critical care department consists of 23 level 3, and 10 level 2 beds.

Background: Florence Nightingale (1860) observed that ‘with the sick, second only to their need of fresh air, is their need of light’. This observation has proved to be uncannily accurate with recent evidence demonstrating that light levels can have a positive impact on a range of outcome measures(1). Over a number of years long term patients have been taken out of our ground floor ITU into the hospital grounds. This intervention, known locally as ‘sunshine

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therapy’, is aimed at reconnecting patients with their natural senses and facilitating quality time with loved ones. Anecdotal feedback has indicated that patients and relatives find this intervention to be a positive experience and beneficial to mood and motivation. Methods: In order to investigate the impact of ‘sunshine therapy’ questionnaires were sent to patients, relatives, and nursing staff in order to collect qualitative feedback on the impact of the intervention.

Results: Provisional results suggest that patients perceive this intervention to have beneficial effects on their physical and psychological recovery from critical illness. Full results are pending and will be available for the event.

Discussion: Our results indicate that this intervention has a positive effect on ITU patients’ experiences. As such we believe that, alongside effective risk reduction strategies, this practice should be supported by critical care teams.

What next?: In 2016 we will complete a 6 bed ITU extension. This development includes a bespoke sunshine therapy zone which we hope will expand the numbers of patients able to benefit from this intervention. This outside area will be designed with both patient safety and experience in mind.

References1. Van, R., Elseviers, M., Schuurmans, M. (2009) Risk factors for delirium in intensive care patients: a prospective cohort study. Critical Care; vol.13, no. 3, pp.77.

C22: Planning of a Web Link Project

Sherwin Sinocruz, MTW NHS Trust, UK

Background: The use of health information technology is essential in the daily management of critically ill patients, from the application of evidence-based practice to managing the administrative processes (Reddy et. al 2008). The NHS has significantly invested in this technology, to optimise access of the necessary information at the point of need (Price, Waterhouse and Cooper’s Report DH 2013) thus improving clinical decision-making and practice, to deliver a safe, efficient and effective nursing care. However, planning a web link that will consolidate all the relevant information necessary to deliver an efficient and effective care has been challenging (Doran et al 2012).

Objective: The main objective of this service evaluation is to explore the different factors that affect the management of the implementation of a web link in a two separated ICUs. This information is vital in planning the project brief that will provide skeletal support to this endeavour.

Method: Thematic analysis using NVIVO will be utilised examining data sources which include staff surveys, reflective accounts, email trails, time and motion activities and informal interviews (Bazeley 2007).

Result: The results showed perceived barriers by the ICU staff from availability of physical computers (Eley et al 2008) to the maintenance of the web link (Zadvinskis 2014). In addition, the staffs also specified the potential benefits of the web link project (Jeskey et al 2011). And the last theme relates to the challenges among the project team in collaborating and communicating issues (Szydlowski and Smith 2009) that resulted in unnecessary delays and implementations of specified tasks.

Conclusion: To enhance the degree of success in implementing the web link, the project manager needs to address and mitigate the issues within the project team, mitigate the barriers and actualise the specified benefits.

Action Plan: A Soft System Methodology will be used to plot the results, find relationships and solutions to create a plan to implement, evaluate and monitor this project (Huaxia 2010).

ReferencesBazeley, P. 2007. Qualitative Data Analysis with NVivo. Los Angeles, CA: Sage. Doran, D., B. Haynes, C. Estabrooks, A. Kushniruk, A. Dubrowski, I. Bajnok, L. McGillis Hall, M. Li, J. Carryer, D. Jedras and Y. Qing Bai. 2012. The role of organizational context and individual nurse characteristics in explaining variation in use of information technologies in evidence based practice. Implementation Science 7: 122. Eley, R., T. Fallon, J. Soar, E. Buikstra and D. Hegney. 2008. Barriers to use of information and computer technology by Australia’s nurses: A national survey. Journal of Clinical Nursing 18: 1151-1158.

C23: Development of non-pharmacological intervention for prevention and treatment of delirium in critically ill patients?

Leona Bannon, Dr Bronagh Blackwood, Professor Danny McAuley, Professor Mike Clarke, Queen’s University Belfast, UK

Aims: To develop and test a non-pharmacological intervention for prevention and treatment of delirium in critically ill patients.

Background: Delirium is common in Intensive Care Unit (ICU) patients with incidence up to 74% in the United Kingdom (Page et al, 2009). In ICU, delirium is associated with negative outcomes including increased mortality and morbidity and cognitive & functional impairment (Salluh et al, 2015). Non-pharmacological interventions are beneficial in the prevention and treatment of delirium in older hospitalised patients (Inouye et al, 1999) however there is a lack of evidence on their efficacy in critically ill patients.

Methods: A mixed methods approach will be utilised by:1. Undertaking a systematic review of studies of non-

pharmacological interventions for prevention and treatment of delirium in critically ill patients to identify draft interventions

2. Convening a delirium expert panel and focus groups of experienced critical care nursing staff, ICU survivors and their

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families to review and assess feasibility and acceptability of the draft interventions.

3. Undertaking a feasibility study where interventions are tested in the clinical setting.

Conclusion: A successful intervention relies upon development that utilises opinions of nursing staff, ICU survivors and their families to produce interventions that are not only evidence based but also informed by clinical expertise and experience. Developing complex interventions in this way will help ensure acceptability and sustainability.

ReferencesPage, V.J., Sachin, N., Gama, S., McAuley, D.F (2009) ‘Routine delirium monitoring in a UK critical care unit’. Critical Care. 13 (1) R16Salluh, J.I.F., Wang, H., Scneider, E.B et al (2015) Outcome of delirium in critically ill patients: systematic review and meta-analysis. British Medical Journal. 350: h2538Inouye, SK., Bogardus, ST Jr., Charpentier, PA et al (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine. 4; 340 (9) pp. 669-76

C24: Reduction in pressure ulcers and incontinence associated dermatitis in Adult Intensive Care Unit

Irena Pukiova, John Radcliffe Hospital, UK

Introduction: Critically ill patients are at increased risk for pressure ulcers (PUs), which are associated with increased morbidity and mortality. Patients in the intensive care unit (ICU) have multiple factors that increase the risk of PUs. Patients often have equipment, multiple devices, and the infusion of vasoactive agents for hypotension that may contribute to difficulties with repositioning and increase the risk of PU development.

Incontinence associated dermatitis (IAD) is defined as “an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin.” Patients with IAD have a 5 times higher risk for PU development.

The objective of this quality improvement initiative was to reduce the incidence of PUs and IAD by identifying areas for clinical improvement and evidence-based prevention, and increasing knowledge and compliance with preventative strategies in the ICU.

Methods: Six components of care were studied and enhanced to effectively reduce PUs and IAD. These included documentation, Tissue Viability Nurse ward rounding, education and teaching, validation of data, financial investment metrics, and implementation of a standardized incontinence cleansing protocol. The effectiveness of QI efforts was measured through validated data collection on a weekly basis for one year.

Results: The incidence of PUs, especially grade II and mucosal PUs showed a reduction from the historical baseline. Pre-implementation, the average monthly IAD rate was 10%.

Post-implementation, the average monthly IAD rate was 2.5%, representing a relative reduction of 75%.

Conclusion: The QI initiative was successful in reducing the incidence of PUs and IAD in high-risk critically ill patients. We attribute this success to team collaboration, standardization of the incontinence cleansing protocol, and analysis and dissemination of metrics associated with QI efforts.

ReferencesKaitani, T, Tokunaga, K, Matsui N, Sanada, H 2010, ‘Risk factors related to the development of pressure ulcers in the critical care setting’, Journal of Clinical Nursing, vol. 19, pp. 414-421. Alderden, J, Whitney, JD, Taylor, SM, Zaratkiewicz, S 2011, ‘Risk profile characteristics associated with outcomes of hospital-acquired pressure ulcers: a retrospective review’, Critical Care Nursing, vol. 31, pp. 30-43. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

C25: An Evolution of Critical Care Research

James Cullinane, Claire Pegg, Catherine Plowright, Medway Maritime Hospital, UK

The Critical Care Research Team (CCRT) was established through the joint efforts of both the Critical Care Consultant Nurse and the Senior Management Team. The aim of the CCRT is to promote, implement and support research within critical care.

The first trial this ICU was involved with was a randomised controlled trial called TracMan in 2004. Since then there have been numerous trials ranging from other RCTs to qualitative research, cohort studies, observational studies and now our first CTIMP. The evolution of the team has been such that we have now been approached by sponsors to implement various research studies based on our research performance.

This presentation will look at how we effectively moved from our first study to introducing our first CTIMP trial. We will look at the areas we did well in and the areas in which we could improve. We will highlight the difficulties and challenges we faced during set up of trials. There is limited literature on the implementation and evolvement of a critical care research team (Albert & Siedlecki, 2008; Camsooksai, Barnes & Reschreiter, 2013) and we anticipate that this presentation will highlight to other critical care teams the challenges of developing research in order that they can set up studies more effectively, recruit higher patient numbers meaning that patients receive the best evidence-based care. This is fundamental because as nurses we must always make sure we “practice in line with the best available evidence” (NMC, 2015).

ReferencesAlbert, N. M. & Siedlecki, S. L. (2008) Developing and Implementing a Nursing Research Team in a Clinical Setting. Journal of Nursing Administration. 38(2), pp. 90-96.

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Camsooksai, J., Barnes, H. & Reschreiter, H. (2013) Critical care research in a district general hospital: the first year. Nursing in Critical Care. 18(5), pp. 229-235. The Nursing and Midwifery Council (NMC) (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC: London.

C26: Anxiety and Depression following Critical Illness. A 5 year review of HADS Screening by the ICU Follow Up Team

Natalie Mason, Daniel Conway, Donna Egan, Scott Hendry, Central Manchester University Hospitals NHS Foundation Trust, UK

Introduction: The psychological impact of critical illness can be severe and long-lasting affecting both patients and their families (1,2). Our ICU Follow-Up service assesses all patients within 72 hours of ICU discharge for psychological distress and rehabilitation needs. We use the Hospital Anxiety and Depression Score (HADS) which has a cut-off for anxiety or depression of ≥ 8/21 and significant anxiety or depression cut-off of ≥12/21 (3). We present the year-by-year HAD screening for ICU survivors following discharge to the ward.

Methods: All patients discharged from critical care are interviewed. Patients can complete the printed HADS alone, or supported by a team member. The completed HADS forms are then transcribed into a purpose designed database. Patients who score ≥ 8/21 for either Anxiety or Depression are offered appropriate support. HADS scores are repeated for those with initial high scores. We analysed HADS for all patients within 72 hours of critical care discharge.

Results: 1317 patients HADS were recorded. The median initial HAD Anxiety score was 5 (IQR 2 to 8) with 474 patients scoring ≥ 8/21 and 208 scoring ≥12/21. The median initial HAD Depression score was 6 (IQR 3 to 9) with 550 patients scoring ≥ 8/21 and 242 scoring ≥12/21. Figure 1 demonstrates initial HAD in consecutive years.

Discussion: Around 36% of patients will screen positive for anxiety, and 41% depression in the days following ICU discharge with some patients scoring with both. Most of these patients received support from the Follow up team.

Conclusion: Monitoring psychological distress reveals high levels of depression and slightly lower levels of anxiety at initial ICU discharge. Due to the limits of this observational audit, it is not possible to say how much changes in ICU practice have contributed to the slight increase in initial mental health morbidity following critical illness.

ReferencesInvestigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study (2012) Dorothy M Wade, David C Howell, John A Weinman, Rebecca J Hardy, Michael G Mythen, Chris R Brewin, Susana Borja-Boluda, Claire F Matejowsky, Rosalind A Raine. Critical Care; 16:R192. Young E, Eddleston J, Ingleby S, Streets J, McJanet L, Wang M, Glover L (2005) Returning home after intensive care: a comparison

of symptoms of anxiety and depression in ICU and elective cardiac surgery patients and their relatives. Intensive Care Med; 31:86-91.

C27: Intensive and critical care nurses’ views on the practice of family presence during resuscitation: Outcomes of a literature review

Dr Wendy Walker, Mrs Catherine Gavin, University of Wolverhampton, UK Introduction: The practice of family presence during resuscitation (FPDR) has stimulated discussion and debate among healthcare teams worldwide. Research has revealed a diversity of staff opinions concerning the implementation of FPDR, particularly in the context of emergency care (Walker 2008). This presentation provides insight into the viewpoint of intensive and critical care (ICC) nurses through a review and synthesis of published research. We demonstrate application of review findings to inform the development of an educational intervention involving simulated FPDR.

Methods: We carried out an electronic search of four databases and manually searched the reference lists of publications applicable to the review. Study selection was aided by a review of abstracts and the application of pre-determined criteria. We included research carried out in environments external to intensive care, thus acknowledging care of the critically ill in a variety of settings. Studies involving participant data triangulation were excluded if it was difficult to discern the discrete opinions of ICC nurses. Findings: Nine studies met the inclusion criteria. Research primarily originated from Europe. Overall, there appeared to be a relationship between nurses’ attitudes toward FPDR and their experience of this practice. A lack of unit/departmental guidelines and conflict in team decision-making was apparent. A wide range of factors inhibited FPDR and nurses’ perceptions were weighted toward concerns about the risks.

Conclusion: Most ICC nurses’ views of FPDR are based on conjecture. Attitudinal change could be achieved through structured implementation of FPDR in accordance with policy guidelines. Interprofessional simulation presents opportunity for learning in a safe and controlled way and should be considered for the mastery of knowledge and skills concerning FPDR.

ReferencesBaker C. Pulling, C. McGraw, R. Dagnone JD. Hopkins-Rosseel D. Medves J. (2008) Simulation in interprofessional education for patient-centred collaborative care. Journal of Advanced Nursing 64(4), 372-379. Royal College of Nursing (2002) Witnessing resuscitation: Guidance for nursing staff. London: RCN. Walker W. (2008) Accident and emergency staff opinion on the effects of family presence during adult resuscitation: critical literature review. Journal of Advanced Nursing 61(4), 348-362.

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C28: Incorporating In Situ Simulation to Improve Interdisciplinary Teamwork

Melissa Pollard, Mike Nickerson, Exeter Hospital, USA

Low volume, high stakes emergencies are those that are rarely encountered, cause the most stress and indecision, and have significant impacts to patient safety. Preparing interdisciplinary teams to work together in these situations presents many challenges; including engagement, creating a realistic situation, and the ability to process improve before an actual event occurs.

Simulation allows for training to take place in a safe and realistic environment. Scenarios can be developed using anticipated concerns, potential emergencies, or those previously encountered by clinical staff. The simulation allows staff to identify strengths and areas for improvement and repeat the scenario until they feel successful and confident in the required skills. Post-scenario debriefing allows for the development of communication skills, role clarification, collaborative practice, and improved critical thinking for the situation encountered.

Our simulation program brings emergency simulations into our critical care areas to promote teamwork in caring for a simulated critically ill patient, developing an emergency that is unusual, and to promote interactions with ad hoc teams of professionals who rarely work together in a stressful situation. The use of the in situ environment brings the education to the clinical staff. By operating in the actual environment they have the opportunity to practice technical skills, critical thinking, and use the equipment available in their area. This also offers a realistic assessment of what other critical resources may be needed.

This presentation will explore the development of this program and ways to adopt this methodology in a cost effective manner that yields benefits to patient safety.

ReferencesHamman, W.R., Beaudin-Seiler, B.M., Beaubien, J.M., Gullickson, A.M., Orizondo-Korotko, K., Gross, A.C., Fuqua, W., & Lammers, R. (2010). Using in situ simulation to identify and resolve latent environmental threats to patient safety: Case study involving operational changes in a labor and delivery ward. Quality Management in Healthcare. 19(3), 226-230. Weinstock, P., & Halamek, L. P. (2008). Teamwork during resuscitation. Pediatric Clinics of North America, 55, 1011-1024. Wilson, K. A., Burke, C. S., Priest, H. A., & Salas, E. (2005). Promoting health care safety through training high reliability teams. Quality and Safety in Health Care, 14, 303-309

C29: The Critical Illness journey- a parallel experience for survivors and family members Pamela Page, Anglia Ruskin University, UK

Introduction: The missing voice of the critically ill has been highlighted by Rier (2000). Whilst physiological survival of the critically ill is a driving imperative there is a heightened awareness of the psychological, cognitive and physiological sequelae that may follow survival. Liminality may provide a theoretical lens to view the parallel realities of survivors and family members.

Method: Utilising Constructivist Grounded Theory, cycles of constant comparative data have been collected from survivors of critical illness and their relatives. Substantive or formal theory may develop that accounts for data and context variations. IRAS and NHS Trust R&D approval granted.

Findings: Analysis of 16 patient and 15 relative interviews is ongoing but emergent focused codes include: (1) Ambiguous Loss (2) Disruption of relationships (3) Dreams and hallucinations (4) Critical junctures (5) Facing mortality. A core category of parallel realities may be linked with the anthropological theory of liminality.

Practical relevance: The concept of “survivorship” -moving from surviving to thriving is a driving imperative in critical illness journey (Hart 2014). Rehabilitation starts IN Critical Care and this study may provide insights into the journey from surviving to thriving from a sociological perspective.

ReferencesHart,N. 2014 Therapeutic and Rehabilitation Strategies in ICU in The Legacy of Critical Care –Textbook of Post-ICU medicine, Oxford University Press Rier, D.A., 2000 The missing voice of the critically ill: a medical sociologist’s first person account. Sociology of Health & Illness Vol. 22, No 1, p68-93

C30: Should we recruit newly qualified nurses into ICU? An online survey

Dean Whiting, Claire Kane, University of Bedfordshire, UK, John Albarran, University of the West of England, UK

Background: The recruitment of newly qualified nurses into Intensive Care Units (ICU) has been a subject of professional debate, although not an area fully explored in the professional literature. Anecdotal evidence indicates that some ICUs in the United Kingdom (UK) are resistant to employing newly qualified nurses. It is argued that newly qualified nurses should gain a minimum of one to two years of clinical experience in other clinical areas before applying for a post within ICU. Other units have a more open approach to recruiting and employing newly qualified nurses, who on appointment are well supported in the transition process by well-established preceptorship programmes (Gohery and Meaney, 2013, Juers et al., 2012). Considerations to the scale of this division and analysis of the challenges of ensuring a sustainable workforce in ICU should be explored.

Aim: To investigate the current practice and range of views on recruiting newly qualified nurses into intensive care units in the

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United Kingdom.

Design: An online survey was emailed to nurse members (n=1545) of the British Association of Critical Care Nursing members with a registered email address.

Results: 205 participants completed the survey between September and October 2014. 45.3% (n=93) participants opposed the concept of employing newly qualified nurses into ICU. 30.7% (n=63) felt it was appropriate and 13.6% (n=28) were unsure. Five broad themes emerged from qualitative analysis and captured the participant’s perspectives of recruiting newly qualified nurses into ICU. These included: ‘ICU as a niche area’, ‘Need to develop basic skills’, ‘Communication’, ‘Insight into Wider Healthcare Settings’ and ‘Support and Teaching’.

Conclusion: Debate remains about whether newly qualified nurses should be employed in ICU’s. ICU’s who engage in this recruiting practice often have established training teams and educational pathways dedicated to supporting new starters. The high acuity of caring for the critically ill patient demands excellent nursing care. The themes raised in this study support the requirement for excellent nursing care and suggest a period of nursing skill consolidation in the wider hospital context.

ReferencesGohery P & Meaney T (2013). Nurses’ role transition from the clinical ward environment to the critical care environment. Intensive and Critical Care Nursing; 29: 321-328. Juers A, Wheeler M, Pascoe H, Gregory N & Steers C (2012). Transition to intensive care nursing: A state-wide, workplace centred program—12 years on. Australian Critical Care; 25: 91-99.

