The Society’s Eighth Annual Audit Meeting was held on Friday 22nd November 2002 in the Education & Conference Centre at Stirling Royal Infirmary. Simon Mackenzie from the Royal Infirmary of Edinburgh, Lead Clinician for the Audit Group, commenced the meeting by welcoming the 86 delegates attending.
The presentations began with Malcolm Booth from Glasgow Royal Infirmary informing the delegates of ‘A pilot study of Hospital Acquired Infection in Scottish ICUs’. Malcolm provided an update to the presentation given at last year’s audit meeting by Ahilya Noone in which she proposed links between the SICS and the Scottish Centre for Infection and Environment Health (SCIEH) to monitor Hospital Acquired Infection (HAI). The aim of these links are to monitor the incidence of HAI in ICUs, antibiotic susceptibility and resistance patterns with the aim to eventually prevent/limit emergence of antibiotic resistance. The pilot Malcolm discussed was proposed to take place as a paper-based exercise at the Southern General Hospital and Glasgow Royal Infirmary between December 2002 and February 2003. The aims of this pilot were to develop a minimum dataset which could be used to guide future modifications to the audit software for inclusion in a larger study.
Ronnie Dornan, Practice Development Nurse from the Borders General Hospital gave a brief rundown on Outreach in Scottish ICUs – present & future. With the assistance of Fiona, Ronnie showed the Outreach screen as it is displayed in Ward Watcher and explained how his hospital made use of this resource. This is a very topical subject which stimulated a lot of interest and questions. It is hoped those involved in Outreach in Scotland may make use of the audit software, particularly to develop a common dataset to enable future comparisons. This brief section demonstrated the need for a meeting specifically on Outreach.
Yadhu Rajalingam, SpR in Anaesthesia at Aberdeen Royal Infirmary gave a high-speed presentation on the ‘Outcome of patients with haematological malignancies admitted to ICU’. Yadhu presented the results of an analysis of the Society’s audit data collected between 1995 & 2000. This haematology audit is still ongoing. With questions like: why do haematological malignancy patients do badly in ICU? What is their mortality? What factors relate to poor/good outcome? and Can we predict poor outcome?, a mountain of information was delivered, showing the enormity of the subject content. The data demonstrated that the outcome following ICU admission is poor but not poorer than that predicted by the APACHE II system. An increase in the length of time in hospital prior to ICU admission significantly increased mortality. Food for thought.
Tim Walsh from the Royal Infirmary of Edinburgh reviewed some of the work of the ‘Audit of Transfusion in Intensive Care in Scotland’ (ATICS) group. ATICS assessed the haemoglobin levels and transfusion rates in 1,000 consecutive admissions to 10 ICUs in Scotland between June and September 2001. Tim’s review of the prevalence of anaemia in Scottish ICUs demonstrated that survivors of ICU have a high prevalence of severe anaemia, with 25% of all ICU survivors being discharged from ICU with a haemoglobin concentration <9g/dL. Tim concluded that it is not known how important this is for functional recovery, quality of life, or long-term survival.
At the ICS Conference held in London, December 2002, Tim presented these data and picked up a prize for the best oral presentation
With the coffee break imminent, Simon Mackenzie demonstrated some changes that are required of the software to improve it as an audit tool for high dependency units as well as intensive care units. The audit group has received requests from staff to have some method of identifying patients as levels 1,2 or 3 on the audit system. The system will be modified to accommodate this in the future. Other modifications in the pipeline include: an audit of Drotrecogin alfa (activated), addition of organ donation fields to assist transplant link nurses and the Scottish Transplant Group and finally, a dataset to assist clinicians identify unusual illnesses, a request received from the Scottish Executive Health Department.
Kevin Rooney, SpR in Anaesthesia & Intensive Care Medicine at the Glasgow Royal Infirmary then gave an aptly timed presentation on ‘Blood glucose and ICU outcome’. The aim of this audit was to assess whether laboratory blood glucose in the first 24 hours of admission is associated with hospital mortality in a cohort of Scottish ICUs. The lowest and highest blood glucose concentrations were collected prospectively as part of the minimum dataset for the national ICU audit between 1995 and 1997. Results showed that 83% or 10,542 patients were hyperglycaemic in first the 24-hours of ICU. Patients with blood glucose concentrations between 4 and 9.9 mmolL-1 during the first 24-hours of intensive care had a significantly lower mortality than those with hyper (or hypo) glycaemia. It is, therefore, possible that blood glucose in the first 24-hours of intensive care is an independent prognostic factor.
The first session in the afternoon was a joint one on sepsis. Simon Mackenzie began by presenting some of the results from the prospective audit of sepsis, the proposal of which had generated vibrant discussion at the previous year’s meeting. The prospective sepsis audit ran successfully between January and May 2002. Simon thanked all units, in particular the nursing staff on whom additional data collection tended to fall. Analyses continue on the data, however, Simon was able to demonstrate that almost half of all ICU admissions developed sepsis early in intensive care, the majority of whom had severe sepsis or septic shock. Hospital outcome data are awaited to complete the analyses and further results will be available in 2003.
Gill Harris, Audit Nurse with SICSAG, proceeded to present initial data generated from Scotland’s developing High Dependency Unit Audit. The data presented were from a 6-month period (April - September 2002) in 25 stand-alone HDUs. There were 7,622 admissions into 176 available beds during that time period. The mean HDU bed occupancy in Scotland was 76.8% with 13 out of the 25 units above this mean. The mean length of stay ranged from 1.8 – 4.5 days with the Scottish mean being 2.8 days. Readmission rates were identified by the HDU Audit Steering Group as an important quality marker. Gill was able to demonstrate wide variation in readmission rates across the HDUs. It was pointed out, however, that in some units the section on Ward Watcher in which ‘Readmission’ appears is not always mandatory. When making any comparisons it is important that the data are comparable. These results demonstrate the need to ensure that the dataset is the same across the HDUs.
In October 2002, Gill visited all participating HDUs in Scotland conducting structured interviews with senior staff in each. The results were positive and are being used to assist us in developing the audit further.
This year we had the privilege of having Dr Martin Tweeddale as a Guest
Speaker. Dr Tweeddale is Clinical Director, Department of Critical Care,
Queen Alexandra Hospital, Portsmouth although he has previously spent
a number of years in Canada. As a member of the Canadian Critical Care
Trials Group he was a participant in the randomised controlled trial
of transfusion requirements in Canada, published in 1999.
For the first time, linkage with the Information & Statistics Division, NHS Scotland, the Registrar General and NHS Greater Glasgow has enabled the audit group to begin to assess the impact of social deprivation on ICU admissions and mortality. Malcolm Booth, finally saw the day draw to a close, presenting initial results from these analyses. Following a review of post-war deprivation studies, Malcolm demonstrated an increase in both ICU and hospital mortality in Scotland with worsening social deprivation, even when adjusted for age and gender. These results are just the beginning of our work on social deprivation and survival, watch this space.
Giving a brief summary of the meeting, and thanking all the speakers for their participation, Alf Shearer, President of the Scottish Intensive Care Society closed the meeting.
Gill Harris, Audit Nurse
SICSAG Meetings reports