A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg In partial fulfillment the requirements for the degree of Master of Science in Nursing Johannesburg, 2017 / Background: Continuity of quality care and patient safety depends mainly on the effective handover. Gaps in communication might lead to omissions of vital information affecting continuity and safety of care and leading to negative consequences and sentinel events. Purpose: The aim of this study was to describe the opinions of nurses regarding the effectiveness of handover practices between nurses in the Emergency Departments and Intensive Care Units in an academic hospital in Johannesburg using a handover rating tool. The recommendations for clinical practice and education were provided thereafter. Method: A descriptive quantitative cross sectional survey was used. Convenience sampling was used. A sample size of hundred and eleven handovers (n=111) was used. Data was collected using a 16 item handover evaluation tool developed by Manser et al. (2010). The handover rating tool is divided into two sections. The first section was the demographic data, the second section asks about the information transfer, shared understanding, working atmosphere, overall handover assessment and circumstances of handover. Data analysis was done by means of descriptive and non parametric statistics using graphs, frequency distributions, medians and interquartile ranges, Wilcoxon rank sum and logistic regression. Testing was done at the 0.05 level of significance. Results: A higher level of qualification and years of experience in trauma and Intensive Care Unit were significant factors related to information transfer, shared understanding and overall handover quality. Univariate ordinal model showed statistical that respondents handing over were more likely to agree with information transfer, shared understanding, working atmosphere, overall handover quality and circumstances of handover compared with those receiving. Univariate ordinal model showed statistical difference that non specialist handing over were likely to agree to overall handover quality whereas multivariate ordinal model also showed statistical difference that non specialist handing over were likely to agree with circumstances of handover. The study suggests that it is necessary for ED and ICU nurses to have an agreement on the content of the structured handover framework as different specialists have different expectations. / MT2017

A research report submitted to the Faculty of health Sciences, University of the Witwatersrand, Johannesburg, in particular fulfillment of requirements for the degree of Masters in Medicine (MMed) Johannesburg, / MT2017

This study prospectively evaluates the recall of one hundred patients following admission to an Intensive Care Unit (ICU) at Groote Schuur Hospital. It was prompted by criticism (by members of staff and visitors to the ICU) of our practice of wardrounds, arterial blood gas sampling, and light sedation of patients. In addition, staff preconceptions about patients' reactions to the ICU needed evaluation. The patients analyzed included a wide spectrum of race, religion, occupation, and educational levels. The more common diagnoses included asthma (22%), pneumonia (14%), trauma (13%), and Adult Respiratory Distress Syndrome (ARDS) (13%). The average APACHE II score (a scoring system widely used to evaluate severity of illness) was 12.27 and 68% of the patients were mechanically ventilated. Objective data collected while the patients were in the ICU included demographic information, diagnosis, APACHE II score, sedation, level of consciousness, and procedures. Within 48 hours of discharge from the ICU, patients were interviewed and asked to quantify their recall of procedures and events which had occurred while they were in the ICU. Data was entered into a microcomputer database for analysis and, where appropriate, statistical tests were performed. Seventy-one patients recalled being admitted to hospital but only 50 remembered being admitted to ICU. Eighty-four patients described the ICU atmosphere as friendly or relaxed. Seventy-three patients felt that they had sufficient sleep while in the ICU. The most frequently reported unpleasant experiences were arterial blood gas sampling (48 patients), tracheal suctioning (30 of 68 ventilated patients), pain (22 patients), and noise (20 patients). Only 6 patients disliked wardrounds and discussion around the bedside. Conclusions include the suggestions that arterial catheters or pulse oximetry should be used when frequent arterial blood gas analyses are needed, and that tracheal suctioning should be performed with more care.

Bakgrunden tar upp tidigare studier att intensiwårdspatienter utsätts kontinuerligt for stress,   höga ljudnivåer och störd sömn, som tillsammans kan leda till en utveckling av IVA syndromet.   Syftet med studien var attkartlägga larmstarter från teknisk apparatur och andra störande     ljud på en intensiwårdsavdelning. Metoden var en observationsstudie dagtid under tre     dagar på två intensiwårdssalar och larmstartsprotokoll användes, for att dokumentera   varje larmstart från teknisk apparatur. En ljudnivåmätare användes ftir att få en uppskattning av decibel på larmstarter från     den tekniska apparaturen. Resultaten belyser att teknisk   apparatur såsom respiratorer, stod for 262larmstarter (cirka 33yo), övervakningsutrustning   som mäter invasivt blodtryck, for 175 larmstarter (cirka 22%o) och saturationlarm ftir 143   larmstarter (cirka 18o/o) av alla larmstarter i studien. Ett medelvärde påvisar 0,72larmstarter   per minut. Andra frekvent störande ljudfaktorer tas också upp i studien, som kan medfora en   ökad ljudnivå fiir patienterna på intensiwårdsavdelningen. Mätningarna visade att respiratorerna och sprutpumparnas larmstarter stod     ft)r de högst uppmätta decibelnivåerna på   80 decibel.

