A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Paediatrics and Child Health 29 May 2017 / Introduction Sepsis, and in particular, severe sepsis, remains a major cause of death in children worldwide. One of the areas where the burden of sepsis is keenly felt is in the paediatric intensive care unit (PICU) setting, contributing significantly to childhood mortality. Fungal organisms have emerged as a major organism contributing to nosocomial sepsis in PICU. No local data regarding nosocomial fungal sepsis in the non-neonatal, PICU population exists regarding this matter. This study describes the characteristics of patients with nosocomial fungal sepsis in the PICU at South Africa’s largest hospital Chris Hani Baragwanath Academic Hospital (CHBAH). Methods This study was a retrospective review of patient records. All patients aged 0-16 years admitted to the PICU at Chris Hani Baragwanath Academic Hospital (CHBAH) from January 2008 through December 2011 were assessed. A total of seventeen patients who developed nosocomial fungal sepsis were included in this study. Results The incidence of candidaemia was reported to be 3.2 per 100 cases. The major age group affected by nosocomial fungal sepsis was the under one age group. The most common diagnoses on admission were lower respiratory tract infection (LRTI) followed by haematology-oncology and acute gastroenteritis cases. ICU factors found to commonly co-­‐exist with proven nosocomial fungal sepsis were presence of a central venous catheter (100%), mechanical ventilation (82%), arterial line (70%), and systemic corticosteroid use (47%). The penicillin class was the most common antimicrobial that patients were found to be on at the time of nosocomial sepsis. The most common fungal organism as a cause for nosocomial sepsis was C. parapsilosis rather than C. albicans. Furthermore, the majority of this study’s isolates were susceptible to voriconazole rather the current empiric antifungal of choice, namely fluconazole. Conclusion The presence of central venous catheters, arterial lines, mechanical ventilation and systemic corticosteroid use is common in paediatric patients with nosocomial fungal sepsis. However, this study was unable to determine statistically significant factors associated with fungal sepsis in a tertiary PICU due to the surprisingly small number of cases (n=35) detected over a four-year period. This perhaps represents the most striking finding of the study together with a concerning pattern of fluconazole resistance (14%) among isolated organisms. / MT2017

