Development and implementation of an integrated nursing admission assessment and care plan: a quality improvement initiative

Development and implementation of an integrated nursing admission assessment and care plan: a quality improvement initiative

114 PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135 was to provide a snapshot of body mass index (BMI) in a sample of Austr...

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PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135

was to provide a snapshot of body mass index (BMI) in a sample of Australian intensive care unit (ICU) patients and compare prevalence to age-matched general population data. A secondary objective was to explore associations between BMI and ICU-related outcomes. Retrospective observational audit of 735 patients admitted to the Sir Charles Gairdner Hospital ICU between November 2012 and June 2014, with patient BMI as primary outcome. Demographic and clinical data were also collected in order to define the cohort and identify risk associated with BMI and length of stay (LOS), mechanical ventilation (MV) or death. Median BMI was 27.9 (IQR 7.9), and there was an increased proportion of overweight (36.6% v 35.5%) and obese (30.9% v 27.2%) patients in the ICU cohort after age-standardizing results against Australian population proportions. Abnormal BMI was not found to impact negatively on mortality (ICU, p=0.373; hospital, p=0.330), however normal BMI patients had shorter length of MV than other BMI categories and the impact of BMI on ICU LOS was dependent on length of MV. Although the obesity-disease relationship is complex, an increased proportion of overweight and obese patients in ICU compared with Australian population proportions may be important given an interaction between patient BMI and ventilation impacted on ICU LOS. Physiological and clinical outcomes associated with fluid bolus therapy administered at rapid response calls for hypotension; a retrospective observational study Sarah Doherty a,∗ , Diane Chamberlain b , Adam Deane a,c , Mark Finnis a,c a

Department of Critical Care Services, Royal Adelaide Hospital, Adelaide b Critical Care Nursing, Flinders University, Bedford Park c Discipline of Acute Care Medicine, Adelaide University, Adelaide, Australia Administration of intravenous fluid bolus (FB) is a ubiquitous treatment strategy for hypotension in hospitalised patients. While accepted as standard care, there is limited evidence of its benefit and injudicious FB administration may be harmful. We aimed to evaluate current practice, physiological response and clinical outcomes associated with administration of FB to hypotensive patients during Rapid Response Team (RRT) review. We conducted an exploratory, single centre, retrospective cohort study over one year, including all patients triggering RRT review for systolic blood pressure (SBP) <90 mmHg. Accordingly, to preexisting literature, a physiological ‘response’ to FB was determined as a SBP increment ≥20%. Clinical outcomes of interest were recurrent RRT review for hypotension and ICU admission within 24 hrs. Data are mean (SD). Variables significant on univariate analysis (P<0.05) were incorporated into a logistic regression model. Of 992 RRT reviews on 804 patients, FB was administered at 785(79%). Patients were aged 68(18)yrs; baseline SBP 85(13)mmHg; and heart rate 82(21)bpm. 876 calls had >1SBP measured allowing us to assess response. ‘Response’ to FB occurred in 36% reviews. The rate of response was unaffected by FB administration, with 37% responding without FB. Responders to FB were older (OR of response for every 10yr increase in age: 1.14; 95%CI 1.03-1.26) and had lower SBP (OR of response for every 10 mmHg increase in SBP: 0.30; 95%CI 0.24-0.38). 56/804 (7%) patients were admitted to ICU and 104/804(13%) had subsequent RRT reviews for

hypotension. The FB volume administered was predictive for ICU admission (for every additional 500mls, OR 1.30; 95%CI 1.06-1.60). FB was administered frequently but ‘response’ occurred in <40% of patients, a response rate similar to those who did not receive FB, and greater FB volumes administered were associated with ICU admission. Accordingly, effectiveness and optimal volume of FB at RRT review warrants further study. Development and implementation of an integrated nursing admission assessment and care plan: a quality improvement initiative Christine N. Duncan ∗ , Karen Laurie Intensive Care Unit, Sir Charles Gairdner Hospital, Nedlands, Australia Objective To develop an integrated nursing care-plan for the intensive care unit (ICU) that fulfils local and national requirements in regard to service provision and documentation whilst improving performance in care delivery and documentation as determined by national standards and local quality improvement initiatives. Methods Following consultation with key stakeholders such the Falls and Wound teams, a plan was undertaken to incorporate several service-wide documents within a new care-plan. A draft integrated care-plan and admission assessment tool was developed and informal cognitive interviews were undertaken to ensure uniformity of completion and identify areas for improvement. A six month trial of the revised tool was undertaken to determine usability and assess the effect upon compliance with practice and documentation. Rates of compliance with national standards, departmental guidelines, and the rate of clinical incidents were compared preand post-introduction of the care plan. Results 17 pages of clinical documentation were combined into one document. Where previously not routinely performed or documented; pressure injury and falls risk assessments, delirium screening and admission assessments are now documented with 82% compliance. Improvement in compliance with departmental guidelines and policy was observed between 6 and 29% in areas such as nasogastric feeding, management of peripheral venous cannulae and invasive devices. The incidence of pressure injuries within ICU reduced from 0.62 to 0.47 per 100 patient days. Discussion This project has demonstrated the feasibility of an integrated nursing admission assessment and care-plan specific to the critical care environment. The volume of mandatory documentation at the bedside has been significantly reduced. Early findings suggest improved compliance with many key areas however continued surveillance is required. As a result of this project the document is approved for ongoing use within the ICU.