Thesis (MNutr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Objectives: The objectives of this study were to determine the nutritional content/ contribution of intravenous (IV) fluid and electrolyte administration on the total feeding prescription of intensive care unit (ICU) patients. Methods: Retrospective review of ICU charts of consecutive patients (>18 years) with APACHE II scores ≥10 and on ≥72 hours nutrition therapy (NT) admitted to a medical/surgical ICU. Total fluid, electrolyte, energy and macronutrient intake from nutritional and non-nutritional sources were reviewed from ICU admission until discharge, discontinuation of NT or death for ≤7 days. Energy and protein delivery were compared to calculated targets of 25.4 – 28.6kCal/kg and 1.3 – 1.5g/kg respectively. Summary statistics, correlation coefficients and appropriate analysis of variance were used to describe and analyse the data. Results: A total of 71 patients (49% male), average age 49.2 ± 17.1, average APACHE II score 21.0 ± 6.1, 68% medical and 32% surgical, were included. Fluid and nutrient intake were reviewed over a mean of 5.7 ± 1.1 days. Mean daily fluid delivery was 3.2 ± 0.6L. IV fluid therapy (IVFT) contributed 32.0 ± 12.0% to total fluid delivery (TFD), whereas IV drug administration, including fluids used for reconstitution and dilution purposes, contributed 20.7 ± 8.1% to TFD. Balanced electrolyte solutions (BES) were the crystalloid of choice, prescribed in 91.5% of patients with a mean daily volume (MDV) of 0.5 ± 0.4L. Hypertonic low molecular weight (LMW) 130/0.4kD hydroxyethyl starch (HES) was the colloid of choice, prescribed in 78.9% of patients with a MDV of 0.2 ± 0.1L. Potassium salts were the most frequently prescribed IV electrolyte supplement (IVES), prescribed in 91% of patients (±20 – 60mmol per administration). NT was initiated within 14.5 ± 14.1 hours. The majority (80%) received enteral nutrition (EN). The mean daily energy delivered was 1613 ± 380kCal (25.1kCal/kg), meeting 93.6 ± 17.7% of mean target range (MTR). Mean daily protein delivery (PD) was 72 ± 22g (1.1g/kg), meeting 82.8 ± 19.9% of MTR. Non-nutritional energy sources (NNES), mostly derived from carbohydrate-containing IV fluids, contributed 10.1 ± 7.5% to total energy delivered (156kCal/d). Mean cumulative energy and protein balance was -674.0 ± 1866.1kCal and -86.0 ± 106.9g respectively. The majority (73%) received >90% of the minimum energy target but only 49% >90% of minimum protein target; 59% of those with energy intake 90-110% of target had adequate protein intake. A significant negative correlation was found between cumulative energy/protein balance and the time to initiation of NT (energy: r=-0.28, p=0.02; protein: r=-0.32, p=0.01). Conclusion: In this ICU BES are the crystalloid of choice and hypertonic LMW 130/0.4kD HES the colloid of choice for IVFT. Potassium salts are the most frequently prescribed IVES. NNES added significantly to energy delivery and should be included in the calculation of feeding prescriptions to avoid the harmful effects of overfeeding. Early initiation of EN with conventional products which are energy rich is insufficient to achieve adequate PD. EN formulae with a more favorable nitrogen to non-protein energy ratio could help to optimise PD during the first week of ICU care. / AFRIKAANSE OPSOMMING: Doelwitte: Die doelwit van hierdie studie was om die voedingswaarde/ bydrae van intraveneuse (IV) vog en elektroliet toediening tot die totale voedings voorskrif van pasiënte in ‘n intensiewe sorg eenheid (ISE) te bepaal. Metodes: Retrospektiewe bestudering van die ISE kaarte van agtereenvolgende pasiënte (>18 jaar) opgeneem in ‘n mediese/chirurgie ISE en met APACHE II tellings ≥10 en ≥72 ure voedingsterapie (VT). Totale vog, elektroliet, energie en makronutriënt inname vanaf voedingsverwante en nie-voedingsverwante bronne is vanaf ISE opname tot en met ontslag, staking van VT of sterfte, vir ≤7 dae hersien. Energie en proteiën inname is vergelyk met berekende doelwitte van 25.4 – 28.6kKal/kg en 1.3 – 1.5g/kg onderskeidelik. Beskrywende statisitiek, korrelasie koeffisiënte en toepaslike analises van variansie is gebruik vir data analise. Resultate: 71 pasiënte (49% mans), gemiddelde ouderdom 49.2 ± 17.1, gemiddelde APACHE II telling 21.0 ± 6.1, 68% medies en 32% chirurgie, is ingesluit. Vog en voedingstof inname is hersien oor ‘n gemiddelde tydperk van 5.7 ± 1.1 dae. Gemiddelde vog inname was 3.2 ± 0.6L/dag. IV vog terapie (IVVT) het 32.0 ± 12.0% bygedra tot totale vog inname (TVI). IV medikasie toediening, insluitende die herkonstruksie en verwatering van medikasie, het 20.7 ± 8.1% bygedra tot TVI. Die mees voorgeskrewe kristalloiëd en kolloiëd vir IVVT was gebalanseerde elektroliet oplossings (GEO), voorgeskryf in 91.5% van pasiënte (gemiddeld 0.5 ± 0.4L/dag), en hipertoniese lae molekulêre gewig (LMG) 130/0.4kD hidroksie-etiel stysel (HES), voorgeskryf in 78.9% van pasiënte (gemiddeld 0.2 ± 0.1L/dag), onderskeidelik. Die mees voorgeskrewe IV elektroliet supplement was kalium soute, voorgeskryf in 91% van pasiënte (±20 – 60 mmol per toediening). VT is binne 14.5 ± 14.1 ure geinisieër. Die meerderheid (80%) het enterale voeding (EV) ontvang. Die gemiddelde daaglikse energie inname van 1613 ± 380kCal (25.1kKal/kg) het 93.6 ± 17.7% van die gemiddelde doelwit rykwydte (GDR) bereik. Die gemiddelde daaglikse proteiën inname van 72 ± 22g (1.1g/kg) het 82.8 ± 19.9% van die GDR bereik. Nie voedings-verwante energie bronne (NVEB), meestal vanaf koolhidraat-bevattende IV vloeistowwe, het 10.1 ± 7.5% tot totale energie inname (TEI) bygedra (156kKal/d). Die gemiddelde kumulatiewe energie en proteiën balans was -674.0 ± 1866.1kKal en -86.0 ± 106.9g onderskeidelik. Die meerderheid (73%) het >90% van die minimum energie doelwit (ED) bereik. Slegs 49% het >90% van die minimum proteiën doelwit (PD) bereik. Opsomming: Die kristalloiëd en kolloiëd van keuse vir IVT is GEO en hipertoniese LMG 130/0.4kD HES onderskeidelik. Kalium soute word mees algemeen voorgeskryf. NVEB dra beduidend by tot TEI en moet inaggeneem word tydens die berekening van voedingsvoorskrifte ten einde oorvoeding te voorkom. Vroeë inisiëring van EV met konvensionele energie-ryke EV produkte is onvoldoende om genoegsame proteiën inname te verseker. EV produkte met ‘n gunstiger stikstof tot nie-proteiën energie verhouding sal help om proteiën inname gedurende die eerste week van intensiewe sorg te optimaliseer.Slegs 59% van pasiënte met genoegsame energie inname (90-110% van ED) het hul minimum PD bereik. Daar was ‘n beduidende negatiewe korrelasie tussen kumulatiewe energie/proteiën balans en die tyd tot inisiëring van VT (energie: r=-0.28, p=0.02; proteiën: r=-0.32, p= 0.01).