C31: The use of patient/family diaries in the Critical Care Unit: interviews with patients

Dr Natalie Pattison, Geraldine O’Gara, Royal Marsden NHS Foundation Trust, UK

Introduction: People who survive critical illness take time to recover physically and psychologically. The use of a diary with entries by nurses, doctors, AHPs and/or patient’s family can potentially help by “filling in gaps” and make sense of time that patients have forgotten, or feel confused/have fears about (Jones et al, 2010). Objectives: The study aimed to qualitatively explore and describe the long-term effects of critical care diaries on patients around the UK. Methods: The interviews formed the first phase of a larger, longitudinal mixed-method study. Long-term effects of critical care diaries were evaluated by interviewing people who had been discharged from critical care units across the UK, and who had received diaries within 1-3 years previously. Participants were recruited via critical care charity websites. Interviews were carried out using in-depth telephone or, where preferred, email interviews, which can yield rich data (Pattison et al 2015). Data were collected

from May 2013-Sep 2014 and subsequently informed questionnaire development and diary intervention for Phase Two. Interviews were audio-recorded and transcribed. Results to date: Eight participants were recruited. Emergent themes included: Being fought for; Vulnerability in a safe place; Disbelief at survival; Continuing burdens of CCU experience; Expectations vs actual recovery; Impact of diary on recovery. An over-arching theme of Ongoing lack of control was identified. All participants reported value in having diaries; some were reliant on them for processing the events in critical care, having gone on to develop PTSD. However, not all wished to revisit them after first reading. This data informed development of Phase two of the study, which is currently underway. Conclusion: Diaries can offer a means of filling gaps for patients who struggle with coming to terms with critical care recovery, however might not be suitable for everyone.

ReferencesJones C, Backman C Capuzzo M et al (2010) Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Crit Care. 14(5):R168 `Pattison N, O’Gara G, Rattray J. (2015) After critical care: Patient support after critical care. A mixed method longitudinal study using email interviews and questionnaires. Intensive Crit Care Nurs. 2015 Mar 3. pii: S0964-3397(14)00126-8. doi: 10.1016/j.iccn.2014.12.002. [Epub ahead of print]

C32: Supporting critically ill patients after hospital discharge: what information do GP practice staff need?

Dr Suzanne Bench, Dr Andreas Xyrichis, King’s College, London, UK

Introduction and background:This paper presents the findings of an exploratory study; seeking the views of patients, relatives and GP practice staff in England about the discharge information GP practices require from critical care staff to support successful rehabilitation after critical illness.Understanding how patients and their families can be best supported after hospital discharge has been identified as one of the top three research priorities for adult critical care (JLA partnership 2014). In line with NICE (2009), Wong & Wickham (2013) recommend that all ICUs should routinely provide discharge information to GPs. Ensuring the information provided meets the needs of patients, their relatives and the GP practice staff who will be receiving it, is a matter of critical importance.

Design and method:This study uses a qualitative design, consisting of focus groups, complemented by semi-structured interviews. In collaboration with the ICUsteps charity, patients and relatives from England, and GP staff (doctors and nurses) from one clinical commissioning group in London (n=45 GP practices) were recruited. Focus groups with each set of stakeholders explored the views about the information

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required by GP staff and the information that is currently received. Qualitative data were imported into Nvivo and underwent an inductive process of thematic analysis. This study received funding from the Faculty of Nursing & Midwifery, King’s College, London.

Results, discussion and conclusion:Data collection took place March-May 2015. The presentation will report sample characteristics and key themes identified from the qualitative analysis. Findings will be discussed in light of their implications for optimizing critical illness recovery post hospital discharge.

ReferencesJames Lind Alliance (JLA) Priority Setting Partnership (2014) Top priorities for Intensive Care Research. Retrieved from http://www.ics.ac.uk/icf/james-lind-alliance/intensive-care-research-top-priorities/ on 20th January 2015. National Institute for Health and Clinical Excellence (NICE) (2009) Rehabilitation after Critical Illness. Retrieved from http://www.nice.org.uk on on 20th January 2015. Wong D. & Wickham A. (2013) A survey of intensive care unit discharge communication practices in the UK. Journal of the Intensive Care Society 14 (4), 330-333.

C33: Project Presentation on Implementation of CAM-ICU in a General Intensive Care Unit

Sinimol Jence, Makan Singh, Wendy Navarro, St Georges Hospital Tooting, UK

Delirium is associated with poor outcomes in terms of cognitive impairment, prolonged intensive care stay and mortality. Therefore early detection is important as it allows supportive care and treatment for reversible causes to be put in place as quickly as possible (NICE 2014).

The main aim of this project was to implement CAM-ICU tool in GICU. For this purpose, the project was planned in several steps. A delirium group was formed who assessed the nurses on their knowledge and assessment of delirium in ICU by distributing a questionnaire which was designed locally. 74 nurses completed the questionnaire between 2nd and 29th of June 2014. This was followed by formal teaching on the use of CAM-ICU tool from 28th July to 24th of August 2014. The CAM-ICU complete training manual from www.icudelirium.org website was used for implementation. Six months following the implementation, nurses’ knowledge and assessment of delirium was re-audited using the same questionnaire. 62 nurses completed the post education questionnaire between 23rd February and 22nd March 2015. Data was collected anonymously and the sample included nurses of all grades with varying years of experience who volunteered to complete the questionnaires. Audit results showed that CAM-ICU tool awareness among staff improved from 51.4% to 95.5%. There was also improvement in the awareness of delirium (91.9% to 100%), development of delirium during critical illness (90.5% to 92.6%), risk factors for developing delirium (97.3% to 98.5%) and motoric subtypes of delirium (75.7% to 77.8%). On the other hand,

31.6% of nurses failed to identify CAM-ICU features correctly. Further ongoing teachings are designed.

A delirium checklist was compiled for doctors to use on patients who are recognised as CAM-ICU positive. A guideline on the use of CAM-ICU tool was added to the unit protocols. Another audit on nurses’ compliance of the tool is planned.

ReferencesNational Institute for Health and Clinical Excellence (2014) Delirium NICE quality standard 63 London: NICE.

C34: Improving Delirium Awareness and Prevention

Laurie Murray, Melissa Pollard, Mike Nickerson Exeter Hospital, USA

Delirium is defined as a disturbance in level of consciousness, with a noted change in cognition, that develops over a short period of time (hours to days) and fluctuates over the course of a day. Delirium is often present after use of anesthesia, sedation, and in ICU patients. It is generally largely under diagnosed in the inpatient population. The longer a patient is delirious, the higher impact it has on their first year post discharge and the consequences of the long-term impairment affect a patient’s ability to function and remain independent. A patient that experiences delirium is associated with a dramatically higher six month mortality rate, a greater duration of mechanical ventilation, and a longer hospital length of stay than a patient without delirium. Research has shown that the implementation of a standard delirium assessment tool and treatment policy promotes early detection of delirium allowing for use of appropriate interventions and treatment. Successful early detection and treatment of delirium decreases a patient’s hospital stay, risk of mortality, and long term cognitive deficiencies.

At our facility, a nurse driven policy using CAM-ICU was created and implemented in the Intensive and Progressive Care Units, followed by implementation of the bCAM on the medical surgical units. The CAM tools increase the level of awareness of delirium through education of nurses and medical providers giving a providing an objective tool for discussion and planning. Nurses were educated on delirium epidemiology and symptoms as well as techniques to prevent and manage the disease, since nurses have the ability to provide patient education on an ongoing basis. Based on current evidence based practice and our experience, the more educated the nurse is as to the symptoms and management techniques, the better equipped he/she is to provide timely education to the patients/family and raise awareness of delirium and it’s different presentations. Follow up research into secondary effects, such a decrease in falls, is being conducted.

ReferencesAllen, J., & Alexander, E. (2012). Delirium in the Intensive Care Unit. AACN Advanced Critical Care, 23(1), 5-11. doi:10.1097/NCI.0b013e31822c3633 Pun, B. T., & Boehm, L. (2011). Delirium in the Intensive Care Unit. AACN Advanced Critical Care, 22(3), 225-237.

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doi:10.1097/NCI.0b013e318220c173 van Eijk, M., & Slooter, A. (2010). Delirium in intensive care unit patients. Seminars In Cardiothoracic & Vascular Anesthesia, 14(2), 141-147. doi:10.1177/1089253210371495

C35: Care Of Patients Connected With Intra- Aortic Balloon Pump

Tharwat Ibrahim Rushdy, Warda Youssef Mohammed Morsy, Hanaa Ali Ahmed Elfeky, Faculty of Nursing, Cairo University, Egypt

Background: Intra-aortic balloon pump (IABP) is the first and the most commonly used mechanical circulatory support for patients with acute coronary syndromes and cardiogenic shock. Therefore, critical care nurses not only have to know how to monitor and operate the IABP, but also to provide interventions for preventing possible complications.

Aim of the study: to assess nurses’ knowledge and practices regarding care of patients connected to IABP at the ICUs of Cairo University Hospitals.

Research design: A descriptive exploratory design was utilized. Sample: Convenience samples of 40 nurses were included in the current study.

Setting: This study was carried out at the Intensive Care Units of Cairo University Hospitals.

Tools of data collection: Three tools were developed, tested for clarity, and feasibility: a- Nurses’ personal background sheet, b- IABP nurses’ knowledge self-administered questionnaire, and c- IABP Nurses’ practice observational checklist.

Results: The majority of the studied sample had unsatisfactory knowledge and practice level (88% & 95%) respectively with a mean of 9.45+2.94 & 30.5+8.7 respectively. Unsatisfactory knowledge was found regarding description and physiological effects, nursing care, indications, contraindications, complications, weaning and removal of IABP in percentage of 95%, 90%, 72.5% & 57.5%, respectively with a mean total knowledge score of 9.45+2.94. In addition, unsatisfactory practice was found regarding about preparation and initiation of IABP therapy, nursing practice during therapy, weaning and removal of IABP in percentages of (97.5%, 97.5% & 90%), respectively. Finally, knowledge level was found to differ significantly in relation to gender (t=2.46, at P ≤ 0.018). However, gender didn’t play a role in relation to practice (t= 0.086, at P≤ 0.932).

Conclusion: In spite of having vital role in assessment and management of critically ill patients, critical care nurses in the current study had in general unsatisfactory knowledge and practice regarding care of patients connected to IABP

Referenceshttp://scholar.cu.edu.eg/?q=Tharwat

C36: During CRRT, Has The use of CVVHDF

When Compared To CVVH Affected The Failed Circuit Life Within A Major Teaching Hospital- a service evaluation

Jody Ede, Andrea Dale, Oxford University Hospital Trust, UK

Aims and Objectives: Premature circuit failure is a significant problem during Continuous Renal Replacement Therapy (CRRT) and this affects the efficacy of treatments. Techniques to improve circuit failure include; circuit anticoagulation, venous access site and/or altering the filtration modality (Shulman et al., 2002; Brophy et al., 2005; Davies & Leslie, 2006; Oudemans-van Straaten et al., 2009; Kishen & Salford Royal, 2009).

The Oxford University Hospital NHS Trust critical care had a changed their Renal Replacement Therapy (RRT) service by predominantly utilising Continuous Veno-venous Haemodiafiltration to improve circuit survival times. The objective of this service evaluation was to ascertain if the change to Continuous Veno-venous Haemodiafiltration (CVVHDF) from Continuous Veno-venous Haemofiltration (CVVH) had affected circuit survival times and rates within this clinical area.

Methods: This was a service evaluation where clinical notes were reviewed before, during and after the service change. In total 78 patients were identified as receiving Continuous Renal Replacement Therapy between May 2011 and January 2012, with a total of 182 circuit failures during treatments.

Results: The median duration of failed circuits during Continuous Veno-venous Haemofiltration was shorter (2.75hrs, SD 13.83hrs) with a 56% failure rate compared to failed circuit duration during Continuous Veno-venous Haemodiafiltration (11hrs, SD 15.26hrs) with a 43% failure rate. These results were analysed using the Wilcoxon Rank Sum Test which showed that a shorter circuit survival time was statistically significant in Continuous Veno-venous Haemofiltration compared to Continuous Veno-venous Haemodiafiltration (p=0.0003 95% CI 2.5-10). Using a Cox Regression analysis, Continuous Veno-venous Haemofiltration appeared to be 1.87times more likely to fail than Continuous Veno-venous Haemodiafiltration.

Key Learning points: The change to Continuous Veno-venous Haemofiltration has had an overall positive effect on the haemofiltration service by reducing the number of failed circuits and increasing circuit survival times. There is a potential for improved responses to Continuous Renal Replacement Therapy by having less interrupted cycles; improving efficiency with less waste of circuits and less nursing time spent troubleshooting.

ReferencesBrophy PD, Somers MJG, Baum MA, Symons JM, McAfee N, Fortenberry JD, Rogers K, Barnett J, Blowey D, Baker C, Bunchman TE and Goldstein SL (2005) Multi-centre evaluation of anticoagulation in patients receiving continuous renal replacement therapy

(CRRT). Nephrology Dialysis Transplantation. 20 (7), 1416–1421.

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Davies H and Leslie G (2006) Maintaining the CRRT circuit: non-anticoagulant alternatives. Australian critical care: official journal of the Confederation of Australian Critical Care Nurses. 19 (4), 133–138. Kishen R and Salford Royal NHS (2009) S Blakeley Portsmouth Hospitals NHS Trust K Bray, Sheffield Teaching Hospitals NHS Foundation Trust.

C37: ERAS+ incorporating iCoughUK. Introducing nurse led interventions to enhance the recovery of major surgical patients within Critical Care

Donna Cummings, Joanna Boorman, Sherly Udeshi, John Moore, CMFT NHS, UK

Introduction: Patients undergoing major surgery and particularly those with cancer are at high risk of complications, with associated morbidity and mortality. Post-operative pulmonary complications are the leading major complication, affecting up to 30% of patients, with a significant impact on patient morbidity and hospital length of stay (Agostini P, et al 2010).

Traditional Enhanced Recovery After Surgery [ERAS] programmes have focussed on ward type care and have shown an impressive reduction in patient length of stay. However, the critical care aspect of a patient’s recovery from major surgery is much less well developed, particularly around the prevention of post-op respiratory complications.

Aim: Using a nurse led service improvement model we aimed to improve the recovery of major surgery patients within critical care with the specific aim of reducing the incidence of post-operative pulmonary complications.

Method: Utilising the Trust’s innovation surgery pathway, ERAS+, we focussed on the critical care aspects of recovery. A MDT development group in collaboration with Boston Medical Centre, USA developed the iCoughUK bundle. This low-cost bundle encompasses lung optimisation, oral healthcare and early mobilisation, and standardises critical care patient recovery after major surgery. Widespread training of the critical care nursing team was undertaken to embed iCough practice. This was supported by regular PDSA which added in a bespoke iCough Prescription, twice weekly compliance audits with weekly feedback to staff and training of patients in a pre-op critical care led innovation ‘Surgery School’.

Results: Over the last 12 months the ICOUGH bundle for major surgical patients has been successfully established within critical care practice in a large university teaching hospital, with compliance levels of 85-90%. Patient satisfaction with the new ERAS+ pathway is extremely high, supported by excellent feedback from pre-op Surgery School. Most importantly this innovation appears to be reducing post-op pulmonary complications.

Conclusion: The ERAS+ pathway incorporating iCoughUK, reduces post-operative patient complications, is easily introduced into critical care and is very well accepted by both patients and staff.

ReferencesAgostini P, Cieslik H, Rathinam S, Bishay E, Kalkat M S, Rajesh P B, Steyn R S, Singh S, Naidu, b (2010). Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax. 65(9):815–8.

C38: Critical Care Nurses Knowlegde Of And Compliance With Physical Restraint Guidelines

Margaret McShane, Kings College Hospital, UK

Background: As delirium had been shown to affect over 30% of ICU patients (Roberts et al; 2006, Salluh et al; 2010), critical care staff face unique challenges when considering the balance of promoting autonomy whilst maintaining patient safety in their best interests. The use of physical restraint has been correlated with higher morbidity and mortality rates, longer hospital stay and increased confusion (Maccioli et al, 2003), so it is imperative that nurses understand how to assess the need for restraint and evidence its use within the relevant legal and professional frameworks.

Aim: To investigate current restraint practices across 3 critical care units in a busy London teaching hospital, specifically nurses knowledge of physical restraint guidelines and compliance with the local assessment tool.

Method: An audit was carried out to obtain data on the use of restraint and compliance with the tool and a questionnaire was used to assess nurses’ awareness of guidelines and documentation.

Results: Initial findings evidenced the need for increased provision of information and raising awareness across the critical care units. Of the 24% of patients with physical restraint applied, 20% had completed the assessment tool and 40% of the nurses were aware of both the guidelines and assessment tool.

Implications for practice: It was evident that increased awareness of Physical Restraint Guidelines and compliance with mandatory documentation was needed in order to ensure safe practice in accordance with the legal and professional guidelines. A newly formatted assessment tool and care plan with key supporting information was developed in conjunction with the Risk Department and Safeguarding team and subsequently launched across the three units. A re-audit will be carried out to evaluate the effectiveness of this intervention in order to ensure patient safety is maintained whilst acting in their best interests.

ReferencesMacciolo G, Dorman T, Brown B, Mazuski J, McLean B, Kuszaj J, Rosenbaum S, Frankel L, Devlin J, Govert J, Smith B, Peruzzi W (2003) Clinical Practice Guidelines for the Maintenance of Patient safety in the intensive care unit: Use of Restraining Therapies – American College of Critical Care Medicine Task Force. Critical Care Medicine, 31(11) pp. 2665-2676. Roberts B, Rickard CM, Rajbhandari D, Turner G, Clarke J, Hill D, Tauschke C, Chaboyer W, Parsons R (2005) Multicentre study of delirium in ICU patients using a simple screening tool. Australian

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Critical Care 18 (1), pp.6-16. Salluh JI, Soares M, Teles JM, Ceraso D, Raimondi N, Nava VS, Blasquez P, Ugarte S, Ibanez-Guzman C, Centeno JV, Laca M, Grecco G, Jimenez E, Arias-Rivera S, Duenas C, Rocha MG (2010) Delirium Epidemiology in Critical Care Study Group: Delirium epidemiology in critical care (DECCA): an international study. Critical Care 14 (6) R210

C39: Evidence-based practice: the relevance of systematic reviews

Jennifer McGaughey, Queen’s University Belfast, UK

Aim: To demonstrate how systematic reviews provide robust evidence to inform clinical decision making in practice.

Background: Systematic reviews collate findings from a number of research studies in order to provide a comprehensive and reliable summary of the best available evidence. The use of systematic reviews to inform practice based decisions has increased as a result of the overwhelming amount of research literature available, poor quality of research evidence and the need to ensure practice is based upon the best available evidence. Systematic reviews are an efficient way of coping with large volumes of data to answer focused research questions. They differ from traditional literature reviews as they adhere to an explicit scientific process. The use of explicit and rigorous methods to identify, appraise and synthesise relevant studies minimises bias and provides a reliable basis for decision making. As a result systematic reviews provide clear evidence on the effectiveness of a healthcare intervention to inform policy and decision making across healthcare systems. An example of how the findings from systematic reviews can provide reliable evidence to inform healthcare decisions will be provided in this presentation1. This will demonstrate how focused clinical questions can be answered by systematic reviews and translated into practice.

References1. McGaughey J, Alderdice F, Fowler R, Kapila A, Moutray M. (2007) Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission admission and death of critically ill adult patients on general hospital wards (REVIEW). The Cochrane Database of Systematic Reviews 3. art no CD005529

C40: BACCN funding to support research: an overview of the process by one successful

Louise Stayt, Oxford Brookes University, UK

C41: Research Symposium: Developing and testing interventions to promote recovery and rehabilitation after critical illnesss

Talk 1: Developing, implementing and testing interventions to improve recovery in survivors of critical illness: an overview of the issues

Dr Janice Rattray, School of Nursing and Midwifery, University of Dundee, UK

Background: Developing and testing interventions to improve recovery after critical illness have been targeted at various stages throughout the recovery trajectory including in ICU, while still in hospital and after discharge from hospital. Intervening in each of these settings presents unique benefits and challenges.

Aim: The aim of this presentation is to highlight the issues and discuss the range of interventions used to improve recovery after critical illness.

Findings: Examples from the literature and our own research work will be discussed during this presentation and symposium. These include in-ICU, hospital and community interventions.