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Masters of Science in Physiotherapy. Johannesburg 2017 / Background: There is limited research available on the use of outcome measures in intensive care units (ICU) in a South African setting.The Chelsea Critical Care Physical Assessment tool (CPAx) is a measure of morbidity related to physical function and assesses respiratory function and functional abilities of critically ill patients. Objectives: The objectives of this study were to establish the effect of the use of the CPAx tool on ICU and hospital length of stay (LOS) in the care of critically ill patients; to establish the usefulness of the CPAx tool according to patient admission diagnosis; to determine if a relationship exists between CPAx scores and severity of illness or general morbidity during ICU admission; and to establish physiotherapists’ perceptions and views towards the use of the CPAx tool in their daily clinical practice in ICU. Design: The study consisted of two parts. Part one was a quasi-experimental design with a historical matched control group. Part two was a survey-based design. Methods: The study took place in a South African public sector hospital. Twenty six participants each were recruited into the experimental and control groups. Participants from the control group were matched with participants in the experimental group according to age, gender, diagnosis and acute physiology and chronic health evaluation (APACHE) II scores. CPAx scores and sequential organ failure assessment (SOFA) scores were calculated for participants in the experimental group on alternate weekdays during their ICU stay. Comparisons of ICU and hospital LOS between the study participants and historical control group were done using an independent t-test. Pearson’s correlation coefficient was used to determine if a relationship existed between CPAx scores, APACHE II scores or SOFA scores. A p-value ≤ 0.05 was deemed statistically significant. A questionnaire was developed and was completed by the research assistants who administered the CPAx tool to participants in the experimental group in order to determine their perceptions of the tool. Results: The mean age for the CPAx group was 37.88 (±13.37) years and for the control group was 37.81 (±12.21) years. The CPAx group consisted of 14 (53.8%) participants who underwent surgical procedures and 12 (46.2%) participants with traumatic orthopaedic injuries. The control group consisted of 14 (53.8%) participants who underwent surgical procedures and 12 (46.2%) participants with traumatic orthopaedic injuries. The mean initial SOFA score for the CPAx group was 2.42 (±1.79) and for the control group was 4.15 (±2.6). A p=0.03 indicates that there was a statistically significant difference between the two groups with regards to initial SOFA scores. The mean SOFA score at ICU discharge for the CPAx group was 1.80 (±0.42) and for the control group was 2.87 (±1.81). A p=0.05 indicates that there was a statistically significant difference between the two groups with regards to SOFA scores at ICU discharge. The mean initial CPAx score for the experimental group was 29.73 points (±14.81) and the mean CPAx score at ICU discharge was 36.15 (±8.33). The mean CPAx scores changed by 9.45 points between admission and discharge from ICU for participants who underwent surgical procedures and the mean CPAx scores changed by 3.9 points between admission and discharge from ICU for participants who sustained traumatic orthopaedic injuries. The mean ICU LOS for the CPAx group was 5.84 days (±7.43) and for the control group was 4.56 days (±5.25). The mean hospital LOS for the CPAx group was 17.43 (±16.68) days and for the control group was 19.31 days (±15.79); however, in both cases differences were not statistically significant. APACHE II scores had a very weak negative correlation with initial CPAx scores. APACHE II scores had a very weak positive correlation with CPAx scores at ICU discharge. There was a statistically significant difference between the two groups with regards to initial SOFA scores (p=0.05). Initial SOFA scores had a statistically significant moderate negative correlation with initial CPAx scores (r=-0.45, p=0.02). Initial SOFA scores had a weak negative correlation with CPAx scores at ICU discharge. Initial CPAx scores had a moderate positive correlation with SOFA scores at ICU discharge. CPAx scores at ICU discharge had a very strong statistically significant positive correlation with SOFA scores at ICU discharge (r=0.80, p=0.05).The CPAx tool proved to be more responsive in a surgical population than in a trauma population. Clinicians had positive perceptions of the CPAx tool in the management of critically ill patients. Discussion: Participants in the CPAx group were well matched with those in the historical control group with regards to age, gender, diagnoses and severity of illness. Those in the CPAx group had lower extent of organ dysfunction than those in the control group which might account for their shorter period of hospitalisation. Patients with a higher risk for mortality on admission into the ICU displayed lower functional abilities and, in turn, lower CPAx scores were measured. A greater change in CPAx scores was observed for participants recovering from surgical interventions compared to those recovering from traumatic orthopaedic injuries. Participants with low morbidity at the time of ICU admission seemed to have a greater ability to perform functional activities during their ICU stay. Limitations of the study included a small patient sample, a limited number of research assistants as well as lack of content validation of the questionnaire used. A multi-centre trial on the use of CPAx in ICU patient management could yield a wider perception of physiotherapists regarding the usefulness of the tool in daily clinical practice. Measuring the effect of the CPAx tool on participants’ length of mechanical ventilation could also be an interesting clinical outcome to consider. Conclusion: The data presented in this study show that the use of the CPAx tool does not have an influence on ICU and hospital LOS in a small sample of surgical and trauma participants. The tool appears to be more useful when used in the care of patients who are recovering from surgical procedures rather than those who sustained complex traumatic injuries. Physiotherapy clinicians that participated in the study supported the use of the CPAx tool in this single-centre trial and generally had positive perceptions towards the use of the tool. / MT2017