Accurate mortality prediction in intensive care units (ICUs) allows for the risk adjustment of study populations, aids in patient care and provides a method for benchmarking overall hospital and ICU performance. ICU risk-adjustment models are primarily comprised of an integer severity of illness score which increases with increasing patient risk of mortality. First published in the 1980s, the improvements to these scores primarily consisted of increasing the dimensionality of the model, and hence also increasing their complexity. This thesis aims to improve upon these models. First, the field is surveyed and the major models for risk-adjusting critically ill patient cohorts are identified including the acute physiology score (APS) and the simplified acute physiology score (SAPS). A key component of model performance is data preprocessing. The effect of preprocessing ICU data is quantified on a dataset of 8,000 ICU patients, and it is shown that after preprocessing to remove extreme values a logistic regression (LR) model performed competitively (AUROC of 0.8633) with the more complex machine learning model; a support vector machine (SVM) which had an AUROC of 0.8653. For validation, model development was repeated in a larger database containing over 80,000 patients admitted to 89 ICUs in the United States. Results were similar (AUROC of 0.8895 for the LR vs 0.8917 for the SVM) but showed the performance gain when using automated outlier rejection is less pronounced in well quality controlled datasets (0.8883 for LR without rejection). It is hypothesised from this that simpler models can perform competitively with more complicated models, while having a greatly reduced burden of data collection. A severity score is developed on the large multi-center database using a Genetic Algorithm and Particle Swarm Optimisation. The severity score, named the Oxford Acute Severity of Illness Score (OASIS), is shown to outperform the APS III (AUROC 0.837 vs 0.822) and perform competitively with APACHE IV when used as a covariate in a regression model (AUROC 0.868 vs 0.881). The severity score requires only 10 variables (58% as many as APS III), reducing the burden of quality control and data collection. These variables are routinely collected in critical care by continuous monitors and do not include comorbidities, diagnosis or laboratory measurements. The severity score is then externally evaluated in an American hospital and shown to discriminate well (AUROC 0.790 vs. 0.782 for the APS III) with excellent calibration. Finally, the severity score was evaluated in an English hospital and compared to other severity scores. OASIS again had excellent calibration and discrimination (AUROC 0.776 vs 0.750 for APS III) whilst requiring a much smaller number of variables. OASIS has many applications, including both simplifying data collection for studies and improving the risk assessment therein.

