Improving delirium care in the intensive care unit: The design of a pragmatic study

PubMed Central

2011-01-01

Background Delirium prevalence in the intensive care unit (ICU) is high. Numerous psychotropic agents are used to manage delirium in the ICU with limited data regarding their efficacy or harms. Methods/Design This is a randomized controlled trial of 428 patients aged 18 and older suffering from delirium and admitted to the ICU of Wishard Memorial Hospital in Indianapolis. Subjects assigned to the intervention group will receive a multicomponent pharmacological management protocol for delirium (PMD) and those assigned to the control group will receive no change in their usual ICU care. The primary outcomes of the trial are (1) delirium severity as measured by the Delirium Rating Scale revised-98 (DRS-R-98) and (2) delirium duration as determined by the Confusion Assessment Method for the ICU (CAM-ICU). The PMD protocol targets the three neurotransmitter systems thought to be compromised in delirious patients: dopamine, acetylcholine, and gamma-aminobutyric acid. The PMD protocol will target the reduction of anticholinergic medications and benzodiazepines, and introduce a low-dose of haloperidol at 0.5-1 mg for 7 days. The protocol will be delivered by a combination of computer (artificial intelligence) and pharmacist (human intelligence) decision support system to increase adherence to the PMD protocol. Discussion The proposed study will evaluate the content and the delivery process of a multicomponent pharmacological management program for delirium in the ICU. Trial Registration ClinicalTrials.gov: NCT00842608 PMID:21645330

Conceptualizing Surrogate Decision-Making at End of Life in the Intensive Care Unit using Cognitive Task Analysis

PubMed Central

Dionne-Odom, J. Nicholas; Willis, Danny G.; Bakitas, Marie; Crandall, Beth; Grace, Pamela J.

2014-01-01

Background Surrogate decision-makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. Purpose Identify and describe the underlying psychological processes of surrogate decision-making for adults at EOL in the ICU. Method Qualitative case study design using a cognitive task analysis (CTA) interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center’s ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semi-structured CTA interviews. Discussion The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions: gist impressions, distressing emotions, and moral intuitions impact a SDM’s judgment about the acceptability of either the patient’s medical treatments or his or her condition. Conclusion The framework offers initial insights about the underlying psychological processes of surrogate decision-making and may facilitate enhanced decision support for SDMs. PMID:25982772

Psychometric properties of the Arabic version of the confusion assessment method for the intensive care unit (CAM-ICU).

PubMed

Aljuaid, Maha H; Deeb, Ahmad M; Dbsawy, Maamoun; Alsayegh, Daniah; Alotaibi, Moteb; Arabi, Yaseen M

2018-04-06

It is recommended that critically ill patients undergo routine delirium monitoring with a valid and reliable tool such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). However, the validity and reliability of the Arabic version of the CAM-ICU has not been investigated. Here, we test the validity and reliability of the Arabic CAM-ICU. We conducted a psychometric study at ICUs in a tertiary-care hospital in Saudi Arabia. We recruited consecutive adult Arabic-speaking patients, who had stayed in the ICU for at least 24 hours, and had a Richmond Agitation-Sedation Scale (RASS) score ≥ - 2 at examination. Two well-trained examiners (ICU nurse and intensivist) independently assessed delirium in eligible patients with the Arabic CAM-ICU. Evaluations by the two examiners were compared with psychiatrist blind clinical assessment of delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Subgroup analyses were conducted for age, invasive mechanical ventilation, and gender. We included 108 patients (mean age: 62.6 ± 17.6; male: 51.9%), of whom 37% were on invasive mechanical ventilation. Delirium was diagnosed in 63% of enrolled patients as per the psychiatrist clinical assessment. The Arabic CAM-ICU sensitivity was 74% (95% confidence interval [CI] = 0.63-0.84) and 56% (95%CI = 0.44-0.68) for the ICU nurse and intensivist, respectively. Specificity was 98% (95%CI = 0.93-1.0) and 92% (95%CI = 0.84-1.0), respectively. Sensitivity was greater for mechanically-ventilated patients, women, and those aged ≥65 years. Specificity was greater for those aged < 65 years, non-mechanically-ventilated patients and men. The median duration to complete the Arabic CAM-ICU was 2 min (interquartile range, 2-3) and 4.5 min (IQR, 3-5) for the ICU nurse and intensivist, respectively. Inter-rater reliability (kappa) was 0.66. The Arabic CAM-ICU demonstrated acceptable reliability and validity to assess delirium in Arabic-speaking ICU patients.

There′s no place like home: Boarding surgical ICU patients in other ICUs and the effect of distances from the home unit

PubMed Central

Pascual, Jose L.; Blank, Nicholas W.; Holena, Daniel N.; Robertson, Matthew P.; Diop, Mouhamed; Allen, Steve R.; Martin, Niels D.; Kohl, Benjamin A.; Sims, Carrie A.; Schwab, C. William; Reilly, Patrick M.

2014-01-01

BACKGROUND Intensive care units (ICUs) function frequently at capacity, requiring incoming critically ill patients to be placed in alternate geographically distinct ICUs. In some medical ICU populations, “boarding” in an overflow ICU has been associated with increased mortality. We hypothesized that surgical ICU patients experience more complications when boarding in an overflow ICU and that the frequency of these complications are greatest in boarders farthest from the home unit (HU). METHODS A 5-year (June 2005 to June 2010) retrospective review of a prospectively maintained ICU database was performed, and demographics, severity of illness, length of stay, and incidence of ICU complications were extracted. Distances between boarding patients’ rooms and the HU were measured. Complications occurring in patients located in the same floor (BUSF) and different floor (BUDF) boarding units were compared and stratified by distance from HU to the patient room. Logistic regression was used to develop control for known confounders. RESULTS A total of 7,793 patients were admitted to the HU and 833 to a boarding unit (BUSF, n = 712; BUDF, n = 121). Boarders were younger, had a lower length of stay, and Acute Physiology and Chronic Health Evaluation II and were more of tentrauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p < 0.01) was greater in BUSF patients and highest in those farthest from the HU (odds ratio [OR],2.39;p =0.01). Delirium occurred less often in HU than in BUDF patients (3.3% vs. 8.3 %, p < 0.01), and both delirium (OR, 6.09, p < 0.01) and ventilator-associated pneumonia (OR, 4.49, p < 0.05) were more frequent in patients farther from the HU. CONCLUSION Certain ICU complications occur more frequently in boarding patients particularly if they are located on a different floor or far from the HU. When surgical ICU bed availability forces overflow admissions to non–home ICUs, greater interdisciplinary awareness, education, and training may be needed to ensure equivalent care and outcomes. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV. PMID:24662877

Factors Affecting Sleep Quality of Patients in Intensive Care Unit

PubMed Central

Bihari, Shailesh; Doug McEvoy, R.; Matheson, Elisha; Kim, Susan; Woodman, Richard J.; Bersten, Andrew D.

2012-01-01

Introduction: Sleep disturbance is a frequently overlooked complication of intensive care unit (ICU) stay. Aim: To evaluate sleep quality among patients admitted to ICU and investigate environmental and non-environmental factors that affect sleep quality in ICU. Methods: Over a 22-month period, we consecutively recruited patients who spent ≥ 2 nights post-endotracheal extubation in ICU and who were orientated to time, place, and person on the day of discharge. Self-reported sleep quality, according to a modified Freedman questionnaire, which provided data on self-reported ICU sleep quality in ICU and environmental factors affecting sleep quality in the ICU, were collected. We also investigated non-environmental factors, such as severity of illness, ICU interventions, and medications that can affect sleep quality. Results: Fifty males and 50 females were recruited with a mean (± SD) age of 65.1 ± 15.2 years. APACHE II score at admission to ICU was 18.1 ± 7.5 with duration of stay 6.7 ± 6.5days. Self-reported sleep quality score at home (1 = worst; 10 = best) was 7.0 ± 2.2; this decreased to 4.0 ± 1.7 during their stay in ICU (p < 0.001). In multivariate analysis with APACHE III as severity of illness (R2 = 0.25), factors [exp(b)(95% CI), p value] which significantly affected sleep in ICU were sex [0.37(0.19-0.72), p < 0.01], age and sex interaction [1.02(1.01-1.03), p < 0.01], bedside phone [0.92(0.87-0.97), p < 0.01], prior quality of sleep at home [1.30(1.05-1.62), p = 0.02], and use of steroids [0.82(0.69-0.98), p = 0.03] during the stay in ICU. Conclusion: Reduced sleep quality is a common problem in ICU with a multifactorial etiology. Citation: Bihari S; McEvoy RD; Kim S; Woodman RJ; Bersten AD. Factors affecting sleep quality of patients in intensive care unit. J Clin Sleep Med 2012;8(3):301-307. PMID:22701388

The 2014 updated version of the Confusion Assessment Method for the Intensive Care Unit compared to the 5th version of the Diagnostic and Statistical Manual of Mental Disorders and other current methods used by intensivists.

PubMed

Chanques, Gérald; Ely, E Wesley; Garnier, Océane; Perrigault, Fanny; Eloi, Anaïs; Carr, Julie; Rowan, Christine M; Prades, Albert; de Jong, Audrey; Moritz-Gasser, Sylvie; Molinari, Nicolas; Jaber, Samir

2018-03-01

One third of patients admitted to an intensive care unit (ICU) will develop delirium. However, delirium is under-recognized by bedside clinicians without the use of delirium screening tools, such as the Intensive Care Delirium Screening Checklist (ICDSC) or the Confusion Assessment Method for the ICU (CAM-ICU). The CAM-ICU was updated in 2014 to improve its use by clinicians throughout the world. It has never been validated compared to the new reference standard, the Diagnostic and Statistical Manual of Mental Disorders 5th version (DSM-5). We made a prospective psychometric study in a 16-bed medical-surgical ICU of a French academic hospital, to measure the diagnostic performance of the 2014 updated CAM-ICU compared to the DSM-5 as the reference standard. We included consecutive adult patients with a Richmond Agitation Sedation Scale (RASS) ≥ -3, without preexisting cognitive disorders, psychosis or cerebral injury. Delirium was independently assessed by neuropsychological experts using an operationalized approach to DSM-5, by investigators using the CAM-ICU and the ICDSC, by bedside clinicians and by ICU patients. The sensitivity, specificity, positive and negative predictive values were calculated considering neuropsychologist DSM-5 assessments as the reference standard (primary endpoint). CAM-ICU inter-observer agreement, as well as that between delirium diagnosis methods and the reference standard, was summarized using κ coefficients, which were subsequently compared using the Z-test. Delirium was diagnosed by experts in 38% of the 108 patients included for analysis. The CAM-ICU had a sensitivity of 83%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 91%. Compared to the reference standard, the CAM-ICU had a significantly (p < 0.05) higher agreement (κ = 0.86 ± 0.05) than the physicians,' residents' and nurses' diagnoses (κ = 0.65 ± 0.09; 0.63 ± 0.09; 0.61 ± 0.09, respectively), as well as the patient's own impression of feeling delirious (κ = 0.02 ± 0.11). Differences between the ICDSC (κ = 0.69 ± 0.07) and CAM-ICU were not significant (p = 0.054). The CAM-ICU demonstrated a high reliability for inter-observer agreement (κ = 0.87 ± 0.06). The 2014 updated version of the CAM-ICU is valid according to DSM-5 criteria and reliable regarding inter-observer agreement in a research setting. Delirium remains under-recognized by bedside clinicians.

An Application of Bayesian Approach in Modeling Risk of Death in an Intensive Care Unit

PubMed Central

Wong, Rowena Syn Yin; Ismail, Noor Azina

2016-01-01

Background and Objectives There are not many studies that attempt to model intensive care unit (ICU) risk of death in developing countries, especially in South East Asia. The aim of this study was to propose and describe application of a Bayesian approach in modeling in-ICU deaths in a Malaysian ICU. Methods This was a prospective study in a mixed medical-surgery ICU in a multidisciplinary tertiary referral hospital in Malaysia. Data collection included variables that were defined in Acute Physiology and Chronic Health Evaluation IV (APACHE IV) model. Bayesian Markov Chain Monte Carlo (MCMC) simulation approach was applied in the development of four multivariate logistic regression predictive models for the ICU, where the main outcome measure was in-ICU mortality risk. The performance of the models were assessed through overall model fit, discrimination and calibration measures. Results from the Bayesian models were also compared against results obtained using frequentist maximum likelihood method. Results The study involved 1,286 consecutive ICU admissions between January 1, 2009 and June 30, 2010, of which 1,111 met the inclusion criteria. Patients who were admitted to the ICU were generally younger, predominantly male, with low co-morbidity load and mostly under mechanical ventilation. The overall in-ICU mortality rate was 18.5% and the overall mean Acute Physiology Score (APS) was 68.5. All four models exhibited good discrimination, with area under receiver operating characteristic curve (AUC) values approximately 0.8. Calibration was acceptable (Hosmer-Lemeshow p-values > 0.05) for all models, except for model M3. Model M1 was identified as the model with the best overall performance in this study. Conclusion Four prediction models were proposed, where the best model was chosen based on its overall performance in this study. This study has also demonstrated the promising potential of the Bayesian MCMC approach as an alternative in the analysis and modeling of in-ICU mortality outcomes. PMID:27007413

Intensivist-reported Facilitators and Barriers to Discussing Post-Discharge Outcomes with Intensive Care Unit Surrogates. A Qualitative Study

PubMed Central

Davis, Wesley E.; Needham, Dale M.; White, Douglas B.; Eakin, Michelle N.

2016-01-01

Rationale: Intensive care unit (ICU) patients’ expected post-discharge outcomes are rarely discussed in family meetings despite this information being centrally important to patients and their families. Objectives: To characterize intensivist-identified barriers and facilitators to discussing post-discharge outcomes with surrogates of ICU patients. Methods: Qualitative study conducted via one-on-one, semistructured telephone interviews with 23 intensivists from 20 hospitals with accreditation council for graduate medical education–accredited critical care medicine programs in 16 states. A limited application of grounded theory methods was used to code transcribed interviews and identify themes and illustrative quotes. Measurements and Main Results: Intensivists reported tension between their professional responsibility to discuss likely functional outcomes versus uncertainty about their ability to predict those outcomes for an individual patient. They cited three main barriers as limiting their ability to conduct conversations about post-discharge outcomes with ICU surrogates: (1) incorrectly optimistic expectations for recovery among ICU surrogates, (2) having little or no contact with their patients after ICU discharge, and (3) minimal confidence applying existing outcomes research to individual patients. Despite these barriers, experience talking to ICU surrogates, seeing ICU survivors in the outpatient setting, and trusted research on functional outcomes were identified as important facilitators to discussing likely patient outcomes with surrogates. Intensivists generally welcomed questions from surrogates about post-discharge outcomes as opportunities to initiate conversations about prognosis and patient values. Conclusions: In this sample of intensivists from 20 academic hospitals, experience conducting conversations with surrogates and interactions with ICU survivors as outpatients were identified as facilitating discussion of expected post-discharge outcomes while optimistic surrogate expectations and prognostic uncertainty were barriers. There was tension between self-perceived ability to prognosticate and belief in a professional obligation to discuss patient outcomes. PMID:27294981

Brazilian version of the Functional Status Score for the ICU: translation and cross-cultural adaptation

PubMed Central

da Silva, Vinicius Zacarias Maldaner; de Araújo Neto, Jose Aires; Cipriano Jr., Gerson; Pinedo, Mariela; Needham, Dale M.; Zanni, Jennifer M.; Guimarães, Fernando Silva

2017-01-01

Objective The aim of the present study was to translate and cross-culturally adapt the Functional Status Score for the intensive care unit (FSS-ICU) into Brazilian Portuguese. Methods This study consisted of the following steps: translation (performed by two independent translators), synthesis of the initial translation, back-translation (by two independent translators who were unaware of the original FSS-ICU), and testing to evaluate the target audience's understanding. An Expert Committee supervised all steps and was responsible for the modifications made throughout the process and the final translated version. Results The testing phase included two experienced physiotherapists who assessed a total of 30 critical care patients (mean FSS-ICU score = 25 ± 6). As the physiotherapists did not report any uncertainties or problems with interpretation affecting their performance, no additional adjustments were made to the Brazilian Portuguese version after the testing phase. Good interobserver reliability between the two assessors was obtained for each of the 5 FSS-ICU tasks and for the total FSS-ICU score (intraclass correlation coefficients ranged from 0.88 to 0.91). Conclusion The adapted version of the FSS-ICU in Brazilian Portuguese was easy to understand and apply in an intensive care unit environment. PMID:28444070

Intensive care unit depth of sleep: proof of concept of a simple electroencephalography index in the non-sedated

PubMed Central

2014-01-01

Introduction Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with possible detrimental effects on short- and long- term outcomes. Investigation into the exact causes and effects of disturbed sleep has been hampered by cumbersome and time consuming methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep analysis, the ICU depth of sleep index (IDOS index), using single channel electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is shown in non-sedated ICU patients. Methods Polysomnographic (PSG) recordings of five ICU patients and 15 healthy outpatients were analyzed using the IDOS index, based on the ratio between gamma and delta band power. Manual selection of thresholds was used to classify data as either wake, sleep or slow wave sleep (SWS). This classification was compared to visual sleep scoring by Rechtschaffen & Kales criteria in normal outpatient recordings and ICU recordings to illustrate face validity of the IDOS index. Results When reduced to two or three classes, the scoring of sleep by IDOS index and manual scoring show high agreement for normal sleep recordings. The obtained overall agreements, as quantified by the kappa coefficient, were 0.84 for sleep/wake classification and 0.82 for classification into three classes (wake, non-SWS and SWS). Sensitivity and specificity were highest for the wake state (93% and 93%, respectively) and lowest for SWS (82% and 76%, respectively). For ICU recordings, agreement was similar to agreement between visual scorers previously reported in literature. Conclusions Besides the most satisfying visual resemblance with manually scored normal PSG recordings, the established face-validity of the IDOS index as an estimator of depth of sleep was excellent. This technique enables real-time, automated, single channel visualization of depth of sleep, facilitating the monitoring of sleep in the ICU. PMID:24716479

Innovative Information Systems in the Intensive Care Unit, King Saud Medical City in Saudi Arabia.

PubMed

Al Saleem, Nouf; Al Harthy, Abdulrahman

2015-01-01

The purpose of this paper is to discuss the experience of implementing innovative information technology to improve the quality of services in one of the largest Intensive Care Units in Saudi Arabia. The Intensive Care Units in King Saud Medical City (ICU-KSMC) is the main ICU in the kingdom that represents the Ministry of Health. KSMC's ICU is also considered one of the largest ICU in the world as it consists of six units with 129 beds. Leaders in KSMC's ICU have introduced and integrated three information technologies to produce powerful, accurate, and timely information systems to overcome the challenges of the ICU nature and improve the quality of service to ensure patients' safety. By 2015, ICU in KSMC has noticed a remarkable improvement in: beds' occupation and utilization, staff communication, reduced medical errors, and improved departmental work flow, which created a healthy professional work environment. Yet, ICU in KSMC has ongoing improvement projects that include future plans for more innovative information technologies' implementation in the department.

Early mobilization in the critical care unit: A review of adult and pediatric literature.

PubMed

Cameron, Saoirse; Ball, Ian; Cepinskas, Gediminas; Choong, Karen; Doherty, Timothy J; Ellis, Christopher G; Martin, Claudio M; Mele, Tina S; Sharpe, Michael; Shoemaker, J Kevin; Fraser, Douglas D

2015-08-01

Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated into daily clinical practice. Early passive, active, and combined progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also suggest that early mobilization is achievable without increasing patient risk. In this review, we provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient outcomes will require further studies on mobilization timing and intensity, particularly within specific ICU populations. Copyright © 2015 Elsevier Inc. All rights reserved.

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit*

PubMed Central

Smith, Heidi A. B.; Boyd, Jenny; Fuchs, D. Catherine; Melvin, Kelly; Berry, Pamela; Shintani, Ayumi; Eden, Svetlana K.; Terrell, Michelle K.; Boswell, Tonya; Wolfram, Karen; Sopfe, Jenna; Barr, Frederick E.; Pandharipande, Pratik P.; Ely, E. Wesley

2013-01-01

Objective To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. Design and Setting A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. Patients A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. Interventions None. Measurements Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. Results A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66–93%), a specificity of 99% (95% confidence interval, 95–100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74–1.0). Conclusions The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children. (Crit Care Med 2011; 39:150–157) PMID:20959783

Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.

PubMed

Smith, Heidi A B; Boyd, Jenny; Fuchs, D Catherine; Melvin, Kelly; Berry, Pamela; Shintani, Ayumi; Eden, Svetlana K; Terrell, Michelle K; Boswell, Tonya; Wolfram, Karen; Sopfe, Jenna; Barr, Frederick E; Pandharipande, Pratik P; Ely, E Wesley

2011-01-01

To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. None. Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (κ = 0.96; 95% confidence interval, 0.74-1.0). The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

Doubling Pharmacist Coverage in the Intensive Care Unit: Impact on the Pharmacists' Clinical Activities and Team Members' Satisfaction.

PubMed

McDaniel, Joshua; Bass, Lynn; Pate, Toni; DeValve, Michael; Miller, Susan

2017-09-01

Background: National professional organizations have recognized pharmacists as essential members of the intensive care unit (ICU) team. Critical care pharmacists' clinical activities have been categorized as fundamental, desirable, and optimal, providing a structure for gauging ICU pharmacy services being provided. Objective: To determine the impact the addition of a second ICU pharmacist covering 30 adult ICU beds at a large regional medical center has on the complexity of pharmacists' interventions, the types of clinical activities performed by the pharmacists, and the ICU team members' satisfaction. Methods: A prospective mixed-method descriptive study was conducted. Pharmacists recorded their interventions and clinical activities performed. A focus group composed of randomly selected ICU team members was held to qualitatively describe the impact of the additional pharmacist coverage on patient care, team dynamics, and pharmacy services provided. Results: The baseline period consisted of 33 days, and the intervention period consisted of 20 days. The average complexity of interventions was 1.72 during the baseline period (mode = 2) versus 1.69 (mode = 2) during the intervention period. The number of desirable and optimal clinical activities performed daily increased during the intervention from 8.4 (n = 279) to 16.4 (n = 328) and 2.3 (n = 75) to 8.6 (n = 171) compared with the baseline, respectively. Focus group members qualitatively described additional pharmacist coverage as beneficial. Conclusion: The additional critical care pharmacist did not increase pharmacy intervention complexity; however, more interventions were performed per day. Additional pharmacist coverage increased the daily number of desirable and optimal clinical activities performed and positively impacted ICU team members' satisfaction.

A Longitudinal Investigation of Alcohol Use over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission

PubMed Central

Davydow, Dimitry S.; Zatzick, Douglas; Hough, Catherine L.; Katon, Wayne J.

2013-01-01

Background There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors. Objective To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission. Method This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Posttraumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use. Results There was a significant decline in the mean AUDIT score from baseline (3.9, 95%Confidence Interval [95%CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95%CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95%CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95%CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95%CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use. Conclusions Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed. PMID:23414847

Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis.

PubMed

Shehata, Nadine; Forster, Alan J; Lawrence, Nadine; Ducharme, Robin; Fergusson, Dean A; Chassé, Michaël; Rothwell, Deanna M; Hébert, Paul C; Tinmouth, Alan T; Wilson, Kumanan

2015-01-01

While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit (ICU), the allocation of blood products at the end of life has not been described. The objective of this study was to describe overall transfusion patterns in the ICU, and specifically in patients who die in hospital. We conducted a retrospective cohort study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006 and June 30, 2012. During the study period, 10,642 patients were admitted at least once to the ICU. Of these patients, 4079 (38.3%) received red blood cells (RBCs), plasma or platelets in the ICU. The ICU mortality rate was 28.1% and in-hospital mortality rate was 32.3%. Among 39,591 blood product units transfused over the course of the study in the ICU (18,144 RBC units, 16,920 plasma units and 4527 platelet units), 46.2% were administered to patients who later died within the same hospitalization (41.2% of RBCs, 50.4% of plasma and 50.8% of platelets). Of all blood product units (RBCs, plasma and platelets) administered in the ICU over the study period, 11% were given within the last 24 hours before death. A large proportion of blood products used in the ICU are administered to patients who ultimately succumb to their illness in hospital, and many of these blood units are given in close proximity to death.

Early Prediction of Intensive Care Unit-Acquired Weakness: A Multicenter External Validation Study.

PubMed

Witteveen, Esther; Wieske, Luuk; Sommers, Juultje; Spijkstra, Jan-Jaap; de Waard, Monique C; Endeman, Henrik; Rijkenberg, Saskia; de Ruijter, Wouter; Sleeswijk, Mengalvio; Verhamme, Camiel; Schultz, Marcus J; van Schaik, Ivo N; Horn, Janneke

2018-01-01

An early diagnosis of intensive care unit-acquired weakness (ICU-AW) is often not possible due to impaired consciousness. To avoid a diagnostic delay, we previously developed a prediction model, based on single-center data from 212 patients (development cohort), to predict ICU-AW at 2 days after ICU admission. The objective of this study was to investigate the external validity of the original prediction model in a new, multicenter cohort and, if necessary, to update the model. Newly admitted ICU patients who were mechanically ventilated at 48 hours after ICU admission were included. Predictors were prospectively recorded, and the outcome ICU-AW was defined by an average Medical Research Council score <4. In the validation cohort, consisting of 349 patients, we analyzed performance of the original prediction model by assessment of calibration and discrimination. Additionally, we updated the model in this validation cohort. Finally, we evaluated a new prediction model based on all patients of the development and validation cohort. Of 349 analyzed patients in the validation cohort, 190 (54%) developed ICU-AW. Both model calibration and discrimination of the original model were poor in the validation cohort. The area under the receiver operating characteristics curve (AUC-ROC) was 0.60 (95% confidence interval [CI]: 0.54-0.66). Model updating methods improved calibration but not discrimination. The new prediction model, based on all patients of the development and validation cohort (total of 536 patients) had a fair discrimination, AUC-ROC: 0.70 (95% CI: 0.66-0.75). The previously developed prediction model for ICU-AW showed poor performance in a new independent multicenter validation cohort. Model updating methods improved calibration but not discrimination. The newly derived prediction model showed fair discrimination. This indicates that early prediction of ICU-AW is still challenging and needs further attention.

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes

PubMed Central

Oles, Sylwia K.; Mundell, James; London, Susan; Khan, Babar

2016-01-01

Objective The purpose of this scoping review was to identify evidence describing benefits of interventions provided in ICU-survivor follow-up clinics. Background Advances in intensive care unit (ICU) treatments have increased the number of survivors who require specialized care for ICU-related sequelae. ICU survivor follow-up clinics exist yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken. Method Ten databases were searched yielding one-hundred eleven relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding non-related publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes. Results Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms whereas evidence to support implementation of other interventions was weak. Conclusions Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains under-explored. Implications ICU survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors. PMID:27309787

Early hospital mortality prediction of intensive care unit patients using an ensemble learning approach.

PubMed

Awad, Aya; Bader-El-Den, Mohamed; McNicholas, James; Briggs, Jim

2017-12-01

Mortality prediction of hospitalized patients is an important problem. Over the past few decades, several severity scoring systems and machine learning mortality prediction models have been developed for predicting hospital mortality. By contrast, early mortality prediction for intensive care unit patients remains an open challenge. Most research has focused on severity of illness scoring systems or data mining (DM) models designed for risk estimation at least 24 or 48h after ICU admission. This study highlights the main data challenges in early mortality prediction in ICU patients and introduces a new machine learning based framework for Early Mortality Prediction for Intensive Care Unit patients (EMPICU). The proposed method is evaluated on the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. Mortality prediction models are developed for patients at the age of 16 or above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU). We employ the ensemble learning Random Forest (RF), the predictive Decision Trees (DT), the probabilistic Naive Bayes (NB) and the rule-based Projective Adaptive Resonance Theory (PART) models. The primary outcome was hospital mortality. The explanatory variables included demographic, physiological, vital signs and laboratory test variables. Performance measures were calculated using cross-validated area under the receiver operating characteristic curve (AUROC) to minimize bias. 11,722 patients with single ICU stays are considered. Only patients at the age of 16 years old and above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU) are considered in this study. The proposed EMPICU framework outperformed standard scoring systems (SOFA, SAPS-I, APACHE-II, NEWS and qSOFA) in terms of AUROC and time (i.e. at 6h compared to 48h or more after admission). The results show that although there are many values missing in the first few hour of ICU admission, there is enough signal to effectively predict mortality during the first 6h of admission. The proposed framework, in particular the one that uses the ensemble learning approach - EMPICU Random Forest (EMPICU-RF) offers a base to construct an effective and novel mortality prediction model in the early hours of an ICU patient admission, with an improved performance profile. Copyright © 2017 Elsevier B.V. All rights reserved.

Does appropriate empiric antibiotic therapy modify intensive care unit-acquired Enterobacteriaceae bacteraemia mortality and discharge?

PubMed

Pouwels, K B; Van Kleef, E; Vansteelandt, S; Batra, R; Edgeworth, J D; Smieszek, T; Robotham, J V

2017-05-01

Conflicting results have been found regarding outcomes of intensive care unit (ICU)-acquired Enterobacteriaceae bacteraemia and the potentially modifying effect of appropriate empiric antibiotic therapy. To evaluate these associations while adjusting for potential time-varying confounding using methods from the causal inference literature. Patients who stayed more than two days in two general ICUs in England between 2002 and 2006 were included in this cohort study. Marginal structural models with inverse probability weighting were used to estimate the mortality and discharge associated with Enterobacteriaceae bacteraemia and the impact of appropriate empiric antibiotic therapy on these outcomes. Among 3411 ICU admissions, 195 (5.7%) ICU-acquired Enterobacteriaceae bacteraemia cases occurred. Enterobacteriaceae bacteraemia was associated with an increased daily risk of ICU death [cause-specific hazard ratio (HR): 1.48; 95% confidence interval (CI): 1.10-1.99] and a reduced daily risk of ICU discharge (HR: 0.66; 95% CI: 0.54-0.80). Appropriate empiric antibiotic therapy did not significantly modify ICU mortality (HR: 1.08; 95% CI: 0.59-1.97) or discharge (HR: 0.91; 95% CI: 0.63-1.32). ICU-acquired Enterobacteriaceae bacteraemia was associated with an increased daily risk of ICU mortality. Furthermore, the daily discharge rate was also lower after acquiring infection, even when adjusting for time-varying confounding using appropriate methodology. No evidence was found for a beneficial modifying effect of appropriate empiric antibiotic therapy on ICU mortality and discharge. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Outcomes of cancer therapy administered to treatment-naïve lung cancer patients in the intensive care unit

PubMed Central

Chen, Yen-Fu; Lin, Jou-Wei; Ho, Chao-Chi; Yang, Ching-Yao; Chang, Chia-Hao; Huang, Tao-Min; Chen, Chung-Yu; Chen, Kuan-Yu; Shih, Jin-Yuan; Yu, Chong-Jen

2017-01-01

Objectives: Therapy outcomes for newly diagnosed, critically ill lung cancer patients have seldom been evaluated. This study evaluated therapy outcomes for treatment-naïve lung cancer patients in the intensive care unit (ICU). Materials and Methods: Patients were excluded if they had previously received lung cancer treatment, such as systemic chemotherapy, targeted therapy, radiotherapy, or surgical lung resection before ICU admission. The therapeutic strategies for the treatment-naïve patients were determined while they were in the ICU. The patients' demographic data, clinical outcomes, and treatment-related toxicities were analyzed. Results: Newly diagnosed lung cancer patients (n = 72) who did not receive any anticancer treatment before ICU admission were included. Most patients had locally advanced disease, and 61 (84.7%) required intensive care due to cancer-related events. In the ICU, 24 (33.3%) patients received chemotherapy, 24 (33.3%) received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and 24 (33.3%) received best supportive care (BSC). Patients receiving chemotherapy or EGFR-TKIs in the ICU demonstrated better ICU (p = 0.011) and in-hospital (p = 0.034) survival than those receiving BSC only. Among patients requiring mechanical ventilation, those receiving chemotherapy had higher weaning rates than those receiving EGFR-TKIs or BSC (p = 0.002). In multivariate analysis, receipt of chemotherapy (hazard ratio [HR], 0.443; p = 0.083) and mechanical ventilation (HR, 0.270; p = 0.022) were significantly associated with longer ICU survival after adjusting for clinical factors. Conclusions: Anticancer therapy in the ICU might provide better short-term ICU survival for treatment-naïve, critically ill lung cancer patients. PMID:28819399

Outcomes of cancer therapy administered to treatment-naïve lung cancer patients in the intensive care unit.

PubMed

Chen, Yen-Fu; Lin, Jou-Wei; Ho, Chao-Chi; Yang, Ching-Yao; Chang, Chia-Hao; Huang, Tao-Min; Chen, Chung-Yu; Chen, Kuan-Yu; Shih, Jin-Yuan; Yu, Chong-Jen

2017-01-01

Objectives: Therapy outcomes for newly diagnosed, critically ill lung cancer patients have seldom been evaluated. This study evaluated therapy outcomes for treatment-naïve lung cancer patients in the intensive care unit (ICU). Materials and Methods: Patients were excluded if they had previously received lung cancer treatment, such as systemic chemotherapy, targeted therapy, radiotherapy, or surgical lung resection before ICU admission. The therapeutic strategies for the treatment-naïve patients were determined while they were in the ICU. The patients' demographic data, clinical outcomes, and treatment-related toxicities were analyzed. Results: Newly diagnosed lung cancer patients (n = 72) who did not receive any anticancer treatment before ICU admission were included. Most patients had locally advanced disease, and 61 (84.7%) required intensive care due to cancer-related events. In the ICU, 24 (33.3%) patients received chemotherapy, 24 (33.3%) received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy and 24 (33.3%) received best supportive care (BSC). Patients receiving chemotherapy or EGFR-TKIs in the ICU demonstrated better ICU (p = 0.011) and in-hospital (p = 0.034) survival than those receiving BSC only. Among patients requiring mechanical ventilation, those receiving chemotherapy had higher weaning rates than those receiving EGFR-TKIs or BSC (p = 0.002). In multivariate analysis, receipt of chemotherapy (hazard ratio [HR], 0.443; p = 0.083) and mechanical ventilation (HR, 0.270; p = 0.022) were significantly associated with longer ICU survival after adjusting for clinical factors. Conclusions: Anticancer therapy in the ICU might provide better short-term ICU survival for treatment-naïve, critically ill lung cancer patients.

Perceptions, attitudes, and current practices regards delirium in China: A survey of 917 critical care nurses and physicians in China.

PubMed

Xing, Jinyan; Sun, Yunbo; Jie, Yaqi; Yuan, Zhiyong; Liu, Wenjuan

2017-09-01

The purpose of this study is to assess the knowledge, attitudes, and managements regarding delirium of intensive care nurses and physicans, and to assess the perceived barriers related to intensive care unit (ICU) delirium monitoring in China. A descriptive survey was distributed to 1156 critical care nurses and physicians from 74 tertiary and secondary hospitals across Shandong province, China. The overall response rate was 86.18% (n = 917). The majority of respondents (88%) believed that deirium was associated with prolonged mechanical ventilation, and 79.72% thought delirium was associated with prolonged length of hospitalization. Only 14.17% of respondents believed that delirium was common in the ICU setting. Only 25.62% of the respondents reported routine screening of ICU delirium, and only 15.81% utilized Confusion Assessment Method for Intensive Care Unit screening tools. "Lack of appropriate screening tools" and "time restraints" were the most common perceived barriers. 45.4% of the participants had never received any education on ICU delirium. In conclusion, most nurses and physicians consider ICU delirium to be a serious problem, but lack knowledge on delirium and monitor this condition poorly. The survey infers a disconnection between the perceived significance and current monitoring of ICU delirium. There is a critical unmet need for in-service education on ICU delirium for physicians and nurses in China.

Perceptions, attitudes, and current practices regards delirium in China

PubMed Central

Xing, Jinyan; Sun, Yunbo; Jie, Yaqi; Yuan, Zhiyong; Liu, Wenjuan

2017-01-01

Abstract The purpose of this study is to assess the knowledge, attitudes, and managements regarding delirium of intensive care nurses and physicans, and to assess the perceived barriers related to intensive care unit (ICU) delirium monitoring in China. A descriptive survey was distributed to 1156 critical care nurses and physicians from 74 tertiary and secondary hospitals across Shandong province, China. The overall response rate was 86.18% (n = 917). The majority of respondents (88%) believed that deirium was associated with prolonged mechanical ventilation, and 79.72% thought delirium was associated with prolonged length of hospitalization. Only 14.17% of respondents believed that delirium was common in the ICU setting. Only 25.62% of the respondents reported routine screening of ICU delirium, and only 15.81% utilized Confusion Assessment Method for Intensive Care Unit screening tools. “Lack of appropriate screening tools” and “time restraints” were the most common perceived barriers. 45.4% of the participants had never received any education on ICU delirium. In conclusion, most nurses and physicians consider ICU delirium to be a serious problem, but lack knowledge on delirium and monitor this condition poorly. The survey infers a disconnection between the perceived significance and current monitoring of ICU delirium. There is a critical unmet need for in-service education on ICU delirium for physicians and nurses in China. PMID:28953621

Accuracy of height estimation and tidal volume setting using anthropometric formulas in an ICU Caucasian population.

PubMed

L'her, Erwan; Martin-Babau, Jérôme; Lellouche, François

2016-12-01

Knowledge of patients' height is essential for daily practice in the intensive care unit. However, actual height measurements are unavailable on a daily routine in the ICU and measured height in the supine position and/or visual estimates may lack consistency. Clinicians do need simple and rapid methods to estimate the patients' height, especially in short height and/or obese patients. The objectives of the study were to evaluate several anthropometric formulas for height estimation on healthy volunteers and to test whether several of these estimates will help tidal volume setting in ICU patients. This was a prospective, observational study in a medical intensive care unit of a university hospital. During the first phase of the study, eight limb measurements were performed on 60 healthy volunteers and 18 height estimation formulas were tested. During the second phase, four height estimates were performed on 60 consecutive ICU patients under mechanical ventilation. In the 60 healthy volunteers, actual height was well correlated with the gold standard, measured height in the erect position. Correlation was low between actual and calculated height, using the hand's length and width, the index, or the foot equations. The Chumlea method and its simplified version, performed in the supine position, provided adequate estimates. In the 60 ICU patients, calculated height using the simplified Chumlea method was well correlated with measured height (r = 0.78; ∂ < 1 %). Ulna and tibia estimates also provided valuable estimates. All these height estimates allowed calculating IBW or PBW that were significantly different from the patients' actual weight on admission. In most cases, tidal volume set according to these estimates was lower than what would have been set using the actual weight. When actual height is unavailable in ICU patients undergoing mechanical ventilation, alternative anthropometric methods to obtain patient's height based on lower leg and on forearm measurements could be useful to facilitate the application of protective mechanical ventilation in a Caucasian ICU population. The simplified Chumlea method is easy to achieve in a bed-ridden patient and provides accurate height estimates, with a low bias.

Intensive Care Nurses’ Belief Systems Regarding the Health Economics: A Focused Ethnography

PubMed Central

Heydari, Abbas; Vafaee-Najar, Ali; Bakhshi, Mahmoud

2016-01-01

Background: Health care beliefs can have an effect on the efficiency and effectiveness of nursing practices. Nevertheless, how belief systems impact on the economic performance of intensive care unit (ICU) nurses is not known. This study aimed to explore the ICU nurses’ beliefs and their effect on nurse’s: practices and behavior patterns regarding the health economics. Methods: In this study, a focused ethnography method was used. Twenty-four informants from ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations were used for data collection. Data analysis was performed using the methods described by Miles and Huberman (1994). Findings: Eight beliefs were found that gave meaning to ICU nurse’s practices regarding the health economics. 1. The registration of medications and supplies disrupt the nursing care; 2. Monitoring and auditing improve consumption; 3. There is a fear of possible shortage in the future; 4. Supply and replacement of equipment is difficult; 5. Higher prices lead to more accurate consumption; 6. The quality of care precedes the costs; 7. Clinical Guidelines are abundant but useful; and 8. Patient economy has priority over hospital economy. Maintaining the quality of patient care with least attention to hospital costs was the main focus of the beliefs formed up in the ICU regarding the health economics. Conclusions: ICU nurses’ belief systems have significantly shaped in relation to providing a high-quality care. Although high quality of care can lead to a rise in the effectiveness of nursing care, cost control perspective should also be considered in planning for improve the quality of care. Therefore, it is necessary to involve the ICU nurses in decision-making about unit cost management. They must become familiar with the principles of heath care economics and productivity by applying an effective cost management program. It may be optimal to implement the reforms in various aspects, such as the hospital’s strategic plan and supply chain management system. PMID:27157164

COSTS AND COST-EFFECTIVENESS OF A TELE-ICU PROGRAM IN SIX INTENSIVE CARE UNITS IN A LARGE HEALTHCARE SYSTEM

PubMed Central

Franzini, Luisa; Sail, Kavita R.; Thomas, Eric J; Wueste, Laura

2011-01-01

Purpose To estimate the costs and cost-effectiveness of a tele-ICU program. Materials and methods We used an observational study with ICU patients cared for during the pre-tele-ICU period and ICU patients cared for during the post-tele-ICU period in 6 ICUs at 5 hospitals, part of a large non-profit health care system in the Gulf Coast region. We obtained data on a sample of 4142 ICU patients: 2,034 in the pre-tele-ICU period and 2,108 in the post-tele-ICU period. Economic outcomes were hospital costs, ICU costs and floor costs, measured for average daily costs, costs per case, and costs per patient. Results After the implementation of the tele-ICU, the hospital daily cost increased from $4,302 to $5,340 (24%), the hospital cost per case from $21,967 to $31,318 (43%), and the cost per patient from $20,231 to $25,846 (28%). While the tele-ICU intervention was not cost effective in patients with SAPS II ≤ 50, it was cost effective in the sickest patients with SAPS II > 50 (17% of patients) as it decreased hospital mortality without increasing costs significantly. Conclusions Hospital administrators may conclude that a tele-ICU program aimed at the sickest patients is cost effective. PMID:21376515

The validity and reliability of the Arabic version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): A prospective cohort study.

PubMed

Selim, Abeer; Kandeel, Nahed; Elokl, Mohamed; Khater, Mohamed Shawky; Saleh, Ashraf Nabil; Bustami, Rami; Ely, E Wesley

2018-04-01

Accurate diagnosis for Arabic speaking critically ill patients suffering from delirium is limited by the need for a valid/reliable translation of a standardized delirium instrument such as the Confusion Assessment Method for the ICU (CAM-ICU). To determine the validity and reliability of the Arabic version of the CAM-ICU. A prospective cohort study design was used to conduct the current study. Data collection took place in Geriatric, Emergency and Surgical intensive care units. Fifty-eight adult patients met the inclusion criteria and participated in the study. Among the participants 22(38%) patients were on mechanical ventilation. After translating the CAM-ICU into Arabic language, the Arabic CAM-ICU was administered by two well-trained critical care nurses and compared with reference standard assessments by delirium experts using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM -IV-TR), along with assessment of severity of illness using Sequential Organ Failure Assessment (SOFA). Concurrent validity was assessed by calculating sensitivity, specificity and positive and negative predictive value (PPV and NPV) for the two Arabic CAM-ICU raters, where calculations were based on considering the DSM-IV-TR criterion as the reference standard. The convergent validity of the Arabic CAM-ICU was explored by comparing the Arabic CAM-ICU ratings and the total score of SOFA (severity of illness) and MMSE (cognitive impairment). A total of 58 ICU patients were included, of whom 27 (47%) were diagnosed with delirium during their ICU stay via DSM-IV criteria. Interrater reliability for the Arabic CAM-ICU, overall and for mechanically ventilated patients assessed using Cohen's kappa (κ) were 0.82 and 1, respectively, p < 0.001. The sensitivities (95% CI) for the two critical care nurses when using the Arabic CAM-ICU compared with the reference standard were 81% (60%-93%) and 85% (65%-95%), respectively, whereas specificity (95% CI) was 81%(62%-92%) for both nurses. High sensitivity and specificity measures were also observed across subgroups; 100% for mechanically ventilated patients, 88% (60%-98%) and 79% (49%-94%) for those aged 65 years or older and 82% (56%-95%) and 75% (43%-93%) for those with SOFA scores at or above the median value. The Arabic CAM-ICU appeared to be valid and reliable tool for diagnosing delirium. Future investigations may lead to a better understanding of the prevalence, predictors, and consequences of delirium among critically ill Arabic speaking patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Quality Improvement in Critical Care: Selection and Development of Quality Indicators

PubMed Central

Martin, Claudio M.; Project, The Quality Improvement in Critical Care

2016-01-01

Background. Caring for critically ill patients is complex and resource intensive. An approach to monitor and compare the function of different intensive care units (ICUs) is needed to optimize outcomes for patients and the health system as a whole. Objective. To develop and implement quality indicators for comparing ICU characteristics and performance within and between ICUs and regions over time. Methods. Canadian jurisdictions with established ICU clinical databases were invited to participate in an iterative series of face-to-face meetings, teleconferences, and web conferences. Eighteen adult intensive care units across 14 hospitals and 5 provinces participated in the process. Results. Six domains of ICU function were identified: safe, timely, efficient, effective, patient/family satisfaction, and staff work life. Detailed operational definitions were developed for 22 quality indicators. The feasibility was demonstrated with the collection of 3.5 years of data. Statistical process control charts and graphs of composite measures were used for data display and comparisons. Medical and nursing leaders as well as administrators found the system to be an improvement over prior methods. Conclusions. Our process resulted in the selection and development of 22 indicators representing 6 domains of ICU function. We have demonstrated the feasibility of such a reporting system. This type of reporting system will demonstrate variation between units and jurisdictions to help identify and prioritize improvement efforts. PMID:27493476

A pilot study of eye-tracking devices in intensive care.

PubMed

Garry, Jonah; Casey, Kelly; Cole, Therese Kling; Regensburg, Angela; McElroy, Colleen; Schneider, Eric; Efron, David; Chi, Albert

2016-03-01

Eye-tracking devices have been suggested as a means of improving communication and psychosocial status among patients in the intensive care unit (ICU). This study was undertaken to explore the psychosocial impact and communication effects of eye-tracking devices in the ICU. A convenience sample of patients in the medical ICU, surgical ICU, and neurosciences critical care unit were enrolled prospectively. Patients participated in 5 guided sessions of 45 minutes each with the eye-tracking computer. After completion of the sessions, the Psychosocial Impact of Assistive Devices Scale (PIADS) was used to evaluate the device from the patient's perspective. All patients who participated in the study were able to communicate basic needs to nursing staff and family. Delirium as assessed by the Confusion Assessment Method for the Intensive Care Unit was present in 4 patients at recruitment and none after training. The device's overall psychosocial impact ranged from neutral (-0.29) to strongly positive (2.76). Compared with the absence of intervention (0 = no change), patients exposed to eye-tracking computers demonstrated a positive mean overall impact score (PIADS = 1.30; P = .004). This finding was present in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all P < .01). There is a population of patients in the ICU whose psychosocial status, delirium, and communication ability may be enhanced by eye-tracking devices. These 3 outcomes are intertwined with ICU patient outcomes and indirectly suggest that eye-tracking devices might improve outcomes. A more in-depth exploration of the population to be targeted, the device's limitations, and the benefits of eye-tracking devices in the ICU is warranted. Copyright © 2016 Elsevier Inc. All rights reserved.

Caring for the caregiver.

PubMed

Levy, Mitchell M

2004-07-01

There are certainly many coping behaviors that may assist ICU caregivers in the process of caring for themselves. Staff support groups,regular interdisciplinary meetings to discuss difficult cases,and bringing trained personnel into the intensive care unit (ICU)environment to offer staff training in communication and conflict resolution skills have been suggested as methods for alleviating caregiver stress. Combining these as well as other tools with a deeper look at the caregiver-patient relationship are important building blocks for creating a sane, healthy environment in the ICU. Over the next years, as the population ages, and as technologic advances continue, the critical care units will play an even more prominent role in health care. Given the threat posed by the severe nursing shortage, it becomes apparent that, to prepare for this increased need for critical care services, efforts must be directed to identify the sources of distress for ICU caregivers and develop focused training programs that alleviate the inevitably strains and pressures that arise in the process of compassionate caring for the critically ill.

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study

PubMed Central

2011-01-01

Introduction The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Methods Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Results Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Conclusions Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design. PMID:21914222

The Ethics of Rationing of Critical Care Services: Should Technology Assessment Play a Role?

PubMed Central

Bloomfield, Eric L.

2009-01-01

The costs of health care continue to increase rapidly and steeply in the United States. One area of great expense is that of intensive care units (ICUs). The causes of inflation have not been addressed effectively. ICU resources could become stretched such that they may no longer be available. This paper discusses some of the ethics and concerns behind decision making when providing ICU services in the United States. In particular, the use of electronic records with decision making tools, risk-analysis methods, and documentation of patient wishes for extraordinary care may help with better utilization of resources in the future. PMID:20798878

Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study).

PubMed

Rosa, Regis Goulart; Falavigna, Maicon; Robinson, Caroline Cabral; da Silva, Daiana Barbosa; Kochhann, Renata; de Moura, Rafaela Moraes; Santos, Mariana Martins Siqueira; Sganzerla, Daniel; Giordani, Natalia Elis; Eugênio, Cláudia; Ribeiro, Tarissa; Cavalcanti, Alexandre Biasi; Bozza, Fernando; Azevedo, Luciano Cesar Pontes; Machado, Flávia Ribeiro; Salluh, Jorge Ibrain Figueira; Pellegrini, José Augusto Santos; Moraes, Rafael Barberena; Hochegger, Taís; Amaral, Alexandre; Teles, José Mario Meira; da Luz, Lucas Gobetti; Barbosa, Mirceli Goulart; Birriel, Daniella Cunha; Ferraz, Iris de Lima; Nobre, Vandack; Valentim, Helen Martins; Corrêa E Castro, Livia; Duarte, Péricles Almeida Delfino; Tregnago, Rogério; Barilli, Sofia Louise Santin; Brandão, Nilton; Giannini, Alberto; Teixeira, Cassiano

2018-04-13

Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. NCT02932358. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Flexible visiting positively impacted on patients, families and staff in an Australian Intensive Care Unit: A before-after mixed method study.

PubMed

Mitchell, Marion L; Aitken, Leanne M

2017-03-01

The admission of a relative to intensive care is stressful for families. To help them support the patient, families need assurance, information and an ability to be near their sick relative. Flexible visiting enables patient access but the impact of this on patients, families and staff is not clear. To assess the impact of flexible visiting from the perspective of patients, families, and Intensive Care Unit (ICU) staff. A before-after mixed method study was used with interviews, focus groups and surveys. Patients were interviewed, family members completed the Family Satisfaction in ICU survey and ICU staff completed a survey and participated in focus groups following the introduction of 21h per day visiting in a tertiary ICU. The study was conducted within a philosophy of family-centred care. All interviewed patients (n=12) positively evaluated the concept of extended visiting hours. Family members' (n=181) overall 'satisfaction with care' did not change; however 85% were 'very satisfied' with increased visiting flexibility. Seventy-six percent of family visits continued to occur within the previous visiting hours (11am-8pm) with the remaining 24% taking place during the newly available visiting hours. Families recognised the priority of patient care with their personal needs being secondary. Three-quarters of ICU staff were 'satisfied' with flexible visiting and suggested any barriers could be overcome by role modelling family inclusion. Patients, families and ICU staff positively evaluated flexible visiting hours in this ICU. Although only a minority of families took advantage of the increased hours they indicated appreciation for the additional opportunities. Junior staff may benefit from peer-support to develop family inclusion skills. More flexible visiting times can be incorporated into usual ICU practice in a manner that is viewed positively by all stakeholders. Copyright © 2016 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Investigation of the Cause of Readmission to the Intensive Care Unit for Patients with Lung Edema or Atelectasis

PubMed Central

Zaitsu, Akinori; Hashizume, Makoto

2008-01-01

Purpose For patients with acute respiratory failure due to lung edema or atelectasis, Surplus lung water that is not removed during an initial stay in the Intensive Care Unit (ICU) may be related to early ICU readmission. Therefore, we performed a retrospective study of patient management during the first ICU stay for such patients. Materials and Methods Of 1,835 patients who were admitted to the ICU in the 36 months from January, 2003 to December, 2005, 141 were patients readmitted, and the reason for readmission was lung edema or atelectasis in 21 patients. For these 21 patients, correlations were investigated between body weight gain at the time of initial ICU discharge (weight upon discharge from the ICU ÷ weight when entering the ICU) and the time to ICU readmission, between body weight gain and the P/F ratio at ICU readmission, between the R/E ratio (the period using a respirator (R) ÷ the length of the ICU stay after extubation (E)) and the time to ICU readmission, between the R/E ratio and body weight gain, and between body weight gain until extubation and the time to extubation. Results A negative linear relationship was found between body weight gain at the time of initial ICU discharge and the time to ICU readmission, and between body weight gain at the time of ICU discharge and the P/F ratio at ICU readmission. If body weight had increased by more than 10% at ICU discharge or the P/F ratio was below 150, readmission to the ICU within three days was likely. Patients with a large R/E ratio, a large body weight gain, and a worsening P/F ratio immediately after ICU discharge were likely to be readmitted soon to the ICU. Loss of body weight during the period of respirator support led to early extubation, since a positive correlation was found between the time to extubation and body weight gain. Conclusion Fluid management failure during the first ICU stay might cause ICU readmission for patients who had lung edema or atelectasis. Therefore, a key to the prevention of ICU readmission is to ensure complete recovery from lung failure before the initial ICU discharge. Strict water management is crucial based on body weight measurement and removal of excess lung water is essential. In addition, an apparent improvement in respiratory state may be due to respiratory support, and such an improvement should be viewed cautiously. Loss of weight at the refilling stage of transfusion prevents ICU readmission and may decrease the length of the ICU stay. PMID:18581592

[The prevalence of nosocomial infection in Intensive Care Units in the State of Rio Grande do Sul].

PubMed

Lisboa, Thiago; Faria, Mario; Hoher, Jorge A; Borges, Luis A A; Gómez, Jussara; Schifelbain, Luciele; Dias, Fernando S; Lisboa, João; Friedman, Gilberto

2007-12-01

To determine the prevalence of intensive care unit (ICU)-acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality. A 1-day point prevalence study. Sixteen ICU of the State of Rio Grande do Sul-Brazil, excluding coronary care and pediatric units. All patients < 12 yrs occupying an ICU bed over a 24-hour period. The 16 ICU provided 174 case reports. rates of ICU-acquired infection, resistance patterns of microbiological isolates, and potential risks factors for ICU-acquired infection and death. A total of 122 patients (71%) was infected and 51 (29%) had ICU-acquired infection. Pneumonia (58.2%), lower tract respiratory infection (22.9%), urinary tract infection (18%) were the most frequents types of ICU infection. Most frequently microorganisms reported were staphylococcus aureus (42% [64% resistant to oxacilin]) and pseudomonas aeruginosa (31%). Six risk factors for ICU acquired infection were identified: urinary catheterization, central vascular line, tracheal intubation for prolonged time (> 4 days), chronic disease and increased length of ICU stay (> 30 days). The risks factors associated with death were age, APACHE II, organ dysfunction, and tracheal intubation with or without mechanical ventilation. ICU-acquired infection is common and often associated with microbiological isolates of resistant organisms. This study may serve as an epidemiological reference to help the discussion of regional infection control policies.

A Conceptual Framework for Improving Critical Care Patient Flow and Bed Use.

PubMed

Mathews, Kusum S; Long, Elisa F

2015-06-01

High demand for intensive care unit (ICU) services and limited bed availability have prompted hospitals to address capacity planning challenges. Simulation modeling can examine ICU bed assignment policies, accounting for patient acuity, to reduce ICU admission delays. To provide a framework for data-driven modeling of ICU patient flow, identify key measurable outcomes, and present illustrative analysis demonstrating the impact of various bed allocation scenarios on outcomes. A description of key inputs for constructing a queuing model was outlined, and an illustrative simulation model was developed to reflect current triage protocol within the medical ICU and step-down unit (SDU) at a single tertiary-care hospital. Patient acuity, arrival rate, and unit length of stay, consisting of a "service time" and "time to transfer," were estimated from 12 months of retrospective data (n = 2,710 adult patients) for 36 ICU and 15 SDU staffed beds. Patient priority was based on acuity and whether the patient originated in the emergency department. The model simulated the following hypothetical scenarios: (1) varied ICU/SDU sizes, (2) reserved ICU beds as a triage strategy, (3) lower targets for time to transfer out of the ICU, and (4) ICU expansion by up to four beds. Outcomes included ICU admission wait times and unit occupancy. With current bed allocation, simulated wait time averaged 1.13 (SD, 1.39) hours. Reallocating all SDU beds as ICU decreased overall wait times by 7.2% to 1.06 (SD, 1.39) hours and increased bed occupancy from 80 to 84%. Reserving the last available bed for acute patients reduced wait times for acute patients from 0.84 (SD, 1.12) to 0.31 (SD, 0.30) hours, but tripled subacute patients' wait times from 1.39 (SD, 1.81) to 4.27 (SD, 5.44) hours. Setting transfer times to wards for all ICU/SDU patients to 1 hour decreased wait times for incoming ICU patients, comparable to building one to two additional ICU beds. Hospital queuing and simulation modeling with empiric data inputs can evaluate how changes in ICU bed assignment could impact unit occupancy levels and patient wait times. Trade-offs associated with dedicating resources for acute patients versus expanding capacity for all patients can be examined.

Educational Intervention on Delirium Assessment Using Confusion Assessment Method-ICU (CAM-ICU) in a General Intensive Care Unit.

PubMed

Ramoo, Vimala; Abu, Harlinna; Rai, Vineya; Surat Singh, Surindar Kaur; Baharudin, Ayuni Asma'; Danaee, Mahmoud; Thinagaran, Raveena Rajalachimi R

2018-05-18

The primary objective was to assess intensive care unit nurses' knowledge of intensive care unit delirium and delirium assessment before and after an educational intervention. In addition, nurses' perception on the usefulness of a delirium assessment tool and barriers against delirium assessment were assessed as secondary objectives. Early identification of delirium in intensive care units is crucial for patient care. Hence, nurses require adequate knowledge to enable appropriate evaluation of delirium using standardised practice and assessment tools. This study, performed in Malaysia, used a single group pretest-posttest study design to assess the effect of educational interventions and hands-on practices on nurses' knowledge of intensive care unit delirium and delirium assessment. Sixty-one nurses participated in educational intervention sessions, including classroom learning, demonstrations, and hands-on practices on the Confusion Assessment Method-Intensive Care Unit. Data were collected using self-administered questionnaires for the pre- and post-intervention assessments. Analysis to determine the effect of the educational intervention consisted of the repeated-measures analysis of covariance. There were significant differences in the knowledge scores pre- and post-intervention, after controlling for demographic characteristics. The two most common perceived barriers to the adoption of the intensive care unit delirium assessment tool were "physicians did not use nurses' delirium assessment in decision making" and "difficult to interpret delirium in intubated patients". Educational intervention and hands-on practices increased nurses' knowledge of delirium assessment. Teaching and inter-professional involvements are essential for a successful implementation of intensive care unit delirium assessment practice. This study supports existing evidences, indicating that education and training could increase nurses' knowledge of delirium and delirium assessment. Improving nurses' knowledge could potentially lead to better delirium management practice and improve ICU patient care. Thus, continuous efforts to improve and sustain nurses' knowledge become relevant in ICU settings. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Critical care medicine beds, use, occupancy and costs in the United States: a methodological review

PubMed Central

Halpern, Neil A; Pastores, Stephen M.

2017-01-01

This article is a methodological review to help the intensivist gain insights into the classic and sometimes arcane maze of national databases and methodologies used to determine and analyze the intensive care unit (ICU) bed supply, occupancy rates, and costs in the United States (US). Data for total ICU beds, use and occupancy can be derived from two large national healthcare databases: the Healthcare Cost Report Information System (HCRIS) maintained by the federal Centers for Medicare and Medicaid Services (CMS) and the proprietary Hospital Statistics of the American Hospital Association (AHA). Two costing methodologies can be used to calculate ICU costs: the Russell equation and national projections. Both methods are based on cost and use data from the national hospital datasets or from defined groups of hospitals or patients. At the national level, an understanding of US ICU beds, use and cost helps provide clarity to the width and scope of the critical care medicine (CCM) enterprise within the US healthcare system. This review will also help the intensivist better understand published studies on administrative topics related to CCM and be better prepared to participate in their own local hospital organizations or regional CCM programs. PMID:26308432

Late HIV diagnosis is a major risk factor for intensive care unit admission in HIV-positive patients: a single centre observational cohort study

PubMed Central

2013-01-01

Background HIV positive patients are at risk of infectious and non-infectious complications that may necessitate intensive care unit (ICU) admission. While the characteristics of patients requiring ICU admission have been described previously, these studies did not include information on the denominator population from which these cases arose. Methods We conducted an observational cohort study of ICU admissions among 2751 HIV positive patients attending King’s College Hospital, South London, UK. Poisson regression models were used to identify factors associated with ICU admission. Results The overall incidence rate of ICU admission was 1.0 [95% CI 0.8, 1.2] per 100 person-years of follow up, and particularly high early (during the first 3 months) following HIV diagnosis (12.4 [8.7, 17.3] per 100 person-years compared to 0.37 [0.27, 0.50] per 100 person-years thereafter; incidence rate ratio 33.5 [23.4, 48.1], p < 0.001). In time-updated analyses, AIDS and current CD4 cell counts of less than 200 cells/mm3 were associated with an increased incidence of ICU admission while receipt of combination antiretroviral therapy (cART) was associated with a reduced incidence of ICU admission. Late HIV diagnosis (initial CD4 cell count <350 or AIDS within 3 months of HIV diagnosis) applied to 81% of patients who were first diagnosed HIV positive during the study period and who required ICU admission. Late HIV diagnosis was significantly associated with ICU admission in the first 3 months following HIV diagnosis (adjusted incidence rate ratio 8.72, 95% CI 2.76, 27.5). Conclusions Late HIV diagnosis was a major risk factor for early ICU admission in our cohort. Earlier HIV diagnosis allowing cART initiation at CD4 cell counts of 350 cells/mm3 is likely to have a significant impact on the need for ICU care. PMID:23331544

Save the patient a trip. Outcome difference between conservatively treated patients with traumatic brain injury in a nonspecialized intensive care unit vs a specialized neurosurgical intensive care unit in the Sultanate of Oman.

PubMed

Al-Kashmiri, Ammar M; Al-Shaqsi, Sultan Z; Al-Kharusi, Adil S; Al-Tamimi, Laila A

2015-06-01

Traumatic brain injury (TBI) continues to be the main cause of death among trauma patients. Accurate diagnosis and timely surgical interventions are critical steps in reducing the mortality from this disease. For patients who have no surgically reversible head injury pathology, the decision to transfer to a dedicated neurosurgical unit is usually controversial. To compare the outcome of patients with severe TBI treated conservatively in a specialized neurosurgical intensive care unit (ICU) and those treated conservatively at a general ICU in the Sultanate of Oman. Retrospective cohort study. This is a retrospective study of patients with severe TBI admitted to Khoula Hospital ICU (specialized neurosurgical ICU) and Nizwa Hospital ICU (general ICU) in Oman in 2013. Surgically treated patients were excluded. Data extracted included demographics, injury details, interventions, and outcomes. The outcome variables included mortality, length of stay, length of ICU days, and ventilated days. There were 100 patients with severe TBI treated conservatively at Khoula Hospital compared with 74 patients at Nizwa Hospital. Basic demographics were similar between the 2 groups. No significant difference was found in mortality, length of stay, ICU days, and ventilation days. There is no difference in outcome between patients with TBI treated conservatively in a specialized neurosurgical ICU and those treated in a general nonspecialized ICU in Oman in 2013. Therefore, unless neurosurgical intervention is warranted or expected, patients with TBI may be managed in a general ICU, saving the risk and expense of a transfer to a specialized neurosurgical ICU. Copyright © 2015 Elsevier Inc. All rights reserved.

Sleep in the Intensive Care Unit

PubMed Central

Friese, Randall S.; Gehlbach, Brian K.; Schwab, Richard J.; Weinhouse, Gerald L.; Jones, Shirley F.

