Distance learning: the “Extension for Community Healthcare Outcomes: ECHO” project: a case study

This article reports a case conference that was part of the Extension for Community Healthcare Outcomes (ECHO®) project, which is a model of monthly telemedicine conferences on chronic disease and behavioral health, important topics for primary care teams in rural areas and for university-based specialists. The ECHO® project has proved to be a successful learning model in health care. The main goal of the project is moving knowledge not the patients, so this tele-mentoring builds capacity and creates access to high-quality specialty care serving local communities. A secondary goal is shared learning between community providers and specialists about best practices that are practical, achievable, and sustainable for the community. We present the case of a critical care patient who was brought to the emergency department with left-side weakness and dysarthria. Computed tomography of the head and electrocardiograms established the diagnosis during the admission. Discussion points from a multidisciplinary team and specialty consultants via telemedicine are listed in this article. Key words: telemedicine, teleconsulting, primary care, developing countries, rural area

What is the impact of COVID-19 on tissue viability services and pressure ulceration?

This paper explores and reviews the relevant literature and examines the impact that the first wave of the COVID-19 pandemic has had on the tissue viability service (TVS) and the incidence of pressure ulcers (PUs) in a large UK teaching hospital NHS trust. A comparison has been undertaken of referral data to the TVS during two time periods—Oct–Dec 2019 and April–June 2020. Data show that the PU rate per 1000 beds increased from a pre-pandemic level of around 1 to over 2.7 in the first month of the pandemic, with an increase in device and prone position-related PUs, particularly in the expanded critical care patient population. Even though the bed occupancy decreased, the proportion of ungradable PUs increased, but there was little change in the number of Category 1 and 2 PUs.

783 Brachial Plexopathy Secondary to Prone Position Used in The Treatment of a Ventilated Patient With COVID-19: A Case Report and Service Improvement Recommendations

Introduction Prone position has been recommended by many authorities as part of the management of ventilated patients with COVID-19. However, proning with concurrent use of sedation and muscle relaxants carries the hypothetical risk of brachial plexus injuries, thought to be due to stretch and compression of the abducted shoulder. Case We report the case of a long-stay critical care patient who required frequent proning due to SARS-CoV-2 infection, and who presented with new right upper limb weakness. This case was referred to our local plastic surgery service and an injury to the upper trunk of the right brachial plexus was confirmed on nerve conduction studies. Recommendations Following this case, we made adaptations to our local practice and modified our prone-specific SSKIN bundle (originally created to prevent pressure sores) to include a section on ‘Nerves’, with an accompanying diagram. We dubbed this the SSKINN bundle. This ensured safe prone positioning. We encourage other hospitals to put in place similar interventions. Conclusions We present this as a pathology to consider in patients proned during the COVID-19 pandemic; and recommend checking for signs of focal neurological deficits of the upper limb upon removal of paralysis and sedation, with early referral of suspected cases.

Increasing patient flow through neurosurgical critical care: the Leeds Improvement Method

At Leeds General Infirmary, a busy tertiary centre for neurosurgery, there has been little visibility of the step-down status of the patients from intensive care to high dependency or from the latter to a ward bed. The only record of the current situation was limited to the paper notes of the bed managers. Furthermore, accuracy of electronic systems used for staffing levels and bed state were underused. There were gaps in information and furthermore information within the system was unreliable (together defined as ‘defects’). These defects mandated bed managers’ physical presence on each ward to obtain reliable data. This led to unwarranted critical care stays and resultant high rates (up to 40%) of elective operation cancellations requiring a critical care bed.The Leeds Improvement Method using principles of the Toyota Production System aimed to improve patient flow through critical care and to assess the impact on elective case activity. Problems were identified and changes were implemented over a 1-week period. The changes included measures to reduce time taken for collation of critical bed-state information and improving patient and staffing data quality collected in the electronic patient management system (EPMS) and electronic staffing record (ESR). Impact was monitored for 30 days pre-implementation and post-implementation.Following intervention, the time taken by the bed manager to gather live bed-state information decreased from 50 to 9 min; the EPMS storing correct bed-state data was improved from 71% to 0% defect; the ESR was improved from 100% to 4% defects; critical care patient step-downs occurring at night (after 20:00) improved from 80% to 20%; and the number of cancelled elective cases over a 30-day period reduced from nine to one.Implementing these organisational efficiencies can significantly improve critical care patient flow and elective case throughput.