Indiana University-Purdue University Indianapolis (IUPUI) / Healthcare workers are responsible for providing evidence-based care to patients; however, many patients receive unnecessary or harmful care. Successful implementation of evidence-based guidelines can improve patient outcomes, particularly among vulnerable neuroscience patients. Focused efforts to improve nursing knowledge of and adherence to these guidelines are warranted. The purpose of this dissertation was to determine the most effective strategies for implementing evidence-based guidelines into nursing practice. First, an integrative review of the literature was conducted to explore studies addressing implementation of evidence-based guidelines in nursing. Implications from the review suggested further research to better understand which strategies should be utilized to best implement evidence-based nursing practices. Two pre- and posttest studies were then designed to identify a bundle of implementation strategies to improve neurocritical care nurses' knowledge of and adherence to stroke and spinal cord injury guidelines. The tailored, multi-faceted strategies consisted of local opinion leaders, printed educational materials, and educational outreach. Improvements in nursing knowledge of and adherence to these guidelines were noted. Lastly, program evaluations were conducted using a mixed-methods study to understand neurocritical care nurses' perceptions of the usefulness of the strategies employed during the two studies. Findings from this research provided support for the most effective implementation strategies to enhance knowledge development and guideline adherence among neurocritical care nurses for implementation of stroke and spinal cord guidelines.

The problem with which this study is concerned is the inclusion of actual critical care experience in generic nursing curricula in the United States. A survey instrument was sent to faculty representatives selected by the dean of each of 312 generic baccalaureate nursing programs.