Discussion: Interventions delivered within the ICU include optimising sedation, commencing early mobilisation and preventing delirium. Interventions within ICU has challenges associated with recruitment and informed consent, intervention fidelity and measurement of impact. Interventions delivered in the hospital environment include providing additional rehabilitation through a generic healthcare assistant, and in the community includes the use of a web based resource, and attendance at an ICU follow-up clinic. Challenges during this time include loss to follow up, lack of recall of the critical illness event and importantly lack of pre-ICU status. Interventions delivered in the home environment enable full participation from the patient, however they present challenges in terms of accurate measurement of the ‘dose’ of the intervention and associated outcomes, as well as ensuring a safe work environment for research staff.

Conclusion: Interventions to improve recovery after critical illness and injury may be delivered at multiple time points and in multiple settings, although each option presents different challenges and benefits. Early intervention is frequently preferred, although sustained or repeated intervention may provide additional benefits.

Talk 2: ‘Doing family’: the why and what of care involvement of families in intensive care

Dr Susanne Kean, University of Edinburgh, UK, Dr Kalliopi Kydonaki, Edinburgh Napier University, UK, Dr Jennifer Tocher, University of Edinburgh, UK

Background: Person-Centred Care (PCC) is emphasised in national and international governmental policies and healthcare research. Family involvement in care is an implicit aspect of PCC and contemporary evidence suggests that family members partnering with nurses can provide support, reassurance and comfort to patients. However, what constitutes care involvement in an intensive care setting from the perspectives of families and patients is little explored and understood.

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Focus of this paper: (1) Is the involvement of families in care in ICU acceptable to families and patients? (2) What are the care activities families are willing to participate in?

Methods: Data for this qualitative exploratory study were collected from two ICUs in two tertiary hospitals in Scotland. Semi-structured interviews were conducted with former ICU patients before hospital discharge and adult family members. Data were analysed using thematic analysis strategies. Ethical approval was granted prior to the study.

Results: ‘Doing family’, a dimension of person-centred care that emerged as a major theme across interviews, emphasise relationality in families. Relationality emphasises the connections within families and their desire to maintain (family) normality as well as addressing patients’ emotional support needs. Nineteen former ICU patients and 16 adult family members were interviewed. Eleven of the interviews were paired (patient with one family member).

Conclusions: Understanding the importance of ‘doing family’ as a driver for family involvement in ICU care allows an insight into the why and what of care activities that are acceptable for ICU patients and their families. This, in turn, enhances our understanding for future intervention studies which are truly based on the co-constructed concept of PCC.

Talk 3: Exploring the use of critical care diaries: a qualitative study

Corrienne McCulloch, NHS Lothian/ University of Edinburgh, UK

Background: Diaries are currently used in some intensive care units (ICUs) across Europe and the UK to help patients and families with recovery, following the experience of critical illness. The diary is written from the perspective of the bedside nurse and family members, providing an account of what happened when the patient was in ICU. Research has mainly focused on the diary being used in the recovery phase and findings suggest that the diary can be a useful aid in helping patients and their families come to terms with the experience of critical illness. However the diary is started in the ICU and used by different people during this time.Aim: The aim of this presentation is to report on a qualitative study exploring the use of diaries from the perspectives and experiences of patients, family members and nurses in a Scottish ICU.

Methods: Data were collected through semi-structured interviews with family members, patients and ICU nurses. Family members and nurses were interviewed around the time the patient was in ICU and patients were interviewed between 3 and 6 months post ICU discharge. A total of 16 interviews were completed, 12 of these included a triad of a patient, one family member and a nurse who had looked after them in the ICU. The interviews were supplemented with field notes and photographs of diary entries. Data were analysed using a thematic approach. NHS ethical approval was granted.

Findings: An example of a theme will be presented to demonstrate how the diary can be used by different people in different ways.

Discussion: Exploring the use of critical care diaries from multiple perspectives during and after ICU gives a unique insight into the complexity of how diaries are used at different times and by different people.

Talk 4: The RECOVER Study: Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Discharge

Dr Lisa Salisbury, University of Edinburgh, UK

Background: It is widely recognised that following critical illness patients frequently experience physical impairments, including muscle weakness, fatigue, and other symptoms that lead to delayed recovery. In turn, this results in a reduced ability to carry out basic activities of daily living. In addition psychological issues are often present including anxiety, depression, cognitive impairment and posttraumatic stress further complicating their recovery after critical illness. The RECOVER study was an RCT of a hospital based rehabilitation package delivered to patients between intensive care discharge and discharge from hospital.

Methods: A parallel group, randomised clinical trial with blinded assessment was conducted. Both control and intervention groups received standard ward-based rehabilitation as routinely delivered in the hospital and a self-directed manual. In addition, the intervention group received access to an increased intensity of exercises and mobility practice, increased dietetic assessment and treatment and access to greater illness-specific information. The increased rehabilitation was delivered by a rehabilitation assistant practitioner who worked with the ward-based staff. The primary outcome was the Rivermead Mobility Index (RMI) with a battery of secondary outcomes collected including Health-Related Quality of Life (HRQoL), psychological outcomes, self-reported symptoms and satisfaction. Patient experience was explored in focus groups.

Findings: No differences were found between the control and intervention group for the primary or any of the secondary measures with the exception of the satisfaction measure which found patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support and nutritional therapy plus information support. Interestingly the focus groups found the care delivered in the intervention group was more patient-centred.

Discussion: Post-ICU hospital-based rehabilitation did not improve physical recovery, HRQoL or self-reported symptoms. However, it did improve patient satisfaction in many aspects of recovery and patients experienced a more patient-centred approach to care.

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Talk 5: EPIC: An experientially meaningful website to support recovery after critical illness

Dr Pam Ramsay, NHS Lothian/University of Edinburgh, UK

Introduction: Survival following critical illness is associated with chronic physical and psychosocial morbidity. Reflecting the absence of a dedicated rehabilitative pathway and policy initiatives for shorter hospital stays, patients are discharged from hospital with sometimes significant ongoing morbidity. The vast majority of recovery takes place at home, where patients have little access to specialist professional support.

Aim: Our aim was to develop and pilot a website providing meaningful information (e.g. on common critical illness-related morbidity), advice (e.g. on self-management or available community resources) and support (from other patients, family members and clinicians), accessible throughout the recovery process, including after hospital discharge.

Setting: participants and methods: Website content and media were iteratively developed using (i) a qualitative metasynthesis of >100 interviews with Intensive Care (ICU) patients in three completed studies (ii) sequential focus groups with recovering ICU patients and family members (iii) consultation with ICU clinicians and web developers with expertise in “the user experience”. The completed studies and website development all took place at a large teaching hospital in South East Scotland. Ethical approval was granted by the local Research Ethics Committee.

Results: A prototypal website has been developed, incorporating: examples of “other people’s experiences”; useful websites; links to community resources; and short webcasts by patients and clinicians on relevant topics, all of which can saved in a personalised online “scrapbook”. A real time chat room and forum have also been developed.

Conclusions: This website is among the first e-health interventions designed to support recovery following critical illness. We will iteratively develop and evaluate the website as part of its integration into an existing ward-based ICU follow-up service (NHS funding awarded). Future work includes the development and piloting of secure teleconsultation facilities (for “virtual” clinics); online self-assessment for common morbidity and individualised recovery plans, both with triggers for professional support.

C42: STITCH : Simulation Training and Interprofessional Teambuilding for Critical Care Healthworkers : a new approach to teambuilding

Abigail Beane, Dr Ming Li Kong, Julie Robinson, Royal London Hospital, UK

Project introduction: Cohesive teams are the underpinning foundation of improved patient safety and excellent care. Yet what can be done to build teams if a third of the team is new or on temporary rotation?

To address this challenge on our 44 bedded tertiary referral critical care unit within a major trauma centre, we developed the STITCH program, where mobile simulation, performed on the unit, allows us to test the processes and response in place to manage emergencies; and debrief on human factors.

Project outcomes: Our objective is to improve our quality of care, in particular, during complex emergency situations highlighted through national audits and departmental incident reporting. All members of the critical care team (nursing, medical, physiotherapy and health care support workers) are involved.

Practice-based outcomes include: increased awareness of local and national guidance for specific emergencies, familiarisation for all staff of the clinical environment, including the location and use of technical equipment necessary during time-critical emergencies and highlighting mechanisms to gain senior assistance.

Behavioral outcomes include: improved team working, challenging hierarchy appropriately, communicating effectively during emergencies and promoting dynamic leadership and assertive followership.

Project results and conclusions: STITCH has helped us to improve our teams and service in several ways. Staff report on its utility and ask to be involved in this and other team building activities. A specific learning need around basic airway maneuvers has been identified, and a separate training stream developed. Teams have identified specific behaviors to develop whilst in the workplace. We have consistently received excellent feedback and will continue to use STITCH to consistently improve teamworking and practice in our unit.

ReferencesBion JF, Abrusci T, Hibbert P.(2010). Human factors in the management of the critically ill patient. Br J Anaesth. Jul;105(1):26-33. doi: 10.1093/bja/aeq126. Epub 2010 May 28. Tennant, S, Field, R, (2004). Continuing professional development: does it make a difference? Nursing in Critical Care, 9(4), 167–172.

C43: SCREAM

Majella Dillon, Regional Intensive Care Unit, RVH.Belfast, UK

SCREAM (Standardised Critical Care Resuscitation and Emergency Airway Management) is an intensive one day programme. The programme consists of three stations. Airway station covering normal intubation protocol, drugs and airway adjuncts, Anaphylaxis scenario and “Can’t intubate can’t ventilate” Algorithm.

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The second station is a Breathing station concentrating on emergency scenarios including a) Blocked Endotracheal tube/ Tracheostomy tube, b) Dislodged Endotracheal/ Tracheostomy tube. c) Care of Laryngectomy stoma and ventilation of same d) Management of the Haemorrhagic protocol for massive blood loss.

The Third station is a Circulatory Station, covering Advance Life Support Scenarios and Bradycardia and Tachycardia Algorithms. The overall approach of the programme focused on ABCDE assessment using simulation training incorporating human factors into each scenario.

In March 2015 RICU plan to move to a purpose built Critical Care Unit comprising of 32 single isolation rooms split over 2 floors. The layout of the unit, based on the Griffin Model, will present new challenges for staff in relation to patient safety, particularly in regard to Emergency Airway Management and Resuscitation. This project was created to equip staff with the necessary skills and knowledge to deal safely with emergency situations using a standardised evidence based approach, highlighting the importance of human factors and team work.

In 2014, 144 critical care nurses from the Regional Intensive Care Unit (RICU) in Northern Ireland completed SCREAM. In preparation for the course a SCREAM manual written by Dr Gareth Morrison Specialist Registrar in Anaesthetics was e-mailed to all candidates. A link for an on line MCQ paper was completed by each candidate prior to the course with a pass mark set at 75%. Pre course confidence levels in relation to each of the stations and post course confidence levels were analysed. Results showed a significant difference in candidate’s confidence post SCREAM.

ReferencesCook T, Woodall N and Frerk C 2011 NAPA 4. 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Major Complications of Airway Management in the United Kingdom. Report and findings March 2011 McGrath Brendan 2013 Comprehensive Tracheostomy Care: The National Tracheostomy Safety Project Manual (Advanced Life Support Group) 2013 Published by Wiley Blackwell Wilkinson K A, Martin IC, Freeth H, Kelly K, Mason M June 2014.NCEPOD report 2014 Tracheostomy Care: On the Right Trach? A review of the care received by patients who underwent a tracheostomy. Published by The National Confidential Enquiry into Patient Outcome and Death (2014)

C44: What are the components of a ‘good’ ward round in a large adult critical care unit and how can we make them happen more often? An Appreciative Inquiry Study

Clair Merriman, Oxford Brookes University, PhD Student Queen Mary University London, UK

Introduction: The ward round (WR) and its place in the promotion of quality care is of particular concern in critical care, where the increasing complexity of work demands excellent communication

within the multidisciplinary team and effective ways of organising interrelated interventions of critical ill patients. However, given the high workloads and emotionally and technically demanding nature of work in critical care, the traditional WR may be viewed as too time consuming. This study aims to support WR practice development in a large regional adult critical care unit (ACCU). This presentation will share with the audience findings of the initial phase of the study.

Study Design and Methodology: This research project is an improvement-focused, collaborative mixed methods study of ACCU WR practices, underpinned by Appreciative Inquiry (AI). AI fundamentally asks two questions:

• What do things look like when they are going really well?• How can we make more things go really well, more of the time?

The initial phase of this study was to develop a sufficiently deep understanding of current ACCU WR practices in their complex context to support the identification of good practices and suggestions for practice development. To do this the following data was collected:

• Ethnographic observation of 16 WRs yielding detailed ‘field notes’ for analysis.

• Quantitative observation of WR communication patterns (Bales 1950).

• Six semi-structured interviews with ACCU staff

Furthermore, to provide baseline data ACCU staff were invited to complete the Team Psychological Safety Questionnaire (7 item scale (Edmondson 1999)).

Provisional headline findings: Three interlinked major themes have emerged in the data analysis to date:

• Ward round logistics• Composition of the ward round• Participation of the bedside nurse (BSN)

Each major theme has subthemes and these have undergone further analysis and will be discussed during the presentation using the AI approach.

ReferencesBales, R.F. (1950). A set of categories for analysis of small group interaction. American Sociological Review, 15, pp. 257-263.Edmondson, A. (1999). Psychological safety and learning behaviour in work teams. Administrative Science Quarterly, 44, pp. 350-383.

C45: Mind the Gap - Critical Care Nurse Recruitment in a Large London Teaching Hospital

Lizzy Leighton, King’s College Hospital NHS Foundation Trust, UK

Background: There is a widely recognised shortage of qualified

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nurses throughout the UK and since April 2014, hospitals have been required to publish their staffing levels (NHS Employers, 2014). This has lead to hospitals reviewing their overall staffing levels, indicating how well individual shifts meet the safer staffing guidelines.

King’s College Hospital NHS Foundation Trust is a leading London teaching hospital and a tertiary referral centre for multiple specialties. As a result of increasing demand on capacity, a significant increase in Critical Care beds led to a sudden and detrimental vacancy of nursing staff (29%, June 2014)

Despite continuous advertising and regular interviewing, supply of Band 5 staff nurses was not meeting the demand, resulting in a huge reliance on temporary staffing at huge financial cost. On some shifts, up to 50% (June 2014) of staff were agency nurses, placing additional stress and responsibility on substantive staff.

Method: An outside recruitment agency was sourced and contracted to provide 67 Band 5 nurses in 6 months. Funding was from the departmental budget but substantially less than the overall expenditure on agency staffing.

Results: This innovative recruitment strategy was a huge success and 67 nurses were recruited within the time frame. They did not all have Critical Care skills but all had at least 6 months post-registration experience in an acute setting. The recruitment agency provided administrative support through the entire recruitment process, allowing the Critical Care team to focus on patient care and staff support. The Practice Development team and recruitment agency worked closely together to ensure standards were maintained and the right people were recruited into the role.

Conclusion: The Critical Care Units vacancy has now reduced to 5% and only 7% of shifts use agency staff (Feb 2015). This has resulted in an established workforce providing safe, efficient and skilled patient care.ReferencesNHS Employers (2014) NHS Qualified Nurse Supply and Demand Survey – Findings. NHS Confederation http://hee.nhs.uk/wp-content/uploads/sites/321/2014/05/NHS-qualified-nurse-supply-and-demand-survey-12-May1.pdf

C46: What barriers are there to nurses using the EWS tool to appropriately escalate patients? – A qualitative study

Katie Burns, Nottingham University Hospitals, UK

Background: Early warning scores are used worldwide as a tool to aid identification of acutely unwell patients by nursing staff. They do this by giving a patient a numerical score based upon physiological parameters (McGinley and Pearse, 2012). Early warning scores have been found useful in many settings and can bring about improvements in patient outcomes (Alam, Hobbelink, Tienhoven et al, 2014). Audit data shows that the rate of escalation is low (UK-based Hospital Trust, 2013).

Aims: To gain understanding of why nurses do not use early warning escalation systems appropriately and to investigate barriers to the use of EWS.

Methods: 14 nurses on acute admissions wards, of different bands and experience levels, took part in semi-structured interviews. Interviews took place in February 2014.

Results/Discussion: 3 main themes were brought out in the data: the gap between the expectations and reality of the tool; the use of the tool being dependent upon the experience of the nurse and lack of belief in the specificity and sensitivity of the tool. Nurses often found that escalation was difficult due to lack of confidence, inability to reach staff to escalate to or other members of staff not believing in the tool. With increased experience, use of the tool decreased as nurses became more reliant upon their own knowledge and intuition. Regarding the sensitivity and specificity of the tool, nurses found that they often escalated patients who did not score high enough to trigger the system, and consequently found it difficult to be taken seriously. They also found that some patients with chronic diseases would trigger the system, but felt there was no need for this.

Conclusions: The findings imply that there could be patients at risk of deterioration that are not being escalated. Knowledge of the barriers to using the tool can be made useful in implementing changes in practise, and improved patient outcomes could be anticipated.

ReferencesAlam, N., Hobbelink, E., van Tienhoven, A., van de Ven, P., Jansma, E. and Nanayakkara, P. (2014). The impact of the use of the Early Warning Score (EWS) on patient outcomes: a systematic review. Resuscitation. 85 (5), 587-594. Mcginley, A and Pearse, R. (2012). A national early warning score for acutely ill patients. British Medical Journal. 345 (7869), 9. UK-based Hospital Trust (2013) EWS Audit Report Feb 13 Update. Unpublished

C47: Experiences of Nurses caring for patients with a tracheostomy on medical and surgical wards

Brian McFetridge, Linda McDaid, Sinead O’Kane Western Health and Social Care Trust, UK

Background: Use of tracheostomy tubes within critical care is common with many patients being transferred to general wards with the tracheostomy still in place. The NCEPOD (2014) report ‘On the right trach’ highlighted challenges experienced in the pathway of a patient with a tracheostomy. While literature relating to the physical care of patients with a tracheostomy is available, there is little research into the experience of nursing staff caring for these patients.

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Aim: To explore the experience of nurses on medical and surgical wards in caring for patients with a tracheostomyMethods: A qualitative methodology using semi-structured interviews was used with core questions based upon available literature. Ethical approval was granted. Interviews were recorded; transcribed and thematic content analysis used to review the data. 16 nurses reflecting a range in years of experience attended for individual interview.

Results: Participants shared very meaningful experiences relating to their care of patients with a tracheostomy. The following themes were identified highlighting the importance that knowledge, skills and experience can have in supporting care of these patients, while maintaining a holistic approach.

‘Fear and anxieties associated with caring for a patient with a tracheostomy’,

‘The value of support when caring for a patient with a tracheostomy’,

‘Experience: developing confidence and reducing anxieties’,

‘Training as a cornerstone for patient care’, and

‘Caring for the patient, not just the tracheostomy’.

Alongside these themes, participants also identified the core skills and information, they find beneficial in support of these patients.

Conclusions: These findings provide a valuable insight into the context of care which nurses experience and to the various factors they face in providing care to a patient with a tracheostomy. These

findings can be used within clinical practice and by educators in support of training and delivery of safe, effective and patient centred care.

ReferencesMcGrath BA, Thomas AN. (2010) Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgrad Med J. 86(1019):522-5. National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2014) On the Right Trach? A review of the care received by patients who underwent a tracheostomy. NCEPOD, London.

C48: Impact of a Designed Nursing Intervention protocol on Myocardial Infarction Patient’s Outcome

Abdelhameed Mahros, Warda Youssef Mohamed, Yousria Abd El-salam Seloma, Hanan El-sayed Zaghla, Faculty of Nursing, Cairo University, Egypt

Background: Myocardial infarction is a life threatening disease that

influences the physical, psychological and social dimensions of the individual. Improper lifestyle is one of the causes of this disease. The designing and implementing of nursing intervention protocol for MI patients could be one of the important and fundamental steps in improving MI patients outcomes.

Aim: The aim of this study was to examine the impact of a designed nursing intervention protocol on myocardial infarction patient’s outcomes as indicated by higher post total mean knowledge scores, higher post total mean practices scores and high level of compliance to lifelong instruction.

Research hypotheses: H1. Patients who will be exposed to a designed nursing intervention protocol will have a higher post total mean knowledge scores; H2. Patients who will be exposed to a designed nursing intervention protocol will have a higher post total mean practices scores; H3. Patients who will be exposed to a designed nursing intervention protocol will have a high level of compliance to lifelong instruction.

Design: A quasi-experimental research design was utilized in this study

Sample: A convenience sample of 40 adult male and female MI patients.