Existing literature has identified that health care providers significantly shape the experiences of parents at the end-of-life in the pediatric intensive care unit. However, there is a gap in the literature of the specific nursing influence on parental experiences of a child’s death in this context. Employing the interpretive descriptive methodology, this qualitative study was designed to explore parents’ moral experiences of nursing care at the end-of-life in the pediatric intensive care unit, and was analyzed through a lens of nursing ethics. Face-to-face, semi-structured interviews were conducted with eleven parents (six mothers and five fathers) of six children who died in a pediatric intensive care unit at a university-affiliated tertiary hospital in Eastern Canada. Study results revealed close connections between parents’ abilities to meaningfully parent a child through their death and the nursing care that they received at the end-of-life, and highlighted the varying helpful guiding roles that nurses adopted at different moments in parental experiences. Results also indicated that parents attributed immense value to feeling that nurses cared-for-and-about their child and the parents themselves, since this made parents feel that their child’s death mattered to the nurses whom they had formed relationships with. This study enhances our understanding of the individualized nature of parents’ moral experiences of nursing care at the end-of-life in the pediatric intensive care unit, and study results suggest implications for nursing practice, education, and research.

MSc (Nursing), Faculty of Health Sciences, University of the Witwatersrand, 2009 / Anxiety, depressive and post-traumatic stress (PTS) symptoms have been identified in many patients following ICU treatment (Rattray, Johnston & Wildsmith 2005). The Intensive Care Unit (ICU) is a stressful environment and patients may be left with long standing psychological symptoms that impair their quality of life (Scragg, Jones & Fauvel 2001). There is a dearth of research on early assessment of the psychological sequelae following treatment in ICU in South Africa and interventions required to aid in the recovery process. Post-traumatic stress symptoms do not appear to decrease over time after ICU discharge (Jones et al 2001, Rattray et al 2005), indeed they may endure for a number of years (Kapfhammer et al 2004) causing the patients significant suffering. The purpose of this study was to investigate the prevalence of symptoms of anxiety, depression and post-traumatic stress in patients, at their first follow up visit in the outpatient department at a level one academic hospital in Johannesburg, South Africa. A prospective, quantitative, cross-sectional, descriptive format was used to investigate these variables. The total sample number was 98 and the instruments used in the structured interview were the Hospital Anxiety and Depression Scale (HADS) and the Experience After Treatment in ICU –7 (ETIC-7). The prevalence of symptoms of anxiety in this sample population was 48%, depression 28% and post-traumatic stress 32%. Fifty-eight percent of the sample had combined anxiety and depression scores severe enough to have a ‘possible clinical disorder’.

Making the transition to an area of specialist nursing practice is challenging for both the learner and staff who are responsible for education and skill development. This study uses grounded theory methodology to explore the question: "How do nurses learn critical care nursing?"The eight registered nurses who participated in this study were recruited from a range of intensive care settings. The criteria for inclusion in the study included the participant having attained competency within the critical care setting. Data was collected from individual interviews. The findings of this study developed during the coding and comparative analysis process, and subsequently theoretical sampling was used to further explore the identified concepts.This study found that nurses' focus on two main areas during their orientation and induction into critical care nursing practice. These are learning to do (skill acquisition) and learning to be (professional socialisation). The process of transition involves two stages: that of learning to do the tasks related to critical care nursing practice, and the ongoing development of competence and confidence in practice ability. The relationship of the learner with the critical care team is a vital part of the transition to competency within the specialist area.This study identifies factors that influence the learner during transition and also provides an understanding of the strategies used by the learners to attain competency. These findings are applicable to educators and leaders responsible for the education and ongoing learning of nurses within critical care practice. The use of strategies such as simulated learning and repetition are significant in skill acquisition. However attention must also be paid to issues which influence the professional socialisation process, such as the quality of preceptor input during orientation and the use of ongoing mentoring of the learner.