The circadian rhythm is an internal body cadence, responsible for regulation of sleep in all mammals. In humans, this clock is altered by several factors, including light and secretion of the hormone melatonin. Within the intensive care unit (ICU) population, it is well evidenced that patients suffer from circadian dysregulation, often for long periods of time. Additionally, many parallels have been noted between severely fragmented sleep and delirium, an acute neurological condition frequently observed in ICU patients. A prospective cohort pilot study of five subjects was undertaken to enable a greater understanding of both sleep in the ICU and the relationship between circadian rhythm and delirium. From a total of thirty-six urine samples per subject, excretion of 6-sulphatoxymelatonin (aMT6s), the urinary metabolite of melatonin was analyzed. T-test comparison (p=0.05) of mean aMT6s (ng/mL) revealed significant differences in the nighttime excretion between subjects in this study and healthy individuals. No significant differences were observed with t-test comparison of mean aMT6s of the first 24 hours from the current study to ICU subjects in previous literature. No subjects were identified as delirious in the study and therefore no relationship could be found between circadian rhythmicity, as evidenced by melatonin excretion and delirium in this study population. / February 2017

Class of 2007 Abstract / Objectives: The purpose of this study is to determine if an antibiotic formulary is beneficial in an inpatient ICU setting. The main goal, of course, is to ensure patients receive the most appropriate antimicrobial therapy resulting in the least amount of resistance, by using an antibiotic formulary and ICU antibiotic intervention. Methods: This project will use a retrospective design in which one-year post-intervention antibiotic resistant trends will be compared with pre-intervention trends at Yuma Regional Medical Center (YRMC). As is common at YRMC, patients started on antibiotic therapy had susceptibility testing performed to determine the best treatment for the patient. This susceptibility data will be the data used for comparison. Comparison of patient charges and hospital costs associated with these patients will also be performed. YRMC employed an ICU antibiotic intervention documentation form that was used to monitor and extrapolate intervention data. Hospital lab percent susceptibility data will be looked at to determine isolate susceptibility data to determine if any trends are present in antibiotic resistance between the time period when the antibiotic formulary was implemented and the previous corresponding period of time before the formulary. This data will also be compared with the hospital trends in resistant isolates as a whole. The data is desensitized, as individual patient data is not being reviewed. In looking at patient charges and hospital costs, charts will be reviewed. These charts will be de-identified to the investigators of this study. Of further note, YRMC placed the intervention in action in February 2006 and began collecting post-intervention data at that time. This study will be using post intervention data collected from February 2006 thru February 2007. Results: Conclusions:

Noise in the Intensive Care Unit (ICU) has been associated with patients experiencing psychological and physical disorders such as anxiety, sleep deprivation, and worsening of hypertension and diabetes. Researchers have suggested that the use of a noise reduction protocol can result in a decrease in noise in the ICU and a subsequent improvement in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. The research question for this project examined the effectiveness of a newly developed noise protocol in minimizing noise in the ICU, since the patients at the facility of study reported noise as being a nuisance that was hampering their sleep and healing; this nuisance has also been reflected in the hospital's low HCAHPS scores. The theoretical premise of the project was the theory of comfort, which suggests that engaging in health-seeking behaviors bring patients comfort. The sources of evidence that guided the project included a literature review using the keywords noise in ICU, sleep disruption, and hospital noise; HCAHPS scores over the past 5 years; and the analysis of data obtained from interviews of 48 nurses and 4 intensivists (critical care doctors) who responded to an open invitation to participate. The interviews were analyzed using codes; the emerging themes were that the protocol was useful, did not interfere with work flow, and allowed patients to rest uninterruptedly. The result from the project can be used by the hospital leadership team to advance the noise reduction protocol to areas of the hospital outside of ICU, and as a training tool to educate the hospital staff on the importance of maintaining a noise-friendly environment.

The purpose of this study was to determine the knowledge of nurses working in ICU with respect to pain management, glycaemic control and weaning from mechanical ventilation, care areas that are commonly guided by protocols. The effect of formal ICU training and years of ICU experience on this knowledge was elicited. A non-experimental, descriptive and contextual two-phase research design was used. The first phase of the study consisted of developing and validating a data collection instrument, using purposive sampling to select two groups of ICU nursing experts. The second phase of the study used the instrument developed in phase one to test the knowledge of nurses working in ICU. The knowledge of 136 ICU nurses (68 ICU trained and 68 non-ICU trained) from three (n=3) public sector and two (n=2) private sector hospitals in Gauteng was tested using the data collection instrument developed by the researcher and the two groups of ICU nursing experts. Knowledge of nurses, both ICU trained and non-ICU trained, working in the ICUs of three public and two private hospitals in Gauteng was found to be lacking in the three care areas tested in this study, namely pain management, glycaemic control and weaning from mechanical ventilation. The difference in knowledge between ICU trained and non-ICU trained nurses was statistically significant but relatively small. A weak correlation was found between level of knowledge and years of ICU experience. Recommendations to address this lack of knowledge of ICU nurses are given for clinical nursing practice, nursing management and nursing educators, as well as recommendations for further research in this area.

