AAGBI/Anaesthesia Departmental Project Grant
Handing Over Care on Patient Discharge from Critical Care Ward to the General Ward: A Multi-Professional, Multi-Level Solution
Dr Shruti Chillistone
Background: Clinical handover is defined as "the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis." Within healthcare, handover is commonplace and it involves multiple teams of healthcare professionals. There is paucity of research in the area of handover, in particular specific to the discharge of a patient from a critical care area to a general ward. Inadequacies in this process may lead to patients requiring readmission to critical care, increases in length of hospital stay and in-hospital deaths. Nice Guideline CG050 (July 2007) has highlighted the need for research in this area. The current handover practices are too simplistic, and ignore the fact that information requirements for different members of staff at different levels (nurses, junior doctors, consultants, physiotherapists, pharmacists) are different. Also, it is often not practically possible for all members of staff, from different teams, to be present at face-to-face handover meetings. Hence, we seek to develop working principles of handover processes where different information requirements of different members of the team can be met by using multiple channels of communications (electronic, paper trail, checklists, telephonic) at different levels.
Aims: In this project, we will explore the principals which underpin effective transition of care from critical care area (one-to-one staff) to the general ward (many-to-one staff). Our aim would be to develop a model of a comprehensive handover process from critical care to the general ward.
Methodology: Handovers in clinical settings will be observed to provide information regarding the current processes. All verbal and written information exchanged will be documented. Doctors and nurses working in critical care and the wards will then be interviewed to explore their perceptions with regard to the areas which can be improved. In addition, Focus Group discussions will be held to work out the principles of the most effective handover process. Discussions during the interviews and focus groups will be recorded, transcribed and analyzed using qualitative research methodology. The emerging themes will be crystallized into principals underpinning an effective handover, and practical solutions. A summary of the conclusions on these principals and practical solutions will be sent to each focus group participant. This will be followed by a telephone call to further ask for opinions and suggestions in the light of previous conclusions. This process will be repeated until a consensus is reached and a system will then be defined to facilitate multi-professional, multi-level handover.
Study outcome: Description of a comprehensive, multi-level, multi-professional handover process for patients being discharged from critical care to the general ward.
Implications: The development of this comprehensive handover process will then be studied to assess its feasibility in a clinical setting (step 2), and its effectiveness in improving patient outcome (reduction in re-admissions, length of hospital stay and death) in a multicentre trial (step3).
Development of a "Glo-Cell" biosensor to investigate the role of zinc in sepsis
Professor Helen Galley
Background: Sepsis, or severe infection kills millions of 18 million people every year. Mitochondria are tiny structures inside cells where energy is made and if they are damaged they can't make enough energy. In patients with sepsis, mitochondria become damaged. Measuring the production of energy is a good measure of damage to mitochondria but current methods are expensive, time consuming and unreliable. Zinc is a metal which we eat in our diets and is essential for fighting infection. Patients with sepsis have low blood levels of zinc and this may contribute to a poorer outcome but we don't know if it affects mitochondria.
Aim: We propose to develop a biosensor -called 'Glo-cell' -to measure energy production by mitochondria. A biosensor is a living thing- in our case a cell- which responds in a measurable way. Our sensor will be cells which have been adapted so they emit light according to the amount of energy they make. By exposing the cells to conditions similar to sepsis we can test the effect of possible treatments on energy production simply by measuring the cells' light output. In the first instance we want to validate the biosensor and then test to see the effect of different zinc levels.
Methodology:
We will use the cells which line veins and arteries, which are important in fighting infection. We will use a cell line so we don't have to isolate the cells from people and will modify the cells so they express an enzyme that uses energy to make them emit light- hence the name 'Glo-cell'. The amount of light the cells emit depends on the energy they make and so is a measure of damage to mitochondria. A special type of virus which is not contagious or dangerous to people, will be used to insert a new gene into the cells. The gene is from fireflies- it is what makes fireflies glow in the dark- and it enables the cells to convert a chemical called luciferin into a substance which gives off light. The generation of light uses energy and so if we supply the cells with luciferin then measure light output, we have a measure of the amount of energy the cells are producing. When we have modified the cells we will expose them to substances which damage mitochondria and measure the change in the light output. We will then assess the affect of treatments which protect against the damage. We will repeat with cells grown under sepsis-like conditions. We will compare our biosensor with other ways of measuring damage to mitochondria and finally we will measure the light output in cells grown in a range of zinc concentrations under sepsis-like conditions.