Hypothermia treatment with cooling to a body temperature of 32-34°C has been shown to be an effective way of improving neurological outcome and survival in unconscious patients successfully resuscitated after cardiac arrest (CA). The method is used clinically but there are still many questions on the biological mechanisms and on how the treatment is best performed. This thesis focuses on cerebral and haemodynamic effects of hypothermia and rewarming. A porcine model of CA was used. To shorten time to reach target temperature, induction of hypothermia, by means of infusion of 4°C cold fluid, was started already during ongoing cardiopulmonary resuscitation. The temperature was satisfactorily reduced without obvious haemodynamic disturbances. Cerebral effects of hypothermia and rewarming were studied. Microdialysis monitoring showed signs of cerebral energy failure (increased lactate/pyruvate-ratio) and excitotoxicity (increased glutamate) immediately after CA. There was a risk of secondary energy failure that was reduced by hypothermia. Intracranial pressure (ICP) increased gradually after CA irrespectively of if hypothermia was used or not. There were no indications of increasing cerebral disturbances during rewarming. Haemodynamic effects of hypothermia treatment and rewarming were examined in a study of patients successfully resuscitated after CA. Hypothermia was induced by means of cold intravenous infusion. No negative effects on the cardiovascular system were revealed. There were indications of decreased intravascular volume in spite of a positive fluid balance. Cerebral microdialysis and ICP recording were performed in four patients. All patients had signs of energy failure and excitotoxicity following CA. ICP was only exceptionally above 20 mmHg. In contrast to the experimental study indications of increasing ischemia were seen during rewarming. Glycerol had a biphasic pattern, perhaps due to an overspill of metabolites from the general circulation. As most patients become extensively anti-coagulated following CA, intracranial monitoring is not suitable to be used in routine care.

Thesis (M.S.N.)--Marshall University, 2002. / Title from document title page. Document formatted into pages; contains v, 60 p. Includes bibliographical references (p. 48-51).

published_or_final_version / Nursing Studies / Master / Master of Nursing

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are together known as venous thrombo-embolism (VTE), one of the most common complications after surgery and trauma injury. In the case of critically ill patients, it is also a significant medical and financial burden, associated with high mortality and morbidity. In recent years, much evidence has come to light showing that DVT prophylaxis can effectively reduce DVT, and it has been incorporated into various evidenced-based guidelines (Geerts et al., 2008; Nicolaides et al., 2006). The objectives of this study are to examine, through a comprehensive literature review of published studies, the effectiveness of various means of DVT prophylaxis aimed at reducing DVT, and to develop an evidence-based guideline for the use of DVT prophylaxis in surgical intensive care unit (ICU) settings. Keywords related to DVT prophylaxis were used in conducting the search in electronic bibliographic databases like MEDLlNE, CINAHL, PubMed and the Cochrane Library. A total of 110 articles were identified, and seven studies fulfilled the inclusion criteria of the study. Data from the seven studies have been extracted to form tables of evidence; the qualities of the studies were then rated, and the levels of evidence assigned according to SIGN 50: A guideline developer’s handbook (Network, Harbour & Forsyth, 2011). Three studies attained a higher level of evidence with strong methodological design and demonstrated a statistically significant reduction in the incidence of DVT. The implementation potential of DVT prophylaxis was examined in terms of target setting, target audience, transferability of findings, feasibility and cost-benefit ratio. And it was found that the development of evidence-based guidelines for DVT prophylaxis was feasible, cost-beneficial and transferable in current settings. The findings of the seven reviewed studies have been translated into an evidence-based DVT prophylaxis guideline. The main focuses of the guideline are the choice of prophylaxis used with surgical ICU patients and the strategies for improving adherence and prophylaxis monitoring. Combined pharmacological and mechanical DVT prophylaxis is recommended for ICU patients who are at high risk of DVT. For patients with active bleeding or high risk of bleeding, mechanical prophylaxis like intermittent pneumatic compressor (IPC) or gradual compression stocking (GCS) should be used first, followed by a review for pharmacological prophylaxis when the risk of bleeding has decreased. In addition, routine assessment of thrombosis and bleeding risk for high-risk ICU patients and regular checking of fitting and functioning of the DVT prophylaxis are recommended. An implementation plan consisting of communication, pilot and evaluation plan was developed. A 12-month programme including communication with stakeholders, marketing of the innovation, training of frontline staff, a five-week pilot study and implementation of the guideline followed by evaluation will be carried out. In the evaluation, programme effectiveness was assessed in terms of patient outcome (e.g. incidence of DVT), process outcomes (e.g. level of knowledge related to DVT, compliance with the guideline and level of staff satisfaction) and system outcome (e.g. financial cost reduction). / published_or_final_version / Nursing Studies / Master / Master of Nursing