Setting: The cardiac care units at a selected Cairo University Hospital were recruited to fulfill the aim of this study.

Tools: Four tools were formulated& tested to collect data pertinent to the study; Socio-demographic and medical data sheet, Pre/Post knowledge questionnaire sheet, an Observational checklist and Compliance assessment sheet. Structured interview, reviewing medical records and direct observation were utilized for data collection.

Results: The study results revealed that the post total mean knowledge scores of the studied subjects is increased significantly with value of t= 20.6 at p=0.000, higher post total practice scores among the studied subjects with t& p values (t=5.6 at p= 0.000 ) also, studied subjects had mild to high compliance level regarding the lifelong instructions.

Conclusion: It can be concluded that, enrichment of patients’ knowledge and practices in relation to their condition and utilization of the effective nursing intervention protocol as an approach of care could have a positive impact upon improvement of patients’ outcome.

Recommendations: The study recommended Conduction of further studies in order to assess the effectiveness of the designed protocol on patients’ outcome regarding different cardiac disorders with replication of this study on a larger probability sample from different geographical locations at the Arab Republic of Egypt, in addition to establishment of cardiac rehabilitation center in the different heath care organizations

Referenceshttp://scholar.cu.edu.eg/?q=abdelhameed/files/8935-11118-1-pb.

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pdfC49: A New Model for Obstetric Critical Care: Introducing Critical Care Nurses into the Central Delivery Unit

Lucy Parry, Countess Of Chester Foundation Trust, UK

The publication of the tri annual CMACE report (2011) and the document from the Royal Society of Anesthetists “providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman” (2011) noted “that there is still a significant number of deaths associated with suboptimal care” and that “The few women who become critically ill during this time should receive the same standard of care for both their pregnancy related and critical care needs, delivered by professionals with the same level of competences irrespective of whether these are provided in a maternity or general critical care setting.”

These recommendations contributed to the drive by the Manchester Obstetricians and Obstetric Anesthetists to improve the care provided on the central delivery unit in St Mary’s hospital. These reports and research coupled with a local review of the midwives confidence/knowledge and skill in caring for these women resulted in an approach being made to Adult critical care for a new collaborative approach to be found.

4 single rooms on the Central Delivery Unit of St Mary’s Hospital were identified and equipped. A Band 6 (junior Sister) critical care nurse is provided 24/7 alongside at least 1 midwife. The nurses have an induction which is now attended by midwives as part of a locally written and delivered Obstetric HDU competency based course.

The service is now entering its 4th year, admitting approx. 600 women/year which equates to 7% of the total admissions. Despite some early misgivings the service has been well received by all the differing professions and is now an integral part of both the delivery and critical care units. Lessons learned include working across professional boundaries requires everyone to be on board, that this model has worked well and the service is needed but may not suit every delivery unit.

ReferencesCentre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203. The Maternal Critical Care Working Group, “Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman” (2011), The Royal College of Anesthetists, pp 1-59, London

C50: Sleep Quality As Perceived By Critically Ill Patients

Mohamed Adel Ahmed Eraky, Warda Youssef Mohamed Morsy, Hanaa Ali Ahmed El-Feky,

Faculty of Nursing, Cairo University, Egypt Background: Literature review cited that sleep is absolutely essential for surviving and reclamation of the quality of life. Critically ill patients often have poor sleep quality with prolonged sleep latency, sleep fragmentation, decreased sleep efficiency and frequent arousals. Nurses have a unique role for early diagnosis of sleep disorders, decreasing stressors levels and providing the necessary environmental regulations to create a therapeutic ambience.

Aim of the study: to assess perceived sleep quality; and identify factors affecting sleep quality among adult critically ill patients At El Manial University Hospital.

Research Design: A descriptive exploratory design was utilized. Research questions: a) how do adult critically ill patients perceive sleep quality in the Critical Care Department of El Manial University Hospital? b) What are the factors affecting sleep quality among adult critically ill patients at El Manial University Hospital?

Setting: selected critical and cardiac care units at El Manial University Hospital. Sample: A samples of convenience consisting of 100 adult male and female patients were included in the study. Tools of data collection: tool 1: Socio-demographic and Medical Data Sheet, tool 2: Modified St Mary’s Hospital Sleep Questionnaire tool 3: Factors Affecting Sleep Quality Questionnaire among ICU Patients.

Results: The current study revealed that 76.0% of the studied sample had lack of sleep disturbance before hospitalization. However, 84 % had sleep disturbances during ICU stay, of these more than two thirds (67 %) had moderate sleep disturbance. Presence of strange and bad odors, noise, having pain, fear of death and a loud voice produced by the ICU personnel had the most significant negative impact on patients’ sleep in percentage of 52.4, 50, 61.9, 45.2.52.4 respectively.

Conclusion: Sleep disturbances in the ICU are multifactorial, and ICU patients’ perceived degrees of sleep disturbance as a moderate degree of sleep disturbance. The etiologies of sleep disturbances in the current study were found to be multifactorial: presence of strange and bad odors, noise, having pain, fear of death, in addition to loud voices which produced by the ICU personnel and represented the most significant factor leading to sleep disturbance. Thus, critical care nurses can enhance ICU patients’ abilities to sleep, make their stay in the ICU more pleasant, and assist patients to recover without increasing financial costs.

Referenceshttp://scholar.cu.edu.eg/?q=mohamed%20Eraky

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ViPER AbstractsV01: Taking wireless transfer-training simulation on the road

Andrew Bates, Dr Laura Tompsett, Royal Bournemouth and Christchurch Hospital, UK, Dr Philip Dickinson, Scarborough Hospital, UK

Medical teams transfer over 4,000 critically ill patients, annually, between Intensive Care Units in the UK (1). Thousands more are taken to CT and MRI scanners, typically located in hospital basements, far removed from the relative safety of Critical Care Units.

Non-clinical Critical Care transfers are associated with an additional three days ICU stay (2), highlighting the potentially deleterious effects of transfer. In order to optimise standards The Intensive Care Society (3) advises that, ‘Critical Care transfers should be undertaken by an appropriately trained doctor and nurse.’ Local clinical staff define what constitutes ‘appropriately trained’.

This ViPER describes how our hospital has utilised high fidelity medical simulation to enhance transfer training. The acquisition of a wireless simulation mannequin has facilitated the first reported use of multi-disciplinary, transfer-medicine simulation in a moving vehicle.

The course timetable consists of an opening lecture, practical equipment workshops, a discussion group and simulated scenarios. Our local ambulance trust provides us with a fully equipped vehicle and crew, in order to mobilise the mannequin around the local area, simulating critical incidents ‘on the road’ in real-time. We believe this novel approach gives our training the highest possible fidelity, providing a safe platform to practice this high-risk procedure.

Our course has received consistently high feedback from candidates. Health Education Wessex awarded us a ‘Notable Practice Award for Innovation in Education’ in 2013 and our poster presentation won first prize at the Intensive Care Society State of the Art meeting, 2013.

I propose developing a ViPER, to present at the BACCN conference. There are three key areas to highlight for group discussion and engagement. Issues arising from the novelty of taking high fidelity medical simulation out of the hospital environment onto the road, our pedagogical reasoning behind course development and assessment of competence.

ReferencesHarrison, D., (2011) Admissions transferred to or from adult, general critical care units in England, Wales and Northern Ireland. Intensive Care National Audit and Research Centre: London Harrison D, Barratt H, Rowan K, Raine R. Effect of non-clinical inter-hospital critical care unit to unit transfer of critically ill patients: a propensity-matched cohort analysis. Journal of Critical Care. 2012; 16: R179

Whiteley, S., Macartney, I., Mark, J., Barratt, H., Binks, R. 3rd Edition (2011) Guidelines for the Transport of the Critically Ill Adult. The Intensive Care Society. London.

V02: Induction Training, Moving Forward

Lisa Toft, Nick Tomlinson, Portsmouth Hospitals NHS Trust, UK

The Practice Educators team from the Department of Critical Care at Queen Alexandra Hospital in Portsmouth provides induction and orientation training for all new Registered Nurses both civilian and military to the department as an introduction to critical care nursing. This programme has been developed to incorporate key learning themes and practical skills that are transferable to clinical practice. We have introduced a practical based learning curriculum which involves workshop sessions supported by formal lectures. The combination of theory based learning and hands on experience has allowed our inductees to gain a greater understanding of the key skills within critical care such as airway management, application of cricoid pressure, invasive and non-invasive ventilation and cardiovascular assessment. Following feedback from the inductees, this practical approach to induction training has benefited the learning as it allows them to apply the theory to practice. Ballangrud et al (2014) highlight the importance of realistic training that better prepare intensive care nurses to manage difficult situations. The team has also introduced the use of an iPad to facilitate the teaching process. With the use of available apps, we have been able to provide simulated training, such as auscultation assessment, with an interactive element. The use of the iPad has also allowed the team to provide portable bedside training to staff, at times suitable for the learner, and using resources such as Power Point presentations, that would have been previously unavailable at the bedside. Clay (2011) explains that mobile devices can be used as an effective way to support and enhance the learning and development of clinical skills in the clinical area.

ReferencesBallangrud R, Hall-Lord M.L, Persenius M and Hedelin B (2014) Intensive care nurses’ perception towards simulation-based training for building patient safety in intensive care: A descriptive qualitative study: Intensive and Critical Care Nursing(30) page 179-187 Clay C.A (2011) Exploring the use of mobile technologies for the acquisition of clinical skills: Nurse Education Today Aug 31 (6) page 582-6

V03: Are Haemofiltration Patients Adequately Anticoagulated?

Sarah Jane Faichney, Philip McCall, Golden Jubilee National Hospital, UK

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Introduction: In patients undergoing continuous veno-venous haemofiltration (CVVH) we noted rather erratic anticoagulation levels and a higher than expected incidence of filter clotting and clogging. In other settings, “sliding-scale” dosing has produced more stable effects (eg Insulin). This study recorded the efficiency of a newly introduced sliding-scale heparin administration regime.

Methodology: A retrospective audit compared levels of anticoagulation in ICU patients on CVVH before and after the introduction of a sliding-scale heparin regime. Anticoagulation was monitored by activated clotting time (ACT) measured by nursing staff at the bedside. Time to reach the therapeutic range, the proportion of time within this range, the number of filter circuit changes and blood transfusion requirements were compared.

Results: Forty three patients were included in the study (22 before and 21 after regime introduction). Sliding-scale heparin administration significantly improved the time taken to achieve therapeutic ACT levels and the time patients remained within the therapeutic ACT range (P<0.01 for both). However, filter durability and transfusion requirements were unaltered.

Conclusion: The main finding of this study was that the introduction of a sliding-scale regime for heparin dosing significantly improved anticoagulation control and stability. However this audit revealed unexpectedly poor control of anticoagulation in general. Even with the sliding-scale regime, patients were within the therapeutic ACT range for less than half the time they remained on haemofiltration. While some adjustment of the heparin dose protocol and tighter monitoring of ACT levels is likely to produce further improvements in anticoagulation control and stability, there is no evidence to suggest that this will improve filter durability. This appears to be associated with the deposition of proteins on filter membranes(1) as well as thrombus formation – suggesting improved anticoagulation alone is unlikely to significantly prolong filter life.

References1. M. Joannidis and H M Oudemans-van Straaten. (2007)Clinical review: Patency of the circuit in continuous renal replacement therapy. Critical Care, 11(4), ccforum [Online]. Available at: http://ccforum.com/content/11/4/218 [accessed 8 March 2015]

V04: The trouble with Trachys revisited

Linda Chu, Anne Carter, Linda Kent, Nazima Hoque, Frimley Health NHS Foundation Trust, UK

Introduction: The importance of tracheostomy training was recently highlighted in the “On the Right Trach?” NCEPOD report, 2014 (1). 61% of ward care was identified as “room for improvement” in training and management of patients with tracheostomies outside critical care. Our tracheostomy policy was re launched in 2012. So far this year we have seen 25 tracheostomy patients over 264 visits. It is essential to ensure staff are trained and maintain their skills when caring for these patients. In situ simulation has been suggested to

have positive impact on learning and organisation performance (2).

Aim: To assess the skills and knowledge of ward based nurses on emergency tracheostomy management and to reassess after a period of education.

Method: Utilising in situ simulation we ran simulation training sessions on emergency management of a tracheostomy in the ward environment. Candidates were assessed utilising a modified emergency tracheostomy algorithm (3). Staff were assessed within their normal clinical roles and area of skill. Following the initial simulation drill a variety of training sessions were organised. The in situ simulation sessions were then repeated and the data set recorded.

Results: 35 ward staff attended the baseline simulation session. Baseline simulation identified that only 38% of staff applied oxygen to both face and tracheostomy, 1/3 of staff failed to activate a crash call despite the patient having a blocked tracheostomy and 21% of staff attempted to pass a suction catheter down a fenestrated tube.

Once the education and repeat simulation has been undertaken outcomes can be compared.

Conclusion: Utilising in situ simulation we have been able to assess the impact of education delivered to ward staff. It has enabled us to improve technical and nontechnical skills and to support wards who manage tracheostomy patients. In situ simulation can be used as an effective education tool.

References(1) On the Right Trach? A review of the care received by patients who underwent a tracheostomy. A report by the National Confidential enquiry into patient outcome and death (NCEPOD) 2014. (2) Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. “Insitu simulation in continuing education for the health professionals: a systematic review”. J Contin Educ Health Prof. 2012 Fall; 32 (4):243-54.doi:10.1002/chp.21152. Review. PubMed PMID: 23280527. (3) National Tracheostomy Safety Project, www.tracheostomy.org.uk

V05: Hotspots: Where are yours? Pressure Ulcer Prevention in General Intensive Care (GICU) - Service Improvement Project

Sarah Farnell-Ward, Grace Lacaden, St Georges NHS trust, UK

Introduction: Pressure Ulcers are considered to be a key quality indicator within the NHS and form part of the NHS Safety Thermometer (CQUIN, 2014). Within our own NHS trust all pressure ulcers have to be reported locally as an incident (Datex) and these have to be investigated to ensure that everything has been done to

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prevent these harms occurring.

Aims:1. To reduce the number of pressure ulcer acquisitions in GICU2. To raise awareness and encouraging staff to think differently

about pressure areas by introducing the concept of ‘Hotspots’3. To encourage staff to develop innovative ways of preventing

‘Hotspots’ becoming pressure ulcers

Study Design: A one year baseline audit (July 2013-14) was undertaken using Datex reports and ninety five pressure ulcer acquisitions were identified. A third of these (33.6%, n=32) were device related (Nasogastric tubes, Oxygen therapy, anti-embolic stockings etc.) and therefore potentially avoidable.

A snapshot audit was undertaken where nurses were asked about their patients’ pressure areas. Many described pressure areas as ‘intact’ or highlighted current pressure ulcers but few identified potential pressure areas of concern. In order to stimulate interest in this project we initially embarked on a ‘Hotspot’ poster campaign and placed ambiguous posters around the unit.

Next we introduced the concept of a ‘Hotspot’ and used photographs to highlight some of the pressure ulcers acquired on GICU.

We have also introduced ‘Hotspot of the month’. Here we focus on one of the Hotspot areas, offer bedside teaching and encourage staff to identify ways of preventing Hotspots becoming pressure ulcers.

Results: Over a three month period (Sept-Dec 2014) GICU have demonstrated a 53.3% reduction in pressure ulcers compared to quarterly data from the previous year. This is an on-going project and we look forward to presenting our latest results and service improvement initiatives.

ReferencesCommissioning for quality and innovation (CQUIN): 2014/15 guidance. Available at: http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf. Accessed March 2015.

V06: Brain Stem Death: Information for relatives

Laura Elizabeth Mathers, Oxford University Hospitals Trust, UK

This presentation is on Brain Stem Death (BSD), with the target audience being patient’s relatives and junior nurses in Intensive Care. It aims to help nurses learn about BSD and improve communication with relatives. Malik, Hall, & Howard (2009) found that healthcare professionals who are expected to aid relatives’ understanding of BSD do not always understand this topic, hence this poster aims to assist with this issue.

The poster will be displayed on the unit and transposed into a leaflet

for relatives. It will define what BSD is by explaining what the brain stem is, its function, and the process of testing. This poster will cover the issue of family presence during testing and ultimately educate patient’s relatives’ understanding of BSD.

BSD is a very sensitive area; nurses need to support relatives by bridging the gap between the clinical intensive care unit setting and the emotional needs of relatives (Maynard, 2010). Health professionals find BSD problematic to explain, and, as a result, it is poorly understood by relatives. This leads to families becoming confused and distraught over a preventable aspect of nursing.

Bonner et al (2005) found that twelve months after bereavement not all relatives understood what BSD was. Relatives also admitted they envisaged ‘invasive drilling’ and ‘gruesome things’ during the BSD tests despite a consultant explaining the procedure at the time. This shows that the circumstances in which a patient dies affects their relatives’ grieving process and their life after the death of the patient (Maynard, 2010). Medical staff must educate the relatives to share the same concept, criteria, and definition of death.

Relatives require empathy, education, and to be in a trusting environment which nurses are central to providing. They can help relatives understand all of the information given to them by multiple health professionals, enabling them to be involved in the decision process and ultimately aid the grieving process.ReferencesShum, H P et al. Regional citrate anti-coagulation in predilution continuous venovenous haemofiltation using Prismocitrate 10/2 solution. Nephrology 2010; 15 (Suppl.3) Hetzel GR et al. Regional citrate versus systemic heparin for anticoagulation in critically ill patients on continuous venovenous haemofiltration: a prospective randomized multicentre trial. Nephrol Dial Transplant. 2011 Jan;26(1):232-9

ReferencesBonner, M., Ormrod, J.A., Ryder, T. & Chadwick, R. J. (2005) Experiences of families when a relative is diagnosed brain stem dead: Understanding of death, observation of brain stem death testing and attitudes to organ donation. Journal of Anaesthesia, 60, 1002-1008 Malik, M., Hall, C., & Howard, D. (2009). Nursing Knowledge and Practice: Foundations for Decision Making (Third Edition ed.). London: Bailliere Tindall. Maynard, A. (2010). Brainstem Death in an Intensive Care Unit: A Cultural Perspective. End of Life Care Journal, 4, 8-14.

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Poster AbstractsP01: Use of heel protection device and honey dressing as a part of treatment and prevention from further deterioration of SDTI on spinal cord injury patient

Irena Pukiova, John Radcliffe Hospital, UK

Introduction: Patients with spinal cord injury (SCI) are at high risk for pressure ulcer (PU) development. In October 2014, a patient with SCI was admitted with ulcers on both heels. This case history describes the evidence-based interventions and progress associated with his care, which led to complete healing within 3.5 months.

Methods: The patient was a 65-year-old male admitted to the adult intensive care unit (AICU). He had SCI due to a fall and C2 fractures, with SDTI on both heels during a prior hospitalization.

The AICU Tissue Viability Nurse assessed the patient on admission, and severe SDTI to both heels were noted with underlying necrotic tissue. Sharp debridement was conducted to expose necrotic tissue and honey dressing was applied to the necrotic areas on both heels. Dressings were changed every 48-72 hours. A heel protector was placed to off-load pressure from the heels and remained in place 24 hours per day.

Results: The following is a summary of treatment progress. Pictures are available for each time point.

1 week: (05/11) Necrotic areas had reduced in size and softened, and surrounding areas showing signs of granulating tissue and improvement.

1 month: (24/11) Necrotic areas were significantly smaller and surrounding skin had begun to granulate and heel. Both heels were sharply debrided by the podiatry team to enhance healing. Honey dressings were applied to necrotic areas.

1.5 months: (10/12) No residual necrotic tissue. The wounds were smaller and wound beds were sloughy. Both heels received sharp debridement by the podiatry team once per week and honey dressings were continued.

2.5 months: (07/01) There was 50% of granulation tissue and 50% of slough, with wounds healing well; surrounding tissue completely healed.

3.5 months: (11/2) Both heels had completely heeled.

Conclusion: This evidence-based approach was successful in healing this patient’s severe wounds.

