Yes / The Biochemistry and Haematology Outcome Model (BHOM) relies on the results from routine index blood tests to predict the patient risk of death. We aimed to externally validate the BHOM model. Method We considered all emergency adult medical patients who were discharged from Northern Lincolnshire and Goole (NLAG) hospital in 2014. We compared patient characteristics between NLAG (the validation sample) and the hospital where BHOM was developed. We evaluated the predictive performance, according to discriminative ability (with a concordance statistic, c), and calibration (agreement between observed and predicted risk). Result There were 29 834 emergency discharges of which 24 696 (83%) had complete data. In comparison with the development sample, the NLAG sample was similar in age, blood test results, but experienced a lower mortality (4.7% vs 8.7%). When applied to NLAG, the BHOM model had good discrimination (c-statistic 0.83 [95% CI 0.823 - 0.842]). Calibration was good overall, although the BHOM model overpredicted for lowest (<5%, observed = 229,predicted =286) and highest (≥50%, observed = 31, predicted = 49) risk groups, even after recalibrating for the differences in baseline risk of death. Conclusion Differences in patient case-mix profile and baseline risk of death need to be considered before the BHOM model can be used in another hospital. After re-calibrating for the baseline difference in risk the BHOM model had good discrimination but less adequate calibration.

Thesis (MMed)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Case Report - A case is described of central oxygen pipeline failure that occurred at a large academic hospital and its subsequent implications for managing the situation. Literature review - The literature review undertaken focused on the current state of affairs with regards to anaesthetic staff's knowledge of and preparedness for the management implications of central oxygen pipeline failure. The events I describe below demonstrate a significant deficiency in the staff’s understanding of and training for the crisis, which should be remedied to improve patient safety. Specific measures are suggested in the literature to prevent such incidents and guidelines are available to manage central oxygen pipeline failure. These are reviewed in this study. Recommendations - This study attempts to bring together the most critical aspects that need to be addressed to safely manage similar future incidents. Prevention should include measures to implement clearly stated disaster management plans and increased awareness with regards to the medical gas pipeline system (MGPS), simulation training, efficient alarm systems, personally conducted routine evaluations of equipment and emergency backup systems by anaesthesiologists and effective communication between hospital staff. Careful planning and successful coordination during maintenance and modification of the medical gas pipeline system, using piston-type or air-driven, rather than oxygen-driven, ventilators and optimal design of the hospital bulk oxygen system can contribute to reduce risks. In the event of central oxygen pipeline failure a specific sequence of actions should be taken by the anaesthesiologist and a clear institutional operational policy is described. / AFRIKAANSE OPSOMMING: Gevalsbeskrywing - 'n Geval van sentrale suurstoftoevoerversaking, wat plaasgevind het by 'n groot opleidingshospitaal, word bespreek. Daar word ook gekyk na die praktiese gevolge met betrekking tot die hantering van die situasie. Literatuurstudie - 'n Literatuurstudie is aangepak met die doel om te fokus op die huidige toedrag van sake betreffende narkosepersoneel se kennis en paraatheid in die hantering van sentrale suurstoftoevoerversaking. 'n Wesenlike gebrek aan begrip en opleiding aangaande hierdie onderwerp is geïdentifiseer – areas wat, met die nodige aandag, verbeter kan word ten einde die welstand van pasiënte te verseker. Spesifieke voorkomende maatreëls en hanteringsriglyne word voorgestel deur die literatuur en word gevolglik hersien in hierdie studie. Aanbevelings - Hierdie studie poog om kernaspekte aan te raak ten einde soortgelyke toekomstige voorvalle veilig en optimaal te kan hanteer. Voorkomende maatreëls behels onder meer die daarstelling van duidelik verstaanbare noodplanne, verbeterde bewustheid aangaande die mediese gaspypsisteem, simulasie-opleiding, doeltreffende alarmstelsels, effektiewe kommunikasie tussen hospitaalpersoneel, sowel as narkotiseurs wat self roetine-evaluasies van hul narkosetoebehore en -noodtoerusting uitvoer. Noukeurige beplanning en neweskikking tydens herstelwerk of werk aan die mediese gaspypsisteem, die gebruik van suierventilators (of dan lugaangedrewe in plaas van suurstofaangedrewe ventilators) en die optimale uitleg van 'n hospitaal se suurstoftoevoer, kan bydra om die risiko's te beperk. In die geval van sentrale suurstoftoevoerversaking behoort die narkotiseur stapsgewyse aksie te neem. 'n Duidelike institusionele noodbeleid word ook omskryf.