2015-01-01

Sleep is an important physiologic process, and lack of sleep is associated with a host of adverse outcomes. Basic and clinical research has documented the important role circadian rhythm plays in biologic function. Critical illness is a time of extreme vulnerability for patients, and the important role sleep may play in recovery for intensive care unit (ICU) patients is just beginning to be explored. This concise clinical review focuses on the current state of research examining sleep in critical illness. We discuss sleep and circadian rhythm abnormalities that occur in ICU patients and the challenges to measuring alterations in circadian rhythm in critical illness and review methods to measure sleep in the ICU, including polysomnography, actigraphy, and questionnaires. We discuss data on the impact of potentially modifiable disruptors to patient sleep, such as noise, light, and patient care activities, and report on potential methods to improve sleep in the setting of critical illness. Finally, we review the latest literature on sleep disturbances that persist or develop after critical illness. PMID:25594808

Memories of being injured and patients' care trajectory after physical trauma

PubMed Central

Ringdal, Mona; Plos, Kaety; Bergbom, Ingegerd

2008-01-01

Background The purpose of this study was to acquire a deeper understanding of patients' memories of being injured and the trajectory of care before, during and after their Intensive Care Unit (ICU) stay. Methods Interviews were conducted with eighteen informants who after physical trauma had been cared for in the ICU. The interviews were analyzed by using a phenomenological hermeneutical method. Results The memories of injury during the trajectory of care are illustrated in a figure in which the injured informants have memories from five scenes; the scene of the accident, emergency unit, ICU, nursing ward and of coming home. Twelve subthemes were abstracted and four themes emerged; a surrealistic world, an injured body, care, and gratitude for life. After the accident, a "surrealistic world" appeared along with bad memories of being in a floating existence where plans had to be changed. This world was unfamiliar, sometimes including delusional and fragmentary memories from the ICU, and it was experienced as uncontrollable. They felt connected to an "injured body", experiencing bad memories from the ICU of being injured, from the nursing ward of simply enduring and of being in a No Man's Land when coming home; their lives had become limited. At the same time they were "connected to care" with good memories of receiving attention from others at the scene of the accident, being taken cared of at the emergency unit and cared for in the ICU. This care made them realise that people are responsible for each other, and they felt comforted but also vulnerable. Finally, they experienced "gratitude for life". This included good memories of being loved together with support from their families at the ICU, wanting to win life back at the nursing ward and acceptance when returning home. The support from their families made them realise that they fit in just as they are. Conclusion When bad memories of a surrealistic world and of being injured are balanced by good ones of care and love with a gratitude for life, there are more possibilities to move on despite an uncertain future following the injury. PMID:18559089

RESOURCE MANAGEMENT AMONG INTENSIVE CARE NURSES: AN ETHNOGRAPHIC STUDY

PubMed Central

Heydari, Abbas; Najar, Ali Vafaee; Bakhshi, Mahmoud

2015-01-01

Background: Nurses are the main users of supplies and equipment applied in the Intensive Care Units (ICUs) which are high-priced and costly. Therefore, understanding ICU nurses’ experiences about resource management contributes to the better control of the costs. Objectives: This study aimed to investigate the culture of nurses’ working environment regarding the resource management in the ICUs in Iran. Patients and Methods: In this study, a focused ethnographic method was used. Twenty-eight informants among ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations as a participant observer was used for data gathering. Data analysis was performed using the methods described by Miles and Huberman (1994). Results: Two main themes describing the culture of ICU nurses regarding resource management included (a) consumption monitoring and auditing, and (b) prudent use. The results revealed that the efforts for resource management are conducted in the conditions of scarcity and uncertainty in supply. ICU nurses had a sense of futurism in the supply and use of resources in the unit and do the planning through taking the rules and guidelines as well as the available resources and their values into account. Improper storage of some supplies and equipment was a reaction to this uncertain condition among nurses. Conclusions: To manage the resources effectively, improvement of supply chain management in hospital seems essential. It is also necessary to hold educational classes in order to enhance the nurses’ awareness on effective supply chain and storage of the items in the unit stock. PMID:26889097

Estimating vaccine effectiveness against severe influenza in England and Scotland 2011/2012: applying the screening method to data from intensive care surveillance systems.

PubMed

Thomas, H L; Andrews, N; Green, H K; Boddington, N L; Zhao, H; Reynolds, A; McMenamin, J; Pebody, R G

2014-01-01

Methods for estimating vaccine effectiveness (VE) against severe influenza are not well established. We used the screening method to estimate VE against influenza resulting in intensive care unit (ICU) admission in England and Scotland in 2011/2012. We extracted data on confirmed influenza ICU cases from severe influenza surveillance systems, and obtained their 2011/2012 trivalent influenza vaccine (TIV) status from primary care. We compared case vaccine uptake with population vaccine uptake obtained from routine monitoring systems, adjusting for age group, specific risk group, region and week. Of 60 influenza ICU cases reported, vaccination status was available for 56 (93%). Adjusted VE against ICU admission for those aged ≥ 65 years was -10% [95% confidence interval (CI) -207 to 60], consistent with evidence of poor protection from the 2011/2012 TIV in 2011/2012. Adjusted VE for those aged <65 years in risk groups was -296% (95% CI -930 to -52), suggesting significant residual confounding using the screening method in those subject to selective vaccination.

Perceptions of Family Participation in Intensive Care Unit Rounds and Telemedicine: A Qualitative Assessment.

PubMed

Stelson, Elisabeth A; Carr, Brendan G; Golden, Kate E; Martin, Niels; Richmond, Therese S; Delgado, M Kit; Holena, Daniel N

2016-09-01

Family-centered rounds involve purposeful interactions between patients' families and care providers to refocus the delivery of care on patients' needs. To examine perspectives of patients' family members and health care providers on family participation in rounds in the surgical intensive care unit (ICU) and the potential use of telemedicine to facilitate this process. Patients' family members and surgical ICU care providers were recruited for semistructured interviews exploring stakeholders' perspectives on family participation in ICU rounds and the potential role of telemedicine. Thirty-two interviews were conducted, audio recorded, and transcribed verbatim. Common coding methods were facilitated by using NVivo 10. A mean coding agreement of 97.3% was calculated for 22% of transcripts. Both patients' family members and health care providers described inconsistent practices surrounding family participation in ICU rounds as well as barriers to and facilitators of family participation. Family members identified 3 primary logistical challenges to participation in ICU rounds: distance to hospitals, work/family obligations, and the rounding schedule. Both family members and providers reported receptivity to virtual participation as a potential solution to these challenges. Understanding the barriers to and facilitators of family participation in ICU rounds is key to encouraging adoption of family-centered rounds. For families that live far away or have competing demands, telemedical options may facilitate participation. ©2016 American Association of Critical-Care Nurses.

RESOURCE MANAGEMENT AMONG INTENSIVE CARE NURSES: AN ETHNOGRAPHIC STUDY.

PubMed

Heydari, Abbas; Najar, Ali Vafaee; Bakhshi, Mahmoud

2015-12-01

Nurses are the main users of supplies and equipment applied in the Intensive Care Units (ICUs) which are high-priced and costly. Therefore, understanding ICU nurses' experiences about resource management contributes to the better control of the costs. This study aimed to investigate the culture of nurses' working environment regarding the resource management in the ICUs in Iran. In this study, a focused ethnographic method was used. Twenty-eight informants among ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations as a participant observer was used for data gathering. Data analysis was performed using the methods described by Miles and Huberman (1994). Two main themes describing the culture of ICU nurses regarding resource management included (a) consumption monitoring and auditing, and (b) prudent use. The results revealed that the efforts for resource management are conducted in the conditions of scarcity and uncertainty in supply. ICU nurses had a sense of futurism in the supply and use of resources in the unit and do the planning through taking the rules and guidelines as well as the available resources and their values into account. Improper storage of some supplies and equipment was a reaction to this uncertain condition among nurses. To manage the resources effectively, improvement of supply chain management in hospital seems essential. It is also necessary to hold educational classes in order to enhance the nurses' awareness on effective supply chain and storage of the items in the unit stock.

Prevalence and Clinical Outcomes of Clostridium difficile Infection in the Intensive Care Unit: A Systematic Review and Meta-Analysis

PubMed Central

Karanika, Styliani; Paudel, Suresh; Zervou, Fainareti N.; Grigoras, Christos; Zacharioudakis, Ioannis M.; Mylonakis, Eleftherios

2016-01-01

Background. Intensive care unit (ICU) patients are at higher risk for Clostridium difficile infection (CDI). Methods. We performed a systematic review and meta-analysis of published studies from 1983 to 2015 using the PubMed, EMBASE, and Google Scholar databases to study the prevalence and outcomes of CDI in this patient population. Among the 9146 articles retrieved from the studies, 22 articles, which included a total of 80 835 ICU patients, were included in our final analysis. Results. The prevalence of CDI among ICU patients was 2% (95% confidence interval [CI], 1%–2%), and among diarrheic ICU patients the prevalence was 11% (95% CI, 6%–17%). Among CDI patients, 25% (95% CI, 5%–51%) were diagnosed with pseudomembranous colitis, and the estimated length of ICU stay before CDI acquisition was 10.74 days (95% CI, 5%–51%). The overall hospital mortality among ICU patients with CDI was 32% (95% CI, 26%–39%), compared with 24% (95% CI, 14%–36%) among those without CDI presenting a statistically significant difference in mortality risk (P = .030). It is worth noting that the length of ICU and hospital stay among CDI patients was significantly longer, compared with non-CDI patients (standardized mean of difference [SMD] = 0.49, 95% CI, .39%–.6%, P = .00 and SMD = 1.15, 95% CI, .44%–1.91%, P = .003, respectively). It is noteworthy that the morbidity score at ICU admission (Acute Physiology and Chronic Health Evaluation II [APACHE II]) was not statistically different between the 2 groups (P = .911), implying that the differences in outcomes can be attributed to CDI. Conclusions. The ICU setting is associated with higher prevalence of CDI. In this setting, CDI is associated with increased hospital mortality and prolonged ICU and overall hospital stay. These findings highlight the need for additional prevention and treatment studies in this setting. PMID:26788544

Propofol or benzodiazepines for short- and long-term sedation in intensive care units? An economic evaluation based on meta-analytic results

PubMed Central

Pradelli, Lorenzo; Povero, Massimiliano; Bürkle, Hartmut; Kampmeier, Tim-Gerald; Della-Rocca, Giorgio; Feuersenger, Astrid; Baron, Jean-Francois; Westphal, Martin

2017-01-01

Purpose This evaluation compares propofol and benzodiazepine sedation for mechanically ventilated patients in intensive care units (ICUs) in order to identify the potential economic benefits from different payers’ perspectives. Methods The patient-level simulation model incorporated efficacy estimates from a structured meta-analysis and ICU-related costs from Italy, Germany, France, UK, and the USA. Efficacy outcomes were ICU length of stay (LOS), mechanical ventilation duration, and weaning time. We calculated ICU costs from mechanical ventilation duration and ICU LOS based on national average ICU costs with and without mechanical ventilation. Three scenarios were investigated: 1) long-term sedation >24 hours based on results from randomized controlled trials (RCTs); 2) long-term sedation based on RCT plus non-RCT results; and 3) short-term sedation <24 hours based on RCT results. We tested the model’s robustness for input uncertainties by deterministic (DSA) and probabilistic sensitivity analyses (PSA). Results In the base case, mean savings with propofol versus benzodiazepines in long-term sedation ranged from €406 (95% confidence interval [CI]: 646 to 164) in Italy to 1,632 € (95% CI: 2,362 to 880) in the USA. Inclusion of non-RCT data corroborated these results. Savings in short-term sedation ranged from €148 (95% CI: 291 to 2) in Italy to €502 (95% CI: 936 to 57) in the USA. Parameters related to ICU and mechanical ventilation had a stronger influence in the DSA than drug-related parameters. In PSA, propofol reduced costs and ICU LOS compared to benzodiazepines in 94%–100% of simulations. The largest savings may be possible in the UK and the USA due to higher ICU costs. Conclusion Current ICU sedation guidelines recommend propofol rather than midazolam for mechanically ventilated patients. This evaluation endorses the recommendation as it may lead to better outcomes and savings for health care systems, especially in countries with higher ICU-related costs. PMID:29184423

An Application of Bayesian Approach in Modeling Risk of Death in an Intensive Care Unit.

PubMed

Wong, Rowena Syn Yin; Ismail, Noor Azina

2016-01-01

There are not many studies that attempt to model intensive care unit (ICU) risk of death in developing countries, especially in South East Asia. The aim of this study was to propose and describe application of a Bayesian approach in modeling in-ICU deaths in a Malaysian ICU. This was a prospective study in a mixed medical-surgery ICU in a multidisciplinary tertiary referral hospital in Malaysia. Data collection included variables that were defined in Acute Physiology and Chronic Health Evaluation IV (APACHE IV) model. Bayesian Markov Chain Monte Carlo (MCMC) simulation approach was applied in the development of four multivariate logistic regression predictive models for the ICU, where the main outcome measure was in-ICU mortality risk. The performance of the models were assessed through overall model fit, discrimination and calibration measures. Results from the Bayesian models were also compared against results obtained using frequentist maximum likelihood method. The study involved 1,286 consecutive ICU admissions between January 1, 2009 and June 30, 2010, of which 1,111 met the inclusion criteria. Patients who were admitted to the ICU were generally younger, predominantly male, with low co-morbidity load and mostly under mechanical ventilation. The overall in-ICU mortality rate was 18.5% and the overall mean Acute Physiology Score (APS) was 68.5. All four models exhibited good discrimination, with area under receiver operating characteristic curve (AUC) values approximately 0.8. Calibration was acceptable (Hosmer-Lemeshow p-values > 0.05) for all models, except for model M3. Model M1 was identified as the model with the best overall performance in this study. Four prediction models were proposed, where the best model was chosen based on its overall performance in this study. This study has also demonstrated the promising potential of the Bayesian MCMC approach as an alternative in the analysis and modeling of in-ICU mortality outcomes.

Tele-ICU "myth busters".

PubMed

Venditti, Angelo; Ronk, Chanda; Kopenhaver, Tracey; Fetterman, Susan

2012-01-01

Tele-intensive care unit (ICU) technology has been proven to bridge the gap between available resources and quality care for many health care systems across the country. Tele-ICUs allow the standardization of care and provide a second set of eyes traditionally not available in the ICU. A growing body of literature supports the use of tele-ICUs based on improved outcomes and reduction in errors. To date, the literature has not effectively outlined the limitations of this technology related to response to changes in patient care, interventions, and interaction with the care team. This information can potentially have a profound impact on service expectations. Some misconceptions about tele-ICU technology include the following: tele-ICU is "watching" 24 hours a day, 7 days a week; tele-ICU is a telemetry unit; tele-ICU is a stand-alone crisis intervention tool; tele-ICU decreases staffing at the bedside; tele-ICU clinical roles are clearly defined and understood; and tele-ICUs are not cost-effective to operate. This article outlines the purpose of tele-ICU technology, reviews outcomes, and "busts" myths about tele-ICU technology.

Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study

PubMed Central

Chant, Clarence; Wilson, Gail; Friedrich, Jan O

2006-01-01

Introduction Anemia among the critically ill has been described in patients with short to medium length of stay (LOS) in the intensive care unit (ICU), but it has not been described in long-stay ICU patients. This study was performed to characterize anemia, transfusion, and phlebotomy practices in patients with prolonged ICU LOS. Methods We conducted a retrospective chart review of consecutive patients admitted to a medical-surgical ICU in a tertiary care university hospital over three years; patients included had a continuous LOS in the ICU of 30 days or longer. Information on transfusion, phlebotomy, and outcomes were collected daily from days 22 to 112 of the ICU stay. Results A total of 155 patients were enrolled. The mean age, admission Acute Physiology and Chronic Health Evaluation II score, and median ICU LOS were 62.3 ± 16.3 years, 23 ± 8, and 49 days (interquartile range 36–70 days), respectively. Mean hemoglobin remained stable at 9.4 ± 1.4 g/dl from day 7 onward. Mean daily phlebotomy volume was 13.3 ± 7.3 ml, and 62% of patients received a mean of 3.4 ± 5.3 units of packed red blood cells at a mean hemoglobin trigger of 7.7 ± 0.9 g/dl after day 21. Transfused patients had significantly greater acuity of illness, phlebotomy volumes, ICU LOS and mortality, and had a lower hemoglobin than did those who were not transfused. Multivariate logistic regression analysis identified the following as independently associated with the likelihood of requiring transfusion in nonbleeding patients: baseline hemoglobin, daily phlebotomy volume, ICU LOS, and erythropoietin therapy (used almost exclusively in dialysis dependent renal failure in this cohort of patients). Small increases in average phlebotomy (3.5 ml/day, 95% confidence interval 2.4–6.8 ml/day) were associated with a doubling in the odds of being transfused after day 21. Conclusion Anemia, phlebotomy, and transfusions, despite low hemoglobin triggers, are common in ICU patients long after admission. Small decreases in phlebotomy volume are associated with significantly reduced transfusion requirements in patients with prolonged ICU LOS. PMID:17002795

An Innovative Approach to Improving the Accuracy of Delirium Assessments Using the Confusion Assessment Method for the Intensive Care Unit.

PubMed

DiLibero, Justin; O'Donoghue, Sharon C; DeSanto-Madeya, Susan; Felix, Janice; Ninobla, Annalyn; Woods, Allison

2016-01-01

Delirium occurs in up to 80% of intensive care unit (ICU) patients. Despite its prevalence in this population, there continues to be inaccuracies in delirium assessments. In the absence of accurate delirium assessments, delirium in critically ill ICU patients will remain unrecognized and will lead to negative clinical and organizational outcomes. The goal of this quality improvement project was to facilitate sustained improvement in the accuracy of delirium assessments among all ICU patients including those who were sedate or agitated. A pretest-posttest design was used to evaluate the effectiveness of a program to improve the accuracy of delirium screenings among patients admitted to a medical ICU or coronary care unit. Two hundred thirty-six delirium assessment audits were completed during the baseline period and 535 during the postintervention period. Compliance with performing at least 1 delirium assessment every shift was 85% at baseline and improved to 99% during the postintervention period. Baseline assessment accuracy was 70.31% among all patients and 53.49% among sedate and agitated patients. Postintervention assessment accuracy improved to 95.51% for all patients and 89.23% among sedate and agitated patients. The results from this project suggest the effectiveness of the program in improving assessment accuracy among difficult-to-assess patients. Further research is needed to demonstrate the effectiveness of this model across other critical care units, patient populations, and organizations.

Patients' and Health Care Providers' Perception of Stressors in the Intensive Care Units.

PubMed

Abuatiq, Alham

2015-01-01

The purposes of this study is first, to investigate intensive care patients' perceptions of stressors; second, to investigate the health care provider's perception of what constitutes a stressor from the patient's perspective; and third, to describe how health care providers manage their patients' stressors. This was a mixed-methods study; the quantitative section replicated Cornock's 1998 study of stress in the intensive care unit (ICU), with difference in sampling to include all health care providers in the ICU, in addition to nurses. The qualitative section added information to the current literature by describing how health care providers manage their patient's stressors. This article reports the quantitative findings of this study, as the qualitative section is presented in a separate article. It is important to describe ICU patients' stressful experiences to assess patient's stressors, provide holistic care to eliminate stressors, and provide feedback to health care providers. There is a need to describe the clinical practice related to stress perception and management of stressors in the critical care environment. A mixed-methods comparative descriptive design was used for the quantitative section, and a phenomenological approach guided the qualitative section. Lazarus and Folkman's theory formed the bases for integrating all variables investigated in this study. The sample included 70 ICU patients and 70 ICU health care providers. After consenting to participate in this study, subjects were given a demographic form and a paper-based tool, the Environmental Stressors graphic data form Questionnaire. Questionnaires were filled out by subjects anonymously in the ICU and returned to the researcher in the same setting. Descriptive statistics were analyzed using SPSS data analysis software. The top 3 most stressful items ranked by the patients included "being in pain," followed by "not being able to sleep" and "financial worries"; on the other hand, health care providers perceived "being in pain" followed by "not being able to communicate" and "not being in control of yourself" as the top 3 stressors perceived by their patients. The findings of this study are crucial and may inform nursing assessments and care of the ICU patient. In addition, this information may encourage the ICU staff to manipulate and redesign the ICU environment to be less stressful. Also, the findings of this study guided the development of an ICU stressor control policy.

Cost containment and mechanical ventilation in the United States.

PubMed

Cohen, I L; Booth, F V

1994-08-01

In many ICUs, admission and discharge hinge on the need for intubation and ventilatory support. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes > or = 50% of ICU patient days and ICU resources. Prolonged ventilatory support and chronic ventilator dependency, both in the ICU and non-ICU settings, have a significant and growing impact on healthcare economics. In the United States, the need for prolonged mechanical ventilation is increasingly recognized as separate and distinct from the initial diagnosis and/or procedure that leads to hospitalization. This distinction has led to improved reimbursement under the prospective diagnosis-related group (DRG) system, and demands more precise accounting from healthcare providers responsible for these patients. Using both published and theoretical examples, mechanical ventilation in the United States is discussed, with a focus on cost containment. Included in the discussion are ventilator teams, standards of care, management protocols, stepdown units, rehabilitation units, and home care. The expanding role of total quality management (TQM) is also presented.

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions

PubMed Central

Benkeser, David; Coe, Norma B.; Engelberg, Ruth A.; Teno, Joan M.; Curtis, J. Randall

2016-01-01

Abstract Background: Terminal intensive care unit (ICU) stays represent an important target to increase value of care. Objective: To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value. Design: Secondary analysis of an intervention study to improve quality of care for critically ill patients. Setting/Patients: 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. Methods: Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models. Main Results: Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics. Conclusions: Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models. PMID:27813724

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Gluconate Bathing in Community Hospital Intensive Care Units.

PubMed

Dicks, Kristen V; Lofgren, Eric; Lewis, Sarah S; Moehring, Rebekah W; Sexton, Daniel J; Anderson, Deverick J

2016-07-01

OBJECTIVE To determine whether daily chlorhexidine gluconate (CHG) bathing of intensive care unit (ICU) patients leads to a decrease in hospital-acquired infections (HAIs), particularly infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). DESIGN Interrupted time series analysis. SETTING The study included 33 community hospitals participating in the Duke Infection Control Outreach Network from January 2008 through December 2013. PARTICIPANTS All ICU patients at study hospitals during the study period. METHODS Of the 33 hospitals, 17 hospitals implemented CHG bathing during the study period, and 16 hospitals that did not perform CHG bathing served as controls. Primary pre-specified outcomes included ICU central-line-associated bloodstream infections (CLABSIs), primary bloodstream infections (BSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTIs). MRSA and VRE HAIs were also evaluated. RESULTS Chlorhexidine gluconate (CHG) bathing was associated with a significant downward trend in incidence rates of ICU CLABSI (incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.93-0.99), ICU primary BSI (IRR, 0.96; 95% CI, 0.94-0.99), VRE CLABSIs (IRR, 0.97; 95% CI, 0.97-0.98), and all combined VRE infections (IRR, 0.96; 95% CI, 0.93-1.00). No significant trend in MRSA infection incidence rates was identified prior to or following the implementation of CHG bathing. CONCLUSIONS In this multicenter, real-world analysis of the impact of CHG bathing, hospitals that implemented CHG bathing attained a decrease in ICU CLABSIs, ICU primary BSIs, and VRE CLABSIs. CHG bathing did not affect rates of specific or overall infections due to MRSA. Our findings support daily CHG bathing of ICU patients. Infect Control Hosp Epidemiol 2016;37:791-797.

Intensivist-reported Facilitators and Barriers to Discussing Post-Discharge Outcomes with Intensive Care Unit Surrogates. A Qualitative Study.

PubMed

Turnbull, Alison E; Davis, Wesley E; Needham, Dale M; White, Douglas B; Eakin, Michelle N

2016-09-01

Intensive care unit (ICU) patients' expected post-discharge outcomes are rarely discussed in family meetings despite this information being centrally important to patients and their families. To characterize intensivist-identified barriers and facilitators to discussing post-discharge outcomes with surrogates of ICU patients. Qualitative study conducted via one-on-one, semistructured telephone interviews with 23 intensivists from 20 hospitals with accreditation council for graduate medical education-accredited critical care medicine programs in 16 states. A limited application of grounded theory methods was used to code transcribed interviews and identify themes and illustrative quotes. Intensivists reported tension between their professional responsibility to discuss likely functional outcomes versus uncertainty about their ability to predict those outcomes for an individual patient. They cited three main barriers as limiting their ability to conduct conversations about post-discharge outcomes with ICU surrogates: (1) incorrectly optimistic expectations for recovery among ICU surrogates, (2) having little or no contact with their patients after ICU discharge, and (3) minimal confidence applying existing outcomes research to individual patients. Despite these barriers, experience talking to ICU surrogates, seeing ICU survivors in the outpatient setting, and trusted research on functional outcomes were identified as important facilitators to discussing likely patient outcomes with surrogates. Intensivists generally welcomed questions from surrogates about post-discharge outcomes as opportunities to initiate conversations about prognosis and patient values. In this sample of intensivists from 20 academic hospitals, experience conducting conversations with surrogates and interactions with ICU survivors as outpatients were identified as facilitating discussion of expected post-discharge outcomes while optimistic surrogate expectations and prognostic uncertainty were barriers. There was tension between self-perceived ability to prognosticate and belief in a professional obligation to discuss patient outcomes.

Priorities for Evaluating Palliative Care Outcomes in Intensive Care Units.

PubMed

Bakitas, Marie; Dionne-Odom, J Nicholas; Kamal, Arif; Maguire, Jennifer M

2015-09-01

Defining the quality of intensive care unit (ICU) care when patients are dying is challenging. Palliative care has been recommended to improve outcomes of dying ICU patients; however, traditional ICU quality indicators do not always align with palliative care. Evidence suggests that some aspects of ICU care improve when palliative care is integrated; however, consensus is lacking concerning the outcomes that should be measured. Overcoming challenges to measuring palliative care will require consensus development and rigorous research on the best way to evaluate ICU palliative care services. Copyright © 2015 Elsevier Inc. All rights reserved.

Intensive Care Nurses' Belief Systems Regarding the Health Economics: A Focused Ethnography.

PubMed

Heydari, Abbas; Vafaee-Najar, Ali; Bakhshi, Mahmoud

2016-09-01

Health care beliefs can have an effect on the efficiency and effectiveness of nursing practices. Nevertheless, how belief systems impact on the economic performance of intensive care unit (ICU) nurses is not known. This study aimed to explore the ICU nurses' beliefs and their effect on nurse's practices and behavior patterns regarding the health economics. In this study, a focused ethnography method was used. Twenty-four informants from ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations were used for data collection. Data analysis was performed using the methods described by Miles and Huberman (1994). Eight beliefs were found that gave meaning to ICU nurse's practices regarding the health economics. 1. The registration of medications and supplies disrupt the nursing care; 2.Monitoring and auditing improve consumption; 3.There is a fear of possible shortage in the future; 4.Supply and replacement of equipment is difficult; 5.Higher prices lead to more accurate consumption; 6.The quality of care precedes the costs; 7. Clinical Guidelines are abundant but useful; and 8.Patient economy has priority over hospital economy. Maintaining the quality of patient care with least attention to hospital costs was the main focus of the beliefs formed up in the ICU regarding the health economics. ICU nurses' belief systems have significantly shaped in relation to providing a high-quality care. Although high quality of care can lead to a rise in the effectiveness of nursing care, cost control perspective should also be considered in planning for improve the quality of care. Therefore, it is necessary to involve the ICU nurses in decision-making about unit cost management. They must become familiar with the principles of heath care economics and productivity by applying an effective cost management program. It may be optimal to implement the reforms in various aspects, such as the hospital's strategic plan and supply chain management system.

Does a single specialty intensive care unit make better business sense than a multi-specialty intensive care unit? A costing study in a trauma center in India

PubMed Central

Kumar, Parmeshwar; Jithesh, Vishwanathan; Gupta, Shakti Kumar

2015-01-01

Context: Though intensive care units (ICUs) only account for 10% of hospital beds, they consume nearly 22% of hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. Aim: To evaluate and compare the cost of intensive care delivery between multi-specialty and neurosurgery ICU in an apex trauma care facility in India. Materials and Methods: The study was conducted in a polytrauma and neurosurgery ICU at a 203 bedded level IV trauma care facility in New Delhi, India from May, 2012 to June 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Statistical Analysis: Fisher's two-tailed t-test. Results: Total cost/bed/day for the multi-specialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU was Rs. 14,306.7/-, manpower constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Conclusions: Quantification of expenditure in running an ICU in a trauma center would assist healthcare decision makers in better allocation of resources. Although multi-specialty ICUs are more expensive, other factors will also play a role in defining the kind of ICU that need to be designed. PMID:25829909

Who should be admitted to the intensive care unit? The outcome of intensive care unit admission in stage IIIB-IV lung cancer patients.

PubMed

Kim, Yu Jung; Kim, Mi-Jung; Cho, Young-Jae; Park, Jong Sun; Kim, Jin Won; Chang, Hyun; Lee, Jeong-Ok; Lee, Keun-Wook; Kim, Jee Hyun; Yoon, Ho Il; Bang, Soo-Mee; Lee, Jae Ho; Lee, Choon-Taek; Lee, Jong Seok

2014-03-01

Critical care for advanced lung cancer patients is still controversial, and the appropriate method for the selection of patients who may benefit from intensive care unit (ICU) care is not clearly defined. We retrospectively reviewed the medical records of stage IIIB-IV lung cancer patients admitted to the medical ICU of a university hospital in Korea between 2003 and 2011. Of 95 patients, 64 (67%) had Eastern Cooperative Oncology Group (ECOG) performance status (PS)≥2, and 79 (84%) had non-small-cell lung cancer. In total, 28 patients (30%) were newly diagnosed or were receiving first-line treatment, and 22 (23%) were refractory or bedridden. Mechanical ventilation was required in 85 patients (90%), and ICU mortality and hospital mortality were 57 and 78%, respectively. According to a multivariate analysis, a PaO2/FiO2 ratio<150 [odds ratio (OR)=5.51, 95% confidence interval (CI) 2.10-14.48, p=0.001] was independently associated with ICU mortality, and an ECOG PS≥2 (OR=9.53, 95% CI 2.03-44.85, p=0.004) and a need for vasoactive agents (OR=6.94, 95% CI 1.61-29.84, p=0.009) were independently associated with hospital mortality. Refractory or bedridden patients (n=22) showed significantly poorer overall survival (11.0 vs. 29.0 days, p=0.005). Among 21 patients who were discharged from the hospital, 11 (52%) received further chemotherapy. Certain advanced lung cancer patients may benefit from ICU management. However, refractory patients and patients with a poor PS do not seem to benefit from ICU care. Oncologists should try to discuss palliative care and end-of-life issues in advance to avoid futile care.

MEASURING WORKLOAD OF ICU NURSES WITH A QUESTIONNAIRE SURVEY: THE NASA TASK LOAD INDEX (TLX).

PubMed

Hoonakker, Peter; Carayon, Pascale; Gurses, Ayse; Brown, Roger; McGuire, Kerry; Khunlertkit, Adjhaporn; Walker, James M

2011-01-01

High workload of nurses in Intensive Care Units (ICUs) has been identified as a major patient safety and worker stress problem. However, relative little attention has been dedicated to the measurement of workload in healthcare. The objectives of this study are to describe and examine several methods to measure workload of ICU nurses. We then focus on the measurement of ICU nurses' workload using a subjective rating instrument: the NASA TLX.We conducted secondary data analysis on data from two, multi-side, cross-sectional questionnaire studies to examine several instruments to measure ICU nurses' workload. The combined database contains the data from 757 ICU nurses in 8 hospitals and 21 ICUs.Results show that the different methods to measure workload of ICU nurses, such as patient-based and operator-based workload, are only moderately correlated, or not correlated at all. Results show further that among the operator-based instruments, the NASA TLX is the most reliable and valid questionnaire to measure workload and that NASA TLX can be used in a healthcare setting. Managers of hospitals and ICUs can benefit from the results of this research as it provides benchmark data on workload experienced by nurses in a variety of ICUs.

MEASURING WORKLOAD OF ICU NURSES WITH A QUESTIONNAIRE SURVEY: THE NASA TASK LOAD INDEX (TLX)

PubMed Central

Hoonakker, Peter; Carayon, Pascale; Gurses, Ayse; Brown, Roger; McGuire, Kerry; Khunlertkit, Adjhaporn; Walker, James M.

2012-01-01

High workload of nurses in Intensive Care Units (ICUs) has been identified as a major patient safety and worker stress problem. However, relative little attention has been dedicated to the measurement of workload in healthcare. The objectives of this study are to describe and examine several methods to measure workload of ICU nurses. We then focus on the measurement of ICU nurses’ workload using a subjective rating instrument: the NASA TLX. We conducted secondary data analysis on data from two, multi-side, cross-sectional questionnaire studies to examine several instruments to measure ICU nurses’ workload. The combined database contains the data from 757 ICU nurses in 8 hospitals and 21 ICUs. Results show that the different methods to measure workload of ICU nurses, such as patient-based and operator-based workload, are only moderately correlated, or not correlated at all. Results show further that among the operator-based instruments, the NASA TLX is the most reliable and valid questionnaire to measure workload and that NASA TLX can be used in a healthcare setting. Managers of hospitals and ICUs can benefit from the results of this research as it provides benchmark data on workload experienced by nurses in a variety of ICUs. PMID:22773941

Assessment of delirium using the PRE-DELIRIC model in an intensive care unit in Argentina

PubMed Central

Sosa, Fernando Ariel; Roberti, Javier; Franco, Margarita Tovar; Kleinert, María Mercedes; Patrón, Agustina Risso; Osatnik, Javier

2018-01-01

Objective To describe the incidence of and risk factors for delirium in the intensive care unit of a tertiary care teaching hospital in Argentina and to conduct the first non-European study exploring the performance of the PREdiction of DELIRium in ICu patients (PRE-DELIRIC) model. Methods Prospective observational study in a 20-bed intensive care unit of a tertiary care teaching hospital in Buenos Aires, Argentina. The PRE-DELIRIC model was applied to 178 consecutive patients within 24 hours of admission to the intensive care unit; delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Results The mean age was 64.3 ± 17.9 years. The median time of stay in the intensive care unit was 6 (range, 2 - 56) days. Of the total number of patients, 49/178 (27.5%) developed delirium, defined as a positive CAM-ICU assessment, during their stay in the intensive care unit. Patients in the delirium group were significantly older and had a significantly higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score. The mortality rate in the intensive care unit was 14.6%; no significant difference was observed between the two groups. Predictive factors for the development of delirium were increased age, prolonged intensive care unit stay, and opioid use. The area under the curve for the PRE-DELIRIC model was 0.83 (95%CI; 0.77 - 0.90). Conclusions The observed incidence of delirium highlights the importance of this problem in the intensive care unit setting. In this first study conducted outside Europe, PRE-DELIRIC accurately predicted the development of delirium. PMID:29742219

Physical Therapist Practice in the Intensive Care Unit: Results of a National Survey

PubMed Central

Ridgeway, Kyle; Nordon-Craft, Amy; Moss, Parker; Schenkman, Margaret; Moss, Marc

2015-01-01

Background Early rehabilitation improves outcomes, and increased use of physical therapist services in the intensive care unit (ICU) has been recommended. Little is known about the implementation of early rehabilitation programs or physical therapists' preparation and perceptions of care in the United States. Objective A national survey was conducted to determine the current status of physical therapist practice in the ICU. Design This study used a cross-sectional, observational design. Methods Self-report surveys were mailed to members of the Acute Care Section of the American Physical Therapy Association. Questions addressed staffing, training, barriers, and protocols, and case scenarios were used to determine perceptions about providing rehabilitation. Results The response rate was 29% (667/2,320). Staffing, defined as the number of physical therapists per 100 ICU beds, was highest in community hospitals (academic: median=5.4 [range=3.6–9.2]; community: median=6.7 [range=4.4–10.0]) and in the western United States (median=7.5 [range=4.2–12.9]). Twelve percent of physical therapists reported no training. Barriers to providing ICU rehabilitation included insufficient staffing and training, departmental prioritization policies, and inadequate consultation criteria. Responses to case scenarios demonstrated differences in the likelihood of consultation and physical therapists' prescribed frequency and intensity of care based on medical interventions rather than characteristics of patients. Physical therapists in academic hospitals were more likely to be involved in the care of patients in each scenario and were more likely to perform higher-intensity mobilization. Limitations Members of the Acute Care Section of the American Physical Therapy Association may not represent most practicing physical therapists, and the 29% return rate may have contributed to response bias. Conclusions Although staffing was higher in community hospitals, therapists in academic and community hospitals cited insufficient staffing as the most common barrier to providing rehabilitation in the ICU. Implementing strategies to overcome barriers identified in this study may improve the delivery of ICU rehabilitation services. PMID:26045604

Music Listening Among Postoperative Patients in the Intensive Care Unit: A Randomized Controlled Trial with Mixed-Methods Analysis

PubMed Central

Ames, Nancy; Shuford, Rebecca; Yang, Li; Moriyama, Brad; Frey, Meredith; Wilson, Florencia; Sundaramurthi, Thiruppavai; Gori, Danelle; Mannes, Andrew; Ranucci, Alexandra; Koziol, Deloris; Wallen, Gwenyth R

2017-01-01

Background: Music listening may reduce the physiological, emotional, and mental effects of distress and anxiety. It is unclear whether music listening may reduce the amount of opioids used for pain management in critical care, postoperative patients or whether music may improve patient experience in the intensive care unit (ICU). Methods: A total of 41 surgical patients were randomized to either music listening or controlled non-music listening groups on ICU admission. Approximately 50-minute music listening interventions were offered 4 times per day (every 4-6 hours) during the 48 hours of patients’ ICU stays. Pain, distress, and anxiety scores were measured immediately before and after music listening or controlled resting periods. Total opioid intake was recorded every 24 hours and during each intervention. Results: There was no significant difference in pain, opioid intake, distress, or anxiety scores between the control and music listening groups during the first 4 time points of the study. However, a mixed modeling analysis examining the pre- and post-intervention scores at the first time point revealed a significant interaction in the Numeric Rating Scale (NRS) for pain between the music and the control groups (P = .037). The Numeric Rating Score decreased in the music group but remained stable in the control group. Following discharge from the ICU, the music group’s interviews were analyzed for themes. Conclusions: Despite the limited sample size, this study identified music listening as an appropriate intervention that improved patients’ post-intervention experience, according to patients’ self-report. Future mixed methods studies are needed to examine both qualitative patient perspectives and methodology to improve music listening in critical care units. PMID:28904523

Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts.

PubMed

Altawalbeh, Shoroq M; Saul, Melissa I; Seybert, Amy L; Thorpe, Joshua M; Kane-Gill, Sandra L

2018-04-01

To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time. Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges. Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges. Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures. Copyright © 2017 Elsevier Inc. All rights reserved.

Myocardial infarction in intensive care units: A systematic review of diagnosis and treatment

PubMed Central

Mount, Thomas; Atkinson, Dougal

2016-01-01

Introduction Patients in the intensive care unit are vulnerable to myocardial injury from a variety of causes, both ischaemic and non-ischaemic. It is challenging for ICU clinicians to apply the conventional guidance concerning diagnosis and treatment. We conducted this review to examine the evidence concerning diagnosis and treatment of myocardial infarction in the ICU. Methods A systematic review was performed to identify relevant studies. Results 19 studies concerning use of ECG, cardiac enzymes, echocardiography and angiography were identified. 4 studies considered treatment of myocardial infarction. Conclusions Regular 12 lead ECG or 12 lead ECG monitoring is more sensitive than 2 lead monitoring, regular measurement of cardiac enzymes is more sensitive than when provoked by symptoms. Coronary angiography rarely identifies treatable lesions, without regional wall motion abnormality on echocardiography. Evidence relating to treatment was limited. A potential strategy to diagnose myocardial infarctions in the ICU is proposed. PMID:28979516

Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States.

PubMed

Cooke, Colin R

2016-01-01

The extent to which geographic variability in ICU admission across the United States is driven by patients with lower risk of death is unknown. To determine whether patients at low to moderate risk of death contribute to geographic variation in ICU admission. Retrospective cohort of hospitalizations among Medicare beneficiaries (age > 64 years) admitted for ten common medical and surgical diagnoses (2004 to 2009). We examined population-adjusted rates of ICU admission per 100 hospitalizations in 304 health referral regions (HRR), and estimated the relative risk of ICU admission across strata of regional ICU and risk of death, adjusted for patient and regional characteristics. ICU admission rates varied nearly two-fold across HRR quartiles (quartile 1 to 4: 13.6, 17.3, 20.0, and 25.2 per 100 hospitalizations, respectively). Observed mortality for patients in regions (quartile 4) with the greatest ICU use was 17% compared to 21% in regions with lowest ICU use (quartile 1) (p<0.001). After adjusting for patient and regional characteristics, including regional differences in ICU, skilled nursing, and long-term acute care bed capacity, individuals' risk of death modified the relationship between regional ICU use and an individual's risk of ICU admission (p for interaction<0.001). Region was least important in predicting ICU admission among patients with high (quartile 4) risk of death (RR 1.27, 95% CI 1.22-1.31, for high versus low ICU use regions), and most important for patients with moderate (quartile 2; RR 1.63, 95% CI 1.53-1.72, quartile 3; RR 1.56 95% CI 1.47-1.65) and low (quartile 1) risk of death (RR 1.50, 95% CI 1.41-1.59). There is wide variation in in ICU use by geography, independent of ICU beds and physician supply, for patients with low and moderate risks of death.

Delirium prediction in the intensive care unit: comparison of two delirium prediction models.

PubMed

Wassenaar, Annelies; Schoonhoven, Lisette; Devlin, John W; van Haren, Frank M P; Slooter, Arjen J C; Jorens, Philippe G; van der Jagt, Mathieu; Simons, Koen S; Egerod, Ingrid; Burry, Lisa D; Beishuizen, Albertus; Matos, Joaquim; Donders, A Rogier T; Pickkers, Peter; van den Boogaard, Mark

2018-05-05

Accurate prediction of delirium in the intensive care unit (ICU) may facilitate efficient use of early preventive strategies and stratification of ICU patients by delirium risk in clinical research, but the optimal delirium prediction model to use is unclear. We compared the predictive performance and user convenience of the prediction  model for delirium (PRE-DELIRIC) and early prediction model for delirium (E-PRE-DELIRIC) in ICU patients and determined the value of a two-stage calculation. This 7-country, 11-hospital, prospective cohort study evaluated consecutive adults admitted to the ICU who could be reliably assessed for delirium using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. The predictive performance of the models was measured using the area under the receiver operating characteristic curve. Calibration was assessed graphically. A physician questionnaire evaluated user convenience. For the two-stage calculation we used E-PRE-DELIRIC immediately after ICU admission and updated the prediction using PRE-DELIRIC after 24 h. In total 2178 patients were included. The area under the receiver operating characteristic curve was significantly greater for PRE-DELIRIC (0.74 (95% confidence interval 0.71-0.76)) compared to E-PRE-DELIRIC (0.68 (95% confidence interval 0.66-0.71)) (z score of - 2.73 (p < 0.01)). Both models were well-calibrated. The sensitivity improved when using the two-stage calculation in low-risk patients. Compared to PRE-DELIRIC, ICU physicians (n = 68) rated the E-PRE-DELIRIC model more feasible. While both ICU delirium prediction models have moderate-to-good performance, the PRE-DELIRIC model predicts delirium better. However, ICU physicians rated the user convenience of E-PRE-DELIRIC superior to PRE-DELIRIC. In low-risk patients the delirium prediction further improves after an update with the PRE-DELIRIC model after 24 h. ClinicalTrials.gov, NCT02518646 . Registered on 21 July 2015.

Early rehabilitation for severe acquired brain injury in intensive care unit: multicenter observational study.

PubMed

Bartolo, Michelangelo; Bargellesi, Stefano; Castioni, Carlo A; Bonaiuti, Donatella; Antenucci, Roberto; Benedetti, Angelo; Capuzzo, Valeria; Gamna, Federica; Radeschi, Giulio; Citerio, Giuseppe; Colombo, Carolina; Del Casale, Laura; Recubini, Elena; Toska, Saimir; Zanello, Marco; D'Aurizio, Carlo; Spina, Tullio; Del Gaudio, Alredo; Di Rienzo, Filomena; Intiso, Domenico; Dallocchio, Giulia; Felisatti, Giovanna; Lavezzi, Susanna; Zoppellari, Roberto; Gariboldi, Valentina; Lorini, Luca; Melizza, Giovanni; Molinero, Guido; Mandalà, Giorgio; Pignataro, Amedeo; Montis, Andrea; Napoleone, Alessandro; Pilia, Felicita; Pisu, Marina; Semerjian, Monica; Pagliaro, Giuseppina; Nardin, Lorella; Scarponi, Federico; Zampolini, Mauro; Zava, Raffaele; Massetti, Maria A; Piccolini, Carlo; Aloj, Fulvio; Antonelli, Sergio; Zucchella, Chiara

2016-02-01

The increased survival after a severe acquired brain injury (sABI) raise the problem of making most effective the treatments in Intensive Care Unit (ICU)/Neurointensive Care Unit (NICU), also integrating rehabilitation care. Despite previous studies reported that early mobilization in ICU was effective in preventing complications and reducing hospital stay, few studies addressed the rehabilitative management of sABI patients in ICU/NICU. To collect clinical and functional data about the early rehabilitative management of sABI patients during ICU/NICU stay. Prospective, observational, multicenter study. Fourteen facilities supplied by intensive neurorehabilitation units and ICU/NICUs. Consecutive sABI patients admitted to ICU/NICU. Patients were evaluated at admission and then every 3-5 days. Clinical, functional and rehabilitative data, including Glasgow Coma Scale (GCS), Disability Rating Scale (DRS), The Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), Early Rehabilitation Barthel Index (ERBI), Glasgow Outcome scale (GOS) and Functional Independence Measure (FIM) were collected. One hundred and two patients (F/M 44/58) were enrolled. The mean duration of ICU stay was 24.7±13.9 days and the first rehabilitative evaluation occurred after 8.7±8.8 days. Regular postural changes and multijoint mobilization were prescribed in 63.7% and 64.7% cases, respectively. The mean session duration was 38±11.5 minutes. Swallowing evaluation was performed in 14.7% patients, psychological support was provided to 12.7% of patients' caregivers, while 17.6% received a psycho-educational intervention, and 28.4% were involved in interdisciplinary team meetings. The main discharge destinations were Severe Acquired Brain Injury rehabilitation units for 43.7%, intensive neurorehabilitation units for 20.7%. Data showed that early rehabilitation was not diffusely performed in sABI subjects in ICU/NICU and rehabilitative interventions were variable; one-third of subjects were not referred to dedicated rehabilitation unit at discharge. The study stresses the need to spread and implement a rehabilitative culture also for critical ill patients due to neurological diseases.

Robotic Telepresence in a Medical Intensive Care Unit—Clinicians' Perceptions

PubMed Central

Becevic, Mirna; Clarke, Martina A.; Alnijoumi, Mohammed M.; Sohal, Harjyot S.; Boren, Suzanne A.; Kim, Min S.; Mutrux, Rachel

2015-01-01

Background Robotic telepresence has been used for outsourcing of healthcare services for more than a decade; however, its use within an academic medical department is not yet widespread. Intensive care unit (ICU) robots can be used to increase access to off-site supervising physicians and other specialists, reducing possible wait time for difficult admissions and procedures. Objective To study the use of ICU robots through a pilot program in an academic hospital and examine provider attitudes toward the usability and effectiveness of an ICU robot. Materials and Methods The study was done as a postinterventional cross-sectional seven-question survey in a medical ICU in an urban academic hospital. Participants were attending physicians, fellows, residents, nurses, and respiratory therapists. Results Users of the ICU robot reported satisfaction with communication, and improved patient care. They also reported perceived improved quality of care with the use of the robot. Conclusions Findings show the importance of a whole-team approach to the installation and implementation of an ICU robot. The ICU robot is an effective tool when it is used to visualize and communicate with patients, bedside staff, and families. However, a number of providers are still not trained or have not been shown how to use the ICU robot, which affects the overall utilization rate. PMID:26396554

Neurocritical care education during neurology residency

PubMed Central

Drogan, O.; Manno, E.; Geocadin, R.G.; Ziai, W.

2012-01-01

Objective: Limited information is available regarding the current state of neurocritical care education for neurology residents. The goal of our survey was to assess the need and current state of neurocritical care training for neurology residents. Methods: A survey instrument was developed and, with the support of the American Academy of Neurology, distributed to residency program directors of 132 accredited neurology programs in the United States in 2011. Results: A response rate of 74% (98 of 132) was achieved. A dedicated neuroscience intensive care unit (neuro-ICU) existed in 64%. Fifty-six percent of residency programs offer a dedicated rotation in the neuro-ICU, lasting 4 weeks on average. Where available, the neuro-ICU rotation was required in the vast majority (91%) of programs. Neurology residents' exposure to the fundamental principles of neurocritical care was obtained through a variety of mechanisms. Of program directors, 37% indicated that residents would be interested in performing away rotations in a neuro-ICU. From 2005 to 2010, the number of programs sending at least one resident into a neuro-ICU fellowship increased from 14% to 35%. Conclusions: Despite the expansion of neurocritical care, large proportions of US neurology residents have limited exposure to a neuro-ICU and neurointensivists. Formal training in the principles of neurocritical care may be highly variable. The results of this survey suggest a charge to address the variability of resident education and to develop standardized curricula in neurocritical care for neurology residents. PMID:22573636

Sleep in the intensive care unit

PubMed Central

Beltrami, Flávia Gabe; Nguyen, Xuân-Lan; Pichereau, Claire; Maury, Eric; Fleury, Bernard; Fagondes, Simone

2015-01-01

ABSTRACT Poor sleep quality is a consistently reported by patients in the ICU. In such a potentially hostile environment, sleep is extremely fragmented and sleep architecture is unconventional, with a predominance of superficial sleep stages and a limited amount of time spent in the restorative stages. Among the causes of sleep disruption in the ICU are factors intrinsic to the patients and the acute nature of their condition, as well as factors related to the ICU environment and the treatments administered, such as mechanical ventilation and drug therapy. Although the consequences of poor sleep quality for the recovery of ICU patients remain unknown, it seems to influence the immune, metabolic, cardiovascular, respiratory, and neurological systems. There is evidence that multifaceted interventions focused on minimizing nocturnal sleep disruptions improve sleep quality in ICU patients. In this article, we review the literature regarding normal sleep and sleep in the ICU. We also analyze sleep assessment methods; the causes of poor sleep quality and its potential implications for the recovery process of critically ill patients; and strategies for sleep promotion. PMID:26785964

Is the intensive care unit traumatic? What we know and don't know about the intensive care unit and posttraumatic stress responses.

PubMed

McGiffin, Jed N; Galatzer-Levy, Isaac R; Bonanno, George A

2016-05-01

The intensive care unit (ICU) has been portrayed as psychologically stressful, with a growing body of research substantiating elevated rates of depression, posttraumatic stress disorder (PTSD), and other psychological disruptions in populations of critical care survivors. To explain these psychopathology elevations, some have proposed a direct effect of ICU admission upon the later development of psychopathology, whereas others highlight the complex interaction between the trauma of a life-threatening illness or injury and the stressful life-saving interventions often administered in the ICU. However, the conclusion that the ICU is an independent causal factor in trauma-related psychological outcomes may be premature. Current ICU research suffers from important methodological problems including lack of true prospective data, failure to employ appropriate comparison groups, sampling bias, measurement issues, and problems with statistical methodology. In addition, the ICU literature has yet to investigate important risk and resilience factors that have been empirically validated in the broader stress-response literature. The authors propose the application of these important constructs to the unique setting of the ICU. This review focuses on multiple aspects of the important but complex research question of whether the ICU confers risk for psychological distress above and beyond the traumatic impact of the serious health events that necessitate ICU treatment. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Perception of intensive care unit stressors in Malaysian Federal Territory hospitals.

PubMed

Soh, Kim Lam; Soh, Kim Geok; Ahmad, Zaiton; Abdul Raman, Rosna; Japar, Salimah

2008-12-01

The Intensive Care Unit (ICU) is a therapeutic place for monitoring critically ill patients. However, it is a stressful area for the patients and it is causing them great anxiety. Previous studies have identified three groups of stressors in ICU namely; physical, psychological and environmental. The aims of this study were to determine the ICU stressors as experienced by patients and to determine the level of stressors felt by patients in ICU. A cross sectional study was done on 70 patients from two tertiary hospitals in Malaysia. A face-to-face interview with structured questionnaire was used for patients. Data collection occurred from 15 December 2006 to 31 January 2007. The five major ICU stressors perceived by patients were pain, being stuck with needles, boredom, missing their spouses and being too hot/cold. The ICU physical stressors were the major items ranked by post ICU patients. The findings from this study provided a set of baseline information to the health care providers, particularly ICU nurses in Malaysia, with which to provide better care for the patients in ICU.

Adoption of intensive care unit telemedicine in the United States

PubMed Central

Kahn, Jeremy M.; Cicero, Brandon D.; Wallace, David J.; Iwashyna, Theodore J.

2013-01-01

Objective Intensive care unit (ICU) telemedicine is a novel approach for providing critical care services from a distance. We sought to study the extent of use and patterns of adoption of this technology in United States ICUs. Design Retrospective study combining a systematic listing of ICU telemedicine installations with hospital characteristic data from the Centers for Medicare and Medicaid Services. We examined adoption over time and compared hospital characteristics between facilities that have adopted ICU telemedicine and those that have not. Setting United States hospitals from 2003 to 2010. Measurements and main results The number of hospitals using ICU telemedicine increased from 16 (0.4% of total) to 213 (4.6% of total) between 2003 and 2010. The number of ICU beds covered by telemedicine increased from 598 (0.9% of total) to 5,799 (7.9% of total). The average annual rate of ICU bed coverage growth was 101% per year in the first four study years but slowed to 8.1% per year over the last four study years (p<0.001 for difference in linear trend). Compared to non-adopting hospitals, hospitals adopting ICU telemedicine were more likely to be large (percentage with >400 beds: 11.1% vs. 3.7%, p<0.001), teaching (percentage with resident coverage: 31.4% vs. 21.9%, p=0.003) and urban (percentage located in metropolitan statistical areas with over one million residents: 45.3% vs. 30.1%, p<0.001). Conclusions ICU telemedicine adoption was initially rapid but recently slowed. Efforts are needed to uncover the barriers to future growth, particularly regarding the optimal strategy for using this technology most effectively and efficiently. PMID:24145839

Strategies to address management challenges in larger intensive care units.

PubMed

Matlakala, M C; Bezuidenhout, M C; Botha, A D H

2015-10-01

To illustrate the need for and suggest strategies that will enhance sustainable management of a large intensive care unit (ICU). The challenges faced by intensive care nursing in South Africa are well documented. However, there appear to be no strategies available to assist nurses to manage large ICUs or for ICU managers to deal with problems as they arise. Data sources to illustrate the need for strategies were challenges described by ICU managers in the management of large ICUs. A purposive sample of managers was included in individual interviews during compilation of evidence regarding the challenges experienced in the management of large ICUs. The challenges were presented at the Critical Care Society of Southern Africa Congress held on 28 August to 2 September 2012 in Sun City North-West province, South Africa. Five strategies are suggested for the challenges identified: divide the units into sections; develop a highly skilled and effective nursing workforce to ensure delivery of quality nursing care; create a culture to retain an effective ICU nursing team; manage assets; and determine the needs of ICU nurses. ICUs need measures to drive the desired strategies into actions to continuously improve the management of the unit. Future research should be aimed at investigating the effectiveness of the strategies identified. This research highlights issues relating to large ICUs and the strategies will assist ICU managers to deal with problems related to large unit sizes, shortage of trained ICU nurses, use of agency nurses, shortage of equipment and supplies and stressors in the ICU. The article will make a contribution to the body of nursing literature on management of ICUs. © 2014 John Wiley & Sons Ltd.

Microbial Colonization in a New Intensive Care Burn Unit. A Prospective Cohort Study

DTIC Science & Technology

1985-02-01

after transfer to the convalescent ward were added to the Total 0 1 ICU patients and presented as a total. Analysis of fre- Enterobacter aerogenes ...ProvIdencia stuartil 0 4 ICU 4 4 Enterobacter agglomerons 3 0 Total 7 9• "•"".’-,••Pseudomonas putida 0 3 t’•••P*ICU indicates Intensive care unit...Staphylococcus aureus Klebsiela pneumonias 1 2 ICU 14 19 Total 18 20 Enterobacter cloacae 0 2 nt.c ussce- Streptococcus pneurnonlae 0 2"".Enterococcus peciesi

Multicenter Observational Study to Evaluate Epidemiology and Resistance Patterns of Common Intensive Care Unit-infections

PubMed Central

Venkataraman, Ramesh; Divatia, Jigeeshu V.; Ramakrishnan, Nagarajan; Chawla, Rajesh; Amin, Pravin; Gopal, Palepu; Chaudhry, Dhruva; Zirpe, Kapil; Abraham, Babu

2018-01-01

Background: There is limited data regarding the microbiology of Intensive Care Unit (ICU)-acquired infections, such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and catheter-related bloodstream infections (CRBSI) from India. Objectives: To explore the microbiology and resistance patterns of ICU-acquired infections and evaluate their outcomes. Materials and Methods: This was a multicenter observational study, conducted by Indian Society of Critical Care Medicine (MOSER study) between August 2011 and October 2012. Patients in the ICU ≥48 h with any ICU-acquired infection within 14 days of index ICU stay were included. Patient demographics, relevant clinical, and microbiological details were collected. Follow-up until hospital discharge or death was done, and 6-month survival data were collected. Results: Of the 381 patients included in the study, 346 patients had 1 ICU infection and 35 had more than one ICU infection. Among patients with single infections, 223 had VAP with Acinetobacter being the most common isolate. CAUTI was seen in 42 patients with Klebsiella as the most common organism. CRBSI was seen in 81 patients and Klebsiella was the most common causative organism. Multidrug resistance was noted in 87.5% of Acinetobacter, 75.5% of Klebsiella, 61.9% of Escherichia coli, and 58.9% of Pseudomonas isolates, respectively. Staphylococcus constituted only 2.4% of isolates. Mortality rates were 26%, 11.9%, and 34.6% in VAP, CAUTI, and CRBSI, respectively. Conclusion: VAP is the most common infection followed by CRBSI and CAUTI. Multidrug-resistant Gram-negative bacteria are the most common organisms. Staphylococcus aureus is uncommon in the Indian setting. PMID:29422728

Gastro-oesophageal reflux disease increases the risk of intensive care unit admittance and mechanical ventilation use among patients with chronic obstructive pulmonary disease: a nationwide population-based cohort study.

PubMed

Tsai, Chen-Liang; Lin, Yu-Huei; Wang, Meng-Ting; Chien, Li-Nien; Jeng, Chii; Chian, Chih-Feng; Perng, Wann-Cherng; Chiang, Chi-Huei; Chiou, Hung-Yi

2015-03-24

Gastro-oesophageal reflux disease (GORD) is common among chronic obstructive pulmonary disease (COPD) patients and may have a deleterious effect on COPD prognosis. However, few studies have investigated whether GORD increases the risk of severe outcomes such as intensive care unit (ICU) admittance or mechanical ventilator use among COPD patients. Propensity score matching by age, sex, comorbidities and COPD severity was used to match the 1,210 COPD patients with GORD sourced in this study to 2,420 COPD patients without GORD. The Kaplan-Meier method was used to explore the incidence of ICU admittance and machine ventilation with the log rank test being used to test for differences. Cox regression analysis was used to explore the risk of ICU admittance and mechanical ventilation use for patients with and without GORD. During the 12-month follow-up, GORD patients and non-GORD patients had 5.22 and 3.01 ICU admittances per 1000 person-months, and 4.34 and 2.41 mechanical ventilation uses per 1000 person-month, respectively. The log rank test revealed a difference in the incidence of ICU admittance and machine ventilation between the two cohorts. GORD was found to be an independent predicator of ICU admittance (adjusted hazard ratio (HRadj) 1.75, 95% confidence interval (CI) 1.28-2.38) and mechanical ventilation (HRadj 1.92, 95% CI 1.35-2.72). This is the first investigation to detect a significantly higher incidence rate and independently increased risk of admission to an ICU and mechanical ventilation use among COPD patients who subsequently developed GORD during the first year following their GORD diagnosis than COPD patients who did not develop GORD.

Validation of Open-Heart Intraoperative Risk score to predict a prolonged intensive care unit stay for adult patients undergoing cardiac surgery with cardiopulmonary bypass

PubMed Central

Tribuddharat, Sirirat; Sathitkarnmanee, Thepakorn; Ngamsaengsirisup, Kriangsak; Wongbuddha, Chawalit

2018-01-01

Background A prolonged stay in an intensive care unit (ICU) after cardiac surgery with cardiopulmonary bypass (CPB) increases the cost of care as well as morbidity and mortality. Several predictive models aim at identifying patients at risk of prolonged ICU stay after cardiac surgery with CPB, but almost all of them involve a preoperative assessment for proper resource management, while one – the Open-Heart Intraoperative Risk (OHIR) score – focuses on intra-operative manipulatable risk factors for improving anesthetic care and patient outcome. Objective We aimed to revalidate the OHIR score in a different context. Materials and methods The ability of the OHIR score to predict a prolonged ICU stay was assessed in 123 adults undergoing cardiac surgery (both coronary bypass graft and valvular surgery) with CPB at two tertiary university hospitals between January 2013 and December 2014. The criteria for a prolonged ICU stay matched a previous study (ie, a stay longer than the median). Results The area under the receiver operating characteristic curve of the OHIR score to predict a prolonged ICU stay was 0.95 (95% confidence interval 0.90–1.00). The respective sensitivity, specificity, positive predictive value, and accuracy of an OHIR score of ≥3 to discriminate a prolonged ICU stay was 93.10%, 98.46%, 98.18%, and 95.9%. Conclusion The OHIR score is highly predictive of a prolonged ICU stay among intraopera-tive patients undergoing cardiac surgery with CPB. The OHIR comprises of six risk factors, five of which are manipulatable intraoperatively. The OHIR can be used to identify patients at risk as well as to improve the outcome of those patients. PMID:29379295

A prospective study of prolonged stay in the intensive care unit: predictors and impact on resource utilization.

PubMed

Arabi, Yaseen; Venkatesh, S; Haddad, Samir; Al Shimemeri, Abdullah; Al Malik, Salim

2002-10-01

To evaluate the predictors of prolonged Intensive Care Unit (ICU) stay and the impact on resource utilization. Prospective study. Adult medical/surgical ICU in a tertiary-care teaching hospital. All admissions to the ICU (numbering 947) over a 20-month period were enrolled. Data on demographic and clinical profile, length of stay, and outcome were collected prospectively. The ICU length of stay and mechanical ventilation days were used as surrogate parameters for resource utilization. Potential predictors were analyzed for possible association with prolonged ICU stay (length of stay > 14 days). Patients with prolonged ICU stay formed only 11% of patients, but utilized 45.1% of ICU days and 55.5% of mechanical ventilation days. Non-elective admissions, readmissions, respiratory or trauma-related reasons for admission, and first 24-hour evidence of infection, oliguria, coagulopathy, and the need for mechanical ventilation or vasopressor therapy had significant association with prolonged ICU stay. Mean APACHE II and SAPS II were slightly higher in patients with prolonged stay. ICU outcome was comparable to patients with < or = 14 days ICU stay. Patients with prolonged ICU stay form a small proportion of ICU patients, yet they consume a significant share of the ICU resources. The outcome of this group of patients is comparable to that of shorter stay patients. The predictors identified in the study can be used in targeting this group to improve resource utilization and efficiency of ICU care.

Lost information during the handover of critically injured trauma patients: a mixed-methods study.