ReferencesVerschueren, JH, Post, MW, de Groot, S, van der Woude, LH, van Asbeck, FW, Rol, M 2011, ‘Occurrence and predictors of pressure

ulcers during primary in-patient spinal cord injury rehabilitation’, Spinal Cord, vol. 49, no. 1, pp. 106-12. Ghaisas, S, Pyatak, EA, Blanche, E, Blanchard, J, Clark, F; PUPS II Study Group 2015, ‘Lifestyle changes and pressure ulcer prevention in adults with spinal cord injury in the pressure ulcer prevention study lifestyle intervention’, American Journal of Occupational Therapy, vol. 69, no. 1, pp. 1-10. Junkin, J, Gray, M 2009, ‘Are pressure redistribution surfaces or heel protection devices effective for preventing heel pressure ulcers?’, Journal of Wound Ostomy Continence Nursing, vol. 36, no. 6, pp. 602-608.

P02: 10 Minute Meeting: “A New Innovation” Quality Improvement Initiative for Cardiac Arrests and Medical Emergencies

Claire Cox, Robert Greenhalgh, David Foxwell, Brighton and Sussex University Hospital , UK

Background: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in an emergency setting; in which ‘ad hoc’ teams have little chance for advanced planning¹. At present there is no pre briefing to introduce team members and allocate roles or assess skills set.

Objectives: To initiate a daily meeting to introduce the MET/CA team, allocate roles; assess skills set and opportunities for learning.

Method: Ad hoc team met daily, chaired by Critical Care Outreach Sister using a prompt card. Members of MET/CA team introduced, roles allocated, learning needs discussed, leadership ascertained and timing of hand over agreed.

An online survey was given to all members of CA/MET given after 1 month of initiation of meeting and 6 months.

I have time booked with the police, armed response team in London to see how their briefings compare to ours.

Results: Please note that I am still in the process of collecting results – so far numbers are small, but indicating that this is having a positive effect on group dynamics and safety.

Conclusion: A daily pre briefing with the MET/CA team lowers stress levels, improves leadership, improves team dynamics therefore improves patient safety.

ReferencesRoberts, N.K (2014) American Journal of Surgery 207(2):170-8.

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P03: Post-registration education contributing to quality and safety in critical care nursing

Heather Baid, Jessica Hargreaves, University of Brighton, UK

The purpose of this poster is to illustrate how a post registration, degree level critical care nursing course from an English university actively promotes safe, high quality clinical practice. The authors are two university lecturers involved with the running of this course which enables students to develop a range of knowledge, skills and professional attributes required of nurses working within a critical care unit. Specifically, the poster will provide an overview for how the course:

Uses simulation to assess clinical skills through OSCEs (objective structured clinical exam).Teaches and assesses non-technical skills including cognitive skills (situation awareness, decision making and task management) and interpersonal skills (communication, teamwork and leadership).Encourages nurses to critically analyse a variety of sources of knowledge to inform their clinical practice such as published documents, clinical experience and service users.

The course curriculum is also underpinned by relevant quality standards for critical care (CC3N 2012; ICS 2013; UKCCNA 2014) as an active attempt for the course’s teaching and assessments to be a way of helping nurses provide safe, high quality care for critically ill patients and their families. This poster is based upon an article which has been accepted for publication in the special edition of the Nursing in Critical Care Journal focused on quality and safety.

ReferencesCC3N (Critical Care Networks National Nurse Leads). 2012. National standards for critical care nurse education. http://www.cc3n.org.uk/education-training/4577977309 UKCCNA (UK Critical Care Nursing Alliance). 2014. Quality assurance standards to underpin student placements in critical care units during post registration critical care education programmes. http://www.cc3n.org.uk/education-training/4577977309 ICS (Intensive Care Society). 2013. Core standards for intensive care units. London: ICS.

P04: New proning protocol and skin bundle

Linda Gregson, East Lancashire NHS Trust, UK

Introduction and Background; High incidence of pressure damage reported in proned patients from either devices or pressure created by procedure. Need for better guidelines and skin bundle. Patients proned for up to 18 hours at a time with only as little as 5-7 hours supine before procedure repeated.

Pressure damage reporting increased IR1 Datix (author will show).

Aims and objectives; The author felt that nurses needed a better understanding of the need for procedure and because of this enrolled assistance of CT5 (doctor) to demonstrate need

There was a higher incidence of pressure damage to face associated with headrest therefore it has been possible to alleviate pressure damage by liaising with manufacturers to design new headrest.

While undertaking this project it was noted that there was a need for universal care plan for all patients proned.

Methodology; A PDSA Cycle was used

Results;

• Checklist pre and post proning for nursing and medical staff• Easy to follow step by step guidelines to proning• Adapted skin care bundle for hourly observations• New proto-type headrest in use

Conclusion;

• Quicker results while proned• Initial 3 patient’s post new guidelines; NO pressure damage

from device or immediate pressure to face• Safer moving and Handling• More uniformed approach.• Greater understanding of need for proning

ReferencesDepatment of Health (2010) Proseva Trial European Respiratory Journal 2002 Lnacs and South Cumbria Network

P05: A Study Of Relationship Between Critical Thinking And Decision Making Among Critical Care Nurses In Malaysia

Assistant Prof. Dr. Salizar Mohamed Ludin, Nor Syuhada Fatihah Razali, Kulliyyah of Nursing, International Islamic University Malaysia Pahang, Malaysia

Introduction: Nurses in critical care settings are expected to have the outstanding critical thinking skills in delivering and helps nurses to overcome complex and challenging clinical judgment and environment which eventually leads to improving patients outcomes (Swinny, 2003, 2010). Nurses thus need to master critical thinking and clinical judgment skills as safe and effective nursing care is essential for both the client’s well-being and the organization’s potential liability.

Problem statement: Nurses and some newly graduated nurses when they make decisions, their focus leans toward doing, rather than on thinking and reflecting (Benner, 1984; Benner, Tanner, & Chesla, 1996). Various studies found that critical thinking and decision-

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making are the vital key components and negatively correlated (Hoffman, 2003), to date the critical thinking and decision making in Malaysian setting is not been closely examined. Thus, this study aims to explore the critical thinking and decision making ability among the registered nurse in critical care areas.

Methodology: This mixed method study will explore Critical Care nurses’ critical thinking and decision making level at a tertiary hospital. Data will be collected from eligible nurses via purposive sampling the population (N=208) using self- administered questionnaire (Short Form-Critical Thinking Disposition Inventory-Chinese Version- SF-CTDI-CV by Hwang et al., 2010) and individual interviews. SPSS software Version22 will be used for descriptive and inferential data analysis and subsequently interpretation of data for emerging themes using thematic analysis

Expected outcome and conclusion: The level of nurses’ critical thinking and the effect to their decision making in the critical care areas will be measured The gap in the critical thinking among critical care nurses and decision making will be countered as it is very important to achieve the demand of current trend of healthcare and to provide the efficient consumer-focused care.

References1. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. 2. Benner, P.,Tanner, C., & Chesla, C. (1996). Expertise in nursing practice: Caring, clinical judgment and ethics. New York: Springer Publishing 3. Hoffman, K & Elwin, C (2003) The relationship between critical thinking and confidence in decision making, Australian Journal of Advanced Nursing, vol. 22, 1 4. Swinny, B. (2003). Assessing and developing critical thinking skills. … University Indianapolis. Handouts Available at Http:// …, 33(1), 2–9. Retrieved from http://cfcc.edu/SACS/QEP/documents/WolcottSKGrayCJ2003.pdf 5. Swinny B. (2010) Assessing and developing critical-thinking skills in the intensive care unit. Critical Care Nursing Quarterly 33(1), 2-9.

P06: Patient Diaries in ICU- Where is the evidence?

Louise Caroline Stayt, Oxford Brookes University, UK, Calum Buchanan, Oxford University Hospitals, UK

Introduction: Admission to an intensive care unit (ICU) is extremely stressful for both patients and their relatives. As a result, patients and their relatives are at significant risk of psychological morbidity such as anxiety, depression and post-traumatic stress disorder (PTSD) both during the ICU admission and up to a year after hospital discharge (Ewens et al. 2014, Hickman and Douglas 2010). ICU or patient diaries have been introduced in an attempt to address patients’ psychological morbidity however the exact role that diaries play in the psychological recovery of patients is unclear. The aim of this poster is to outline and review the existing evidence base that evaluates ICU patient diaries.

Findings: Recent studies, although limited in number and methodological rigour, have demonstrated that patient diaries may have a positive impact on a patient’s psychological recovery (Aitken et al. 2013). There is however, much variation in both the format of the diary and the way they are implemented. Furthermore, it is unclear how patients and their relative use diaries to support the patients’ psychological recovery.

Conclusions: Further research that clarifies the exact role of the diary in the patients’ psychological recovery, the best format of the diary and how they may be implemented is required in order to underpin patient diaries as an effective therapeutic intervention.

ReferencesAitken, L., Rattray, J., Hull, A., Kenardy, J., Le Brocque, R. & Ullman, A. (2013) The use of diaries in psychological recovery from intensive care. Critical Care, 17(6), 253.Ewens, B., Chapman, R., Tulloch, A. & Hendricks, J. (2014) ICU survivors’ utilisation of diaries post discharge: A qualitative descriptive study. Australian Critical Care, 27, 28-35. Hickman, R. & Douglas, S. (2010) Impact of Chronic Critical Illness on the Psychological Outcomes of Family Members. American Association of Critical Care Nurses Advances in Critical Care, 21(1), 80-91.

P07: E-learning for introduction to Rapid Response Team (RRT), Early Warning Signs (EWS) and sepsis treatment

Kristina Kjaer Larsen, Nina Lennert, Lisbeth Gamst, Hospital Vejle, Denmark, A Part of Lillebaelt Hospital

P08: Deprivation of Liberty Safeguards, delirium, dementia and lack of mental capacity

Heather Howells, Hywel Dda University Health Board, UK

Managing patients who lack mental capacity within critical care is an increasing challenge. Patients present with learning disabilities, dementia, and or develop delirium. Frequently management measures include closer observation to manage behaviour than would be indicated by clinical status alone and the use of restraint through the use of verbal, physical or pharmacological mechanisms. Aimed at ensuring patient safety and consistent with obligations of duty of care and carried out in the patient’s best interests, there are circumstances when these measures can be considered to be a deprivation of a patient’s liberty.

The Deprivation of Liberty Safeguards (DOLS) were added to the Mental Capacity Act 2005 via the Mental Health Act 2007 and came into force in 2009. However more recently a Supreme Court ruling in 2014 overturned previous finding in cases where it had originally been considered that the varying degrees of restraint that had been

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used to facilitate care in a community setting did not constitute a deprivation of liberty (P v Cheshire West and Chester Council and P&Q v Surrey County Council 2014). The significance of this case was that the judgement of the majority identified an ‘acid test’ for deprivation of liberty, namely that if a person is under continuous supervision and is not free to leave then they are considered to be deprived of their liberty. In December 2014 the chief coroner advised that patients who died while subject to a DOL authorisation should be considered as a death in state detention.

The potential impact in Critical Care was unclear, thus a review of relevant literature and legal guidance was undertaken in order to develop a resource that critical care staff could utilise to help in the decision making process to identify potential situations where a deprivation of liberty authorisation would be required.

ReferencesP v Cheshire West and Chester Council and another P&Q v Surrey County Council [2014] UKSC. Ministry of Justice. Mental Capacity Act 2005: Deprivation of Liberty Safeguards - Code of Practice to supplement the main Mental Capacity Act 2005 Code of Practice. London. The Stationary Office 2008 UK Government Legislation. Mental Capacity Act 2005. London. The Stationary Office.

P09: The improvement plan of enhancing the accuracy rate of ICU nurses’ changes of patients’ positions by using multimedia videos

Yi-Ying Sung, Shiu-Mieh Chen, Chi-Mei Medical Center, Taiwan

The incidence of pressure sores among patients in the intensive care unit (ICU) had remained high from January, 2013 to June, 2013.The rate of pressure sores is an assurance and an important indicator of nursing quality. 80 percent of the nursing staff in ICU had participated in the in-service training program for prevention of pressure sores at the end of August. However, it was noticed that the way how nurses change patients’ positions was inconsistent among each other. In addition, wound management nurses had discovered that the incidence of pressure sores at sacrum was especially high while they assessing patients’ pressure sore condition. After further investigation, it was found that the accuracy rate of position change among nurses in ICU was 0%. The results of questionnaires showed that nurses’ knowledge of pressure sore prevention was 62.5% and nurses’ accuracy rate of position change was 0%. Hence, a special team was established in September, 2013, and by implementing 4 steps, including (1) practical drill, (2) provision of videos of changing patients’ positions, (3) continuous advocacy, and (4) clinical monitoring, the incidence of pressure sores had reduced from % to % since September, 2013 to November, 2013. Also, nurses’ accuracy rate of position change had achieved 100%. The outcome of this implementation was extraordinary. Therefore, we expect the results of this study could serve as a reference for nurses in ICU to appropriately change patients’ positions, in order to reduce the incidence of pressure sores.

References

Ulrika, K & Suserud, BO 2009, ‘knowledge,attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment-a survey in a Swedish healthcare setting,’ Scand Journal of Caring Science, vol. 23, pp. 334-341. Zhang,SH, Zhang, CX & Chen, NW 2012, ‘Nurses investigate acts of pressure ulcer prevention,’ Hiromitsu Journal, vol. 69, pp.136-153.

P10: The tolerability and adequacy of enteral nutrition in patients with haemodynamic failure after cardiac surgery-A Pilot Study

Mihaela Gaspar, Allan Seraj, Royal Brompton & Harefield NHS Foundation Trust

Background: Enteral nutrition (EN) is recommended within the first 24-48 hours following admission to intensive care unit (ITU), but is still controversial in patients with circulatory compromise. This pilot study explores the tolerability and adequacy of enteral nutrition in patients with haemodynamic failure after cardiac surgery.

Method: A retrospective observational audit was conducted in a cardiac intensive care unit over three months which included cardiac surgery patients with haemodynamic failure defined as dependence on one or more vasoactive agents (of which one has to be Noradrenaline ≥ 0.1mcg/kg/min) but no mechanical circulatory support and requiring at least 48 hours of mechanical ventilation. EN tolerability was defined as an absence of residual gastric volumes (RGV) ≥ 1000ml/day, and a daily nutrition adequacy (defined as the amount of calories received divided by the amount prescribed expressed as a percentage) of 80%, as recommended in the local policy (RBHT, 2012).

Results: of 191 patients admitted to ITU, 10 patients (5.2%) met the inclusion criteria. Overall tolerability was 100%. Adverse events included paralytic ileus (100%); high RGV (50%); abdominal distension (50%) and diarrhoea (30%) and met the criteria for gastrointestinal dysfunction grade II (Reintam Blaser, Malbrain et al. 2012). No case of bowel ischaemia was detected, and all patients survived hospital discharge. A weak correlation was detected between Noradrenaline and RGV [r(Spearman) =0.24, p=0.51]. Daily nutrition adequacy was 86.7% overall, with 30% of patients receiving less than 40% of their nutritional goal and 40% receiving >80% of prescribed nutrition. Discussion and Conclusion: Early EN is feasible in haemodynamically unstable patients and not associated with serious complications. However, is difficult to make recommendations due to the limitations of the audit. The findings point to a need for careful monitoring of signs warning of GI dysfunction and a need for improving of nutritional delivery.

ReferencesReintam Blaser, A., Malbrain, M. L., Starkopf, J., Fruhwald, S., Jakob, S. M., De Waele, J., Braun, J. P., Poeze, M. & Spies, C. (2012) Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems. Intensive Care Medicine.

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38 (3), 384-394. Royal Brompton & Harefield NHS Foundation Trust (2012) Adult enteral feeding policy.

P11: Implementation of a Patient Profile for Critically Ill Patients

Helen Whiting, West Suffolk Hospital, UK

The purpose of this poster is to review the use of a Patient Profile. It gives personal individual information about the critically ill patient who is unable to communicate their own personal needs. A literature search only found a few patient information documents, such as the ‘This Is Me’ document (Alzeimers’s Society 2014); however all were unsuitable for Critical Care patients.

The Patient Profile was introduced as an A4 sheet to be completed. It contains various sized bubbles with key titles in each section. Titles include: my personality; I like to be called; my hobbies/interests; I work/before I retired and I am left/right handed. The relatives with some guidance take ownership of the form inspiring them to feel they play an important part in the patient’s progress and thus involves little work for the nursing staff. Some relatives added photos of the patient and family which allowed the nurses to open up discussion with the patient and family making them feel more at ease. Key points can be added but only for the nurse to read at the start of their shift then placed in a confidential folder.

Six months after implementation a questionnaire was given to 20 nursing staff at various grades. The feedback was positive with 100% of staff liking the profile, feeling that it enhanced and changed patient care, humanising the patient more and helping patients move forward when rehabilitation is started. The nurses all felt that relatives enjoyed writing the profile, as were more involved in the patient’s progress. Changes have been made to prompt staff to view the profile at the start of their shift by using our computerised paperless system. This is a simple but really effective tool, highlighting an innovation in Critical Care.

ReferencesAlzeimers’s Society (2014) http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1290 (accessed 18/11/2014)

P12: Review of the Follow- up Screening tool following ITU/Recovery Discharge, to provide an effective and efficient Outreach Service

Ellen Dunthorne, Helen Street, Harefield Hospital, UK Helen Dell

Overview: Following introduction of ‘Patient at Risk’ (PAR) scoring (NICE, 2007), the opening of our Cardiothoracic Recovery in 2009, and the widening of the Primary Angioplasty’s catchment area, the referrals to the Outreach team increased exponentially.

Aim: To devise a Follow-up Screening tool to streamline the

assessment of patients that are seen post discharge from the ITU/Recovery and allow more time to be spent with ‘At Risk’ patients.

Data Collection: After performing a literature search of current Outreach practice and referral criteria used elsewhere, a Follow-up screening tool was devised. The results of the literature review were very limited and so personal experience and current local ITU discharge criteria were used to compile the criteria.

The criteria was then audited over a three month period. The Outreach Nurses reviewed each patient on discharge from ITU and using the criteria decided to ‘review’ or ‘not review’ each patient. A record of all patients was kept and details about readmission to Outreach using PAR and readmission to ITU/Recovery was also recorded.

Results: Following the 3 month audit, results were collated and they demonstrated a 36.8% reduction of patients being seen by the Outreach Team following discharge from Recovery/ITU. This reduction provided approximately 35 hours over the three months audited of extra time used to assess and provide treatment for ‘At Risk’ patients

Of the 106 patients not followed up, 6 patients (5.6%) were referred to the Outreach team using the PAR scoring system. Of these 6 patients, 5 presented with a common post-operative complication that required minimal intervention. None of the 106 were readmitted to ITU.

ReferencesDepartment of Health (2000) Comprehensive Critical Care: A review of Adult Critical Care Services. London. Crown Copy. NICE (2007) Acutely Ill Patients in Hospital: Recognition of and response to Acute Illness in Adults in Hospital. London. National Institute of Clinical Excellence

P13: A4A - AIM for Africa© - Uganda. Evaluating the impact of Acute Illness Management teaching in a poorly resourced low to middle income healthcare setting

Sharon Whiting, Samantha Cook, Greater Manchester Critical Care Skills Institute, UK, Dr Matthew Jackson, North Western Deanery, UK, Rosemary MaCarthy, University of Salford, UK Uganda has been described as a place where: ‘there is no concept of ABCDE assessment....no prioritization, no equipment....extremely limited oxygen supply’ (Credland 2014:213).

We (a small team of critical care nurse educators, midwives, and doctors) have experience of delivering bespoke one-day courses which teach a systematic A-to-E approach to assess and manage the acutely ill adult; or pregnant woman. These are known as the AIM© (GMCCSI 2014) and Maternal AIM© (GMCCSI 2013). By working with a Greater Manchester medical-education charity (Gulu-Manlink)

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we have previously delivered both courses to medical students, trainee clinical officers, and qualified hospital staff in Gulu, Northern Uganda.

In our experience the UK courses, though well evaluated (Jackson et al 2013; McCarthy et al 2015), do not meet the specific requirements of a population whose average age is 15.5years, life expectancy 54, and women have 6 children (Index Mundi 2014). In response we have developed an AIM adaptation - AIM for Africa© (A4A - GMCCSI 2015) to better meet this demographic. The A4A is tailored to local healthcare demands, including: the burden of infectious disease and higher incidence of maternal cases. The course development has involved wide medical, nursing and educational collaboration. Throughout development feedback from previous Ugandan course candidates has helped hone the materials. A4A was piloted in the UK with healthcare professionals experienced in working in similar locations.

