The aim of this thesis was to examine the use of modelling techniques in the economic evaluation of selective decontamination of the digestive tract (SDD), used to prevent intensive care unit (ICU) acquired pneumonia. The need for evidence for the effectiveness and cost effectiveness of technologies used in intensive care was highlighted through an examination of the literature. The clinical and economic issues pertinent to ICU-acquired pneumonia and SDD were described. It was suggested that an economic evaluation of SDD was required. An evaluation using modelling techniques was proposed. A secondary economic evaluation of SDD was carried out, utilising a decision-analytic model and published clinical and economic evidence to derive cost/outcome ratios. This analysis showed that SDD could be a dominant therapy, but improved economic and long term outcome evidence was required to increase the robustness of conclusions. This thesis concentrated on improving the economic evidence. A national survey of SDD use provided information on clinical practice. A prospective observational study was carried out at two British ICUs to obtain evidence on the economic impact of ICU-acquired pneumonia. The impact of infection and confounding factors on resource use was handled quantitatively, using regression techniques. It was found that ICU-acquired pneumonia significantly increased length of ICU stay. These two sets of empirical data were used in a revised economic evaluation of SDD. SDD was found to be a dominant therapy at both centres. Uncertainty around cost/outcome ratios was considered to be decreased, or at least quantified, by this primary economic evidence. This thesis concludes that modelling has a place in economic evaluation in intensive care, if rigorous methods are used. It has also demonstrated that current, reliable and applicable economic evidence is a prerequisite to any economic evaluation, if it is to be included in the decision-making process.

Bakgrund: Patienter på en intensivvårdsavdelning är ofta i behov av avancerad medicinsk behandling på grund av sitt livshotande sjukdomstillstånd. Återkommande störningar av sömnen är ett av de vanligaste återkommande klagomålen från patienter vilket bidrar till att perioden upplevs som särskilt svår. Syfte: Att belysa vad vuxna patienter upplever stör sömnen på en intensivvårdsavdelning. Metod: Allmän litteraturstudie där 12 vetenskapliga artiklar ligger till grund för resultatet. Resultat: I analysen av artiklarna framträdde fyra kategorier som alla tillsammans påverkade patientens sömn negativt. Kategorierna var rädsla/oro över att inte bli frisk, smärta från till exempel operationssår, inskränkning av integriteten samt störningar från vårdrelaterade interventioner såsom kontroll av vitalparametrar, munvård och förbandsbyte. Diskussion: Tidigare forskning har påvisat ljus och ljud från apparater som störande för patientens sömn, resultatet från denna studie visar dock att samtal mellan personalen är mer störande. Personalen kan behöva uppmärksamma detta och anpassa samtalsnivån därefter. Genom att informera patienten om vad som händer på intensivvårdsavdelningen kan man öka deras känsla av trygghet. Rutinmässiga vårdrelaterade interventioner skulle kunna samordnas nattetid för att ge patienterna sammanhängande sömn. Slutsats: Personal inom intensivvården skulle behöva uppmärksamma vad patienten upplever stör sömnen under vårdtiden. Ytterligare forskning med kvalitativ ansats behövs där patientens upplevelser sätts i fokus. / Background: Patients in an intensive care unit (ICU) often require sophisticated treatment due to life-threatening conditions, but disturbed sleep has been found to be one of the most reoccurring complaints from patients in intensive care. Purpose: To highlight what adults perceive disturb their sleep in an intensive care unit. Method: General literature review where twelve scientific articles form the basis of the results. Result: When analysed, four categories emerged, which when combined adversely affected patients sleep. The categories were fear/worry about not recovering, pain from e.g. surgical wounds, limitations of integrity caused by being attached to wires and tubes, and disturbance from care related interventions by staff checking vital observations, oral hygiene, wound dressings. Discussion: Previous research has found light and machinery noise disruptive, however, our findings show staff communication levels to be more disturbing. Straff need to be aware of speech noise levels, reminding colleagues when required. Informing patients of ICU activity helps increase patients’ sense of security which when combined with coordinated, care related interventions at night helps with continous periods of sleep. Conclusion: ICU staff need to identify patients concerns regarding perceived sleep disruption. Further research is required where patients perception of sleepdisturbances is in focus.