PubMed

Zakrison, Tanya Liv; Rosenbloom, Brittany; McFarlan, Amanda; Jovicic, Aleksandra; Soklaridis, Sophie; Allen, Casey; Schulman, Carl; Namias, Nicholas; Rizoli, Sandro

2016-12-01

Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer. A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis. Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety. Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Patients' recollections of experiences in the intensive care unit may affect their quality of life

PubMed Central

Granja, Cristina; Lopes, Alice; Moreira, Sara; Dias, Claudia; Costa-Pereira, Altamiro; Carneiro, António

2005-01-01

Introduction We wished to obtain the experiences felt by patients during their ICU stay using an original questionnaire and to correlate the memories of those experiences with health-related quality of life (HR-QOL). Methods We conducted a prospective study in 10 Portuguese intensive care units (ICUs). Six months after ICU discharge, an original questionnaire on experiences of patients during their ICU stay, the recollection questionnaire, was delivered. HR-QOL was evaluated simultaneously, with the EQ-5D questionnaire. Between 1 September 2002 and 31 March 2003 1433 adult patients were admitted. ICU and hospital mortalities were 21% and 28%, respectively. Six months after ICU discharge, 464 patients completed the recollection questionnaire. Results Thirty-eight percent of the patients stated they did not remember any moment of their ICU stay. The ICU environment was described as friendly and calm by 93% of the patients. Sleep was described as being good and enough by 73%. The experiences reported as being more stressful were tracheal tube aspiration (81%), nose tube (75%), family worries (71%) and pain (64%). Of respondents, 51% experienced dreams and nightmares during their ICU stay; of these, 14% stated that those dreams and nightmares disturb their present daily life and they exhibit a worse HR-QOL. Forty-one percent of patients reported current sleep disturbances, 38% difficulties in concentrating in current daily activities and 36% difficulties in remembering recent events. More than half of the patients reported more fatigue than before the ICU stay. Multiple and linear regression analysis showed that older age, longer ICU stay, higher Simplified Acute Physiology Score II, non-scheduled surgery and multiple trauma diagnostic categories, present sleep disturbances, daily disturbances by dreams and nightmares, difficulties in concentrating and difficulties in remembering recent events were independent predictors of worse HR-QOL. Multicollinearity analysis showed that, with the exception of the correlation between admission diagnostic categories and length of ICU stay (0.47), all other correlations between the independent variables and coefficient estimates included in the regression models were weak (below 0.30). Conclusion This study suggests that neuropsychological consequences of critical illness, in particular the recollection of ICU experiences, may influence subsequent HR-QOL. PMID:15774056

Changes in appetite related gut hormones in intensive care unit patients: a pilot cohort study

PubMed Central

Nematy, Mohsen; O'Flynn, Jacqui E; Wandrag, Liesl; Brynes, Audrey E; Brett, Stephen J; Patterson, Michael; Ghatei, Mohammad A; Bloom, Stephen R; Frost, Gary S

2006-01-01

Introduction The nutritional status of patients in the intensive care unit (ICU) appears to decline not only during their stay in the ICU but also after discharge from the ICU. Recent evidence suggests that gut released peptides, such as ghrelin and peptide YY (PYY) regulate the initiation and termination of meals and could play a role in the altered eating behaviour of sick patients. The aim of this study was to assess the patterns of ghrelin and PYY levels during the stay of ICU patients in hospital. Methods Sixteen ICU patients (60 ± 4.7 years, body mass index (BMI) 28.1 ± 1.7 kg/m2 (mean ± standard error of the mean)) underwent fasting blood sample collections on days 1, 3, 5, 14, 21 and 28 of their stay at Hammersmith and Charing Cross Hospitals. Changes in appetite and biochemical and anthropometric markers of nutritional status were recorded. A comparison was made to a group of 36 healthy volunteers matched for age and BMI (54.3 ± 2.9 years, p = 0.3; BMI 25.8 ± 0.8 kg/m2 p = 0.2). Results Compared to healthy subjects, ICU patients exhibited a significantly lower level of ghrelin (day one 297.8 ± 76.3 versus 827.2 ± 78.7 pmol/l, p < 0.001) during their stay in the ICU. This tended to rise to the normal level during the last three weeks of hospital stay. Conversely, ICU patients showed a significantly higher level of PYY (day one 31.5 ± 9.6 versus 11.3 ± 1.0 pmol/l, p < 0.05) throughout their stay in the ICU and on the ward, with a downward trend to the normal level during the last three weeks of stay. Conclusions Results from our study show high levels of PYY and low levels of ghrelin in ICU patients compared to healthy controls. There appears to be a relationship between the level of these gut hormones and nutritional intake. PMID:16420657

National audit of critical care resources in South Africa - nursing profile.

PubMed

Scribante, Juan; Bhagwanjee, Sats

2007-12-01

(i) To determine the profile and number of nurses working in South African intensive care units (ICUs) and high care units (HCUs); (ii) to determine the number of beds in ICU and HCUs in South Africa; and (iii) to determine the ratio of nurses to ICU/HC beds. A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and HCUs in South Africa was undertaken. A 100% was sample obtained; 74.8% of the ICU nursing managers were ICU-trained nurses with an average of 12.8 years of ICU experience. Only 25.6% of nurses working in ICU were ICU trained. The majority were registered nurses (49.2%), while 21.4% were semi-professional nurses. Private sector nurses represented 50.3% of all nurses. Some 42.8% of the professional nurses had 0 - 5 years of experience and 28.7% had 5 - 10 years. The groups 10 - 15 and 15 - 20 years represented 16.1% and 6.6% respectively. Only 5.7% nurses had 20 and more years' experience. In the units that used agency staff the ratio of permanent to agency nursing staff for the month of June 2003 was 64.5% versus 35.5%. In total there are 4,168 ICU and HC beds in South Africa that are serviced by 4,584 professional nurses. The nurse:bed ratio is 1.1 nurses per ICU/HC bed. This study demonstrates that ICU nursing in South Africa faces the challenge of an acute shortage of trained and experienced nurses. Our nurses are tired, often not healthy, and are plagued by discontent and low morale.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician’s decision-making process

PubMed Central

2014-01-01

Introduction ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. Methods COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation. Results Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation. Conclusions The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient’s personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed. PMID:24898342

Identifying Elements of ICU Care That Families Report as Important But Unsatisfactory

PubMed Central

Osborn, Tristan R.; Curtis, J. Randall; Nielsen, Elizabeth L.; Back, Anthony L.; Shannon, Sarah E.

2012-01-01

Background: One in five deaths in the United States occurs in the ICU, and many of these deaths are experienced as less than optimal by families of dying people. The current study investigated the relationship between family satisfaction with ICU care and overall ratings of the quality of dying as a means of identifying targets for improving end-of-life experiences for patients and families. Methods: This multisite cross-sectional study surveyed families of patients who died in the ICU in one of 15 hospitals in western Washington State. Measures included the Family Satisfaction in the ICU (FS-ICU) and the Single-Item Quality of Dying (QOD-1) questionnaires. Associations between FS-ICU items and the QOD-1 were examined using multivariate linear regression controlling for patient and family demographics and hospital site. Results: Questionnaires were returned for 1,290 of 2,850 decedents (45%). Higher QOD-1 scores were significantly associated (all P < .05) with (1) perceived nursing skill and competence (β = 0.15), (2) support for family as decision-makers (β = 0.10), (3) family control over the patient’s care (β = 0.18), and (4) ICU atmosphere (β = 0.12). FS-ICU items that received low ratings and correlated with higher QOD-1 scores (ie, important items with room for improvement) were (1) support of family as decision-maker, (2) family control over patient’s care, and (3) ICU atmosphere. Conclusions: Increased support for families as decision-makers and for their desired level of control over patient care along with improvements in the ICU atmosphere were identified as aspects of the ICU experience that may be important targets for quality improvement. Trial registry: ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov. PMID:22661455

CONSUMPTION TRENDS OF RESCUE ANTI-PSYCHOTICS FOR DELIRIUM IN INTENSIVE CARE UNITS (ICU DELIRIUM) SHOW INFLUENCE OF CORRESPONDING LUNAR PHASE CYCLES: A RETROSPECTIVE AUDIT STUDY FROM ACADEMIC UNIVERSITY HOSPITAL IN THE UNITED STATES.

PubMed

Gupta, Deepak; Pallekonda, Vinay; Thomas, Ronald; Mckelvey, George; Ghoddoussi, Farhad

2015-02-01

The etiology of delirium in intensive care units (ICU) is usually multi-factorial. There is common "myth" that lunar phases affect human body especially human brains (and minds). In the absence of any pre-existing studies in ICU patients, the current retrospective study was planned to investigate whether lunar phases play any role in ICU delirium by assessing if lunar phases correlate with prevalence of ICU delirium as judged by the corresponding consumptions of rescue anti-psychotics used for delirium in ICU. After institutional review board approval with waived consent, the daily census of ICU patients from the administrative records was accessed at an academic university's Non-Cancer Hospital in a Metropolitan City of United States. Thereafter, the ICU pharmacy's electronic database was accessed to obtain data on the use of haloperidol and quetiapine over the two time periods for patients aged 18 years or above. Subsequently the data was analyzed for whether the consumption of haloperidol or quetiapine followed any trends corresponding to the lunar phase cycles. A total of 5382 pharmacy records of haloperidol equivalent administrations were analyzed for this study. The cumulative prevalence of incidents of haloperidol equivalent administrations peaked around the full moon period and troughed around the new moon period. As compared to male patients, female patients followed much more uniform trends of haloperidol equivalent administrations' incidents which peaked around the full moon period and troughed around the new moon period. Further sub-analysis of 70-lunar cycles across the various solar months of the total 68-month study period revealed that haloperidol equivalent administrations' incidents peaked around the full moon periods during the months of November-December and around the new moon periods during the month of July which all are interestingly the major holiday months (a potential confounding factor) in the United States. Consumption trends of rescue anti-psychotics for ICU delirium revealed an influence by lunar phase cycles particularly that of full moon periods on female patients in the ICU.

Barriers to intensive care unit nurses' autonomy in Iran: A qualitative study.

PubMed

AllahBakhshian, Maryam; Alimohammadi, Nasrollah; Taleghani, Fariba; Nik, Ahmadreza Yazdan; Abbasi, Saeed; Gholizadeh, Leila

The acute nature of the intensive care unit (ICU) environment necessitates that urgent clinical decisions are frequently made by the health care team. Therefore, it is important that critical care nurses have the authority to make decisions about their patient care. The purpose of this study was to explore perceived barriers to the practice of professional autonomy from the perspectives of ICU nurses in Iran. In this qualitative study, 28 critical care nurses were interviewed using a semistructured in-depth interview method. The interviews were recorded, transcribed verbatim, and analyzed using content analysis. Data analysis led to identification of two main themes and five subthemes: (a) the profession-related barriers with two associated subthemes of "lack of capacity to exercise autonomy" and "lack of strong professional bodies"; (b) organizational barriers with the associated subthemes of "role ambiguity," "a directive rather than supportive workplace," and "lack of motivation." ICU nurses in Iran may face many challenges in gaining professional autonomy. The identified inter- and intraprofessional barriers to the exercise of autonomy need to be addressed to promote critical thinking, job satisfaction, and motivation of ICU nurses, which can in turn lead to improved patient outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparing Average Levels and Peak Occurrence of Overnight Sound in the Medical Intensive Care Unit on A-weighted and C-weighted Decibel Scales

PubMed Central

Knauert, Melissa; Jeon, Sangchoon; Murphy, Terrence E.; Yaggi, H. Klar; Pisani, Margaret A.; Redeker, Nancy S.

2016-01-01

Purpose Sound levels in the intensive care unit (ICU) are universally elevated and are believed to contribute to sleep and circadian disruption. The purpose of this study is to compare overnight ICU sound levels and peak occurrence on A- versus C-weighted scales. Materials and Methods This was a prospective observational study of overnight sound levels in 59 medical ICU patient rooms. Sound level was recorded every 10 seconds on A- and C-weighted decibel scales. Equivalent sound level (Leq) and sound peaks were reported for full and partial night periods. Results The overnight A-weighted Leq of 53.6 dBA was well above World Health Organization (WHO) recommendations; overnight C-weighted Leq was 63.1 dBC (no WHO recommendations). Peak sound occurrence ranged from 1.8 to 23.3 times per hour. Illness severity, mechanical ventilation and delirium were not associated with Leq or peak occurrence. Leq and peak measures for A- and C-weighted decibel scales were significantly different from each other. Conclusions Sound levels in the medical ICU are high throughout the night. Patient factors were not associated with Leq or peak occurrence. Significant discordance between A- and C-weighted values suggests that low frequency sound is a meaningful factor in the medical ICU environment. PMID:27546739

Nosocomial infections and risk factors in the intensive care unit of a teaching and research hospital: A prospecive cohort study

PubMed Central

Ak, Oznur; Batirel, Ayse; Ozer, Serdar; Čolakoğlu, Serhan

2011-01-01

Summary Background To evaluate the incidence, risk factors and etiology of nosocomial infections (NIs) in the intensive care unit (ICU) of our hospital in order to improve our infection control policies. Material/Methods A 1-year prospective cohort study of nosocomial infection (NI) surveillance was conducted in our ICU in 2008. Results Out of 1134 patients hospitalized in the ICU for a period of 6257 days, 115 patients acquired a total of 135 NIs distributed as follows: 36.3% bacteremia, 30.4% ventilator-associated pneumonia (VAP), 18.5% catheter-associated urinary tract infection, 7.4% central-line infection, 5.9% cutaneous infection, and 1.3% meningitis. The incidence rate of NI was 21.6 in 1000 patient-days, and the rate of NI was 25.6%. Length of ICU stay, central venous catheterisation, mechanical ventilation and tracheostomy were statistically significant risk factors for NI. Of all NI, 112 (83%) were microbiologically-confirmed and 68.8% of the isolates were Gram-negative, 27.6% were Gram-positive, and 3.6% were fungi. 23 (17%) were clinically-defined infections. The most frequently isolated organism was P. aeruginosa (25%), followed by S. aureus (21.4%), E. coli (18.7%) and A. baumannii (16.9%). Conclusions The bloodstream was the most common site and Gram-negatives were the most commonly reported causes of ICU infections. PMID:21525819

A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units.

PubMed

Carayon, Pascale; Gürses, Ayşe P

2005-10-01

In this paper, we review the literature on nursing workload in intensive care units (ICUs) and its impact on patient safety and quality of working life of nurses. We then propose a conceptual framework of ICU nursing workload that defines causes, consequences and outcomes of workload. We identified four levels of nursing workload (ICU/unit level, job level, patient level, and situation level), and discuss measures associated with each of the four levels. A micro-level approach to ICU nursing workload at the situation level is proposed and recommended in order to reduce workload and mitigate its negative impact. Performance obstacles are conceptualized as causes of ICU nursing workload at the situation level.

Validation of the ICU-DaMa tool for automatically extracting variables for minimum dataset and quality indicators: The importance of data quality assessment.

PubMed

Sirgo, Gonzalo; Esteban, Federico; Gómez, Josep; Moreno, Gerard; Rodríguez, Alejandro; Blanch, Lluis; Guardiola, Juan José; Gracia, Rafael; De Haro, Lluis; Bodí, María

2018-04-01

Big data analytics promise insights into healthcare processes and management, improving outcomes while reducing costs. However, data quality is a major challenge for reliable results. Business process discovery techniques and an associated data model were used to develop data management tool, ICU-DaMa, for extracting variables essential for overseeing the quality of care in the intensive care unit (ICU). To determine the feasibility of using ICU-DaMa to automatically extract variables for the minimum dataset and ICU quality indicators from the clinical information system (CIS). The Wilcoxon signed-rank test and Fisher's exact test were used to compare the values extracted from the CIS with ICU-DaMa for 25 variables from all patients attended in a polyvalent ICU during a two-month period against the gold standard of values manually extracted by two trained physicians. Discrepancies with the gold standard were classified into plausibility, conformance, and completeness errors. Data from 149 patients were included. Although there were no significant differences between the automatic method and the manual method, we detected differences in values for five variables, including one plausibility error and two conformance and completeness errors. Plausibility: 1) Sex, ICU-DaMa incorrectly classified one male patient as female (error generated by the Hospital's Admissions Department). Conformance: 2) Reason for isolation, ICU-DaMa failed to detect a human error in which a professional misclassified a patient's isolation. 3) Brain death, ICU-DaMa failed to detect another human error in which a professional likely entered two mutually exclusive values related to the death of the patient (brain death and controlled donation after circulatory death). Completeness: 4) Destination at ICU discharge, ICU-DaMa incorrectly classified two patients due to a professional failing to fill out the patient discharge form when thepatients died. 5) Length of continuous renal replacement therapy, data were missing for one patient because the CRRT device was not connected to the CIS. Automatic generation of minimum dataset and ICU quality indicators using ICU-DaMa is feasible. The discrepancies were identified and can be corrected by improving CIS ergonomics, training healthcare professionals in the culture of the quality of information, and using tools for detecting and correcting data errors. Copyright © 2018 Elsevier B.V. All rights reserved.

Impact and utilization studies of a PACS display station in an ICU setting

NASA Astrophysics Data System (ADS)

Andriole, Katherine P.; Storto, Maria L.; Gamsu, Gordon; Huang, H. K.

1996-05-01

An assessment of changes in health-care professional behavior as a result of the introduction of a PACS (picture archiving and communication system) display station to an adult medical- surgical intensive care unit (ICU) is investigated via pre- and post-PACs evaluations. ICU display station utilization and the impact on clinical operations are also examined. Parameters measured both pre- and post-PACS ICU display station placement include the number of films per patient day, the number of clinician reviews of a patient's images per day and the percentage of images on which the unit interacts with a radiologist. The elapsed times from the time of exposure to the time of: review by the referring physician, radiologist-unit interaction and clinical action based on image information are also measured. The results of this investigation suggest that the introduction of a PaCS display station in the ICU may reduce the number of exams per patient day, decrease the elapsed time from the time of exposure to the time of review by the unit clinician, and improve the time to clinical action. Note, however, that it does not appear to change the percentage of total images on which the unit interacts with a radiologist.

No Exit: Identifying Avoidable Terminal Oncology Intensive Care Unit Hospitalizations

PubMed Central

Hantel, Andrew; Wroblewski, Kristen; Balachandran, Jay S.; Chow, Selina; DeBoer, Rebecca; Fleming, Gini F.; Hahn, Olwen M.; Kline, Justin; Liu, Hongtao; Patel, Bhakti K.; Verma, Anshu; Witt, Leah J.; Fukui, Mayumi; Kumar, Aditi; Howell, Michael D.; Polite, Blase N.

2016-01-01

Purpose: Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. Methods: This was a retrospective case series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. Results: Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). Conclusion: Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care. PMID:27601514

Fatigue in Family Caregivers of Adult Intensive Care Unit Survivors

PubMed Central

Choi, JiYeon; Tate, Judith A.; Hoffman, Leslie A.; Schulz, Richard; Ren, Dianxu; Donahoe, Michael P.; Given, Barbara A.; Sherwood, Paula R.

2014-01-01

Context Family caregivers are a vital resource in the recovery of intensive care unit (ICU) survivors. Of concern, the stress associated with this role can negatively affect caregiver health. Fatigue, an important health indicator, has been identified as a predictor of various illnesses, greater use of health services, and early mortality. Examining the impact of fatigue on caregivers’ physical health can assist in identifying critical time points and potential targets for intervention. Objectives To describe self-reported fatigue in caregivers of ICU survivors from patients’ ICU admission to ≤ two weeks, two- and four-months post-ICU discharge. Methods Patient-caregiver pairs were enrolled from a medical ICU. Caregiver fatigue was measured using the Short-Form-36 Health Survey Vitality subscale (SF-36 Vitality). Caregiver psychobehavioral stress responses included depressive symptoms, burden, health risk behaviors, and sleep quality. Patient data included self-reported physical symptoms and disposition (home vs. institution). Results Forty seven patient-caregiver pairs were initially enrolled. Clinically significant fatigue (SF-36 Vitality ≤ 45) was reported by 43% to 53% of caregivers across the time points and these caregivers reported worse scores in measures of depressive symptoms, burden, health risk behaviors and sleep quality, and patients’ symptom burden. In 26 caregivers with data for all time points (55% of the total sample), SF-36 Vitality scores showed trends of improvement when the patient returned home and greater impairment when institutionalization continued. Conclusion In caregivers of ICU survivors, fatigue is common and potentially linked with poor psychobehavioral responses. Worsening fatigue was associated with greater symptom distress and long-term patient institutionalization. PMID:24439845

Jejunal feeding tubes can be efficiently and independently placed by intensive care unit teams.

PubMed

Welpe, Pascal; Frutiger, Adrian; Vanek, Patrik; Kleger, Gian-Reto

2010-01-01

Nutrition support is an important therapeutic measure in critically ill patients. Several studies have shown that the enteral route is preferable to the parenteral route. Insertion of a feeding tube beyond the ligament of Treitz combined with continuous gastric drainage will reduce regurgitation and probably also the rate of nosocomial pneumonia. This study was conducted to assess the safety, success rate, and time required to establish jejunal nutrition by the fluoroscopy-guided technique in intensive care unit (ICU) patients. This was a prospective observational study in the ICUs of a 300-bed and a 600-bed community hospital. Indications were large gastric residuals during attempted gastric feeding, severe acute pancreatitis, or recurrent aspiration. Feeding tubes were introduced by the ICU staff at bedside under fluoroscopic guidance (a senior ICU physician and a resident or a registered ICU nurse). The correct jejunal position was documented by the application of a radiopaque contrast medium through the tube. After confirmation of the correct position, jejunal tube feeding was immediately started. The insertion procedure in 38 patients lasted a median of 17 minutes. The median time from decision to place the tube until start of enteral feeding was 141 minutes. The success rate was 84.2%. No adverse events were observed. Fluoroscopic placement of a jejunal feeding tube at the bedside is fast, is safe, and has a high success rate when performed by well-trained ICU staff. Using this method makes the ICU team more self-sufficient when critically ill patients require enteral nutrition and no gastroenterologist is available.

N-gram support vector machines for scalable procedure and diagnosis classification, with applications to clinical free text data from the intensive care unit.

PubMed

Marafino, Ben J; Davies, Jason M; Bardach, Naomi S; Dean, Mitzi L; Dudley, R Adams

2014-01-01

Existing risk adjustment models for intensive care unit (ICU) outcomes rely on manual abstraction of patient-level predictors from medical charts. Developing an automated method for abstracting these data from free text might reduce cost and data collection times. To develop a support vector machine (SVM) classifier capable of identifying a range of procedures and diagnoses in ICU clinical notes for use in risk adjustment. We selected notes from 2001-2008 for 4191 neonatal ICU (NICU) and 2198 adult ICU patients from the MIMIC-II database from the Beth Israel Deaconess Medical Center. Using these notes, we developed an implementation of the SVM classifier to identify procedures (mechanical ventilation and phototherapy in NICU notes) and diagnoses (jaundice in NICU and intracranial hemorrhage (ICH) in adult ICU). On the jaundice classification task, we also compared classifier performance using n-gram features to unigrams with application of a negation algorithm (NegEx). Our classifier accurately identified mechanical ventilation (accuracy=0.982, F1=0.954) and phototherapy use (accuracy=0.940, F1=0.912), as well as jaundice (accuracy=0.898, F1=0.884) and ICH diagnoses (accuracy=0.938, F1=0.943). Including bigram features improved performance on the jaundice (accuracy=0.898 vs 0.865) and ICH (0.938 vs 0.927) tasks, and outperformed NegEx-derived unigram features (accuracy=0.898 vs 0.863) on the jaundice task. Overall, a classifier using n-gram support vectors displayed excellent performance characteristics. The classifier generalizes to diverse patient populations, diagnoses, and procedures. SVM-based classifiers can accurately identify procedure status and diagnoses among ICU patients, and including n-gram features improves performance, compared to existing methods. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

The Prevalence of Compassion Fatigue and Burnout among Healthcare Professionals in Intensive Care Units: A Systematic Review

PubMed Central

van Mol, Margo M. C.; Kompanje, Erwin J. O.; Benoit, Dominique D.; Bakker, Jan; Nijkamp, Marjan D.

2015-01-01

Background Working in the stressful environment of the Intensive Care Unit (ICU) is an emotionally charged challenge that might affect the emotional stability of medical staff. The quality of care for ICU patients and their relatives might be threatened through long-term absenteeism or a brain and skill drain if the healthcare professionals leave their jobs prematurely in order to preserve their own health. Purpose The purpose of this review is to evaluate the literature related to emotional distress among healthcare professionals in the ICU, with an emphasis on the prevalence of burnout and compassion fatigue and the available preventive strategies. Methods A systematic literature review was conducted, using Embase, Medline OvidSP, Cinahl, Web-of-science, PsychINFO, PubMed publisher, Cochrane and Google Scholar for articles published between 1992 and June, 2014. Studies reporting the prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals were included, as well as related intervention studies. Results Forty of the 1623 identified publications, which included 14,770 respondents, met the selection criteria. Two studies reported the prevalence of compassion fatigue as 7.3% and 40%; five studies described the prevalence of secondary traumatic stress ranging from 0% to 38.5%. The reported prevalence of burnout in the ICU varied from 0% to 70.1%. A wide range of intervention strategies emerged from the recent literature search, such as different intensivist work schedules, educational programs on coping with emotional distress, improving communication skills, and relaxation methods. Conclusions The true prevalence of burnout, compassion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare professionals remains open for discussion. A thorough exploration of emotional distress in relation to communication skills, ethical rounds, and mindfulness might provide an appropriate starting point for the development of further preventive strategies. PMID:26322644

Neuromuscular disorders in the intensive care unit.

PubMed

Marinelli, William A; Leatherman, James W

2002-10-01

Neuromuscular disorders encountered in the ICU can be categorized as muscular diseases that lead to ICU admission and those that are acquired in the ICU. This article discusses three neuromuscular disorders can lead to ICU admission and have a putative immune-mediated pathogenesis: the Guillian-Barré syndrome, myasthenia gravis, and dermatomyositis/polymyositis. It also reviews critical care polyneuropathy and ICU acquired myopathy, two disorders that, alone or in combination, are responsible for nearly all cases of severe ICU acquired muscle weakness.

Communication skills in ICU and adult hospitalisation unit nursing staff.

PubMed

Ayuso-Murillo, D; Colomer-Sánchez, A; Herrera-Peco, I

In this study researchers are trying to analyse the personality factors related to social skills in nurses who work in: Intensive Care Units, ICU, and Hospitalisation units. Both groups are from the Madrid Health Service (SERMAS). The present investigation has been developed as a descriptive transversal study, where personality factors in ICU nurses (n=29) and those from Hospitalisation units (n=40) were compared. The 16PF-5 questionnaire was employed to measure the personality factors associated with communication skills. The comparison of the personality factors associated to social skills, communication, in both groups, show us that nurses from ICU obtain in social receptivity: 5,6 (A+), 5,2 (C-), 6,2 (O+), 5,1 (H-), 5,3 (Q1-), and emotional control: 6,1 (B+), 5,9 (N+). Meanwhile the data doesn't adjust to the expected to emotional and social expressiveness, emotional receptivity and social control, there are not evidence. The personality factors associated to communication skills in ICU nurses are below those of hospitalisation unit nurses. The present results suggest the necessity to develop training actions, focusing on nurses from intensive care units to improve their communication social skills. Copyright © 2016 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

The pediatric intensive care unit business model.

PubMed

Schleien, Charles L

2013-06-01

All pediatric intensivists need a primer on ICU finance. The author describes potential alternate revenue sources for the division. Differentiating units by size or academic affiliation, the author describes drivers of expense. Strategies to manage the bottom line including negotiations for hospital services are covered. Some of the current trends in physician productivity and its described metrics, with particular focus on clinical FTE management is detailed. Methods of using this data to enhance revenue are discussed. Some of the other current trends in the ICU business related to changes at the federal and state level as well as in the insurance sector, moving away from fee-for-service are covered. Copyright © 2013 Elsevier Inc. All rights reserved.

Epidemiological features of influenza in Canadian adult intensive care unit patients.

PubMed

Taylor, G; Abdesselam, K; Pelude, L; Fernandes, R; Mitchell, R; McGeer, A; Frenette, C; Suh, K N; Wong, A; Katz, K; Wilkinson, K; Mersereau, T; Gravel, D

2016-03-01

To identify predictive factors and mortality of patients with influenza admitted to intensive care units (ICU) we carried out a prospective cohort study of patients hospitalized with laboratory-confirmed influenza in adult ICUs in a network of Canadian hospitals between 2006 and 2012. There were 626 influenza-positive patients admitted to ICUs over the six influenza seasons, representing 17·9% of hospitalized influenza patients, 3·1/10,000 hospital admissions. Variability occurred in admission rate and proportion of hospital influenza patients who were admitted to ICUs (proportion range by year: 11·7-29·4%; 21·3% in the 2009-2010 pandemic). In logistic regression models ICU patients were younger during the pandemic and post-pandemic period, and more likely to be obese than hospital non-ICU patients. Influenza B accounted for 14·2% of all ICU cases and had a similar ICU admission rate as influenza A. Influenza-related mortality was 17·8% in ICU patients compared to 2·0% in non-ICU patients.

Simplified Acute Physiology Score II as Predictor of Mortality in Intensive Care Units: A Decision Curve Analysis

PubMed Central

Allyn, Jérôme; Ferdynus, Cyril; Bohrer, Michel; Dalban, Cécile; Valance, Dorothée; Allou, Nicolas

2016-01-01

Background End-of-life decision-making in Intensive care Units (ICUs) is difficult. The main problems encountered are the lack of a reliable prediction score for death and the fact that the opinion of patients is rarely taken into consideration. The Decision Curve Analysis (DCA) is a recent method developed to evaluate the prediction models and which takes into account the wishes of patients (or surrogates) to expose themselves to the risk of obtaining a false result. Our objective was to evaluate the clinical usefulness, with DCA, of the Simplified Acute Physiology Score II (SAPS II) to predict ICU mortality. Methods We conducted a retrospective cohort study from January 2011 to September 2015, in a medical-surgical 23-bed ICU at University Hospital. Performances of the SAPS II, a modified SAPS II (without AGE), and age to predict ICU mortality, were measured by a Receiver Operating Characteristic (ROC) analysis and DCA. Results Among the 4.370 patients admitted, 23.3% died in the ICU. Mean (standard deviation) age was 56.8 (16.7) years, and median (first-third quartile) SAPS II was 48 (34–65). Areas under ROC curves were 0.828 (0.813–0.843) for SAPS II, 0.814 (0.798–0.829) for modified SAPS II and of 0.627 (0.608–0.646) for age. DCA showed a net benefit whatever the probability threshold, especially under 0.5. Conclusion DCA shows the benefits of the SAPS II to predict ICU mortality, especially when the probability threshold is low. Complementary studies are needed to define the exact role that the SAPS II can play in end-of-life decision-making in ICUs. PMID:27741304

The instrument control unit of SPICA SAFARI: a macro-unit to host all the digital control functionalities of the spectrometer

NASA Astrophysics Data System (ADS)

Di Giorgio, Anna Maria; Biondi, David; Saggin, Bortolino; Shatalina, Irina; Viterbini, Maurizio; Giusi, Giovanni; Liu, Scige J.; Cerulli-Irelli, Paquale; Van Loon, Dennis; Cara, Christophe

2012-09-01

We present the preliminary design of the Instrument Control Unit (ICU) of the SpicA FAR infrared Instrument (SAFARI), an imaging Fourier Transform Spectrometer (FTS) designed to give continuous wavelength coverage in both photometric and spectroscopic modes from around 34 to 210 µm. Due to the stringent requirements in terms of mass and volume, the overall SAFARI warm electronics will be composed by only two main units: Detector Control Unit and ICU. ICU is therefore a macro-unit incorporating the four digital sub-units dedicated to the control of the overall instrument functionalities: the Cooler Control Unit, the Mechanism Control Unit, the Digital processing Unit and the Power Supply Unit. Both the mechanical solution adopted to host the four sub-units and the internal electrical architecture are presented as well as the adopted redundancy approach.

Development and evaluation of an influenza pandemic intensive care unit triage protocol.

PubMed

Cheung, Winston; Myburgh, John; Seppelt, Ian M; Parr, Michael J; Blackwell, Nikki; Demonte, Shannon; Gandhi, Kalpesh; Hoyling, Larissa; Nair, Priya; Passer, Melissa; Reynolds, Claire; Saunders, Nicholas M; Saxena, Manoj K; Thanakrishnan, Govindasamy

2012-09-01

To develop an influenza pandemic ICU triage (iPIT) protocol that excludes patients with the highest and lowest predicted mortality rates, and to determine the increase in ICU bed availability that would result. Post-hoc analysis of a study evaluating two triage protocols, designed to determine which patients should be excluded from access to ICU resources during an influenza pandemic. ICU mortality rates were determined for the individual triage criteria in the protocols and included criteria based on the Sequential Organ Failure Assessment (SOFA) score. Criteria resulting in mortality rates outside the 25th and 75th percentiles were used as exclusion criteria in a new iPIT-1 protocol. The SOFA threshold component was modified further and reported as iPIT-2 and iPIT-3. Increase in ICU bed availability. The 25th and 75th percentiles for ICU mortality were 8.3% and 35.2%, respectively. Applying the iPIT-1 protocol resulted in an increase in ICU bed availability at admission of 71.7% ± 0.6%. Decreasing the lower SOFA score exclusion criteria to ≤6 (iPIT-2) and ≤4 (iPIT-3) resulted in an increase in ICU bed availability at admission of 66.9% ± 0.6% and 59.4 ± 0.7%, respectively (P < 0.001). The iPIT protocol excludes patients with the lowest and highest ICU mortality, and provides increases in ICU bed availability. Adjusting the lower SOFA score exclusion limit provides a method of escalation or de- escalation to cope with demand.

The Effect of Race and Ethnicity on Outcomes Among Patients in the Intensive Care Unit: A Comprehensive Study Involving Socioeconomic Status and Resuscitation Preferences

PubMed Central

Erickson, Sara E.; Vasilevskis, Eduard E.; Kuzniewicz, Michael W.; Cason, Brian A.; Lane, Rondall K.; Dean, Mitzi L.; Rennie, Deborah J.; Dudley, R. Adams

2013-01-01

Objective We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit (ICU) length of stay (LOS) among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences. Design Historical cohort study of patients hospitalized in intensive care units. Setting Adult intensive care units in 35 California hospitals during the years 2001-2004. Patients A total of 9,518 ICU patients (6334 white, 655 black, 1917 Hispanic and 612 Asian/Pacific Islander patients). Measurements and Main Results The primary outcome was risk-adjusted mortality and a secondary outcome was risk-adjusted ICU LOS. Crude hospital mortality was 15.9% among the entire cohort. Asian patients had the highest crude hospital mortality at 18.6% and black patients had the lowest at 15.0%. After adjusting for age and gender, Hispanic and Asian patients had a higher risk of death compared to white patients, but these differences were not significant after additional adjustment for severity of illness. Black patients had more acute physiologic derangements at ICU admission and longer unadjusted ICU LOS. ICU LOS was not significantly different among racial/ethnic groups after adjustment for demographic, clinical, socioeconomic factors and do-not-resuscitate status. In an analysis restricted only to those who died, decedent black patients averaged 1.1 additional days in the ICU (95% CI – 0.26 to 2.6) compared to white patients who died, although this was not statistically significant. Conclusions Hospital mortality and ICU LOS did not differ by race or ethnicity among this diverse cohort of critically ill patients after adjustment for severity of illness, resuscitation status, SES, insurance status and admission type. Black patients had more acute physiologic derangements at ICU admission and were less likely to have a DNR order. These results suggest that among ICU patients, there are not racial or ethnic differences in mortality within individual hospitals. If disparities in ICU care exist, they may be explained by differences in the quality of care provided by hospitals that serve high proportions of minority patients. PMID:21187746

Intensive Care Unit Utilization Among Medicare Patients Hospitalized with Non-ST-Segment Elevation Myocardial Infarction

PubMed Central

Fanaroff, Alexander C; Peterson, Eric D; Chen, Anita Y; Thomas, Laine; Doll, Jacob D; Fordyce, Christopher B; Newby, L Kristin; Amsterdam, Ezra A; Kosiborod, Mikhail N; de Lemos, James A; Wang, Tracy Y

2018-01-01

Importance Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Objectives To examine inter-hospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with at low, moderate, or high mortality risk. Design, Settings and Participants Retrospective analysis of 28,018 Medicare patients ≥65 years old admitted with NSTEMI to 346 hospitals participating in ACTION Registry-GWTG between April 1, 2011 and December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Exposure Hospitals with high (>70% NSTEMI patients treated in an ICU during the index hospitalization), intermediate (30–70%), or low (< 30%) ICU utilization rates Main Outcome and Measure 30-day mortality Results Of NSTEMI patients ≥ 65 years old, 11,934 (43%) had an ICU stay. The proportion of NSTEMI patients treated in the ICU varied across hospitals (median 38% [26%, 54%]), but there were no significant differences in hospital characteristics or NSTEMI patient characteristics between hospitals with high, intermediate, or low ICU utilization rates. Compared with high ICU utilization hospitals, hospitals with low or intermediate ICU utilizations rates were only marginally more selective of higher risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs. low: 8.7% vs. 8.7%, adjusted OR 0.91, 95% CI 0.76–1.08; intermediate vs. low: 9.6% vs. 8.7%, adjusted OR 1.06, 95% CI 0.94–1.20). The relationship between hospital ICU utilization and mortality was similar in analyses stratified by low, moderate, or high ACTION risk score categories (adjusted interaction p 0.86). Conclusions and Relevance ICU utilization for older NSTEMI patients varied significantly among hospitals. This variability was not explained by hospital characteristics nor driven by patient risk. Post-MI mortality did not significantly differ among hospitals with high, intermediate, or low ICU utilization. PMID:27806171

Toward an Integrated Research Agenda for Critical Illness in Aging

PubMed Central

Milbrandt, Eric B.; Eldadah, Basil; Nayfield, Susan; Hadley, Evan; Angus, Derek C.

2010-01-01

Aging brings an increased predisposition to critical illness. Patients older than 65 years of age account for approximately half of all intensive care unit (ICU) admissions in the United States, a proportion that is expected to increase considerably with the aging of the population. Emerging research suggests that elderly survivors of intensive care suffer significant long-term sequelae, including accelerated age-related functional decline. Existing evidence-based interventions are frequently underused and their efficacy untested in older subjects. Improving ICU outcomes in the elderly will require not only better methods for translating sound science into improved ICU practice but also an enhanced understanding of the underlying molecular, physiological, and pathophysiological interactions of critical illness with the aging process itself. Yet, significant barriers to research for critical illness in aging exist. We review the state of knowledge and identify gaps in knowledge, research opportunities, and barriers to research, with the goal of promoting an integrated research agenda for critical illness in aging. PMID:20558632

Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice.

PubMed

Murphy, David J; Pronovost, Peter J; Lehmann, Christoph U; Gurses, Ayse P; Whitman, Glenn J R; Needham, Dale M; Berenholtz, Sean M

2014-10-01

Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence. A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland. Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers. Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices. © 2014 AABB.

Endotoxin Elimination in Patients with Septic Shock: An Observation Study.

PubMed

Adamik, Barbara; Zielinski, Stanislaw; Smiechowicz, Jakub; Kübler, Andrzej

2015-12-01

To evaluate the effectiveness of endotoxin elimination with an adsorption column in patients with septic shock and endotoxemia. The elimination therapy was guided by a new bedside method of measuring endotoxin activity (EA). Intensive care unit (ICU) patients with septic shock and suspected Gram-negative infection were consecutively added to the study group within the first 24 h. Endotoxin elimination was performed using hemoperfusion with the Alteco LPS Adsorber. The primary endpoint was improvement in organ function within the first 24 h of treatment. A secondary objective was to assess the usefulness of a new method of measuring EA to help guide endotoxin elimination therapy. Out of 64 patients 18 had a high baseline EA [0.70 EA units (0.66-0.77)]. Those patients had endotoxin elimination treatment in addition to conventional medical therapy. At 24 h after endotoxin elimination, the EA had decreased to 0.56 EA units (0.43-0.77), (p = 0.005); MAP increased from 69 (62-80) to 80 mm Hg (68-88), (p = 0.002), and noradrenaline use decreased from 0.28 (0.15-0.80) to 0.1 μg/kg/min (0.00-0.70) at the same time (p = 0.04). The SOFA score had decreased from 11 (9-15) to 9 (7-14) points 24 h after endotoxin elimination (p = 0.01) with a median delta SOFA -2 points. Endotoxin elimination did not have a significant effect on the ICU length of stay or ICU mortality. Effective endotoxin elimination resulted in a significant improvement in hemodynamic parameters and of organ function. The application of the EA assay was useful for the bedside monitoring of endotoxemia in critically ill ICU patients.

Effects of reflection on clinical decision-making of intensive care unit nurses.

PubMed

Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani

2018-07-01

Nurses are one of the most influential factors in overcoming the main challenges faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. This study evaluated the effects of implementing Tanner's reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). This study used an experimental, pretest, posttest design. The setting was the intensive care unit of Amin Hospital Isfahan, Iran. The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-14). The questionnaire was completed before and one week after the intervention. The data were analyzed using SPSS 21.0. The two groups were not significantly different in terms of the level and mean scores of clinical decision-making before the intervention (P = 0.786). Based on the results of independent t-test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann Whitney test showed that one week after the intervention, the nurses' level of clinical decision-making in the case group rose to the next level (P = 0.001). Reflection could improve the clinical decision-making of ICU nurses. It is, thus, recommended to incorporate this method into the nursing curriculum and care practices. Copyright © 2018. Published by Elsevier Ltd.

Poststroke delirium incidence and outcomes: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

PubMed

Mitasova, Adela; Kostalova, Milena; Bednarik, Josef; Michalcakova, Radka; Kasparek, Tomas; Balabanova, Petra; Dusek, Ladislav; Vohanka, Stanislav; Ely, E Wesley

2012-02-01

To describe the epidemiology and time spectrum of delirium using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and to validate a tool for delirium assessment in patients in the acute poststroke period. A prospective observational cohort study. The stroke unit of a university hospital. A consecutive series of 129 patients with stroke (with infarction or intracerebral hemorrhage, 57 women and 72 men; mean age, 72.5 yrs; age range, 35-93 yrs) admitted to the stroke unit of a university hospital were evaluated for delirium incidence. None. Criterion validity and overall accuracy of the Czech version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were determined using serial daily delirium assessments with CAM-ICU by a junior physician compared with delirium diagnosis by delirium experts using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria that began the first day after stroke onset and continued for at least 7 days. Cox regression models using time-dependent covariate analysis adjusting for age, gender, prestroke dementia, National Institutes of Stroke Health Care at admission, first-day Sequential Organ Failure Assessment, and asphasia were used to understand the relationships between delirium and clinical outcomes. An episode of delirium based on reference Diagnostic and Statistical Manual assessment was detected in 55 patients with stroke (42.6%). In 37 of these (67.3%), delirium began within the first day and in all of them within 5 days of stroke onset. A total of 1003 paired CAM-ICU/Diagnostic and Statistical Manual of Mental Disorders daily assessments were completed. Compared with the reference standard for diagnosing delirium, the CAM-ICU demonstrated a sensitivity of 76% (95% confidence interval [CI] 55% to 91%), a specificity of 98% (95% CI 93% to 100%), an overall accuracy of 94% (95% CI 88% to 97%), and high interrater reliability (κ = 0.94; 95% CI 0.83-1.0). The likelihood ratio of the CAM-ICU in the diagnosis of delirium was 47 (95% CI 27-83). Delirium was an independent predictor of increased length of hospital stay (hazard ratio 1.63; 95% CI 1.11-2.38; p = .013). Poststroke delirium may frequently be detected provided that the testing algorithm is appropriate to the time profile of poststroke delirium. Early (first day after stroke onset) and serial screening for delirium is recommended. CAM-ICU is a valid instrument for the diagnosis of delirium and should be considered an aid in delirium screening and assessment in future epidemiologic and interventional studies in patients with stroke.

The effect of intensive care unit admission on smokers' attitudes and their likelihood of quitting smoking.

PubMed

Polmear, C M; Nathan, H; Bates, S; French, C; Odisho, J; Skinner, E; Karahalios, A; McGain, F

2017-11-01

We sought to estimate the proportion of patients admitted to a metropolitan intensive care unit (ICU) who were current smokers, and the relationships between ICU survivors who smoked and smoking cessation and/or reduction six months post-ICU discharge. We conducted a prospective cohort study at a metropolitan level III ICU in Melbourne, Victoria. One hundred consecutive patients who met the inclusion criteria were included in the study. Inclusion criteria consisted of patients who were smokers at time of ICU admission, had an ICU length of stay greater than one day, survived to ICU discharge, and provided written informed consent. A purpose-designed questionnaire which included the Fagerstrom test for nicotine dependence and evaluation of patients' attitude towards smoking cessation was completed by participants following ICU discharge and prior to hospital discharge. Participants were re-interviewed over the phone at six months post-ICU discharge. Of the 1,062 patients admitted to ICU, 253 (23%) were current smokers and 100 were enrolled. Six months post-ICU discharge, 28 (33%) of the 86 participants who were alive and contactable had quit smoking and 35 (41%) had reduced smoking. The median number of reported cigarettes smoked per day reduced by 40%. Participants who initially believed their ICU admission was smoking-related were more likely to have quit six months post-ICU discharge (odds ratio 2.98; 95% confidence interval 1.07 to 8.26; P=0.036). Six months post-ICU discharge, 63/86 (74%) of participants had quit or reduced their smoking. Further research into targeted smoking cessation counselling for ICU survivors is indicated.

Effects of Stress on Critical Care Nurses: A National Cross-Sectional Study.

PubMed

Vahedian-Azimi, Amir; Hajiesmaeili, Mohammadreza; Kangasniemi, Mari; Fornés-Vives, Joana; Hunsucker, Rita L; Rahimibashar, Farshid; Pourhoseingholi, Mohammad A; Farrokhvar, Leily; Miller, Andrew C

2017-01-01

Health care is a demanding field, with a high level of responsibility and exposure to emotional and physical danger. High levels of stress may result in depression, anxiety, burnout syndrome, and in extreme cases, post-traumatic stress disorder. The aim of this study was to determine which personal, professional, and organizational variables are associated with greater perceived stress among critical care nurses for purposes of developing integrative solutions to decrease stress in the future. We conducted a correlation research survey using a cross-sectional design and an in-person survey method. The questionnaire consisted of 2 parts: (1) socioeconomic, professional, and institutional variables and (2) work stressors. Surveys were conducted between January 1, 2011, and December 1, 2015. Multistage cluster random sampling was utilized for data collection. Inclusion criteria were (1) age ≥18 years, (2) registered nurse, (3) works in the intensive care unit (ICU), and (4) willing and able to complete the survey. We surveyed 21 767 ICU nurses in Iran and found that male sex, lower levels of peer collaboration, working with a supervisor in the unit, nurse-patient ratios, and working in a surgical ICU were positively associated with greater stress levels. Increasing age and married status were negatively associated with stress. Intensive care unit type (semi-closed vs open), ICU bed number, shift time, working on holidays, education level, and demographic factors including body mass index, and number of children were not significantly associated with stress levels. As the largest study of its kind, these findings support those found in various European, North, and South American studies. Efforts to decrease workplace stress of ICU nurses by focusing on facilitating peer collaboration, improving resource availability, and staffing ratios are likely to show the greatest impact on stress levels.

Procalcitonin decrease over 72 hours in US critical care units predicts fatal outcome in sepsis patients

PubMed Central

2013-01-01

Introduction Close monitoring and repeated risk assessment of sepsis patients in the intensive care unit (ICU) is important for decisions regarding care intensification or early discharge to the ward. We studied whether considering plasma kinetics of procalcitonin, a biomarker of systemic bacterial infection, over the first 72 critical care hours improved mortality prognostication of septic patients from two US settings. Methods This retrospective analysis included consecutively treated eligible adults with a diagnosis of sepsis from critical care units in two independent institutions in Clearwater, FL and Chicago, IL. Cohorts were used for derivation or validation to study the association between procalcitonin change over the first 72 critical care hours and mortality. Results ICU/in-hospital mortality rates were 29.2%/31.8% in the derivation cohort (n = 154) and 17.6%/29.4% in the validation cohort (n = 102). In logistic regression analysis of both cohorts, procalcitonin change was strongly associated with ICU and in-hospital mortality independent of clinical risk scores (Acute Physiology, Age and Chronic Health Evaluation IV or Simplified Acute Physiology Score II), with area under the curve (AUC) from 0.67 to 0.71. When procalcitonin decreased by at least 80%, the negative predictive value for ICU/in-hospital mortality was 90%/90% in the derivation cohort, and 91%/79% in the validation cohort. When procalcitonin showed no decrease or increased, the respective positive predictive values were 48%/48% and 36%/52%. Discussion In septic patients, procalcitonin kinetics over the first 72 critical care hours provide prognostic information beyond that available from clinical risk scores. If these observations are confirmed, procalcitonin monitoring may assist physician decision-making regarding care intensification or early transfer from the ICU to the floor. PMID:23787145

Prevention of ventilator-associated pneumonia, mortality and all intensive care unit acquired infections by topically applied antimicrobial or antiseptic agents: a meta-analysis of randomized controlled trials in intensive care units

PubMed Central

2011-01-01

Introduction Given the high morbidity and mortality attributable to ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients, prevention plays a key role in the management of patients undergoing mechanical ventilation. One of the candidate preventive interventions is the selective decontamination of the digestive or respiratory tract (SDRD) by topical antiseptic or antimicrobial agents. We performed a meta-analysis to investigate the effect of topical digestive or respiratory tract decontamination with antiseptics or antibiotics in the prevention of VAP, of mortality and of all ICU-acquired infections in mechanically ventilated ICU patients. Methods A meta-analysis of randomised controlled trials was performed. The U.S. National Library of Medicine's MEDLINE database, Embase, and Cochrane Library computerized bibliographic databases, and reference lists of selected studies were used. Selection criteria for inclusion were: randomised controlled trials (RCTs); primary studies; examining the reduction of VAP and/or mortality and/or all ICU-acquired infections in ICU patients by prophylactic use of one or more of following topical treatments: 1) oropharyngeal decontamination using antiseptics or antibiotics, 2) gastrointestinal tract decontamination using antibiotics, 3) oropharyngeal plus gastrointestinal tract decontamination using antibiotics and 4) respiratory tract decontamination using antibiotics; reported enough data to estimate the odds ratio (OR) or risk ratio (RR) and their variance; English language; published through June 2010. Results A total of 28 articles met all inclusion criteria and were included in the meta-analysis. The overall estimate of efficacy of topical SDRD in the prevention of VAP was 27% (95% CI of efficacy = 16% to 37%) for antiseptics and 36% (95% CI of efficacy = 18% to 50%) for antibiotics, whereas in none of the meta-analyses conducted on mortality was a significant effect found. The effect of topical SDRD in the prevention of all ICU-acquired infections was statistically significant (efficacy = 29%; 95% CI of efficacy = 14% to 41%) for antibiotics whereas the use of antiseptics did not show a significant beneficial effect. Conclusions Topical SDRD using antiseptics or antimicrobial agents is effective in reducing the frequency of VAP in ICU. Unlike antiseptics, the use of topical antibiotics seems to be effective also in preventing all ICU-acquired infections, while the effectiveness on mortality of these two approaches needs to be investigated in further research. PMID:21702946

Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.

PubMed

Garrouste-Orgeas, Maité; Montuclard, Luc; Timsit, Jean-François; Reignier, Jean; Desmettre, Thibault; Karoubi, Philippe; Moreau, Delphine; Montesino, Laurent; Duguet, Alexandre; Boussat, Sandrine; Ede, Christophe; Monseau, Yannick; Paule, Thierry; Misset, Benoit; Carlet, Jean

2005-04-01

To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. Observational, prospective, multiple-center study. Four university hospitals and seven primary-care hospitals in France. None. Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.

Team situation awareness and the anticipation of patient progress during ICU rounds.

PubMed

Reader, Tom W; Flin, Rhona; Mearns, Kathryn; Cuthbertson, Brian H

2011-12-01

The ability of medical teams to develop and maintain team situation awareness (team SA) is crucial for patient safety. Limited research has investigated team SA within clinical environments. This study reports the development of a method for investigating team SA during the intensive care unit (ICU) round and describes the results. In one ICU, a sample of doctors and nurses (n = 44, who combined to form 37 different teams) were observed during 34 morning ward rounds. Following the clinical review of each patient (n = 105), team members individually recorded their anticipations for expected patient developments over 48 h. Patient-outcome data were collected to determine the accuracy of anticipations. Anticipations were compared among ICU team members, and the degree of consensus was used as a proxy measure of team SA. Self-report and observational data measured team-member involvement and communication during patient reviews. For over half of 105 patients, ICU team members formed conflicting anticipations as to whether patients would deteriorate within 48 h. Senior doctors were most accurate in their predictions. Exploratory analysis found that team processes did not predict team SA. However, the involvement of junior and senior trainee doctors in the patient decision-making process predicted the extent to which those team members formed team SA with senior doctors. A new method for measuring team SA during the ICU round was successfully employed. A number of areas for future research were identified, including refinement of the situation awareness and teamwork measures.

Variation in intensive care unit utilization and mortality after blunt splenic injury.

PubMed

Kaufman, Elinore J; Wiebe, Douglas J; Martin, Niels D; Pascual, Jose L; Reilly, Patrick M; Holena, Daniel N

2016-06-15

Although trauma patients are frequently cared for in the intensive care unit (ICU), admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission. We conducted a retrospective cohort study of patients treated for blunt splenic injuries from 2011-2014 at 30 level I and II Pennsylvania trauma centers. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman's rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement between high and low-ICU-utilization centers. Of 2587 patients with blunt splenic injuries, 63.9% (1654) were admitted to the ICU. Median injury severity score was 17 overall, 13 for non-ICU patients and 17 for ICU patients (P < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9%-87.3%. Risk-adjusted mortality rates ranged from 1.2%-9.6%. There was no correlation between observed-to-expected ratios for ICU utilization and mortality (Spearman's rho = -0.2595, P = 0.2103). Proportionately fewer ICU patients received critical care procedures at high-utilization centers than at low-utilization centers. Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality. Copyright © 2016 Elsevier Inc. All rights reserved.

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units.

PubMed

Parshuram, Christopher S; Kirpalani, Haresh; Mehta, Sangeeta; Granton, John; Cook, Deborah

2006-06-01

Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs. : Cross-sectional survey. Canadian adult and pediatric ICUs. ICU directors. ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs. Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, <1 yr, >10 yrs); 129 (48%) had <3 months of ICU experience. Most shifts (83%) were >20 hrs long. In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.

Risk factors for post-ICU red blood cell transfusion: a prospective study

PubMed Central

Marque, Sophie; Cariou, Alain; Chiche, Jean-Daniel; Mallet, Vincent Olivier; Pene, Frédéric; Mira, Jean-Paul; Dhainaut, Jean-François; Claessens, Yann-Erick

2006-01-01

Introduction Factors predictive of the need for red blood cell (RBC) transfusion in the intensive care unit (ICU) have been identified, but risk factors for transfusion after ICU discharge are unknown. This study aims identifies risk factors for RBC transfusion after discharge from the ICU. Methods A prospective, monocentric observational study was conducted over a 6-month period in a 24-bed medical ICU in a French university hospital. Between June and December 2003, 550 critically ill patients were consecutively enrolled in the study. Results A total of 428 patients survived after treatment in the ICU; 47 (11% of the survivors, 8.5% of the whole population) required RBC transfusion within 7 days after ICU discharge. Admission for sepsis (odds ratio [OR] 341.60, 95% confidence interval [CI] 20.35–5734.51), presence of an underlying malignancy (OR 32.6, 95%CI 3.8–280.1), female sex (OR 5.4, 95% CI 1.2–24.9), Logistic Organ Dysfunction score at ICU discharge (OR 1.45, 95% CI 1.1–1.9) and age (OR 1.06, 95% CI 1.02–1.12) were independently associated with RBC transfusion after ICU stay. Haemoglobin level at discharge predicted the need for delayed RBC transfusion. Use of vasopressors (OR 0.01, 95%CI 0.001–0.17) and haemoglobin level at discharge from the ICU (OR 0.02, 95% CI 0.007–0.09; P < 0.001) were strong independent predictors of transfusion of RBC 1 week after ICU discharge. Conclusion Sepsis, underlying conditions, unresolved organ failures and haemoglobin level at discharge were related to an increased risk for RBC transfusion after ICU stay. We suggest that strategies to prevent transfusion should focus on homogeneous subgroups of patients and take into account post-ICU needs for RBC transfusion. PMID:16965637

Increasing Access to Palliative Care Services in the Intensive Care Unit.

PubMed

McCarroll, Caitlin Marie

The Institute of Medicine's report, Dying in America, highlights the critical need for the widespread implementation of palliative care to improve end-of-life care. Approximately 20% of all deaths in America occur during or shortly after an intensive care unit (ICU) admission; therefore, it is important for critical care units to have systems in place to facilitate patient access to palliative care services. The aim of this quality improvement (QI) project was to develop and implement a palliative care screening tool using evidence-based triggers to help increase the proportion of palliative care consultations in the ICU setting. A QI project was designed and implemented in a 14-bed medical-surgical ICU in the southeastern United States using the Plan-Do-Study-Act cycle. A palliative care screening tool was developed by an interdisciplinary team of key stakeholders in the ICU using evidence-based triggers, and staff were educated on the intervention. The proportion of ICU patients who received a palliative care consultation was compared preintervention and postintervention to determine whether the QI project contributed to an increased proportion of palliative care consultations. The proportion of palliative care consultations among patients admitted to the ICU by the pulmonary critical care team increased from 1 of 10 preintervention to 3 of 10 postintervention, resulting in a promising increase in patients receiving palliative care services consistent with evidence-based recommendations. The use of an evidence-based screening tool to trigger palliative care consultation in the ICU setting can aid in increasing the proportion of critical care patients who receive a palliative care referral. The increase in the proportion of palliative care referrals by the pulmonary critical care service warrants expansion of the intervention to include additional medical subspecialists who frequently admit patients in this ICU setting. Further assessment of the intervention is warranted to determine whether the screening tool can aid in increasing palliative care consultations for more patients admitted to the hospital's ICU.

To develop a regional ICU mortality prediction model during the first 24 h of ICU admission utilizing MODS and NEMS with six other independent variables from the Critical Care Information System (CCIS) Ontario, Canada.

PubMed

Kao, Raymond; Priestap, Fran; Donner, Allan

2016-01-01

Intensive care unit (ICU) scoring systems or prediction models evolved to meet the desire of clinical and administrative leaders to assess the quality of care provided by their ICUs. The Critical Care Information System (CCIS) is province-wide data information for all Ontario, Canada level 3 and level 2 ICUs collected for this purpose. With the dataset, we developed a multivariable logistic regression ICU mortality prediction model during the first 24 h of ICU admission utilizing the explanatory variables including the two validated scores, Multiple Organs Dysfunctional Score (MODS) and Nine Equivalents Nursing Manpower Use Score (NEMS) followed by the variables age, sex, readmission to the ICU during the same hospital stay, admission diagnosis, source of admission, and the modified Charlson Co-morbidity Index (CCI) collected through the hospital health records. This study is a single-center retrospective cohort review of 8822 records from the Critical Care Trauma Centre (CCTC) and Medical-Surgical Intensive Care Unit (MSICU) of London Health Sciences Centre (LHSC), Ontario, Canada between 1 Jan 2009 to 30 Nov 2012. Multivariable logistic regression on training dataset (n = 4321) was used to develop the model and validate by bootstrapping method on the testing dataset (n = 4501). Discrimination, calibration, and overall model performance were also assessed. The predictors significantly associated with ICU mortality included: age (p < 0.001), source of admission (p < 0.0001), ICU admitting diagnosis (p < 0.0001), MODS (p < 0.0001), and NEMS (p < 0.0001). The variables sex and modified CCI were not significantly associated with ICU mortality. The training dataset for the developed model has good discriminating ability between patients with high risk and those with low risk of mortality (c-statistic 0.787). The Hosmer and Lemeshow goodness-of-fit test has a strong correlation between the observed and expected ICU mortality (χ (2) = 5.48; p > 0.31). The overall optimism of the estimation between the training and testing data set ΔAUC = 0.003, indicating a stable prediction model. This study demonstrates that CCIS data available after the first 24 h of ICU admission at LHSC can be used to create a robust mortality prediction model with acceptable fit statistic and internal validity for valid benchmarking and monitoring ICU performance.

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey.

PubMed

Bakhru, Rita N; McWilliams, David J; Wiebe, Douglas J; Spuhler, Vicki J; Schweickert, William D

2016-09-01

Early mobilization (EM) improves outcomes for mechanically ventilated patients. Variation in structure and organizational characteristics may affect implementation of EM practices. We queried intensive care unit (ICU) environment and standardized ICU practices to evaluate organizational characteristics that enable EM practice. We recruited 151 ICUs in France, 150 in Germany, 150 in the United Kingdom, and 500 in the United States by telephone. Survey domains included respondent characteristics, hospital and ICU characteristics, and ICU practices and protocols. We surveyed 1,484 ICU leaders and received a 64% response rate (951 ICUs). Eighty-eight percent of respondents were in nursing leadership roles; the remainder were physiotherapists. Surveyed ICUs were predominantly mixed medical-surgical units (67%), and 27% were medical ICUs. ICU staffing models differed significantly (P < 0.001 each) by country for high-intensity staffing, nurse/patient ratios, and dedicated physiotherapists. ICU practices differed by country, with EM practices present in 40% of French ICUs, 59% of German ICUs, 52% of U.K. ICUs, and 45% of U.S. ICUs. Formal written EM protocols were present in 24%, 30%, 20%, and 30%, respectively, of those countries' ICUs. In multivariate analysis, EM practice was associated with multidisciplinary rounds (odds ratio [OR], 1.77; P = 0.001), setting daily goals for patients (OR, 1.62; P = 0.02), presence of a dedicated physiotherapist (OR, 2.48; P < 0.001), and the ICU's being located in Germany (reference, United States; OR, 2.84; P < 0.001). EM practice was also associated with higher nurse staffing levels (1:1 nurse/patient ratio as a reference; 1:2 nurse/patient ratio OR, 0.59; P = 0.05; 1:3 nurse/patient ratio OR, 0.33; P = 0.005; 1:4 or less nurse/patient ratio OR, 0.37; P = 0.005). Those responding rarely cited ambulation of mechanically ventilated patients, use of a bedside cycle, or neuromuscular electrical stimulation as part of their EM practice. Physical therapy initiation, barriers to EM practice, and EM equipment were highly variable among respondents. International ICU structure and practice is quite heterogeneous, and several factors (multidisciplinary rounds, setting daily goals for patients, presence of a dedicated physiotherapist, country, and nurse/patient staffing ratio) are significantly associated with the practice of EM. Practice and barriers may be far different based upon staffing structure. To achieve successful implementation, whether through trials or quality improvement, ICU staffing and practice patterns must be taken into account.

A comparison of intensive care unit care of surgical patients in teaching and nonteaching hospitals.

PubMed Central

Fakhry, S M; Buehrer, J L; Sheldon, G F; Meyer, A A

1991-01-01

Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care. PMID:2064466

Infrastructure for quality transformation: measurement and reporting in veterans administration intensive care units.

PubMed

Render, Marta L; Freyberg, Ron W; Hasselbeck, Rachael; Hofer, Timothy P; Sales, Anne E; Deddens, James; Levesque, Odette; Almenoff, Peter L

2011-06-01

BACKGROUND Veterans Health Administration (VA) intensive care units (ICUs) develop an infrastructure for quality improvement using information technology and recruiting leadership. METHODS Setting Participation by the 183 ICUs in the quality improvement program is required. Infrastructure includes measurement (electronic data extraction, analysis), quarterly web-based reporting and implementation support of evidence-based practices. Leaders prioritise measures based on quality improvement objectives. The electronic extraction is validated manually against the medical record, selecting hospitals whose data elements and measures fall at the extremes (10th, 90th percentile). results are depicted in graphic, narrative and tabular reports benchmarked by type and complexity of ICU. RESULTS The VA admits 103 689±1156 ICU patients/year. Variation in electronic business practices, data location and normal range of some laboratory tests affects data quality. A data management website captures data elements important to ICU performance and not available electronically. A dashboard manages the data overload (quarterly reports ranged 106-299 pages). More than 85% of ICU directors and nurse managers review their reports. Leadership interest is sustained by including ICU targets in executive performance contracts, identification of local improvement opportunities with analytic software, and focused reviews. CONCLUSION Lessons relevant to non-VA institutions include the: (1) need for ongoing data validation, (2) essential involvement of leadership at multiple levels, (3) supplementation of electronic data when key elements are absent, (4) utility of a good but not perfect electronic indicator to move practice while improving data elements and (5) value of a dashboard.

