chani

greetings from Down under As some of you may know we dont have RTs in ICU in Australia so the nurses are responsible for most respiratory care including ETT management. At present I am reviewing the evidence for ETT cuff pressure management. I would like to ask who uses intermittent or continuous direct measurement and if anyone is using continuous control. I have looked through past posts and cannot find this question there. For continuous measurement you might like to read Mary-lou Sole's recent publications http://ajcc.aacnjournals.org/content/18/2/133.short http://www.aacn.org/WD/CETests/Media/A1120023.pdf EVALUATION OF AN INTERVENTION TO MAINTAIN ENDOTRACHEAL TUBE CUFF PRESSURE WITHIN THERAPEUTIC RANGE AJCC cheers

there appears to be little difference between OZ and NZ from above. What happens in OZ is how differ area health services (in NSW) interpret the nurses & midwifery act and then how this translates into actual practice. As an ICU nurse we continue to only having EN in as support staff (equipment) however in some combined units (HDU) there are some ENs looking after patients

As always if you dont know what to do DONT. Unfortunately as a new grad you are in an unequal power relationship however you will need to stand your ground. Explain politely you are unsure of what to do however are happy to do so with instruction.

Dear all on aussie forum we have also been discussing CVP. Below is a posting from a senior ICU specialist about the physiology of CVP. CVP Measurement This is the Achilles heel of the CVP. Like all intravascular measurements the baseline MUST be checked prior to every recording. if using the centre of the RA always use a spirit level or other manometer to a zero permanently marked on the patients lateral chest wall. Neglect of this basic prerequisite is the commonest cause of fluctuating incorrect CVP readings.A simple alternative is to use a" centrally measured JVP". This is done by taping the transducer to the patients manubrium sterni. With the catheter in the SVC the normal reading is +/- 2mm Hg . This reading is done with the patient at 30 degrees to give a little hydrostatic stress to the circulation and to reduce the effect of raised intra-abdominal pressure. The beauty of this technique is that the baseline is a constant bony landmark and a spirit level is not necessary. Also observation of the patients JVP allows direct comparison and helps reinforce clinical skills in measuring this critical sign. This "central"JVP is my preference CVP Interpretation CVP is determined by 4 factors 1. Blood volume 2. R heart function This includes conditions such as a.Pericardial tamponade b.RV dysfunction c.Tricuspid and pulmonary valve pathology d.Pulmonary hypertension due to pulmonary embolism, lung disease, acute sepsis, many but not all cases of LV failure etc 3. Pleural pressure with IPPV, PEEP, tension pneumothorax 4. Venous tone --Be aware that with acute hypovolaemia there is acute sympathetic induced venoconstriction that takes considerable time to wear off. The CVP can be quite high during the initial stages of fluid resuscitation before it drops.All these factors must be considered when assessing the CVP. In the majority of cases it is the relatively simple problem of adjusting blood volume. In summary A low CVP is due to 1. Low blood volume 2. Venodilatation with peripheral vasodilatation from various causes A high CVP is due to 1. High blood volume - overtransfusion 2. Impaired R heart function 3. Raised pleural pressure 4. Venoconstriction Because of these varying influences one must relate both the actual level of the CVP and the relative changes that occur during the course of a patients illness. It must also be correlated with other observations such as temperature, pulse, BP, fluid administration, urine output, CXR, cardiac output and ECHO to name the key ones. It is a shame that folks cannot think of patients in physiological terms and and utilise this simple measurement which for 50 years has been one of the key vital signs of clinical Intensive Care. I dont take credit for the review

putting aside my misgivings for patient being treated. Patient needs appropriate investigation to identify reasons for low BP and urine output. That means ECG and cardiac echo to rule out intra-op infarction or perhaps another cause. Agree that normal saline will lead to an acidosis, as someone said on another forum just the other day 'there isnt anything normal about normal saline'. Agree absolutely that levophed is not to way to go. If the patient is hypovolaemic then flogging an empty CVS will increase cardiac workload unnecessarily. Adrenaline is a better way to go IF they need it. So echo, ECG and proper haemodynamic monitoring, afterall if the patient wants everything then they need to have appropriate ongoing monitoring not half measures

many oz docs refer to CVP as a random number generator and many posters have identified all the things (abdominal ascites, ventilation, PEEP) which interfere with a 'correct' reading. Additionally this patient is losing protein into the abdomen so NS replacement?? Anyway fluid replacement for liver failure is like poring fluid into a sieve. If the patient still has significant SIRS or sepsis then they require proper haemodynamic monitoring such a PICCO or [biting my tongue] PA catheter.