Promoting subglottic secretion drainage: a quality improvement project in a UK critical care unit

The aim of the study was to promote the practice of subglottic secretion drainage (SSD) in a UK critical care unit. SSD is a technique employed to reduce microaspiration of oropharyngeal secretions in patients with cuffed endotracheal airways. Aspiration of oropharyngeal secretions is the accepted cause of the majority of ventilator-associated pneumonia (VAP), a complication of invasive ventilation with high associated mortality. The plan–do–study–act methodology was employed. The local critical care patient database was searched for patients requiring mechanical ventilation via a tracheostomy tube with subglottic port in the 3 months prior to intervention. Patient records were interrogated for evidence of the practice of SSD. The intervention involved the introduction of a tracheostomy care bundle to be prescribed on insertion of a tracheostomy on the critical care unit, in combination with departmental teaching. The bundle included prompts for nursing staff to practise regular SSD and to complete a tracheostomy care plan at the end of shift. A total of 24 patients were included. A review of practice was conducted every 3 months for 1 year. This showed an improvement in documented evidence of SSD from 0% of days at baseline to 85.7% of days at 1 year. Implementation of a tracheostomy order set prescribing regular SSD resulted in an improvement in the practice of SSD in patients ventilated via tracheostomy. This has implications for patient outcomes and healthcare costs, given that SSD has been shown to reduce incidence of VAP.

Facilitating Factors in the Proper Identification of Acute Skin Failure: A Systematic Review

Background Acute skin failure is a significant medical finding for both the critical care patient and the hospital. Proper identification is key to prevention and treatment, but diagnosis of acute skin failure in critical care patients is often missed. This diagnostic oversight may be due to a lack of knowledge about acute skin failure and its presentation. Objective To investigate the literature for facilitating factors that would ease the identification of acute skin failure for clinicians. Methods The research team conducted a systematic literature review via PubMed, CINAHL, and Academic Search Ultimate to collect data about acute skin failure and how it might be identified. Results Ten common facilitation themes around acute skin failure and its identification were found in the literature. In total, 110 examples of facilitating factors were identified. Conclusions There is little factual information available regarding the identification of acute skin failure, and the literature is lacking in this area overall. Acute skin failure may develop in the body in a number of ways, and understanding commonalities that occur in patients who experience acute skin failure and applying that information to patients in the future may assist identification.

The risk of developing Pressure Ulcer and its relation to the patient`s Status and treatment received in na intensive care Unit in Angola.

Background: Pressure ulcers (PU) are common in patients in intensive care unit (ICU). Many factors contribute to this which include the patient´s status and the characteristics and type of the treatment applied in this level of care1-3. In Angola, a low-middle-income country, the study of this topic is still incipient, which makes it relevant to know whether the Braden scale score differs significantly in different groups of critical care patient. De Alirio Martinho Belchior para Todos: 10:40 AM Aims: To determine if there is a statistically significant difference between the risk of developing pressure ulcers, and the groups of patients sorted by the severity of their disease, organ function/ rate of failure and type of the treatment applied in the ICU. On this behalf the following variables were established: patients treated with sedatives, vasoactive drugs, mechanical ventilation, haemodialysis; Braden Scale average score, the APACHE II (Acute Physiology and Chronic Health Evaluation) score, the SOFA (Sequential Organ Failure Assessment) score and the duration of hospitalization (days) in ICU. Methods: An observational, descriptive, prospective and longitudinal study with a quantitative nature was developed in an ICU ward in a hospital in Angola. Results: The sample was composed of 123 patients; the average value of the Braden scale was 14.15 points. Patients being treated with sedatives showed statistically significant difference in the average Braden scale score compared to those who did not. This difference was also verified in relation to the patients who were treated with vasopressors and mechanical ventilation. Negative, moderate to weak, but statistically significant correlations were found between the Braden scale score and the APACHE score, SOFA score and duration of ICU stay. De Alirio Martinho Belchior para Todos: 10:40 AM Conclusion: The patients have a higher risk of developing pressure ulcers when exposed to risk factors that are already known and specifically associated with some treatments implemented in the ICU. Higher rates of disease severity, mortality risk and longer duration of stay in ICU are associated with a higher risk of PU.