Class of 2005 Abstract / Objectives: The purpose of this retrospective investigation is to compare the quantity, importance, and associated cost implications of drug-related problems identified (and ultimately resolved) through order entry/verification versus other clinical activities of a decentralized critical care pharmacist. Methods: The data from this study was collected by one decentralized pharmacist assigned to a surgical intensive care unit. A standard form was used to document all interventions during the period of this observation. For the purposes of this retrospective evaluation the following data will be extracted from the existing database: amount of time spent performing various clinical activities, how drug-related problems were identified (e.g., order entry verification versus chart reviews), the time it took to identify and resolve drug-related problems, a general description of interventions, the importance of the intervention, and the estimated economic impact associated with interventions. Results: In only a 41⁄2 month period, 111 patients would have likely experienced an adverse drug event had the ICU pharmacist not intervened. This equals a cost avoidance to the institution of anywhere from $200,000 to $280,000 for as little on average of 15-30 minutes of the pharmacist time. Implications: As previous studies have shown, the presence of a pharmacist in an ICU is crucial to lowering the incidence of adverse drug events. Our results have proven the interventions pharmacist make during team rounding and chart review are not only cost effective, but substantially improve patient care.

Nurses who work in the intensive care settings (or units, ICU) in Canada encounter a growing number of patients living with obesity (PLWO) in clinical practice. Many authors suggest that the number of PLWO who are admitted to the ICU has increased significantly because obesity is on the rise in Canada. PLWO are thought to be at a higher risk for developing chronic illnesses and life-threatening complications that require an admission to the ICU. They are also more likely to develop postoperative complications that require life-sustaining treatments, invasive hemodynamic monitoring and evaluation, assistive devices, pharmacological interventions, parenteral nutrition, fluid and electrolyte management, and prolonged admission with associated risks of complications. Yet, there is limited research on the experience of nurses providing care to PLWO. The goal of this qualitative study was to examine the experiences of ICU nurses who work with PLWO and how these experiences affect the way they provide care. More specifically, this study was designed to describe and explore the inclusionary and exclusionary practices developed by nurses providing care to PLWO by drawing Canales’ (2000) Othering framework. Lastly, an additional goal of this study was to document the needs of ICU nurses with respect to the care of PLWO and areas of improvement in the ICU. A total of 11 ICU nurses were interviewed for this study. Data analysis followed the principles of Applied Thematic Analysis (ATA) and revealed four themes. The first theme describes how the PLWO become “Other” in the ICU context. The second theme focuses on exclusionary Othering and how it manifests itself in the way PLWO are differentiated, cared for, and viewed in the ICU context. The third theme sheds light on inclusionary Othering in the form of strategies that are used by ICU nurses to engage with PLWO in a way that is inclusive and transformative. Finally, the last theme concentrates on the ICU environment itself and the resources available (or not available) to nurses, with a particular emphasis on the needs of nurses who provide care to PLWO.

The overall aim throughout the project was to outline a new modular platform for a future generation of ventilators as well as designing a ventilator based on the defined platform. Doing so through a conceptual approach, looking at enabling cost efficient development, manufature and product scalability as well as taking the users needs for flexibility, improved usability, cable management and transport into consideration. The project used a traditional user centric design approach while also having a strong manufacturers focus when it came to looking at modularity and the company’s product offering.  The main insights throughout the project revolved around looking at the entire ecosystem of products and how they worked together in the intensive care unit (ICU). Understanding the core struggles and time consuming tasks in order further improve the workflow in the ICU. A big part of the ideation and concept development process was spent on building rough mock-ups for fast evaluation together with users and the collaborating partner. The result was a combined, highly modular, ventilator and monitoring system called Servo One. With a new tubing system that incorporated both humidifier and patient filter in a flexible way, together with an external sensor system, the concept drastically improved cable and tubing management - one of the biggest challenges in the ICU.

MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand / The purpose of the study was to describe and compare the limits of agreement between invasive blood pressure (IBP) and non-invasive blood pressure (NIBP) readings obtained on patients in the adult critical care units (CCU) of a tertiary health care institution, to describe the factors that affect accuracy of both techniques, to describe the difference in terms of accuracy and sensitivity and the reasons given by the clinical practitioners for their choice of blood pressure measurement technique. A non-experimental descriptive comparative, prospective design was utilized in this two part study. The sample comprised of CCU patients (n = 80) in five adult critical care units over a 3-month period. Non-probability purposive sampling was utilized to obtain the desired sample in part one of the study. Data collection was via IBP and NIBP measurements obtained by the researcher and a record review of the patient’s critical care charts. Part two of the study comprised of clinical practitioners (n=50) and convenience sampling method was utilized. Descriptive and inferential statistics were used to analyse data. At the 95% confidence interval, the limits of agreements were found to be in range of ± 35 mmhg of IBP and NIBP systolic, ± 19.5 mmHg of IBP and NIBP diastolic and ±19.3 mmhg IBP and NIBP of mean arterial pressure. In practical terms this means that IBP and NIBP can not be used interchangeably in CCUs as the two methods did not consistently provide similar measurements because there was a high level of disagreement that included clinically important discrepancy of more than 10 mmhg which is the cut off acceptable reference in terms of discrepancy between the two BP techniques and add to the growing literature suggesting that IBP remains the gold standard technique for measuring the blood pressure in critical care setting. Factors such as Inotropic/ vasopressor support, sedation / analgesia, mechanical ventilation and severity of illness (APACHE II score) did not show significant influence on the discrepancy of the two BP techniques. In the second part of the study, more than 80 % of the sample of clinical practitioners acknowledged that the IBP technique remains the gold standard.

M.Sc. (Nursing), Faculty of Health Sciences, University of the Witwatersrand, 2009

Background: With the COVID-19 pandemic, there has been an influx of patients with acute respiratory distress syndrome (ARDS), an inflammatory lung condition. ARDS survivors are at high risk for developing post-traumatic stress disorder (PTSD) due to intensive care unit (ICU) medical treatments/procedures. They are known to have traumatic memories triggered by their sensorium months to years after being discharged from the ICU. One study found that 23% of ARDS survivors experienced long-term PTSD symptoms 2-3 years after hospital discharge (Bienvenu et al., 2018). Unknown is whether there are similarities in the memories and sensory triggers of PTSD amongst ARDS and COVID ARDS survivors. Purpose: The purpose of this study was to 1) identify the most common vivid ICU memories and sensory triggers for PTSD symptoms in survivors of ARDS and COVID positive ARDS; 2) to analyze the frequency of sensory triggers and determine whether differences exist between ARDS and COVID ARDS survivors. Method: A multi-step, thematic analysis of qualitative data from 27 patients was completed (20 COVID ARDS patients and 7 ARDS patients) by a team of 7 researchers. Patients were asked a series of open-ended questions regarding vivid memories and sensory triggers for them. Major themes were generated from their responses. Results: Major themes identified were prevalent in both COVID ARDS and ARDS groups. Prominent vivid memories included medical treatment/procedures, emergence delirium, illusions/hallucinations, vivid nonsense dreams and sensory to dream conversion. Common sensory triggers included seeing medical equipment, hearing beeping/alarms, seeing media depictions of the hospital setting, hospital smells and seeing doctors, nurses, hospitals. Differences between COVID-ARDS and ARDS groups were not notable. Conclusion: The data collected in this study revealed ARDS and COVID ARDS patients experience sensory inputs during their ICU stay that contribute to the development of vivid, long-lasting memories and subsequent PTSD symptoms. Survivors' everyday lives are altered by these symptoms, impacting their ability to work, familial relationships, and likelihood to seek out healthcare. Data from this study is being used in a compressed exposure therapy trial and should be incorporated into future PTSD preventative and treatment interventions.

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