The impact of reducing intensive care unit length of stay on hospital costs: evidence from a tertiary care hospital in Canada.

PubMed

Evans, Jessica; Kobewka, Daniel; Thavorn, Kednapa; D'Egidio, Gianni; Rosenberg, Erin; Kyeremanteng, Kwadwo

2018-02-23

To use theoretical modelling exercises to determine the effect of reduced intensive care unit (ICU) length of stay (LOS) on total hospital costs at a Canadian centre. We conducted a retrospective cost analysis from the perspective of one tertiary teaching hospital in Canada. Cost, demographic, clinical, and LOS data were retrieved through case-costing, patient registry, and hospital abstract systems of The Ottawa Hospital Data Warehouse for all new in-patient ward (30,483) and ICU (2,239) encounters between April 2012 and March 2013. Aggregate mean daily variable direct (VD) costs for ICU vs ward encounters were summarized by admission day number, LOS, and cost centre. The mean daily VD cost per ICU patient was $2,472 (CAD), accounting for 67.0% of total daily ICU costs per patient and $717 for patients admitted to the ward. Variable direct cost is greatest on the first day of ICU admission ($3,708), and then decreases by 39.8% to plateau by the fifth day of admission. Reducing LOS among patients with ICU stays ≥ four days could potentially result in an annual hospital cost saving of $852,146 which represents 0.3% of total in-patient hospital costs and 1.2% of ICU costs. Reducing ICU LOS has limited cost-saving potential given that ICU costs are greatest early in the course of admission, and this study does not support the notion of reducing ICU LOS as a sole cost-saving strategy.

End-of-Life Care in the Intensive Care Unit

PubMed Central

Engelberg, Ruth A.; Bensink, Mark E.; Ramsey, Scott D.

2012-01-01

The incidence and costs of critical illness are increasing in the United States at a time when there is a focus both on limiting the rising costs of healthcare and improving the quality of end-of-life care. More than 25% of healthcare costs are spent in the last year of life, and approximately 20% of deaths occur in the intensive care unit (ICU). Consequently, there has been speculation that end-of-life care in the ICU represents an important target for cost savings. It is unclear whether efforts to improve end-of-life care in the ICU could significantly reduce healthcare costs. Here, we summarize recent studies suggesting that important opportunities may exist to improve quality and reduce costs through two mechanisms: advance care planning for patients with life-limiting illness and use of time-limited trials of ICU care for critically ill patients. The goal of these approaches is to ensure patients receive the intensity of care that they would choose at the end of life, given the opportunity to make an informed decision. Although these mechanisms hold promise for increasing quality and reducing costs, there are few clearly described, effective methods to implement these mechanisms in routine clinical practice. We believe basic science in communication and decision making, implementation research, and demonstration projects are critically important if we are to translate these approaches into practice and, in so doing, provide high-quality and patient-centered care while limiting rising healthcare costs. PMID:22859524

Occurrence of bla genes encoding carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii from Intensive Care Unit in a tertiary care hospital

PubMed Central

Subramaniyan, Jayanthi Siva; Sundaram, Jeya Meenakshi

2018-01-01

CONTEXT: ICU shows increasing incidence of infection associated with the use of invasive procedures for the diagnostic purpose as well as the indiscriminate use of antibiotics. Pseudomonas aeruginosa and Acinetobacter species are “very successful” pathogen and the emergence of the Metallo-β-Lactamases (MBL) is becoming a therapeutic challenge. AIMS: To isolate the Nonfermenting Gram negative bacilli from the ICU samples. To identify the metallo betalactamase producers and to detect the bla gene presence among the Pseudomonas aeruginosa and Acinetobacter baumannii. SETTINGS AND DESIGN: The Nonfermenting Gram negative bacilli isolates from the ICU samples were taken over for 5 years (2009-2014) in a tertiary care hospital. METHODS AND MATERIALS: The isolates of Pseudomonas species and Acinetobacter species were confirmed by API analyser and processed according to standard procedures. Detection of the MBL producers were done by E strip method and subjected for bla gene detection by PCR method. RESULTS: In our study a total of 195 isolates of NFGNB were obtained from various ICU. Of these MBL producers, 26 % were Pseudomonas aeruginosa and 25 % were Acinetobacter baumannii. The subtypes of blaVIM MBL producing P.aeruginosa were 26%. The predominant gene coding for MBL activity in A.baumannii were found to be blaOXA gene 11.9%. The gene accession numbers were KF975367, KF975372. CONCLUSIONS: We have to control the development and dissemination of these superbugs among the ICU's. PMID:29692589

An External Independent Validation of APACHE IV in a Malaysian Intensive Care Unit.

PubMed

Wong, Rowena S Y; Ismail, Noor Azina; Tan, Cheng Cheng

2015-04-01

Intensive care unit (ICU) prognostic models are predominantly used in more developed nations such as the United States, Europe and Australia. These are not that popular in Southeast Asian countries due to costs and technology considerations. The purpose of this study is to evaluate the suitability of the acute physiology and chronic health evaluation (APACHE) IV model in a single centre Malaysian ICU. A prospective study was conducted at the single centre ICU in Hospital Sultanah Aminah (HSA) Malaysia. External validation of APACHE IV involved a cohort of 916 patients who were admitted in 2009. Model performance was assessed through its calibration and discrimination abilities. A first-level customisation using logistic regression approach was also applied to improve model calibration. APACHE IV exhibited good discrimination, with an area under receiver operating characteristic (ROC) curve of 0.78. However, the model's overall fit was observed to be poor, as indicated by the Hosmer-Lemeshow goodness-of-fit test (Ĉ = 113, P <0.001). Predicted in-ICU mortality rate (28.1%) was significantly higher than the actual in-ICU mortality rate (18.8%). Model calibration was improved after applying first-level customisation (Ĉ = 6.39, P = 0.78) although discrimination was not affected. APACHE IV is not suitable for application in HSA ICU, without further customisation. The model's lack of fit in the Malaysian study is attributed to differences in the baseline characteristics between HSA ICU and APACHE IV datasets. Other possible factors could be due to differences in clinical practice, quality and services of health care systems between Malaysia and the United States.

Incidence and Risk Factors for Intensive Care Unit–related Post-traumatic Stress Disorder in Veterans and Civilians

PubMed Central

Jackson, James C.; Morandi, Alessandro; Girard, Timothy D.; Hughes, Christopher G.; Thompson, Jennifer L.; Kiehl, Amy L.; Elstad, Mark R.; Wasserstein, Mitzi L.; Goodman, Richard B.; Beckham, Jean C.; Chandrasekhar, Rameela; Dittus, Robert S.; Ely, E. Wesley; Pandharipande, Pratik P.

2016-01-01

Rationale: The incidence and risk factors of post-traumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience have not been reported in a mixed veteran and civilian cohort. Objectives: To describe the incidence and risk factors for ICU-related PTSD in veterans and civilians. Methods: This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness after respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without preexisting PTSD (i.e., PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3 and 12 months post hospitalization. Measurements and Main Results: Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in up to 10% of patients at either follow-up time point, whether assessed by PTSD Checklist Event-Specific Version (score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, preexisting PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was preexisting depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48). Conclusions: This study found around 1 in 10 ICU survivors experienced ICU-related PTSD (i.e., PTSD anchored to their critical illness) in the year after hospitalization. Preexisting PTSD and depression were strongly associated with ICU-related PTSD. PMID:26735627

In Silico Testing of an Artificial-Intelligence-Based Artificial Pancreas Designed for Use in the Intensive Care Unit Setting

PubMed Central

DeJournett, Leon; DeJournett, Jeremy

2016-01-01

Background: Effective glucose control in the intensive care unit (ICU) setting has the potential to decrease morbidity and mortality rates which should in turn lead to decreased health care expenditures. Current ICU-based glucose controllers are mathematically derived, and tend to be based on proportional integral derivative (PID) or model predictive control (MPC). Artificial intelligence (AI)–based closed loop glucose controllers may have the ability to achieve control that improves on the results achieved by either PID or MPC controllers. Method: We conducted an in silico analysis of an AI-based glucose controller designed for use in the ICU setting. This controller was tested using a mathematical model of the ICU patient’s glucose-insulin system. A total of 126 000 unique 5-day simulations were carried out, resulting in 107 million glucose values for analysis. Results: For the 7 control ranges tested, with a sensor error of ±10%, the following average results were achieved: (1) time in control range, 94.2%, (2) time in range 70-140 mg/dl, 97.8%, (3) time in hyperglycemic range (>140 mg/dl), 2.1%, and (4) time in hypoglycemic range (<70 mg/dl), 0.09%. In addition, the average coefficient of variation (CV) was 11.1%. Conclusions: This in silico study of an AI-based closed loop glucose controller shows that it may be able to improve on the results achieved by currently existing ICU-based PID/MPC controllers. If these results are confirmed in clinical testing, this AI-based controller could be used to create an artificial pancreas system for use in the ICU setting. PMID:27301982

Population pharmacokinetic study of isepamicin with intensive care unit patients.

PubMed Central

Tod, M; Padoin, C; Minozzi, C; Cougnard, J; Petitjean, O

1996-01-01

The pharmacokinetics (PK) of isepamicin, a new aminoglycoside, were studied in 85 intensive care unit (ICU) patients and were compared with those observed in 10 healthy volunteers. A parametric method based on a nonlinear mixed-effect model was used to assess population PK. Isepamicin was given intravenously over 0.5 h at dosages of 15 mg/kg once daily or 7.5 mg/kg twice daily. The data were fitted to a bicompartmental open model. Compared with healthy volunteers, the mean values of the PK parameters were profoundly modified in ICU patients: elimination clearance was reduced by 48%, the volume of distribution in the central compartment (Vc) was increased by 50%, the peripheral volume of distribution was 70% higher, the distribution clearance was 146% lower, and the elimination half-life was ca. 3.4 times higher. The interindividual variability in PK parameters was about 50% in ICU patients. Five covariates (body weight [BW], simplified acute physiology score [SAPS], temperature, serum creatinine level, and creatinine clearance [CLCR]) were tentatively correlated with PK parameters by multivariate linear regression analysis with stepwise addition and deletion. The variability of isepamicin clearance was explained by three covariates (BW, SAPS, and CLCR), that of Vc was explained by BW and SAPS, and that of the elimination half-life was explained by CLCR and SAPS. Simulation of the concentration-versus-time profile for 500 individuals showed that the mean peak (0.75 h) concentration was 18% lower in ICU patients than in healthy volunteers and that the range in ICU patients was very broad (28.4 to 95.4 mg/liter). Therefore, monitoring of the isepamicin concentration is in ICU patients is mandatory. PMID:8849264

Incidence, Microbiological Profile and Risk Factors of Healthcare-Associated Infections in Intensive Care Units: A 10 Year Observation in a Provincial Hospital in Southern Poland

PubMed Central

Kołpa, Małgorzata; Wałaszek, Marta; Gniadek, Agnieszka; Wolak, Zdzisław; Dobroś, Wiesław

2018-01-01

Healthcare-associated infections (HAIs) occurring in patients treated in an intensive care unit (ICU) are serious complications in the treatment process. Aetiological factors of these infections can have an impact on treatment effects, treatment duration and mortality. The aim of the study was to determine the prevalence and microbiological profile of HAIs in patients hospitalized in an ICU over a span of 10 years. The active surveillance method was used to detect HAIs in adult patients who spent over 48 h in a general ICU ward located in southern Poland between 2007 and 2016. The study was conducted in compliance with the methodology recommended by the Healthcare-associated Infections Surveillance Network (HAI-Net) of the European Centre for Disease Prevention and Control (ECDC). During the 10 years of the study, 1849 patients hospitalized in an ICU for a total of 17,599 days acquired 510 with overall HAIs rates of 27.6% and 29.0% infections per 1000 ICU days. Intubation-associated pneumonia (IAP) posed the greatest risk (15.2 per 1000 ventilator days), followed by CLA-BSI (8.0 per 1000 catheter days) and CA-UTI (3.0 per 1000 catheter days). The most common isolated microorganism was Acinetobacter baumannii (25%) followed by Coagulaase-negativ staphylococci (15%), Escherichia coli (9%), Pseudomonas aeruginosa (8%), Klebsiella pneumoniae (7%), Candida albicans (6%). Acinetobacter baumannii in 87% and were classified as extensive-drug resistant (XDR). In summary, in ICU patients pneumonia and bloodstream infections were the most frequently found. Acinetobacter baumannii strains were most often isolated from clinical materials taken from HAI patients and showed resistance to many groups of antibiotics. A trend of increasing resistance of Acinetobacter baumannii to carbapenems was observed. PMID:29324651

Development of a Post-Intensive Care Unit Storytelling Intervention for Surrogates Involved in Decisions to Limit Life-Sustaining Treatment

PubMed Central

Schenker, Yael; Dew, Mary Amanda; Reynolds, Charles F.; Arnold, Robert M.; Tiver, Greer A.; Barnato, Amber E.

2014-01-01

Objectives Surrogates involved in decisions to limit life-sustaining treatment for a loved one in the intensive care unit (ICU) are at increased risk for adverse psychological outcomes lasting months to years after the ICU experience. Post-ICU interventions to reduce surrogate distress have not been developed. We sought to 1) describe a conceptual framework underlying the beneficial mental health effects of storytelling and 2) present formative work developing a storytelling intervention to reduce distress for recently bereaved surrogates. Methods An interdisciplinary team conceived the idea for a storytelling intervention based upon evidence from narrative theory that storytelling reduces distress from traumatic events through emotional disclosure, cognitive processing, and social connections. We developed an initial storytelling guide based upon this theory and the clinical perspectives of team members. We then conducted a case series with recently bereaved surrogates to iteratively test and modify the guide. Results The storytelling guide covered three key domains of the surrogate's experience of the patient's illness and death: antecedents, ICU experience, and aftermath. The facilitator focused on parts of the story that appeared to generate strong emotions and used non-judgmental statements to attend to these emotions. Between September 2012 and May 2013 we identified 28 eligible surrogates from 1 medical ICU and consented 20 for medical record review and recontact; 10 became eligible of whom 6 consented and completed the storytelling intervention. The single-session storytelling intervention lasted 40-92 minutes. All storytelling participants endorsed the intervention as acceptable, and 5 of 6 reported that it was helpful. Significance of Results Surrogate storytelling is an innovative and acceptable post-ICU intervention for recently bereaved surrogates and should be evaluated further. PMID:24524736

Operations research in intensive care unit management: a literature review.

PubMed

Bai, Jie; Fügener, Andreas; Schoenfelder, Jan; Brunner, Jens O

2018-03-01

The intensive care unit (ICU) is a crucial and expensive resource largely affected by uncertainty and variability. Insufficient ICU capacity causes many negative effects not only in the ICU itself, but also in other connected departments along the patient care path. Operations research/management science (OR/MS) plays an important role in identifying ways to manage ICU capacities efficiently and in ensuring desired levels of service quality. As a consequence, numerous papers on the topic exist. The goal of this paper is to provide the first structured literature review on how OR/MS may support ICU management. We start our review by illustrating the important role the ICU plays in the hospital patient flow. Then we focus on the ICU management problem (single department management problem) and classify the literature from multiple angles, including decision horizons, problem settings, and modeling and solution techniques. Based on the classification logic, research gaps and opportunities are highlighted, e.g., combining bed capacity planning and personnel scheduling, modeling uncertainty with non-homogenous distribution functions, and exploring more efficient solution approaches.

Exploring Communication Challenges Between Nurses and Mechanically Ventilated Patients in the Intensive Care Unit: A Structured Review.

PubMed

Dithole, Kefalotse; Sibanda, Sambulelwe; Moleki, Mary M; Thupayagale-Tshweneagae, Gloria

2016-06-01

Mechanical ventilation is a necessary procedure for patients with a range of illnesses and conditions. Mechanical ventilation affects voice production, leaving patients unable to communicate their needs with nurses and family. The communication difficulty causes distress, frustration, and anger if not attended to. This structured review sought to identify communication challenges which exist between nurses and mechanically ventilated patients in intensive care units (ICU) and hence explore possible solutions to improve these communication challenges. A electronic search of MEDLINE, CINAHL, and PsycINFO was conducted to identify relevant literature on nurse-patient communication challenges in the ICU published between January 2005 and December 2014. Studies meeting the inclusion criteria were retrieved in full, reviewed, and study quality assessed. Six studies were identified for inclusion in the review. Analysis identified five core influences on communication in the ICU: patient's consciousness level, nature of nurse-patient interactions, communication methods, staff skills and perceptions, and the intensive care physical environment. An evidence-based and multifactorial communication intervention encompassing staff skills development and training, development of relevant patient materials or devices and collaborations with relevant health professionals like speech and language therapists has the potential to improve nurse-patient communication in the ICU and hence improve patient outcomes. © 2016 Sigma Theta Tau International.

Prediction and early detection of delirium in the intensive care unit by using heart rate variability and machine learning.

PubMed

Oh, Jooyoung; Cho, Dongrae; Park, Jaesub; Na, Se Hee; Kim, Jongin; Heo, Jaeseok; Shin, Cheung Soo; Kim, Jae-Jin; Park, Jin Young; Lee, Boreom

2018-03-27

Delirium is an important syndrome found in patients in the intensive care unit (ICU), however, it is usually under-recognized during treatment. This study was performed to investigate whether delirious patients can be successfully distinguished from non-delirious patients by using heart rate variability (HRV) and machine learning. Electrocardiography data of 140 patients was acquired during daily ICU care, and HRV data were analyzed. Delirium, including its type, severity, and etiologies, was evaluated daily by trained psychiatrists. HRV data and various machine learning algorithms including linear support vector machine (SVM), SVM with radial basis function (RBF) kernels, linear extreme learning machine (ELM), ELM with RBF kernels, linear discriminant analysis, and quadratic discriminant analysis were utilized to distinguish delirium patients from non-delirium patients. HRV data of 4797 ECGs were included, and 39 patients had delirium at least once during their ICU stay. The maximum classification accuracy was acquired using SVM with RBF kernels. Our prediction method based on HRV with machine learning was comparable to previous delirium prediction models using massive amounts of clinical information. Our results show that autonomic alterations could be a significant feature of patients with delirium in the ICU, suggesting the potential for the automatic prediction and early detection of delirium based on HRV with machine learning.

Heterogeneous postsurgical data analytics for predictive modeling of mortality risks in intensive care units.

PubMed

Yun Chen; Hui Yang

2014-01-01

The rapid advancements of biomedical instrumentation and healthcare technology have resulted in data-rich environments in hospitals. However, the meaningful information extracted from rich datasets is limited. There is a dire need to go beyond current medical practices, and develop data-driven methods and tools that will enable and help (i) the handling of big data, (ii) the extraction of data-driven knowledge, (iii) the exploitation of acquired knowledge for optimizing clinical decisions. This present study focuses on the prediction of mortality rates in Intensive Care Units (ICU) using patient-specific healthcare recordings. It is worth mentioning that postsurgical monitoring in ICU leads to massive datasets with unique properties, e.g., variable heterogeneity, patient heterogeneity, and time asyncronization. To cope with the challenges in ICU datasets, we developed the postsurgical decision support system with a series of analytical tools, including data categorization, data pre-processing, feature extraction, feature selection, and predictive modeling. Experimental results show that the proposed data-driven methodology outperforms traditional approaches and yields better results based on the evaluation of real-world ICU data from 4000 subjects in the database. This research shows great potentials for the use of data-driven analytics to improve the quality of healthcare services.

Impact of clinical pharmacist on cost of drug therapy in the ICU

PubMed Central

Aljbouri, Tareq M.; Alkhawaldeh, Mohammed S.; Abu-Rumman, Ala’a eddeen K.; Hasan, Thamer A.; Khattar, Hakeem M.; Abu-Oliem, Atallah S.

2013-01-01

Objective To determine whether the presence of Clinical Pharmacist affects the cost of drug therapy for patients admitted to the Intensive Care Unit (ICU) at Al-Hussein hospital at Royal Medical Services in Amman, Jordan. Method This study compares the consumed quantities of drugs over two periods of time. Each period was ten months long. In the second period there was a Clinical Pharmacist. The decrease in consumption rate of drugs is considered to be an indicator of the success of Clinical Pharmacist in the ICU, as any decrease in consumption rate reflects the correct application of Clinical Pharmacy practices. The cost of this decrease in consumption rate represents the total reduction of drug therapy cost. Results The total reduction of drug therapy cost after applying Clinical Pharmacy practices in the ICU over a period of ten months was 149946.80 JD (211574.90 USD), which represents an average saving of 35.8% when compared to the first period in this study. Conclusion The results of this study showed a significant reduction in the consumed quantities of drugs and therefore a reduction in cost of drug therapy. Such findings highlight the importance of the presence of Clinical Pharmacist in all Jordanian hospitals wards and units. PMID:24227956

Implementation of a Nurse-Led Family Meeting in a Neuroscience Intensive Care Unit.

PubMed

Wu, Huixin; Ren, Dianxu; Zinsmeister, Glenn R; Zewe, Gretchen E; Tuite, Patricia K

2016-01-01

The aims of this study were to develop, implement, and evaluate the impact of early intensive care unit (ICU) nurse-led family meetings on nurse-family communication, family decision making, and satisfaction of family members. Intensive care unit nurses are in an ideal position to meet family needs, and family members may cope better with the crisis of an ICU admission if consistent honest information is provided by nurses; however, there are no early ICU family meetings led by bedside nurses. This quality improvement project was implemented in a 10-bed neuroscience ICU over a 3-month period. A convenience sample of 23 nurses participated in the project. Following development of a communication protocol to facilitate nurse-led meetings, the nurses received education and then implemented the protocol. Thirty-one family members participated in the project. Family members were surveyed before and after the meetings. Mean meeting time was 26 (SD, 14) minutes. Following implementation of the meetings, findings demonstrated that families felt that communication improved (P = .02 and P = .008), they had appropriate information for decision making allowing them to feel in control (P = .002), and there was an increase in family satisfaction (P = .001). Early ICU nurse-led family meetings were feasible, improved communication between ICU nurses and family members, facilitated decision making in ICU families, and increased satisfaction of family members.

Periscopic Spine Surgery.

DTIC Science & Technology

2000-02-01

radiation medicine, the neurosurgery intensive care unit (ICU), and the pediatrics ICU [Geary 1999a]. The major procedures impacted are spine tumor...radiation medicine, and the pediatric intensive care unit . Hardware and software problems addressed included modifications of patient positioning...planning. Attempts have been made to link mechanical tissue properties to cellular interaction through electrical impedance [7] and to Hounsfield units

Prospective study of device-related complications in intensive care unit detected by virtual autopsy.

PubMed

Wichmann, D; Heinemann, A; Zähler, S; Vogel, H; Höpker, W; Püschel, K; Kluge, S

2018-06-01

There has been increasing use of invasive techniques, such as extracorporeal organ support, in intensive care units (ICU), and declining autopsy rates. Thus, new measures are needed to maintain high-quality standards. We investigated the potential of computed tomography (CT)-based virtual autopsy to substitute for medical autopsy in this setting. We investigated the potential of virtual autopsy by post-mortem CT to identify complications associated with medical devices in a prospective study of patients who had died in the ICU. Clinical records were reviewed to determine the number and types of medical devices used, and findings from medical and virtual autopsies, related and unrelated to the medical devices, were compared. Medical and virtual autopsies could be performed in 61 patients (Group M/V), and virtual autopsy only in 101 patients (Group V). In Group M/V, 41 device-related complications and 30 device malpositions were identified, but only with a low inter-method agreement. Major findings unrelated to a device were identified in about 25% of patients with a high level of agreement between methods. In Group V, 8 device complications and 36 device malpositions were identified. Device-related complications are frequent in ICU patients. Virtual and medical autopsies showed clear differences in the detection of complications and device malpositions. Both methods should supplement each other rather than one alone for quality control of medical devices in the ICU. Further studies should focus on the identification of special patient populations in which virtual autopsy might be of particular benefit. NCT01541982. Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

A Case Study on Improving Intensive Care Unit (ICU) Services Reliability: By Using Process Failure Mode and Effects Analysis (PFMEA)

PubMed Central

Yousefinezhadi, Taraneh; Jannesar Nobari, Farnaz Attar; Goodari, Faranak Behzadi; Arab, Mohammad

2016-01-01

Introduction: In any complex human system, human error is inevitable and shows that can’t be eliminated by blaming wrong doers. So with the aim of improving Intensive Care Units (ICU) reliability in hospitals, this research tries to identify and analyze ICU’s process failure modes at the point of systematic approach to errors. Methods: In this descriptive research, data was gathered qualitatively by observations, document reviews, and Focus Group Discussions (FGDs) with the process owners in two selected ICUs in Tehran in 2014. But, data analysis was quantitative, based on failures’ Risk Priority Number (RPN) at the base of Failure Modes and Effects Analysis (FMEA) method used. Besides, some causes of failures were analyzed by qualitative Eindhoven Classification Model (ECM). Results: Through FMEA methodology, 378 potential failure modes from 180 ICU activities in hospital A and 184 potential failures from 99 ICU activities in hospital B were identified and evaluated. Then with 90% reliability (RPN≥100), totally 18 failures in hospital A and 42 ones in hospital B were identified as non-acceptable risks and then their causes were analyzed by ECM. Conclusions: Applying of modified PFMEA for improving two selected ICUs’ processes reliability in two different kinds of hospitals shows that this method empowers staff to identify, evaluate, prioritize and analyze all potential failure modes and also make them eager to identify their causes, recommend corrective actions and even participate in improving process without feeling blamed by top management. Moreover, by combining FMEA and ECM, team members can easily identify failure causes at the point of health care perspectives. PMID:27157162

Acute Kidney Injury Enhances Outcome Prediction Ability of Sequential Organ Failure Assessment Score in Critically Ill Patients

PubMed Central

Chang, Chih-Hsiang; Fan, Pei-Chun; Chang, Ming-Yang; Tian, Ya-Chung; Hung, Cheng-Chieh; Fang, Ji-Tseng; Yang, Chih-Wei; Chen, Yung-Chang

2014-01-01

Introduction Acute kidney injury (AKI) is a common and serious complication in intensive care unit (ICU) patients and also often part of a multiple organ failure syndrome. The sequential organ failure assessment (SOFA) score is an excellent tool for assessing the extent of organ dysfunction in critically ill patients. This study aimed to evaluate the outcome prediction ability of SOFA and Acute Physiology and Chronic Health Evaluation (APACHE) III score in ICU patients with AKI. Methods A total of 543 critically ill patients were admitted to the medical ICU of a tertiary-care hospital from July 2007 to June 2008. Demographic, clinical and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission. Results One hundred and eighty-seven (34.4%) patients presented with AKI on the first day of ICU admission based on the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. Major causes of the ICU admissions involved respiratory failure (58%). Overall in-ICU mortality was 37.9% and the hospital mortality was 44.7%. The predictive accuracy for ICU mortality of SOFA (areas under the receiver operating characteristic curves: 0.815±0.032) was as good as APACHE III in the AKI group. However, cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.001) for SOFA score ≤10 vs. ≥11 in these ICU patients with AKI. Conclusions For patients coexisting with AKI admitted to ICU, this work recommends application of SOFA by physicians to assess ICU mortality because of its practicality and low cost. A SOFA score of ≥ “11” on ICU day 1 should be considered an indicator of negative short-term outcome. PMID:25279844

[Quality management in intensive care medicine].

PubMed

Martin, J; Braun, J-P

2014-02-01

Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to external quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

[Quality management in intensive care medicine].

PubMed

Martin, J; Braun, J-P

2013-09-01

Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to extern quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

Non-linear feature extraction from HRV signal for mortality prediction of ICU cardiovascular patient.

PubMed

Karimi Moridani, Mohammad; Setarehdan, Seyed Kamaledin; Motie Nasrabadi, Ali; Hajinasrollah, Esmaeil

2016-01-01

Intensive care unit (ICU) patients are at risk of in-ICU morbidities and mortality, making specific systems for identifying at-risk patients a necessity for improving clinical care. This study presents a new method for predicting in-hospital mortality using heart rate variability (HRV) collected from the times of a patient's ICU stay. In this paper, a HRV time series processing based method is proposed for mortality prediction of ICU cardiovascular patients. HRV signals were obtained measuring R-R time intervals. A novel method, named return map, is then developed that reveals useful information from the HRV time series. This study also proposed several features that can be extracted from the return map, including the angle between two vectors, the area of triangles formed by successive points, shortest distance to 45° line and their various combinations. Finally, a thresholding technique is proposed to extract the risk period and to predict mortality. The data used to evaluate the proposed algorithm obtained from 80 cardiovascular ICU patients, from the first 48 h of the first ICU stay of 40 males and 40 females. This study showed that the angle feature has on average a sensitivity of 87.5% (with 12 false alarms), the area feature has on average a sensitivity of 89.58% (with 10 false alarms), the shortest distance feature has on average a sensitivity of 85.42% (with 14 false alarms) and, finally, the combined feature has on average a sensitivity of 92.71% (with seven false alarms). The results showed that the last half an hour before the patient's death is very informative for diagnosing the patient's condition and to save his/her life. These results confirm that it is possible to predict mortality based on the features introduced in this paper, relying on the variations of the HRV dynamic characteristics.

Delirium and coma evaluated in mechanically ventilated patients in the intensive care unit in Japan: a multi-institutional prospective observational study.

PubMed

Tsuruta, Ryosuke; Oda, Yasutaka; Shintani, Ayumi; Nunomiya, Shin; Hashimoto, Satoru; Nakagawa, Takashi; Oida, Yasuhisa; Miyazaki, Dai; Yabe, Shigemi

2014-06-01

The object of this study is to evaluate the prevalence and effects of delirium on 28-day mortality in critically ill patients on mechanical ventilation in Japan. Prospective cohort study was conducted in medical and surgical intensive care units (ICUs) of 24 medical centers. Patients were followed up daily for delirium during ICU stay after enrollment. Coma was defined with the Richmond Agitation Sedation Scale score of -4 or -5. Delirium was diagnosed using the Confusion Assessment Method for the ICU. The Cox proportional hazards regression model was used to assess the effects of delirium and coma on 28-day mortality, time to extubation, and time to ICU discharge; delirium and coma were included as time-varying covariates after controlling for age, Acute Physiology and Chronic Health Evaluation II score, ventilator-associated pneumonia, and the reason for intubation with infection. Of 180 patients, 115 patients (64%) developed delirium. Moreover, 15 patients (8%) died within 28 days after ICU admission, including 7 patients who experienced coma and 8 patients who experienced both coma and delirium. There were no deaths among patients who did not experience coma. Delirium was associated with a shorter time to extubation (hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.65-3.85; P<.001) and a shorter ICU length of stay in comatose patients (HR, 1.59; 95% CI, 1.04-2.44; P=.034), whereas delirium appeared with prolonged time to ICU discharge among patients without coma, although statistical significance was not detected due to limited analytical power (HR, 0.62; 95% CI, 0.34-1.12; P=.114). Delirium during ICU stay was not associated with higher mortality. Further study is needed to investigate the discrepancy between these and previous data. Copyright © 2014 Elsevier Inc. All rights reserved.

Do survivors of acute neurologic injury remember their stay in the neuroscience intensive care unit?

PubMed

Hocker, Sara; Anderson, Heidi L; McMahon, Katherine E; Wijdicks, Eelco F M

2013-06-01

Patients in medical, surgical, and trauma intensive care units (ICUs) are at risk for later development of symptoms of post-traumatic stress disorder (PTSD). Because acute brain injury can impair recall; we sought to show that neuroscience patients undergoing prolonged neuroscience ICU admission have limited memory of their ICU stay and thus are less likely to develop symptoms of PTSD. We surveyed patients >18 years admitted for 10 days or more to our neuroscience ICU over a 10-year period. The survey response rate was 50.5% (47/93). Forty percent (19/47) of respondents presented with coma. Recall of details of the ICU admission was limited. Fewer than 10% of patients who required mechanical ventilation recalled being on a ventilator. Only five patients (11%) had responses suggestive of possible post-traumatic stress syndrome. The most commonly experienced symptoms following discharge were difficulty sleeping, difficulty with concentration, and memory loss. Patients requiring prolonged neuroscience ICU admission do not appear to be traumatized by their ICU stay.

Patients with cancer in the intensive monitoring unit. New perspectives.

PubMed

Prieto Del Portillo, I; Polo Zarzuela, M; Pujol Varela, I

2014-10-01

In recent years, there has been a significant improvement in the survival of patients with cancer in intensive care units (ICUs). Advances in medical and surgical treatments and better selection of patients has helped improve the life expectancy of this type of patient. An appropriate and early resuscitation in the ICU, without initial limitations on the life support techniques, has been shown to also decrease the mortality of patients with cancer. At present, we should not deny admission to the ICU based only on the underlying neoplastic disease. However, the mortality rate for patients with cancer in the ICU, especially those with hematologic disease, remains high. In some cases, an ICU admission test (ICU test) is required for at least 3 days to identify patients who can benefit from intensive treatment. We would like to propose a decision algorithm for ICU admission that will help in making decisions in an often complex situation. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

The organizational structure of intensive care units and its influence on patient outcomes.

PubMed

Kutsogiannis, D J; Hague, C; Triska, O H; Johnston, R G; Noseworthy, T

2001-01-01

Despite the growing body of knowledge on the theory of organization, the application of such theory to the organization of intensive care units is in its infancy. Our knowledge about the influence of ICU organization on patient outcomes is limited. Development of instruments to measure ICU organization, and their implementation in studies of new therapies and technologies, will assist in demonstrating the effect of various models of ICU organization on the provision of clinical care.

National survey of outcomes and practices in acute respiratory distress syndrome in Singapore

PubMed Central

Puthucheary, Zudin; Phua, Jason; Ho, Benjamin; Tan, Jonathan; Chuin, Siau; Lim, Noelle Louise; Soh, Chai Rick; Loo, Chian Min; Tan, Addy Y. H.; Mukhopadhyay, Amartya; Khan, Faheem Ahmed; Johan, Azman; Tan, Aik Hau; MacLaren, Graeme; Taculod, Juvel; Ramos, Blesilda; Han, Tun Aung; Cove, Matthew E.

2017-01-01

Introduction In the past 20 years, our understanding of acute respiratory distress syndrome (ARDS) management has improved, but the worldwide incidence and current outcomes are unclear. The reported incidence is highly variable, and no studies specifically characterise ARDS epidemiology in Asia. This observation study aims to determine the incidence, mortality and management practices of ARDS in a high income South East Asian country. Methods We conducted a prospective, population based observational study in 6 public hospitals. During a one month period, we identified all ARDS patients admitted to public hospital intensive care units (ICU) in Singapore, according to the Berlin definition. Demographic information, clinical management data and ICU outcome data was collected. Results A total of 904 adult patients were admitted to ICU during the study period and 15 patients met ARDS criteria. The unadjusted incidence of ARDS was 4.5 cases per 100,000 population, accounting for 1.25% of all ICU patients. Most patients were male (75%), Chinese (62%), had pneumonia (73%), and were admitted to a Medical ICU (56%). Management strategies varied across all ICUs. In-hospital mortality was 40% and median length of ICU stay was 7 days. Conclusion The incidence of ARDS in a developed S.E Asia country is comparable to reported rates in European studies. PMID:28622342

REAL-TIME FEEDBACK FOR IMPROVING COMPLIANCE TO HAND SANITIZATION AMONG HEALTHCARE WORKERS IN AN OPEN LAYOUT ICU USING RADIOFREQUENCY IDENTIFICATION

PubMed Central

Waghmare, Abijeet; Ekstrand, Maria; Raj, Tony; Selvam, Sumithra; Sreerama, Sai Madhukar; Sampath, Sriram

2015-01-01

Objective To increase hand sanitizer usage among healthcare workers by developing and implementing a low-cost intervention using RFID and wireless mesh networks to provide real-time alarms for increasing hand hygiene compliance during opportune moments in an open layout Intensive Care Unit (ICU). Method A wireless, RFID based system was developed and deployed in the ICU. The ICU beds were divded into an intervention arm (n=10) and a control arm (n=14). Passive RFID tags were issued to the doctors, nurses and support staff of the ICU. Long range RFID readers were positioned strategically. Sensors were placed beneath the hand sanitizers to record sanitizer usage. The system would alert the HCWs by flashing a light if an opportune moment for hand sanitization was detected. Results A significant increase in hand sanitizer use was noted in the intervention arm. Usage was highest during the early part of the workday and decreased as the day progressed. Hand wash events per person hour was highest among the ancilliary staff followed by the doctors and nurses. Conclusion Real-time feedback has potential to increase hand hygiene compliance among HCWs. The system demonstrates the possibility of automating compliance monitoring in an ICU with an open layout. PMID:25957165

Occurrence of bla genes encoding carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii from Intensive Care Unit in a tertiary care hospital.

PubMed

Subramaniyan, Jayanthi Siva; Sundaram, Jeya Meenakshi

2018-01-01

ICU shows increasing incidence of infection associated with the use of invasive procedures for the diagnostic purpose as well as the indiscriminate use of antibiotics. Pseudomonas aeruginosa and Acinetobacter species are "very successful" pathogen and the emergence of the Metallo-β-Lactamases (MBL) is becoming a therapeutic challenge. To isolate the Nonfermenting Gram negative bacilli from the ICU samples. To identify the metallo betalactamase producers and to detect the bla gene presence among the Pseudomonas aeruginosa and Acinetobacter baumannii . The Nonfermenting Gram negative bacilli isolates from the ICU samples were taken over for 5 years (2009-2014) in a tertiary care hospital. The isolates of Pseudomonas species and Acinetobacter species were confirmed by API analyser and processed according to standard procedures. Detection of the MBL producers were done by E strip method and subjected for bla gene detection by PCR method. In our study a total of 195 isolates of NFGNB were obtained from various ICU. Of these MBL producers, 26 % were Pseudomonas aeruginosa and 25 % were Acinetobacter baumannii . The subtypes of bla VIM MBL producing P.aeruginosa were 26%. The predominant gene coding for MBL activity in A.baumannii were found to be bla OXA gene 11.9%. The gene accession numbers were KF975367, KF975372. We have to control the development and dissemination of these superbugs among the ICU's.

Sleep Disturbances in Patients Admitted to a Step-Down Unit After ICU Discharge: the Role of Mechanical Ventilation

PubMed Central

Fanfulla, Francesco; Ceriana, Piero; D'Artavilla Lupo, Nadia; Trentin, Rossella; Frigerio, Francesco; Nava, Stefano

2011-01-01

Background: Severe sleep disruption is a well-documented problem in mechanically ventilated, critically ill patients during their time in the intensive care unit (ICU), but little attention has been paid to the period when these patients become clinically stable and are transferred to a step-down unit (SDU). We monitored the 24-h sleep pattern in 2 groups of patients, one on mechanical ventilation and the other breathing spontaneously, admitted to our SDU to assess the presence of sleep abnormalities and their association with mechanical ventilation. Methods: Twenty-two patients admitted to an SDU underwent 24-h polysomnography with monitoring of noise and light. Results: One patient did not complete the study. At night, 10 patients showed reduced sleep efficiency, 6 had reduced percentage of REM sleep, and 3 had reduced percentage of slow wave sleep (SWS). Sleep amount and quality did not differ between patients breathing spontaneously and those on mechanical ventilation. Clinical severity (SAPSII score) was significantly correlated with daytime total sleep time and efficiency (r = 0.51 and 0.5, P < 0.05, respectively); higher pH was correlated with reduced sleep quantity and quality; and higher PaO2 was correlated with increased SWS (r = 0.49; P = 0.02). Conclusions: Patients admitted to an SDU after discharge from an ICU still have a wide range of sleep abnormalities. These abnormalities are mainly associated with a high severity score and alkalosis. Mechanical ventilation does not appear to be a primary cause of sleep impairment. Citation: Fanfulla F; Ceriana P; Lupo ND; Trentin R; Frigerio F; Nava S. Sleep disturbances in patients admitted to a step-down unit after ICU discharge: the role of mechanical ventilation. SLEEP 2011;34(3):355-362. PMID:21358853

Robust parameter extraction for decision support using multimodal intensive care data

PubMed Central

Clifford, G.D.; Long, W.J.; Moody, G.B.; Szolovits, P.

2008-01-01

Digital information flow within the intensive care unit (ICU) continues to grow, with advances in technology and computational biology. Recent developments in the integration and archiving of these data have resulted in new opportunities for data analysis and clinical feedback. New problems associated with ICU databases have also arisen. ICU data are high-dimensional, often sparse, asynchronous and irregularly sampled, as well as being non-stationary, noisy and subject to frequent exogenous perturbations by clinical staff. Relationships between different physiological parameters are usually nonlinear (except within restricted ranges), and the equipment used to measure the observables is often inherently error-prone and biased. The prior probabilities associated with an individual's genetics, pre-existing conditions, lifestyle and ongoing medical treatment all affect prediction and classification accuracy. In this paper, we describe some of the key problems and associated methods that hold promise for robust parameter extraction and data fusion for use in clinical decision support in the ICU. PMID:18936019

Severity of acidosis affects long-term survival in COPD patients with hypoxemia after intensive care unit discharge

PubMed Central

Gungor, Sinem; Kargin, Feyza; Irmak, Ilim; Ciyiltepe, Fulya; Acartürk Tunçay, Eylem; Atagun Guney, Pinar; Aksoy, Emine; Ocakli, Birsen; Adiguzel, Nalan; Karakurt, Zuhal

2018-01-01

Background Patients admitted to the intensive care unit (ICU) with acute respiratory failure (ARF) due to COPD have high mortality and morbidity. Acidosis has several harmful effects on hemodynamics and metabolism, and the current knowledge regarding the relationship between respiratory acidosis severity on the short- and long-term survival of COPD patients is limited. We hypothesized that COPD patients with severe acidosis would have a poorer short- and long-term prognosis compared with COPD patients with mild-to-moderate acidosis. Patients and methods This retrospective observational cohort study was conducted in a level III respiratory ICU of a tertiary teaching hospital for chest diseases between December 1, 2013, and December 30, 2014. Subject characteristics, comorbidities, ICU parameters, duration of mechanical ventilation, length of ICU stay, ICU mortality, use of domiciliary noninvasive mechanical ventilation (NIMV) and long-term oxygen therapy (LTOT), and short- and long-term mortality were recorded. Patients were grouped according to their arterial blood gas (ABG) values during ICU admission: severe acidotic (pH≤7.20) and mild-to-moderate acidotic (pH 7.21–7.35). These groups were compared with the recorded data. The mortality predictors were analyzed by logistic regression test in the ICU and the Cox regression test for long-term mortality predictors. Results During the study period, a total of 312 COPD patients admitted to the ICU with ARF, 69 (72.5% male) in the severe acidosis group and 243 (79% male) in the mild-to-moderate acidosis group, were enrolled. Group demographics, comorbidities, duration of mechanical ventilation, and length of ICU stay were similar in the two groups. The severe acidosis group had a significantly higher rate of NIMV failure (60.7% vs 40%) in the ICU. Mild-to-moderate acidotic COPD patients using LTOT had longer survival after ICU discharge than those without LTOT. On the other hand, severely acidotic COPD patients without LTOT showed shorter survival than those with LTOT. Kaplan–Meier cumulative survival analysis showed that the 28-day and 1-, 2-, and 3-year mortality rates were 12.2%, 36.2%, 52.6%, 63.3%, respectively (p=0.09). The Cox regression analyses showed that older age, PaO2/FiO2 <300 mmHg, and body mass index ≤20 kg/m2 was associated with mortality of all patients after 3 years. Conclusion Severely acidotic COPD patients had a poorer short- and long-term prognosis compared with mild-to-moderate acidotic COPD patients if acute and chronic hypoxemia was predominant. PMID:29780244

The impact of sepsis, delirium, and psychological distress on self-rated cognitive function in ICU survivors-a prospective cohort study.

PubMed

Brück, Emily; Schandl, Anna; Bottai, Matteo; Sackey, Peter

2018-01-01

Many intensive care unit (ICU) survivors develop psychological problems and cognitive impairment. The relation between sepsis, delirium, and later cognitive problems is not fully elucidated, and the impact of psychological symptoms on cognitive function is poorly studied in ICU survivors. The primary aim of this study was to examine the relationship between sepsis, ICU delirium, and later self-rated cognitive function. A second aim was to investigate the association between psychological problems and self-rated cognitive function 3 months after the ICU stay. Patients staying more than 24 h at the general ICU at the Karolinska University Hospital Solna, Stockholm, Sweden, were screened for delirium with the Confusion Assessment Method-ICU (CAM-ICU) during their ICU stay. Sepsis incidence and severity were recorded. Three months later, 216 patients received the Cognitive Failures Questionnaire (CFQ), Hospital Anxiety and Depression Scale (HADS), and Post-Traumatic Stress Symptoms-10 (PTSS-10) questionnaires via postal mail. One hundred twenty-five patients (60%) responded to all questionnaires. Among respondents, the incidence of severe sepsis or septic shock was 42%. The overall incidence of delirium was 34%. Patients with severe sepsis/septic shock had a higher incidence of delirium, with an odds ratio (OR) of 3.7 (95% confidence interval (CI), 1.7-8.1). Self-rated cognitive problems 3 months post-ICU were found in 58% of the patients. We did not find any association between sepsis or delirium and late self-rated cognitive function. However, there was a correlation between psychological symptoms and self-rated cognitive function, with the strongest correlation between PTSS-10 scores and CFQ scores ( r  = 0.53; p  < 0.001). ICU delirium is more common in severely septic/septic shock patients. In our cohort, neither severe sepsis nor ICU delirium was associated with self-rated cognitive function 3 months after the ICU stay. Ongoing psychological symptoms, particularly post-traumatic stress was associated with worse self-rated cognitive function. Psychological symptoms need to be taken into account when assessing cognitive function in ICU survivors.

[Cost of intensive care in a German hospital: cost-unit accounting based on the InEK matrix].

PubMed

Martin, J; Neurohr, C; Bauer, M; Weiss, M; Schleppers, A

2008-05-01

The aim of this study was to determine the actual cost per intensive care unit (ICU) day in Germany based on routine data from an electronic patient data management system as well as analysis of cost-driving factors. A differentiation between days with and without mechanical ventilation was performed. On the ICU of a German focused-care hospital (896 beds, 12 anesthesiology ICU beds), cost per treatment day was calculated with or without mechanical ventilation from the perspective of the hospital. Costs were derived retrospectively with respect to the period between January and October 2006 by cost-unit accounting based on routine data collected from the ICU patients. Patients with a length of stay of at least 2 days on the ICU were included. Demographic, clinical and economical data were analyzed for patient characterization. Data of 407 patients (217 male and 190 female) were included in the analysis, of which 159 patients (100 male, 59 female) were completely or partially mechanically ventilated. The mean simplified acute physiology (SAPS) II score at the onset of ICU stay was 28.2. Average cost per ICU day was 1,265 EUR and costs for ICU days with and without mechanical ventilation amounted to 1,426 EUR and 1,145 EUR, respectively. Personnel costs (50%) showed the largest cost share followed by drugs plus medicinal products (18%) and infrastructure (16%). For the first time, a cost analysis of intensive care in Germany was performed with routine data based on the matrix of the institute for reimbursement in hospitals (InEK). The results revealed a higher resource use on the ICU than previously expected. The large share of personnel costs on the ICU was evident but is comparable to other medical departments in the hospital. The need for mechanical ventilation increases the daily costs of resources by approximately 25%.

Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient.

PubMed

Phillips, Stuart M; Dickerson, Roland N; Moore, Frederick A; Paddon-Jones, Douglas; Weijs, Peter J M

2017-04-01

Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.

Factors influencing intensive care unit survival for critically ill elderly patients.

PubMed

Kleinpell, R M; Ferrans, C E

1998-01-01

To examine factors influencing intensive care unit (ICU) survival for critically ill elderly patients and to compare survivors and nonsurvivors of ICU on demographic and illness-related variables. Retrospective, ex post facto research design. Adult medical and surgical ICUs. The records of 164 survivors and 111 nonsurvivors from 2 medical-surgical ICUs were examined. Patients were placed into 3 age groups (middle-aged, young-old, and old-old) to compare outcomes for elderly ICU patients. ICU survival, ICU treatments received, severity of illness. The Acute Physiology Age and Chronic Health Evaluation II (APACHE II) was used to assess illness severity. Additional illness-related information was collected by chart review. Predictors of ICU nonsurvival were severity of illness (measured by APACHE II scores) and intubation. Comparison of survivors and nonsurvivors revealed no statistically significant differences in sex or age. For all age groups, nonsurvivors had significantly higher mean days of ICU hospitalization (F (1,239) = 7.20 P < .0078) and higher APACHE II scores (F (1,239) = 106.5 P < .0001). Analysis of ICU treatments received by the 3 age groups of survivors revealed a significant difference only on oxygen therapy, (chi-square = 10.2, df = 2, P = .006), with more young-old (aged 65 to 79) and old-old (aged 80 and older) ICU patients receiving oxygen therapy than middle-aged patients (aged 45 to 64). The findings of this study demonstrated that severity of illness was a predictor of ICU outcome; age was not. Additionally, age was not related to ICU treatments received.

Barbara's story: a thematic analysis of a relative's reflection of being in the intensive care unit.

PubMed

Christensen, Martin; Probst, Barbara

2015-03-01

The aim of this reflective account is to provide a view of the intensive care unit (ICU) relative's experiences of supporting and being supported in the ICU. Understanding the relatives' experiences of ICU is important especially because a recent work has identified the potential for this group to develop post-traumatic stress disorder, a condition that is normally equated with the ICU survivor. A thematic analysis was used in identifying emerging themes that would be significant in an ICU nursing context. The incident took place in two 8-bedded ICUs (Private and National Health Service) in October. Two emergent themes were identified from the reflective story - fear of the technological environment and feeling hopeless and helpless. The use of relative stories as an insight into the live experiences of ICU relatives may give a deeper understanding of their life-world. The loneliness, anguish and pain of the ICU relative extends beyond the walls of the ICU, and this is often negated as the focus of the ICU team is the patient. Developing strategies to support relatives might include the use of relative diaries used concurrently with patient diaries to support this groups recovery or at the very least a gaining a sense of understanding for their ICU experience. Relative follow-up clinics designed specifically to meet their needs where support and advice can be given by the ICU team, in addition to making timely and appropriate referrals to counselling services and perhaps involving spiritual leaders where appropriate. © 2014 British Association of Critical Care Nurses.

The control unit of the near infrared spectrograph of the Euclid space mission: detailed design

NASA Astrophysics Data System (ADS)

Toledo-Moreo, Rafael; Colodro-Conde, Carlos; Gómez-Sáenz-de-Tejada, Jaime; Pérez-Lizán, David; Díaz-García, José Javier; Tubío-Araujo, Óscar; Raichs, Cayetano; Catalán, Jordi; Rebolo-López, Rafael

2016-07-01

The Near Infrared Spectrograph and Photometer (NISP) is one of the instruments on board the ESA EUCLID mission. The Universidad Politécnica de Cartagena and Instituto de Astrofísica de Canarias are responsible of the Instrument Control Unit of the NISP (NI-ICU) in the Euclid Consortium. The NI-ICU hardware is developed by CRISA (Airbus Defence and Space), and its main functions are: communication with the S/C and the Data Processing Unit, control of the Filter and Grism Wheels, control of the Calibration Unit and thermal control of the instrument. This paper presents the NI-ICU status of definition and design at the end of the detailed design phase.

Direct cost analysis of intensive care unit stay in four European countries: applying a standardized costing methodology.

PubMed

Tan, Siok Swan; Bakker, Jan; Hoogendoorn, Marga E; Kapila, Atul; Martin, Joerg; Pezzi, Angelo; Pittoni, Giovanni; Spronk, Peter E; Welte, Robert; Hakkaart-van Roijen, Leona

2012-01-01

The objective of the present study was to measure and compare the direct costs of intensive care unit (ICU) days at seven ICU departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology. A retrospective cost analysis of ICU patients was performed from the hospital's perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom-up approach for "hotel and nutrition" and the top-down approach for "diagnostics," "consumables," and "labor." Direct costs per ICU day ranged from €1168 to €2025. Even though the distribution of costs varied by cost component, labor was the most important cost driver at all departments. The costs for "labor" amounted to €1629 at department G but were fairly similar at the other departments (€711 ± 115). Direct costs of ICU days vary widely between the seven departments. Our standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from differences in patient case-mix. Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Role of a service corridor in ICU noise control, staff stress, and staff satisfaction: environmental research of an academic medical center.

PubMed

Wang, Zhe; Downs, Betsy; Farell, Ashley; Cook, Kimberly; Hourihan, Peter; McCreery, Shimby

2013-01-01

To investigate the role of a dedicated service corridor in intensive care unit (ICU) noise control and staff stress and satisfaction. Shared corridors immediately adjacent to patient rooms are generally noisy due to a variety of activities, including service deliveries and pickups. The strategy of providing a dedicated service corridor is thought to reduce noise for patient care, but the extent to which it actually contributes to noise reduction in the patient care environment and in turn improves staff performance has not been previously documented. A before-and-after comparison was conducted in an adult cardiac ICU. The ICU was relocated from a traditional hospital environment to a new addition with a dedicated service corridor. A total of 118 nursing staff participated in the surveys regarding pre-move and post-move environmental comfort, stress, and satisfaction in the previous and new units. Acoustical measures of noise within the new ICU and a control environment of the previous unit were collected during four work days, along with on-site observations of corridor traffic. Independent and paired sample t-tests of survey data showed that the perceived noise level was lower and staff reported less stress and more satisfaction in the new ICU (p < 0.01). Analyses of acoustical data confirmed that the new ICU was significantly quieter (p < 0.02). Observations revealed how the service corridor impacted patient care services and traffic. The addition of a dedicated service corridor works in the new unit for improving noise control and staff stress and satisfaction. Critical care/intensive care, noise, satisfaction, staff, work environment.

Robotic Telepresence in a Medical Intensive Care Unit--Clinicians' Perceptions.

PubMed

Becevic, Mirna; Clarke, Martina A; Alnijoumi, Mohammed M; Sohal, Harjyot S; Boren, Suzanne A; Kim, Min S; Mutrux, Rachel

2015-01-01

Robotic telepresence has been used for outsourcing of healthcare services for more than a decade; however, its use within an academic medical department is not yet widespread. Intensive care unit (ICU) robots can be used to increase access to off-site supervising physicians and other specialists, reducing possible wait time for difficult admissions and procedures. To study the use of ICU robots through a pilot program in an academic hospital and examine provider attitudes toward the usability and effectiveness of an ICU robot. The study was done as a postinterventional cross-sectional seven-question survey in a medical ICU in an urban academic hospital. Participants were attending physicians, fellows, residents, nurses, and respiratory therapists. Users of the ICU robot reported satisfaction with communication, and improved patient care. They also reported perceived improved quality of care with the use of the robot. Findings show the importance of a whole-team approach to the installation and implementation of an ICU robot. The ICU robot is an effective tool when it is used to visualize and communicate with patients, bedside staff, and families. However, a number of providers are still not trained or have not been shown how to use the ICU robot, which affects the overall utilization rate.

Satisfaction in the Intensive Care Unit (ICU). Patient opinion as a cornerstone.

PubMed

Holanda Peña, M S; Talledo, N Marina; Ots Ruiz, E; Lanza Gómez, J M; Ruiz Ruiz, A; García Miguelez, A; Gómez Marcos, V; Domínguez Artiga, M J; Hernández Hernández, M Á; Wallmann, R; Llorca Díaz, J

2017-03-01

To study the agreement between the level of satisfaction of patients and their families referred to the care and attention received during admission to the ICU. A prospective, 5-month observational and descriptive study was carried out. ICU of Marqués de Valdecilla University Hospital, Santander (Spain). Adult patients with an ICU stay longer than 24h, who were discharged to the ward during the period of the study, and their relatives. Instrument: FS-ICU 34 for assessing family satisfaction, and an adaptation of the FS-ICU 34 for patients. The Cohen kappa index was calculated to assess agreement between answers. An analysis was made of the questionnaires from one same family unit, obtaining 148 pairs of surveys (296 questionnaires). The kappa index ranged between 0.278-0.558, which is indicative of mild to moderate agreement. The families of patients admitted to the ICU cannot be regarded as good proxies, at least for competent patients. In such cases, we must refer to these patients in order to obtain first hand information on their feelings, perceptions and experiences during admission to the ICU. Only when patients are unable to actively participate in the care process should their relatives be consulted. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Infection control in intensive care units and prevention of ventilator-associated pneumonia.

PubMed

Bonten, M J; Weinstein, R A

2000-12-01

Ventilator-associated pneumonia (VAP) is considered the most frequent infection in the intensive care unit (ICU), although incidence rates depend on the diagnostic methods. Because VAP has been associated with increased mortality and greater costs for medical care, prevention remains an important goal for intensive care medicine. Selective digestive decontamination (SDD), the most frequently studied method of infection prevention, is still controversial despite more than 30 prospective randomized trials and 6 metaanalyses. SDD reduces the incidence of VAP diagnoses, but beneficial effects on duration of ventilation or ICU stay, antibiotic use, and patient survival have not been shown unequivocally. Although recent metaanalyses suggest a 20% to 40% decrease in ICU mortality for SDD used with systemic prophylaxis, this benefit should be confirmed in a large, prospective, randomized study, preferably with a cost-benefit analysis. Selection of pathogens resistant to the antibiotics used in SDD remains the most important drawback of SDD, rendering SDD contraindicated in wards with endemic resistant problems. Other methods of infection prevention that do not create a selective growth advantage for resistant microorganisms may be more useful. Among these are the use of endotracheal tubes with the possibility of continuous aspiration of subglottic secretions, oropharyngeal decontamination with antiseptics, or the semirecumbent treatment position of patients. Although these methods were successful in single studies, more data are needed. Notwithstanding the potential benefits of these interventions, such classic infection control measures as handwashing remain the cornerstone of infection prevention.

Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study.

PubMed

Checkley, William; Martin, Greg S; Brown, Samuel M; Chang, Steven Y; Dabbagh, Ousama; Fremont, Richard D; Girard, Timothy D; Rice, Todd W; Howell, Michael D; Johnson, Steven B; O'Brien, James; Park, Pauline K; Pastores, Stephen M; Patil, Namrata T; Pietropaoli, Anthony P; Putman, Maryann; Rotello, Leo; Siner, Jonathan; Sajid, Sahul; Murphy, David J; Sevransky, Jonathan E

2014-02-01

Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sought to characterize the organizational structure, processes of care, use of protocols, and standardized outcomes in a large sample of U.S. ICUs. We surveyed 69 ICUs about organization, size, volume, staffing, processes of care, use of protocols, and annual ICU mortality. ICUs participating in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Sixty-nine intensivists completed the survey. We characterized structure and process variables across ICUs, investigated relationships between these variables and annual ICU mortality, and adjusted for illness severity using Acute Physiology and Chronic Health Evaluation II. Ninety-four ICU directors were invited to participate in the study and 69 ICUs (73%) were enrolled, of which 25 (36%) were medical, 24 (35%) were surgical, and 20 (29%) were of mixed type, and 64 (93%) were located in teaching hospitals with a median number of five trainees per ICU. Average annual ICU mortality was 10.8%, average Acute Physiology and Chronic Health Evaluation II score was 19.3, 58% were closed units, and 41% had a 24-hour in-house intensivist. In multivariable linear regression adjusted for Acute Physiology and Chronic Health Evaluation II and multiple ICU structure and process factors, annual ICU mortality was lower in surgical ICUs than in medical ICUs (5.6% lower [95% CI, 2.4-8.8%]) or mixed ICUs (4.5% lower [95% CI, 0.4-8.7%]). We also found a lower annual ICU mortality among ICUs that had a daily plan of care review (5.8% lower [95% CI, 1.6-10.0%]) and a lower bed-to-nurse ratio (1.8% lower when the ratio decreased from 2:1 to 1.5:1 [95% CI, 0.25-3.4%]). In contrast, 24-hour intensivist coverage (p = 0.89) and closed ICU status (p = 0.16) were not associated with a lower annual ICU mortality. In a sample of 69 ICUs, a daily plan of care review and a lower bed-to-nurse ratio were both associated with a lower annual ICU mortality. In contrast to 24-hour intensivist staffing, improvement in team communication is a low-cost, process-targeted intervention strategy that may improve clinical outcomes in ICU patients.

Family members' satisfaction with care and decision-making in intensive care units and post-stay follow-up needs-a cross-sectional survey study.

PubMed

Frivold, Gro; Slettebø, Åshild; Heyland, Daren K; Dale, Bjørg

2018-01-01

The aim of this study was to explore family members' satisfaction with care and decision-making during the intensive care units stay and their follow-up needs after the patient's discharge or death. A cross-sectional survey study was conducted. Family members of patients recently treated in an ICU were participating. The questionnaire contented of background variables, the instrument Family Satisfaction in ICU (FS-ICU 24) and questions about follow-up needs. Descriptive and non-parametric statistics and a multiple linear regression were used in the analysis. A total of 123 (47%) relatives returned the questionnaire. Satisfaction with care was higher scored than satisfaction with decision-making. Follow- up needs after the ICU stay was reported by 19 (17%) of the participants. Gender and length of the ICU stay were shown as factors identified to predict follow-up needs.

Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist

PubMed Central

Mendez-Tellez, Pedro A.; Nusr, Rasha; Feldman, Dorianne; Needham, Dale M.

2012-01-01

Advances in critical care have resulted in improved intensive care unit (ICU) mortality. However, improved ICU survival has resulted in a growing number of ICU survivors living with long-term sequelae of critical illness, such as impaired physical function and quality of life (QOL). In addition to critical illness, prolonged bed rest and immobility may lead to severe physical deconditioning and loss of muscle mass and muscle weakness. ICU-acquired weakness is associated with increased duration of mechanical ventilation and weaning, longer ICU and hospital stay, and increased mortality. These physical impairments may last for years after ICU discharge. Early Physical Medicine and Rehabilitation (PM&R) interventions in the ICU may attenuate or prevent the weakness and physical impairments occurring during critical illness. This article reviews the evidence regarding safety, feasibility, barriers, and benefits of early PM&R interventions in ICU patients and discusses the limited existing data on early PM&R in the neurological ICU and future directions for early PM&R in the ICU. PMID:23983871

Models to predict length of stay in the Intensive Care Unit after coronary artery bypass grafting: a systematic review.

PubMed

Atashi, Alireza; Verburg, Ilona W; Karim, Hesam; Miri, Mirmohammad; Abu-Hanna, Ameen; de Jonge, Evert; de Keizer, Nicolette F; Eslami, Saeid

2018-06-01

Intensive Care Units (ICU) length of stay (LoS) prediction models are used to compare different institutions and surgeons on their performance, and is useful as an efficiency indicator for quality control. There is little consensus about which prediction methods are most suitable to predict (ICU) length of stay. The aim of this study is to systematically review models for predicting ICU LoS after coronary artery bypass grafting and to assess the reporting and methodological quality of these models to apply them for benchmarking. A general search was conducted in Medline and Embase up to 31-12-2016. Three authors classified the papers for inclusion by reading their title, abstract and full text. All original papers describing development and/or validation of a prediction model for LoS in the ICU after CABG surgery were included. We used a checklist developed for critical appraisal and data extraction for systematic reviews of prediction modeling and extended it on handling specific patients subgroups. We also defined other items and scores to assess the methodological and reporting quality of the models. Of 5181 uniquely identified articles, fifteen studies were included of which twelve on development of new models and three on validation of existing models. All studies used linear or logistic regression as method for model development, and reported various performance measures based on the difference between predicted and observed ICU LoS. Most used a prospective (46.6%) or retrospective study design (40%). We found heterogeneity in patient inclusion/exclusion criteria; sample size; reported accuracy rates; and methods of candidate predictor selection. Most (60%) studies have not mentioned the handling of missing values and none compared the model outcome measure of survivors with non-survivors. For model development and validation studies respectively, the maximum reporting (methodological) scores were 66/78 and 62/62 (14/22 and 12/22). There are relatively few models for predicting ICU length of stay after CABG. Several aspects of methodological and reporting quality of studies in this field should be improved. There is a need for standardizing outcome and risk factor definitions in order to develop/validate a multi-institutional and international risk scoring system.