"clinical practice and evidence based practice, knowledge versus reality of practice." while you are working over the next couple of shifts see if you can identify something that seems contrary to what you were taught at uni. as you are in a neuro ward assessment of gcs springs to mind other topics could be frequency of obs especially post op or you could look at what the local guidelines for skin care are and see if they are in practice? for instance they may have second hrly turns and pressure relieving mattresses for pressure area prevention but they dont have the manpower or equpment to achieve from memory jo briggs institute has reviews on all of these items that should help you to identify the research practice gap. nb there is an evolving view that the evidence-practice gap is not about recalcitrant clinicians but about the realities of practice

I was asked the comment on something the other day which initially made me go YUCK and then I thought am I just being precious and not keeping up with the times. I was asked whether sterile gloves were still the recommendation for CVC line and dressing changes. This person was reviewing a guideline where no-touch technique plus use of alcohol handrub was advocated. The most recent US (CDC) and European (EPIC2) still advocate aseptic technique, and ofcourse alcohol handrubs do not kill c diff, so it would seem I am probably correct. However as I like to check I would like to hear from the general members.

I have to say I am torn regarding the evidence regarding the efficacy of chlor hex bag baths. From a nursing perspective regarding time and efficiency I love the product however I am yet to find more than 2 well designed studies conducted in ICU and even neither of those are not blinded RCTs. There are a number of before and after studies however most of these are confounded by failure to report hand hygiene studies and/or compliance with VAP or CRBSI bundles. In addition environmental hygiene is rarely if ever described. There are currently 9 studies registered with the clinical trials site and none of these are RCTs although one is a cluster randomised study. No results as yet. I am doing a systematic review at the moment and will be finished before long. As I am at home I dont have my citations on me but will post them next week. What I cant fathom is why a blinded RCT is not being done? There are a number of US institutions where VAP and CRBSI bundles have been in place for a number of years so undertaking one in these settings should account for the confounding variables. The company produces both medicated and non-medicated cloths so should be able to come to the party with product especially as a blinded study would put the matter to rest both in the mind of the purist EBP crowd and the money men. Of course an RCT might not be the answer BUT please do a better designed prospective before and after or cross over study! So would I want them on my family if they were in ICU, you betcha. Would I fall on the side of mandating them for patients who are not colonised with resistant bugs - No But if I had a problem with resistant bugs in my unit - Emphatically :up:YES! greetings from OZ and thank heaven there are universal nursing problems!

In NSW & Victoria Australia we have had large numbers of both H1N1 and influenza A as well as non-specific flu-like patients admitted, who then crash & burn within 24 hrs. Both states are over the worst (Victoria was the first state in Australia with H1N1 patients) now however it stretched our public system to the limit with vents, oscillators & ECMO resources maxed out for several weeks. Patients covered the usual suspects however there were a number of young ante/post partum women who were severely ill and several who died unfortunately. Our national ICU medical body (ANZICS) is collecting stats on all patients so hopefully we will be able to get a better epidemiological picture. I suspect this is happening elsewhere. In addition there were also a number of issues with false positives, negatives and 'what the' diagnosis. Infection control departments were also continually vexed by the cavalier attitude of emergency department personnel.

I would have to agree with both sides of the debate here. I am concerned over the dilution of nursing degrees away from an applied science degree and do feel that there is a lack of certain somethings. But who is to blame? Well all of us. Can we all say we have welcomed undergrads and postgrads with open arms? I'm not sure as a community we have. Do we steer a negative discussion about student nurses into a constructive discussion to enhance the students experience No we dont. For me I think the real crux of the matter is that in 1985 when Health departments dumped the responsiblity for RN education on the tertiary sector they then took on no responsibility for undergraduate or postgraduate continuing education. I would love to develop a partnership model of education between a university and a hospital where the undergrads were employed as student nurses and spent half the year at work undertaking their clinical experience with the other half of the year at university learning the theory. Increase the time to four years with the hospitals taking responsibility for the development of what is without doubt their most valuable worker!

Inotropes/pressors = A line. this is standard practice in Australia also. I would only use CVC/Picc for bloods as a last resort and that is ususally a long term patient who is stable & not on haemodynamic support. Remember any breaks into a CVC increases infection risks. PS if using an A-line always check the flush bag before taking the blood incase someone as put up dextrose instead of saline.

:banghead:this is me after 20 years. The basic problem is that they are brought up to think its womens work and need to be thanked profusely if they do anything. Now my hubby does alot compared to some and not so much compared to others. He aske wehn I would stop complaining and I said when he is doing at 50% without being asked or prompted. I dont believe the crap about the other countries either. there is good and bad and it depends on your perspective!

http://intensivecare.hsnet.nsw.gov.au this is a comprehensive aussie website

well done for focussing on the many items that needed to be done and not getting caught up in the emergency. Too often I see the outgoing shift running around finishing their work while the oncoming shift is sitting at the desk chatting about the latest TV show. Teamwork is an essential item in ICU and too many nurses only focus on what they have to do.