In April 2015 A4A will be taught in Uganda for the first time, a mix of 100 students, medical and clinical officer are registered to attend. Candidates will complete a course evaluation questionnaire. One month later they will complete another to assess the impact A4A training has on patient care. This is part of a larger, longitudinal research project determining intention to apply knowledge learned to care (Hart et al 2014) supported by HEE.

Outcomes and findings: to be established.

My aim: to share our findings and experience of delivering A4A with BACCN conference delegates.

ReferencesCredland N. (2014). Critical care nursing in Mbarara, Uganda. Nursing in Critical Care. Vol19: No4. 213. GMCCSI (2015). AIM © Course Manual. Acute Illness Management (AIM) for Africa. Greater Manchester Critical Care Skills Institute: Manchester. Hart J; Byrne G; Armitage C; Johnston M; Byrne-Davis L. (2014) Enhancing the impact of training on healthcare professional practice. [Poster - available from [email protected]; [email protected] ]

P14: What are staffs’ perceptions of a 24/7 Critical Care Outreach Team (CCOT)

Elaine Woodhams, Christopher Donnelly, Catherine Plowright, Medway Maritime NHS Trust, UK

Background: In November 2012 our CCOT expanded the service in line with the NCEPOD (2005) recommendations from a seven-day service to a 24 /7 service. In 2014 we undertook a staff audit to evaluate the perceived impact this expanded service had and how well supported the staff felt when identifying and caring for the deteriorating and critically ill patients. We compared this to previous perception audits.

Methodology: The audit tool used was slightly adapted from a

previous one used, and sought staff perceptions regarding the CCOT. 100 questionnaires were hand delivered to different staff groups within the district general hospital. The questionnaires were anonymously completed and returned via internal mail system to the CCOT office.

The hospital audit team collated the data and helped produce a report. We were able to compare previous results with 2014 results. From this comparison we were able to develop some conclusions regarding the impact the 24 - hour service on the staff,

Results: The return rate was 47%. The results were generally positive and staff were appreciative of the 24/7 service, although some areas of improvement and awareness of the role of CCOT were required.

The Future: Plans are being developed to increase awareness of the CCOT and its role with the hospital.

ReferencesNCEPOD. (2005). AnAcuteProblem. Available: http://www.ncepod.org.uk/2005report/summary.pdf Accessed27th Feb2015.

P15: Explore the knowledge, attitude of ICU nurses on pressure ulcer prevention in southern Taiwan

Shiu-Mieh Chen, Chi-Mei Medical Center, Taiwan Jeng Wang, School of Nursing, Chang Gung University of Science & Technology, Taiwan

Background and Purpose: Recent studies suggested not all pressure ulcers may be preventable. Sometimes, ICU intervention may contraindicate to good care for skin, for example, many patients with ventilators have to sit up to a 30° to 40°degree to prevent occurrence of pneumonia, but this angle may damage the integrity of skin. Therefore, the purpose of this study is to examine whether ICU nurses with updated knowledge about pressure ulcers would affect their attitude and practice toward providing care for ICU patients.

Methods: As the nurses agree to participate in the study, a pressure ulcer prevention scale with good validity was used to measure knowledge, attitude and practice of ICU nurses. The demographic data of nurses were collected.

Results: There were 30 nurses with 6.9 years of working experience (±5.23) involved in the study. 27 nurses (90%) completed the latest pressure ulcer course. Consequently, nurses attending the training course demonstrated significantly higher score on knowledge, attitude, and practice (1.71±.08, vs.1.50±.06, p<.01; 1.93±.010, vs.1.72±.009,p<.00; 1.94±.08, vs.1.83±.08,p<.00) about pressure ulcers. Moreover, this group of nurses are more likely to use the most updated tool to assess their patients.(p<.00).

Conclusions: This study indicated that ICU nurses need to periodically update their knowledge about pressure ulcer, which would have influence on their attitudes and abilities to practice

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precisely and accurately. However, small sample size may have affected the external generalizability of this study.

ReferencesBeeckman, D, Defloor, T, Schoonhoven, L & Vanderwee, K 2011, ‘Knowledge and attitudes of nurses on pressure ulcer prevention: across-sectional multi center study in Belgianhospital’ ,Worldviews on Evidence-basednursing, vol. 8, no. 3, pp.166-176. Strand, T & Lindgren, M 2010, ‘Knowledge attitudes and barriers towards prevention of pressure ulcers in intensive care units: A descriptive cross-sectional. study’ ,Intensive and Critical Care Nursing, vol. 26, pp. 335-342.

P16: Effectiveness of Delirium Prevention Intervention for The Post Intensive Care Elderly

Hui-Wen Chang, Shou-Wen Wang, Department of Nursing, National Cheng Kung University Hospital , Taiwan, Ching-Huey Chen, Department of Nursing & Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Taiwan

Background: Delirium is a common complication among hospitalized elderly. Increased delirium durations are significantly associated with higher mortality. No relevant study on investigating effects of delirium prevention intervention for the post intensive care elderly has previously been conducted.

Aims:This study evaluates the effects of delirium prevention intervention for the post intensive care elderly.

Methods: An experimental design was employed and 60 patients who were older than 65 years and transferred from intensive care unit (ICU) to the general wards were randomly assigned to either the experimental group (n = 30) or the control group (n = 30). The experimental group was provided aids enable to move to public place and to enhance cognition training (introduction of care-team members or caregiver, and discussion daily schedule and current events, reorient the surrounding) 30 minutes per day for14 days. The control group was provided the routine care.

Results: The overall incidence of delirium was 48.3 %. There was no significant statistical differences in the incidence of delirium between the intervention group and the control group(50% vs 46.7%, p=1.000). The duration of delirium was significantly lower in the intervention group, compared to controls (2.13 vs. 3.29days, respectively, p=.011). The cases with delirious days ≦ 2 days in the experimental group were significantly more than the control group (X2 = 5.855, p = .016).

Conclusion: The findings of study suggest that nursing intervention is effective to decrease duration of delirium among the elderly in post-intensive care.

ReferencesGonzalez, M., Martinez, G., Calderon, J., Villarroel, L., Yuri, F., Rojas, C., Jeria, A., Valdivia, G., Marin, P. P., & Carrasco, M., 2009. Impact of

delirium on short-term mortality in elderly inpatients: a prospective cohort study. Psychosomatics, 50(3), p.234-238. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S., 2014. Delirium in elderly people. The Lancet, 383(9920), p.911-922. Naughton, B. J., Saltzman, S., Ramadan, F., Chadha, N., Priore, R., & Mylotte, J., M., 2005. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. Journal of the American Geriatrics Society, 53(1), p.18-23.

P17: Bridge the Gap between Novice and Competent Nurses: Effectiveness of Clinical Simulated Learning Program in Improving Students’ Nursing Competence of Critical Care

Wei-Shu Lai, Department of Nursing, Meiho University, Taiwan, Shiow-Li Hwang, Department of Nursing, Asia University, Taiwan, Ming-Yueh Tseng, Department of Nursing, Meiho University, Taiwan, Yu-Jue Hong, Department of Nursing, Chung-Jen Junior College of Nursing, Health Sciences and Management, Taiwan

Background: Nursing education emphasizes pragmatic application. Some nursing schools offer students exposure to critical care, but most of a critical care nurse’s specialty education and orientation is provided by the employer. Clinical simulated learning provides opportunities for students to integrate knowledge, develop nursing skills, and apply in clinical situations. Bridge the gap between novice and competent nurses is imperative, clinical simulated learning helps in preparing nursing students to work in the complex clinical environments.

Aim: To determine the effects of a clinical simulated learning program in improving students’ nursing competence of critical care.

Methods: A quasi-experimental design and reflective feedbacks were employed in this study. Forty-eight second year nursing bachelor students who participated in a require course of critical care were enrolled in this study. The clinical simulated learning program consisted of virtual-reality scenarios and post-simulation debriefing process. A reflective feedback and self-assessed Competency Inventory of Nursing Students (CINS) were used to evaluate the effectiveness of the program before and after the course.

Results: Objective positive outcome revealed that clinical simulated learning program improve students’ nursing competence in critical care. The subjective learning outcomes included: 1) making inferential link between thinking and doing; 2) setting priorities in complex situation; 3) awareness of unique person in the unique context; 4) enhancing efficient problem-solving and communication skills; 5) act and response to changes in situation; 6) nurturing clinical reasoning-in-transition; 7) appreciating the value of nursing.

Conclusions: Clinical simulated learning is an effective learning

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strategy, it provides positive opportunities for students developing competence and confidence. Clinical simulated learning represents a powerful form of pedagogy that integrates nursing knowledge and clinical practice. It also facilitates nursing curriculum design and teaching, and can be used as a reference in nursing education.

Key Words: clinical simulated learning, novice, nursing competence, critical care

P18: Reducing Acute Kidney Injury in Thoracic Surgical Patients – A Critical Care Outreach Team Initiative

Julia Shears, Royal Brompton and Harefield Trust, UK

Background: Acute Kidney Injury (AKI) can be defined as a reduction in renal function characterised by oliguria (Mehta et al 2007). AKI has been identified as affecting 13-18% of in-patients, costing the NHS up to £620 million a year (National Institute for Health & Care Excellence 2013). A Critical Care Outreach Team (CCOT) at a Cardio-Thoracic Hospital recognized an increase in referrals for oliguria in Thoracic Surgical patients. A project was initiated to retrospectively audit patient data with the aim of reducing future incidences of AKI.

Methods: The CCOT database on ICIP software was examined using “Reduced Urine Output” for patients under any Thoracic Surgeon.

Results: 92 patients were found, 57 male 35 female, between 20 and 90 years old. 60(n) were successfully treated with fluid resuscitation. This audit was limited by using ICIP rather than patient notes to examine patient treatment, as it relied on the CCOT to input detailed data for each patient.

Discussion: In response, patients were given water to drink at 06.00 on the day of surgery rather than nil-by-mouth at midnight and referrals decreased by 81%. Fluid resuscitation decisions had been left to junior staff who exhibited a lack of awareness of AKI and its treatment. A risk assessment score was initiated in order to identify patients at risk pre-operatively and an algorithm introduced to manage post-operative oliguria in this patient population.

Conclusion: AKI is often caused by dehydration in the post-operative patient; a simple, low cost intervention has had a positive impact on preventing AKI. However, some patients will still develop a degree of renal injury or failure, and need to be identified pre-operatively. CCOTs are in a unique position to identify patient trends and outcomes; can develop procedures and policies that improve patient care, reduce length of stay and decrease costs.

Referencesehta R, Kellum J, Shah S et al (2007) Acute Kidney Injury Network: a report of an intiative to improve outcomes in acute kidney injury Critical Care 11: R31 National Institute for Health & Care Excellence (2013) Acute Kidney Injury: Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy [online 01.03.15] https://www.nice.org.uk/guidance/cg169

P19: Preventing a Never Event - Overcoming challenges in an ICU when using national guidelines for testing nasogastric tube (NGT) position

Sonja Monnery, Surrey & Sussex Healthcare Trust, UK

Background: Focus group research within a 10 bedded Intensive Care Unit in 2013, identified that nurses did not regularly follow national NGT position checking guidelines because they perceived the pH test as ineffective for patients on continuous feeds. They were also frustrated by the frequent inability to gain aspirate from fine bore tubes; the consequence of which led to increased time and workload pressures and unscheduled interruptions to patient feeding.

Aims: The aim of this service improvement project was to increase guideline compliance by addressing the issues raised.

Methods: A four step approach was used to guide the project (NHSIQ, 2012). Changes included an educational campaign to raise awareness of importance of following guidelines on NGT position for patient safety; a simplification of the process to reduce time and workload pressures; a scheduled break in feeding to prevent buffering of gastric aspirates and ensure target feed rates achieved and a trial of larger bore feeding tubes to improve aspiration success. The interventions’ effectiveness was evaluated using a staff questionnaire and audit checklist.

Results: Three months after the intervention, questionnaire results showed an improvement (60%) in nurses’ knowledge of critical aspects of the guidelines. Audit results showed this was accompanied by an improvement (66%) in compliance with the use of pH testing as the first line method in checking for correct NGT position.

Discussion & Conclusions: Results showed that the service improvement project met its aim. It is postulated that the educational campaign, by increasing knowledge of the guidelines, and a simplification of the process; played a key role in the success of this project. It cannot be shown, that the break in feed regime accounted for the significant improvement in the use of pH testing. Recommendations include identifying reasons for continuing non-compliance and a repeat audit to monitor improvement.

ReferencesNational Health Service Improving Quality (NHS IQ) (2012) First Steps Towards Quality Improvement: A Simple Guide to Improving Services [Online]. Available at: www.nhsiq.nhs.uk/resource-search/publications/nhs-imp-service-improvement-guide.aspx (Accessed: 23 February 2013)

P20: Delirium: Early screening in critical care, an audit of CAM-ICU

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Kat Thomas, BSUH, UK

Background: Delirium in critical care is often seen and is associated with poor patient outcomes (Pun & Devlin, 2013). Early detection may improve patient safety and overall outcomes by aiding earlier treatment and prevention methods. Due to multiple and varying presentations, delirium is often undetected without a screening tool (Van den Boogaard et al, 2012). CAM-ICU training and changes to delirium documentation were recently introduced to a 28 bedded NHS England adult critical care unit. Aim: This audit aimed to compare delirium screening practice in the critical care unit with NICE (2014) Quality Standard 63 which states all hospitalised adults at risk for delirium should be assessed for recent signs of delirium. Methodology: Retrospective data were collated from critical care admissions occurring 01/09/14 to 30/09/14 (inclusion criteria: > 24 hours in critical care, patients >18 years old). Electronic records for 24 hours from admission were consulted. Nurses could score the patient for delirium (with options: Yes/No) and/or use the CAM-ICU (with outcomes: CAM-ICU positive/CAM-ICU negative). Results: Nurses were often scoring patients for delirium without using a validated screening tool (i.e. CAM-ICU). Furthermore, delirium was more likely to be detected with using CAM-ICU. Only 33% of patients were screened with the CAM-ICU tool. The discussion of results will address barriers to screening, including: staff attitudes, lack of confidence in CAM-ICU and in assessment ability, time required and delirium screening not valued by physicians. Conclusion: This audit demonstrated delirium screening in a critical care unit is not meeting the NICE quality standards for delirium. A multi-faceted approach is required to improve practice involving: changes in documentation, improved communication between the MDT regarding delirium management/prevention, education on delirium and CAM-ICU and on-going support to ensure standards are maintained.

ReferencesNICE. 2014. Delirium. Quality Standard 63. Available from: https://www.nice.org.uk/guidance/qs63 [27/03/15] Pun, B.T. and J.W. Devlin. 2013. Delirium monitoring in the ICU: strategies for initiating and sustaining screening efforts. Seminars in Respiratory and Critical Care Medicine. 34 (2): 179-188. Van den Boogaard, M. et al. 2012. Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study. International Journal of Nursing Studies. 49 (7): 775-783.

P21: Implementing a Weekly Multi-Disciplinary Team (MDT) Meeting to achieve Rehabilitation Needs in Critical Care

Janet Thomas, West Suffolk NHS Foundation Trust,

UK

Many people experience physical and non-physical issues after a period of critical illness. NICE (CG83) guideline “Rehabilitation after critical illness” recommends that assessment to determine the patient’s risk of developing physical and non-physical morbidity is undertaken as early as clinically possible to identify rehabilitation needs. With this in mind it was felt that a weekly MDT approach to rehabilitation in the critically ill at the West Suffolk Hospital would be the best way forward and take into account patients’ needs and preferences.

Critical Care Services, Speech and Language Therapy (SALT) and Occupational Therapy (OT) have been working together to build a stronger relationship to highlight the key roles SALT and OT should have within Critical Care. Qualitative data identified staff views on the roles of SALT and OT, which patients it was thought might benefit most and what the benefits and boundaries of SALT and OT in Critical Care were.

Not all services are funded for this group of patients and initial implementation of weekly MDT meetings failed due to lack of continuity in attendance. The proposal was presented to the senior management team in Critical Care and the Therapies Service Manager for support.

MDT meetings consist of a junior doctor, Follow-up sister, physiotherapist, speech and language therapist, occupational therapist and dietitian. The doctor presents feedback from the morning consultant’s round. The weekly MDT meeting has resulted in improved compliance with NICE (CG83) guideline and a more holistic approach to rehabilitation. All patients have short and comprehensive assessments and a weekly review of their rehabilitation needs and goals. Closer links between SALT and Critical Care has had a positive effect on referral patterns, dysphagia awareness and development of dyspahgia guidelines. OT remains unfunded. It is hoped results from qualitative data and collection of data regarding OT referrals in Critical Care will lead to change and that patients waiting for a ward bed will have an initial OT assessment in preparation for discharge. For patients discharged home from Critical Care, delays could be avoided.

ReferencesNational Institute for Health and Clinical Excellence (2009) Rehabilitation after critical illness. London: National Institute for Health and Clinical Excellence. Available from: www.nice.org.uk/CG83

P22: Early Steps Count

Sarah Leadsom, Claire Mead, Morecambe Bay NHS Trust, UK

A key group of people from the critical care teams at the MBHT have been looking at ways in which the patient rehab and follow up experience can be improved. The aim is that by improving these areas there will be a noticeable improvement in patient experience

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and also a reduction in patient length of stay with patients able to return to their original state of health, if possible, much quicker. With the help of the listening into action (LiA) team, they have set out a 20 week programme to improve key areas within the patient journey including many people from the multi-disciplinary team, including nurses, medics, physiotherapists, occupational therapist and other specialists

As recommended by the NICE (2009) guidelines for Rehabilitation after Critical Care, the LiA group is putting in place a number of initiatives aimed at improving the experiences of the patient surviving the critical care admission. Following collaboration with our sister hospital and research from intensive care units around the country a patient diary is to be rolled out as a major part of the project. The patient diary is common place in many intensive care units in the UK, and particularly in Scandinavia. The diary will be commenced on day 2 of ICU admission and will be completed by all members of the MDT, with contributions welcomed and encouraged from family members. There will be ample space provided to family members to write/ place cards/ draw pictures etc., with the ultimate aim being to involve the family in the psychological care of the recovering patient. The diary will allow recovering critical care patients to make sense of their time on ICU and also will provide a prompt for discussion at follow up clinic.

A second initiative planned by the LiA project is an extension of our existing follow up service. We also plan to have an increased presence on the unit from the physiotherapy team. We plan to create a poster for the 2015 BACCN conference which will highlight the aims, methods and results of this project.

ReferencesNational Institute of Health and Care Excellence (2009), Rehabilitation after critical illness. Available at https://www.nice.org.uk/guidance/cg83/resources last accessed 30.3.2015

P23: GHOSTMIND – A Delirium Prevention Tool

Anne Marie Sanderson, Elaine Magee, Sara Ward, Clare Harte, Belfast health and social care trust, UK

Cardiac surgery in Belfast is carried out in a single centre, and provides a total of 1100 procedures per annum for the population of Northern Ireland. Following surgery patients are expected to spend 24hrs in intensive care before moving to high dependency care (HDU). Slower recovery rates can lead to other surgeries being cancelled due to a lack of beds. Patients suffering from delirium make up a significant proportion of our long stay patients.

Delirium represents an important and growing area of clinical practice. Behavioural and psychological symptoms of delirium include agitation, psychosis, aggression and a variety of inappropriate behaviours. These symptoms are among the most complex, stressful and costly aspects of care and a contribution to morbidity and prolonged hospital stay (Barr et al 2013).

Research shows that there is a lack of awareness of different types of delirium among healthcare professionals in up to 66% of cases (Cadogan et al, 2009).This has a direct impact on the outcomes for patients.

Within the unit, a team was created and motivated by MSc research completed by a clinical sister in the field of Delirium. The delirium team was created to improve the care and management of patients suffering from the condition, and through this work a tool was formulated to support continuous improvement in the care of patients with Delirium.

To aid in the diagnosis of Delirium, the assessment tool (CAM-ICU) is used in daily practice, though as with many conditions, prevention is better than cure – therefore the Delirium team has proposed and introduced the acronym “GHOSTMIND” as an aid-memoir to support staff in the prevention of Delirium.