Computers in anesthesia and intensive care: lack of evidence that the central unit serves as reservoir of pathogens.

PubMed

Quinzio, Lorenzo; Blazek, Michael; Hartmann, Bernd; Röhrig, Rainer; Wille, Burkhard; Junger, Axel; Hempelmann, Gunter

2005-01-01

Computers are becoming increasingly visible in operating rooms (OR) and intensive care units (ICU) for use in bedside documentation. Recently, they have been suspected as possibly acting as reservoirs for microorganisms and vehicles for the transfer of pathogens to patients, causing nosocomial infections. The purpose of this study was to examine the microbiological (bacteriological and mycological) contamination of the central unit of computers used in an OR, a surgical and a pediatric ICU of a tertiary teaching hospital. Sterile swab samples were taken from five sites in each of 13 computers stationed at the two ICUs and 12 computers at the OR. Sample sites within the chassis housing of the computer processing unit (CPU) included the CPU fan, ventilator, and metal casing. External sites were the ventilator and the bottom of the computer tower. Quantitative and qualitative microbiological analyses were performed according to commonly used methods. One hundred and ninety sites were cultured for bacteria and fungi. Analyses of swabs taken at five equivalent sites inside and outside the computer chassis did not find any significant-number of potentially pathogenic bacteria or fungi. This can probably be attributed to either the absence or the low number of pathogens detected on the surfaces. Microbial contamination in the CPU of OR and ICU computers is too low for designating them as a reservoir for microorganisms.

Factors Affecting the Length of Stay in the Intensive Care Unit: Our Clinical Experience

PubMed Central

Sengul Samanci, Nilay; Akkoc, İbrahim; Yucetas, Esma; Cebeci, Egemen; Ozturk, Savas

2018-01-01

Background and Aim Long hospital days in intensive care unit (ICU) due to life-threatening diseases are increasing in the world. The primary goal in ICU is to decrease length of stay in order to improve the quality of medical care and reduce cost. The aim of our study is to identify and categorize the factors associated with prolonged stays in ICU. Materials and Method We retrospectively analyzed 3925 patients. We obtained the patients' demographic, clinical, diagnostic, and physiologic variables; mortality; lengths of stay by examining the intensive care unit database records. Results The mean age of the study was 61.6 ± 18.9 years. The average length of stay in intensive care unit was 10.2 ± 25.2 days. The most common cause of hospitalization was because of multiple diseases (19.5%). The length of stay was positively correlated with urea, creatinine, and sodium. It was negatively correlated with uric acid and hematocrit levels. Length of stay was significantly higher in patients not operated on than in patients operated on (p < 0.001). Conclusion Our study showed a significantly increased length of stay in patients with cardiovascular system diseases, multiple diseases, nervous system diseases, and cerebrovascular diseases. Moreover we showed that when urea, creatinine, and sodium values increase, in parallel the length of stay increases. PMID:29750174

A visit to the intensive cares unit: a family-centered culture change to facilitate pediatric visitation in an adult intensive care unit.

PubMed

Hanley, Julie Boyer; Piazza, Julie

2012-01-01

To guide family adjustment, an effort was made to facilitate pediatric visitation in an adult intensive care unit (ICU). Goals were to improve customer satisfaction and to raise staff comfort level with child visitation. After implementing an open visitation policy, concerns around pediatric visitation in the ICU remained. Fears centered on risks to both patient and child. Literature was reviewed before a book was written entitled A Visit to the ICU. It contained information about what a child visiting the ICU would see, hear, and feel when visiting a loved one. The book provided reassurance for caregivers and children, informing them about what to expect when visiting. The goal of the book was to provide caregivers with a framework for age-appropriate education. Staff education was provided on developmental stages, including a child's understandings of illness and death. Nursing interventions were reviewed and resources provided. A survey demonstrated that the book increased staff comfort level with children visiting the unit, was a positive tool for patients and families, and eased fears among children while helping to facilitate coping mechanisms. The article will describe the practice change of pediatric visitation in an ICU and how it could be applied to other critical care settings.

Intersecting vulnerabilities in professionals and patients in intensive care.

PubMed

Meunier-Beillard, Nicolas; Dargent, Auguste; Ecarnot, Fiona; Rigaud, Jean-Philippe; Andreu, Pascal; Large, Audrey; Quenot, Jean-Pierre

2017-12-01

In the context of healthcare delivery, the vulnerabilities of patients in the intensive care unit (ICU) are intricately linked with those experienced on a daily basis by caregivers in the ICU in a symbiotic relation, whereby patients who are suffering can in turn engender suffering in the caregivers. In the same way, caregivers who are suffering themselves may be a source of suffering for their patients. The vulnerabilities of both patients and caregivers in the ICU are simultaneously constituted through a process that is influenced on the one hand by the healthcare objectives of the ICU, and on the other hand, by the conformity of the patients who are managed in that ICU. The specific challenges of management in high-technology units such as an ICU may have consequences on the practices and work conditions of healthcare professionals. Constructing the patient, collectively redefining the patient's identity, and ascribing the patient to a specific healthcare trajectory enables professionals to circumscribe, contain and fight against the spectrum of extreme vulnerabilities of their patients. Imposing this normative framework is the sole means of guiding these professionals through their daily practices. In spite of this, situations of suffering remain a constitutive feature of the caregiving relation in the ICU.

The impact of hospital and ICU organizational factors on outcome in critically ill patients: results from the Extended Prevalence of Infection in Intensive Care study.

PubMed

Sakr, Yasser; Moreira, Cora L; Rhodes, Andrew; Ferguson, Niall D; Kleinpell, Ruth; Pickkers, Peter; Kuiper, Michael A; Lipman, Jeffrey; Vincent, Jean-Louis

2015-03-01

To investigate the impact of various facets of ICU organization on outcome in a large cohort of ICU patients from different geographic regions. International, multicenter, observational study. All 1,265 ICUs in 75 countries that contributed to the 1-day point prevalence Extended Prevalence of Infection in Intensive Care study. All adult patients present on a participating ICU on the study day. None. The Extended Prevalence of Infection in Intensive Care study included data on 13,796 adult patients. Organizational characteristics of the participating hospitals and units varied across geographic areas. Participating North American hospitals had greater availability of microbiologic examination and more 24-hour emergency departments than did the participating European and Latin American units. Of the participating ICUs, 82.9% were closed format, with the lowest prevalence among North American units (62.7%) and the highest in ICUs in Oceania (92.6%). The proportion of participating ICUs with 24-hour intensivist coverage was lower in North America than in Latin America (86.8% vs 98.1%, p = 0.002). ICU volume was significantly lower in participating ICUs from Western Europe, Latin America, and Asia compared with North America. In multivariable logistic regression analysis, medical and mixed ICUs were independently associated with a greater risk of in-hospital death. A nurse:patient ratio of more than 1:1.5 on the study day was independently associated with a lower risk of in-hospital death. In this international large cohort of ICU patients, hospital and ICU characteristics varied worldwide. A high nurse:patient ratio was independently associated with a lower risk of in-hospital death. These exploratory data need to be confirmed in large prospective studies that consider additional country-specific ICU practice variations.

Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians.

PubMed

Danckers, Mauricio; Grosu, Horiana; Jean, Raymonde; Cruz, Raul B; Fidellaga, Amelita; Han, Qifa; Awerbuch, Elizabeth; Jadhav, Nagesh; Rose, Keith; Khouli, Hassan

2013-08-01

Ventilator weaning protocols can improve clinical outcomes, but their impact may vary depending on intensive care unit (ICU) structure, staffing, and acceptability by ICU physicians. This study was undertaken to examine their relationship. We prospectively examined outcomes of 102 mechanically ventilated patients for more than 24 hours and weaned using nurse-driven protocol-directed approach (nurse-driven group) in an intensivist-led ICU with low respiratory therapist staffing and compared them with a historic control of 100 patients who received conventional physician-driven weaning (physician-driven group). We administered a survey to assess ICU physicians' attitude. Median durations of mechanical ventilation (MV) in the nurse-driven and physician-driven groups were 2 and 4 days, respectively (P = .001). Median durations of ICU length of stay (LOS) in the nurse-driven and physician-driven groups were 5 and 7 days, respectively (P = .01). Time of extubation was 2 hours and 13 minutes earlier in the nurse-driven group (P < .001). There was no difference in hospital LOS, hospital mortality, rates of ventilator-associated pneumonia, or reintubation rates between the 2 groups. We identified 4 independent predictors of weaning duration: nurse-driven weaning, Acute Physiology and Chronic Health Evaluation II score, vasoactive medications use, and blood transfusion. Intensive care unit physicians viewed this protocol implementation positively (mean scores, 1.59-1.87 on a 5-point Likert scale). A protocol for liberation from MV driven by ICU nurses decreased the duration of MV and ICU LOS in mechanically ventilated patients for more than 24 hours without adverse effects and was well accepted by ICU physicians. Copyright © 2013 Elsevier Inc. All rights reserved.

Interprofessional collaboration and family member involvement in intensive care units: emerging themes from a multi-sited ethnography.

PubMed

Reeves, Scott; McMillan, Sarah E; Kachan, Natasha; Paradis, Elise; Leslie, Myles; Kitto, Simon

2015-05-01

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature.

Priority Queuing Models for Hospital Intensive Care Units and Impacts to Severe Case Patients

PubMed Central

Hagen, Matthew S.; Jopling, Jeffrey K; Buchman, Timothy G; Lee, Eva K.

2013-01-01

This paper examines several different queuing models for intensive care units (ICU) and the effects on wait times, utilization, return rates, mortalities, and number of patients served. Five separate intensive care units at an urban hospital are analyzed and distributions are fitted for arrivals and service durations. A system-based simulation model is built to capture all possible cases of patient flow after ICU admission. These include mortalities and returns before and after hospital exits. Patients are grouped into 9 different classes that are categorized by severity and length of stay (LOS). Each queuing model varies by the policies that are permitted and by the order the patients are admitted. The first set of models does not prioritize patients, but examines the advantages of smoothing the operating schedule for elective surgeries. The second set analyzes the differences between prioritizing admissions by expected LOS or patient severity. The last set permits early ICU discharges and conservative and aggressive bumping policies are contrasted. It was found that prioritizing patients by severity considerably reduced delays for critical cases, but also increased the average waiting time for all patients. Aggressive bumping significantly raised the return and mortality rates, but more conservative methods balance quality and efficiency with lowered wait times without serious consequences. PMID:24551379

Temperature Variability during Delirium in ICU Patients: An Observational Study

PubMed Central

van der Kooi, Arendina W.; Kappen, Teus H.; Raijmakers, Rosa J.; Zaal, Irene J.; Slooter, Arjen J. C.

2013-01-01

Introduction Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the intensive care unit (ICU) and associated with impaired long-term outcome. Despite its frequency and impact, delirium is poorly recognized by ICU-physicians and –nurses using delirium screening tools. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting component to monitor delirium, but whether temperature regulation is different during ICU delirium has not yet been investigated. The aim of this study was to investigate whether ICU delirium is related to temperature variability. Furthermore, we investigated whether ICU delirium is related to absolute body temperature. Methods We included patients who experienced both delirium and delirium free days during ICU stay, based on the Confusion Assessment method for the ICU conducted by a research- physician or –nurse, in combination with inspection of medical records. We excluded patients with conditions affecting thermal regulation or therapies affecting body temperature. Daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. Temperature variability (primary outcome) and absolute body temperature (secondary outcome) were compared between delirium- and non-delirium days with a linear mixed model and adjusted for daily mean Richmond Agitation and Sedation Scale scores and daily maximum Sequential Organ Failure Assessment scores. Results Temperature variability was increased during delirium-days compared to days without delirium (βunadjusted=0.007, 95% confidence interval (CI)=0.004 to 0.011, p<0.001). Adjustment for confounders did not alter this result (βadjusted=0.005, 95% CI=0.002 to 0.008, p<0.001). Delirium was not associated with absolute body temperature (βunadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.61). This did not change after adjusting for confounders (βadjusted=-0.03, 95% CI=-0.17 to 0.10, p=0.63). Conclusions Our study suggests that temperature variability is increased during ICU delirium. PMID:24194955

The Design of Adult Acute Care Units in U.S. Hospitals

PubMed Central

Catrambone, Cathy; Johnson, Mary E.; Mion, Lorraine C.; Minnick, Ann F.

2010-01-01

Purpose To describe the current state of design characteristics determined to be desirable by the Agency for Health Research and Quality (AHRQ) in U.S. adult medical, surgical, and intensive care units (ICUs). Design Descriptive study of patient visibility; distance to hygiene, toileting, charting, and supplies; unit configuration; percentage of private rooms; and presence or absence of carpeting in 56 ICUs and 81 medical-surgical units in six metropolitan areas. Methods Data were collected via observation, measurement, and interviews. Unit configurations were classified via an iterative process. Descriptive data were analyzed according to ICU and non-ICU status using SPSS (Version 15). Findings Analysis of unit configurations indicated eight unit designs. Statistical analysis showed inter- and intrahospital variation in unit configurations, percentage private rooms, carpeting, visibility, and distance to supplies and charting. Few units met the AHRQ designated design elements studied. Conclusions A wide gap exists between desirable characteristics in ICUs and medical-surgical units. Future research is needed to explore operationalization of unit design elements as risk adjustments, how design elements contribute to patient outcomes, and how design elements influence one another. Clinical Relevance There is room for improvement on almost every design variable, particularly on medical-surgical units. Future planning should take into consideration the interaction of bed capacity and unit configuration. PMID:19335681

The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation.

PubMed

Lecuyer, Lucien; Chevret, Sylvie; Thiery, Guillaume; Darmon, Michael; Schlemmer, Benoît; Azoulay, Elie

2007-03-01

Cancer patients requiring mechanical ventilation are widely viewed as poor candidates for intensive care unit (ICU) admission. We designed a prospective study evaluating a new admission policy titled The ICU Trial. Prospective study. Intensive care unit. One hundred eighty-eight patients requiring mechanical ventilation and having at least one other organ failure. Over a 3-yr period, all patients with hematologic malignancies or solid tumors proposed for ICU admission underwent a triage procedure. Bedridden patients and patients in whom palliative care was the only cancer treatment option were not admitted to the ICU. Patients at earliest phase of the malignancy (diagnosis < 30 days) were admitted without any restriction. All other patients were prospectively included in The ICU Trial, consisting of a full-code ICU admission followed by reappraisal of the level of care on day 5. Among the 188 patients, 103 survived the first 4 ICU days and 85 died from the acute illness. Hospital survival was 21.8% overall. Among the 103 survivors on day 5, none of the characteristics of the malignancy were significantly different between the 62 patients who died and the 41 who survived. Time course of organ dysfunction over the first 6 ICU days differed significantly between survivors and nonsurvivors. Organ failure scores were more accurate on day 6 than at admission or on day 3 for predicting survival. All patients who required initiation of mechanical ventilation, vasopressors, or dialysis after 3 days in the ICU died. Survival was 40% in mechanically ventilated cancer patients who survived to day 5 and 21.8% overall. If these results are confirmed in future interventional studies, we recommend ICU admission with full-code management followed by reappraisal on day 6 in all nonbedridden cancer patients for whom lifespan-extending cancer treatment is available.

Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients.

PubMed

Landry, Elizabeth K; Gabriel, Rodney A; Beutler, Sascha; Dutton, Richard P; Urman, Richard D

2017-03-01

Currently, there are only a few retrospective, single-institution studies that have addressed the prevalence and risk factors associated with unplanned admissions to the pediatric intensive care unit (ICU) after surgery. Based on the limited amount of studies, it appears that airway and respiratory complications put a child at increased risk for unplanned ICU admission. A more extensive and diverse analysis of unplanned postoperative admissions to the ICU is needed to address risk factors that have yet to be revealed by the current literature. To establish a rate of unplanned postoperative ICU admissions in pediatric patients using a large, multi-institution data set and to further characterize the associated risk factors. Data from the National Anesthesia Clinical Outcomes Registry were analyzed. We recorded the overall risk of unplanned postoperative ICU admission in patients younger than 18 years and performed univariate and multivariate logistic regression analysis to identify the associated patient, surgical, and anesthetic-related characteristics. Of the 324 818 cases analyzed, 211 reported an unexpected ICU admission. There was an increased likelihood of unplanned postoperative ICU in infants (age <1 year) and children who were classified as American Society of Anesthesiologists physical status classification of III or IV. Likewise, longer case duration and cases requiring general anesthesia were also associated with unplanned ICU admissions. This study establishes a rate of unplanned ICU admission following surgery in the heterogeneous pediatric population. This is the first study to utilize such a large data set encompassing a wide range of practice environments to identify risk factors leading to unplanned postoperative ICU admissions. Our study revealed that patient, surgical, and anesthetic complexity each contributed to an increased number of unplanned ICU admissions in the pediatric population.

Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project.

PubMed

McWilliams, David; Weblin, Jonathan; Atkins, Gemma; Bion, Julian; Williams, Jenny; Elliott, Catherine; Whitehouse, Tony; Snelson, Catherine

2015-02-01

Prolonged periods of mechanical ventilation are associated with significant physical and psychosocial adverse effects. Despite increasing evidence supporting early rehabilitation strategies, uptake and delivery of such interventions in Europe have been variable. The objective of this study was to evaluate the impact of an early and enhanced rehabilitation program for mechanically ventilated patients in a large tertiary referral, mixed-population intensive care unit (ICU). A new supportive rehabilitation team was created within the ICU in April 2012, with a focus on promoting early and enhanced rehabilitation for patients at high risk for prolonged ICU and hospital stays. Baseline data on all patients invasively ventilated for at least 5 days in the previous 12 months (n = 290) were compared with all patients ventilated for at least 5 days in the 12 months after the introduction of the rehabilitation team (n = 292). The main outcome measures were mobility level at ICU discharge (assessed via the Manchester Mobility Score), mean ICU, and post-ICU length of stay (LOS), ventilator days, and in-hospital mortality. The introduction of the ICU rehabilitation team was associated with a significant increase in mobility at ICU discharge, and this was associated with a significant reduction in ICU LOS (16.9 vs 14.4 days, P = .007), ventilator days (11.7 vs 9.3 days, P < .05), total hospital LOS (35.3 vs 30.1 days, P < .001), and in-hospital mortality (39% vs 28%, P < .05). A quality improvement strategy to promote early and enhanced rehabilitation within this European ICU improved levels of mobility at critical care discharge, and this was associated with reduced ICU and hospital LOS and reduced days of mechanical ventilation. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Radiology workstation design for the medical intensive care unit.

PubMed

Moise, Adrian; Atkins, Stella M

2002-01-01

The "one-size-fits-all" approach for radiology workstation design is not good enough anymore. While most of the picture archiving and communication system (PACS) vendors are racing to add more features to the radiology workstation, there is little interest in addressing the specific needs of other hospital departments. Significant delays in the availability of radiology reports are often caused by the fact there is not enough Intensive Care Unit (ICU) volume to justify a full time radiologist. Consequently, the radiologist assigned to cover the ICU exams, most likely working from a different building, will read the ICU exams only at certain times, depending on the limitations for remote image availability. This paper addresses the main objectives in designing a digital radiology workstation for use in the medical ICU (MICU), requiring enhancements to current PACS systems. Our suggestions for PACS improvement follow the ICU digital workflow starting with the transfer of the images from the modality, continuing with the presentation of the radiology examination to different types of users (radiologists or ICU staff), up to the creation and distribution of the reports.

Short- and long-term outcomes of adult allogeneic hematopoietic stem cell transplant patients admitted to the intensive care unit in the peritransplant period.

PubMed

Mayer, Sebastian; Pastores, Stephen M; Riedel, Elyn; Maloy, Molly; Jakubowski, Ann A

2017-02-01

Survival of allogeneic hematopoietic stem cell transplant (aHSCT) recipients in the intensive care unit (ICU) has been poor. We retrospectively analyzed the short- and long-term outcomes of aHSCT patients admitted to the ICU over a 12-year period. Of 1235 adult patients who had aHSCT between 2002 and 2013, 161 (13%) were admitted to the ICU. The impact of clinical parameters was assessed and outcomes were compared for the periods 2002-2007 and 2008-2013. The ICU, in-hospital, 1- and 5-year survival rates were 64.6%, 46%, 33% and 20%, respectively. Mechanical ventilation and vasopressor use predicted for worse hospital- and overall survival (OS). After 2008, the requirement for mechanical ventilation and vasopressors, and the diagnosis of sepsis were reduced. While hospital mortality decreased from 69% to 44%, long-term survival (LTS) remained unchanged. Late deaths, due to causes not associated with the ICU such as relapse and graft-versus-host disease, increased. As thresholds for transplant are lowered, improvements in ICU outcomes for aHSCT recipients may be limited.

Patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomised controlled trial of a preoperative patient education intervention

PubMed Central

Leung, Patricia; Chiu, Chun Hung; Ho, Ka Man; Gomersall, Charles David; Underwood, Malcolm John

2016-01-01

Introduction Patients and their families are understandably anxious about the risk of complications and unfamiliar experiences following cardiac surgery. Providing information about postoperative care in the intensive care unit (ICU) to patients and families may lead to lower anxiety levels, and increased satisfaction with healthcare. The objectives of this study are to evaluate the effectiveness of preoperative patient education provided for patients undergoing elective cardiac surgery. Methods and analysis 100 patients undergoing elective coronary artery bypass graft, with or without valve replacement surgery, will be recruited into a 2-group, parallel, superiority, double-blinded randomised controlled trial. Participants will be randomised to either preoperative patient education comprising of a video and ICU tour with standard care (intervention) or standard education (control). The primary outcome measures are the satisfaction levels of patients and family members with ICU care and decision-making in the ICU. The secondary outcome measures are patient anxiety and depression levels before and after surgery. Ethics and dissemination Ethical approval has been obtained from the Joint Chinese University of Hong Kong—New Territories East Cluster Clinical Research Ethics Committee (reference number CREC 2015.308). The findings will be presented at conferences and published in peer-reviewed journals. Study participants will receive a 1-page plain language summary of results. Trial registration number ChiCTR-IOR-15006971. PMID:27334883

Effect of a multi-level intervention on nurse—patient communication in the intensive care unit: Results of the SPEACS trial

PubMed Central

Happ, Mary Beth; Garrett, Kathryn L.; Tate, Judith A.; DiVirgilio, Dana; Houze, Martin P.; Demirci, Jill R.; George, Elisabeth; Sereika, Susan M.

2014-01-01

Objective To test the impact of two levels of intervention on communication frequency, quality, success, and ease between nurses and intubated intensive care unit (ICU) patients. Design Quasi-experimental, 3-phase sequential cohort study: (1) usual care, (2) basic communication skills training (BCST) for nurses, (3) additional training in augmentative and alternative communication devices and speech language pathologist consultation (AAC + SLP). Trained observers rated four 3-min video-recordings for each nurseepatient dyad for communication frequency, quality and success. Patients self-rated communication ease. Setting Two ICUs in a university-affiliated medical center. Participants 89 intubated patients awake, responsive and unable to speak and 30 ICU nurses. Main results Communication frequency (mean number of communication acts within a communication exchange) and positive nurse communication behaviors increased significantly in one ICU only. Percentage of successful communication exchanges about pain were greater for the two intervention groups than the usual care/control group across both ICUs (p = .03) with more successful sessions about pain and other symptoms in the AAC + SLP group (p = .07). Patients in the AAC SLP intervention group used significantly more AAC methods (p = .002) and rated communication at high difficulty less often (p < .01). Conclusions This study provides support for the feasibility, utility and efficacy of a multi-level communication skills training, materials and SLP consultation intervention in the ICU. PMID:24495519

Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal.

PubMed

Reignier, Jean; Dumont, Romain; Katsahian, Sandrine; Martin-Lefevre, Laurent; Renard, Benoit; Fiancette, Maud; Lebert, Christine; Clementi, Eva; Bontemps, Frederic

2008-07-01

To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU. Prospective observational cohort study. A medical-surgical ICU. Consecutive patients referred to the ICU during a one-yr period. None. Of 898 triaged patients, 147 were deemed too well to benefit from ICU admission. Decisions to forego LST were made in 148 of 666 (22.2%) admitted patients and in all 85 patients deemed too sick for ICU admission. Independent predictors of decisions to forego LST at ICU refusal rather than after ICU admission were: age; underlying disease; living in an institution; preexisting cognitive impairment; admission for medical reasons; and acute cardiac failure, acute central neurologic illness, or sepsis. Hospital mortality after decisions to forego LST was not significantly different in refused and admitted patients (77.5% vs. 86.5%; p = .1). Decisions to forego LST were made via telephone in 58.8% of refused patients and none of the admitted patients. Nurses caring for the patient had no direct contact with the ICU physicians for 62.3% of the decisions in refused patients, whereas meetings between nurses and physicians occurred in 70.3% of decisions to forego LST in the ICU. Patients or relatives were involved in 28.2% of decisions to forego LST at ICU refusal compared with 78.4% of decisions to forego LST in ICU patients (p < .001). All patients deemed too sick for ICU admission had decisions to forego LST. These decisions were made without direct patient examination in two-thirds of refused patients (vs. none of admitted patients) and were associated with less involvement of nurses and relatives compared with decisions in admitted patients. Further work is needed to improve decisions to forego LST made under the distinctive circumstances of triage.

Acute kidney injury burden in different clinical units: Data from nationwide survey in China

PubMed Central

Yu, Shengqiang; Yang, Li; Mei, Changlin

2017-01-01

Background The inpatient morbidity and mortality of acute kidney injury (AKI) vary considerably in different clinical units, yet studies to compare the difference remain limited. Methods We compared the clinical characteristics of AKI in Intensive Care Unit (ICU), medical and surgical departments by using the data derived from the 2013 nationwide cross-sectional survey of AKI in China to capture variations among different clinical departments in recognition, management, and outcomes of AKI. Suspected AKI patients were identified based on changes in serum creatinine during hospitalization, and confirmed by reviewing medical records. Results The detection rate of AKI was the highest in ICU (22.46%), followed by the rates in medical (1.96%) and surgical departments (0.96%). However, the absolute number of cases was the largest in medical departments, which contributed to 50% of the cases. In medical departments, 78% of AKI cases were extensively distributed in cardiac, nephrology, oncology, gastroenterology, pneumology and neurology departments. In contrast, 87% of AKI cases in surgical departments were mainly from urology, general surgery and cardiothoracic departments. The in-time recognition rates were extremely low in all departments except nephrology. Only 10.5~15.0% AKI patients from non-nephrology departments received renal referral. Among all the death cases, 50% and 39% came from ICU and medical departments while only 11% from surgical departments. Older age, higher AKI stage and renal replacement therapy indication were identified as risk factors for high mortality in all departments. Delayed recognition and no renal referral were significantly associated with increased mortality in medical and ICU patients. Conclusions These findings suggest that ICU and medical departments are major affected departments in China with a large number of AKI cases and subsequent high mortality. The reality is more alarming considering the low awareness of AKI and the paucity of effective interventions in the high-risk patients in these departments. PMID:28152018

Readmission to the Intensive Care Unit: Incidence, Risk Factors, Resource Use, and Outcomes. A Retrospective Cohort Study.

PubMed

Ponzoni, Carolina R; Corrêa, Thiago D; Filho, Roberto R; Serpa Neto, Ary; Assunção, Murillo S C; Pardini, Andreia; Schettino, Guilherme P P

2017-08-01

Readmission to the intensive care unit (ICU) is associated with poor clinical outcomes, increased length of ICU and hospital stay, and higher costs. Nevertheless, knowledge of epidemiology of ICU readmissions, risk factors, and attributable outcomes is restricted to developed countries. To determine the effect of ICU readmissions on in-hospital mortality, determine incidence of ICU readmissions, identify predictors of ICU readmissions and hospital mortality, and compare resource use and outcomes between readmitted and nonreadmitted patients in a developing country. This retrospective single-center cohort study was conducted in a 40-bed, open medical-surgical ICU of a private, tertiary care hospital in São Paulo, Brazil. The Local Ethics Committee at Hospital Israelita Albert Einstein approved the study protocol, and the need for informed consent was waived. All consecutive adult (≥18 yr) patients admitted to the ICU between June 1, 2013 and July 1, 2015 were enrolled in this study. Comparisons were made between patients readmitted and not readmitted to the ICU. Logistic regression analyses were performed to identify predictors of ICU readmissions and hospital mortality. Out of 5,779 patients admitted to the ICU, 576 (10%) were readmitted to the ICU during the same hospitalization. Compared with nonreadmitted patients, patients readmitted to the ICU were more often men (349 of 576 patients [60.6%] vs. 2,919 of 5,203 patients [56.1%]; P = 0.042), showed a higher (median [interquartile range]) severity of illness (Simplified Acute Physiology III score) at index ICU admission (50 [41-61] vs. 42 [32-54], respectively, for readmitted and nonreadmitted patients; P < 0.001), and were more frequently admitted due to medical reasons (425 of 576 [73.8%] vs. 2,998 of 5,203 [57.6%], respectively, for readmitted and nonreadmitted patients; P < 0.001). Simplified Acute Physiology III score (P < 0.001), ICU admission from the ward (odds ratio [OR], 1.907; 95% confidence interval [CI], 1.463-2.487; P < 0.001), vasopressors need during index ICU stay (OR, 1.391; 95% CI, 1.130-1.713; P = 0.002), and length of ICU stay (P = 0.001) were independent predictors of ICU readmission. After adjusting for severity of illness, ICU readmission (OR, 4.103; 95% CI, 3.226-5.518; P < 0.001), admission source, presence of cancer, use of vasopressors, mechanical ventilation or renal replacement therapy, length of ICU stay, and nighttime ICU discharge were associated with increased risk of in-hospital death. Readmissions to the ICU were frequent and strongly related to poor outcomes. The degree to which ICU readmissions are preventable as well as the main causes of preventable ICU readmissions need to be further determined.

[Analysis of the web pages of the intensive care units of Spain].

PubMed

Navarro-Arnedo, J M

2009-01-01

In order to determine the Intensive Care Units (ICU) of Spanish hospitals that had a web site, to analyze the information they offered and to know what information they needed to offer according to a sample of ICU nurses, a cross-sectional observational, descriptive study was carried out between January and September 2008. For each ICU website, an analysis was made on the information available on the unit, its care, teaching and research activity on nursing. Simultaneously, based on a sample of intensive care nurses, the information that should be contained on an ICU website was determined. The results, expressed in absolute numbers and percentage, showed that 66 of the 292 hospitals with ICU (22.6%) had a web site; 50.7% of the sites showed the number of beds, 19.7% the activity report, 11.3% the published articles/studies and followed research lines and 9.9% the organized formation courses. 14 webs (19.7%) displayed images of nurses. However, only 1 (1.4%) offered guides on the actions followed. No web site offered a navigation section for nursing, the E-mail of the chief nursing, the nursing documentation used or if any nursing model of their own was used. It is concluded that only one-fourth of the Spanish hospitals with ICU have a web site; number of beds was the data offered by the most sites, whereas information on care, educational and investigating activities was very reduced and that on nursing was practically omitted on the web pages of intensive care units.

Physical Therapy Utilization in Intensive Care Units: Results from a National Survey

PubMed Central

Hodgin, Katherine E.; Nordon-Craft, Amy; McFann, Kim K.; Mealer, Meredith L.; Moss, Marc

2009-01-01

Objective Patients who survive admission to the intensive care unit (ICU) commonly complain of fatigue, weakness, and poor functional status. This study sought to determine the utilization of inpatient physical therapy for patients recovering from critical illness. Design Surveys were mailed to 984 physical therapists from across the United States. Each survey included questions concerning staffing and availability of physical therapists for ICU patients, and the utilization of physical therapy (PT) for six patient scenarios requiring ICU admission and mechanical ventilation. Main Results Overall 482 physical therapists completed their survey. The majority of hospitals (89%) at which the physical therapists were employed require a physician consultation to initiate PT for ICU patients. Established hospital criteria for the initiation of PT in the ICU were present at only 10% of the hospitals. Community hospitals were more likely to routinely provide PT on weekends compared to academic hospitals (p=0.03). The likelihood of routine PT involvement varied significantly with the clinical scenario (highest 87% status post cerebrovascular accident, lowest 64% chronic obstructive pulmonary disease, p<0.001). The most common types of PT that would be performed on these critically ill patients were functional mobility retraining and therapeutic exercise. The type of PT identified by the physical therapists as having the most positive impact also significantly varied according to the clinical scenario (p<0.001). Conclusions PT is commonly administered to ICU patients during the recovery from critical illness in the United States. However the frequency and type of PT significantly varies based on the type of hospital and the clinical scenario. PMID:19114903

Economics of ICU organization and management.

PubMed

Wunsch, Hannah; Gershengorn, Hayley; Scales, Damon C

2012-01-01

The intensive care unit (ICU) is a complex system and the economic implications of altering care patterns in the ICU can be difficult to unravel. Few studies have specifically examined the economics of implementing organizational and management changes or acknowledged the many competing economic interests of patient, hospital,payer, and society. With continuously increasing healthcare costs,there is a great need for more studies focused on the optimal organization of the ICU. These studies should not focus solely on reductions in ICU length of stay but should strive to measure the true costs of care within a given healthcare system.

Monitoring intensive care unit performance—impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol

PubMed Central

Neilipovitz, David; Sarti, Aimee J; Rosenberg, Erin; Ishaq, Rabia; Thornton, Mary; Kim, John

2018-01-01

Introduction Patients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance is required. Performance scorecards are used by institutions for the purposes of driving quality improvement. There is no widely accepted or standardised scorecard that has been used for overall CCM performance. We aim to improve quality of care, patient safety and patient/family experience in CCM practice through the utilisation of a standardised, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics. Methods and analysis This will be a mixed-methods, controlled before and after study to assess the impact of a CCM-specific quality scorecard. Scorecard metrics were developed through expert consensus and existing literature. The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation are collected daily from bedside flow sheets. Preintervention baseline data will be collected for 6 months for each participant. After this, each participant will receive their scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics following the provision of scorecard feedback to subjects. A cost analysis will also be performed, with the purpose of comparing total ICU costs prior to implementation of the scorecard with total ICU costs following implementation of the scorecard. The qualitative portion will include interviews with participants following the intervention phase. Interviews will be analysed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement. Ethics and dissemination This protocol has been approved by the local research ethics board. Publication of results is anticipated in 2019. If this intervention is found to improve patient- and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilisation of such a scorecard as a quality standard in CCM. PMID:29358441

Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review [Formula: see text].

PubMed

Lew, Charles Chin Han; Yandell, Rosalie; Fraser, Robert J L; Chua, Ai Ping; Chong, Mary Foong Fong; Miller, Michelle

2017-07-01

Malnutrition is associated with poor clinical outcomes among hospitalized patients. However, studies linking malnutrition with poor clinical outcomes in the intensive care unit (ICU) often have conflicting findings due in part to the inappropriate diagnosis of malnutrition. We primarily aimed to determine whether malnutrition diagnosed by validated nutrition assessment tools such as the Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) is independently associated with poorer clinical outcomes in the ICU and if the use of nutrition screening tools demonstrate a similar association. PubMed, CINAHL, Scopus, and Cochrane Library were systematically searched for eligible studies. Search terms included were synonyms of malnutrition, nutritional status, screening, assessment, and intensive care unit. Eligible studies were case-control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools before or within 48 hours of ICU admission; and reported the prevalence of malnutrition and relevant clinical outcomes including mortality, length of stay (LOS), and incidence of infection (IOI). Twenty of 1168 studies were eligible. The prevalence of malnutrition ranged from 38% to 78%. Malnutrition diagnosed by nutrition assessments was independently associated with increased ICU LOS, ICU readmission, IOI, and the risk of hospital mortality. The SGA clearly had better predictive validity than the MNA. The association between malnutrition risk determined by nutrition screening was less consistent. Malnutrition is independently associated with poorer clinical outcomes in the ICU. Compared with nutrition assessment tools, the predictive validity of nutrition screening tools were less consistent.

Intersecting vulnerabilities in professionals and patients in intensive care

PubMed Central

Dargent, Auguste; Ecarnot, Fiona; Rigaud, Jean-Philippe; Andreu, Pascal; Large, Audrey; Quenot, Jean-Pierre

2017-01-01

In the context of healthcare delivery, the vulnerabilities of patients in the intensive care unit (ICU) are intricately linked with those experienced on a daily basis by caregivers in the ICU in a symbiotic relation, whereby patients who are suffering can in turn engender suffering in the caregivers. In the same way, caregivers who are suffering themselves may be a source of suffering for their patients. The vulnerabilities of both patients and caregivers in the ICU are simultaneously constituted through a process that is influenced on the one hand by the healthcare objectives of the ICU, and on the other hand, by the conformity of the patients who are managed in that ICU. The specific challenges of management in high-technology units such as an ICU may have consequences on the practices and work conditions of healthcare professionals. Constructing the patient, collectively redefining the patient’s identity, and ascribing the patient to a specific healthcare trajectory enables professionals to circumscribe, contain and fight against the spectrum of extreme vulnerabilities of their patients. Imposing this normative framework is the sole means of guiding these professionals through their daily practices. In spite of this, situations of suffering remain a constitutive feature of the caregiving relation in the ICU. PMID:29302595

Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit.

PubMed

Festic, Emir; Wilson, Michael E; Gajic, Ognjen; Divertie, Gavin D; Rabatin, Jeffrey T

2012-02-01

The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement. To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. Cross-sectional survey of 69 ICU physicians and 629 ICU nurses. Single tertiary care academic medical institution. A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level. Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.

Conceptualizing surrogate decision making at end of life in the intensive care unit using cognitive task analysis.

PubMed

Dionne-Odom, J Nicholas; Willis, Danny G; Bakitas, Marie; Crandall, Beth; Grace, Pamela J

2015-01-01

Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition. The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs. Copyright © 2015 Elsevier Inc. All rights reserved.

Case mix, outcome and activity for patients admitted to intensive care units requiring chronic renal dialysis: a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

Hutchison, Colin A; Crowe, Alex V; Stevens, Paul E; Harrison, David A; Lipkin, Graham W

2007-01-01

Introduction This report describes the case mix, outcome and activity for admissions to intensive care units (ICUs) of patients who require prior chronic renal dialysis for end-stage renal failure (ESRF), and investigates the effect of case mix factors on outcome. Methods This was a secondary analysis of a high-quality clinical database, namely the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, which includes 276,731 admissions to 170 adult ICUs across England, Wales and Northern Ireland from 1995 to 2004. Results During the eight year study period, 1.3% (n = 3,420) of all patients admitted to ICU were receiving chronic renal dialysis before ICU admission. This represents an estimated ICU utilization of six admissions (32 bed-days) per 100 dialysis patient-years. The ESRF group was younger (mean age 57.3 years versus 59.5 years) and more likely to be male (60.2% versus 57.9%) than those without ESRF. Acute Physiology and Chronic Health Evaluation II score and Acute Physiology Score revealed greater severity of illness on admission in patients with ESRF (mean 24.7 versus 16.6 and 17.2 versus 12.6, respectively). Length of stay in ICU was comparable between groups (median 1.9 days versus 1.8 days) and ICU mortality was only slightly elevated in the ESRF group (26.3% versus 20.8%). However, the ESRF group had protracted overall hospital stay (median 25 days versus 17 days), and increased hospital mortality (45.3% versus 31.2%) and ICU readmission (9.0% vs. 4.7%). Multiple logistic regression analysis adjusted for case mix identified the increased hospital mortality to be associated with increasing age, emergency surgery and nonsurgical cases, cardiopulmonary resuscitation before ICU admission and extremes of physiological norms. The adjusted odds ratio for ultimate hospital mortality associated with chronic renal dialysis was 1.24 (95% confidence interval 1.13 to 1.37). Conclusion Patients with ESRF admitted to UK ICUs are more likely to be male and younger, with a medical cause of admission, and to have greater severity of illness than the non-ESRF population. Outcomes on the ICU were comparable between the two groups, but those patients with ESRF had greater readmission rates, prolonged post-ICU hospital stay and increased post-ICU hospital mortality. This study is by far the largest comparative outcome analysis to date in patients with ESRF admitted to the ICU. It may help to inform clinical decision-making and resource requirements for this patient population. PMID:17451605

Male-female patient differences in association between end-of-life discussions and receipt of intensive care near death

PubMed Central

Sharma, Rashmi K.; Prigerson, Holly G.; Penedo, Frank J.; Maciejewski, Paul K.

2015-01-01

Background Patient gender plays a significant role in patient-physician communication, patient illness understanding and aggressiveness of end of life (EoL) care. However, little is known about the extent to which gender differences in the effects of EoL discussions on EoL care contribute to gender differences in EoL care. The present study aims to determine if gender differences exist in receipt of intensive care unit (ICU) care near death and in the association between EoL discussions and receipt of ICU EoL care. Methods Multi-site, prospective, cohort study of patients (N=353) with metastatic cancers, identified as terminally ill at study enrollment and interviewed a median of 4.1 months before their deaths. Postmortem chart reviews and caregiver interviews documented ICU stays in the last week of life. Results Patients who received ICU care at the EoL were more likely to be male than those who did not (73% male vs. 52% male, p=0.02). Adjusting for potential confounds, male patients reporting an EoL discussion were less likely to have an ICU stay in the last week of life than male patients with no EoL discussion (AOR=0.26, 95% CI 0.07–0.91; p=0.04). There was no association between EoL discussions and ICU stays near death among female patients. Conclusions Men with advanced cancers are more likely than women to receive aggressive, non-beneficial, ICU care near death. Gender differences in effects of EoL discussions on EoL care likely contribute to, and may even explain, gender differences in receipt of ICU care in the last week of life. PMID:25975179

Incidence of bacteremia at the time of ICU admission and its impact on outcome

PubMed Central

Nasa, Prashant; Juneja, Deven; Singh, Omender; Dang, Rohit; Arora, Vikas; Saxena, Sanjay

2011-01-01

Context: Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome. Methods: Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score. Statistical Analysis: Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality. Results: Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6–100). Conclusions: Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics. PMID:22223904

Serum selenium and glutathione peroxidase-3 activity: biomarkers of systemic inflammation in the critically ill?

PubMed

Manzanares, William; Biestro, Alberto; Galusso, Federico; Torre, Maria H; Mañay, Nelly; Pittini, Gustavo; Facchin, Gianella; Hardy, Gil

2009-05-01

To confirm the influence of systemic inflammatory response syndrome (SIRS) on selenium (Se) levels and prospectively evaluate the relationship between serum Se concentration [Se], glutathione peroxidase activity [GPx-3] and injury severity in patients at the time of intensive care unit (ICU) admission. Prospective, observational study. Multidisciplinary University Hospital ICU. A total of 36 ICU patients and 23 healthy volunteer subjects (HVS). Healthy volunteer subjects were designated as controls (Group 1). ICU patients were divided into three groups: without SIRS (Group 2); with SIRS (Group 3); with SIRS and multiple organ dysfunction syndrome (MODS) (Group 4). The latter groups had APACHE II scores >15. [GPx-3] and [Se] were determined by standard methods within the first 48 h of admission to ICU. Kruskal-Wallis and Mann-Whitney U test were used for analysis of non-parametric continuous variables. The predictive value of [Se] and [GPx-3] for SIRS was calculated using a receiver operating characteristics (ROC) analysis. In SIRS and MODS patients [GPx-3] and [Se] decreased significantly (P = 0.0001 and P = 0.002, respectively). After ICU admission [GPx-3] and [Se] had a predictive value for SIRS ([GPx-3] sensitivity: 90%, specificity: 86.2% (cut-off value: 0.5 U/mL); [Se]: sensitivity 90%, specificity 72.4% (cut-off value: 60 microg/L). [Se] had predictive value for ICU mortality (P = 0.034). Systemic inflammatory response syndrome and MODS were associated with early decreases in [Se] and [GPx-3]. Low [Se] and [GPx-3] after ICU admission had a predictive value for SIRS, which may aid future selection of patients who could benefit from Se supplementation.

A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion.

PubMed

Mahmoudian-Dehkordi, Amin; Sadat, Somayeh

2017-01-01

Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date. We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients' hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion. Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios. In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.

Patient and Family Member-Led Research in the Intensive Care Unit: A Novel Approach to Patient-Centered Research.

PubMed

Gill, Marlyn; Bagshaw, Sean M; McKenzie, Emily; Oxland, Peter; Oswell, Donna; Boulton, Debbie; Niven, Daniel J; Potestio, Melissa L; Shklarov, Svetlana; Marlett, Nancy; Stelfox, Henry T

2016-01-01

Engaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown. We tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis. Participants described three phases in the patient/family "ICU journey"; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient's voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These "ICU journey" experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes. Patient and family member-led research is feasible and can identify opportunities for improving care.

An analysis of the predictors of mortality and morbidity in patients admitted after suicidal hanging to an Indian multidisciplinary Intensive Care Unit

PubMed Central

Renuka, MK; Kalaiselvan, MS; Arunkumar, AS

2017-01-01

Background and Aims: Hanging is a frequently used method to attempt suicide in India. There is a lack of data in the Indian population regarding clinical features and outcomes of suicidal hanging. The purpose of this study was to evaluate the factors affecting mortality and morbidity in patients admitted with suicidal hanging to the Intensive Care Unit (ICU). Methods: A 6-year retrospective study of adult patients admitted to the ICU with suicidal hanging was analysed for demographics, mode of hanging, lead time to emergency room (ER) admission, clinical presentation, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, admission Glasgow coma scale (GCS) and neurological outcomes. The primary outcome was in-hospital mortality rate. Secondary outcomes were hospital length of stay (LOS), ICU-LOS, time for neurological recovery, organ support and duration of mechanical ventilation. Statistical analysis was performed using the Student's t-test for continuous variables and Chi-square test for categorical variables. Results: We analysed data of 106 patients. The median age was 27 years [Interquartile Range (IQR) (22–34)]. The median lead time to ER admission was 1 h [IQR (0.5–1.4)] with median ICU stay of 3 days [IQR (2–4)]. Vasopressors were administered to 27.4% patients. GCS was ≤7 in 65% patients, and 84.9% patients received mechanical ventilation. Mortality rate was 10.3%. Survivors recovered with normal organ function. Conclusion: Suicidal hanging is associated with significant mortality. Admission GCS, APACHE II and 48 h SOFA score were predictors of poor outcome. PMID:28794524

Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses

PubMed Central

Ng, George Wing Yiu; Pun, Jack Kwok Hung; So, Eric Hang Kwong; Chiu, Wendy Wai Hang; Leung, Avis Siu Ha; Stone, Yuk Han; Lam, Chung Ling; Lai, Sarah Pui Wa; Leung, Rowlina Pui Wah; Luk, Hing Wah; Leung, Anne Kit Hung; Au Yeung, Kin Wah; Lai, Kang Yiu; Slade, Diana; Chan, Engle Angela

2017-01-01

Objectives Despite growing recognition of the importance of speaking up to protect patient safety in critical care, little research has been performed in this area in an intensive care unit (ICU) context. This study explored the communication openness perceptions of Chinese doctors and nurses and identified their perceptions of issues in ICU communication, their reasons for speaking up and the possible factors and strategies involved in promoting the practice of speaking up. Design A mixed-methods design with quantitative and sequential qualitative components was used. Setting and participants Eighty ICU staff members from a large public hospital in Hong Kong completed a questionnaire regarding their perceptions of communication openness. Ten clinicians whose survey responses indicated support for open communication were then interviewed about their speak-up practices. Results The participating ICU staff members had similar perceptions of their openness to communication. However, the doctors responded more positively than the nurses to many aspects of communication openness. The two groups also had different perceptions of speaking up. The interviewed ICU staff members who indicated a high level of communication openness reported that their primary reasons for speaking up were to seek and clarify information, which was achieved by asking questions. Other factors perceived to influence the motivation to speak up included seniority, relationships and familiarity with patient cases. Conclusions Creating an atmosphere of safety and equality in which team members feel confident in expressing their personal views without fear of reprisal or embarrassment is necessary to encourage ICU staff members, regardless of their position, to speak up. Because harmony and saving face is valued in Chinese culture, training nurses and doctors to speak up by focusing on human factors and values rather than simply addressing conflict management is desirable in this context. PMID:28801406

Perceptions of “futile care” among caregivers in intensive care units

PubMed Central

Sibbald, Robert; Downar, James; Hawryluck, Laura

2007-01-01

Background Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of “futile care” or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources. Methods Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach. Results From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines. Interpretation ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU. PMID:17978274

Suvorexant is associated with a low incidence of delirium in critically ill patients: a retrospective cohort study.

PubMed

Masuyama, Tomoyuki; Sanui, Masamitsu; Yoshida, Naoto; Iizuka, Yusuke; Ogi, Kunio; Yagihashi, Satoko; Nagatomo, Kanae; Sasabuchi, Yusuke; Lefor, Alan K

2018-02-08

Benzodiazepine use is a risk factor for the development of delirium in adult intensive care unit (ICU) patients. Suvorexant is an alternative to benzodiazepines to induce sleep, but the incidence of delirium in critically ill patients is unknown. We undertook this retrospective study to investigate the incidence of delirium in patients who receive suvorexant in the ICU. This retrospective cohort study was conducted in a closed 12-bed ICU at a tertiary teaching hospital. Patients admitted to the ICU for 72 h or longer between January and June 2015 were evaluated for delirium using the Confusion Assessment Method for the Intensive Care Unit tool. We evaluated the incidence of delirium in patients who received suvorexant and those who did not. To adjust for confounding factors, multivariable logistic regression analysis was conducted. Study subjects included 118 patients, with a median age of 72 years and a median Acute Physiology and Chronic Health Evaluation II score of 18 points. Eighty-two patients (69.5%) were admitted after cardiovascular surgery. In the suvorexant group, there were fewer post-cardiovascular surgical patients and more medical patients. The duration of mechanical ventilation during ICU stay was longer in the suvorexant group, and sedatives and sleep inducers other than suvorexant were used more frequently in the suvorexant group. The incidence of delirium was 43.8% in the suvorexant group and 58.8% in the non-suvorexant group (P = 0.149). After adjustment for risk factors using multivariable logistic regression analysis, suvorexant was associated with a lower incidence of delirium (odds ratio = 0.23, 95% confidence interval: 0.07-0.73; P = 0.012). Suvorexant was associated with decreased odds of transitioning to delirium in critically ill patients. The use of suvorexant may lower the incidence of delirium in ICU patients. Future prospective studies are warranted. © 2018 Japanese Psychogeriatric Society.

Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses.

PubMed

Ng, George Wing Yiu; Pun, Jack Kwok Hung; So, Eric Hang Kwong; Chiu, Wendy Wai Hang; Leung, Avis Siu Ha; Stone, Yuk Han; Lam, Chung Ling; Lai, Sarah Pui Wa; Leung, Rowlina Pui Wah; Luk, Hing Wah; Leung, Anne Kit Hung; Au Yeung, Kin Wah; Lai, Kang Yiu; Slade, Diana; Chan, Engle Angela

2017-08-11

Despite growing recognition of the importance of speaking up to protect patient safety in critical care, little research has been performed in this area in an intensive care unit (ICU) context. This study explored the communication openness perceptions of Chinese doctors and nurses and identified their perceptions of issues in ICU communication, their reasons for speaking up and the possible factors and strategies involved in promoting the practice of speaking up. A mixed-methods design with quantitative and sequential qualitative components was used. Eighty ICU staff members from a large public hospital in Hong Kong completed a questionnaire regarding their perceptions of communication openness. Ten clinicians whose survey responses indicated support for open communication were then interviewed about their speak-up practices. The participating ICU staff members had similar perceptions of their openness to communication. However, the doctors responded more positively than the nurses to many aspects of communication openness. The two groups also had different perceptions of speaking up. The interviewed ICU staff members who indicated a high level of communication openness reported that their primary reasons for speaking up were to seek and clarify information, which was achieved by asking questions. Other factors perceived to influence the motivation to speak up included seniority, relationships and familiarity with patient cases. Creating an atmosphere of safety and equality in which team members feel confident in expressing their personal views without fear of reprisal or embarrassment is necessary to encourage ICU staff members, regardless of their position, to speak up. Because harmony and saving face is valued in Chinese culture, training nurses and doctors to speak up by focusing on human factors and values rather than simply addressing conflict management is desirable in this context. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Intensive care unit-acquired blood stream infections: a 5-year retrospective analysis of a single tertiary care hospital in Korea.

PubMed

Lim, S J; Choi, J Y; Lee, S J; Cho, Y J; Jeong, Y Y; Kim, H C; Lee, J D; Hwang, Y S

2014-10-01

Bloodstream infections (BSIs) are serious complications with high mortality and morbidity in patients with critical illness. This study was conducted to analyze the clinical and microbiological characteristics as well as outcomes in patients with intensive care unit (ICU)-acquired BSIs. Data from 1,545 patients admitted to the ICU were retrospectively collected from January 2005 to December 2010. ICU-acquired BSI was defined as a positive blood culture for a clinically significant bacterial or fungal pathogen obtained >72 h after admission to the ICU. Data on clinical and demographic characteristics, comorbid illness, causes of infections, causative pathogens, and clinical outcomes were analyzed. Among the 1,545 ICU patients analyzed, 129 ICU-acquired BSIs occurred in 124 patients. Catheter-related BSIs (CR-BSIs) and ventilator-associated pneumonia (VAP) were the most common causes (29.4 and 20.9%, respectively). The most common isolates were Staphylococcus aureus in 35 (25.7%) and Candida species in 32 (24.8%) cases. Ninety-eight patients died (overall hospital mortality rate, 75.9%). ICU-acquired BSI-related mortality occurred in 23 (63.8%) and 7 (19.4%) of the VAP and CR-BSIs cases, respectively. The most commonly isolated microorganisms from these fatalities were S. aureus (12, 25.7%) and Acinetobacter species (12, 25.7%). In 99 ICU-acquired BSI cases, patients did not receive adequate empirical antimicrobial treatment at the onset of BSIs, whereas the patients in 30 cases did. ICU-acquired BSIs may be associated with high mortality in patients with critical illness. Meticulous infection control and adequate treatment may reduce ICU-acquired BSI-related mortality.

Economic Feasibility of Staffing the Intensive Care Unit with a Communication Facilitator.

PubMed

Khandelwal, Nita; Benkeser, David; Coe, Norma B; Engelberg, Ruth A; Curtis, J Randall

2016-12-01

In the intensive care unit (ICU), complex decision making by clinicians and families requires good communication to ensure that care is consistent with the patients' values and goals. To assess the economic feasibility of staffing ICUs with a communication facilitator. Data were from a randomized trial of an "ICU communication facilitator" linked to hospital financial records; eligible patients (n = 135) were admitted to the ICU at a single hospital with predicted mortality ≥30% and a surrogate decision maker. Adjusted regression analyses assessed differences in ICU total and direct variable costs between intervention and control patients. A bootstrap-based simulation assessed the cost efficiency of a facilitator while varying the full-time equivalent of the facilitator and the ICU mortality risk. Total ICU costs (mean 22.8k; 95% CI, -42.0k to -3.6k; P = 0.02) and average daily ICU costs (mean, -0.38k; 95% CI, -0.65k to -0.11k; P = 0.006)] were reduced significantly with the intervention. Despite more contacts, families of survivors spent less time per encounter with facilitators than did families of decedents (mean, 25 [SD, 11] min vs. 36 [SD, 14] min). Simulation demonstrated maximal weekly savings with a 1.0 full-time equivalent facilitator and a predicted ICU mortality of 15% (total weekly ICU cost savings, $58.4k [95% CI, $57.7k-59.2k]; weekly direct variable savings, $5.7k [95% CI, $5.5k-5.8k]) after incorporating facilitator costs. Adding a full-time trained communication facilitator in the ICU may improve the quality of care while simultaneously reducing short-term (direct variable) and long-term (total) health care costs. This intervention is likely to be more cost effective in a lower-mortality population.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

PubMed

Hung, Shih-Chiang; Kung, Chia-Te; Hung, Chih-Wei; Liu, Ber-Ming; Liu, Jien-Wei; Chew, Ghee; Chuang, Hung-Yi; Lee, Wen-Huei; Lee, Tzu-Chi

2014-08-23

The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

A cross-sectional survey of Australian and New Zealand public opinion on methods totriage intensive care patients in an influenza pandemic.

PubMed

Cheung, Winston; Myburgh, John; McGuinness, Shay; Chalmers, Debra; Parke, Rachael; Blyth, Fiona; Seppelt, Ian; Parr, Michael; Hooker, Claire; Blackwell, Nikki; DeMonte, Shannon; Gandhi, Kalpesh; Kol, Mark; Kerridge, Ian; Nair, Priya; Saunders, Nicholas M; Saxena, Manoj K; Thanakrishnan, Govindasamy; Naganathan, Vasi

2017-09-01

An influenza pandemic has the potential to overwhelm intensive care resources, but the views of the general public on how resources should be allocated in such a scenario were unknown. We aimed to determine Australian and New Zealand public opinion on how intensive care unit beds should be allocated during an influenza pandemic. A postal questionnaire was sent to 4000 randomly selected registered voters; 2000 people each from the Australian Electoral Commission and New Zealand Electoral Commission rolls. The respondents' preferred method to triage ICU patients in an influenza pandemic. Respondents chose from six methods: use a "first in, first served" approach; allow a senior doctor to decide; use pre-determined health department criteria; use random selection; use the patient's ability to pay; use the importance of the patient to decide. Respondents also rated each of the triage methods for fairness. Australian respondents preferred that patients be triaged to the ICU either by a senior doctor (43.2%) or by pre-determined health department criteria (38.7%). New Zealand respondents preferred that triage be performed by a senior doctor (45.9%). Respondents from both countries perceived triage by a senior doctor and by pre-determined health department criteria to be fair, and the other four methods of triage to be unfair. In an influenza pandemic, when ICU resources would be overwhelmed, survey respondents preferred that ICU triage be performed by a senior doctor, but also perceived the use of pre-determined triage criteria to be fair.

Effectiveness of classroom based crew resource management training in the intensive care unit: study design of a controlled trial

PubMed Central

2011-01-01

Background Crew resource management (CRM) has the potential to enhance patient safety in intensive care units (ICU) by improving the use of non-technical skills. However, CRM evaluation studies in health care are inconclusive with regard to the effect of this training on behaviour and organizational outcomes, due to weak study designs and the scarce use of direct observations. Therefore, the aim of this study is to determine the effectiveness and cost-effectiveness of CRM training on attitude, behaviour and organization after one year, using a multi-method approach and matched control units. The purpose of the present article is to describe the study protocol and the underlying choices of this evaluation study of CRM in the ICU in detail. Methods/Design Six ICUs participated in a paired controlled trial, with one pre-test and two post test measurements (respectively three months and one year after the training). Three ICUs were trained and compared to matched control ICUs. The 2-day classroom-based training was delivered to multidisciplinary groups. Typical CRM topics on the individual, team and organizational level were discussed, such as situational awareness, leadership and communication. All levels of Kirkpatrick's evaluation framework (reaction, learning, behaviour and organisation) were assessed using questionnaires, direct observations, interviews and routine ICU administration data. Discussion It is expected that the CRM training acts as a generic intervention that stimulates specific interventions. Besides effectiveness and cost-effectiveness, the assessment of the barriers and facilitators will provide insight in the implementation process of CRM. Trial registration Netherlands Trial Register (NTR): NTR1976 PMID:22073981

Targeted temperature management in neurological intensive care unit

PubMed Central

Muengtaweepongsa, Sombat; Srivilaithon, Winchana

2017-01-01

Targeted temperature management (TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy (HIE). In addition, TTM is also useful for treatment of elevated intracranial pressure (ICP). HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit (ICU). The most common cause of HIE is cardiac arrest. Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest. Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies. Several methods of TTM have been reported in the literature. TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU. PMID:28706860

On the Edge of Life, II: House Officer Struggles Recorded in an Intensive Care Unit Journal

PubMed Central

Sekeres, Mikkael A.; Stern, Theodore A.

2002-01-01

Background: In a general hospital, few clinical settings match the intensity of the intensive care unit (ICU) experience. Clinical rotations in ICUs elicit and emphasize the struggles house officers face on a daily basis throughout their training. Method: These struggles were recorded by hundreds of residents in a journal maintained in one Medical ICU for the past 20 years. We systematically reviewed these unsolicited entries to develop categories that define and illustrate common stressors. Results: Stressors for house officers include isolation, insecurity, care for the terminally ill, sleep deprivation, and long work weeks. Conclusion: By placing the struggles of house staff in context, trainees and their residency training programs can be prepared for the intensity of the experience and for work in clinical practice settings that follows completion of training. PMID:15014706

Simplified Acute Physiology Score II as Predictor of Mortality in Intensive Care Units: A Decision Curve Analysis.

PubMed

Allyn, Jérôme; Ferdynus, Cyril; Bohrer, Michel; Dalban, Cécile; Valance, Dorothée; Allou, Nicolas

2016-01-01

End-of-life decision-making in Intensive care Units (ICUs) is difficult. The main problems encountered are the lack of a reliable prediction score for death and the fact that the opinion of patients is rarely taken into consideration. The Decision Curve Analysis (DCA) is a recent method developed to evaluate the prediction models and which takes into account the wishes of patients (or surrogates) to expose themselves to the risk of obtaining a false result. Our objective was to evaluate the clinical usefulness, with DCA, of the Simplified Acute Physiology Score II (SAPS II) to predict ICU mortality. We conducted a retrospective cohort study from January 2011 to September 2015, in a medical-surgical 23-bed ICU at University Hospital. Performances of the SAPS II, a modified SAPS II (without AGE), and age to predict ICU mortality, were measured by a Receiver Operating Characteristic (ROC) analysis and DCA. Among the 4.370 patients admitted, 23.3% died in the ICU. Mean (standard deviation) age was 56.8 (16.7) years, and median (first-third quartile) SAPS II was 48 (34-65). Areas under ROC curves were 0.828 (0.813-0.843) for SAPS II, 0.814 (0.798-0.829) for modified SAPS II and of 0.627 (0.608-0.646) for age. DCA showed a net benefit whatever the probability threshold, especially under 0.5. DCA shows the benefits of the SAPS II to predict ICU mortality, especially when the probability threshold is low. Complementary studies are needed to define the exact role that the SAPS II can play in end-of-life decision-making in ICUs.

Development of a Canadian deceased donation education program for health professionals: a needs assessment survey.

PubMed

Hancock, Jennifer; Shemie, Sam D; Lotherington, Ken; Appleby, Amber; Hall, Richard

2017-10-01

The purpose of this survey was to determine how Canadian healthcare professionals perceive their deficiencies and educational requirements related to organ and tissue donation. We surveyed 641 intensive care unit (ICU) physicians, 1,349 ICU nurses, 1,561 emergency room (ER) physicians, and 1,873 ER nurses. The survey was distributed by the national organization for each profession (the Canadian Association of Emergency Physicians, the Canadian Association of Critical Care Nurses, and the National Emergency Nurses Association). Canadian Blood Services developed the critical care physician list in collaboration with the Canadian Critical Care Society. Survey development included questions related to comfort with, and knowledge of, key competencies in organ and tissue donation. Eight hundred thirty-one (15.3%) of a possible 5,424 respondents participated in the survey. Over 50% of respondents rated the following topics as highly important: knowledge of general organ and tissue donation, neurological determination of death, donation after cardiac death, and medical-legal donation issues. High competency comfort levels ranged from 14.7-50.9% for ICU nurses and 8.0-34.6% for ER nurses. Competency comfort levels were higher for ICU physicians (67.5-85.6%) than for ER physicians who rated all competencies lower. Respondents identified a need for a curriculum on national organ donation and preferred e-learning as the method of education. Both ICU nurses and ER practitioners expressed low comfort levels with their competencies regarding organ donation. Intensive care unit physicians had a much higher level of comfort; however, the majority of these respondents were specialty trained and working in academic centres with active donation and transplant programs. A national organ donation curriculum is needed.