Early in my ICU career I learnt to plan so I knew when items such as meds and obs needed to be done, so that then I could slot in bigger items such as dressings and line changes. One of the biggest lessons I have learnt over my 20+ years is to complete all routine tasks like dressings or line changes over early in your shift. You never know when the s**t will hit the fan and you run out of time to get straight forward tasks done

I must say I am dismayed by the tone of most of the emails in this discussion thread. I'm afraid that most of you are appear as though you have absolutely no idea or compassion for what the families of critically ill patients are going through. Now as you are working in ICU I dont think that is a fair representation of what you are really like. While I agree some visitors can get in your face and in your way when you are trying to care of patients. And some get get quite inappropriate with the yelling for the patient to wake up. And some get even get violent BUT they are in the minority. As my references are in my work computer I will post them here when I'm at work next week. However the most important need for relatives is to be close to their loved one and its largely irrelevant what age they are because whether they are 4 or 40 or 60 they may have a parent who wants to be with them. Relatives are stressed, they dont understand whats going on, they are sleep deprived and they are unable to process information properly. So they will seem to be asking questions after question but thats because cognitively they are not process information. As a number of members have said, get them on side, explain whats going on, explain the rules and they will usually play by the rules

As a general rule vital signs q1h for stable ICU patients and q2h for non-intubated patients. Vital signs are HR, BP, RR, O2 Sats and pain When titrating meds - 1/4 hrly when changing (any more frequent is not useful) and you can go back and look at what its been. Ventilator obs hrly Head to toe assessment once per shift chest Auscultation 2qh for ventilated or respiratory patients Neuro patients GCS hrly when stable, more often if not. GCS is only appropriate for neuro patients who are not receiving meds that might alter the level. Non-neuro patients require an appropriate sedation +/- agitation or delirium assessment - hrly to 4hrly BSL 1-4qh depending on diagnosis, insulin infusion and stability Urinalsys - daily unless indicated by diagnosis or treatment Fluid balance hrly All manual as no computer system. Really important to get it right if you are using a patient outcome database like APACHE or SAPS because if you dont get the correct vitals documented the patients scores will be wrong, they wont score as appropriate and this will have an effect on your units outcome stats

the short answer is too much! At a hospital where I used to work we had 'hover matts' however not sure they are still used. They were great for lifting in that they created a cushion of air enabling three people (one for tube and two for lift) to move just about any size patient with ease. that is up the bed, out of the bed and from bed to CT table. there is always a but though and the bigs buts were pressure areas (the addition of the mat beneath the patient cancelled out the low air loss mattress) and infection control. http://www.hovermatt.com/ from the land down under

This question troubles us in Australia. When we looked for evidence we couldn't find it. And considering how essential the practice is in intensive care this is appalling. I'm used to either 1"wide cotton tape or 1" wide adhesive medical tape. Companies have been slow to distribute in Oz and the money men are reluctant to spend the money. As the RN is totally responsible for the patient in Oz, the tapes are generally changed at least once per day (unless a specific product such as Hollister) using two people. Be careful of Hollister E-tad (b?) as I have seen a nasty lip pressure area BUT I'm not sure the tube was supported or moved the way it is supposed to be My practice is to match the method to the patient so no adhesive tape for sweaty or combative patients. Need to worry about jugular blood flow for neuro patients if you are using a method that goes around the neck. And pressure sores on the back of the neck. OUCH And if there is some research out there PLEASE send some names!

Is the package graded for different levels of clinicians and other workers in health care?

So this CAS test. When was it implemented in QLD and are you aware of the background behind it? What support does the hospital give to you to complete and how does it map to across different nursing specialties. from south of the border

The NHS infection control e-learning package is being trialled in NSW (Australia). Love to here from NHS staff who have experienced this package. All the gory details please!!!!!!!!!!

From the land downunder OMIGOD I have just read through the horrendous nurse patient ratios they expect what I assume to be US nurses. Are you kidding me! the hospitals a committing way mega fraud charging patients for 'intensive care nursing'. WHAT A CROOK!. I know you have respiratory techs plus other aids however it appears this doesn't happen all the time and in all units. No wonder you long for heavily sedated vented patients. And you do it for 12 hrs.:bow: Here is Oz its 1:1 for everyday ventilated, 2:1 for extremely unstable (all the machines plus the one that goes ping!) 1:2 (sometimes 3) for non-vented patients who may be on bipap but certainly NOT on inotropes etc. Post op Cardiac SX are 1:1 but extubated fairly quickly then the ratio changes. Its amazing to me more things don't go wrong! So in the absence of a smilie that says 'hats of to you' :urck:

Agreed there are many potential fomites in ICU and curtains are down the list. However if you observe behaviour HCW often touch curtains without then completing hand hygiene and changing between patients is difficult cause supply is always low. As for the infection control department referred to above , Does that mean they only change their clothes and undies when they are visibly soiled. When I find the evidence or lack of I will let you know. It appears to be a common practice in UK so are there any members from blighty out there?