Delirium is a frequent complication of intensive care unit (ICU) admissions manifesting as acute confusion with inattention and disordered thinking. Patients in the ICU who develop acute delirium are more likely to experience long term disability and mortality. The purpose of this doctoral project was to evaluate an existing organizational quality improvement project to guide recommendations on improving care in the ICU. The practice-focused research question was: Does improving adherence to the ICU Liberation ABCDEF bundle for patients admitted to the ICU decrease incidence of delirium compared to outcomes prior to implementation? The Program Logic Model served as a framework for analysis of the organization's planning and implementation of this quality improvement project. Benchmark data from an organization's participation in the ICU Liberation Collaborative served as the primary source of evidence for analysis of outcomes. In addition, baseline data on current practice and outcomes in the organization's trauma ICU was analyzed and compared to the benchmark data. Analyses of data revealed strengths and opportunities for improvement in both the organization's project management and in current practices supporting adherence to the ABCDEF bundle guidelines. Incidence of delirium remained unchanged and far below national averages indicating need for further investigation into practices to verify this finding. Better prevention, identification, and management of delirium will lead to a positive impact on society, as patients who develop delirium rarely return to their baseline level of functioning.

Submitted by Barroso Patrícia (barroso.p2010@gmail.com) on 2014-07-25T13:46:57Z No. of bitstreams: 1 Tese completa.pdf: 8251118 bytes, checksum: 98b6c612ff36e77d9d166e2802b3ec1f (MD5) / Made available in DSpace on 2014-07-25T13:46:57Z (GMT). No. of bitstreams: 1 Tese completa.pdf: 8251118 bytes, checksum: 98b6c612ff36e77d9d166e2802b3ec1f (MD5) / Delirium é uma das formas comuns de apresentação de disfunção neurológica aguda em pacientes graves. É definido segundo os critérios do DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) como um transtorno agudo e flutuante da consciência e cognição, tem alta prevalência em unidades de terapia intensiva (UTI) e está associado a alta mortalidade e maior tempo de internamento hospitalar. A despeito da sua importância, por muito tempo os estudos clínicos a respeito deste tema foram comprometidos pela ausência de uma terminologia uniforme e de critérios específicos para o diagnóstico. O objetivo desta tese é estudar as propriedades psicométricas de ferramentas diagnósticas para delirium, com ênfase: 1) na validação para o idioma português brasileiro de três instrumentos para o diagnóstico de delirium no paciente grave: o Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), o CAM-ICU Flowsheet e o Intensive Care Delirium Screening Checklist (ICDSC), 2) na realização da síntese por meta-análise da acurácia de duas destas ferramentas (CAM-ICU e ICDSC), 3) na identificação de limitações para o uso do CAM-ICU. No estudo de validação, 119 pacientes foram avaliados e 38,6% foram diagnosticados com delirium pelos critérios do DSM-IV. O CAM-ICU e CAM-ICU Flowsheet apresentaram a mesma acurácia com uma sensibilidade de 72,5% e uma especificidade de 96,2 e o ICDSC teve uma sensibilidade de 96,0% e uma especificidade de 72,4%. No subgrupo de pacientes em uso de ventilação nãoinvasiva a concordância entre o CAM-ICU e o DSM-IV foi de 100%. Na metaanálise, foram incluídos na análise final 09 estudos que avaliaram o CAM-ICU (totalizando 969 pacientes) e quatro estudos que avaliaram o ICDSC (n= 361 pacientes). A sensibilidade combinada do CAM-ICU foi de 80,0% (95% intervalo de confiança (IC): 77,1-82,6%), e a especificidade combinada foi de 95,9% (95 % IC: 94,8-96,8 %). A sensibilidade combinada do ICDSC foi de 74 % (IC de 95%: 65,3- 81,5%), e a especificidade combinada foi de 81,9% (IC 95%: 76,7-86,4%). Foi também observado que o CAM-ICU tem menor sensibilidade para diagnosticar delirium em pacientes com níveis menores de sedação. Em conclusão, o diagnóstico de delirium no paciente grave pode ser realizado, com boa acurácia, utilizando o CAM-ICU e o ICDSC no idioma português brasileiro. A versão modificada, o CAMICU Flowsheet, também pode ser utilizada com a vantagem de permitir que a avaliação ocorra de forma mais rápida. Nos pacientes em uso de suporte ventilatório não invasivo o diagnóstico de delirium pode ser feito utilizando o CAM-ICU. Por fim, em pacientes com menores níveis de sedação o CAM-ICU parece perder acurácia.