| Decubitus at 30º |
96.0; 100.0 (0.5360) 96.0; 100.0 (0.5360) |
Daily round with the use of checklist: Practice that ensures the best care for critically ill patients |
S - [...] when you prevent, which is the issue of the 30° head of bed elevation, it reduces the risk of the patient evolving (death, pneumonia). (P5) |
| MV usage time |
72.9; 60.2 (0.0184) 72.9; 52.9 (0.0001)
|
S - With the round and checklist filled out daily, you observe the parameters (clinical conditions) of the patient and schedule the removal of invasive devices (MV, CVC, IDC). (P1) S - The main reason for reducing the usage time of invasive devices is the daily checklist, as we were 'forced' to check all the items in the instrument and assess the need to maintain it. (P4) S - In the round, when checking if the patient had good renal function, good balanced fluid and was free of vasoactive drugs, we removed the IDC, the CVC and placed a peripheral venous catheter. (P5) S - In the past (before the round was implemented) we had a lot of resistance from the (nursing) team to remove IDC. (P6) C - [...] (before the implementation of the round) sometimes we were worried about the general condition of the patient and if he had a central venous access, which had no phlogistic sign, we kept it (CVC). (P4) C - The Hospital Infection Control Committee - HICC (nurse and infectious disease specialist) in the round disclosed the rates of infections associated with the device (mechanical ventilation-associated pneumonia, catheter-associated bloodstream infection and urinary tract infection). So, we were able to ground that the less we used the device, the lower the risk of infection and the better for the patient. (P6) |
| CVC usage time |
87.9; 87.9 (0.9980) 87.9; 73.8 (0.0170)
|
| IDC usage time |
98.5; 86.2 (0.0505) 98.5; 57.3 (0.0001)
|
| VTE prophylaxis |
62.0; 54.6 (0.1800) 62.0; 83.8 (0.0017)
|
S - The decrease in VTE prophylaxis in the second period is a combo: 1st - human error went unnoticed and we have to be humble to talk about it; 2nd - perhaps a period when we have more neurocritical patients, because in the initial phase prophylaxis is not performed, and ends up being forgotten; 3rd - filling out the checklist only three times a week. (P7) C - When you noticed that VTE prophylaxis was not being performed, during the round (in the 3rd period of the study) you already asked: what about enoxaparin? Then what was wrong was corrected. (P5) |
| Gastric ulcer prophylaxis |
95.8; 95.6 (0.9800) 95.8; 93.0 (0.6600) |
S - The slight reduction in gastric ulcer prophylaxis may be a failure to readjust the medical prescription according to the items and goals listed in the checklist during the round. (P6) S - If the patient is targeting an appropriate diet and has reached the caloric goal, the pump inhibitor may not be necessary. But the decrease in prophylaxis can be due to the human factor, for forgetfulness. (P7) C - About the reduction of gastric ulcer prophylaxis I don't know how to answer. (P2, P4) |
| Proper nutrition |
72.5; 69.5 (0.5870) 72.5; 78.6 (0.2800) |
S - Nutrition is the first therapeutic item of the medical prescription, it is not an ornament, it has to be started as early as possible. But the decrease in nutrition in the second period can be for three reasons: 1st - the surgeon (for surgical patients) understands that has to start a little later; 2nd - forgetfulness; 3rd - suspension of the diet after return of gastric residue through the nasogastric tube. (P7) S - The daily checklist is very important, because I observe if the diet is going to be started early, if the caloric goal is being reached, if it is being tolerated well, if the patient is not opening the tube (nasogastric) and this brings a huge benefit. (P3) |
| Analgesia |
80.3; 64.4 (0.0046) 80.3; 80.2 (0.9837) |
S - In the ICU, the patient cannot feel pain, but if I am able to assess by pain scale that he/she does not need to use the analgesic, he/she will not use the analgesic. (P7) C - When there was no analgesic prescribed, I would talk to the intensivist and he would say that in the physical examination, if the patient did not have expression of pain, he chose not to prescribe it. (P4) |
| Antimicrobial |
81.8; 71.2 (0.0662) 81.8; 74.9 (0.2367) |
S - Nowadays we do not use antibiotic period for the pathology. I need to assess daily whether another day is needed or not and this has reduced indiscriminate use. (P6) S - [...] joining forces, you have the intensivist, the HICC, all on evidence-based medicine. You rationalize the use of antibiotics. (P7) S - [...]if the patient is progressing well and without fever, I will safely de-escalate the antibiotic, so as not to select microbial flora. (P5) S - Before the round, we noticed the indiscriminate use of polymyxin (P2); [...] the use of broad-spectrum antibiotics, such as polymyxin, was like ‘water’ here. (P7) C - The professionals did not have the patience to count the days of antibiotic usage, to check the culture, to observe if there was already 48 hours without fever to suspend. The proposal for the participation of the HICC in the round was very good. (P5) C - It was a 'fight' about antibiotics. One physician started in the morning, the other changed in the afternoon, but it improved with the presence of the infectious diseases specialist in the round. (P2) |
| Light sedation |
10.8; 9.9 (0.4130) 10.8; 37.9 (0.0001)
|
S - Light sedation is the goal I've been looking for since I took over the ICU (April 2018) and to maintain cooperative sedation, it must be a very well trained team. (P7) |
| Blood glucose control |
99.4; 98.0 (0.8370) 99.4; 100.0 (0.9230) |
S - The slight decrease in blood glucose control in the second period refers to the higher knowledge curve. There is a protocol, but many colleagues (physicians) do not pay attention. In the third period, we started NPH insulin and this changed the blood glucose profile. (P7) |
| Round and checklists |
- |
Round with use of checklist: Care strategy that increases the work satisfaction of the multidisciplinary team |
S - The round together with the checklist was a dream for me [...], I realized that there was a lack of empowerment from other professions. So, I believe this is the opportunity to express an opinion and have the power of action. (P1) S - We like to have the round because we stay updated on all patients. The focus is not only on our area, so we learn a lot. (P2) S - It is the moment (round) when all professionals are together, exchange information and enlight the conduct of each one. (P4) S - I see that every professional becomes happy, satisfied to be there (round), to give the best they can and assist the patient so that he/she has a quick recovery. This teamwork adds a lot. (P3) S - When we fill in the checklist during the visit, you feel safer, because all items have been checked, such as medication, nutrition, and physical therapy. This brings satisfaction and safety. (P2) C - In our case, the physician (intensivist in charge) liked it a lot and therefore implemented the round with the checklist. (P2) |