Thesis (DSc)--Stellenbosch University, 2013. / AFRIKAANSE OPSOMMING: Hierdie DSc is fundeer op ‘n aantal aspekte rondom ‘n sentrale tema naamlik die algemene en streeksfunksie van die normale hart of die hart blootgestel aan die risiko van miokardiale isgemie. Die werk is oor ‘n bestek van 25 jaar gedoen en sluit in eksperimentele werk in groot en kleindiere sowel as data verkry in pasiënte. Hoofstuk 1 handel met globale en streeksfunksie in die normale hart met die klem op die meer moderne benadering tot die koppeling van die hart met die sirkulasie en effek van middels op die twee komponente. Hierdie hoofstuk het waardevolle inligting gegee t.o.v. fisiologie maar ook gehelp om die middels te kies vir daaropvolgende studies. Hoofstuk 2 bevat navorsing wat verwys na die hart met kroonaarstenose. Onder andere word gesteun op ‘n dieremodel van kroonaarstenose. Die hoofstuk sluit data in wat , as eerste en unieke bydrae, gewys het dat inhalasie narkose middels die reperfusie besering van die hart kan verminder. Hierdie data het spesifiek bygedra om die kliniese praktyk van narkose vir hierdie pasiënte te verander. Hoofstuk 3 verwys na werk gedoen om die hart gedurende elektiewe chirurgiese arres te oksigeneer. Die effektiwiteit van verskillende kardioplegiese vloeistofsamestellings is ook krities ontleed. Die vierde hoofstuk handel met ‘n ernstige kliniese probleem naamlik akute pulmonêre hipertensie. By pasiënte met akute long besering is hierdie verskynsel baiemaal die oorsaak van dood en of moeitevolle oksigenasie. Die werk het gelei tot beter insigte t.o.v. pasiënt hantering tot die punt dat baie van die pasiënte vandag gered kan word. / ENGLISH ABSTRACT: This thesis is based on a number of aspects with a central theme of global and regional cardiac function in the normal heart and the heart at risk of ischemia. It summarizes work done over 25 years and includes experimental work in large and small animals as well as data obtained from human clinical practice. Chapter one deals with global and regional heart function and especially the physiological concept of ventriculo-arterial coupling as a mechanism to explain and understand the effects of inter alia commonly used drugs. Chapter 2 summarizes work done in hearts with a coronary artery stenosis. One of the interesting ,and at that time, unique findings was that inhalation anesthetic drugs are effective in limiting the reperfusion injury of the heart. This insight helped to redirect techniques used to anaesthetize patients with coronary artery disease. The third chapter examines methods to improve myocardial oxygenation during elective surgical cardiac arrest. It also includes data showing that not all the cardioplegic solutions are equally effective. Chapter four deals with a significant clinical problem i.e. acute pulmonary artery hypertension. This condition is often responsible for patient death, or contributes to, difficult oxygenation in patients with acute lung injury. The work in this chapter assisted in understanding the pathophysiology of the condition and improved the management thererof. This insight, combined with progress in other areas in the pathology or acute lung injury, has led to many of the patients today surviving their illness.

Moral distress is a complex and challenging problem that may cause negative biopsycohosical and professional outcomes for critical care nurses. The purpose of this work was to explore the relationship between the ethical climate of the work environment and moral distress as experienced by critical care nurses; and to explore relationships among mediators of stress (nurse characteristics e.g. education (BSN, nonBSN), years certified as a critical care nurse, and tolerance of ambiguity) and their relationship with perceived stress, moral distress, health status and salivary alpha amylase. A descriptive correlational cross-sectional design was used for this pilot study of 100 critical care nurses working in adult intensive care units in one large academic medical center. Data were analyzed using descriptive statistics to characterize the sample and the model variables. Regression analysis using a stepwise regression model building technique was used to determine predictors of the study outcomes (moral distress, health status, and salivary alpha amylase). The findings demonstrate that the ethical characteristics of the work environment and perceived stress were predictive of moral distress, psychological/emotional outcomes and stress symptoms. Other variables thought to mediate these relationships were not significant. Future research is needed to find ways to prevent moral distress from occurring and to support nurses dealing with moral distress.