The threat of antimicrobial resistance particularly in the intensive care unit has become a global issue. This study aimed to evaluate the effectiveness of antimicrobial stewardship in limiting the spread of antimicrobial resistance in the hospital’s ICU. The study further determined the deficiencies of the ASP and recommended strategies to remedy the identified deficiencies. A quasi-experimental descriptive quantitative design was used in this study. The study was conducted at the intensive care unit of an academic hospital. A structured questionnaire was used to extract information from patients’ medical records. This evaluation showed that the antimicrobial stewardship program had a sufficient impact on the appropriate use of antimicrobials in the hospital’s ICU. While there were a small (19.05 %) number of patients inappropriately prescribed antimicrobials, a moderate (35.59%) number of patients developed hospital acquired infections during the study period. In addition, the results revealed a lack of the facility’s leadership commitment to antimicrobial stewardship, which is crucial for ensuring the availability of human, financial and information technology resources Through the evaluation of the program the deficiency in the program’s performance can be identified and optimised. For the studied facility, the performance of the program could be improved by gaining the support of the facility leadership. The present study endorses the evaluation of health promotion initiatives to improve patients’ safety and outcome in healthcare institutions. Keywords / Health Studies / D. Litt. et Phil. (Health Studies)

This descriptive case study examines the use of medical simulation technology in the three-year Thompson Rivers University respiratory therapy training program. Qualitative analysis of data gathered from 78 participants through interviews, observations, and discussion groups reveal a wide variety of low- intermediate- and high-fidelity technologies used for education and evaluation. Deliberate practice is the predominant learning theory informing the use of simulation for safe and ethical training in competencies that would otherwise pose significant risk to patients. Recommendations include enhancements of the existing technology with psychological and environmental fidelity, and for optimal curriculum placement of high-fidelity simulators at hospital sites for student development of critical thinking and team training. Further research into learning with high-fidelity simulation specifically within the context of a student respiratory therapist as an embedded hospital team member is needed. Keywords: respiratory therapy, patient simulation, critical thinking, learning, critical care, deliberate practice

MCur / Department of Advanced Nursing Science / Background: Doctors and nurses working in ICU are always confronted with ethical dilemmas when caring for critically ill patients no matter where they practice. The ethical dilemmas experienced by ICU nurses and doctors include amongst other: freedom of choice, truth telling, distribution of resources and confidentiality. Purpose: The study sought to explore the ethical dilemmas experienced by healthcare professionals working in ICU, Vhembe district in Limpopo province. Setting: The setting of the study was Tshilidzini hospital, Vhembe district in Limpopo Province Methodology: A qualitative, explorative, descriptive design was used. The population was nurses and doctors working in ICU, Tshilidzini hospital, Vhembe district in Limpopo province. A purposive sampling was used to select the study sample, and the study hospital. Data was collected by means of Semi-structured, in-depth interviews. Data was analyzed using Tesch`s method. Ethical considerations were adhered to. Findings: Participants expressed ethical dilemmas related to lack of resources, unsuitable infrastructure, hospital policies and patient`s decision making. Recommendations: The study recommends better policies by government and critical care societies to help guide resource allocation for ICU services. The number of ICU beds must be allocated according to the population it serves, in-service trainings to be conducted on regular bases in order to equip ICU health care professionals with knowledge of ethics and skills of decision-making, an active ethics committee to be elected to assist ICU practitioners when they encounter ethically challenging situation. / NRF

