Journal of the Intensive Care Society

We evaluated intensive care medicine trainees’ practice of emergency intubations in the United Kingdom.

Retrospective analysis of 881 in-hospital emergency intubations over a three-year period using an online trainee logbook.

Emergency intubations out-of-hours were less frequent than in-hours, both on weekdays and weekends. Complications occurred in 9% of cases, with no association with time of day/day of week (p = 0.860). Complications were associated with higher Cormack and Lehane grades (p=0.004) and number of intubation attempts (p < 0.001), but not American Society of Anesthesiologist grade. Capnography usage was ≥99% in all locations except in wards (85%; p = 0.001). Ward patients were the oldest (p < 0.001), had higher American Society of Anesthesiologist grades (p < 0.001) and lowest Glasgow Coma Scale (p < 0.001).

Complications of intubations are associated with higher Cormack and Lehane grades and number of attempts, but not time of day/day of week. The uptake of capnography is reassuring, although there is scope for improvement on the ward.

Enteral nutrition delivery in the critically ill is frequently interrupted for surgical and airway procedures to avoid aspiration of stomach contents. Recurrent fasting leads to under delivery of enteral nutrition and this underfeeding is associated with worse outcomes. International fasting recommendations do not provide guidance for intubated patients receiving enteral nutrition. This study aimed to gain a detailed perspective of UK critical care fasting practices.

A web-based survey was sent to 232 UK intensive care units consisting of questions relating to fasting practices, presence of guidelines, average fasting times for common procedures and dietitian time per intensive care unit bed.

A total of 176 intensive care units responded. Only 20% of units had guidelines and respondents stated that they were not consistently adhered to (mean compliance 66%). Units with greater dietetic involvement were more likely to have guidelines (p = 0.04). Fasting times were shorter for abdominal surgery (p = 0.002), non-abdominal surgery (p = 0.016) and radiology (p = 0.015) if a guideline was present. Fasting for extubation and tracheostomy was similar irrespective of the presence of a guideline. Considerable variation in fasting times was reported, usually due to inconsistencies in clinical decision-making.

This survey of national practice demonstrates that fasting times are varied and inconsistent, which may lead to under-delivery of enteral nutrition. More dietetic input was associated with increased likelihood of a fasting guideline.

Suicide is increasing in the UK, and hanging is now the commonest mechanism. United Kingdom intensive care unit outcomes (including organ donation) after hanging have not been reported.

Retrospective analysis of cases admitted to a UK tertiary intensive care unit with a primary or secondary diagnosis of hanging/asphyxia. Case analysis divided between those with and without a history of cardiopulmonary resuscitation, and outcomes described using the cerebral performance category score.

A total of 33 cases were reviewed, 19 with a history of cardiopulmonary resuscitation (three survivors with cerebral performance category of 1–2), 14 without history of cardiopulmonary resuscitation (14 survivors, 11 cerebral performance category score of 1, 3 cerebral performance category score of 3). Three cases went on to have a good neurological outcome with a cerebral performance category score of one, and 16 died. The three survivors only had bystander cardiopulmonary resuscitation and cardiac arrest was not independently confirmed. All three had a good neurological recovery despite two having hypoxic–ischaemic encephalopathy on computed tomography head. Of the three survivors, one received no temperature management and two received targeted temperature management. Median intensive care unit length of stay after hanging with cardiopulmonary resuscitation was 3.0 days (2.4–6.7 days). Fifteen patients were discussed with the organ donation specialist nurse, with six consenting to donation and six declining consent, with 18 solid organs donated. All 14 of those without a history of cardiopulmonary resuscitation survived, 11 with a cerebral performance category score of 1 and three having a cerebral performance category score of 3. No patients received active temperature management. Median intensive care unit length of stay in this group was 2.9 days (1.2–3.8).

Outcomes after confirmed cardiac arrest following hanging are poor, in keeping with existing international data, even in those surviving to intensive care unit admission. Despite low rates of consent to organ donation, the overall organ donation is high due to high referral rates. Despite the poor prognosis in this population, early initiation of full resuscitation should be offered to optimise survival and facilitate the possibility of donation.

To describe the case mix, resource use and outcomes for adolescents admitted to intensive care units in the UK.

Analysis of national prospectively collected data for all adolescents aged 12–19 years admitted to UK adult or paediatric intensive care units.

There were 37,320 admissions of adolescents during the eight–year study period. Excluding elective surgery, respiratory diagnoses were the most common reason for paediatric intensive care unit (PICU) admission, with trauma and intoxication the most common reasons for adult intensive care unit (AICU) admission. Intensive care unit mortality was 6.0% and 5.7% for those admitted to PICUs and AICUs, respectively.