A comparative cost analysis of polytrauma and neurosurgery Intensive Care Units at an apex trauma care facility in India

PubMed Central

Kumar, Parmeshwar; Jithesh, V.; Gupta, Shakti Kumar

2016-01-01

Context: Although Intensive Care Units (ICUs) only account for 10% of the hospital beds, they consume nearly 22% of the hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. Aim: The aim of this study was to evaluate and compare the cost of intensive care delivery between multispecialty and neurosurgery ICUs at an apex trauma care facility in India. Materials and Methods: The study was conducted in a polytrauma and neurosurgery ICU at a 203-bedded Level IV trauma care facility in New Delhi, India, from May 1, 2012 to June 30, 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in the study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Statistical Analysis: Statistical analysis was performed by Fisher's two tailed t-test. Results: Total cost/bed/day for the multispecialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU, it was Rs. 14,306.7/-, workforce constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Conclusions: Quantification of expenditure in running an ICU in a trauma center would assist health-care decision makers in better allocation of resources. Although multispecialty ICUs are more cost-effective, other factors will also play a role in defining the kind of ICU that needs to be designed. PMID:27555693

Association between Hyponatremia and Higher Bronchiolitis Severity among Children in the Intensive Care Unit with Bronchiolitis

PubMed Central

Hasegawa, Kohei; Stevenson, Michelle D.; Mansbach, Jonathan M.; Schroeder, Alan R.; Sullivan, Ashley F.; Espinola, Janice A.; Piedra, Pedro A.; Camargo, Carlos A.

2016-01-01

Background It remains unclear whether hyponatremia independently predicts a higher severity in children with bronchiolitis. Objective To investigate the association between hyponatremia and bronchiolitis severity in children hospitalized to the intensive care unit (ICU) for bronchiolitis. Methods We conducted a 16-center, prospective cohort study of hospitalized children age <2 years with bronchiolitis during the winters of 2007 to 2010. We classified patients into two groups: normonatremia (135–145 mEq/L) and hyponatremia (<135 mEq/L) based on the first-measured serum sodium concentration on the day of hospitalization. Outcomes were use of mechanical ventilation and ICU length-of-stay (LOS). To examine the association of sodium status with outcomes, we fit logistic and linear regression models with propensity score adjustment. Results Of 231 children hospitalized to the ICU for bronchiolitis, 193 patients (84%) were categorized into the normonatremia group, and 38 children (16%) into hyponatremia group. Compared to children with normonatremia, those with hyponatremia had higher risks of mechanical ventilation use (40% vs. 58%; P=0.04) and longer ICU LOS (median, 3 days vs. 6 days; P=0.007). Likewise, in the adjusted analyses, children with hyponatremia had significantly higher risks of mechanical ventilation use (OR, 2.14; 95%CI, 1.03–4.48; P=0.04) and longer ICU LOS (β-coefficient 2.21 days; 95%CI, 0.68–3.73 days; P=0.003). Conclusions In this prospective, multicenter study of children hospitalized for bronchiolitis, hyponatremia on the day of hospitalization was associated with a higher severity. Our data support hyponatremia as a prognostic factor that might improve the ability of clinicians to predict the disease course of children with severe bronchiolitis. PMID:26136313

Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

PubMed Central

Douglas, Sara L.; O’Toole, Elizabeth; Gordon, Nahida H.; Hejal, Rana; Peerless, Joel; Rowbottom, James; Garland, Allan; Lilly, Craig; Wiencek, Clareen; Hickman, Ronald

2010-01-01

Background: Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. Methods: One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. Results: Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. Conclusions: The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. Trial registry: ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov PMID:20576734

Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients

PubMed Central

Mahmoodpoor, Ata; Hamishehkar, Hadi; Shadvar, Kamran; Beigmohammadi, Mohammadtaghi; Iranpour, Afshin; Sanaie, Sarvin

2016-01-01

Background and Aims: The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA1c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients. Materials and Methods: Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A1c (HbA1c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients. Results: Without considering the history of diabetes, nonsurvivors had significantly higher HbA1c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004–1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA1c increased the risk of death; with each increase in HbA1c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933–1.58, RR: 1.2). Conclusions: Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia. PMID:27076705

A multicentre evaluation of two intensive care unit triage protocols for use in an influenza pandemic.

PubMed

Cheung, Winston K; Myburgh, John; Seppelt, Ian M; Parr, Michael J; Blackwell, Nikki; Demonte, Shannon; Gandhi, Kalpesh; Hoyling, Larissa; Nair, Priya; Passer, Melissa; Reynolds, Claire; Saunders, Nicholas M; Saxena, Manoj K; Thanakrishnan, Govindasamy

2012-08-06

To determine the increase in intensive care unit (ICU) bed availability that would result from the use of the New South Wales and Ontario Health Plan for an Influenza Pandemic (OHPIP) triage protocols. Prospective evaluation study conducted in eight Australian, adult, general ICUs, between September 2009 and May 2010. All patients who were admitted to the ICU, excluding those who had elective surgery, were prospectively evaluated using the two triage protocols, simulating a pandemic situation. Both protocols were originally developed to determine which patients should be excluded from accessing ICU resources during an influenza pandemic. Increase in ICU bed availability. At admission, the increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 3.5%, 14.7% and 22.7%, respectively, and 52.8% using the OHPIP triage protocol (P < 0.001). Re-evaluation of patients at 12 hours after admission using Tiers 1, 2 and 3 of the NSW triage protocol incrementally increased ICU bed availability by 19.2%, 16.1% and 14.1%, respectively (P < 0.001). The maximal cumulative increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 23.7%, 31.6% and 37.5%, respectively, at 72 hours (P < 0.001), and 65.0% using the OHPIP triage protocol, at 120 hours (P < 0.001). Both triage protocols resulted in increases in ICU bed availability, but the OHPIP protocol provided the greatest increase overall. With the NSW triage protocol, ICU bed availability increased as the protocol was escalated.

The Host Response in Patients with Sepsis Developing Intensive Care Unit-acquired Secondary Infections.

PubMed

van Vught, Lonneke A; Wiewel, Maryse A; Hoogendijk, Arie J; Frencken, Jos F; Scicluna, Brendon P; Klein Klouwenberg, Peter M C; Zwinderman, Aeilko H; Lutter, Rene; Horn, Janneke; Schultz, Marcus J; Bonten, Marc M J; Cremer, Olaf L; van der Poll, Tom

2017-08-15

Sepsis can be complicated by secondary infections. We explored the possibility that patients with sepsis developing a secondary infection while in the intensive care unit (ICU) display sustained inflammatory, vascular, and procoagulant responses. To compare systemic proinflammatory host responses in patients with sepsis who acquire a new infection with those who do not. Consecutive patients with sepsis with a length of ICU stay greater than 48 hours were prospectively analyzed for the development of ICU-acquired infections. Twenty host response biomarkers reflective of key pathways implicated in sepsis pathogenesis were measured during the first 4 days after ICU admission and at the day of an ICU-acquired infection or noninfectious complication. Of 1,237 admissions for sepsis (1,089 patients), 178 (14.4%) admissions were complicated by ICU-acquired infections (at Day 10 [6-13], median with interquartile range). Patients who developed a secondary infection showed higher disease severity scores and higher mortality up to 1 year than those who did not. Analyses of biomarkers in patients who later went on to develop secondary infections revealed a more dysregulated host response during the first 4 days after admission, as reflected by enhanced inflammation, stronger endothelial cell activation, a more disturbed vascular integrity, and evidence for enhanced coagulation activation. Host response reactions were similar at the time of ICU-acquired infectious or noninfectious complications. Patients with sepsis who developed an ICU-acquired infection showed a more dysregulated proinflammatory and vascular host response during the first 4 days of ICU admission than those who did not develop a secondary infection.

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review.

PubMed

de Almeida, Cesar Cimonari; Boone, M Dustin; Laviv, Yosef; Kasper, Burkhard S; Chen, Clark C; Kasper, Ekkehard M

2018-02-01

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

Validation of the Intensive Care Unit Early Warning Dashboard: Quality Improvement Utilizing a Retrospective Case-Control Evaluation.

PubMed

Kavanaugh, Michael J; So, Joanne D; Park, Peter J; Davis, Konrad L

2017-02-01

Risk stratification with the Modified Early Warning System (MEWS) or electronic cardiac arrest trigger (eCART) has been utilized with ward patients to preemptively identify high-risk patients who might benefit from enhanced monitoring, including early intensive care unit (ICU) transfer. In-hospital mortality from cardiac arrest is ∼80%, making preventative interventions an important focus area. ICUs have lower patient to nurse ratios than wards, resulting in less emphasis on the development of ICU early warning systems. Our institution developed an early warning dashboard (EWD) identifying patients who may benefit from earlier interventions. Using the adverse outcomes of cardiac arrest, ICU mortality, and ICU readmissions, a retrospective case-control study was performed using three demographic items (age, diabetes, and morbid obesity) and 24 EWD measured items, including vital signs, laboratory values, ventilator information, and other clinical information, to validate the EWD. Ten statistically significant areas were identified for cardiac arrest and 13 for ICU death. Identified items included heart rate, dialysis, leukocytosis, and lactate. The ICU readmission outcome was compared to controls from both ICU patients and ward patients, and statistical significance was identified for respiratory rate >30. With several statistically significant data elements, the EWD parameters have been incorporated into advanced clinical decision algorithms to identify at-risk ICU patients. Earlier identification and treatment of organ failure in the ICU improve outcomes and the EWD can serve as a safety measure for both at-risk in-house patients and also extend critical care expertise through telemedicine to smaller hospitals.

A model to create an efficient and equitable admission policy for patients arriving to the cardiothoracic ICU.

PubMed

Yang, Muer; Fry, Michael J; Raikhelkar, Jayashree; Chin, Cynthia; Anyanwu, Anelechi; Brand, Jordan; Scurlock, Corey

2013-02-01

To develop queuing and simulation-based models to understand the relationship between ICU bed availability and operating room schedule to maximize the use of critical care resources and minimize case cancellation while providing equity to patients and surgeons. Retrospective analysis of 6-month unit admission data from a cohort of cardiothoracic surgical patients, to create queuing and simulation-based models of ICU bed flow. Three different admission policies (current admission policy, shortest-processing-time policy, and a dynamic policy) were then analyzed using simulation models, representing 10 yr worth of potential admissions. Important output data consisted of the "average waiting time," a proxy for unit efficiency, and the "maximum waiting time," a surrogate for patient equity. A cardiothoracic surgical ICU in a tertiary center in New York, NY. Six hundred thirty consecutive cardiothoracic surgical patients admitted to the cardiothoracic surgical ICU. None. Although the shortest-processing-time admission policy performs best in terms of unit efficiency (0.4612 days), it did so at expense of patient equity prolonging surgical waiting time by as much as 21 days. The current policy gives the greatest equity but causes inefficiency in unit bed-flow (0.5033 days). The dynamic policy performs at a level (0.4997 days) 8.3% below that of the shortest-processing-time in average waiting time; however, it balances this with greater patient equity (maximum waiting time could be shortened by 4 days compared to the current policy). Queuing theory and computer simulation can be used to model case flow through a cardiothoracic operating room and ICU. A dynamic admission policy that looks at current waiting time and expected ICU length of stay allows for increased equity between patients with only minimum losses of efficiency. This dynamic admission policy would seem to be a superior in maximizing case-flow. These results may be generalized to other surgical ICUs.

Development of a Model of Interprofessional Shared Clinical Decision Making in the ICU: A Mixed-Methods Study.

PubMed

DeKeyser Ganz, Freda; Engelberg, Ruth; Torres, Nicole; Curtis, Jared Randall

2016-04-01

To develop a model to describe ICU interprofessional shared clinical decision making and the factors associated with its implementation. Ethnographic (observations and interviews) and survey designs. Three ICUs (two in Israel and one in the United States). A convenience sample of nurses and physicians. None. Observations and interviews were analyzed using ethnographic and grounded theory methodologies. Questionnaires included a demographic information sheet and the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration. From observations and interviews, we developed a conceptual model of the process of shared clinical decision making that involves four stepped levels, proceeding from the lowest to the highest levels of collaboration: individual decision, information exchange, deliberation, and shared decision. This process is influenced by individual, dyadic, and system factors. Most decisions were made at the lower two levels. Levels of perceived collaboration were moderate with no statistically significant differences between physicians and nurses or between units. Both qualitative and quantitative data corroborated that physicians and nurses from all units were similarly and moderately satisfied with their level of collaboration and shared decision making. However, most ICU clinical decision making continues to take place independently, where there is some sharing of information but rarely are decisions made collectively. System factors, such as interdisciplinary rounds and unit culture, seem to have a strong impact on this process. This study provides a model for further study and improvement of interprofessional shared decision making.

Validation of a Sampling Method to Collect Exposure Data for Central-Line-Associated Bloodstream Infections.

PubMed

Hammami, Naïma; Mertens, Karl; Overholser, Rosanna; Goetghebeur, Els; Catry, Boudewijn; Lambert, Marie-Laurence

2016-05-01

Surveillance of central-line-associated bloodstream infections requires the labor-intensive counting of central-line days (CLDs). This workload could be reduced by sampling. Our objective was to evaluate the accuracy of various sampling strategies in the estimation of CLDs in intensive care units (ICUs) and to establish a set of rules to identify optimal sampling strategies depending on ICU characteristics. Analyses of existing data collected according to the European protocol for patient-based surveillance of ICU-acquired infections in Belgium between 2004 and 2012. CLD data were reported by 56 ICUs in 39 hospitals during 364 trimesters. We compared estimated CLD data obtained from weekly and monthly sampling schemes with the observed exhaustive CLD data over the trimester by assessing the CLD percentage error (ie, observed CLDs - estimated CLDs/observed CLDs). We identified predictors of improved accuracy using linear mixed models. When sampling once per week or 3 times per month, 80% of ICU trimesters had a CLD percentage error within 10%. When sampling twice per week, this was >90% of ICU trimesters. Sampling on Tuesdays provided the best estimations. In the linear mixed model, the observed CLD count was the best predictor for a smaller percentage error. The following sampling strategies provided an estimate within 10% of the actual CLD for 97% of the ICU trimesters with 90% confidence: 3 times per month in an ICU with >650 CLDs per trimester or each Tuesday in an ICU with >480 CLDs per trimester. Sampling of CLDs provides an acceptable alternative to daily collection of CLD data.

Analysis of the interface and data transfer from ICU to normal wards in a German University Hospital.

PubMed

Vollmer, Anne-Maria; Skonetzki-Cheng, Stefan; Prokosch, Hans-Ulrich

2013-01-01

Typically general wards and intensive care units (ICU) have very different labor organizations, structures and IT-systems in Germany. There is a need for coordination, because of the different working arrangements. Our team investigated the interface between ICU and general ward and especially the respective information transfer in the University hospital in Erlangen (Bavaria, Germany). The research team used a combination of interviews, observations and the analysis of transfer records and forms as part of a methodical triangulation. We identified 41 topics, which are discussed or presented in writing during the handover. In a second step, we investigate the requirements of data transmission in expert interviews. A data transfer concept from the perspective of the nurses and physicians was developed and we formulated recommendations for improvements of process and communication for this interface. Finally the data transfer concept was evaluated by the respondents.

Interpretable Deep Models for ICU Outcome Prediction

PubMed Central

Che, Zhengping; Purushotham, Sanjay; Khemani, Robinder; Liu, Yan

2016-01-01

Exponential surge in health care data, such as longitudinal data from electronic health records (EHR), sensor data from intensive care unit (ICU), etc., is providing new opportunities to discover meaningful data-driven characteristics and patterns ofdiseases. Recently, deep learning models have been employedfor many computational phenotyping and healthcare prediction tasks to achieve state-of-the-art performance. However, deep models lack interpretability which is crucial for wide adoption in medical research and clinical decision-making. In this paper, we introduce a simple yet powerful knowledge-distillation approach called interpretable mimic learning, which uses gradient boosting trees to learn interpretable models and at the same time achieves strong prediction performance as deep learning models. Experiment results on Pediatric ICU dataset for acute lung injury (ALI) show that our proposed method not only outperforms state-of-the-art approaches for morality and ventilator free days prediction tasks but can also provide interpretable models to clinicians. PMID:28269832

A Typology of ICU Patients and Families from the Clinician Perspective: Toward Improving Communication.

PubMed

Leslie, Myles; Paradis, Elise; Gropper, Michael A; Milic, Michelle M; Kitto, Simon; Reeves, Scott; Pronovost, Peter

2017-06-01

This paper presents an exploratory case study of clinician-patient communications in a specific clinical environment. It describes how intensive care unit (ICU) clinicians' technical and social categorizations of patients and families shape the flow of communication in these acute care settings. Drawing on evidence from a year-long ethnographic study of four ICUs, we develop a typology of patients and families as viewed by the clinicians who care for them. Each type, or category, of patient is associated with differing communication strategies, with compliant patients and families engaged in greater depth. In an era that prioritizes patient engagement through communication for all patients, our findings suggest that ICU teams need to develop new strategies for engaging and communicating with not just compliant patients and families, but those who are difficult as well. We discuss innovative methods for developing such strategies.

“The problem often is that we do not have a family spokesperson but a spokesgroup”: Family Member Informal Roles in End-of-Life Decision-Making in Adult ICUs

PubMed Central

Quinn, Jill R.; Schmitt, Madeline; Baggs, Judith Gedney; Norton, Sally A.; Dombeck, Mary T.; Sellers, Craig R.

2013-01-01

Background To support the process of effective family decision-making, it is important to recognize and understand informal roles various family members may play in the end-of-life decision-making process. Objective The purpose of this study was to describe some informal roles consistently enacted by family members involved in the process of end-of-life decision-making in intensive care units (ICUs). Methods Ethnographic study. Data were collected via participant observation with field notes and semi-structured interviews on four ICUs in an academic health center in the mid-Atlantic United States from 2001 to 2004. The units studied were a medical ICU, a surgical ICU, a burn and trauma ICU, and a cardiovascular ICU. Participants Participants included health care clinicians, patients, and family members. Results Informal roles for family members consistently observed were:, Primary Caregiver, Primary Decision Maker, Family Spokesperson, Out-of-Towner, Patient Wishes Expert, Protector, Vulnerable Member, and Health Care Expert. The identified informal roles were part of family decision making processes, and each role was part of a potentially complicated family dynamic for end-of-life decision-making within the family system, and between the family and health care domains. Conclusions These informal roles reflect the diverse responses to demands for family decision making in what is usually a novel and stressful situation. Identification and description of these family member informal roles can assist clinicians to recognize and understand the functions of these roles in family decision making at the end-of-life, and guide development of strategies to support and facilitate increased effectiveness of family discussions and decision-making processes. PMID:22210699

Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial

PubMed Central

De La Rosa, Gisela Del Carmen; Donado, Jorge Hernando; Restrepo, Alvaro Humberto; Quintero, Alvaro Mauricio; González, Luis Gabriel; Saldarriaga, Nora Elena; Bedoya, Marisol; Toro, Juan Manuel; Velásquez, Jorge Byron; Valencia, Juan Carlos; Arango, Clara Maria; Aleman, Pablo Henrique; Vasquez, Esdras Martin; Chavarriaga, Juan Carlos; Yepes, Andrés; Pulido, William; Cadavid, Carlos Alberto

2008-01-01

Introduction Critically ill patients can develop hyperglycaemia even if they do not have diabetes. Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit (ICU) and decreases morbidity in patients in a medical ICU. The effect of this therapy on patients in a mixed medical/surgical ICU is unknown. Our goal was to assess whether the effect of intensive insulin therapy, compared with standard therapy, decreases morbidity and mortality in patients hospitalised in a mixed ICU. Methods This is a prospective, randomised, non-blinded, single-centre clinical trial in a medical/surgical ICU. Patients were randomly assigned to receive either intensive insulin therapy to maintain glucose levels between 80 and 110 mg/dl (4.4 to 6.1 mmol/l) or standard insulin therapy to maintain glucose levels between 180 and 200 mg/dl (10 and 11.1 mmol/l). The primary end point was mortality at 28 days. Results Over a period of 30 months, 504 patients were enrolled. The 28-day mortality rate was 32.4% (81 of 250) in the standard insulin therapy group and 36.6% (93 of 254) in the intensive insulin therapy group (Relative Risk [RR]: 1.1; 95% confidence interval [CI]: 0.85 to 1.42). The ICU mortality in the standard insulin therapy group was 31.2% (78 of 250) and 33.1% (84 of 254) in the intensive insulin therapy group (RR: 1.06; 95%CI: 0.82 to 1.36). There was no statistically significant reduction in the rate of ICU-acquired infections: 33.2% in the standard insulin therapy group compared with 27.17% in the intensive insulin therapy group (RR: 0.82; 95%CI: 0.63 to 1.07). The rate of hypoglycaemia (≤ 40 mg/dl) was 1.7% in the standard insulin therapy group and 8.5% in the intensive insulin therapy group (RR: 5.04; 95% CI: 1.20 to 21.12). Conclusions IIT used to maintain glucose levels within normal limits did not reduce morbidity or mortality of patients admitted to a mixed medical/surgical ICU. Furthermore, this therapy increased the risk of hypoglycaemia. Trial Registration clinicaltrials.gov Identifiers: 4374-04-13031; 094-2 in 000966421 PMID:18799004

Improved ICU design reduces acquisition of antibiotic-resistant bacteria: a quasi-experimental observational study.

PubMed

Levin, Phillip D; Golovanevski, Mila; Moses, Allon E; Sprung, Charles L; Benenson, Shmuel

2011-01-01

The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to single-patient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.

Intensive care unit patients with lower respiratory tract nosocomial infections: the ENIRRIs project.

PubMed

De Pascale, Gennaro; Ranzani, Otavio T; Nseir, Saad; Chastre, Jean; Welte, Tobias; Antonelli, Massimo; Navalesi, Paolo; Garofalo, Eugenio; Bruni, Andrea; Coelho, Luis Miguel; Skoczynski, Szymon; Longhini, Federico; Taccone, Fabio Silvio; Grimaldi, David; Salzer, Helmut J F; Lange, Christoph; Froes, Filipe; Artigas, Antoni; Díaz, Emili; Vallés, Jordi; Rodríguez, Alejandro; Panigada, Mauro; Comellini, Vittoria; Fasano, Luca; Soave, Paolo M; Spinazzola, Giorgia; Luyt, Charles-Edouard; Alvarez-Lerma, Francisco; Marin, Judith; Masclans, Joan Ramon; Chiumello, Davide; Pezzi, Angelo; Schultz, Marcus; Mohamed, Hafiz; Van Der Eerden, Menno; Hoek, Roger A S; Gommers, D A M P J; Pasquale, Marta Di; Civljak, Rok; Kutleša, Marko; Bassetti, Matteo; Dimopoulos, George; Nava, Stefano; Rios, Fernando; Zampieri, Fernando G; Povoa, Pedro; Bos, Lieuwe D; Aliberti, Stefano; Torres, Antoni; Martín-Loeches, Ignacio

2017-10-01

The clinical course of intensive care unit (ICU) patients may be complicated by a large spectrum of lower respiratory tract infections (LRTI), defined by specific epidemiological, clinical and microbiological aspects. A European network for ICU-related respiratory infections (ENIRRIs), supported by the European Respiratory Society, has been recently established, with the aim at studying all respiratory tract infective episodes except community-acquired ones. A multicentre, observational study is in progress, enrolling more than 1000 patients fulfilling the clinical, biochemical and radiological findings consistent with a LRTI. This article describes the methodology of this study. A specific interest is the clinical impact of non-ICU-acquired nosocomial pneumonia requiring ICU admission, non-ventilator-associated LRTIs occurring in the ICU, and ventilator-associated tracheobronchitis. The clinical meaning of microbiologically negative infectious episodes and specific details on antibiotic administration modalities, dosages and duration are also highlighted. Recently released guidelines address many unresolved questions which might be answered by such large-scale observational investigations. In light of the paucity of data regarding such topics, new interesting information is expected to be obtained from our network research activities, contributing to optimisation of care for critically ill patients in the ICU.

Organizing Safe Transitions from Intensive Care

PubMed Central

Häggström, Marie; Bäckström, Britt

2014-01-01

Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team. An understanding of discharge practices is needed in order to ultimate patients' transfers from high technological intensive care units (ICU) to general wards. Aim. To describe, as experienced by intensive care and general ward staff, what strategies could be used when organizing patient's care before, during, and after transfer from intensive care. Method. Interviews of 15 participants were conducted, audio-taped, transcribed verbatim, and analyzed using qualitative content analysis. Results. The results showed that the categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and patient/families, between team members and involved units, and between patient/family and environment. Discussion/Conclusions. The findings highlight that ICU transitional care implies critical care rehabilitation. Discharge procedures need to be safe and structured and involve collaboration, encouraging support, optimal timing, early mobilization, and a multidiscipline approach. PMID:24782924

Horner's syndrome in patients admitted to the intensive care unit that have undergone central venous catheterization: a prospective study.

PubMed

Butty, Z; Gopwani, J; Mehta, S; Margolin, E

2016-01-01

PurposeCentral venous catheterization (CVC) is estimated to be performed in millions of patients per year. Swan-Ganz catheters used for CVC are most often inserted into the internal jugular vein and during this procedure they may come into contact with the sympathetic chain. This study aims to determine the incidence of Horner's syndrome in patients admitted to intensive care unit that have undergone internal jugular CVC insertion during their admission and to determine whether ultrasonography-assisted insertion has decreased the frequency of this complication.Patients and methodsA total of 100 prospective patients admitted to the ICU were examined for the presence of anisocoria and ptosis after undergoing recent CVC. Presence of Horner's syndrome was confirmed by testing with 0.5% apraclonidine and looking for the reversal of anisocoria.ResultsFrequency of Horner's syndrome after CVC was 2% in a sample of 100 prospectively examined patients.ConclusionHorner's syndrome remains a relatively rare but definitive complication of CVC. ICU physicians should be educated about its existence and prevalence and ophthalmologists should inquire about any history of ICU admission necessitating CVC insertion in any patient presenting with Horner's syndrome.

Effect of therapeutic Swedish massage on anxiety level and vital signs of Intensive Care Unit patients.

PubMed

Alves da Silva, Tatiana; Stripari Schujmann, Debora; Yamada da Silveira, Leda Tomiko; Caromano, Fátima Aparecida; Fu, Carolina

2017-07-01

To evaluate how Swedish massage affects the level of anxiety and vital signs of Intensive Care Unit (ICU) patients. Quasi-experimental study. ICU patients, 18-50 years old, cooperative, respiratory and hemodynamic stable, not under invasive mechanical ventilation. allergic to massage oil, vascular or orthopedic post-operative, skin lesions, thrombosis, fractures. A 30-min Swedish massage was applied once. arterial pressure, heart rate, respiratory rate, S-STAI questionnaire. Timing of evaluation: pre-massage, immediately post-massage, 30 min post-massage. Comparison: T-test, corrected by Bonferroni method, level of significance of 5%, confidence interval of 95%. 48 patients included, 30 (62.5%) female, mean age 55.46 (15.70) years old. Mean S-STAI pre-massage: 42.51 (9.48); immediately post-massage: 29.34 (6.37); 30 min post-massage: 32.62 (8.56), p < 0.001 for all comparison. Mean vital signs achieved statistical significance between pre-massage and immediately post-massage. Swedish massage reduced anxiety of ICU patients immediately and 30 min post-massage. Vital signs were reduced immediately post-massage. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Intensive care unit profesionals's knowledge about non invasive ventilation comparative analysis].

PubMed

Raurell-Torredà, M; Argilaga-Molero, E; Colomer-Plana, M; Ruiz-García, T; Galvany-Ferrer, A; González-Pujol, A

2015-01-01

The literature highlights the lack of noninvasive ventilation (NIV) protocols and the variability of the knowledge of NIV between intensive care units (ICU) and hospitals, so we want to compare NIV nurses's Knowledge from 4 multipurpose ICU and one surgical ICU. Multicenter, crosscutting, descriptive study in three university hospitals. The survey instrument was validated in a pilot test, and the calculated Kappa index was 0.9. Returning a completed survey is an indication of informed consent. Analysis by Chi square test. 117 responded (65%) nurses, 11±9.7 years of experience in ICU and 9.2±7.2 in use of NIV. One of the multipurpose ICU, was initiated NIV an average of 6 years later than the others (95% CI [3.3 to 8.6], P<.001). Only 23.1% of nurses would place a non-vented mask (with no exhalation port) by conventional ventilator, the rest any kind of face mask. 12.7% believed that the mask must be adjusted to the "2-finger" fit while 29% would seal the mask to the patient's face and cover the mask opening where air escapes to facilitate patient/ventilator synchronization. In the surgical ICU agitation identifies mostly as a complication of NIV compared with multipurpose UCIs (31.6% vs 1.8%, P<.001). 56.4% of nurses do not consider respiratory physiotherapy as nursing care, with no difference between units. Knowledge about types of interface is very dependent on the material of the unit. More training for complications of NIV as agitation and handling secretions it is necessary. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

Effect of collaborative care on cost variation in an intensive care unit.

PubMed

Garland, Allan

2013-05-01

Improving the cost-effectiveness of health care requires an understanding of the genesis of health care costs and in particular the sources of cost variation. Little is known about how multiple physicians, caring collaboratively for patients, contribute to costs. To explore the effect of collaborative care by physicians on variation in discretionary costs in an intensive care unit (ICU) by determining the contributions of the attending intensivists and ICU fellows. Prospective, observational study using a multivariable model of median discretionary costs for the first day in the ICU, adjusting for confounding variables. Analysis included 3514 patients who spent more than 2 hours in the ICU on the initial day. Impact of the physicians was assessed via variables representing the specific intensivist and ICU fellow responsible on the first ICU day and allowing for interaction terms. On the initial day, patients spent a median of 10.6 hours (interquartile range, 6.3-16.5) in the ICU, with median discretionary costs of $1343 (interquartile range, $788-2208). There was large variation in adjusted costs attributable to both the intensivists ($359; 95% CI, $244-$474) and the fellows ($756; 95% CI, $550-$965). The interaction terms were not significant (P = .12-.79). In an ICU care model with intensivists and subspecialty fellows, both types of physicians contributed significantly to the observed variation in discretionary costs. However, even in the presence of a hierarchical arrangement of clinical responsibilities, the influences on costs of the 2 types of physicians were independent.

Medication issues experienced by patients and carers after discharge from the intensive care unit.

PubMed

Eijsbroek, Heleen; Howell, David C J; Smith, Felicity; Shulman, Rob

2013-02-01

Medication-related problems (MRPs) frequently occur at the interfaces of care settings. We examined this further because little has been published about MRPs experienced by patients/carers after discharge from the intensive care unit (ICU). Medication history data were collected before, during, and after ICU admission and by face-to-face semistructured interviews with 21 patients and 13 carers attending the ICU Follow-up Clinic (FC) of our 35-bed adult ICU. A total of 122 drugs were prescribed regularly before ICU admission, 168 on ICU discharge, 132 at hospital discharge, and 128 at the FC. Medication-related problems were identified with hypnotics/anxiolytics, antidepressants, proton pump inhibitors, and analgesics. Good follow-up was observed in all 4 cases where the antidysrhythmic agent amiodarone was initiated on ICU. Patients/carers described 20 cases of difficulty in obtaining appropriate and timely supplies and 19 of insufficient information. These results show that our incidence of MRPs after ICU discharge was encouragingly infrequent, in which we attribute it to targeted medicine reconciliation and the availability of our FC. However, MRPs were perceived to stem from inadequate communication at the interfaces of care and the lack of opportunity for patients/carers to obtain relevant information. We recommend that FC should focus on MRPs during their consultation and that further research in this area should be performed to examine our observations further. Copyright © 2013 Elsevier Inc. All rights reserved.

Management strategies to effect change in intensive care units: lessons from the world of business. Part III. Effectively effecting and sustaining change.

PubMed

Gershengorn, Hayley B; Kocher, Robert; Factor, Phillip

2014-03-01

Reaping the optimal rewards from any quality improvement project mandates sustainability after the initial implementation. In Part III of this three-part ATS Seminars series, we discuss strategies to create a culture for change, improve cooperation and interaction between multidisciplinary teams of clinicians, and position the intensive care unit (ICU) optimally within the hospital environment. Coaches are used throughout other industries to help professionals assess and continually improve upon their practice; use of this strategy is as of yet infrequent in health care, but would be easily transferable and potentially beneficial to ICU managers and clinicians alike. Similarly, activities focused on improving teamwork are commonplace outside of health care. Simulation training and classroom education about key components of successful team functioning are known to result in improvements. In addition to creating an ICU environment in which individuals and teams of clinicians perform well, ICU managers must position the ICU to function well within the hospital system. It is important to move away from the notion of a standalone ("siloed") ICU to one that is well integrated into the rest of the institution. Creating a "pull-system" (in which participants are active in searching out needed resources and admitting patients) can help ICU managers both provide better care for the critically ill and strengthen relationships with non-ICU staff. Although not necessary, there is potential upside to creating a unified critical care service to assist with achieving these ends.

Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

PubMed Central

Ñamendys-Silva, Silvio A; Correa-García, Paulina; García-Guillén, Francisco J; González-Herrera, María O; Pérez-Alonso, Américo; Texcocano-Becerra, Julia; Herrera-Gómez, Angel; Cornejo-Juárez, Patricia; Meneses-García, Abelardo

2015-01-01

AIM: To describe the intensive care unit (ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii (AB) infection. METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico (INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required. RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23 (4.6%) of whom developed AB infections. Sixteen (60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock (56.2%) and postoperative care (21.7%). The respiratory tract was the most frequent site of AB infection (91.3%). The most common organ dysfunction observed in our group of patients were the respiratory (100%), cardiovascular (100%), hepatic (73.9%) and renal dysfunction (65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7% (2/17) compared with 66.6% (4/6) for the group of patients with 4 or more organ system dysfunctions (P = 0.021). Multivariate analysis identified blood lactate levels (BLL) as the only variable independently associated with in-ICU death (OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively. CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was a BLL ≥ 2.6 mmol/L in the first day of stay in the ICU. PMID:26261778

Impact of Neurointensivist Co-management on the Clinical Outcomes of Patients Admitted to a Neurosurgical Intensive Care Unit

PubMed Central

2017-01-01

Limited data are available on improved outcomes after initiation of neurointensivist co-management in neurosurgical intensive care units (NSICUs) in Korea. We evaluated the impact of a newly appointed neurointensivist on the outcomes of neurosurgical patients admitted to an intensive care unit (ICU). This retrospective observational study involved neurosurgical patients admitted to the NSICU at Samsung Medical Center between March 2013 and May 2016. Neurointensivist co-management was initiated in October 1 2014. We compared the outcomes of neurosurgical patients before and after neurointensivist co-management. The primary outcome was ICU mortality. A total of 571 patients were admitted to the NSICU during the study period, 291 prior to the initiation of neurointensivist co-management and 280 thereafter. Intracranial hemorrhage (29.6%) and traumatic brain injury (TBI) (26.6%) were the most frequent reasons for ICU admission. TBI was the most common cause of death (39.0%). There were no significant differences in mortality rates and length of ICU stay before and after co-management. However, the rates of ICU and 30-day mortality among the TBI patients were significantly lower after compared to before initiation of neurointensivist co-management (8.5% vs. 22.9%; P = 0.014 and 11.0% vs. 27.1%; P = 0.010, respectively). Although overall outcomes were not different after neurointensivist co-management, initiation of a strategy of routine involvement of a neurointensivist significantly reduced the ICU and 30-day mortality rates of TBI patients. PMID:28480662

Hand hygiene compliance rates in the United States--a one-year multicenter collaboration using product/volume usage measurement and feedback.

PubMed

McGuckin, Maryanne; Waterman, Richard; Govednik, John

2009-01-01

Hand hygiene (HH) is the single most important factor in the prevention of health care-acquired infections. The 3 most frequently reported methods of measuring HH compliance are: (1) direct observation, (2) self-reporting by health care workers (HCWs), and (3) indirect calculation based on HH product usage. This article presents the results of a 12-month multicenter collaboration assessing HH compliance rates at US health care facilities by measuring product usage and providing feedback about HH compliance. Our results show that HH compliance at baseline was 26% for intensive care units (ICUs) and 36% for non-ICUs. After 12 months of measuring product usage and providing feedback, compliance increased to 37% for ICUs and 51% for non-ICUs. (ICU, P = .0119; non-ICU, P < .001). HH compliance in the United States can increase when monitoring is combined with feedback. However, HH still occurs at or below 50% compli- ance for both ICUs and non-ICUs.

Mobile phones and computer keyboards: unlikely reservoirs of multidrug-resistant organisms in the tertiary intensive care unit.

PubMed

Smibert, O C; Aung, A K; Woolnough, E; Carter, G P; Schultz, M B; Howden, B P; Seemann, T; Spelman, D; McGloughlin, S; Peleg, A Y

2018-03-02

Few studies have used molecular epidemiological methods to study transmission links to clinical isolates in intensive care units. Ninety-four multidrug-resistant organisms (MDROs) cultured from routine specimens from intensive care unit (ICU) patients over 13 weeks were stored (11 meticillin-resistant Staphylococcus aureus (MRSA), two vancomycin-resistant enterococci and 81 Gram-negative bacteria). Medical staff personal mobile phones, departmental phones, and ICU keyboards were swabbed and cultured for MDROs; MRSA was isolated from two phones. Environmental and patient isolates of the same genus were selected for whole genome sequencing. On whole genome sequencing, the mobile phone isolates had a pairwise single nucleotide polymorphism (SNP) distance of 183. However, >15,000 core genome SNPs separated the mobile phone and clinical isolates. In a low-endemic setting, mobile phones and keyboards appear unlikely to contribute to hospital-acquired MDROs. Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Age of red blood cells and outcome in acute kidney injury

PubMed Central

2013-01-01

Introduction Transfusion of red blood cells (RBCs) and, in particular, older RBCs has been associated with increased short-term mortality in critically ill patients. We evaluated the association between age of transfused RBCs and acute kidney injury (AKI), hospital, and 90-day mortality in critically ill patients. Methods We conducted a prospective, observational, predefined sub-study within the FINNish Acute Kidney Injury (FINNAKI) study. This study included all elective ICU admissions with expected ICU stay of more than 24 hours and all emergency admissions from September to November 2011. To study the age of RBCs, we classified transfused patients into quartiles according to the age of oldest transfused RBC unit in the ICU. AKI was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Results Out of 1798 patients, 652 received at least one RBC unit. The median [interquartile range] age of the oldest RBC unit transfused was 12 [11-13] days in the freshest quartile and 21 [17-27] days in the quartiles 2 to 4. On logistic regression, RBC age was not associated with the development of KDIGO stage 3 AKI. Patients in the quartile of freshest RBCs had lower crude hospital and 90-day mortality rates compared to those in the quartiles of older blood. After adjustments, older RBC age was associated with significantly increased risk for hospital mortality. Age, Simplified Acute Physiology Score II (SAPS II)-score without age points, maximum Sequental Organ Failure Assessment (SOFA) score and the total number of transfused RBC units were independently associated with 90-day mortality. Conclusions The age of transfused RBC units was independently associated with hospital mortality but not with 90-day mortality or KDIGO stage 3 AKI. The number of transfused RBC units was an independent risk factor for 90-day mortality. PMID:24093554

Does a full-time, 24-hour intensivist improve care and efficiency?

PubMed

Carlson, R W; Weiland, D E; Srivathsan, K

1996-07-01

This article reviews the hypothesis that staffing with full-time intensive care physicians leads to improvements in the management of ICUs and in the outcome for ICU patients. Variations in the professional organization of critical care units in the United States are discussed. The advantages and disadvantages of open, closed, and transitional (comanagement) ICU organizational structures are presented.

Patient Care Utility Module for DEPMEDS Hospitals

DTIC Science & Technology

1991-06-05

identified in the patient care utility capability in Deployable Medical S-:tems (DEPMEDS) hospitals, especially in the Intensive Care Unit (ICU). A...identified in the patient care utility capability in Deployable Medical Systems (DEPMEDS) hospitals, especially in the Intensive Care Unit (ICU). A...REQUEST FROM DEFENSE MEDICAL STANDARDIZATION BOARD TO STUDY SPACE AROUND PATIENT BEDSIDE IN DEPHEDS HOSPITALS 28 DEFENSE MEDICAL STANDARDIZATION BOARD FONT

Measuring tele-ICU impact: does it optimize quality outcomes for the critically ill patient?

PubMed

Goran, Susan F

2012-04-01

To determine the relationship between tele-ICU (intensive care unit) implementations and improvement in quality measures and patient outcomes. Tele-ICUs were designed to leverage scarce critical-care experts and promised to improve patient quality. Abstracts and peer-reviewed articles were reviewed to identify the associations between tele-ICU programmes and clinical outcomes, cost savings, and customer satisfaction. Few peer-reviewed studies are available and many variables in each study limit the ability to associate study conclusions to the overall tele-ICU programme. Further research is required to explore the impact of the tele-ICU on patient/family satisfaction. Research findings are highly dependent upon the level of ICU acceptance. The tele-ICU, in collaboration with the ICU team, can be a valuable tool for the enhancement of quality goals although the ability to demonstrate cost savings is extremely complex. Studies clearly indicate that tele-ICU nursing vigilance can enhance patient safety by preventing potential patient harm. Nursing managers and leaders play a vital part in optimizing the quality role of the tele-ICU through supportive modelling and the maximization of ICU integration. © 2012 Blackwell Publishing Ltd.

Assessment of satisfaction with care among family members of survivors in a neuroscience intensive care unit.

PubMed

Hwang, David Y; Yagoda, Daniel; Perrey, Hilary M; Tehan, Tara M; Guanci, Mary; Ananian, Lillian; Currier, Paul F; Cobb, J Perren; Rosand, Jonathan

2014-04-01

Many prior nursing studies regarding family members specifically of neuroscience intensive care unit (neuro-ICU) patients have focused on identifying their primary needs. A concept related to identifying these needs and assessing whether they have been met is determining whether families explicitly report satisfaction with the care that both they and their loved ones have received. The objective of this study was to explore family satisfaction with care in an academic neuro-ICU and compare results with concurrent data from the same hospital's medical ICU (MICU). Over 38 days, we administered the Family Satisfaction-ICU instrument to neuro-ICU and MICU patients' families at the time of ICU discharge. Those whose loved ones passed away during ICU admission were excluded. When asked about the respect and compassion that they received from staff, 76.3% (95% CI [66.5, 86.1]) of neuro-ICU families were completely satisfied, as opposed to 92.7% in the MICU (95% CI [84.4, 101.0], p = .04). Respondents were less likely to be completely satisfied with the courtesy of staff if they reported participation in zero formal family meeting. Less than 60% of neuro-ICU families were completely satisfied by (1) frequency of physician communication, (2) inclusion and (3) support during decision making, and (4) control over the care of their loved ones. Parents of patients were more likely than other relatives to feel very included and supported in the decision-making process. Future studies may focus on evaluating strategies for neuro-ICU nurses and physicians to provide better decision-making support and to implement more frequent family meetings even for those patients who may not seem medically or socially complicated to the team. Determining satisfaction with care for those families whose loved ones passed away during their neuro-ICU admission is another potential avenue for future investigation.

The ICM research agenda on intensive care unit-acquired weakness.

PubMed

Latronico, Nicola; Herridge, Margaret; Hopkins, Ramona O; Angus, Derek; Hart, Nicholas; Hermans, Greet; Iwashyna, Theodore; Arabi, Yaseen; Citerio, Giuseppe; Wesley Ely, E; Hall, Jesse; Mehta, Sangeeta; Puntillo, Kathleen; Van den Hoeven, Johannes; Wunsch, Hannah; Cook, Deborah; Dos Santos, Claudia; Rubenfeld, Gordon; Vincent, Jean-Louis; Van den Berghe, Greet; Azoulay, Elie; Needham, Dale M

2017-09-01

We present areas of uncertainty concerning intensive care unit-acquired weakness (ICUAW) and identify areas for future research. Age, pre-ICU functional and cognitive state, concurrent illness, frailty, and health trajectories impact outcomes and should be assessed to stratify patients. In the ICU, early assessment of limb and diaphragm muscle strength and function using nonvolitional tests may be useful, but comparison with established methods of global and specific muscle strength and physical function and determination of their reliability and normal values would be important to advance these techniques. Serial measurements of limb and respiratory muscle strength, and systematic screening for dysphagia, would be helpful to clarify if and how weakness of these muscle groups is independently associated with outcome. ICUAW, delirium, and sedatives and analgesics may interact with each other, amplifying the effects of each individual factor. Reduced mobility in patients with hypoactive delirium needs investigations into dysfunction of central and peripheral nervous system motor pathways. Interventional nutritional studies should include muscle mass, strength, and physical function as outcomes, and prioritize elucidation of mechanisms. At follow-up, ICU survivors may suffer from prolonged muscle weakness and wasting and other physical impairments, as well as fatigue without demonstrable weakness on examination. Further studies should evaluate the prevalence and severity of fatigue in ICU survivors and define its association with psychiatric disorders, pain, cognitive impairment, and axonal loss. Finally, methodological issues, including accounting for baseline status, handling of missing data, and inclusion of patient-centered outcome measures should be addressed in future studies.

[End-of-Life Care in Intensive Care Units: Nursing strategies of family involvement at the end of life].

PubMed

Cyrol, Katharina; Fröhlich, Martin R; Piatti, Francesca; Imhof, Lorenz

2018-06-01

Background: Family members of people dying in the intensive care unit (ICU) are exposed to many stress factors and they often do not experience involvement in End-of-Life (EoL) situations. For example, they criticize a low degree of participation in patients care, delayed or incomplete information and lack of privacy. Even nursing staff is facing various obstacles in EoL situations in ICUs. Aim: This study investigates strategies used by ICU nursing staff in German-speaking Switzerland to increase family members participation in situations at the end of life. Method: Data was collected by conducting 12 semi-structured interviews using an approach based on Grounded Theory. A model was developed to explain nursing strategies for family involvement in EoL situations in the ICU. Conclusions: Nurses provide personal space and tranquillity for family members and allow them to be present at any time. Against this background, they support family members and enable them to say goodbye consciously to a loved one. Subsequent work should examine the effectiveness of the strategies described, particularly in terms of stress reactions displayed by family members in the aftermath of EoL situations. In practice, family members should be provided space for privacy. The entire healthcare team is recommended to identify and pursue common values and objectives. Moreover, intradisciplinary exchange and mentoring need to be encouraged. In order to prepare future nursing staff for EoL situations in the ICU, recognizing and promoting their educational skills is mandatory.

Engineering waterborne Pseudomonas aeruginosa out of a critical care unit.

PubMed

Garvey, Mark I; Bradley, Craig W; Wilkinson, Martyn A C; Bradley, Christina; Holden, Elisabeth

2017-08-01

To describe engineering and holistic interventions on water outlets contaminated with Pseudomonas aeruginosa and the observed impact on clinical P. aeruginosa patient isolates in a large Intensive Care Unit (ICU). Descriptive study. Queen Elizabeth Hospital Birmingham (QEHB), part of University Hospitals Birmingham (UHB) NHS Foundation Trust is a tertiary referral teaching hospital in Birmingham, UK and provides clinical services to nearly 1 million patients every year. Breakpoint models were used to detect any significant changes in the cumulative yearly rates of clinical P. aeruginosa patient isolates from August 2013-December 2016 across QEHB. Water sampling undertaken on the ICU indicated 30% of the outlets were positive for P. aeruginosa at any one time. Molecular typing of patient and water isolates via Pulsed Field Gel Electrophoresis suggested there was a 30% transmission rate of P. aeruginosa from the water to patients on the ICU. From, February 2014, QEHB implemented engineering interventions, consisting of new tap outlets and PALL point-of-use filters; as well as holistic measures, from February 2016 including a revised tap cleaning method and appropriate disposal of patient waste water. Breakpoint models indicated the engineering and holistic interventions resulted in a significant (p<0.001) 50% reduction in the number of P. aeruginosa clinical patient isolates over a year. Here we demonstrate that the role of waterborne transmission of P. aeruginosa in an ICU cannot be overlooked. We suggest both holistic and environmental factors are important in reducing transmission. Copyright © 2017 Elsevier GmbH. All rights reserved.

Comparative Evaluation of Accuracy of Pulse Oximeters and Factors Affecting Their Performance in a Tertiary Intensive Care Unit

PubMed Central

Sahi, Malvinder Singh; Mahawar, Bablesh; Rajpurohit, Sajjan

2017-01-01

Introduction Pulse oximetry is a widely used tool, unfortunately there is a paucity of data investigating its accuracy in Intensive Care Units (ICU) and if they are able to meet mandated FDA criteria as claimed by them in critically ill patients. Aim To assess bias, precision and accuracy of pulse oximeters used in ICU and factors affecting them. Materials and Methods A prospective cohort study, including 129 patients admitted to the ICU of a tertiary referral centre. Pulse oximetry and blood gas were done simultaneously. Pulse oximetry was done using two pulse oximetres: Nonin and Philips. All physiological variables like haemoglobin, lactate, use of vasopressors and blood pressure were recorded. Bland Altman curves were constructed to determine bias and limits of agreement. Effect of physiological variables on bias and difference between performance characteristics of bias was determined using SPSS. Results Pulse oximetry overestimated arterial oxygen saturation (SaO2) by 1.44%. There was negative correlation between bias and SaO2 (r=-0.32) and positive correlation with lactate (r=0.16). The Philips pulse oximeter had significant higher bias and variability than Nonin pulse oximeter. (2.49±2.99 versus 0.46±1.68, mean difference = 1.98, 95% C.I. = 1.53 – 2.43, p-value <0.001). Conclusion Pulse oximetry overestimates SaO2. Bias tends to increase with rising lactate and hypoxia. There is heterogeneity in performance of various pulse oximetry devices in ICU. PMID:28764215

CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients

PubMed Central

Molloy, Alexander J; Clarke, France; Herridge, Margaret S; Koo, Karen K Y; Rudkowski, Jill; Seely, Andrew J E; Pellizzari, Joseph R; Tarride, Jean-Eric; Mourtzakis, Marina; Karachi, Timothy; Cook, Deborah J

2016-01-01

Introduction Early exercise with in-bed cycling as part of an intensive care unit (ICU) rehabilitation programme has the potential to improve physical and functional outcomes following critical illness. The objective of this study is to determine the feasibility of enrolling adults in a multicentre pilot randomised clinical trial (RCT) of early in-bed cycling versus routine physiotherapy to inform a larger RCT. Methods and analysis 60-patient parallel group pilot RCT in 7 Canadian medical-surgical ICUs. We will include all previously ambulatory adult patients within the first 0–4 days of mechanical ventilation, without exclusion criteria. After informed consent, patients will be randomised using a web-based, centralised electronic system, to 30 min of in-bed leg cycling in addition to routine physiotherapy, 5 days per week, for the duration of their ICU stay (28 days maximum) or routine physiotherapy alone. We will measure patients' muscle strength (Medical Research Council Sum Score, quadriceps force) and function (Physical Function in ICU Test (scored), 30 s sit-to-stand, 2 min walk test) at ICU awakening, ICU discharge and hospital discharge. Our 4 feasibility outcomes are: (1) patient accrual of 1–2 patients per month per centre, (2) protocol violation rate <20%, (3) outcome measure ascertainment >80% at the 3 time points and (4) blinded outcomes ascertainment >80% at hospital discharge. Hospital outcome assessors are blinded to group assignment, whereas participants, ICU physiotherapists, ICU caregivers, research coordinators and ICU outcome assessors are not blinded to group assignment. We will analyse feasibility outcomes with descriptive statistics. Ethics and dissemination Each participating centre will obtain local ethics approval, and results of the study will be published to inform the design and conduct of a future multicentre RCT of in-bed cycling to improve physical outcomes in ICU survivors. Trial registration number NCT02377830; Pre-results. PMID:27059469

Temperature variability during delirium in ICU patients: an observational study.

PubMed

van der Kooi, Arendina W; Kappen, Teus H; Raijmakers, Rosa J; Zaal, Irene J; Slooter, Arjen J C

2013-01-01

Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the intensive care unit (ICU) and associated with impaired long-term outcome. Despite its frequency and impact, delirium is poorly recognized by ICU-physicians and -nurses using delirium screening tools. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting component to monitor delirium, but whether temperature regulation is different during ICU delirium has not yet been investigated. The aim of this study was to investigate whether ICU delirium is related to temperature variability. Furthermore, we investigated whether ICU delirium is related to absolute body temperature. We included patients who experienced both delirium and delirium free days during ICU stay, based on the Confusion Assessment method for the ICU conducted by a research- physician or -nurse, in combination with inspection of medical records. We excluded patients with conditions affecting thermal regulation or therapies affecting body temperature. Daily temperature variability was determined by computing the mean absolute second derivative of the temperature signal. Temperature variability (primary outcome) and absolute body temperature (secondary outcome) were compared between delirium- and non-delirium days with a linear mixed model and adjusted for daily mean Richmond Agitation and Sedation Scale scores and daily maximum Sequential Organ Failure Assessment scores. Temperature variability was increased during delirium-days compared to days without delirium (β(unadjuste)d=0.007, 95% confidence interval (CI)=0.004 to 0.011, p<0.001). Adjustment for confounders did not alter this result (β(adjusted)=0.005, 95% CI=0.002 to 0.008, p<0.001). Delirium was not associated with absolute body temperature (β(unadjusted)=-0.03, 95% CI=-0.17 to 0.10, p=0.61). This did not change after adjusting for confounders (β(adjusted)=-0.03, 95% CI=-0.17 to 0.10, p=0.63). Our study suggests that temperature variability is increased during ICU delirium.

Neural Network Prediction of ICU Length of Stay Following Cardiac Surgery Based on Pre-Incision Variables

PubMed Central

Pothula, Venu M.; Yuan, Stanley C.; Maerz, David A.; Montes, Lucresia; Oleszkiewicz, Stephen M.; Yusupov, Albert; Perline, Richard

2015-01-01

Background Advanced predictive analytical techniques are being increasingly applied to clinical risk assessment. This study compared a neural network model to several other models in predicting the length of stay (LOS) in the cardiac surgical intensive care unit (ICU) based on pre-incision patient characteristics. Methods Thirty six variables collected from 185 cardiac surgical patients were analyzed for contribution to ICU LOS. The Automatic Linear Modeling (ALM) module of IBM-SPSS software identified 8 factors with statistically significant associations with ICU LOS; these factors were also analyzed with the Artificial Neural Network (ANN) module of the same software. The weighted contributions of each factor (“trained” data) were then applied to data for a “new” patient to predict ICU LOS for that individual. Results Factors identified in the ALM model were: use of an intra-aortic balloon pump; O2 delivery index; age; use of positive cardiac inotropic agents; hematocrit; serum creatinine ≥ 1.3 mg/deciliter; gender; arterial pCO2. The r2 value for ALM prediction of ICU LOS in the initial (training) model was 0.356, p <0.0001. Cross validation in prediction of a “new” patient yielded r2 = 0.200, p <0.0001. The same 8 factors analyzed with ANN yielded a training prediction r2 of 0.535 (p <0.0001) and a cross validation prediction r2 of 0.410, p <0.0001. Two additional predictive algorithms were studied, but they had lower prediction accuracies. Our validated neural network model identified the upper quartile of ICU LOS with an odds ratio of 9.8(p <0.0001). Conclusions ANN demonstrated a 2-fold greater accuracy than ALM in prediction of observed ICU LOS. This greater accuracy would be presumed to result from the capacity of ANN to capture nonlinear effects and higher order interactions. Predictive modeling may be of value in early anticipation of risks of post-operative morbidity and utilization of ICU facilities. PMID:26710254

The Effect of Adding Comorbidities to Current Centers for Disease Control and Prevention Central-Line-Associated Bloodstream Infection Risk-Adjustment Methodology.

PubMed

Jackson, Sarah S; Leekha, Surbhi; Magder, Laurence S; Pineles, Lisa; Anderson, Deverick J; Trick, William E; Woeltje, Keith F; Kaye, Keith S; Stafford, Kristen; Thom, Kerri; Lowe, Timothy J; Harris, Anthony D

2017-09-01

BACKGROUND Risk adjustment is needed to fairly compare central-line-associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes. METHODS Using a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank. RESULTS Overall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51-0.59) for the ICU-type model and 0.64 (95% CI, 0.60-0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model. CONCLUSIONS Our risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals. Infect Control Hosp Epidemiol 2017;38:1019-1024.

Prevalence of use of advance directives, health care proxy, legal guardian, and living will in 512 patients hospitalized in a cardiac care unit/intensive care unit in 2 community hospitals.

PubMed

Kumar, Anil; Aronow, Wilbert S; Alexa, Margelusa; Gothwal, Ritu; Jesmajian, Stephen; Bhushan, Bharat; Gaba, Praveen; Catevenis, James

2010-04-30

The prevalence of use of any advance directives was 26% in 112 patients hospitalized in a cardiac care unit (CCU)/intensive care unit (ICU) in an academic medical center. We investigated in 2 community hospitals the prevalence of use of advance directives (AD), health care proxy (HCP), legal guardian (LG), and living will (LW) in 512 patients hospitalized in a CCU/ ICU approached for AD and HCP. The use of AD was 22%, of HCP was 19%, of LG was 16%, and of LW was 5%. The use of AD was 22%, of HCP was 19%, of LG was 16%, and of LW was 5% in patients hospitalized in a CCU/ICU. Educational programs on use of AD and of HCP need to be part of cardiovascular training programs and of cardiovascular continuing medical education.

Baclofen to prevent agitation in alcohol-addicted patients in the ICU: study protocol for a randomised controlled trial.

PubMed

Vourc'h, Mickael; Feuillet, Fanny; Mahe, Pierre-Joachim; Sebille, Véronique; Asehnoune, Karim

2016-08-19

Alcohol is the leading psychoactive substance consumed in France, with about 15 million regular consumers. The National institute on Alcohol Abuse and Alcoholism (NIAAA) considers alcohol abuse to be more than 14 units of alcohol a week for men and 7 units for women. The specific complication of alcoholism is the alcohol withdrawal syndrome. Its incidence reaches up to 30 % and its main complications are delirium tremens, restlessness, extended hospital stay, higher morbidity, and psychiatric and cognitive impairment. Without appropriate treatment, delirium tremens can lead to death in up to 50 % of patients. This prospective, double-blind, randomised controlled study versus placebo will be conducted in twelve French intensive care units (ICU). Patients with an alcohol intake level higher than the NIAAA threshold, who are under mechanical ventilation, will be included. The primary objective is to determine whether baclofen is more efficient than placebo in preventing restlessness-related side effects in the ICU. Secondary outcomes include mechanical ventilation duration, length of ICU stay, and cumulative doses of sedatives and painkillers received within 28 days of ICU admission. Restlessness-related side effects in the ICU are defined as unplanned extubation, medical disposal removal (such as urinary catheter, venous or arterial line or surgical drain), falling out of bed, ICU runaway (leaving ICU without physician's approval), immobilisation device removal, self-aggression or aggression towards medical staff. Daily doses of baclofen/placebo will be guided by daily creatinine clearance assessment. Restlessness in alcoholic patients is a life-threatening issue in ICUs. BACLOREA is a randomised study assessing the capacity of baclofen to prevent agitation in mechanically ventilated patients. Enrolment of 314 patients will begin in June 2016 and is expected to end in October 2018. ClinicalTrials.gov Identifier: NCT02723383 , registered on 3 March 2016.

Burnout in the intensive care unit professionals: A systematic review.

PubMed

Chuang, Chien-Huai; Tseng, Pei-Chi; Lin, Chun-Yu; Lin, Kuan-Han; Chen, Yen-Yuan

2016-12-01

Burnout has been described as a prolonged response to chronic emotional and interpersonal stress on the job that is often the result of a period of expending excessive effort at work while having too little recovery time. Healthcare workers who work in a stressful medical environment, especially in an intensive care unit (ICU), may be particularly susceptible to burnout. In healthcare workers, burnout may affect their well-being and the quality of professional care they provide and can, therefore, be detrimental to patient safety. The objectives of this study were: to determine the prevalence of burnout in the ICU setting; and to identify factors associated with burnout in ICU professionals. The original articles for observational studies were retrieved from PubMed, MEDLINE, and Web of Science in June 2016 using the following MeSH terms: "burnout" and "intensive care unit". Articles that were published in English between January 1996 and June 2016 were eligible for inclusion. Two reviewers evaluated the abstracts identified using our search criteria prior to full text review. To be included in the final analysis, studies were required to have employed an observational study design and examined the associations between any risk factors and burnout in the ICU setting. Overall, 203 full text articles were identified in the electronic databases after the exclusion of duplicate articles. After the initial review, 25 studies fulfilled the inclusion criteria. The prevalence of burnout in ICU professionals in the included studies ranged from 6% to 47%. The following factors were reported to be associated with burnout: age, sex, marital status, personality traits, work experience in an ICU, work environment, workload and shift work, ethical issues, and end-of-life decision-making. The impact of the identified factors on burnout remains poorly understood. Nevertheless, this review presents important information, suggesting that ICU professionals may suffer from a high level of burnout, potentially threatening patient care. Future work should address the effective management of the factors negatively affecting ICU professionals.

Model Development for EHR Interdisciplinary Information Exchange of ICU Common Goals

PubMed Central

Collins, Sarah A.; Bakken, Suzanne; Vawdrey, David K.; Coiera, Enrico; Currie, Leanne

2010-01-01

Purpose Effective interdisciplinary exchange of patient information is an essential component of safe, efficient, and patient–centered care in the intensive care unit (ICU). Frequent handoffs of patient care, high acuity of patient illness, and the increasing amount of available data complicate information exchange. Verbal communication can be affected by interruptions and time limitations. To supplement verbal communication, many ICUs rely on documentation in electronic health records (EHRs) to reduce errors of omission and information loss. The purpose of this study was to develop a model of EHR interdisciplinary information exchange of ICU common goals. Methods The theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5 hours of interdisciplinary rounds in a Neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted. Results Current documentation tools in the ICU were not sufficient to capture the nurses' and physicians' collaborative decision-making and verbal communication of goal-directed actions and interactions. Clinicians perceived the EHR to be inefficient for information retrieval, leading to a further reliance on verbal information exchange. Conclusion The model suggests that EHRs should support: 1) Information tools for the explicit documentation of goals, interventions, and assessments with synthesized and summarized information outputs of events and updates; and 2) Messaging tools that support collaborative decision-making and patient safety double checks that currently occur between nurses and physicians in the absence of EHR support. PMID:20974549

Occupational Therapy in the Intensive Care Unit: A Systematic Review.

PubMed

Weinreich, Mark; Herman, Jennifer; Dickason, Stephanie; Mayo, Helen

2017-07-01

This paper is a synthesis of the available literature on occupational therapy interventions performed in the adult intensive care unit (ICU). The databases of Ovid MEDLINE, Embase, the Cochrane Library, ClinicalTrials.gov and CINAHL databases were systematically searched from inception through August 2016 for studies of adults who received occupational therapy interventions in the ICU. Of 1,938 citations reviewed, 10 studies met inclusion criteria. Only one study explicitly discussed occupational therapy interventions performed and only one study specifically tested the efficacy of occupational therapy. Future research is needed to clarify the specific interventions and role of occupational therapy in the ICU and the efficacy of these interventions.

Early prediction of intensive care unit-acquired weakness using easily available parameters: a prospective observational study.

PubMed

Wieske, Luuk; Witteveen, Esther; Verhamme, Camiel; Dettling-Ihnenfeldt, Daniela S; van der Schaaf, Marike; Schultz, Marcus J; van Schaik, Ivo N; Horn, Janneke

2014-01-01

An early diagnosis of Intensive Care Unit-acquired weakness (ICU-AW) using muscle strength assessment is not possible in most critically ill patients. We hypothesized that development of ICU-AW can be predicted reliably two days after ICU admission, using patient characteristics, early available clinical parameters, laboratory results and use of medication as parameters. Newly admitted ICU patients mechanically ventilated ≥2 days were included in this prospective observational cohort study. Manual muscle strength was measured according to the Medical Research Council (MRC) scale, when patients were awake and attentive. ICU-AW was defined as an average MRC score <4. A prediction model was developed by selecting predictors from an a-priori defined set of candidate predictors, based on known risk factors. Discriminative performance of the prediction model was evaluated, validated internally and compared to the APACHE IV and SOFA score. Of 212 included patients, 103 developed ICU-AW. Highest lactate levels, treatment with any aminoglycoside in the first two days after admission and age were selected as predictors. The area under the receiver operating characteristic curve of the prediction model was 0.71 after internal validation. The new prediction model improved discrimination compared to the APACHE IV and the SOFA score. The new early prediction model for ICU-AW using a set of 3 easily available parameters has fair discriminative performance. This model needs external validation.