Expected outcomes: This biosensor will enable us to test possible new treatments quickly and easily, simply by measuring light output. The work will also tell us if zinc is important for energy production by cells. The biosensor will be useful not only for sepsis-related studies, but also for other conditions.
Comparison of analgesic efficacy of posterior transversus abdominis plane (TAP) catheters with epidural analgesia in patients undergoing laparoscopic colorectal surgery
Dr Niraj Gopinath
Pain relief is an important aspect of patient care after major operation on the abdomen. Currently there are limited options for providing pain relief after surgery on the abdomen. Pain relief by epidural is considered to be the most effective. However epidural can cause both minor side effects like fall in blood pressure, headache, vomiting and major (rare) side effects like meningitis, epidural infection causing paralysis of the legs and nerve damage. Transversus Abdominis Plane (TAP) block is a new technique of blocking pain carrying nerve system of the abdomen and thus provides pain relief after surgery on the abdomen. However by inserting a catheter (plastic tube) into the TA plane, it would be possible to block the nerves without causing discomfort to the patient and thereby provide pain relief over a prolonged period after surgery. The technique has an excellent safety profile to date.
The main aim of the proposed study is to compare pain relief efficacy of the ultrasound guided TAP block catheters with thoracic epidural infusions in terms of reduction in postoperative pain scores during the first 48 hours after lower abdominal surgery. 70 adult patients will be divided into two groups by randomization i.e. by chance: epidural and TAP Catheter. Epidural will be inserted as standard. The TAP catheter will be inserted at the end of surgery with the patient under general anaesthesia. The patients will be followed up at six points over 48 hours to assess their pain at rest and on coughing, after which study period ends for participant. The study is expected to last 24 months.
The relationship between transcranial bioimpedance and invasive intracranial pressure measurement in traumatic brain injury patients
Dr Christopher Hawthorne
Background: Traumatic brain injury is a significant cause of illness and death and has major economic costs to society. In Scotland there are an estimated 100 000 Emergency Department attendances per year with head injury with a 15% admission rate. The majority of these are with minor head injury and the case fatality rate is low. However, trauma is the primary cause of death in the under 45s and traumatic brain injury may account for up to half of these deaths. In patients with a traumatic brain injury, the pressure within the skull (intracranial pressure, or ICP) can be raised because of swelling of the brain or bleeding. This is associated with an increased risk of death. Therefore, monitoring of ICP is necessary for the best possible clinical care. Currently it is necessary to drill a hole in the skull to place a pressure monitor within the brain tissue. A non-invasive device providing information on ICP would avoid the risk of this procedure and make monitoring available to more patients.
Aims: In patients with traumatic brain injury, we plan to establish the relationship between ICP and the non-invasive measurement of transcranial bioimpedance.
Methodology: Transcranial bioimpedance measures resistance to flow of a small electric current applied between skin electrodes on the skull and thus across the brain. Current can flow through cells in the intracellular space or between cells in the extracellular space. Depending on the amount of resistance to the current flow, intracellular and extracellular volumes can be estimated. An increase in ICP, caused by swelling of the brain cells or bleeding into the space around the cells, changes the intracellular and extracellular volumes. This means an increase in ICP should be associated with changes in transcranial bioimpedance. This is an observational study of patients with traumatic brain injury. We propose the measurement of transcranial bioimpedance in patients who are already receiving invasive ICP monitoring as part of their routine management on neurointensive care. Measurement of bioimpedance is entirely non-invasive and participation in the study will not influence the patient's clinical management in any way.
Implications: Ultimately, we aim to develop transcranial bioimpedance as a technique to non-invasively estimate ICP. This would be extremely useful not only in traumatic brain injury but also in brain injury of any cause.