Mortality is similar among adolescents admitted to AICUs and PICUs; however, these rates have not been corrected for severity of acute illness or underlying burden of chronic illness, which may be different between AICUs and PICUs. Services planned for the majority of AICU and PICU patients may not be optimal for critically ill adolescents treated in UK intensive care units, who may need special consideration.

We aimed to measure the safety culture across a network of critical care units to compare units, track temporal changes and to present easy to interpret information back to staff.

We provided adapted paper versions of the short ICU ‘Safety attitude questionnaire’ to 14 critical care units annually between 2015 and 2017. The responses were analysed to establish scores for individual safety domains. Feedback used colour conditional formatted tables to allow easy identification of high and low scores.

There was an inverse relation between median unit score and standardised mortality (r_s = 0.4). Rates of staff fatigue increased between 2016 and 2017 (two-point change on a 1–5 scale).

A critical care network can usefully collect and feedback safety attitude questionnaires which show a relationship with patient outcome. Units should monitor overtime working.

Critical care services underpin the delivery of many types of secondary care, and there is increasing focus on how to best deliver such services. The aim of this study was to investigate the impact of establishing a medical high dependency unit, in a tertiary referral center, on the workload, case mix, and mortality of the intensive care unit.

Single-center, 11-year retrospective study of patients admitted to the general intensive care unit, before and after the opening of the medical high dependency unit, using interrupted time series methodology.

Over the duration of the study period, 3209 medical patients were admitted to the intensive care unit. There was a constant rate of medical admissions to the intensive care unit until the opening of the medical high dependency unit, followed by a statistically significant decline thereafter. There was a statistically significant decrease in the average severity of illness of medical patients prior to the opening of the medical high dependency unit, but there was no evidence of a change following the opening of the unit. There was no evidence of a statistically significant change in the estimated mean standardized mortality ratio for either medical or surgical admissions after the intervention.

The opening of a medical high dependency unit had a minimal impact on the intensive care unit. There was, in all likelihood, an unmet need—of less seriously ill patients, who were previously looked after on a normal ward, but did not require intensive care unit admission—who are now cared for in the new medical high dependency unit. Interrupted time series analysis, although not without limitations, is a useful mean of evaluating changes in service delivery.

Both in the UK and internationally, discharge from an intensive care unit to home for end of life care is a rare and challenging occurrence. These challenges include clinicians’ ability to identify appropriate patients in whom it is possible to communicate with about their wishes and preferences, the critical nature of their condition and the interface between hospital and community services.

We present a case report of a patient who had been admitted to hospital with a myocardial infarction and subsequently suffered a cardiac arrest, from which he was successfully resuscitated. Subsequently, he suffered multi-organ failure, but despite treatments, the ceiling of care was reached. With a poor prognosis, medical and nursing staff engaged in advance care planning to determine his wishes and preferences at the end of life and to facilitate his discharge from the intensive care unit to his home.

This case study has highlighted that through good communication amongst patients, families and professionals and collaborative working across boundaries and organisations, appropriate patients in the critical care setting can have a real choice regarding where they wish to be cared for and die at the end of their life.

Both Scottish and UK standards guidelines recommend that intensive care units should hold regular, structured, multidisciplinary morbidity and mortality meetings. The aim of this survey was to ascertain the nature of current practice with regards to morbidity and mortality case reviews and meetings in all intensive care units in Scotland.

Semi-structured telephone interviews were conducted with a consultant from all Scottish intensive care units. A list of intensive care units in Scotland was obtained from the Scottish Intensive Care Society Audit Group annual report.

All 24 intensive care units (100%) in Scotland were surveyed. The interviews took an average of 20 min. The three cardiac intensive care units were excluded from analysis. All other intensive care units had morbidity and mortality meetings and 18 units had a morbidity and mortality clinical lead. Nineteen intensive care units held joint morbidity and mortality meetings, eight of which were regular. In all intensive care units, meetings were attended by consultants and trainees. In 14 intensive care units, meetings were attended by nurses, seven by allied health professionals, 1 by a manager and 11 by other professionals. All mortality cases in intensive care unit were discussed in 19 intensive care units, in the other two intensive care units, 10–20% of mortality cases were discussed.

There is a wide variation in the processes of reviewing mortality cases and significant events in intensive care units across Scotland, and in the way morbidity and mortality meetings are organised and held. Based on this survey, there is scope for improving the consistency of approach to morbidity and mortality case reviews and meetings in order to improve education and facilitate shared learning.