Risk, Predictors, and Outcomes of Acute Kidney Injury in Patients Admitted to Intensive Care Units in Egypt.

PubMed

Abd ElHafeez, Samar; Tripepi, Giovanni; Quinn, Robert; Naga, Yasmine; Abdelmonem, Sherif; AbdelHady, Mohamed; Liu, Ping; James, Matthew; Zoccali, Carmine; Ravani, Pietro

2017-12-07

Epidemiology of acute kidney injury (AKI) in developing countries is under-studied. We evaluated the risk and prognosis of AKI in patients admitted to intensive care units (ICUs) in Egypt. We recruited consecutive adults admitted to ICUs in Alexandria Teaching Hospitals over six months. We used the KDIGO criteria for AKI. We followed participants until the earliest of ICU discharge, death, day 30 from entry or study end. Of the 532 participants (median age 45 (Interquartile range [IQR]: 30-62) years, 41.7% male, 23.7% diabetics), 39.6% had AKI at ICU admission and 37.4% developed AKI after 24 hours of ICU admission. Previous need of diuretics, sepsis and low education were associated with AKI at ICU admission; APACHE II score independently predicted AKI after ICU admission. A total of 120 (22.6%) patients died during 30-day follow-up. Compared to patients who remained AKI-free, mortality was significantly higher in patients who had AKI at study entry (Hazard Ratio [HR] 2.14; 95% Confidence Interval [CI] 1.02-4.48) or developed AKI in ICU (HR 2.74; 95% CI 1.45-5.17). The risk of AKI is high in critically ill people and predicts poor outcomes. Further studies are needed to estimate the burden of AKI among patients before ICU admission.

Effect of neuromuscular stimulation and individualized rehabilitation on muscle strength in Intensive Care Unit survivors: A randomized trial.

PubMed

Patsaki, Irini; Gerovasili, Vasiliki; Sidiras, Georgios; Karatzanos, Eleftherios; Mitsiou, Georgios; Papadopoulos, Emmanuel; Christakou, Anna; Routsi, Christina; Kotanidou, Anastasia; Nanas, Serafim

2017-08-01

Intensive Care Unit (ICU) survivors experience muscle weakness leading to restrictions in functional ability. Neuromuscular electrical stimulation (NMES) has been an alternative to exercise in critically ill patients. The aim of our study was to investigate its effects along with individualized rehabilitation on muscle strength of ICU survivors. Following ICU discharge, 128 patients (age: 53±16years) were randomly assigned to daily NMES sessions and individualized rehabilitation (NMES group) or to control group. Muscle strength was assessed by the Medical Research Council (MRC) score and hand grip at hospital discharge. Secondary outcomes were functional ability and hospital length of stay. MRC, handgrip, functional status and hospital length of stay did not differ at hospital discharge between groups (p>0.05). ΔMRC% one and two weeks after ICU discharge tended to be higher in NMES group, while it was significant higher in NMES group of patients with ICU-acquired weakness at two weeks (p=0.05). NMES and personalized physiotherapy in ICU survivors did not result in greater improvement of muscle strength and functional status at hospital discharge. However, in patients with ICU-aw NMES may be effective. The potential benefits of rehabilitation strategies should be explored in larger number of patients in future studies. www.Clinicaltrials.gov: NCT01717833. Copyright © 2017. Published by Elsevier Inc.

Implementing the ABCDE Bundle into Everyday Care: Opportunities, Challenges and Lessons Learned for Implementing the ICU Pain, Agitation and Delirium (PAD) Guidelines

PubMed Central

Balas, Michele C.; Burke, William J.; Gannon, David; Cohen, Marlene Z.; Colburn, Lois; Bevil, Catherine; Franz, Doug; Olsen, Keith M.; Ely, E. Wesley; Vasilevskis, Eduard E.

2014-01-01

Objective The Awakening and Breathing Coordination, Delirium monitoring/management and Early exercise/mobility (ABCDE) bundle is an evidence-based, interprofessional, multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation and managing intensive care unit (ICU) acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to ABCDE bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Design Prospective, before-after, mixed-methods study. Setting Five adult ICUs, 1 step-down unit, and a special care unit located in a 624 bed, academic medical center Subjects Interprofessional ICU team members at participating institution. Interventions and Measurements In collaboration with the participating institution, we developed, implemented, and refined an ABCDE bundle policy. Over the course of an 18 month period, all ICU team members were offered the opportunity to participate in numerous, multimodal educational efforts. Three focus group sessions, 3 online surveys, and 1 educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. Main Results Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds, 2) engagement of key implementation leaders, 3) sustained and diverse educational efforts, and 4) the bundle's quality and strength. Barriers identified included: 1) intervention related issues (e.g. timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members. Conclusions In this study of the implementation of the ABCDE bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU Pain, Agitation and Delirium (PAD) Guidelines, which has many similarities but also some important differences as compared to the ABCDE bundle PMID:23989089

Variable-Domain Functional Regression for Modeling ICU Data.

PubMed

Gellar, Jonathan E; Colantuoni, Elizabeth; Needham, Dale M; Crainiceanu, Ciprian M

2014-12-01

We introduce a class of scalar-on-function regression models with subject-specific functional predictor domains. The fundamental idea is to consider a bivariate functional parameter that depends both on the functional argument and on the width of the functional predictor domain. Both parametric and nonparametric models are introduced to fit the functional coefficient. The nonparametric model is theoretically and practically invariant to functional support transformation, or support registration. Methods were motivated by and applied to a study of association between daily measures of the Intensive Care Unit (ICU) Sequential Organ Failure Assessment (SOFA) score and two outcomes: in-hospital mortality, and physical impairment at hospital discharge among survivors. Methods are generally applicable to a large number of new studies that record a continuous variables over unequal domains.

Outcome of Patients with Systemic Sclerosis in the Intensive Care Unit.

PubMed

Pène, Frédéric; Hissem, Tarik; Bérezné, Alice; Allanore, Yannick; Geri, Guillaume; Charpentier, Julien; Avouac, Jérôme; Guillevin, Loïc; Cariou, Alain; Chiche, Jean-Daniel; Mira, Jean-Paul; Mouthon, Luc

2015-08-01

Patients with systemic sclerosis (SSc) are prone to disease-specific or treatment-related life-threatening complications that may warrant intensive care unit (ICU) admission. We assessed the characteristics and current outcome of patients with SSc admitted to the ICU. We performed a single-center retrospective study over 6 years (November 2006-December 2012). All patients with SSc admitted to the ICU were enrolled. Short-term (in-ICU and in-hospital) and longterm (6-mo and 1-yr) mortality rates were studied, and the prognostic factors were analyzed. Forty-one patients with a median age of 50 years [interquartile range (IQR) 40-65] were included. Twenty-nine patients (72.5%) displayed diffuse cutaneous SSc. The time from diagnosis to ICU admission was 78 months (IQR 34-128). Twenty-eight patients (71.7%) previously had pulmonary fibrosis, and 12 (31.5%) had pulmonary hypertension. The main reason for ICU admission was acute respiratory failure in 27 patients (65.8%). Noninvasive ventilation was first attempted in 13 patients (31.7%) and was successful in 8 of them, whereas others required endotracheal intubation within 24 h. Altogether, 13 patients (31.7%) required endotracheal intubation and mechanical ventilation. The overall in-ICU, in-hospital, 6-month, and 1-year mortality rates were 31.8%, 39.0%, 46.4%, and 61.0%, respectively. Invasive mechanical ventilation was the worst prognostic factor, associated with an in-hospital mortality rate of 84.6%. This study provides reliable prognostic data in patients with SSc who required ICU admission. The devastating outcome of invasive mechanical ventilation in patients with SSc requires a reappraisal of indications for ICU admission and early identification of patients likely to benefit from noninvasive ventilation.

Virtual collaboration, satisfaction, and trust between nurses in the tele-ICU and ICUs: Results of a multilevel analysis.

PubMed

Hoonakker, Peter L T; Pecanac, Kristen E; Brown, Roger L; Carayon, Pascale

2017-02-01

The purpose of the study was to examine how tele-intensive care unit (tele-ICU) nurse characteristics and organizational characteristics influence tele-ICU nurses' trust and satisfaction of monitored bedside ICU nurses, and whether these influences are mediated by communication. Data of tele-ICU characteristics and characteristics of the ICUs they monitored were collected at 5 tele-ICUs located throughout the country. One hundred ten tele-ICU nurses at those tele-ICUs completed a questionnaire containing items related to their characteristics and their trust, satisfaction, and perceived communication with monitored bedside nurses. We analyzed the data using a hierarchical path model, with communication variables entered as mediators. Many of the tele-ICU nurse characteristics (age, currently or previously worked at the monitored ICU, hours worked per week, and years as a ICU nurse) had statistically significant direct effects on perception of communication timeliness, accuracy, and openness, as well as trust and satisfaction with monitored bedside ICU nurses. Communication openness mediated the relationships of both working at a monitored ICU and being older (≥55) on satisfaction. Communication accuracy mediated the relationships of both a specialized monitored ICU and working at a monitored ICU on trust. Tele-ICUs and monitored ICUs should work to optimize communication so that trust can be established among the nurses. Copyright © 2016 Elsevier Inc. All rights reserved.

Comparison of methods of temperature measurement in swine.

PubMed

Hanneman, S K; Jesurum-Urbaitis, J T; Bickel, D R

2004-07-01

The purpose of these experiments was to test the equivalence of pulmonary artery, urinary bladder, tympanic, rectal and femoral artery methods of temperature measurement in healthy and critically ill swine under clinical intensive care unit (ICU) conditions using a prospective, time series design. First, sensors were tested for error and sensitivity to change in temperature with a precision-controlled water bath and a laboratory-certified digital thermometer for temperatures 34-42 degrees C. There was virtually no systematic (bias) or random (precision) error (<0.2 degrees C). The bladder sensor had the slowest response time to change in temperature (105-120 s). Next, testing was done in an experimental porcine ICU in a non-profit research institution with four male, sedated, and mechanically ventilated domestic farm pigs. The in vivo experiments were conducted over periods of 41-168 h with temperatures measured every 1-5 s. The bladder, tympanic and rectal methods had unacceptable bias (>or=0.5 degrees C) and/or precision (>or=0.2 degrees C). Response time varied from 7 s with the femoral artery method to 280 s (4.7 min) with the tympanic method. We concluded that equivalence of the methods was insufficient for them to be used interchangeably in the porcine ICU. Intravascular monitoring of core body temperature produces optimal measurement of porcine temperature under varying conditions of physiological stability.

Glucose control and use of continuous glucose monitoring in the intensive care unit: a critical review.

PubMed

De Block, Christophe; Manuel-y-Keenoy, Begoña; Rogiers, Peter; Jorens, Philippe; Van Gaal, Luc

2008-08-01

Stress hyperglycemia recently became a major therapeutic target in the Intensive Care Unit (ICU) since it occurs in most critically ill patients and is associated with adverse outcome, including increased mortality. Intensive insulin therapy to achieve normoglycemia may reduce mortality, morbidity and the length of ICU and in-hospital stay. However, obtaining normoglycemia requires extensive efforts from the medical staff, including frequent glucose monitoring and adjustment of insulin dose. Current insulin titration is based upon discrete glucose measurements, which may miss fast changes in glycemia and which does not give a full picture of overall glycemic control. Recent evidence suggests that continuous monitoring of glucose levels may help to signal glycemic excursions and eventually to optimize insulin titration in the ICU. In this review we will summarise monitoring and treatment strategies to achieve normoglycemia in the ICU, with special emphasis on the possible advantages of continuous glucose monitoring.

Predictors of nursing workload in elderly patients admitted to intensive care units.

PubMed

Sousa, Cleber Ricardo de; Gonçalves, Leilane Andrade; Toffoleto, Maria Cecília; Leão, Karine; Padilha, Kátia Grillo

2008-01-01

The age of patients is a controversial issue in admission to intensive care unit (ICU). The aim of this study was to compare severity and nursing workload of elderly patients with 60-69, 70-79, and e"80 years of age and to identify predictors of nursing workload in elderly patients. A cross sectional study was performed with a sample of 71 elderly patients admitted to three ICU in the city of Sao Paulo, Brazil from October to November 2004. Data were prospectively collected using Nursing Activities Score (NAS) and Simplified Acute Physiology Score II (SAPS II). There was no significant difference in nursing workload among the elderly patients age subgroups (p=0.84). Multiple regression analysis indicated that the independent risk factors of high nursing workload were severity, age e"70 years, and to be a surgical ICU patient. Age as an isolated factor should not be discriminative for elderly patients admission to ICU.

Perceived and actual noise levels in critical care units.

PubMed

White, Brittany Lynn; Zomorodi, Meg

2017-02-01

To compare the noise levels perceived by critical care nurses in the Intensive Care Unit (ICU) to actual noise levels in the ICU. Following a pilot study (n=18) and revision of the survey tool, a random sample of nurses were surveyed twice in a 3-day period (n=108). Nurses perception of noise was compared to the actual sound pressure level using descriptive statistics. Nurses perceived the ICUs to be noisier than the actual values. The ICU was louder than the recommended noise level for resotrative sleep. This finding raises the question of how we can assist nurses to reduce what they perceive to be a loud environment. Future work is needed to develop interventions specifically for nurses to raise awareness of noise in the ICU and to provide them with skills to assist in noise reduction. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Transfer of allogeneic stem cell transplant recipients to the intensive care unit: Guidelines from the Francophone society of marrow transplantation and cellular therapy (SFGM-TC)].

PubMed

Moreau, Anne-Sophie; Bourhis, Jean-Henri; Contentin, Nathalie; Couturier, Marie-Anne; Delage, Jeremy; Dumesnil, Cécile; Gandemer, Virginie; Hichri, Yosr; Jost, Edgar; Platon, Laura; Jourdain, Mercé; Pène, Frédéric; Yakoub-Agha, Ibrahim

2016-11-01

Transferring a patient undergoing an allogeneic stem cell transplantation to the intensive care unit (ICU) is always a challenging situation on a medical and psychological point of view for the patient and his relatives as well as for the medical staff. Despite the progress in hematology and intensive care during the last decade, the prognosis of these patients admitted to the ICU remains poor and mortality is around 50 %. The harmonization working party of the SFGM-TC assembled hematologists and intensive care specialist in order to improve conditions and modalities of the transfer of a patient after allogeneic stem cell transplantation to the ICU. We propose a structured medical form comprising all essential information necessary for optimal medical care on ICU. Copyright © 2016. Published by Elsevier Masson SAS.

[The response of the intensive care units during the influenza A H1N1 pandemic: the experience in Chiapas, Mexico].

PubMed

Volkow, Patricia; Bautista, Edgar; de la Rosa, Margarita; Manzano, Graciela; Muñoz-Torrico, Marcela Verónica; Pérez-Padilla, Rogelio

2011-01-01

Respiratory virus epidemics had highlighted the importance of the Intensive Care Unit (ICU) to save life of severe cases. ICU functioning and outcomes depends on infrastructure and trained healthcare personnel. In Chiapas, a Southern state in Mexico,an area to care for severe H1N1 cases on respiratory distress during the second H1N1-2009 outbreak, had to be habilitated.This had to be done without sufficient equipment and ICU un-experienced healthcare workers. It was possible to improve its performance through training and standardizing attention care processes for critically ill patients. In preparation for the next pandemic it is essential to designate hospitals with preexistent ICU where to refer severe cases and avoid improvisations.The experience in Chiapas showed that standardization of medical care processes are clue and in case of an overwhelming emergency it is possible to habilitate an ICU although it is imperative to take advantage from installed facilities in each city with the official authority.

Assessing and developing critical-thinking skills in the intensive care unit.

PubMed

Swinny, Betsy

2010-01-01

A lot of resources are spent on the development of new staff in the intensive care unit (ICU). These resources are necessary because the environment in the ICU is complex and the patients are critically ill. Nurses need an advanced knowledge base, the ability to accurately define and change priorities rapidly, good communication and teamwork skills, and the ability to work in a stressful environment in order to succeed and give their patients quality care. Critical thinking helps the nurse to navigate the complex and stressful environment of the ICU. Critical thinking includes more than just nursing knowledge. It includes the ability to think through complex, multifaceted problems to anticipate needs, recognize potential and actual complications, and to expertly communicate with the team. A nurse who is able to think critically will give better patient care. Various strategies can be used to develop critical thinking in ICU nurses. Nurse leaders are encouraged to support the development of critical-thinking skills in less experienced staff with the goal of improving the nurse's ability to work in the ICU and improving patient outcomes.

Cluster randomized trials in comparative effectiveness research: randomizing hospitals to test methods for prevention of healthcare-associated infections.

PubMed

Platt, Richard; Takvorian, Samuel U; Septimus, Edward; Hickok, Jason; Moody, Julia; Perlin, Jonathan; Jernigan, John A; Kleinman, Ken; Huang, Susan S

2010-06-01

The need for evidence about the effectiveness of therapeutics and other medical practices has triggered new interest in methods for comparative effectiveness research. Describe an approach to comparative effectiveness research involving cluster randomized trials in networks of hospitals, health plans, or medical practices with centralized administrative and informatics capabilities. We discuss the example of an ongoing cluster randomized trial to prevent methicillin-resistant Staphylococcus aureus (MRSA) infection in intensive care units (ICUs). The trial randomizes 45 hospitals to: (a) screening cultures of ICU admissions, followed by Contact Precautions if MRSA-positive, (b) screening cultures of ICU admissions followed by decolonization if MRSA-positive, or (c) universal decolonization of ICU admissions without screening. All admissions to adult ICUs. The primary outcome is MRSA-positive clinical cultures occurring >or=2 days following ICU admission. Secondary outcomes include blood and urine infection caused by MRSA (and, separately, all pathogens), as well as the development of resistance to decolonizing agents. Recruitment of hospitals is complete. Data collection will end in Summer 2011. This trial takes advantage of existing personnel, procedures, infrastructure, and information systems in a large integrated hospital network to conduct a low-cost evaluation of prevention strategies under usual practice conditions. This approach is applicable to many comparative effectiveness topics in both inpatient and ambulatory settings.

Worrisome trends in incidence and mortality of candidemia in intensive care units (Paris area, 2002-2010).

PubMed

Lortholary, Olivier; Renaudat, Charlotte; Sitbon, Karine; Madec, Yoann; Denoeud-Ndam, Lise; Wolff, Michel; Fontanet, Arnaud; Bretagne, Stéphane; Dromer, Françoise

2014-09-01

To analyze trends in incidence and mortality of candidemia in intensive care units (ICUs) vs. non-ICU hospitalized patients and to determine risk factors for infection by specific species and for death. Active hospital-based surveillance program of incident episodes of candidemia due to common species in 24 tertiary care hospitals in the Paris area, France between October 2002 and September 2010. Among 2,507 adult cases included, 2,571 Candida isolates were collected and species were C. albicans (56 %), C. glabrata (18.6 %), C. parapsilosis (11.5 %), C. tropicalis (9.3 %), C. krusei (2.9 %), and C. kefyr (1.8 %). Candidemia occurred in ICU in 1,206 patients (48.1 %). When comparing ICU vs. non-ICU patients, the former had significantly more frequent surgery during the past 30 days, were more often preexposed to fluconazole and treated with echinocandin, and were less frequently infected with C. parapsilosis. Risk factors and age remained unchanged during the study period. A significant increased incidence in the overall population and ICU was found. The odds of being infected with a given species in ICU was influenced by risk factors and preexposure to fluconazole and caspofungin. Echinocandins initial therapy increased over time in ICU (4.6 % first year of study, to 48.5 % last year of study, p < 0.0001). ICU patients had a higher day-30 death rate than non-ICU patients (odds ratio [OR] 2.12; 95 % confidence interval [CI] 1.66-2.72; p < 0.0001). The day-30 and early (

Views regarding the training of ethics consultants: a survey of physicians caring for patients in ICU

PubMed Central

Chwang, Eric; Landy, David C; Sharp, Richard R

2007-01-01

Background Despite the expansion of ethics consultation services, questions remain about the aims of clinical ethics consultation, its methods and the expertise of those who provide such services. Objective To describe physicians' expectations regarding the training and skills necessary for ethics consultants to contribute effectively to the care of patients in intensive care unit (ICU). Design Mailed survey. Participants Physicians responsible for the care of at least 10 patients in ICU over a 6‐month period at a 921‐bed private teaching hospital with an established ethics consultation service. 69 of 92 (75%) eligible physicians responded. Measurements Importance of specialised knowledge and skills for ethics consultants contributing to the care of patients in ICU; need for advanced disciplinary training; expectations regarding formal‐training programmes for ethics consultants. Results Expertise in ethics was described most often as important for ethics consultants taking part in the care of patients in ICU, compared with expertise in law (p<0.03), religious traditions (p<0.001), medicine (p<0.001) and conflict‐mediation techniques (p<0.001). When asked about the formal training consultants should possess, however, physicians involved in the care of patients in ICU most often identified advanced medical training as important. Conclusions Although many physicians caring for patients in ICU believe ethics consultants must possess non‐medical expertise in ethics and law if they are to contribute effectively to patient care, these physicians place a very high value on medical training as well, suggesting a “medicine plus one” view of the training of an ideal ethics consultant. As ethics consultation services expand, clear expectations regarding the training of ethics consultants should be established. PMID:17526680

Evaluating team-based inter-professional advanced life support training in intensive care-a prospective observational study.

PubMed

Brewster, D J; Barrett, J A; Gherardin, E; O'Neill, J A; Sage, D; Hanlon, G

2017-01-01

Recent focus on national standards within Australian hospitals has prompted a focus on the training of our staff in advanced life support (ALS). Research in critical care nursing has questioned the traditional annual certification of ALS competence as the best method of delivering this training. Simulation and team-based training may provide better ALS education to intensive care unit (ICU) staff. Our new inter-professional team-based advanced life support program involved ICU staff in a large private metropolitan ICU. A prospective observational study using three standardised questionnaires and two multiple choice questionnaire assessments was conducted. Ninety-nine staff demonstrated a 17.8% (95% confidence interval 4.2-31, P =0.01) increase in overall ICU nursing attendance at training sessions. Questionnaire response rates were 93 (94%), 99 (100%) and 60 (61%) respectively; 51 (52%) staff returned all three. Criteria were assessed by scores from 0 to 10. Nurses reported improved satisfaction with the education program (9.4 to 7.1, P <0.001), as well as improvement in role understanding (8.7 and 9.1 versus 7.9 and 8.2, P <0.001) and confidence (8.4 and 8.8 versus 7.4 and 7.8, P <0.001) during ALS provision (outside ICU and inside ICU) following the course when compared to before the program. Doctors' only statistically significant improvement was in their confidence in ALS provision outside ICU (8.7 versus 8.1, P =0.04). The new program cost approximately an extra $16,500 in nursing salaries. We concluded that team-based, inter-professional ALS training produced statistically significant improvements in nursing attendance, satisfaction with ALS education, confidence and role understanding compared to traditional ALS training.

Structure, Process, and Culture of Intensive Care Units Treating Patients with Severe Traumatic Brain Injury: Survey of Centers Participating in the American College of Surgeons Trauma Quality Improvement Program.

PubMed

Alali, Aziz S; McCredie, Victoria A; Mainprize, Todd G; Gomez, David; Nathens, Avery B

2017-10-01

Outcome after severe traumatic brain injury (TBI) differs substantially between hospitals. Explaining this variation begins with understanding the differences in structures and processes of care, particularly at intensive care units (ICUs) where acute TBI care takes place. We invited trauma medical directors (TMDs) from 187 centers participating in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) to complete a survey. The survey domains included ICU model, type, availability of specialized units, staff, training programs, standard protocols and order sets, approach to withdrawal of life support, and perceived level of neurosurgeons' engagement in the ICU management of TBI. One hundred forty-two TMDs (76%) completed the survey. Severe TBI patients are admitted to dedicated neurocritical care units in 52 hospitals (37%), trauma ICUs in 44 hospitals (31%), general ICUs in 34 hospitals (24%), and surgical ICUs in 11 hospitals (8%). Fifty-seven percent are closed units. Board-certified intensivists directed 89% of ICUs, whereas 17% were led by neurointensivists. Sixty percent of ICU directors were general surgeons. Thirty-nine percent of hospitals had critical care fellowships and 11% had neurocritical care fellowships. Fifty-nine percent of ICUs had standard order sets and 61% had standard protocols specific for TBI, with the most common protocol relating to intracranial pressure management (53%). Only 43% of TMDs were satisfied with the current level of neurosurgeons' engagement in the ICU management of TBI; 46% believed that neurosurgeons should be more engaged; 11% believed they should be less engaged. In the largest survey of North American ICUs caring for TBI patients, there is substantial variation in the current approaches to ICU care for TBI, highlighting multiple opportunities for comparative effectiveness research.

Does a single specialty intensive care unit make better business sense than a multi-specialty intensive care unit? A costing study in a trauma center in India.

PubMed

Kumar, Parmeshwar; Jithesh, Vishwanathan; Gupta, Shakti Kumar

2015-01-01

Though intensive care units (ICUs) only account for 10% of hospital beds, they consume nearly 22% of hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. To evaluate and compare the cost of intensive care delivery between multi-specialty and neurosurgery ICU in an apex trauma care facility in India. The study was conducted in a polytrauma and neurosurgery ICU at a 203 bedded level IV trauma care facility in New Delhi, India from May, 2012 to June 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Fisher's two-tailed t-test. Total cost/bed/day for the multi-specialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU was Rs. 14,306.7/-, manpower constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Quantification of expenditure in running an ICU in a trauma center would assist healthcare decision makers in better allocation of resources. Although multi-specialty ICUs are more expensive, other factors will also play a role in defining the kind of ICU that need to be designed.

Universal Pressure Ulcer Prevention Bundle With WOC Nurse Support.

PubMed

Anderson, Megan; Finch Guthrie, Patricia; Kraft, Wendy; Reicks, Patty; Skay, Carol; Beal, Alan L

2015-01-01

This study examined the effectiveness of a universal pressure ulcer prevention bundle (UPUPB) applied to intensive care unit (ICU) patients combined with proactive, semiweekly WOC nurse rounds. The UPUBP was compared to a standard guideline with referral-based WOC nurse involvement measuring adherence to 5 evidence-based prevention interventions and incidence of pressure ulcers. The study used a quasi-experimental, pre-, and postintervention design in which each phase included different subjects. Descriptive methods assisted in exploring the content of WOC nurse rounds. One hundred eighty-one pre- and 146 postintervention subjects who met inclusion criteria and were admitted to ICU for more than 24 hours participated in the study. The research setting was 3 ICUs located at North Memorial Medical Center in Minneapolis, Minnesota. Data collection included admission/discharge skin assessments, chart reviews for 5 evidence-based interventions and patient characteristics, and WOC nurse rounding logs. Study subjects with intact skin on admission identified with an initial skin assessment were enrolled in which prephase subjects received standard care and postphase subjects received the UPUPB. Skin assessments on ICU discharge and chart reviews throughout the stay determined the presence of unit-acquired pressure ulcers and skin care received. Analysis included description of WOC nurse rounds, t-tests for guideline adherence, and multivariate analysis for intervention effect on pressure ulcer incidence. Unit assignment, Braden Scale score, and ICU length of stay were covariates for a multivariate model based on bivariate logistic regression screening. The incidence of unit-acquired pressure ulcers decreased from 15.5% to 2.1%. WOC nurses logged 204 rounds over 6 months, focusing primarily on early detection of pressure sources. Data analysis revealed significantly increased adherence to heel elevation (t = -3.905, df = 325, P < .001) and repositioning (t = -2.441, df = 325, P < .015). Multivariate logistic regression modeling showed a significant reduction in unit-acquired pressure ulcers (P < .001). The intervention increased the Nagelkerke R-Square value by 0.099 (P < .001) more than 0.297 (P < .001) when including only covariates, for a final model value of 0.396 (P < .001). The UPUPB with WOC nurse rounds resulted in a statistically significant and clinically relevant reduction in the incidence of pressure ulcers.

Introduction of Tele-ICU in rural hospitals: Changing organisational culture to harness benefits.

PubMed

Goedken, Cassie Cunningham; Moeckli, Jane; Cram, Peter M; Reisinger, Heather Schacht

2017-06-01

This study evaluates rural hospital staff perceptions of a telemedicine ICU (Tele-ICU) before and after implementation. We conducted a longitudinal qualitative study utilising semistructured group or individual interviews with staff from three rural ICU facilities in the upper Midwest of the United States that received Tele-ICU support. Interviews occurred pre-implementation and at two time points post-implementation. Interviews were conducted with: ICU administrators (n=6), physicians (n=3), nurses (n=9), respiratory therapists (n=5) and other (n=1) from July 2011 to May 2013. Transcripts were analysed for thematic content. Overall, rural ICU staff viewed Tele-ICU as a welcome benefit for their facility. Major themes included: (1) beneficial where recruitment and retention of staff can be challenging; (2) extra support for day shifts and evening, night and weekend shifts; (3) reduction in the number of transfers larger tertiary hospitals in the community; (4) improvement in standardisation of care; and (5) organisational culture of rural ICUs may lead to under-utilisation. ICU staff at rural facilities view Tele-ICU as a positive, useful tool to provide extra support and assistance. However, more research is needed regarding organisational culture to maximise the potential benefits of Tele-ICU in rural hospitals. Published by Elsevier Ltd.

Associations Between Enteral Colonization With Gram-Negative Bacteria and Intensive Care Unit-Acquired Infections and Colonization of the Respiratory Tract.

PubMed

Frencken, Jos F; Wittekamp, Bastiaan H J; Plantinga, Nienke L; Spitoni, Cristian; van de Groep, Kirsten; Cremer, Olaf L; Bonten, Marc J M

2018-02-01

Enteral and respiratory tract colonization with gram-negative bacteria may lead to subsequent infections in critically ill patients. We aimed to clarify the interdependence between gut and respiratory tract colonization and their associations with intensive care unit (ICU)-acquired infections in patients receiving selective digestive tract decontamination (SDD). Colonization status of the rectum and respiratory tract was determined using twice-weekly microbiological surveillance in mechanically ventilated subjects receiving SDD between May 2011 and June 2015 in a tertiary medical-surgical ICU in the Netherlands. Acquisition of infections was monitored daily by dedicated observers. Marginal structural models were used to determine the associations between gram-negative rectal colonization and respiratory tract colonization, ICU-acquired gram-negative infection, and ICU-acquired gram-negative bacteremia. Among 2066 ICU admissions, 1157 (56.0%) ever had documented gram-negative carriage in the rectum during ICU stay. Cumulative incidences of ICU-acquired gram-negative infection and bacteremia were 6.0% (n = 124) and 2.1% (n = 44), respectively. Rectal colonization was an independent risk factor for both respiratory tract colonization (cause-specific hazard ratio [CSHR], 2.93 [95% confidence interval {CI}, 2.02-4.23]) and new gram-negative infection in the ICU (CSHR, 3.04 [95% CI, 1.99-4.65]). Both rectal and respiratory tract colonization were associated with bacteremia (CSHR, 7.37 [95% CI, 3.25-16.68] and 2.56 [95% CI, 1.09-6.03], respectively). Similar associations were observed when Enterobacteriaceae and glucose nonfermenting gram-negative bacteria were analyzed separately. Gram-negative rectal colonization tends to be stronger associated with subsequent ICU-acquired gram-negative infections than gram-negative respiratory tract colonization. Gram-negative rectal colonization seems hardly associated with subsequent ICU-acquired gram-negative respiratory tract colonization. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

The effects of cognitive intervention on cognitive impairments after intensive care unit admission.

PubMed

Zhao, Jingjing; Yao, Li; Wang, Changqing; Sun, Yun; Sun, Zhongwu

2017-04-01

Patients who survive critical illness commonly suffer cognitive impairments. We aimed to study the effects of cognitive intervention to treat the long-term impairments observed among different populations of intensive care unit (ICU) survivors. The results showed that the intervention significantly suppressed the deterioration of cognitive function in these patients. Medical and neurological ICU survivors were more susceptible than post-anaesthesia ICU patients to severe cognitive damage. In the former, the deterioration of impairments can be slowed by cognitive intervention. In comparison, intervention exerted significantly positive effects on the recovery of the cognitive functions of post-anaesthesia care unit patients. Furthermore, young populations were more likely than older populations to recover from acute cognitive impairments, and the impairment observed among the older population seemed to be multi-factorial and irreversible.

A family intervention to reduce delirium in hospitalised ICU patients: A feasibility randomised controlled trial.

PubMed

Mitchell, Marion L; Kean, Susanne; Rattray, Janice E; Hull, Alastair M; Davis, Chelsea; Murfield, Jenny E; Aitken, Leanne M

2017-06-01

Family members could play an important role in preventing and reducing the development of delirium in Intensive Care Units (ICU) patients. This study sought to assess the feasibility of design and recruitment, and acceptability for family members and nurses of a family delivered intervention to reduce delirium in ICU patients. A single centre randomised controlled trial in an Australian medical/surgical ICU was conducted. Sixty-one family members were randomised (29 in intervention and 32 in non-intervention group). Following instructions, the intervention comprised the family members providing orientation or memory clues (family photographs, orientation to surroundings) to their relative each day. In addition, family members conducted sensory checks (vision and hearing with glasses and hearing aids); and therapeutic or cognitive stimulation (discussing family life, reminiscing) daily. Eleven ICU nurses were interviewed to gain insight into the feasibility and acceptability of implementing the intervention from their perspective. Recruitment rate was 28% of eligible patients (recruited n=90, attrition n=1). Following instruction by the research nurse the family member delivered the intervention which was assessed to be feasible and acceptable by family members and nurses. Protocol adherence could be improved with alternative data collection methods. Nurses considered the activities acceptable. The study was able to recruit, randomise and retain family member participants. Further strategies are required to assess intervention fidelity and improve data collection. Copyright © 2017 Elsevier Ltd. All rights reserved.

Study of Obstetric Admissions to the Intensive Care Unit of a Tertiary Care Hospital.

PubMed

Rathod, Ashakiran T; Malini, K V

2016-10-01

To analyze obstetric admissions to intensive care unit and to identify the risk factors responsible for intensive care admission. This is a retrospective study of all obstetric cases admitted to the intensive care unit over a period of 3 years. Data were collected from case records. The risk factors responsible for ICU admission were analyzed. There were 765 obstetric admissions to ICU accounting for 1.24 % of all deliveries. 56.20 % were in the age group of 20-25 years. 38.43 % were in their first pregnancy. 36.48 % of cases were at 37-40 weeks of gestation. Postpartum admissions were 80.91 %. Major conditions responsible were obstetric hemorrhage in 44.05 %, hypertensive disorders of pregnancy in 28.88 %, severe anemia in 14.37 %, heart disease in 12.15 %, and sepsis in 7.97 % of ICU cases. 40.39 % cases required high dependency care. Maternal mortality was seen in 15.55 % of ICU cases. Commonest cause of mortality was hemorrhagic shock (26.89 %) and multiorgan dysfunction syndrome (26.05 %). Commonest risk factors for ICU admissions are obstetric hemorrhage and hypertensive disorders of pregnancy. Other major risk factors are severe anemia, heart disease, sepsis, more than one diagnosis on admission, and the need for cesarean delivery.

[Antibiotic Consumption and the Development of Antibiotic Resistance in Surgical Units].

PubMed

Tammer, I; Geginat, G; Lange, S; Kropf, S; Lodes, U; Schlüter, D; Lippert, H; Meyer, F

2016-02-01

Antibiotic resistence is increasing worldwide. A longitudinal analysis of the influence of the density of antibiotic use on the development of resistance in surgical units was undertaken. Over five years the incidence of pathogens and the resistance rates of isolates from patients of normal surgical units and those of a surgical ICU at a university hospital were examined. The resistence rates were correlated with the density of antibiotic use - calculated from the antibiotic consumption (in DDD) and the number of patient-days. At both units, Enterobacteriaceae and Enterococci were mostly cultured. Among the Enterobacteriaceae, E. coli, Klebsiella spp., Proteus mirabilis and Enterobacter predominated. In the group of Enterococci, E. faecalis predominated at wards whereas at ICU E. faecium was the most frequent. Anaerobes ranked third at normal wards and Candida spp. at ICU. From 2007 to 2011, there was an increasing resistance against ciprofloxacin in P. mirabilis (r = 0.87; p = 0.054) and against imipenem (r = 0.86; p = 0.06) and piperacillin (r = 0.81; p = 0.09) in P. aeruginosa at normal wards. At ICU, the resistance rates of imipenem in P. aeruginosa rose (r = 0.88; p = 0.049). Resistance against ciprofloxacin in E. coli increased (r = 0.65; p = 0.23). Due to the increasing use of ciprofloxacin and meropenem at normal wards, the density of antibiotic usage rose 1.4 %/year (r = 0.94; p = 0.02). Despite the increase of meropenem use at ICU (r = 0.9; p = 0.035), the total antibiotic uptake rate remained almost constant. The antibiotic usage density was 3-fold higher at ICU than at normal wards. At normal wards, the ciprofloxacin usage correlated with the rate of resistance against ciprofloxacin in P. mirabilis P. m. At ICU, an association was detected between the uptake rate of ceftazidime and the rate of resistance against cefotaxime in the CES group. In P. aeruginosa, the use of piperacillin and the rate of resistance against piperacillin correlated. The high uptake rates of fluoroquinolones and carbapenems were accompanied by increases in resistances. The resistance rates are influenced by hygiene management and microbiological diagnostics. The extensive use of carbapenems should be reassessed on both units to counter further development of antibiotic resistance. Georg Thieme Verlag KG Stuttgart · New York.

Incidence and factors related to delirium in an intensive care unit.

PubMed

Mori, Satomi; Takeda, Juliana Rumy Tsuchihashi; Carrara, Fernanda Souza Angotti; Cohrs, Cibelli Rizzo; Zanei, Suely Sueko Viski; Whitaker, Iveth Yamaguchi

2016-01-01

To identify the incidence of delirium, compare the demographic and clinical characteristics of patients with and without delirium, and verify factors related to delirium in critical care patients. Prospective cohort with a sample made up of patients hospitalized in the Intensive Care Unit (ICU) of a university hospital. Demographic, clinical variables and evaluation with the Confusion Assessment Method for Intensive Care Unit to identify delirium were processed to the univariate analysis and logistic regression to identify factors related to the occurrence of delirium. Of the total 149 patients in the sample, 69 (46.3%) presented delirium during ICU stay, whose mean age, severity of illness and length of ICU stay were statistically higher. The factors related to delirium were: age, midazolam, morphine and propofol. Results showed high incidence of ICU delirium associated with older age, use of sedatives and analgesics, emphasizing the need for relevant nursing care to prevent and identify early, patients presenting these characteristics. Identificar a incidência de delirium, comparar as características demográficas e clínicas dos pacientes com e sem delirium e verificar os fatores relacionados ao delirium em pacientes internados em Unidade de Terapia Intensiva (UTI). Coorte prospectiva, cuja amostra foi constituída de pacientes internados em UTI de um hospital universitário. Variáveis demográficas, clínicas e da avaliação com o Confusion Assessment Method for Intensive Care Unit para identificação de delirium foram processadas para análise univariada, e regressão logística para identificar fatores relacionados à ocorrência do delirium. Do total de 149 pacientes da amostra, 69 (46,3%) apresentaram delirium durante a internação na UTI, observando-se que a média da idade, o índice de gravidade e o tempo de permanência nas UTI foram estatisticamente maiores. Os fatores relacionados ao delirium foram: idade, midazolam, morfina e propofol. Os resultados mostraram elevada incidência de delirium na UTI e sua ocorrência associada às idades mais avançadas e o uso de sedativos e analgésicos, ressaltando-se a importância da atuação do enfermeiro na prevenção e identificação precoce do quadro nos pacientes com essas características.

[Evaluation of the status of patients with severe infection, criteria for intensive care unit admittance. Spanish Society for Infectious Diseases and Clinical Microbiology. Spanish Society of Intensive and Critical Medicine and Coronary Units].

PubMed

Olaechea, Pedro M; Alvarez-Lerma, Francisco; Sánchez, Miguel; Torres, Antonio; Palomar, Mercedes; Fernández, Pedro; Miró, José M; Cisneros, José Miguel; Torres, Manuel

2009-06-01

Recent studies have shown that early attention in patients with serious infections is associated with a better outcome. Assistance in intensive care units (ICU) can effectively provide this attention; hence patients should be admitted to the ICU as soon as possible, before clinical deterioration becomes irreversible. The objective of this article is to compile the recommendations for evaluating disease severity in patients with infections and describe the criteria for ICU admission, updating the criteria published 10 years ago. A literature review was carried out, compiling the opinions of experts from the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC, Spanish Society for Infectious Diseases and Clinical Microbiology) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC, Spanish Society for Intensive Medicine, Critical Care and Coronary Units) as well as the working groups for infections in critically ill patients (GEIPC-SEIMC and GTEI-SEMICYUC). We describe the specific recommendations for ICU admission related to the most common infections affecting patients, who will potentially benefit from critical care. Assessment of the severity of the patient's condition to enable early intensive care is stressed.

Evacuation of Intensive Care Units During Disaster: Learning From the Hurricane Sandy Experience.

PubMed

King, Mary A; Dorfman, Molly V; Einav, Sharon; Niven, Alex S; Kissoon, Niranjan; Grissom, Colin K

2016-02-01

Data on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities. We conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations. Sixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment considered most helpful included flashlights (24%), transport sleds (21%), and oxygen tanks and respiratory therapy supplies (19%). An evacuation wish list included walkie-talkies/phones (26%), lighting/electricity (18%), flashlights (10%), and portable ventilators and suction (16%). ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest links in the patient evacuation process were communication and the availability of practical tools. Incorporating ICU providers into hospital evacuation planning and training, developing standard evacuation communication processes and tools, and collecting a uniform dataset among all evacuating hospitals could better inform critical care evacuation in the future.

Bench-to-bedside review: Dealing with increased intensive care unit staff turnover: a leadership challenge

PubMed Central

Laporta, Denny P; Burns, Judy; Doig, Chip J

2005-01-01

Critical care leaders frequently must face challenging situations requiring specific leadership and management skills for which they are, not uncommonly, poorly prepared. Such a fictitious scenario was discussed at a Canadian interdisciplinary critical care leadership meeting, whereby increasing intensive care unit (ICU) staff turnover had led to problems with staff recruitment. Participants discussed and proposed solutions to the scenario in a structured format. The results of the discussion are presented. In situations such as this, the ICU leader should first define the core problem, its complexity, its duration and its potential for reversibility. These factors often reside within workload and staff support issues. Some examples of core problems discussed that are frequently associated with poor retention and recruitment are a lack of a positive team culture, a lack of a favorable ICU image, a lack of good working relationships between staff and disciplines, and a lack of specific supportive resources. Several tools or individuals (typically outside the ICU environment) are available to help determine the core problem. Once the core problem is identified, specific solutions can be developed. Such solutions often require originality and flexibility, and must be planned, with specific short-term, medium-term and long-term goals. The ICU leader will need to develop an implementation strategy for these solutions, in which partners who can assist are identified from within the ICU and from outside the ICU. It is important that the leader communicates to all stakeholders frequently as the process moves forward. PMID:16277732

Bench-to-bedside review: dealing with increased intensive care unit staff turnover: a leadership challenge.

PubMed

Laporta, Denny P; Burns, Judy; Doig, Chip J

2005-10-05

Critical care leaders frequently must face challenging situations requiring specific leadership and management skills for which they are, not uncommonly, poorly prepared. Such a fictitious scenario was discussed at a Canadian interdisciplinary critical care leadership meeting, whereby increasing intensive care unit (ICU) staff turnover had led to problems with staff recruitment. Participants discussed and proposed solutions to the scenario in a structured format. The results of the discussion are presented. In situations such as this, the ICU leader should first define the core problem, its complexity, its duration and its potential for reversibility. These factors often reside within workload and staff support issues. Some examples of core problems discussed that are frequently associated with poor retention and recruitment are a lack of a positive team culture, a lack of a favorable ICU image, a lack of good working relationships between staff and disciplines, and a lack of specific supportive resources. Several tools or individuals (typically outside the ICU environment) are available to help determine the core problem. Once the core problem is identified, specific solutions can be developed. Such solutions often require originality and flexibility, and must be planned, with specific short-term, medium-term and long-term goals. The ICU leader will need to develop an implementation strategy for these solutions, in which partners who can assist are identified from within the ICU and from outside the ICU. It is important that the leader communicates to all stakeholders frequently as the process moves forward.

Admission factors can predict the need for ICU monitoring in gallstone pancreatitis.

PubMed

Arnell, T D; de Virgilio, C; Chang, L; Bongard, F; Stabile, B E

1996-10-01

The purpose was 1) to prospectively determine the prevalence of adverse events necessitating intensive care unit (ICU) monitoring in gallstone pancreatitis (GP) and 2) To identify admission prognostic indicators that predict the need for ICU unit monitoring. Prospective laboratory data, physiologic parameters, and APACHE II scores were gathered on 102 patients with GP over 14 months. Adverse events were defined as cardiac, respiratory, or renal failure, gastrointestinal bleeding, stroke, sepsis, and necrotizing pancreatitis. Patients were divided into Group 1 (no adverse events, n=95) and Group 2 (adverse events, n=7). There were no deaths and 7 (7%) adverse events, including necrotizing pancreatitis (3), cholangitis (2), and cardiac (2). APACHE 11 > or = 5 (P < 0.005), blood urea nitrogen (BUN) > or = 12 mmol/L (P < 0.005), white blood cell count (WBC) > or = 14.5 x 10(9)/L, (P < 0.001), heart rate > or = 100 bpm (P < 0.001), and glucose > or = 150 mg/dL (P < 0.005) were each independent predictors of adverse events. The sensitivity and specificity of these criteria for predicting severe complications requiring ICU care varied from 71 to 86 per cent and 78 to 87 per cent, respectively. The prevalence of adverse events necessitating ICU care in GP patients is low. Glucose, BUN, WBC, heart rate, and APACHE II scores are independent predictors of adverse events necessitating ICU care. Single criteria predicting the need for ICU care on admission are readily available on admission.

Financial impact of nursing professionals staff required in an Intensive Care Unit 1

PubMed Central

de Araújo, Thamiris Ricci; Menegueti, Mayra Gonçalves; Auxiliadora-Martins, Maria; Castilho, Valéria; Chaves, Lucieli Dias Pedreschi; Laus, Ana Maria

2016-01-01

ABSTRACT Objective: to calculate the cost of the average time of nursing care spent and required by patients in the Intensive Care Unit (ICU) and the financial expense for the right dimension of staff of nursing professionals. Method: a descriptive, quantitative research, using the case study method, developed in adult ICU patients. We used the workload index - Nursing Activities Score; the average care time spent and required and the amount of professionals required were calculated using equations and from these data, and from the salary composition of professionals and contractual monthly time values, calculated the cost of direct labor of nursing. Results: the monthly cost of the average quantity of available professionals was US$ 35,763.12, corresponding to 29.6 professionals, and the required staff for 24 hours of care is 42.2 nurses, with a monthly cost of US$ 50,995.44. Conclusion: the numerical gap of nursing professionals was 30% and the monthly financial expense for adaptation of the structure is US$ 15,232.32, which corresponds to an increase of 42.59% in the amounts currently paid by the institution. PMID:27878219

Therapeutic hypothermia in Italian Intensive Care Units after 2010 resuscitation guidelines: still a lot to do.

PubMed

Gasparetto, Nicola; Scarpa, Daniele; Rossi, Sandra; Persona, Paolo; Martano, Luigi; Bianchin, Andrea; Castioni, Carlo Alberto; Ori, Carlo; Iliceto, Sabino; Cacciavillani, Luisa

2014-03-01

Therapeutic hypothermia (TH) is one of three interventions that have demonstrated to improve patients' neurological outcome after cardiac arrest. The aim of this study was to investigate the effect of the 2010 resuscitation guidelines on TH implementation in various Italian Intensive Care Units (ICU). A structured questionnaire was submitted to Italian ICU. The questionnaire was addressed to determine the procedures of TH in each ICU or, on the contrary, the reason for not employing the therapy. We obtained complete information from 770 of 847 Italian ICU (91%). Out of 405 Units included in the analysis only 223 (55.1%) reported to use TH in comatose patients after return of spontaneous circulation. The trend of TH implementation shows a stable increase, particularly after 2006 but there is no evident acceleration after the strong indication of the 2010 guidelines. There was a rise of about 3.4 times in the number of Italian ICU using TH as compared to the 2007 survey (an increase of 68% per year). One hundred and eighty-two (44.9%) units did not use TH mainly because of lack of equipment, economic issues or the conviction of the difficulty of execution. TH is still under-used in Italy (55.1%) even though the therapy is strongly recommended in the 2010 guidelines. However, the increase in the adoption of hypothermia has been significant in the past 5 years (68%/years) and the awareness of the efficacy is almost consolidated among intensivists, being logistic problems the leading cause for non-adoption. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Data Acquisition for a Patient-directed Intervention Protocol in the Dynamic Intensive Care Unit Setting

PubMed Central

Chlan, Linda; Patterson, Robert P.; Heiderscheit, Annie

2011-01-01

Methods to easily, accurately, and efficiently obtain data in an ICU-based clinical trial can be challenging in this high-tech setting. Patient medical status and the dynamic nature of this clinical setting further complicates data collection. The purpose of this paper is to describe the modifications of commercially available headphones and the application of a data logging device to capture frequency and length of protocol use (music listening or headphones only for noise cancellation) without burdening participants or busy ICU nurses. With the automatic capture of protocol use by research participants, there have been no instances of lost data for this clinical trial. PMID:21382515

Data acquisition for a patient-directed intervention protocol in the dynamic intensive care unit setting.

PubMed

Chlan, Linda; Patterson, Robert P; Heiderscheit, Annie

2011-07-01

Methods to easily, accurately, and efficiently obtain data in an ICU-based clinical trial can be challenging in this high-tech setting. Patient medical status and the dynamic nature of this clinical setting further complicate data collection. The purpose of this paper is to describe the modifications of commercially available headphones and the application of a data logging device to capture frequency and length of protocol use (music listening or headphones only for noise cancellation) without burdening participants or busy ICU nurses. With the automatic capture of protocol use by research participants, there have been no instances of lost data for this clinical trial. Copyright © 2011 Elsevier Inc. All rights reserved.

Cost effectiveness of intensive care in a low resource setting: A prospective cohort of medical critically ill patients

PubMed Central

Cubro, Hajrunisa; Somun-Kapetanovic, Rabija; Thiery, Guillaume; Talmor, Daniel; Gajic, Ognjen

2016-01-01

AIM: To calculate cost effectiveness of the treatment of critically ill patients in a medical intensive care unit (ICU) of a middle income country with limited access to ICU resources. METHODS: A prospective cohort study and economic evaluation of consecutive patients treated in a recently established medical ICU in Sarajevo, Bosnia and Herzegovina. A cost utility analysis of the intensive care of critically ill patients compared to the hospital ward treatment from the perspective of the health care system was subsequently performed. Incremental cost effectiveness was calculated using estimates of ICU vs non-ICU treatment effectiveness based on a formal systematic review of published studies. Decision analytic modeling was used to compare treatment alternatives. Sensitivity analyses of the key model parameters were performed. RESULTS: Out of 148 patients, seventy patients (47.2%) survived to one year after critical illness with a median quality of life index 0.64 [interquartile range(IQR) 0.49-0.76]. Median number of life years gained per patient was 30 (IQR 16-40) or 18 quality adjusted life years (QALYs) (IQR 7-28). The cost of treatment of critically ill patients varied between 1820 dollar and 20109 dollar per hospital survivor and between 100 dollar and 2514 dollar per QALY saved. Mean factors that influenced costs were: Age, diagnostic category, ICU and hospital length of stay and number and type of diagnostic and therapeutic interventions. The incremental cost effectiveness ratio for ICU treatment was estimated at 3254 dollar per QALY corresponding to 35% of per capita GDP or a Very Cost Effective category according to World Health Organization criteria. CONCLUSION: The ICU treatment of critically ill medical patients in a resource poor country is cost effective and compares favorably with other medical interventions. Public health authorities in low and middle income countries should encourage development of critical care services. PMID:27152258

The surgical Apgar score is strongly associated with ICU admission after high-risk intra-abdominal surgery

PubMed Central

Sobol, Julia B.; Gershengorn, ayley B.; Wunsch, Hannah; Li, Guohua

2014-01-01

Background Understanding intensive care unit (ICU) triage decisions for high-risk surgical patients may ultimately facilitate resource allocation and improve outcomes. The surgical Apgar score (SAS) is a simple score that uses intraoperative information on hemodynamics and blood loss to predict postoperative morbidity and mortality, with lower scores associated with worse outcomes. We hypothesized that the SAS would be associated with the decision to admit a patient to the ICU postoperatively. Methods Retrospective cohort study of adults undergoing major intra-abdominal surgery from 2003 to 2010 at an academic medical center. We calculated the SAS (0 – 10) for each patient based on intraoperative heart rate, mean arterial pressure, and estimated blood loss. Using logistic regression, we assessed the association of the SAS with the decision to admit a patient directly to the ICU after surgery. Results The cohort consisted of 8,501 patients, with 72.7% having a SAS of 7-10 and less than 5% a SAS of 0-4. A total of 8.7% of patients were transferred immediately to the ICU postoperatively. After multivariate adjustment, there was a strong association between the SAS and the decision to admit a patient to the ICU (adjusted odds ratio 14.41 [95% CI 6.88 – 30.19, P < 0.001] for SAS 0-2, 4.42 [95% CI 3.19 – 6.13, P <0.001] for SAS 3-4, and 2.60 [95% CI 2.08 – 3.24, P < 0.001] for SAS 5-6 compared with SAS 7-8). Conclusions The SAS is strongly associated with clinical decisions regarding immediate ICU admission after high-risk intra-abdominal surgery. These results provide an initial step towards understanding whether intraoperative hemodynamics and blood loss influence ICU triage for post-surgical patients. PMID:23744956

The effect of nursing participation in the design of a critical care information system: a case study in a Chinese hospital.

PubMed

Qin, Yanhong; Zhou, Ranyun; Wu, Qiong; Huang, Xiaodi; Chen, Xinli; Wang, Weiwei; Wang, Xun; Xu, Hua; Zheng, Jing; Qian, Siyu; Bai, Changqing; Yu, Ping

2017-12-06

Intensive care information systems (ICIS) are continuously evolving to meet the ever changing information needs of intensive care units (ICUs), providing the backbone for a safe, intelligent and efficient patient care environment. Although beneficial for the international advancement in building smart environments to transform ICU services, knowledge about the contemporary development of ICIS worldwide, their usage and impacts is limited. This study aimed to fill this knowledge gap by researching the development and implementation of an ICIS in a Chinese hospital, nurses' use of the system, and the impact of system use on critical care nursing processes and outcomes. This descriptive case study was conducted in a 14-bed Respiratory ICU in a tertiary hospital in Beijing. Participative design was the method used for ICU nurses, hospital IT department and a software company to collaboratively research and develop the ICIS. Focus group discussions were conducted to understand the subjective perceptions of the nurses toward the ICIS. Nursing documentation time and quality were compared before and after system implementation. ICU nursing performance was extracted from the annual nursing performance data collected by the hospital. A participative design process was followed by the nurses in the ICU, the hospital IT staff and the software engineers in the company to develop and implement a highly useful ICIS. Nursing documentation was fully digitized and was significantly improved in quality and efficiency. The wrong data, missing data items and calculation errors were significantly reduced. Nurses spent more time on direct patient care after the introduction of the ICIS. The accuracy and efficiency of medication administration was also improved. The outcome was improvement in ward nursing performance as measured by ward management, routine nursing practices, disinfection and isolation, infection rate and mortality rate. Nurses in this ICU unit in China actively participated in the ICIS development and fully used the system to document care. Introduction of the ICIS led to significant improvement in quality and efficiency in nursing documentation, medication order transcription and administration. It allowed nurses to spend more time with patients to improve quality of care. These led to improvement in overall nursing performance. Further study should investigate how the ICIS system contributes to the improvement in decision making of ICU nurses and intensivists.

Updated cost-effectiveness analysis of supplemental glutamine for parenteral nutrition of intensive-care patients

PubMed Central

Pradelli, L; Povero, M; Muscaritoli, M; Eandi, M

2015-01-01

Background/Objectives: Intravenous (i.v.) glutamine supplementation of parenteral nutrition (PN) can improve clinical outcomes, reduce mortality and infection rates and shorten the length of hospital and/or intensive care unit (ICU) stays compared with standard PN. This study is a pharmacoeconomic analysis to determine whether i.v. glutamine supplementation of PN remains both a highly favourable and cost-effective option for Italian ICU patients. Subjects/Methods: A previously published discrete event simulation model was updated by incorporating the most up-to-date and clinically relevant efficacy data (a clinically realistic subgroup analysis from a published meta-analysis), recent cost data from the Italian health-care system and the latest epidemiology data from a large Italian ICU database (covering 230 Italian ICUs and more than 77 000 patients). Sensitivity analyses were performed to test the robustness of the results. Results: Parenteral glutamine supplementation can significantly improve ICU efficiency in Italy, as the additional cost of supplemented treatment is more than completely offset by cost savings in hospital care. Supplementation was more cost-effective (cost-effectiveness ratio (CER)=€35 165 per patient discharged alive) than standard, non-supplemented PN (CER=€40 156 per patient discharged alive), and it resulted in mean cost savings of €4991 per patient discharged alive or €1047 per patient admitted to the hospital. Sensitivity analyses confirmed the robustness of these results. Conclusions: Alanyl-glutamine supplementation of PN is a clinically and economically attractive strategy for ICU patients in Italy and may be applicable to selected ICU patient populations in other countries. PMID:25469466

Critical care of the hematopoietic stem cell transplant recipient.

PubMed

Afessa, Bekele; Azoulay, Elie

2010-01-01

An estimated 50,000 to 60,000 patients undergo hematopoietic stem cell transplantation (HSCT) worldwide annually, of which 15.7% are admitted to the intensive care unit (ICU). The most common reason for ICU admission is respiratory failure and almost all develop single or multiorgan failure. Most HSCT recipients admitted to ICU receive invasive mechanical ventilation (MV). The overall short-term mortality rate of HSCT recipients admitted to ICU is 65%, and 86.4% for those receiving MV. Patient outcome has improved over time. Poor prognostic indicators include advanced age, poor functional status, active disease at transplant, allogeneic transplant, the severity of acute illness, and the development of multiorgan failure. ICU resource limitations often lead to triage decisions for admission. For HSCT recipients, the authors recommend (1) ICU admission for full support during their pre-engraftment period and when there is no evidence of disease recurrence; (2) no ICU admission for patients who refuse it and those who are bedridden with disease recurrence and without treatment options except palliation; (3) a trial ICU admission for patients with unknown status of disease recurrence with available treatment options.

Epidemiology and Outcome of Severe Sepsis and Septic Shock in Intensive Care Units in Mainland China

PubMed Central

Zhou, Jianfang; Qian, Chuanyun; Zhao, Mingyan; Yu, Xiangyou; Kang, Yan; Ma, Xiaochun; Ai, Yuhang; Xu, Yuan; Liu, Dexin; An, Youzhong; Wu, Dawei; Sun, Renhua; Li, Shusheng; Hu, Zhenjie; Cao, Xiangyuan; Zhou, Fachun; Jiang, Li; Lin, Jiandong; Mao, Enqiang; Qin, Tiehe; He, Zhenyang; Zhou, Lihua; Du, Bin

2014-01-01

Introduction Information about sepsis in mainland China remains scarce and incomplete. The purpose of this study was to describe the epidemiology and outcome of severe sepsis and septic shock in mixed ICU in mainland China, as well as the independent predictors of mortality. Methods We performed a 2-month prospective, observational cohort study in 22 closed multi-disciplinary intensive care units (ICUs). All admissions into those ICUs during the study period were screened and patients with severe sepsis or septic shock were included. Results A total of 484 patients, 37.3 per 100 ICU admissions were diagnosed with severe sepsis (n = 365) or septic shock (n = 119) according to clinical criteria and included into this study. The most frequent sites of infection were the lung and abdomen. The overall ICU and hospital mortality rates were 28.7% (n = 139) and 33.5% (n = 162), respectively. In multivariate analyses, APACHE II score (odds ratio[OR], 1.068; 95% confidential interval[CI], 1.027–1.109), presence of ARDS (OR, 2.676; 95%CI, 1.691–4.235), bloodstream infection (OR, 2.520; 95%CI, 1.142–5.564) and comorbidity of cancer (OR, 2.246; 95%CI, 1.141–4.420) were significantly associated with mortality. Conclusions Our results indicated that severe sepsis and septic shock were common complications in ICU patients and with high mortality in China, and can be of help to know more about severe sepsis and septic shock in China and to improve characterization and risk stratification in these patients. PMID:25226033

High creatinine clearance in critically ill patients with community-acquired acute infectious meningitis.

PubMed

Lautrette, Alexandre; Phan, Thuy-Nga; Ouchchane, Lemlih; Aithssain, Ali; Tixier, Vincent; Heng, Anne-Elisabeth; Souweine, Bertrand

2012-09-27

A high dose of anti-infective agents is recommended when treating infectious meningitis. High creatinine clearance (CrCl) may affect the pharmacokinetic / pharmacodynamic relationships of anti-infective drugs eliminated by the kidneys. We recorded the incidence of high CrCl in intensive care unit (ICU) patients admitted with meningitis and assessed the diagnostic accuracy of two common methods used to identify high CrCl. Observational study performed in consecutive patients admitted with community-acquired acute infectious meningitis (defined by >7 white blood cells/mm3 in cerebral spinal fluid) between January 2006 and December 2009 to one medical ICU. During the first 7 days following ICU admission, CrCl was measured from 24-hr urine samples (24-hr-UV/P creatinine) and estimated according to Cockcroft-Gault formula and the simplified Modification of Diet in Renal Disease (MDRD) equation. High CrCl was defined as CrCl >140 ml/min/1.73 m2 by 24-hr-UV/P creatinine. Diagnostic accuracy was performed with ROC curves analysis. Thirty two patients were included. High CrCl was present in 8 patients (25%) on ICU admission and in 15 patients (47%) during the first 7 ICU days for a median duration of 3 (1-4) days. For the Cockcroft-Gault formula, the best threshold to predict high CrCl was 101 ml/min/1.73 m2 (sensitivity: 0.96, specificity: 0.75, AUC = 0.90 ± 0.03) with a negative likelihood ratio of 0.06. For the simplified MDRD equation, the best threshold to predict high CrCl was 108 ml/min/1.73 m2 (sensitivity: 0.91, specificity: 0.80, AUC = 0.88 ± 0.03) with a negative likelihood ratio of 0.11. There was no difference between the estimated methods in the diagnostic accuracy of identifying high CrCl (p = 0.30). High CrCl is frequently observed in ICU patients admitted with community-acquired acute infectious meningitis. The estimated methods of CrCl could be used as a screening tool to identify high CrCl.

Simplified Mortality Score for the Intensive Care Unit (SMS-ICU): protocol for the development and validation of a bedside clinical prediction rule.