L’obstruction de la chambre de chasse du ventricule droit (OCCVD) chez les adultes subissant une chirurgie cardiaque est un diagnostic rarement décrit dans la littérature. Dans le cadre de cette maîtrise, plusieurs études ont été réalisées afin de répondre aux questions suivantes qui sont importantes cliniquement : Quelle est la prévalence de l’OCCVD en chirurgie cardiaque adulte? Et quelle est sa prévalence dans une population adulte de chirurgie cardiaque sous surveillance hémodynamique constante avec un cathéter pulmonaire capable de mesure le gradient de pression de la chambre de chasse du ventricule droit? D’abord, une revue de littérature sur l’OCCVD a été réalisée en faisant une recherche systématique avec des mots-clés dans la base de données MEDLINE dans PubMed. À partir de toutes les études décrivant l’OCCVD en chirurgie cardiaque adulte, une prévalence de 4 % a été calculée. L’étiologie la plus courante de ce phénomène était mécanique et associée à une compression extrinsèque. Par la suite, une étude rétrospective sur une base de données du centre hospitalier affilié au programme a démontré une corrélation positive entre la survenue d’une OCCVD et une détérioration clinique postopératoire. Un total de 295 patients de 67.2 ± 9.26 ans (79% male) avec des mesures d’OCCVD pré et post-circulation extracorporelle (CEC) ont été analysés. Une OCCVD avec un gradient ≥ 6 mmHg a été observée avant la CEC chez 89 patients [30,2 % (25,1 % - 35,6 %)] et après la CEC chez 129 patients [43,7 % (38,2 % - 49,4 %)]. Nous avons déterminé que l’OCCVD est une complication rare mais importante à étudier et à suspecter puisqu’elle peut être ciblée par des traitements selon son étiologie. / Right ventricular outflow tract obstruction (RVOTO) is a diagnosis rarely described in adult patients undergoing cardiac surgery. In order to write this Master’s thesis, studies were conducted to determine the prevalence of RVOTO in adult cardiac surgery patients, as well as the prevalence in a similar population with continuous monitoring of pressure gradient data across the right ventricular outflow tract using a pulmonary artery catheter. First, we reviewed the literature on RVOTO by performing a systematic keyword search in the MEDLINE database via PubMed. A prevalence of 4% was calculated by extrapolating the results of all the studies describing RVOTO in adult cardiac surgery. The most common etiology for this phenomenon was mechanical and subsequent to an extrinsic compression. Second, a retrospective study on a database from the university-affiliated hospital center showed a positive correlation between the development of RVOTO and a postoperative clinical decline. A total of 295 patients aged 67.2 ± 9.26 years old (79% male) with RVOTO data from before and after cardiopulmonary bypass (CPB) were analysed. A RVOTO with a gradient ≥ 6 mmHg was observed before CPB in 89 patients [30.2% (25.1% - 35.6%)] et after CPB in 129 patients [43.7 % (38.2 % - 49.4 %)]. We determined that RVOTO is a rare but important complication because it can be targeted with therapies according to its etiology.

This qualitative study was aimed at exploring and describing the theoretical and practical experiences of second-year critical care nursing students. Purposive sampling was done, and unstructured interviews and narrative descriptions were used as data collection tools. An adaptation of Johns's Framework, the Guideline for the Facilitation of Reflection as Teaching Strategy, was used during interviews to guide participants in reflecting on theory-practice integration. Multiple strategies were used to ensure the trustworthiness of the study. Concerning patient data, communication, and the administration of life-saving medications, theory-practice integration did occur. Regarding treatment and the outcome of nursing interventions, it seemed that knowledge deficiencies and a lack of exposure to practical situations contributed to the inability to apply theory to practice. This apparent inability evoked negative feelings, such as guilt. Discrepancies between practice and theory taught led to confusion. Guided reflection assisted students in gaining a new perspective on nursing and theory-practice integration. / Health Studies / M.A. (Health Studies)

This qualitative study was aimed at exploring and describing the theoretical and practical experiences of second-year critical care nursing students. Purposive sampling was done, and unstructured interviews and narrative descriptions were used as data collection tools. An adaptation of Johns's Framework, the Guideline for the Facilitation of Reflection as Teaching Strategy, was used during interviews to guide participants in reflecting on theory-practice integration. Multiple strategies were used to ensure the trustworthiness of the study. Concerning patient data, communication, and the administration of life-saving medications, theory-practice integration did occur. Regarding treatment and the outcome of nursing interventions, it seemed that knowledge deficiencies and a lack of exposure to practical situations contributed to the inability to apply theory to practice. This apparent inability evoked negative feelings, such as guilt. Discrepancies between practice and theory taught led to confusion. Guided reflection assisted students in gaining a new perspective on nursing and theory-practice integration. / Health Studies / M.A. (Health Studies)