Intensive care units (ICUs) emerged across Canada during the early 1960s, significantly contributing to the image of Western hospitals as places of scientific advancement that predominated over much of the twentieth century. ICUs rapidly became both a resource intensive and expensive type of care as the number and size of units increased to accommodate diverse patient populations and treatment options. Nurses enabled the formation and growth of ICUs through their constant presence and skilled care. There has been limited research, however, regarding the historical development of Canadian ICUs, the relationships between nurses and other personnel in such units, how they developed an identity as ICU nurses, or how ICU nursing became a specialty practice. Situated within the broader histories of hospitals, healthcare, and nursing, this study uses a social history approach to examine nurses’ experiences within Canadian ICUs between 1960 and 2002. Berger and Luckmann’s Social Construction of Reality provided a lens for analysis and interpretation of oral histories, photographs, professional literature of the time period under study, and both archival and organizational records. This thesis argues that ICU nurses’ relationships with one another, in the context of a technologically complex environment, socially constructed their knowledge and skill acquisition, their socialization as ICU nurses, and the development of a specialized body of knowledge that ultimately led to formal recognition of ICU nursing as a specialty in Canada.

Bakgrund: Intensivvårdspatienter utsätts för en påfrestande situation, vilket kan bidra till utvecklandet av iva-delirium. Iva-delirium är en form av hjärndysfunktion som leder till ökad sjuklighet, ökad mortalitet och ökade vårdkostnader i form av förlängd vårdtid. Studier visar att trots att iva-delirium är vanligt förekommande inom intensivvården så missas tillståndet ofta. Bedömningsinstrument för att identifiera iva-delirium finns men används vanligen i liten utsträckning inom svensk intensivvård. Detta kan leda till att intensivvårdssjuksköterskor, utifrån personlig erfarenhet, utvecklar olika strategier för att vårda patienter med iva-delirium. Syfte: Att beskriva intensivvårdssjuksköterskors personliga erfarenheter av att bedöma patienter som riskerar att drabbas av iva-delirium samt hur syndromet identifieras och förebyggs. Metod: En kvalitativ studie innehållande sex intervjuer genomfördes och analyserades utifrån en deskriptiv innehållsanalys. Resultat: Resultatet visade att intensivvårdssjuksköterskorna med hjälp av personliga erfarenheter skapade en framförhållning genom att förutse riskfaktorer och att identifiera kliniska tecken. Vidare visade intensivvårdssjuksköterskorna en förmåga att förebygga och resonera kring utförda åtgärder. En förståelse för vården av patienter med iva-delirium skapades genom etiska reflektioner. Slutsats: Intensivvårdssjuksköterskornas erfarenheter utgjordes av tre domäner; att se, att göra och att känna. Dessa olika erfarenheter interagerade med varandra, skedde simultant och skapade ett expertkunnande hos intensivvårdssjuksköterskorna. Trots denna förmåga framkom det att intensivvårdssjuksköterskornas kunskaper om iva-delirium och deras strategier varierade beroende på personlig erfarenhet. Klinisk betydelse: Genom att belysa intensivvårdssjuksköterskornas erfarenheter kan en ökad medvetenhet kring iva-delirium skapas och därmed förhoppningsvis medföra minskad prevalens. / Background: Critical care patients are exposed to a stressful situation, which could contribute to the development of icu-delirium. Icu-delirium is a form of brain dysfunction leading to higher morbidity, higher mortality and higher cost of care due to extended hospital stays. Even though studies show that icu-delirium is common within critical care the syndrome is often unrecognized. Delirium screening tools exist but are rarely used within Swedish critical care. The low implementation of screening tools could lead to that critical care nurses, based on personal experience, develop individual strategies for care of patients with icu-delirium. Aim: To describe experiences of assessing patients with risk for developing icu-delirium and how the syndrome is identified and prevented by critical care nurses. Methods: A qualitative study with six interviews was conducted and analyzed based on a descriptive qualitative content analysis. Results: The results showed that critical care nurses, based on earlier experiences, created an anticipation by discerning risk factors and identifying clinical signs. The critical care nurses showed an ability to perform preventive measurements while reasoning about already performed measurements. Through ethical reflections an understanding for the care of patients with icu-delirium was created. Conclusions: The experiences by critical care nurses was based on three domains; to see, to do and to feel. These domains occurred simultaneously and created the expertise of the critical care nurse. Despite this ability the knowledge of critical care nurses and their clinical assessment methods varied depending on earlier experiences. Relevance to clinical practice: By illuminating the experiences of critical care nurses hopefully a higher awareness regarding icu-delirium is created which will hopefully result in a lower prevalence.