The aim of the Delirium Team is to communicate the paradigm shift needed to fully institute tailored treatments for patients and their families in dealing with the symptoms of delirium.

ReferencesBarr, J., Fraser, G., Puntillo, K., Ely, W., Gelinas, C., Dasta,J., Davidson, J., Devlin, J., Kress, J., Joffe, A., Coursin, D., Herr, D., Tung, A., Robinson, B., Fontaine, D., Ramsay, M., Riker, R., Sessler, C., Pun, B., Skrobik, Y., Jaeschke, R (2013). Critical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 41(1) 278-280. Cadogan FL, Riekerk B, Vreeswijk R, Rommes JH, Toornvliet AC, Honing ML, Spronk PE (2009). Current awareness of delirium in the intensive care unit: a postal survey in the Netherlands. The Netherlands Journal of Medicine. 67(7):296-300. Inouye, S.K.,van Dyck, C.H.,Alessi, C.A.,Balkin,S.,Siegal, A (1990). Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 11(113), 941-948.

P24: Comparison of the Efficiency of the STOP-BANG and the Berlin Obstructive Sleep Apnea Syndrome Questionnaires for Determining Respiratory Complications during the Perioperative Period

Pervin Gokay, Sevinc Tastan, Gulhane Military Medical Academy, School of Nursing, Turkey, Mehmet Emin Orhan, Gulhane Military Medical Academy, Department of Anaesthesiology and Reanimation, Turkey

Introduction: The prevalence of Obstructive Sleep Apnea Syndrome (OSAS) is higher for the population that underwent an operation compared to the general population. Anesthesia for the patients diagnosed with OSAS may lead to respiratory complications, unplanned transfer to the intensive care unit and prolonged stays at the hospital. This study aims to compare the efficiency of the

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STOP-BANG and the Berlin OSAS Questionnaires for evaluating the respiratory complications during the perioperative period.

Methods: This is a descriptive study. The sample of the study consist of 126 surgical patients, who underwent laparoscopic cholecystectomy between November 2013 and March 2014. OSAS screening tests were administered in all patients during preoperative period. The patients were evaluated in terms of the respiratory complications during intubation, extubation and during evaluation in Post-Anesthesia Care Unit (PACU)

Results: During intubation, the study found statistically meaningful differences in difficult intubation, difficult facemask ventilation and desaturation frequency for the group, which had hig-risk of OSA based on the STOP-BANG questionnaire, compared to the low-risk group (p<0.05). During extubation, statistically meaningful differences in airway obstruction and desaturation frequency were found for the high risk for OSA group according to the STOP-BANG questionnaire, compared to the low risk group. Besides, statistically meaningful differences in coughing, breath-holding and desaturation frequency were found for the high risk for OSA group compared to the low risk group according to the Berlin questionnaire (p<0.05). For determining the respiratory complications in PACU, such as mild desaturation, serious desaturation and the need for oxygen support, both questionnaires found statistically meaningful differences between low-and high-risk groups.

Conclusions: we recommend use of OSAS screening tests to predict respiratory complications during perioperative period. STOP-BANG testing may be preferred primarily in clinics because of it’s easy of use and efficiency predicting respiratory complications

Keywords: Sleep Apnea, OSAS Screening Tests, Respiratory Complications

ReferencesChung F., Yegneswaran B., Liao P., Chung S.A., Vairavanathan S. & Islam S. (2008) Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 108 (5), 822–30. DOİ: 10.1097/ALN.0b013e31816d91b5. Gali B., Whalen F., Schroeder D.R., Gay P. & Plevak D. (2009) Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiolgy 110 (4), 869-77. DOI: 10.1097/ALN.0b013e31819b5d70. Kim J.A. & Lee J.J. (2006) Preoperatif predictors of difficult intubation in patient with obstructive sleep apnea syndrome. Canadian Journal Anesthesia 53 (4), 393–397.

P25: An audit of delayed discharges from critical care

Marta Soares, Brighton Sussex University Hospitals, UK

Aim: to audit delayed discharges from critical care and to make recommendations for improvements with the flow of patients out of critical care.

Background: Patient flow is crucial for an efficient, high quality and safe critical care service. A delayed discharge is when a patient is transferred to a ward > 4 hours from the decision to discharge (Intensive Care Society, 2013). Delayed discharges hinder the efficiency and effectiveness of critical care services and have a negative impact on the patient experience (Stelfox HT, et al. 2013).

Method: This was a retrospective audit of discharges from a 28 bedded NHS England adult critical care unit (16 ICU beds + 12 HDU beds) from 01/01/15 to 31/01/15. A total of 130 discharges occurred but 36 were excluded (patients who died, were discharged home or transferred to another hospital) leaving 94 discharges reviewed for the audit. Data were collected using the Metavision electronic clinical information system (iMDsoft®) including: date/time of the critical care discharge to an acute care ward, the length of stay in critical care and reason for delayed discharges.

Results: 24% of discharges occurred < 4 hours from the decision to discharge, 50% happened > 4 hours and 26% had no documentation. Reasons for delays included shortage of ward beds (72%), lack of side room (2%), 4% of delayed discharges had documented “other reason”, 15% didn’t have any documentation and 7% the documentation was wrong.

Conclusion: This audit has shown delayed discharges from critical care are common with a shortage of ward beds identified as the biggest reason; however, a large number of discharges were lacking documentation. New strategies and education interventions are suggested in order to reduce safety risks resulting from delayed discharges.

ReferencesIntensive Care Society, 2013. Core standards for intensive care units. London: Intensive Care Society. Stelfox HT, et al. 2013. Identifying Intensive care unit discharge planning tools: protocol for a scooping review. BMJ open: 3 (4).

P26: Supporting Mentors to support New Starters

Rebecca Sumnall, Deborah Preston, Caroline Wordsworth, Ruth Ibbotson, University Hospitals of Leicester NHS Trust, UK

Following a bulk recruitment campaign our critical care units received an unprecedented number of new nurses with limited experience. The Education and Practice Development team (EPD) were aware that this would impact on the skill mix of staff and increase pressure on relatively junior mentors to ensure that these new starters could practice safely and were fit for purpose. Mentors are key in the development of clinical skills. In order for them to function effectively in this demanding role we must provide them with education, training and ongoing facilitation. (Hayes, 2006)

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To address this the EPD team prepared 6 interactive forums for band 5 mentors in critical care. Learning outcomes for these forums were:

1. Provide practical support for nurses mentoring new starters in practice.

2. Gain insight into the challenges and barriers our mentors were facing in practice

3. Gain understanding as to the quality of mentoring our new staff received

4. Ensure our mentors felt valued and identify if any mentor burn out existed,

During each forum the staff were split into groups and asked to discuss key themes surrounding mentoring and supporting new starters. Following on from this, staff were given the opportunity to feedback to the wider group and answers were given to questions posed on corporate and local programmes, staff queries and concerns.

The 6 forums provided feedback to us on various issues that needed to be addressed including the perceived level of support provided to the band 5 mentors by the band 6/7 team. We addressed this by planning a similar event with the senior teams to give them feedback from the band 5 events.

We have also planned an event to talk to some of the new starters we have had during the last year to investigate their perceptions of the mentoring they received.

ReferencesHayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchand, J., Hughese, F., Spence Laschingerg,H.K., North, N. & Stone, P.W. (2006) Nurse turnover: A literature review. International Journal of Nursing Studies 43 237–263

P27: Does Electronic Prescribing really reduce Critical incidents?

David Sapsford, Hayley Gilbrook, West Suffolk Hospital, UK

Introduction and Aims: In recent years we have witnessed increased emphasis on electronic patient records, data collection, prescribing and clear lines of governance. Much of the literature suggests that the introduction of an electronic prescribing system improves the quality of prescriptions and reduces drug errors (Donyai et al. 2008).

Over a four year period we have implemented electronic prescribing from a previous paper based system and subsequently upgraded the system to improve functionality and accessibility to users. This work aims to compare all drug related incidents for one year prior to implementation of electronic prescribing, one year following implementation and one year following subsequent development and upgrade.

Methods: The trust electronic incident reporting system (Datix®) was interrogated and drug related incident reports were categorised

into Prescription errors, Administration errors and Other.

Results: The results were collected over a period from October 2009 until November 2014.Paper based prescribing between 01/10/2009 – 01/10/2010 showed 23 incidents in total: 2 (8.7%) prescription related incidents, 9 (39.1%) Administration related incidents and 12 (52.2%) other incidents. Electronic prescribing using Metavision≦ between 01/11/2011 – 01/11/2012 showed 19 incidents in total: 4 (21.1%) prescription related incidents, 7 (36.8%) Administration related incidents and 8 (42.1%) other incidents. Electronic prescribing using Metavision≦ MetaOrders between 01/11/2013 – 01/11/2014 showed 18 incidents in total: 6 (33.3%) prescription related incidents, 7 (38.9%) Administration related incidents and 5 (27.8%) other incidents.

These results describe a slight reduction in reported incidents over the five year period since implementing an electronic prescribing system. It appears from the results that prescribing errors have increased in frequency however on further analysis, up to 50% of these errors occur on transcription of the electronic chart when preparing the patient for ward based care using paper drug charts. With a trust wide electronic system these transcribing errors would have been eliminated. Additionally, some of the more recent errors have been as a result of systems errors. These have been successfully rectified and as such should not feature in the future.

As barriers to reporting incidents decrease and perceptions change allowing us to learn from these events, reporting should be encouraged. Indeed this study was critically limited by collecting data in a retrospective manner which is possibly reflected in the low number of incidents reported. It is unknown whether this data set is truly representative of all drug incidents or errors.

ReferencesDonyai, P. O’Grady, K. Jacklin, A. Barber, N. Franklin, B. (2008) The effects of electronic prescribing on the quality of prescribing. British journal of clinical pharmacology 65(2) p. 230-7

P28: ‘All About me on Critical Care’

Rhona Hayden, Anthony Coombs, Southend University Hospital NHS Foundation Trust, UK

Critical Care patients are often sedated, unable to communicate; this affects how communication takes place. Also relatives often experience anxiety and can be distressed. As nursing staff we must take into account that our patients and staff may be from different cultures with English not necessarily being their first language.

Inherent in caring for patients is the requirement that we optimise communication opportunities. This is pertinent in all areas and specifically in patients where there are communication barriers. Articles published on this topic report that ‘Nurses on critical care are the most frequent communication partners to critically ill patients’ (Radtke, Tate & Happ 2012). Also events that occur during periods of unconsciousness or sedation can impact on long term psychological outcomes ( Hofhuis et Al 2008). Nurses will frequently

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care for patients with varied communication needs but have had minimal education in facilitating communication and interpreting the patient with communication impairment (Grossbach, et al 2010).

In response to the above we looked if we could improve how we communicate with tour patients. We found a disparity between patients who had been with us for some time and those who had just been admitted. Longer term patient’s staff had built a rapport with families and gained knowledge about the patient’s life and what families felt was important. This information was valuable in initiating discussion with the patient and forged links with the families.

We produced a sheet for relatives to complete entitled ‘All about Me on Critical Care’. We based our communication tool on the ‘This is me’ document produced by the Alzheimer’s society. Families have said they feel they are given the opportunity to tell a little about their relative. Nurses report that they like to read what has been written by the families and use this information to talk to their patients.

ReferencesGrossbach, I. Stranberg, S. and Chlan, L., 2011. Promoting Effective Communication for Patients Receiving Mechanical Ventilation. Critical Care Nurse, 31(3), pp. 46-61. Hofhuis, J. Spronk, P. Van Stel, H. Shrijvers, A. Rommes, J. and Bakker, J., (2008). Experiences of critically ill patients in the ICU. Intensive and Critical Care Nursing, 4 (3), pp. 227-232. Radtke, J, V. Tate, J, A. and Happ, M, B., 2012. Nurses’ perceptions of communication training in the ICU. Intensive and Critical Care Nursing, 28, pp. 16-25.

P29: Challenges in Early Mobilization of the critical ill patient due to heterogeneous allocation of Treatment Teams

Karin Klas, IMC FH Krems, Austria, Peter Nydahl, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Germany, Petra Kozisnik, IMC FH Krems, Austria

Early Mobilization of the critical ill patient can be seen as a standardized treatment programme on ICUs (Intensive Care Units) nowadays. Numerous research papers and studies show the benefit for the patient’s outcome. Not only the benefit for the individual patient (e.g. quicker convalescence, reduction of VAP) but also the benefit for the general public (e.g. cost reduction through shorter in hospital stays) hereby has to be mentioned.

Due to the very heterogonous allocation of Treatment Teams at ICUs worldwide it is difficult to make universally applicable statements referring to the responsibilities and duties of members of the Therapeutic Team (e.g. Nurses, Physiotherapists, Consultants, Occupational therapists) on ICUs during early mobilization and weaning of patients.

During the 2nd Conference on Weaning and Early Mobilization of Critical Ill Patients, 2014 in Athens/Gr and the 25th Symposium for Intensivmedicine and Intensivcare, 2015 in Bremen/D participants had been asked to participate in the survey. Participants of the conference (Physiotherapists, Critical Care Nurses, Clinicians and occupational Therapists) from all over the world were included into these descriptive studies. An identical (English and German) standardized questionnaire was used.

A description and interpretation of the results and a comparison of the statements, made by the different professions under notice of the national working conditions and settings, has been performed and showed a diverse picture in both surveys. This might have been influenced by the number of participants of the different professions in the two surveys. Nevertheless the results line out the necessity of a multiprofessionel training of the therapeutic Team working on ICU’s in the field of Early Mobilization and Weaning for the future. Further research has to be conducted and special multiprofessionel training programmes should be developed to implement, improve and standardize Early Mobilization and Weaning on ICU’s.

ReferencesBalas, MC., Vasilevskis, EE., Olsen, KM., Schmid, KK., Shostrom, V., Cohen, MZ., Peitz, G., Gannon, DE., Sisson, J., Sullivan, J., Stothert, JC., Lazure, J., Nuss, SL., Jawa, RS., Freihaut, F., Ely, EW., Burke, WJ.: Effectiveness and safety of the awakening and breathing coordination, Delirium Monitoring/Management, and early exercise/mobility bundle. In: Crit Care Med 42/2014, 5, 1024-1036 Garzon-Serrano, J., Ryan, C., Waak, K., Hirschberg, R., Tully, S., Bittner, EA., Chipman, DW., Schmidt, U., Kasotakis, G., Benjamin, J., Zafonte, R., Eigermann, M.: Early mobilization in critically ill patients: patients’ mobilization Level depends on health care provider’s Profession. In: PM R 3/2011, 4, 307-313 Lord, RK., Mayhew, CR., Korupolu, R., Mantheiy, EC., Friedman, MA., Palmer, JB., Needham, DM.: ICU early physical Rehabilitation programs: financial modeling of cost savings. In: Critical Care Medicine 41/2013, 3, 717-724

P30: Service evaluation to measure night-time care activities and perception of sleep in Level 2 patients on a General Intensive Care Unit (ICU)

Charlotte Tulloch, Leanne Gallagher, University Hospital Southampton NHS Foundation Trust, UK

Background: Deprivation of sleep in critically ill patients is a well-described problem. Research has highlighted nocturnal noise and light as important variables that contribute to sleep deprivation. Sleep deprivation can lead to physiological and psychological dysfunctions that increase morbidity and mortality (Morton 2013). Some studies within critical care have shown how the reduction of light and noise overnight can improve sleep and reduce the incidence of delirium (Patel 2014).

Aims: To explore the type and frequency of night-time care

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activities, and assess how patients perceived sleep, on a 25 bedded teaching hospital general ICU.

Methods: As a service evaluation, 57 patients (aged >18, Level 2 care) were observed between 23:00 and 06:00 on 6 consecutive nights. Care activities were observed for 5 minutes every hour on the hour and documented as: personal care, re-positioning, medications, noise stimulation, light stimulation or medical intervention. Twenty-five of these patients (CAM-ICU negative) were evaluated using the Richards-Campbell Sleep Questionnaire (RCSQ). The RCSQ evaluates perceptions of depth of sleep, sleep onset latency, number of awakenings, time spent awake and overall sleep quality.

Results: The RCSQ Likert scale mean scores suggested most patients’ sleep was light (63.5%). Some patients struggled to fall asleep (40%), experienced disturbed sleep (47.4%), and rated their sleep as of poor quality (51%).

The mean number of undisturbed hours was 4.6. Only 40% had an undisturbed night. Of the patients observed, 63% had <5 undisturbed hours. Care activity rates were observed as follows:

• Medical intervention (22.7%)• Noise stimulation (19.6%)• Personal care (19.6%)• Light stimulation (19%) • Medications (11.1%)• Re-positioning (8%)

Discussion and conclusion: Sleep deprivation is common and its causes are multi-faceted. Changes in nocturnal care by the multi-disciplinary team are required to facilitate improved sleep.

ReferencesMorton, P. G. and Fontaine, K. D. (2013) Critical Care Nursing: A Holistic Approach. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins. Patel, J., Baldwin, P., Bunting, P. And Laha, S. (2014) ‘The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients.’ Anaesthesia. 69 (6): pp 540-549.

P31: Building workforce capacity to improve standards of patient care

Jo Tillman, Barts Health, UK

The Adult Critical Care Unit (ACCU) at the Royal London Hospital (RLH) is committed to recruiting, developing, supporting and retaining nursing staff to ensure evidenced based, safe, harm free care within a busy and dynamic 44 bedded unit.

Eighteen months ago, the ACCU had a vacancy rate of 35% with a staff turnover of approximately 5% per month. To comply with Trust and National guidelines on safer staffing levels we embarked upon a quality improvement drive to build our workforce capacity to ensure

sustained delivery of the highest standards of care. The initial local recruitment strategy that was implemented reduced our vacancy rate by 40%. In addition, an international recruitment campaign was held which successfully recruited to the majority of vacancies. The ongoing strategy to recruit to establishment is now linked into rolling NHS job adverts, recruitment open days and appropriate advertisement and promotion of the ACCU.

In addition to recruitment, particular attention was focused on retention and the strategy that has been embedded has seen a 70% reduction in the turnover of ACCU staff. This focused on the development opportunities for all nurses and healthcare support workers, from Band 3 through to the senior clinical nursing team. This has provided access and structure to both in-house and external training and development opportunities, both formal and informal, and utlising the diverse opportunity for education in the direct clinical setting. The focus is on combining and offering opportunities in the following domains: professional development including excellence in clinical skills, academic accreditation in postgraduate study, clinical governance and team building.

Outcomes measures used to assess the success of this strategy include; improved patient safety, enhanced patient experience, reduced reliance/spend on bank and agency, development of expert clinicians and greater staff retention, paving the way for quality improvement and innovation in health care.

P32: Continuous Renal Replacement Therapy: Under Control Non- Anticoagulant Strategies to Prevent Circuit Failure

Ria Diel, Royal Berkshire Hospital, UK

Aim: This poster is aimed at critical care, acute renal and haemodialysis nurses for review of practice. The objective is to discuss specific nursing management approach essential to prevent circuit failure during continuous renal replacement therapy (CRRT) not related to anti-coagulation. The evidence-based factors regarding complex technical filtration settings that could extend filter life will also be evaluated. This poster is not designed to ‘spoon feed’ all the facts but serves to motivate self-directed learning.

Abstract: Continuous renal replacement therapy (CRRT) was deemed to be a superior and widely used treatment modality for critically ill patients who develop Acute Kidney Injury for it attains better solute clearance and volume control (Kellum et al 2009). The extracorporeal circuit is the lifeline as well as the Achilles’ heel of CRRT, hence, it is crucial to maintain its patency and avoid unplanned circuit failure. Recurrent circuit clotting could lead to suboptimal treatment, blood loss, over utilising supplies and increased staff workload (Joannidis and Oudemans-van Straaten 2007). The anti-coagulant regimen that would best promote circuit life has been debated over decades, however, it is more of a medical and institutional choice. Whilst nurses who manage the CRRT around the clock have more control on aspects of patient care to maintain the treatment regardless of what anticoagulant is in use. The ‘ABC’ nursing strategies to prevent circuit failure are specified

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to: Access: Vascular Access Care; Blood flow rate, Pre-dilution and Filtration Fraction; and Correcting alarms promptly. Vascular access care for CRRT involves technical monitoring skills and also basic nursing care for instance securing the access, troubleshooting and management when not in use. Settings and modes of CRRT such as blood flow rate, pre-dilution and filtration fraction could be adjusted to prevent blood stasis and promote haemodilution thereby delaying blood clot formation. Pre-dilution and filtration fraction are perhaps often overlooked as factors which have huge impact in preventing circuit failure. A 3% decrease in filtration fraction improves the circuit life comparable to the effect of 10 seconds increase in activated partial thromboplastin time (MacEwen et al 2014). Additionally, responding to alarms quickly would prevent treatment interruption and prolonged blood stasis due to suspension of blood flow. Prompt and correct assessment of the alarm is imperative before doing any adjustments.