Vivências do CTI: Visão da Equipe Multiprofissional Frente ao Paciente em Cuidados Paliativos

Objetivo: Analisar a visão dos profissionais de saúde frente ao paciente fora de possibilidade terapêutica na Unidade de Terapia Intensiva (UTI). Método: Estudo descritivo, de abordagem qualitativa, realizado com 15 profissionais de saúde da UTI de um Hospital Universitário submetidos a entrevista semiestruturada. Resultados: Os profissionais veem esses pacientes como pessoas que necessitam de cuidados e medidas que tornem o processo de morte menos sofrido e mais digno, porém também demonstram insatisfação com a realidade do cenário atual dos cuidados paliativos na terapia intensiva. Conclusão: A implementação dos cuidados paliativos na UTI é um desafio para toda a equipe, visando o equilíbrio entre medidas paliativas e curativas. Portanto, alguns avanços precisam acontecer, principalmente em pesquisas na área bem como no campo da legislação.Descritores: Cuidados Críticos; Equipe de Assistência ao Paciente; Cuidados Paliativos.EXPERIENCES OF THE ICU: MULTIPROFESSIONAL TEAM'S VIEW OF THE PATIENT IN PALLIATIVE CAREObjective: To analyze the vision of the health professionals before the patient outside the therapeutic possibility in the Intensive Care Unit (ICU). Method: Descriptive study with a qualitative approach, performed with 15 health professionals from a University Hospital submitted to a semi - structured interview. Results: The professionals see these patients as needing care and measures that make the death process less painful and more dignified, but also demonstrate dissatisfaction with the reality of the current scenario of palliative care in intensive care. Conclusion: Of palliative care in the ICU is a challenge for the whole team, aiming at balancing palliative and curative measures. Therefore, some advances need to happen, especially in research in the area as well as in the field of legislation.Descriptors: Critical Care; Patient Care Team; Palliative Care. EXPERIENCIAS DE LA UCI: VISIÓN DEL EQUIPO MULTIPROFESIONAL DEL PACIENTE EN CUIDADOS PALIATIVOSObjetivo: Es analizar la visión de los profesionales de salud frente al paciente fuera de posibilidad terapéutica en la Unidad de Terapia Intensiva (UTI) Método: Estudio descriptivo con enfoque cualitativo, realizado con 15 profesionales de salud de la UTI de un Hospital Universitario sometidos a entrevista semiestructurada. Resultados: Los profesionales ven a estos pacientes como personas que necesitan cuidados y medidas que hacen el proceso de muerte menos sufrido y más digno, pero también demuestran insatisfacción con la realidad del escenario actual de los cuidados paliativos en la terapia intensiva. Conclusión: Para los cuidados paliativos en la UTI es un desafío para todo el equipo, buscando el equilibrio entre medidas paliativas y curativas. Por lo tanto, se necesitan algunos avances, principalmente en la investigación en el área, así como en el campo de la legislación.Descriptores: Cuidados Críticos; Equipo de Asistencia al Paciente; Cuidados Paliativos.