The purpose of this research was to seek a deep understanding of the lived experience of intensive care nurses caring for patients with delirium. Delirium affects a large proportion of adult patients in the intensive care unit (ICU). Delirium has been linked to increased morbidity and mortality, longer intensive care and hospital length of stay, long-term cognitive impairments, short-term and long-term psychological distress, and increased hospital and health system costs. Critical care nurses play central roles in preventing, identifying, and treating ICU patients with delirium. Semi-structured interviews were conducted with eight intensive care nurses working in an ICU in a tertiary level, university-affiliated hospital in Ontario, Canada. The researcher analyzed the interviews using an interpretive phenomenological approach as described by van Manen (1990). The essence of the experience of critical care nurses caring for ICU patients with delirium was revealed to be finding a way to help them come through it. Six main themes emerged: It's Exhausting; Making a Picture of the Patient's Mental Status; Keeping Patients Safe: It's a Really Big Job; Everyone Is Unique; Riding It Out With Families; and Taking Every Experience With You. The findings describe how intensive care nurses find a way to help patients and their families through this complex and often distressing experience. This study has contributed to the understanding of the lived experience of ICU nurses caring for patients with delirium.

Intensive care units (ICUs) emerged across Canada during the early 1960s, significantly contributing to the image of Western hospitals as places of scientific advancement that predominated over much of the twentieth century. ICUs rapidly became both a resource intensive and expensive type of care as the number and size of units increased to accommodate diverse patient populations and treatment options. Nurses enabled the formation and growth of ICUs through their constant presence and skilled care. There has been limited research, however, regarding the historical development of Canadian ICUs, the relationships between nurses and other personnel in such units, how they developed an identity as ICU nurses, or how ICU nursing became a specialty practice. Situated within the broader histories of hospitals, healthcare, and nursing, this study uses a social history approach to examine nurses’ experiences within Canadian ICUs between 1960 and 2002. Berger and Luckmann’s Social Construction of Reality provided a lens for analysis and interpretation of oral histories, photographs, professional literature of the time period under study, and both archival and organizational records. This thesis argues that ICU nurses’ relationships with one another, in the context of a technologically complex environment, socially constructed their knowledge and skill acquisition, their socialization as ICU nurses, and the development of a specialized body of knowledge that ultimately led to formal recognition of ICU nursing as a specialty in Canada.

Introduction: Traumatic Brain Injury (TBI) remains a significant public health burden in the United States. Persons afflicted with more severe TBIs are usually admitted to an ICU, where they are at risk for a number of complications throughout their hospitalization. Recent literature has attempted to describe such complications from a cardiovascular perspective as part of a “cardio-cerebral syndrome.” We described the frequency of cardiac complications in the ICU among patients with a TBI and compared patients with and without measured cardiac dysfunction. We investigated the potential impact of cardiac dysfunction on in-hospital mortality. Methods: This was a retrospective review of a prospective cohort study in adult ICU patients with moderate-to-severe TBI (GCS≤12). We measured cardiac dysfunction using initial EKG echocardiography findings and peak serum troponin levels during hospitalization. Primary outcome was in-hospital mortality for patients with and without cardiac dysfunction using multivariable adjusted Cox Proportional Hazards Regression. Secondary outcomes examined the relationship between severity of brain injury and degree of cardiac dysfunction. Results: Ordinal logistic regression showed patients with more indicators of cardiac injury were significantly more likely to have greater brain injury as reflected by lower GCS scores (OR 0.76; 95%CI 0.58-0.99). There was a significantly increased multivariable adjusted risk of dying for each increase in measured cardiac injury (HR 2.41; 95% CI 1.29-4.53). Conclusions: Cardiac dysfunction was frequently observed in patients with TBI and we showed an association between increasing TBI severity and development of cardiac injury. Cardiovascular dysfunction was associated with an increased risk of in-hospital death. Adverse outcomes from TBI could potentially be mediated by cardiac injury, which could be used as a target for therapeutic intervention.