Background Severe impairment of physiologic functioning brings the focus of intensive care unit (ICU) on the reversal of acute organ failure which will threaten one’s survival if it is left untreated (Morris, 2007). Providing respiratory support to majority of ICU patients, mechanical ventilation (MV) is a life saving intervention. MV patients constitute one-third of ICU patients worldwide and 46% of them are put on ventilator support more than 24 hours having the mean duration ranged from 15.4 to 33.2 days (Adler & Malone, 2012). The aim of ICU care places most of the attention on resuscitation and survival while the neuromuscular functioning is often overlooked as raised by a number of recent studies. Poor physical functioning was reported by all the patients due to loss of muscle mass, muscle weakness and fatigue (Herridge et al., 2011). Only 50% of them got employed 1 year after recovery while the rest of them were still unemployed because of persistent fatigue, poor functional status like foot drop and large joint immobility (Herridge at al., 2011). ICU-acquired weakness accounts for neuropathies and myopathies after recovery from critically illness and respiratory failure as manifested by loss of body mass, severe weakness and physical dysfunction (Cheung et al., 2006). De Jonghe and colleagues (2002) found that 25% of MV patients developed the ICU-acquired weakness and they determined MV as one of the key etiologies. Kasper and colleagues (2002) stressed that muscle atrophy happens within a few hours of bed rest having 4% to 5% depreciation of muscle strength for one week bed rest. Moreover, insulin resistance appears after merely 5 days of bed rest. On the other hand, immobility interferes baroreceptors bringing hypotension and tachycardia, giving rise to reduced cardiac output and gaseous exchange therefore deterioration of cardiac function (Convertino, Bloomfield & Greenleaf, 1997). It is obvious that a viscous cycle is present while leaving survivors from recovery of critical illness immobilized. Mobilizing MV patients can train up their limb power and their ADL ability (Burtin et al., 2009; Chiang, Wang, Wu, Wu, & Wu, 2005; Martin, Hincapie, Nimchuk, Gaughan, & Criner, 2005). Burtin and colleagues (2009) illustrated that patients receiving mobilization program had a better score in SF-36PF showing the attainment of better quality of life (QOL). Early mobilization can increase the number of day of ventilator free (Schweickert et al., 2009) and shortening ICU and hospital length of stay (Morris et al., 2008). Purpose The dissertation is aiming at seeking for the best evidence to establish an evidence – based mobilization guideline for those mechanically ventilated patients. The goal is to optimizing the physical outcomes of mechanically ventilated critically ill patients. Method The three electronic databases including Medline (Ovid SP), CINAHL (Ovid SP), PudMed and Cochrane Library were searched through while doing the systematic search of scientific literature. Subsequently, five articles confining to the inclusion criteria were sieved in the literature review and evidence extraction was performed. Quality assessment of the 5 studies was done using a critical appraisal tool derived by Scottish Intercollegiate Guideline Network (SIGN) (2008) and thereafter an evidence-based guideline for early mobilization of the mechanically ventilated patients was established. An implementation plan was then set up which comprised of the communication plan between different level of stakeholders of ICU and the pilot testing. Apart from communicating with the stakeholders, the plan also delineated the way of initiating, guiding and sustaining the change. A pilot study was planned to execute in order to test the sufficiency of training workshop, determine the feasibility of the mobilization protocol and the evaluation plan. Lastly, an evaluation plan was considered to assess the success of mobilization guideline in terms of patient outcomes, healthcare provider outcomes and organizational outcomes. / published_or_final_version / Nursing Studies / Master / Master of Nursing