ReferencesReference List Joannidis M and Oudemans-van Straaten H (2007) Clinical review: patency of the circuit in continuous renal replacement therapy.Critical Care. 11(4), 218. Available at: http://ccforum.com/content/11/4/218 (accessed 01/03/2015).Kellum J, Bellomo R and Ronco C (2009) Continuous renal replacement therapy. Oxford: Oxford University Press. MacEwen C, Watkinson P and Winearls C (2014) Circuit life versus bleeding risk: the impact of achieved activated partial thromboplastin time versus achieved filtration fraction. Therapeutic Apheresis and Dialysis. doi: 10.1111/1744-9987.12253.

P33: Developing a simulation programme in Adult Critical Care to support the induction of new staff nurses

Vicky Burch, Laura Bathe, Kate Towne, Nottingham University Hospitals NHS Trust, UK

Aim: To share the experience of developing a simulation programme for new nurses to critical care from developing learning outcomes, scenarios, and a robust debriefing processes to meeting the challenges.

Abstract: Simulation has been introduced into our Adult Critical Care area to support a pre-existing and established classroom based Critical Care Foundation Course that new nurses attend within their first 6 months. It is widely known that the effectiveness of adult learning is greatly increased by having elements of active participation in teaching programmes and adding simulation into this course has allowed development of experiential learning opportunities. According to Fanning & Gaba (2007) this is a process of ‘learning by doing, thinking about, and assimilation of lessons learnt into everyday behaviours (p115).’ Similar processes have also been discussed by Kolb and Gibbs and provide the basis for what we aimed to achieve through this simulation programme.

As the course is aimed at nurses new to Critical Care the key aims are to understand the importance of human factors in Critical Care, team working, and the ‘perfect’ handover and communication,

in order to provide safe patient care. Three different scenarios are played out over a half day course in which staff have the opportunity to both participate and observe. Staff observing are given an exercise to enable constructive feedback. The scenarios have been carefully developed with the support of the faculty from the Trent Simulation and Clinical Skills Centre to place the staff in situations that test their team working and communication skills but also create opportunity to demonstrate and practice critical care clinical skills within a safe environment.

Developing this programme has been challenging and is ever evolving. Pre and post evaluation give insight into the anxieties staff feel about this type of learning, their willingness to participate, challenges around the falseness of the environment and ensuring learning outcomes are clear and debriefing is correctly pitched. Post evaluation also show increased confidence in communication with multidisciplinary team, increased confidence in their practice and an increase in their pleasure at being involved in simulation.

Learning Objectives:• Developing scenarios with clear learning objectives• Understanding and developing skills in debriefing to maximise

learning• Evaluating to continually develop the programme

ReferencesReading Fanning, R & Gaba, D (2008) Simulation-Based Learning as an Education Tool. Anaesthesia Informatics http://link.springer.com/chapter/10.1007%2F978-0-387-76418-4_24#page-1 Fanning, R. & Gaba, D. (2007) The Role of Debriefing in Simulation-Based Learning. Simulation in Healthcare. 2(2), pp115-125 http://www.med.wisc.edu/files/smph/docs/clinical_simulation_program/The_Role_of_Debriefing_in_Simulation_Based.71.pdf Teunissen, PW. & Bok, HGJ. (2013)Believing is seeing: how people’s beliefs influence goals, emotions and behaviour. Medical Education. 47, pp. 1064-1072Nursing Standard. 24 (2), 35; Humphreys M. (2013). Developing an educational framework for the teaching of simulation within nurse education. OJ. Vol 3 (No 3), p35 Rudolph J. (2006). There’s no such thing as ‘ non judgmental’ debriefing, Simulation in Health care. Nurse education today. 1 (1), p49; HEE.nhs.uk/work-programme/tel - accessed 15/2/15 14.3

P34: Staff’s perceptions of MetaVision one year on

Chris Wolstencroft, Medway NHS Foundation Trust, UK

Background: The Intensive Care Unit (ICU) at Medway NHS Foundation Trust started using MetaVision iMDsoft in April 2014 to capture and manage all ICU patient related dataMetaVision is known to reduce errors, save time, improve patient record keeping by the multi disciplinary team, assist with patient safety, increase compliance with best practice and protocols, assist with research and improve reporting and maximise billing. Over the years a number of papers have shown the impact of using a system such as MetaVision. Bourne & Choo (2012) found that critical care medical staff were more likely to accept recommendations

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made by pharmacy staff using MetaVision, and Schwann, Bretz, Eid et al (2011) found an increased compliance with that antibiotic administration and a decrease in wound infections. Wilks (2013) examined nurses’ perceptions of using MetaVision and found that the results were in the main positive.

Having used MetaVision for 12 months we wanted to get an understanding of our nurses’, doctors’ and allied health are professionals’ perceptions of the system, and how it has affected their practice

Methodology: All nurses, doctors and allied health are professionals involved in the care of the ICU patients were given a questionnaire to complete. These were completed anonymously and returned to a central collection point.

Results: The results were generally positive and staff found MetaVision to have a positive impact on the critically ill patient

ReferencesBourne RS, Choo CL (2012). Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit. International Journal of Clinical Pharmacology. 34(2):351-357 Schwann NM, Bretz KA, Eid S, Burger T, Fry D et al (2011). Point of care electronic prompts: an effective means of increasing compliance, demonstrating quality and improving outcome. Anesthesia & Analgesia. 113(1): 869: 876 Wilks J (2013) Nursing perceptions’ of clinical information systems in a completely electronic ICU—A unique experience. 26(2): 94

P35: Nurse Grief Too: Caring for Nursing Students Working With Dying Patients in Critical Care Units

Wei-Shu Lai, Department of Nursing, Meiho University, Taiwan

Background: Critical care nurses are faced with repeated exposure to death and dying as they are involved in caring for patients with life-threatening conditions. Without the opportunities to explore one’s grief in response to the death of a patient, nurses may lead to occupational stress, and ultimately burn out. However, nurses’ grief is not often acknowledged or discussed and little attention is given to preparing nurses for this experience in schools of nursing. To provide outstanding nursing care, it is critical for nurses to be aware of their own grief in nursing care.

Aim: To explore the impacts regarding caring for dying patients of nursing students in critical care units, and to determine the effects of bereavement debriefing sessions in nursing education.

Method: Focus groups were held with nursing students to explore the impacts regarding caring for dying patients. Eight second year nursing bachelor students who had experience of caring for dying patients in critical care units were enrolled in this study. A structured format for conducting bereavement debriefing sessions were specifically aimed at providing emotional support and increasing

one’s ability to cope with grief. Data were collected to capture themes discussed.

Results: Subjective positive outcome revealed that bereavement debriefing sessions can provide emotional support and increasing nursing students’ ability to cope with grief. Seven primary themes emerged: 1) insights into own life experiences with loss; 2) recognizing hidden sorrow-- making the invisible grief visible; 3) to express and accept a full range of grief feelings; 4) to be aware of the limitations of medicine as well as own limitations as caregivers; 5) reflecting boundaries of helping relationships; 6) transforming and transcending the personal suffering in their lives; 7) therapeutic use of self to help others.

Conclusions: Bereavement debriefing sessions can be an effective approach to support nursing students in face of the patient death. This transformation has a positive impact on nursing profession as a whole. Promoting an environment of care where respect the need to express grief is important.

Keywords: grief, critical care, bereavement debriefing, nursing students

ReferencesWenzel, J., Shaha, M., Klimmek, R.,& Krumm, S. (2011). Working Through Grief and Loss: Oncology Nurses’ Perspectives on Professional Bereavement. Oncology Nursing Forum, 38(4), E272-282. Keene, E. A., Hutton, N., Hal, B., & Rushton, C. (2010). Bereavement Debriefing Sessions: An Intervention to Support Health Care Professionals in Managing their Grief after the Death of a Patient. Pediatric Nursing, 36(4),185-189.

P36: Designing and Implementing a tool to review Critical Care Research processes

James Cullinane, Claire Pegg, Catherine Plowright, Medway Maritime Hosptial, UK

Clinical audit has been defined as ‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’ (NICE, 2011).

Due to the stringent regulations in place for Clinical Trials of an Investigational Medicinal Product (CTIMP) we recognised that our current research practice needed reviewing and if necessary improving. Before setting up LeoPARDS (our first CTIMP trial) there were no “official” in-house processes in place within our team for monitoring our trial site files to make sure they stayed up-to-date or accurate. Therefore we needed an audit tool to demonstrate transparency in our documentation processes but also to comply with MHRA (Medicines and Healthcare products Regulatory Agency) regulations and Good Clinical Practice (GCP) (MHRA, 2014).

Examining our existing documentation we developed a basic framework for what information should be included in the tool. Liaising with our senior research nurse, R&D department and Audit

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Lead about the tool informed us as to what extra needed to be included. Upon completion of the tool our senior research nurse was very enthusiastic about incorporating it into her research team’s practice.

This presentation will look at why the tool was developed, the processes we went through in designing it and also how it has changed our practice for future trials. The aim of this presentation is to share with other healthcare professionals working within critical care research the tool we developed to further improve research practice. This is importance because as nurses we should all be looking to constantly improve our practice to benefit patient care (NMC, 2015).

ReferencesNational Institute of Clinical Excellence (NICE) (2011) Principles for Best Practice in Clinical Audit. Oxford: Radcliffe Medical Press. Medicines and Healthcare products Regulatory Agency (MHRA) (2014) Good Clinical Practice for Clinical Trials. Available at: https://www.gov.uk/good-clinical-practice-for-clinical-trials (Last Accessed: 19/03/2015) The Nursing and Midwifery Council (NMC) (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. Available at: http://www.nmc-uk.org/The-revised-Code/ (Last Accessed: 19/03/2015)

P37: Transition Experiences of Newly Graduated Nurses during First Six Months in Critical Care Units

Ming-Yueh Tseng, Graduate Institute of Health Care, Meiho University, Taiwan, Shiow-Li Hwang, Department of Nursing, Asia University, Taiwan, Wei-Shu Lai, Department of Nursing, Meiho University, Taiwan, Yu-Jue Hong, Department of Nursing, Chung-Jen Junior College of Nursing, Health Sciences and Management, Taiwan

Background: The transition period for newly graduated nurses is a dynamic process which fulfills stressful and challenges, especially in critical care units. Understand their experiences, consolidate their nursing knowledge and assist them in their continuing nursing career is important issue. Aim: The purpose of this study was to explore the perceptions and experience for newly graduated nurses work in critical care units during their first six months of nursing career.Methods: This study was used a qualitative approach, and semi structured interviews were conducted with the participation of 8 graduated nurses from September 2014 to March 2015 work in intensive care units. Data were analyzed using category-content analysis.

Results: The findings included six categories identified as (1) insufficient nursing competences to handle critical situations, (2) lack of control over practice and work overload, (3) feelings of

multiple stresses and anxiety, (4) lack of support and belonging in clinical settings, (5) lack of communication skills, clinical reasoning, and self-confidences, (6) insufficient career planning.Conclusions and practical application: The results of this research increase the understanding of newly graduated nurses regarding the transition experiences and needs in critical care units. Strategies such as multiple social networks, orientation and mentoring programs, and simulation teaching method were applied to establish newly graduated nurses reflective thinking, communication skills, and problem solving skills. Thus, helping newly graduated nurses to adapt new environment, successfully role transition into nursing practice and build up the value of nursing professional. Keywords: newly graduated nurses, transition, qualitative study, critical care units

ReferencesDuchscher, J. E. B. (2009). Transition shock: the initial stage of role adaptation for newly graduated Registered Nurses. Journal of Advanced Nursing, 65 (5), 1103-1113. Dyess, S. M. & Sherman, R. O. (2009). The first year of practice: new graduate nurses’ transition and learning needs. Journal of Continuing Education in Nursing, 40 (9), 403-410. Edwards, D., Hawker, C., Carrier, J. & Rees, C. (2011). The effectiveness of strategies and interventions that aim to assist the transition from student to newly qualified nurse. JBI Library of Systematic Reviews, 9(53), 2215-2323.

P38: Perceptions of Experienced ward nurses transition into the Critical Care Environment

Nicola Gower, Victoria Rutherford, Gemma Sutton, West Suffolk Hospital, UK

The aim of this poster is to explore the transition from ward nurse to critical care nurse, the challenges that are faced and the support mechanisms that could be implemented to make the transition easier. It has been recently documented that this transition period can be a challenging time (Scoles 2015). As nurses who have recently relocated from other clinical areas, we have identified difficulties commonly experienced.

Nurses that had moved to the critical care environment within the last 18 months were asked to complete an anonymous questionnaire about their experiences of changing to a different clinical areas.

The questionnaire looked at:

• How long they have worked as a nurse prior to moving to the critical care unit

• If their previous experience was acknowledged• The amount of time that they have been allocated to work

alongside their mentors• The length of time they were given to enable adjustment to the

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new environment• How these factors influenced their adjustment to the critical

care environment.• If having a peer mentor would have been of benefit

Common themes that were identified from the research included that many nurses felt that a slightly longer period of supernumerary time would have been beneficial. They identified that there were occasions where they could have been more supported by their mentor as working alongside different nurses can cause confusion with understanding of some key topics.

Other key points of note were the limited number of shifts that were worked alongside allocated mentors, as a result it was difficult for new and established staff members to gauge their progress.

The peer mentor idea seemed to be taken as a positive idea which staff members thought may work within the clinical area, identifying someone to approach that can help with queries and reassure the new members of staff.

ReferencesScoles, J. (2015) The support for newly qualified practitioners and new staff entering the critical care environment. Nursing in Critical Care. 20(1) pg 1-2

P39: PICC Line Management

Sarah Smith, Hywel Dda Health Board, UK

A Peripherally inserted central catheter (PICC) or long line as it is sometimes referred to, s a catheter which is inserted into the ante-cubital fossa or upper arm and ends up in the superior vena cava where blood flow is high and allows dilution of drugs. PICC lines are becoming more popular within the critical care environment and are invaluable for patients who have fragile veins and/or require long term venous access. In my critical care unit they are now being used as an early intervention rather than a last resort mechanism and inserted prior to the patient being transferred out to a ward area.

A PICC line has advantageous benefits for patients compared to other catheters, if cared for properly the line can remain in use for several months. It prevents the patient having to be bled or cannulated frequently, and because of the end location of the catheter parental feeding and irritant drugs can be administered through the line. Although PICC lines have many advantages over peripheral cannulas, if they are are not maintained and cared for properly the catheter can cause serious harm to the patient to include local phlebitis or septicaemia in some cases , Were early signs of infection are not identified in its early stage. Therefore education regarding there management is essential to enable health professionals to care for these lines effectively and appropriately with a view of reducing the complications associated with there use and enhance the benefits . My aim is to provide a quick reference guide to PICC line management in the form of a poster in order for PICC lines to be

used to there full potential . Key interventions will be highlighted such as dressing change procedure , flushing the lines, early indication of inflammation and infection and troubleshooting issues associated with line use.

ReferencesCotongni P, Pittiruti. M. (2014) Focus on peripherally inserted central catheters in critically ill patients [Online] PubMed 3 (4) 80-94 Available from: http://ncbi.nlm.nih.gov. [Accessed on 6th april 2015]

P40: New guidelines for the management of diabetic ketoacidosis: An education for those providing Critical Care

Sara Oddy, Hywel Dda Health Board, NHS Trust, UK

Introduction: Diabetic ketoacidosis (DKA) is defined as an acute metabolic emergency characterised by a triad of hyperglycaemia, ketonaemia and acidosis (Crasto et al., 2015). Generally associated with type 1 diabetes, if mismanaged, DKA can result in critical care admission, significant morbidity and mortality (Rudd et al., 2013).

Background: Guidelines for the management of DKA were published in 2010 by the Joint British Diabetes Society (JBDS) having established a link between a lack of concise and current guidance and poor patient outcomes (Crasto et al., 2015). However, Rudd et al., (2013) claim that these guidelines were criticised for the non-consultation of Intensivists, despite DKA management often involving admission to a Critical Care Unit.

In response to criticism the JBDS published a revised, second edition of guidelines (JBDS, 2013), having consulted the Intensive Care Society for their review and consultation. Following publication of these guidelines an Adult DKA Care Bundle was introduced within a local Health Board and in turn their Adult Critical Care Unit. Clear and concise DKA management and a care pathway were included in order to ensure timely, effective patient care.

Crasto et al., (2015) state that despite adherence to the JBDS guidelines in the initial management of DKA; iatrogenic hypoglycaemia and inadequate fluid resuscitation and metabolic monitoring highlight a deficit in the ongoing management and a need for further education and dissemination of the guidelines. Rudd et al., (2013) concur, claiming that effective communication and training of new protocols and guidelines relating to DKA is essential if effective, safe practice is to ensue.

Purpose: In order to compliment a Health Board wide distribution and education on the revised Adult DKA Care Bundle, a Poster Presentation has been prepared with particular emphasis upon management of those with severe DKA who require critical care.

ReferencesCrasto, W., Htike, Z., Turner, L., Higgins, K. (2015) ‘Management of diabetic ketoacidosis following implementation of the Joint British Diabetes Societies guidelines: where are we and where should we go?’, The British Journal of Diabetes and Vascular Disease, 15 (1), pp.

11-16. Joint British Diabetes Societies Inpatient Care Group (2013) The management of diabetic ketoacidosis in adults: second edition. London: Joint British Diabetes Societies Inpatient Care Group for NHS Diabetes. Rudd, B., Patel, K., Levy, N., Dhatariya, K. (2013) ‘A survey of the implementation of the National Health Service diabetes guidelines for management of diabetic ketoacidosis in the intensive care units of the East of England’, Journal of the Intensive Care Society, 14 (1), pp. 60-64

P41: Making the Critical Care Environment safer: Reducing accidental device displacements

Catherine Dunston, Sarah McHenry, Blackpool Teaching Hospitals NHS Foundation Trust, UK

Providing a safe environment within Critical Care can be challenging. Within Lancashire and South Cumbria Critical Care Network we have started to monitor more closely the number of accidental device displacements that occur using a safety cross. Following the implementation of this tool Blackpool Teaching Hospitals NHSF Trust, along with raising awareness we saw a sharp increase in the number of device displacements being reported. Devices reported included endotracheal tubes, tracheostomy tubes, nasogastric tubes, central venous catheters, chest drains, arterial lines and peripheral cannula.

Literature demonstrates that device removal by critical care patients is common, resulting in harm in one fourth of patients and significant resource expenditure. 1 The risk of harm can be reduced through education, correct staffing ratios and learning form incidents. 2

With this in mind we decided that we needed to develop something to encourage people to be mindful about device displacements. We came up with the S.A.F.E mnemonic: Secure, Free, Attached, Easy to see. Using this we created a poster to make staff aware that they need to check they are S.A.F.E when moving patients. This has subsequently been developed into a network wide poster and is used and displayed in all the Critical Care units across the network.

Work continues to reduce the number of unintentional device displacements. The challenges lie in ensuring that the topic is high on the nursing agenda at all times. We have developed a bedside reporting form for occasions when staff are unable to leave their patient to use the online reporting system. This form can then be used as the basis of the root cause analysis so that we can try and identify themes as they occur. Early indications seem to be that the majority of device displacements in our area occur for two reasons; Mobilisation or delirium.

ReferencesMion, L (et.al). 2007. Patient-initiated device removal in intensive care units: A national prevalence study Critical Care Medicine, 35 (12) 2714-2720.

McNeil A., Koppel, B. 2015. Managing Quality and Compliance. Critical Care Nursing, 38 (1) 89-96

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