The incidence and causes of diarrhoea among critically ill patients receiving enteral tube feeding were investigated. Sixty acutely ill surgical or medical intensive care patients who had had a minimum of 48 hrs bowel rest were entered into the study. They were randomly assigned to receive one of two lactose free liquid formula diets - "Ensure", a commercially available feed containing 825 kCal/L and 34 g/L of protein with an osmolality of 441mOsm/1 or "Casilan Oil", a home-made feed containing 840 kCal /L and 45g/L of protein with an osmolality of 383 mOsm/1. The feeds were administered by constant nasogastric infusion. Patients received 1000ml at a rate of 40ml per hour for the first day and up to 2000ml at 80 ml per hour for the remainder of the study period. Investigations included documentation of medical history, medications administered and clinical details for each patient. Serum albumin was measured and the nutritional status of each patient was assessed using anthropometric measurements. Feeds were tested for bacterial contamination on the three days following the start of feeding and small intestinal bacterial overgrowth was assessed by the 1 g-¹⁴C Xylose breath test of Toskes and King. Twelve of the sixty patients had to be withdrawn from the trial within 24 hours of the start of enteral feeding for medical reasons. The remaining forty eight patients completed at least three days on enteral feeding and thereby became eligible for analysis. In 10/48 patients (21%) diarrhoea was present before enteral feeding began. Four of these 1 O patients continued to pass loose stools when enteral feeding was started while the remaining 6 settled. Diarrhoea developed in a further 10 patients (21%) after enteral feeding began. The overall incidence of diarrhoea in the group of critically ill patients studied was therefore 42% (20/48). However, of the fourteen patients who experienced diarrhoea during enteral feeding four had diarrhoea before feeding began. Therefore, the true incidence of diarrhoea related to enteral feeding was only 10/38 (26%). Furthermore, in 7 of these 10 patients, another possible cause of diarrhoea was present. There was no significant association between diarrhoea and nutritional status, hypoalbuminaemia, sepsis, length of bowel rest, sucralfate and antibiotic therapy other than amikacin. Twenty one patients received Ensure and 27 received Casilan Oil. Despite the differences in the composition of the feeds, the incidence of diarrhoea was similar on the Ensure and the Casilan Oil. No particular factor pertaining to the composition of the feeds was associated with diarrhoea. Significant contamination of feeds was universal but there was no constant relationship between bacterial counts, or types, and the occurrence of diarrhoea. Certain other factors were found to be significantly associated with diarrhoea. Abdominal injury was positively associated with the occurrence of diarrhoea (p&lt;0.05). Diarrhoea could have been attributed to the underlying disease state in 7 of the patients. All three patients who were receiving lactulose as treatment for liver failure developed diarrhoea. While no association was noted between diarrhoea and antibiotic therapy in general, treatment with the antibiotic, amikacin, correlated significantly, albeit marginally, with the occurrence of diarrhoea (p&lt;0.05). Twenty six patients were tested for small intestinal bacterial overgrowth. Only one patient, with an elevated excretion of ¹⁴CO₂, indicative of small intestinal bacterial overgrowth, developed diarrhoea. There was, however, a positive association between diarrhoea and decreased excretion of ¹⁴CO₂. It would appear that the bacterial flora was suppressed in patients with diarrhoea. Amikacin therapy was also associated with decreased excretion of ¹⁴CO₂. This may suggest that amikacin could have altered the bowel flora with resultant development of diarrhoea. While abdominal injury and disease were associated with the development of diarrhoea and amikacin was a possible factor associated with diarrhoea, the results of the present study indicate that enteral tube feeding with either the commercial feed, Ensure or the home-made feed, Casilan Oil was not a cause of diarrhoea in the majority of critically ill patients assessed. Furthermore, in most patients who commenced the trial with diarrhoea, improvement was noted on enteral feeding.