PubMed

Granholm, Anders; Perner, Anders; Krag, Mette; Hjortrup, Peter Buhl; Haase, Nicolai; Holst, Lars Broksø; Marker, Søren; Collet, Marie Oxenbøll; Jensen, Aksel Karl Georg; Møller, Morten Hylander

2017-03-09

Mortality prediction scores are widely used in intensive care units (ICUs) and in research, but their predictive value deteriorates as scores age. Existing mortality prediction scores are imprecise and complex, which increases the risk of missing data and decreases the applicability bedside in daily clinical practice. We propose the development and validation of a new, simple and updated clinical prediction rule: the Simplified Mortality Score for use in the Intensive Care Unit (SMS-ICU). During the first phase of the study, we will develop and internally validate a clinical prediction rule that predicts 90-day mortality on ICU admission. The development sample will comprise 4247 adult critically ill patients acutely admitted to the ICU, enrolled in 5 contemporary high-quality ICU studies/trials. The score will be developed using binary logistic regression analysis with backward stepwise elimination of candidate variables, and subsequently be converted into a point-based clinical prediction rule. The general performance, discrimination and calibration of the score will be evaluated, and the score will be internally validated using bootstrapping. During the second phase of the study, the score will be externally validated in a fully independent sample consisting of 3350 patients included in the ongoing Stress Ulcer Prophylaxis in the Intensive Care Unit trial. We will compare the performance of the SMS-ICU to that of existing scores. We will use data from patients enrolled in studies/trials already approved by the relevant ethical committees and this study requires no further permissions. The results will be reported in accordance with the Transparent Reporting of multivariate prediction models for Individual Prognosis Or Diagnosis (TRIPOD) statement, and submitted to a peer-reviewed journal. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Identifying unusual performance in Australian and New Zealand intensive care units from 2000 to 2010

PubMed Central

2014-01-01

Background The Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) collects voluntary data on patient admissions to Australian and New Zealand intensive care units (ICUs). This paper presents an in-depth statistical analysis of risk-adjusted mortality of ICU admissions from 2000 to 2010 for the purpose of identifying ICUs with unusual performance. Methods A cohort of 523,462 patients from 144 ICUs was analysed. For each ICU, the natural logarithm of the standardised mortality ratio (log-SMR) was estimated from a risk-adjusted, three-level hierarchical model. This is the first time a three-level model has been fitted to such a large ICU database anywhere. The analysis was conducted in three stages which included the estimation of a null distribution to describe usual ICU performance. Log-SMRs with appropriate estimates of standard errors are presented in a funnel plot using 5% false discovery rate thresholds. False coverage-statement rate confidence intervals are also presented. The observed numbers of deaths for ICUs identified as unusual are compared to the predicted true worst numbers of deaths under the model for usual ICU performance. Results Seven ICUs were identified as performing unusually over the period 2000 to 2010, in particular, demonstrating high risk-adjusted mortality compared to the majority of ICUs. Four of the seven were ICUs in private hospitals. Our three-stage approach to the analysis detected outlying ICUs which were not identified in a conventional (single) risk-adjusted model for mortality using SMRs to compare ICUs. We also observed a significant linear decline in mortality over the decade. Distinct yearly and weekly respiratory seasonal effects were observed across regions of Australia and New Zealand for the first time. Conclusions The statistical approach proposed in this paper is intended to be used for the review of observed ICU and hospital mortality. Two important messages from our study are firstly, that comprehensive risk-adjustment is essential in modelling patient mortality for comparing performance, and secondly, that the appropriate statistical analysis is complicated. PMID:24755369

The costs of fluid overload in the adult intensive care unit: is a small-volume infusion model a proactive solution?

PubMed Central

Child, Debra L; Cao, Zhun; Seiberlich, Laura E; Brown, Harold; Greenberg, Jordan; Swanson, Anne; Sewall, Martha R; Robinson, Scott B

2015-01-01

Purpose Fluid overload (FO) in critically ill patients remains a challenging clinical dilemma, and many continuous intravenous (IV) medications in the US are being delivered as a dilute solution, adding significantly to a patient’s daily intake. This study describes the costs and outcomes of FO in patients receiving multiple continuous infusions. Materials and methods A retrospective study was conducted using a hospital administrative database covering >500 US hospitals. An FO cohort included adult intensive care unit (ICU) patients with a central line receiving IV loop diuretics and 2+ continuous IV infusions on 50%+ of their ICU days; a directly matched non-FO cohort included patients without IV diuretic use. The primary outcome of the study was total hospitalization costs per visit. Additional outcomes were ICU costs, mortality, total and ICU length of stay (LOS), 30-day readmission rates, and ventilator use. Unadjusted descriptive analysis was performed using chi-squared or paired t-tests to compare outcomes between the two cohorts. Results A total of 63,974 patients were identified in each cohort. The total hospitalization cost per visit for the FO cohort was US$15,344 higher than the non-FO cohort (US$42,386 vs US$27,042), and the ICU cost for the FO cohort was US$5,243 higher than the non-FO cohort (US$10,902 vs US$5,659). FO patients had higher mortality (20% vs 16.8%), prolonged LOS (11.5 vs 8.0 days), longer ICU LOS (6.2 vs 3.6 days), higher risk of 30-day readmission (21.8% vs 21.3%), and ventilator usage (47.7% vs 28.3%) than the non-FO cohort (all P<0.05). Conclusion In patients receiving multiple continuous infusions, FO is associated with increased health care resources and costs. Maximally concentrating medications and proactively providing continuous medications in small-volume infusions (SVI) could be a potential solution to prevent iatrogenic FO in critically ill patients. Further prospective research is warranted to assess the impact of the SVI dispensing model on patient outcomes and health care costs. PMID:25548524

Severity scores in trauma patients admitted to ICU. Physiological and anatomic models.

PubMed

Serviá, L; Badia, M; Montserrat, N; Trujillano, J

2018-02-02

The goals of this project were to compare both the anatomic and physiologic severity scores in trauma patients admitted to intensive care unit (ICU), and to elaborate mixed statistical models to improve the precision of the scores. A prospective study of cohorts. The combined medical/surgical ICU in a secondary university hospital. Seven hundred and eighty trauma patients admitted to ICU older than 16 years of age. Anatomic models (ISS and NISS) were compared and combined with physiological models (T-RTS, APACHE II [APII], and MPM II). The probability of death was calculated following the TRISS method. The discrimination was assessed using ROC curves (ABC [CI 95%]), and the calibration using the Hosmer-Lemeshoẃs H test. The mixed models were elaborated with the tree classification method type Chi Square Automatic Interaction Detection. A 14% global mortality was recorded. The physiological models presented the best discrimination values (APII of 0.87 [0.84-0.90]). All models were affected by bad calibration (P<.01). The best mixed model resulted from the combination of APII and ISS (0.88 [0.83-0.90]). This model was able to differentiate between a 7.5% mortality for elderly patients with pathological antecedents and a 25% mortality in patients presenting traumatic brain injury, from a pool of patients with APII values ranging from 10 to 17 and an ISS threshold of 22. The physiological models perform better than the anatomical models in traumatic patients admitted to the ICU. Patients with low scores in the physiological models require an anatomic analysis of the injuries to determine their severity. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Age as an independent risk factor for intensive care unit admission or death due to 2009 pandemic influenza A (H1N1) virus infection.

PubMed

Nickel, Katelin B; Marsden-Haug, Nicola; Lofy, Kathryn H; Turnberg, Wayne L; Rietberg, Krista; Lloyd, Jennifer K; Marfin, Anthony A

2011-01-01

This study evaluated risk factors for intensive care unit (ICU) admission or death among people hospitalized with 2009 pandemic influenza A (pH1N1) virus infection. We based analyses on data collected in Washington State from April 27 to September 18, 2009, on deceased or hospitalized people with laboratory-confirmed pH1N1 infection reported by health-care providers and hospitals as part of enhanced public health surveillance. We used bivariate analyses and multivariable logistic regression to identify risk factors associated with ICU admission or death due to pH1N1. We identified 123 patients admitted to the hospital but not an ICU and 61 patients who were admitted to an ICU or died. Independent of high-risk medical conditions, both older age and delayed time to hospital admission were identified as risk factors for ICU admission or death due to pH1N1. Specifically, the odds of ICU admission or death were 4.44 times greater among adults aged 18-49 years (95% confidence interval [CI] 1.97, 10.02) and 5.93 times greater among adults aged 50-64 years (95% CI 2.24, 15.65) compared with pediatric patients < 18 years of age. Likewise, hospitalized cases admitted more than two days after illness onset had 2.17 times higher odds of ICU admission or death than those admitted within two days of illness onset (95% CI 1.10, 4.25). Although certain medical conditions clearly influence the need for hospitalization among people infected with pH1N1 virus, older age and delayed time to admission each played an independent role in the progression to ICU admission or death among hospitalized patients.

Platelet transfusions in cancer patients with hypoproliferative thrombocytopenia in the intensive care unit.

PubMed

Habr, Bassem; Charpentier, Julien; Champigneulle, Benoît; Dechartres, Agnès; Daviaud, Fabrice; Geri, Guillaume; Cariou, Alain; Chiche, Jean-Daniel; Mira, Jean-Paul; Pène, Frédéric

2015-12-01

Thrombocytopenia is a frequent finding in critically ill cancer patients for whom indications of platelet transfusions are unclear. We herein addressed the current practices in platelet transfusion and the risk of bleeding in cancer patients with hypoproliferative thrombocytopenia in the intensive care unit (ICU). A retrospective monocenter study over a 7-year period was conducted in a medical ICU. Adult patients with malignancies and hypoproliferative thrombocytopenia, and who received at least one platelet concentrate during their ICU stay, were included. 296 patients were included and received a total of 904 platelet transfusions, for prophylactic indications in 300 (33.2 %) episodes, for securing an invasive procedure in 257 (28.4 %), and for treatment of minor to major bleeding manifestations in 347 (38.4 %). Most prophylactic transfusions (80 %) were performed at platelet count thresholds below 10-20 × 10(9)/L. Platelet increments were generally low in all three indications, 10 (interquartile range 2-25), 11 (2-25), and 8 (0-21) × 10(9)/L, respectively. A total of 97 major ICU-acquired bleeding events occurred in 40 patients. About half of those bleeding episodes (54.7 %) occurred at platelet counts below 20 × 10(9)/L. However, neither low admission platelet count nor low nadir platelet counts were predictive of ICU-acquired bleeding. The in-ICU mortality rate tended to be higher in patients with severe ICU-acquired bleeding events (50 vs. 36 %). Most prophylactic platelet transfusions were given using thresholds of 10-20 × 10(9)/L in critically ill thrombocytopenic cancer patients. The individual risk of ICU-acquired severe bleeding appears hardly predictable with the depth of thrombocytopenia.

Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.

PubMed

Levesque, Eric; Hoti, Emir; Azoulay, Daniel; Ichaï, Philippe; Habouchi, Houssam; Castaing, Denis; Samuel, Didier; Saliba, Faouzi

2012-01-01

Cirrhotic patients admitted to an Intensive Care Unit (ICU) have a poor prognosis. Identifying patients in whom ICU care will be useful can be challenging. The aim of this study was to assess the predictive value of prognostic scores with respect to mortality and to identify mortality risk factors. Three hundred and seventy-seven cirrhotic patients admitted to a Liver ICU between May 2005 and March 2009 were enrolled in this study. Their average age was 55.5±11.4 years. The etiology of cirrhosis was alcohol (68%), virus hepatitis (18%), or mixed (5.5%). The main causes of hospitalization were gastrointestinal hemorrhage (43%), sepsis (19%), and hepatic encephalopathy (12%). ICU and in-hospital mortality rates were 34.7% and 43.0%, respectively. Infection was the major cause of death (81.6%). ROC curve analysis demonstrated that SOFA (0.92) and SAPS II (0.89) scores calculated within 24h of admission predicted ICU mortality better than the Child-Pugh score (0.79) or MELD scores with (0.79-0.82) or without the incorporation of serum sodium levels (0.82). Statistical analysis showed that the prognostic severity scores, organ replacement therapy, and infection were accurate predictors of mortality. On multivariate analysis, mechanical ventilation, vasopressor therapy, bilirubin level at admission, and infection were independently associated with ICU mortality. For cirrhotic patients admitted to the ICU, SAPS II, and SOFA scores predicted ICU mortality better than liver-specific scores. Mechanical ventilation or vasopressor therapy, bilirubin levels at admission and infection in patients with advanced cirrhosis were associated with a poor outcome. Copyright © 2011 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Applying social network analysis to the examination of interruptions in healthcare.

PubMed

McCurdie, Tara; Sanderson, Penelope; Aitken, Leanne M

2018-02-01

Examinations of interruptions in healthcare often focus on a single clinical discipline, and solutions are targeted accordingly. This approach does not take into account the inter-disciplinary dependencies and other sociotechnical aspects that make up the healthcare work system, and suggested solutions may not meet the needs of all stakeholders. In this article a sociotechnical systems perspective is used to uncover the interdependencies between 16 unique work roles that result in interruptions in an intensive care unit (ICU). By applying social network analysis techniques to data collected using the Dual Perspectives Method, we identified targeted systems-based interventions that may reduce unnecessary interruptions while avoiding unintended consequences that impose additional burden on ICU staff. The rich insights gained into the interruptive communication patterns in the ICU work system stand in contrast to findings that would have otherwise been obtained by focusing only on a single clinical discipline or a single perspective. Copyright © 2017. Published by Elsevier Ltd.

Developing a Business Plan for Critical Care Pharmacy Services

PubMed Central

Erstad, Brian L.; Mann, Henry J.; Weber, Robert J.

2016-01-01

Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs. This article provides the elements for a business plan to justify critical care pharmacy services by describing the pertinent background and benefit of ICU pharmacy services, detailing a current assessment of ICU pharmacy services, listing the essential ICU pharmacy services, describing service metrics, and delineating an appropriate timeline for implementing an ICU pharmacy service. The structure and approach of this business plan can be applied to a variety of pharmacy services. By following the format and information listed in this article, the pharmacy director can move closer to developing patient-centered pharmacy services for ICU patients. PMID:27928193

Developing a Business Plan for Critical Care Pharmacy Services.

PubMed

Erstad, Brian L; Mann, Henry J; Weber, Robert J

2016-11-01

Critical care medicine has grown from a small group of physicians participating in patient care rounds in surgical and medical intensive care units (ICUs) to a highly technical, interdisciplinary team. Pharmacy's growth in the area of critical care is as exponential. Today's ICU requires a comprehensive pharmaceutical service that includes both operational and clinical services to meet patient medication needs. This article provides the elements for a business plan to justify critical care pharmacy services by describing the pertinent background and benefit of ICU pharmacy services, detailing a current assessment of ICU pharmacy services, listing the essential ICU pharmacy services, describing service metrics, and delineating an appropriate timeline for implementing an ICU pharmacy service. The structure and approach of this business plan can be applied to a variety of pharmacy services. By following the format and information listed in this article, the pharmacy director can move closer to developing patient-centered pharmacy services for ICU patients.

Rational Use of Second-Generation Antipsychotics for the Treatment of ICU Delirium.

PubMed

Mo, Yoonsun; Yam, Felix K

2017-02-01

Delirium, described as an acute neuropsychiatric syndrome, occurs commonly in critically ill patients and leads to many negative outcomes including increased mortality and long-term cognitive deficits. Despite the lack of clinical data supporting the use of antipsychotics for the management of intensive care unit (ICU) delirium, pharmacological interventions are often needed to control acutely agitated patients. Given that the most current guidelines do not advocate the use of haloperidol for either the prevention or treatment of ICU delirium due to a lack of evidence, second-generation antipsychotics (SGAs) have been commonly used as alternatives to haloperidol for ICU patients with delirium. Nonetheless, the evidence supporting the use of SGAs to treat ICU delirium remains limited. This review is designed to assess the available clinical evidence and highlights the different neuropharmacological and safety properties of SGAs in order to guide the rational use of SGAs for the treatment of ICU delirium.

Post-traumatic Stress Symptoms in Post-ICU Family Members: Review and Methodological Challenges

PubMed Central

Petrinec, Amy B.; Daly, Barbara J.

2018-01-01

Family members of intensive care unit (ICU) patients are at risk for symptoms of post-traumatic stress disorder (PTSD) following ICU discharge. The aim of this systematic review is to examine the current literature regarding post-ICU family PTSD symptoms with an emphasis on methodological issues in conducting research on this challenging phenomenon. An extensive review of the literature was performed confining the search to English language studies reporting PTSD symptoms in adult family members of adult ICU patients. Ten studies were identified for review published from 2004–2012. Findings demonstrate a significant prevalence of family PTSD symptoms in the months following ICU hospitalization. However, there are several methodological challenges to the interpretation of existing studies and to the conduct of future research including differences in sampling, identification of risk factors and covariates of PTSD, and lack of consensus regarding the most appropriate PTSD symptom measurement tools and timing. PMID:25061017

Benchmarking glycemic control in u.s. Hospitals.

PubMed

Bersoux, Sophie; Cook, Curtiss B; Kongable, Gail L; Shu, Jianfen; Zito, Denise R

2014-09-01

Report data on glucose control from 635 U.S. hospitals. Point-of-care blood glucose (POC-BG) test data from January through December 2012 from 635 facilities were extracted. Glucose control was evaluated using patient-day-weighted mean POC-BG values. We calculated hypoglycemia and hyperglycemia rates, stratified by presence or absence of intensive care unit (ICU) admission, and we evaluated the relationship between glycemic control and hospital characteristics. In total, 51,375,764 POC-BG measurements (non-ICU, 39,197,762; ICU, 12,178,002) from 2,612,966 patients (non-ICU, 2,415,209; ICU, 575,084) were analyzed. The mean POC-BG was 167 mg/dL for non-ICU patients and 170 mg/dL for ICU patients. The prevalence of hyperglycemia (defined as glucose value >180 mg/dL) was 32.3 and 28.2% in non-ICU and ICU patients, respectively. The prevalence of hypoglycemia (defined as glucose value <70 mg/dL) was 6.1 and 5.6% in non-ICU and ICU patients, respectively. In non-ICU and ICU settings, the patient-day-weighted mean glucose was highest in the smallest hospitals, in rural hospitals, and in hospitals located in the Northeast (all P<.01). For non-ICU patients, we observed a significant difference in the percentage of patient days with hypoglycemia by geographic region only (P<.001). In ICU patients, the prevalence of hypoglycemia varied significantly by hospital type (P<.03) and geographic region (P<.01). In this largest POC-BG data set analysis conducted to date, glycemic control varied according to hospital characteristics. Our findings remain consistent with previous reports. Among other variables, national benchmarking of inpatient glucose data will need to consider differences in hospital characteristics.

Association Between Intensive Care Unit Utilization During Hospitalization and Costs, Use of Invasive Procedures, and Mortality.

PubMed

Chang, Dong W; Shapiro, Martin F

2016-10-01

Maximizing the value of critical care services requires understanding the relationship between intensive care unit (ICU) utilization, clinical outcomes, and costs. To examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality. Retrospective cohort study of 156 842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012. Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions. The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs. The 94 hospitals and 156 842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from 16.3% to 81.2% for DKA, 5.0% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ ≥ 0.90 for all comparisons; P < .01 for all). For each condition, hospital-level ICU utilization rate was not associated with hospital mortality. Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital.

Patient outcomes for the chronically critically ill: special care unit versus intensive care unit.

PubMed

Rudy, E B; Daly, B J; Douglas, S; Montenegro, H D; Song, R; Dyer, M A

1995-01-01

The purpose of this study was to compare the effects of a low-technology environment of care and a nurse case management case delivery system (special care unit, SCU) with the traditional high-technology environment (ICU) and primary nursing care delivery system on the patient outcomes of length of stay, mortality, readmission, complications, satisfaction, and cost. A sample of 220 chronically critically ill patients were randomly assigned to either the SCU (n = 145) or the ICU (n = 75). Few significant differences were found between the two groups in length of stay, mortality, or complications. However, the findings showed significant cost savings in the SCU group in the charges accrued during the study period and in the charges and costs to produce a survivor. The average total cost of delivering care was $5,000 less per patient in the SCU than in the traditional ICU. In addition, the cost to produce a survivor was $19,000 less in the SCU. Results from this 4-year clinical trial demonstrate that nurse case managers in a SCU setting can produce patient outcomes equal to or better than those in the traditional ICU care environment for long-term critically ill patients.

[Factors influencing relocation stress syndrome in patients following transfer from intensive care units].

PubMed

Park, Jin-Hee; Yoo, Moon-Sook; Son, Youn-Jung; Bae, Sun Hyoung

2010-06-01

The purpose of this study was to identify the levels of relocation stress syndrome (RSS) and influencing the stress experienced by Intensive Care Unit (ICU) patients just after transfer to general wards. A cross-sectional study was conducted with 257 patients who transferred from the intensive care unit. Data were collected through self-report questionnaires from May to October, 2009. Data were analyzed using the Pearson correlation coefficient, t-test, one-way ANOVA, and stepwise multiple linear regression with SPSS/WIN 12.0. The mean score for RSS was 17.80+/-9.16. The factors predicting relocation stress syndrome were symptom experience, differences in scope and quality of care provided by ICU and ward nursing staffs, satisfaction with transfer process, length of stay in ICU and economic status, and these factors explained 40% of relocation stress syndrome (F=31.61, p<.001). By understanding the stress experienced by ICU patients, nurses are better able to provide psychological support and thus more holistic care to critically ill patients. Further research is needed to consider the impact of relocation stress syndrome on patients' health outcomes in the recovery trajectory.

The implementation of a postoperative care process on a neurosurgical unit.

PubMed

Douglas, Mary; Rowed, Sheila

2005-12-01

The postoperative phase is a critical time for any neurosurgical patient. Historically, certain patients having neurosurgical procedures, such as craniotomies and other more complex surgeries, have been nursed postoperatively in the intensive care unit (ICU) for an overnight stay, prior to transfer to a neurosurgical floor. At the Hospital for Sick Children in Toronto, because of challenges with access to ICU beds and the cancellation of surgeries because of lack of available nurses for the ICU setting, this practice was reexamined. A set of criteria was developed to identify which postoperative patients should come directly to the neurosurgical unit immediately following their anesthetic recovery. The criteria were based on patient diagnosis, preoperative condition, comorbidities, the surgical procedure, intraoperative complications, and postoperative status. A detailed process was then outlined that allowed the optimum patients to be selected for this process to ensure patient safety. Included in this process was a postoperative protocol addressing details such as standard physician orders and the levels of monitoring required. Outcomes of this new process include fewer surgical cancellations for patients and families, equally safe, or better patient care, and the conservation of limited ICU resources. The program has currently been expanded to include patients who have undergone endovascular therapies.

A Preliminary Analysis of Compassion Satisfaction and Compassion Fatigue With Considerations for Nursing Unit Specialization and Demographic Factors.

PubMed

Mooney, Claire; Fetter, Katrina; Gross, Brian W; Rinehart, Cole; Lynch, Caitlin; Rogers, Frederick B

Compassion fatigue (CF), or vicarious traumatization, is a state of physical/emotional distress that results from caring for those experiencing pain. We sought to characterize levels of CF in intensive care unit (ICU) and oncology nursing populations with subanalyses comparing specific personal/professional demographic factors. The Professional Quality of Life (ProQOL) scale, a validated tool for assessing CF, burnout (BO), and compassion satisfaction (CS), was distributed to the ICU and oncology divisions of a community hospital. Demographic data and ProQOL scale scores were collected and compared within specialty and gender subgroups. Two-sample t tests and regression analyses were used to compare groups. Statistical significance was defined as p < .05. A total of 86 nurses submitted completed surveys able to be analyzed. Levels of CS were significantly lower (p = .023) and levels of BO were significantly higher (p = .029) in ICU nurses than in oncology nurses. Male nurses exhibited significantly higher CS (p = .001) and significantly lower BO (p = .021) and CF (p = .014) than female nurses. Intensive care unit nurses and female nurses from both ICU and oncology specialties may be at increased risk for developing a poorer overall ProQOL and CF.

Whole-body vibration to prevent intensive care unit-acquired weakness: safety, feasibility, and metabolic response.

PubMed

Wollersheim, Tobias; Haas, Kurt; Wolf, Stefan; Mai, Knut; Spies, Claudia; Steinhagen-Thiessen, Elisabeth; Wernecke, Klaus-D; Spranger, Joachim; Weber-Carstens, Steffen

2017-01-09

Intensive care unit (ICU)-acquired weakness in critically ill patients is a common and significant complication affecting the course of critical illness. Whole-body vibration is known to be effective muscle training and may be an option in diminishing weakness and muscle wasting. Especially, patients who are immobilized and not available for active physiotherapy may benefit. Until now whole-body vibration was not investigated in mechanically ventilated ICU patients. We investigated the safety, feasibility, and metabolic response of whole-body vibration in critically ill patients. We investigated 19 mechanically ventilated, immobilized ICU patients. Passive range of motion was performed prior to whole-body vibration therapy held in the supine position for 15 minutes. Continuous monitoring of vital signs, hemodynamics, and energy metabolism, as well as intermittent blood sampling, took place from the start of baseline measurements up to 1 hour post intervention. We performed comparative longitudinal analysis of the phases before, during, and after intervention. Vital signs and hemodynamic parameters remained stable with only minor changes resulting from the intervention. No application had to be interrupted. We did not observe any adverse event. Whole-body vibration did not significantly and/or clinically change vital signs and hemodynamics. A significant increase in energy expenditure during whole-body vibration could be observed. In our study the application of whole-body vibration was safe and feasible. The technique leads to increased energy expenditure. This may offer the chance to treat patients in the ICU with whole-body vibration. Further investigations should focus on the efficacy of whole-body vibration in the prevention of ICU-acquired weakness. Applicability and Safety of Vibration Therapy in Intensive Care Unit (ICU) Patients. ClinicalTrials.gov NCT01286610 . Registered 28 January 2011.

Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II score, and predicted probability of mortality in an electronic intensive care unit database.

PubMed

Wenner, Joshua B; Norena, Monica; Khan, Nadia; Palepu, Anita; Ayas, Najib T; Wong, Hubert; Dodek, Peter M

2009-09-01

Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied. Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlain's percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A kappa statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality. Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by kappa statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71). Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts.

MRSA acquisition in an intensive care unit.

PubMed

Dancer, Stephanie J; Coyne, Michael; Speekenbrink, A; Samavedam, Sam; Kennedy, Julie; Wallace, Peter G M

2006-02-01

This paper describes a retrospective investigation of methicillin-resistant Staphylococcus aureus (MRSA) acquisition in an 8-bed intensive care unit (ICU) over a 5-month period. Clinical and microbiologic data were collected from the ICU, including MRSA detection dates, patient dependency scores, standardized environmental screening data, weekly bed occupancies, number of admissions, and nurse staffing levels. MRSA acquisition weeks were defined as weeks during which initial delivery of MRSA occurred before sampling and laboratory confirmation. Weekly workloads were plotted against staffing levels and modelled against MRSA acquisition weeks and hygiene failures. Of 174 patients admitted into the ICU, 28 (16%) were found to have MRSA; 12 of these (7%) acquired MRSA on the ICU within 7 of the 23 weeks studied. Six of these 7 weeks were associated with a deficit of trained nurses during the day and 5 with hygiene failures (data unavailable for 2). Pulsed-field gel electrophoresis (PFGE) profiles demonstrated relationships between staphylococci from staff hands, hand-touch sites, and patients' blood. MRSA acquisition in the ICU was temporally associated with reduced numbers of trained nurses and hygiene failures predominantly involving hand-touch sites. Epidemiologic analysis suggested that patient acquisitions were 7 times more likely to occur during periods of nurse understaffing.

[Four years of raw mortality in an intensive care unit].

PubMed

Loria, Alvar; Rosas-Baruch, Agustina; Posadas, Juan Gabriel; Domínguez-Cherit, Guillermo; Rivero-Sigarroa, Eduardo

2008-01-01

To characterize magnitude and variability of raw mortality in a Mexican Intensive Care Unit (ICU). Demographic and clinical data were analyzed in 1,746 patients discharged from the ICU of the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. The data was obtained from an administrative database and covered four years (2003-2006). Overall ICU-mortality was 23% (410/1746) and was associated with two binary variables (higher mortality in weekend admissions and non-surgical cases) and three multicategorical variables (gradient of increasing mortality with increasing age, increasing diagnostic risk and increasing number of high-rish diagnoses). First biennium mortality was significantly higher than in the second biennium (29% us 19%). This higher mortality was not associated with the high risk categories of the five variables described above nor with other ICU-variables such as number of nurses and admission and discharge criteria. The only biennium difference was a higher number of physicians (specialists + residents) in the second biennium (16-20 versus 14-15 in the first). The four-year long-term ICU-mortality showed a significant decrease in the second biennium. Number of physicians was the only variable associated with the decreased mortality.

Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates.

PubMed

Miller, David C; McSparron, Jakob I; Clardy, Peter F; Sullivan, Amy M; Hayes, Margaret M

2016-09-01

Effective communication between providers and patients and their surrogates in the intensive care unit (ICU) is crucial for delivery of high-quality care. Despite the identification of communication as a key education focus by the American Board of Internal Medicine, little emphasis is placed on teaching trainees how to effectively communicate in the ICU. Data are conflicting on the best way to teach residents, and institutions vary on their emphasis of communication as a key skill. There needs to be a cultural shift surrounding the education of medical residents in the ICU: communication must be treated with the same emphasis, precision, and importance as placing a central venous catheter in the ICU. We propose that high-stakes communications between physicians and patients or their surrogates must be viewed as a medical procedure that can be taught, assessed, and quality controlled. Medical residents require training, observation, and feedback in specific communication skill sets with the goal of achieving mastery. It is only through supervised training, practice in real time, observation, and feedback that medical residents can become skillful practitioners of communication in the ICU.

The direct costs of intensive care management and risk factors for financial burden of patients with severe sepsis and septic shock.

PubMed

Khwannimit, Bodin; Bhurayanontachai, Rungsun

2015-10-01

The costs of severe sepsis care from middle-income countries are lacking. This study investigated direct intensive care unit (ICU) costs and factors that could affect the financial outcomes. A prospective cohort study was conducted in the medical ICU of a tertiary referral university teaching hospital in Thailand. A total of 897 patients were enrolled in the study, with 683 (76.1%) having septic shock. Community-, nosocomial, and ICU-acquired infections were documented in 574, 282, and 41 patients, respectively. The median ICU costs per patient were $2716.5 ($1296.1-$5367.6) and $599.9 ($414.3-$948.6) per day. The ICU costs accounted for 64.7% of the hospital costs. In 2008 to 2011, the ICU costs significantly decreased by 40% from $3542.5 to $2124.9, whereas, the daily ICU costs decreased only 3.3% from $609.7 to $589.7. By multivariate logistic regression analysis, age, nosocomial or ICU infection, admission from the emergency department, number of organ failures, ICU length of stay, and fluid balance the first 72 hours were independently associated with ICU costs. The ICU costs of severe sepsis management significantly declined in our study. However, the ICU costs were a financial burden accounting for two thirds of the hospital costs. It is essential for intensivists to contribute a high standard of care within a restricted budget. Copyright © 2015 Elsevier Inc. All rights reserved.

The Effect of Whole Body Massage on the Process and Physiological Outcome of Trauma ICU Patients: A Double-Blind Randomized Clinical Trial

PubMed Central

Hatefi, Masoud; Jaafarpour, Molouk; Khajavikhan, Javaher; Kokhazade, Taleb

2015-01-01

Background and Aim Hospitalization of traumatic patients in the Intensive Care Unit (ICU) and their critical condition can cause haemodynamic instabilities and deterioration in the level of consciousness. The study aimed to investigate the effect of whole body massage on the vital signs, Glasgow Coma Scale (GCS) scores and arterial blood gases (ABG) in trauma ICU patients. Materials and Methods In a randomized, double-blind trial, 108 trauma ICU patients received whole body massage {experimental group (n=54)}, or routine care {control group (n=54)}. The patients vital signs; systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate (RR), pulse rate (PR), Temperature (T), GCS score and ABG parameters were measured by a nurse at the same time in both groups before the intervention and 1 hour and 3 hours after the intervention with a checklist. The patient in experimental group received full body massage in 45 minute by a family member. Results According to the findings, significant differences were observed between experimental and control groups in SBP 1 hour and 3 hours after intervention (p< 0.001), DBP, RR and PR 1 hour after intervention (p<0.001) and GCS 1 hour and 3 hours after intervention (p<0.05). Of ABG parameters, significant differences were observed between experimental and control groups in O2 saturation (p<0.001), PH (p<0.001) and pO2 (p<0.05). No significant differences between experimental and control groups in Temperature, pCO2 and HCO3 (p>0.05). Conclusion With respect to this study, massage therapy is a safe and effective treatment in intensive care units to reduce patient’s physical and psychological problems. Therefore the use of massage therapy is recommended to clinical practice as a routine method. PMID:26266191

EFFECT of daily antiseptic body wash with octenidine on nosocomial primary bacteraemia and nosocomial multidrug-resistant organisms in intensive care units: design of a multicentre, cluster-randomised, double-blind, cross-over study

PubMed Central

Meißner, Anne; Hasenclever, Dirk; Brosteanu, Oana; Chaberny, Iris Freya

2017-01-01

Introduction Nosocomial infections are serious complications that increase morbidity, mortality and costs and could potentially be avoidable. Antiseptic body wash is an approach to reduce dermal micro-organisms as potential pathogens on the skin. Large-scale trials with chlorhexidine as the antiseptic agent suggest a reduction of nosocomial infection rates. Octenidine is a promising alternative agent which could be more effective against Gram-negative organisms. We hypothesise that daily antiseptic body wash with octenidine reduces the risk of intensive care unit (ICU)-acquired primary bacteraemia and ICU-acquired multidrug-resistant organisms (MDRO) in a standard care setting. Methods and analysis EFFECT is a controlled, cluster-randomised, double-blind study. The experimental intervention consists in using octenidine-impregnated wash mitts for the daily routine washing procedure of the patients. This will be compared with using placebo wash mitts. Replacing existing washing methods is the only interference into clinical routine. Participating ICUs are randomised in an AB/BA cross-over design. There are two 15-month periods, each consisting of a 3-month wash-out period followed by a 12-month intervention and observation period. Randomisation determines only the sequence in which octenidine-impregnated or placebo wash mitts are used. ICUs are left unaware of what mitts packages they are using. The two coprimary endpoints are ICU-acquired primary bacteraemia and ICU-acquired MDRO. Endpoints are defined based on individual ward-movement history and microbiological test results taken from the hospital information systems without need for extra documentation. Data on clinical symptoms of infection are not collected. EFFECT aims at recruiting about 45 ICUs with about 225 000 patient-days per year. Ethics and dissemination The study was approved by the ethics committee of the University of Leipzig (number 340/16-ek) in November 2016. Findings will be published in peer-reviewed journals. Trial registration number DRKS-ID: DRKS00011282. PMID:29122787

A novel method of optimizing patient- and family-centered care in the ICU.

PubMed

Allen, Steven R; Pascual, Jose; Martin, Niels; Reilly, Patrick; Luckianow, Gina; Datner, Elizabeth; Davis, Kimberly A; Kaplan, Lewis J

2017-03-01

Patient- and family-centered care permeates critical care where there are often multiple teams involved in management. A method of facilitating information sharing to support shared decision making is essential in appropriately rendering care.This study sought to determine whether incorporating family members on rounds in the intensive care unit (ICU) improves patient and family knowledge and whether doing so improves team time management and satisfaction with the process. A nonrandomized comparative before-and-after trial of incorporating family members on rounds (July to December 2009 vs January to July 2010) in a single quarternary center's surgical ICU assessed (1) family members' knowledge, (2) nurse's and physician's satisfaction with the intervention, (3) frequency and timing of family meetings, and (4) physician's workflow. Intensive care unit demographics and use were similar between time frames. Presurvey (n = 412 family members; 49 nurses) and postsurvey (n = 427 family members; 47 nurses) were coupled with presurvey (n = 5) and postsurvey (n = 6) physicians' informal feedback. Family knowledge of the clinical course and plans increased from 146 (35.4%) of 412 to 374 (87.6%) of 427 (p < 0.0001). Nurses were nearly uniformly satisfied with planned family interaction on rounds (presurvey: 9/49 [18.4%] vs postsurvey: 46/47 [97.9%]; p < 0.0001). Family meetings per week outside of rounds substantially decreased from a mean of 5.3 ± 2.7 to 0.3 ± 0.9; p < 0.001). Goals of therapy including end-of-life care became an element frequently discussed on rounds with families (presurvey: 9.4% ± 4.7% vs postsurvey: 82.5% ± 14.8%; p < 0.0001). One intensivist was dissatisfied with the process. Incorporating family members on rounds in the ICU improves communication and satisfaction and shifts the team's time away from family communication events outside of rounds, condensing most of those activities within the rounding structure. Critical care nurses and intensivists were principally satisfied with the process. Therapeutic, level III.

The ability of intensive care unit physicians to estimate long-term prognosis in survivors of critical illness.

PubMed

Soliman, Ivo W; Cremer, Olaf L; de Lange, Dylan W; Slooter, Arjen J C; van Delden, Johannes Hans J M; van Dijk, Diederik; Peelen, Linda M

2018-02-01

To assess the reliability of physicians' prognoses for intensive care unit (ICU) survivors with respect to long-term survival and health related quality of life (HRQoL). We performed an observational cohort-study in a single mixed tertiary ICU in The Netherlands. ICU survivors with a length of stay >48h were included. At ICU discharge, one-year prognosis was estimated by physicians using the four-option Sabadell score to record their expectations. The outcome of interest was poor outcome, which was defined as dying within one-year follow-up, or surviving with an EuroQoL5D-3L index <0.4. Among 1399 ICU survivors, 1068 (76%) subjects were expected to have a good outcome; 243 (18%) a poor long-term prognosis; 43 (3%) a poor short-term prognosis, and 45 (3%) to die in hospital (i.e. Sabadell score levels). Poor outcome was observed in 38%, 55%, 86%, and 100% of these groups respectively (concomitant c-index: 0.61). The expected prognosis did not match observed outcome in 365 (36%) patients. This was almost exclusively (99%) due to overoptimism. Physician experience did not affect results. Prognoses estimated by physicians incorrectly predicted long-term survival and HRQoL in one-third of ICU survivors. Moreover, inaccurate prognoses were generally the result of overoptimistic expectations of outcome. Copyright © 2017 Elsevier Inc. All rights reserved.

The Family Navigator: A Pilot Intervention to Support Intensive Care Unit Family Surrogates.

PubMed

Torke, Alexia M; Wocial, Lucia D; Johns, Shelley A; Sachs, Greg A; Callahan, Christopher M; Bosslet, Gabriel T; Slaven, James E; Perkins, Susan M; Hickman, Susan E; Montz, Kianna; Burke, Emily S

2016-11-01

Communication problems between family surrogates and intensive care unit (ICU) clinicians have been documented, but few interventions are effective. Nurses have the potential to play an expanded role in ICU communication and decision making. To conduct a pilot randomized controlled trial of the family navigator (FN), a distinct nursing role to address family members' unmet communication needs early in an ICU stay. An interprofessional team developed the FN protocol. A randomized controlled pilot intervention trial of the FN was performed in a tertiary referral hospital's ICU to test the feasibility and acceptability of the intervention. The intervention addressed informational and emotional communication needs through daily contact by using structured clinical updates, emotional and informational support modules, family meeting support, and follow-up phone calls. Twenty-six surrogate/patient pairs (13 per study arm) were enrolled. Surrogates randomized to the intervention had contact with the FN on 90% or more of eligible patient days. All surrogates agreed that they would recom mend the FN to other families. Open-ended comments from both surrogates and clinicians were uniformly positive. Having a fully integrated nurse empowered to facilitate decision making is a feasible intervention in an ICU and is well-received by ICU families and staff. A larger randomized controlled trial is needed to demonstrate impact on important outcomes, such as surrogates' well-being and decision quality. ©2016 American Association of Critical-Care Nurses.

[Expectations of relatives of critically ill patients regarding medical information. Qualitative research study].

PubMed

Alonso-Ovies, A; Álvarez, J; Velayos, C; García, M M; Luengo, M J

2014-01-01

To determine and analyse the expectations, needs and experiences of relatives of critically ill patients as regards medical information and the level of their understanding. To find keys for improving communication and to draw up best practices in clinical information. Qualitative research study through semi-structured interviews carried out in a polyvalent adult intensive care unit (ICU) in a University Hospital. relatives of patients who were admitted to the ICU and who were discharged alive from the Unit. Ten interviews were performed taking into account diversification variables such as, type of family relationship with patients, patient age, length of ICU stay, origin, and location at the time of the interview. The results of the analysis of 10 interviews focused on: the subjective position of the family in the ICU (the agonizing wait), what the ICU represents for the family (surveillance and monitoring of a situation between life and death), perceived care (complete delegation of care), and medical information (what and how they expect and what and how they receive it), as much in the first information (sincerity, hope, delicacy) as in the successive. There is divergence between what families expect and what they get as regards medical information. To know the expectations of the families will help to provide higher quality care and more humane treatment in the ICU. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.

C-terminal and intact FGF23 in critical illness and their associations with acute kidney injury and in-hospital mortality.

PubMed

Rygasiewicz, Karolina; Hryszko, Tomasz; Siemiatkowski, Andrzej; Brzosko, Szymon; Rydzewska-Rosolowska, Alicja; Naumnik, Beata

2018-03-01

FGF23 proved its value in prognostication of cardiovascular events and mortality among renal patients and general population. Limited data exist whether FGF23 may have any use in prediction of negative outcomes among critically ill patients admitted to intensive care unit (ICU). Single center cohort study performed among patients admitted to ICU. The primary exposure was FGF23 plasma concentration measured within 24 h of ICU admission. The primary outcome was incident Acute Kidney Injury (AKI) and in-hospital mortality during the ICU stay. The study enrolled 79 patients admitted to ICU. C-terminal FGF23 (cFGF23) but not intact FGF23 (iFGF23) concentration was significantly elevated in patients, who acquired AKI and non-survivors (p < .001). ROC analysis of cFGF23 yielded an AUC of 0.81 and 0.85 for prediction of incident AKI and death during ICU stay, respectively. Multivariate analysis showed higher odds for AKI (OR 1.80; 95% CI 1.10-2.96) and in-hospital mortality (OR 2.85; 95% CI 1.60-5.06) for one unit increase of log transformed cFGF23. cFGF23 measurement may serve as a novel biomarker for incident AKI and death among critically ill patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

PubMed

Dietz, Aaron S; Pronovost, Peter J; Mendez-Tellez, Pedro Alejandro; Wyskiel, Rhonda; Marsteller, Jill A; Thompson, David A; Rosen, Michael A

2014-12-01

Teamwork is essential for ensuring the quality and safety of health care delivery in the intensive care unit (ICU). This article addresses what we know about teamwork, team tasks, and team improvement strategies in the ICU to identify the strengths and limitations of the existing knowledge base to guide future research. A keyword search of the PubMed database was conducted in February 2013. Keyword combinations focused on 3 areas: (1) teamwork, (2) the ICU, and (3) training/quality improvement interventions. All studies that investigated teamwork, team tasks, or team interventions within the ICU (ie, intradepartment) were selected for inclusion. Teamwork has been investigated across an array of research contexts and task types. The terminology used to describe team factors varied considerably across studies. The most common team tasks involved strategy and goal formulation. Team training and structured protocols were the most widely implemented quality improvement strategies. Team research is burgeoning in the ICU, yet low-hanging fruit remains that can further advance the science of teams in the ICU if addressed. Constructs must be defined, and theoretical frameworks should be referenced. The functional characteristics of tasks should also be reported to help determine the extent to which study results might generalize to other contexts of work. Copyright © 2014 Elsevier Inc. All rights reserved.

Empiric therapy directed against MRSA in patients admitted to the intensive care unit does not improve outcomes in community-acquired pneumonia.

PubMed

Griffin, A T; Peyrani, P; Wiemken, T L; Ramirez, J A; Arnold, F W

2013-04-01

The Infectious Diseases Society of America has recommended empiric therapy active against methicillin-resistant Staphylococcus aureus (MRSA) for all community-acquired pneumonia (CAP) patients admitted to the intensive care unit (ICU). However, there is sparse data to support this recommendation. The objective of our study was to ascertain if such a practice improves outcomes. This study was a secondary, retrospective analysis of the Community-Acquired Pneumonia Organization (CAPO) international database on CAP. Outcomes in patients admitted to the ICU were compared according to empiric initiation of anti-MRSA therapy (vancomycin or linezolid) with standard ICU CAP therapy (MRSA therapy group) or standard therapy alone for ICU CAP (standard therapy group). A total of 621 patients were identified with ICU pneumonia, of whom 57 patients had been initiated empirically on vancomycin or linezolid (MRSA therapy group). Patients of the MRSA therapy group had more comorbidities and were more severely ill than those of the standard therapy group. However, there were no statistical differences between the MRSA therapy group and standard therapy group for the primary outcomes of in-hospital and 28-day mortality, length of stay and time to clinical stability. These findings suggest that empiric MRSA therapy in all ICU CAP patients may not improve outcomes and argue for clinician review of local epidemiologic trends on MRSA prevalence to ascertain the need for empiric MRSA coverage.

Severity of Acute Illness is Associated with Baseline Readiness to Change in Medical Intensive Care Unit Patients with Unhealthy Alcohol Use

PubMed Central

Clark, Brendan J.; Smart, Alexandra; House, Robert; Douglas, Ivor; Burnham, Ellen L.; Moss, Marc

2011-01-01

Introduction Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use. Materials and Methods We performed a cross-sectional observational study of current regular drinkers in three medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient’s acute illness was assessed by calculating the Acute Physiology and Chronic Healthy Evaluation II score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires. Results Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHEII score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale) (p< 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term). Conclusion Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers. PMID:21950704

Using an intervention mapping approach to develop a discharge protocol for intensive care patients.

PubMed

van Mol, Margo; Nijkamp, Marjan; Markham, Christine; Ista, Erwin

2017-12-19

Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need. Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study. Four former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice. Intervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.

The role of the intensive care unit in real-time surveillance of emerging pandemics: the Italian GiViTI experience.

PubMed

Bertolini, G; Nattino, G; Langer, M; Tavola, M; Crespi, D; Mondini, M; Rossi, C; Previtali, C; Marshall, J; Poole, D

2016-01-01

The prompt availability of reliable epidemiological information on emerging pandemics is crucial for public health policy-makers. Early in 2013, a possible new H1N1 epidemic notified by an intensive care unit (ICU) to GiViTI, the Italian ICU network, prompted the re-activation of the real-time monitoring system developed during the 2009-2010 pandemic. Based on data from 216 ICUs, we were able to detect and monitor an outbreak of severe H1N1 infection, and to compare the situation with previous years. The timely and correct assessment of the severity of an epidemic can be obtained by investigating ICU admissions, especially when historical comparisons can be made.

The nursing role during end-of-life care in the intensive care unit related to the interaction between patient, family and professional: an integrative review.

PubMed

Noome, Marijke; Beneken Genaamd Kolmer, Deirdre M; van Leeuwen, Evert; Dijkstra, Boukje M; Vloet, Lilian C M

2016-12-01

The aim of this study was to explore how intensive care unit (ICU) nurses describe their role during End-of-Life Care (EOLC) in the ICU, related to the interaction between patient, family and professionals (care triad). Three electronic databases, PubMed, CINAHL and EMBASE, and reference lists of included studies were searched for studies in English, Dutch or German between January 2002 and August 2015. Studies were included if they presented data about EOLC in the adult ICU, and the role of ICU nurses around EOLC. Quantitative and qualitative studies and opinion articles were extracted. Inductive content analysis was carried out to analyse and categorise the data. Twenty studies were included. Four categories emerged: care for the ICU patient, care for the family, environmental aspects of EOLC and organisational aspects of EOLC. Regarding the care triad, a gap exists between theoretical models and the actual care provided by ICU nurses during EOLC. The relational aspect of care, like aimed with care triad, is absent. The literature clearly indicates that the role of ICU nurses concerns care for the patient, family and environment. It described which care should be given, but it remains unclear how care should be given (attitude). Therefore, it is difficult for ICU nurses to provide this care. Further, it seems that care provided to family mainly consists of giving advice on how to care for the patient; care for family members themselves was only mentioned in a few studies. Therefore, it seems that family does not always receive adequate care yet, which may be helpful in preventing problems like depression, anxiety or post-traumatic stress disorder. It can be concluded that it is important for ICU nurses to be aware of the existing relationships; however, comparing the literature, care triad does not appear to be reached. © 2016 Nordic College of Caring Science.

A Time-Motion Study of ICU Workflow and the Impact of Strain.

PubMed

Hefter, Yosefa; Madahar, Purnema; Eisen, Lewis A; Gong, Michelle N

2016-08-01

Understanding ICU workflow and how it is impacted by ICU strain is necessary for implementing effective improvements. This study aimed to quantify how ICU physicians spend time and to examine the impact of ICU strain on workflow. Prospective, observational time-motion study. Five ICUs in two hospitals at an academic medical center. Thirty attending and resident physicians. None. In 137 hours of field observations, the most time-84 hours (62% of total observation time)-was spent on professional communication. Reviewing patient data and documentation occupied a combined 52 hours (38%), whereas direct patient care and education occupied 24 hours (17%) and 13 hours (9%), respectively. The most frequently used tool was the computer, used in tasks that occupied 51 hours (37%). Severity of illness of the ICU on day of observation was the only strain factor that significantly impacted work patterns. In a linear regression model, increase in average ICU Sequential Organ Failure Assessment was associated with more time spent on direct patient care (β = 4.3; 95% CI, 0.9-7.7) and education (β = 3.2; 95% CI, 0.7-5.8), and less time spent on documentation (β = -7.4; 95% CI, -11.6 to -3.2) and on tasks using the computer (β = -7.8; 95% CI, -14.1 to -1.6). These results were more pronounced with a combined strain score that took into account unit census and Sequential Organ Failure Assessment score. After accounting for ICU type (medical vs surgical) and staffing structure (resident staffed vs physician assistant staffed), results changed minimally. Clinicians spend the bulk of their time in the ICU on professional communication and tasks involving computers. With the strain of high severity of illness and a full unit, clinicians reallocate time from documentation to patient care and education. Further efforts are needed to examine system-related aspects of care to understand the impact of workflow and strain on patient care.

Intensive Care and its Discontents: Psychiatric Illness in the Critically Ill.

PubMed

Hashmi, Ali M; Han, Jin Y; Demla, Vishal

2017-09-01

Critically ill patients can develop a host of cognitive and psychiatric complaints during their intensive care unit (ICU) stay, many of which persist for weeks or months following discharge from the ICU and can seriously affect their quality of life, including their ability to return to work. This article describes some common psychiatric problems encountered by clinicians in the ICU, including their assessment and management. A comprehensive approach is needed to decrease patient suffering, improve morbidity and mortality, and ensure that critically ill patients can return to the highest quality of life after an ICU stay. Copyright © 2017 Elsevier Inc. All rights reserved.

Non-convulsive seizures and non-convulsive status epilepticus monitoring in the intensive care unit. A real need for the Gulf Cooperation Council countries.

PubMed

Mesraoua, Boulenouar; Wieser, Heinz G

2009-10-01

Continuous EEG (cEEG) monitoring in the intensive care unit (ICU) is essential for detecting non-convulsive seizures/status epilepticus (NCSs, NCSE). Currently there exist a number of continuous EEG monitoring systems adapted for use in the ICU. However, these systems have been trained using EEG data collected from healthy, neurologically intact patients with epileptic seizures, a very different patient population from ICU patients. The review consists of 2 parts, clinical and technological aspects. In the first one, we summarize the electroencephalographic aspects of NCSs/NCSE and other EEG patterns encountered in the ICU. In the second part, we explain how to develop a novel cEEG monitoring system to be used in Hamad Medical Corporation ICUs, Doha, Qatar, that is able to detect pathological EEG patterns commonly occurring in the critically ill patient. Real-time monitoring of seizure discharges, and other pathological EEG patterns will allow correct diagnosis and adequate treatment in a timely fashion.

Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

PubMed

Sada, Oumer; Melkie, Addisu; Shibeshi, Workineh

2015-09-16

Medication errors (MEs) are important problems in all hospitalized populations, especially in intensive care unit (ICU). Little is known about the prevalence of medication prescribing errors in the ICU of hospitals in Ethiopia. The aim of this study was to assess medication prescribing errors in the ICU of Tikur Anbessa Specialized Hospital using retrospective cross-sectional analysis of patient cards and medication charts. About 220 patient charts were reviewed with a total of 1311 patient-days, and 882 prescription episodes. 359 MEs were detected; with prevalence of 40 per 100 orders. Common prescribing errors were omission errors 154 (42.89%), 101 (28.13%) wrong combination, 48 (13.37%) wrong abbreviation, 30 (8.36%) wrong dose, wrong frequency 18 (5.01%) and wrong indications 8 (2.23%). The present study shows that medication errors are common in medical ICU of Tikur Anbessa Specialized Hospital. These results suggest future targets of prevention strategies to reduce the rate of medication error.

Changes of geriatric syndromes in older adults survived from Intensive Care Unit.

PubMed

Tang, Hsin-Ju; Tang, Hsin-Yi Jean; Hu, Fang-Wen; Chen, Ching-Huey

Nearly 90% of the older adult patients discharged from hospital with a cluster of geriatric syndromes. The patterns of geriatric syndromes in older adult ICU survivors are to be further explored. The aim of this study was to examine the risk factors and patterns of geriatric syndromes among older adult patients before admitting to ICU and throughout their hospitalization. A total of 137 older adult patients (age 76.9 ± 6.6; 52.6% male) participated in the study. The results showed significant increase in the occurrence of geriatric syndromes from T0 (upon ICU admission) to T1 (transition to inpatient care unit), with improvement at T2 (hospital discharge), but did not return to the baseline. The three most prevalent geriatric syndromes were: functional decline, urination incontinence, and defecation incontinence. Polypharmacy was associated with functioning decline. Patients with delirium were six times more likely to be re-admitted to ICU. Copyright © 2016 Elsevier Inc. All rights reserved.

Quality of Sleep Among Intensive Care Unit Patients: A Literature Review.

PubMed

Bani Younis, Mohammad; Hayajneh, Ferial A

Investigating sleep disturbances among intensive care unit (ICU) patients and its serious consequences is considered a crucial issue for nurses. The need of sleep increases during hospitalization time to preserve energy for the healing process. Previous studies have demonstrated that sleep disturbance is one of the most common complaints of patients in the ICUs, with a prevalence of more than 50%. Although the total sleep time might be normal, the patients' sleep is fragmented and light in the intensive care settings. The main purpose of this review is to generate a clear view of what is known about sleep disturbances among ICU patients as well as to identify the gap in knowledge regarding this issue. This was done by describing, summarizing, clarifying, and evaluating well-selected previous studies about this topic. In addition, this concise review has focused on the prevalence of sleep disturbances in the ICU, factors contributing to poor quality of sleep among ICU patients, and the physiological effects of poor sleep on the patients' prognosis.

Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model.

PubMed

Dodek, Peter M; Wong, Hubert; Jaswal, Danny; Heyland, Daren K; Cook, Deborah J; Rocker, Graeme M; Kutsogiannis, Demetrios J; Dale, Craig; Fowler, Robert; Ayas, Najib T

2012-02-01

The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = -0.46; P = .03), and teamwork across hospital units (r = -0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture. Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs. Copyright © 2012 Elsevier Inc. All rights reserved.

Multicenter Observational Study to Evaluate Epidemiology and Resistance Patterns of Common Intensive Care Unit-infections.

PubMed

Venkataraman, Ramesh; Divatia, Jigeeshu V; Ramakrishnan, Nagarajan; Chawla, Rajesh; Amin, Pravin; Gopal, Palepu; Chaudhry, Dhruva; Zirpe, Kapil; Abraham, Babu

2018-01-01

There is limited data regarding the microbiology of Intensive Care Unit (ICU)-acquired infections, such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and catheter-related bloodstream infections (CRBSI) from India. To explore the microbiology and resistance patterns of ICU-acquired infections and evaluate their outcomes. This was a multicenter observational study, conducted by Indian Society of Critical Care Medicine (MOSER study) between August 2011 and October 2012. Patients in the ICU ≥48 h with any ICU-acquired infection within 14 days of index ICU stay were included. Patient demographics, relevant clinical, and microbiological details were collected. Follow-up until hospital discharge or death was done, and 6-month survival data were collected. Of the 381 patients included in the study, 346 patients had 1 ICU infection and 35 had more than one ICU infection. Among patients with single infections, 223 had VAP with Acinetobacter being the most common isolate. CAUTI was seen in 42 patients with Klebsiella as the most common organism. CRBSI was seen in 81 patients and Klebsiella was the most common causative organism. Multidrug resistance was noted in 87.5% of Acinetobacter, 75.5% of Klebsiella , 61.9% of Escherichia coli , and 58.9% of Pseudomonas isolates, respectively. Staphylococcus constituted only 2.4% of isolates. Mortality rates were 26%, 11.9%, and 34.6% in VAP, CAUTI, and CRBSI, respectively. VAP is the most common infection followed by CRBSI and CAUTI. Multidrug-resistant Gram-negative bacteria are the most common organisms. Staphylococcus aureus is uncommon in the Indian setting.

Frequency of hospital acquired pneumonia and its microbiological etiology in medical intensive care unit.

PubMed

Imran, Muhammad; Amjad, Alina; Haidri, Fakhir Raza

2016-01-01

The objectives were to assess the frequency of hospital acquired pneumonia (HAP) in patients admitted to intensive care unit (ICU) and to determine the frequencies of different etiological organisms in these patients. This was descriptive cross sectional study, which was carried out in medical ICU of Shifa International Hospital Islamabad from January 2013 to January 2014. A total of 1866 patients were admitted in the department of medicine including medical ICU. They were evaluated for HAP and the causative organisms were cultured from these patients. Identification was carried out by standard biochemical profile of the organisms. The total number of patients admitted in medical ICU for any reason were 346. HAP was diagnosed in 88 patients (25.4%). The average age of patients admitted in Medical ICU with HAP was 48 years with the range of 16 to 82 years. 56 were male and 32 females. 42 patients (47.7%) died in medical ICU with HAP. Microbiological analysis showed that Pseudomonas aeruginosa were 27 (30.6%), Acinetobacter spp. were 12 (13.6%), Candida albicans were 12 (13.6%), Klebsiellapneumoniae were 9 (10.2%), Streptococcus spp. were 9 (10.2%), Escherichia coli were 5 (5.6%), Stenotrophomonas spp. were 4(4.5%), Methicillin Resistant Staphylococcus Aureus (MRSA) were 4 (4.5%) others organisms 6 (6.8%). The frequency of HAP in Medical ICU of our hospital is 88 out of 346 (25.4%). The commonest organism identified was Pseudomonas aeruginosa (30.6%) followed by Acinetobacter and Candida albican (13.6% each).

[Development and construction mode of critical care medicine: 22 years of development and construction of intensive care units of Guizhou Medical University].

PubMed

Wang, Difen; Liu, Ying; Fu, Jiangquan; Liu, Yuanyi; Cheng, Yumei; Wang, Ying; Li, Liang; Liu, Ming; Tang, Yan; Shen, Feng; Liu, Xu; Yuan, Jia; Chen, Xianjun; Bi, Hongying; Wang, Hongxia; Li, Wei; Chen, Qimin; Wang, Cui

2017-10-01

To provide decision-making basis for promoting the rapid and healthy development of critical care medicine/intensive care unit (ICU) through discussing the mode of development and construction of the department of ICU. The situations of ICU of Affiliated Hospital of Guizhou Medical University from July 1994 to December 2016 were analyzed and summed up. Data of the situations in different development stages included the location and area of the ward, the number of beds, the number of physicians and nurses, the structure of academic titles and educational levels, the number of patients admitted to ICU per year, the proportion of patients used ventilator per year, the mortality, the mode of the discipline management, the number of medical postgraduates and undergraduates trained in the ICU, the number of teaching hours, the achievements, the number of research projects, the number of published monographs and papers, the number of the multicenter trials that we participated in, the construction of the team, the personal honor, and so on. From 1994 to 2016, the department of ICU had three development stages: the initial development stage of the discipline (from July 1994 to March 2005), the standardization development stage of the discipline (from April 2005 to December 2015), the acceleration development stage of the discipline (from December 2015 to December 2016). The scale of the department expanded from an open unit with 6 beds which was shared with the department of cardiothoracic surgery to 6 enclosed units with 90 beds which were managed independently by the intensivists. The area of the department increased from less than 300 m 2 to more than 7 000 m 2 . There were 46 beds in the mixed ICU, which covered an area of 4 210 m 2 . There was only one physician in 1994 while the number of the physicians increased to 19 in 2016. The number of nurses increased from 4 in 1994 to 69 in 2016. The proportion of highly educated talents significantly increased. Furthermore, from 1994 to 2016, the number of beds increased from 6 to 46; the number of patients admitted to ICU per year increased from 138 to 1 080; and the number of patients used ventilator increased from 24 to 1 057. The mean acute physiology and chronic health evaluation II (APACHE II) score was > 24.0 at admission, while < 12.6 at discharge. From 1997 to 2016, a total of 79 postgraduates had studied in the department, and 390 teaching hours we had undertaken. From 2011 to 2016, a total of 250 undergraduates had studied in the department, and 540 teaching hours we had undertaken. From 1994 to 2016, 8 achievements were obtained, 22 projects were undertook, 4 monographs were published, 6 books were edited that the physicians in the ICU as key editors, 104 papers were published, and 8 national multicenter trials that the physicians in the ICU were as key participants, and multiple team and individual honors were obtained. The construction of ICU hardware is the basis and prerequisite for the development of the discipline and the construction of ICU software is the soul and motivation of the discipline. The operation indexes of clinical medical treatment, teaching and scientific researches reflect the overall operation status of the discipline and the hospital.

Intensive care unit research ethics and trials on unconscious patients.

PubMed

Gillett, G R

2015-05-01

There are widely acknowledged ethical issues in enrolling unconscious patients in research trials, particularly in intensive care unit (ICU) settings. An analysis of those issues shows that, by and large, patients are better served in units where research is actively taking place for several reasons: i) they do not fall prey to therapeutic prejudices without clear evidential support, ii) they get a chance of accessing new and potentially beneficial treatments, iii) a climate of careful monitoring of patients and their clinical progress is necessary for good clinical research and affects the care of all patients and iv) even those not in the treatment arm of a trial of a new intervention must receive best current standard care (according to international evidence-based treatment guidelines). Given that we have discovered a number of 'best practice' regimens of care that do not optimise outcomes in ICU settings, it is of great benefit to all patients (including those participating in research) that we are constantly updating and evaluating what we do. Therefore, the practice of ICU-based clinical research on patients, many of whom cannot give prospective informed consent, ticks all the ethical boxes and ought to be encouraged in our health system. It is very important that the evaluation of protocols for ICU research should not overlook obvious (albeit probabilistic) benefits to patients and the acceptability of responsible clinicians entering patients into well-designed trials, even though the ICU setting does not and cannot conform to typical informed consent procedures and requirements.

The effect of an acidic cleanser versus soap on the skin pH and micro-flora of adult patients: a non-randomised two group crossover study in an intensive care unit.

PubMed

Duncan, Christine N; Riley, Thomas V; Carson, Kerry C; Budgeon, Charley A; Siffleet, Joanne

2013-10-01

To test the effects of two different cleansing regimens on skin surface pH and micro-flora, in adult patients in the intensive care unit (ICU). Forty-three patients were recruited from a 23-bed tertiary medical/surgical ICU. The nineteen patients in Group One were washed using soap for daily hygiene care over a four week period. In Group 2, 24 patients were washing daily using an acidic liquid cleanser (pH 5.5) over a second four week period. Skin pH measurements and bacterial swabs were sampled daily from each for a maximum of ten days or until discharged from the ICU. Skin surface pH and quantitative skin cultures (colony forming units). Skin pH measurements were lower in patients washed with pH 5.5 cleanser than those washed with soap. This was statistically significant for both the forearm (p = 0.0068) and leg (p = 0.0015). The bacterial count was not statistically significantly different between the two groups. Both groups demonstrated that bacterial counts were significantly affected by the length of stay in ICU (p = 0.0032). This study demonstrated that the product used in routine skin care significantly affects the skin pH of ICU patients, but not the bacterial colonisation. Bacterial colonisation of the skin increases with length of stay. Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.

Case mix, outcome and activity for patients with severe acute kidney injury during the first 24 hours after admission to an adult, general critical care unit: application of predictive models from a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

Kolhe, Nitin V; Stevens, Paul E; Crowe, Alex V; Lipkin, Graham W; Harrison, David A

2008-01-01

Introduction This study pools data from the UK Intensive Care National Audit and Research Center (ICNARC) Case Mix Programme (CMP) to evaluate the case mix, outcome and activity for 17,326 patients with severe acute kidney injury (AKI) occurring during the first 24 hours of admission to intensive care units (ICU). Methods Severe AKI admissions (defined as serum creatinine ≥300 μmol/l and/or urea ≥40 mmol/l during the first 24 hours) were extracted from the ICNARC CMP database of 276,326 admissions to UK ICUs from 1995 to 2004. Subgroups of oliguric and nonoliguric AKI were identified by daily urine output. Data on surgical status, survival and length of stay were also collected. Severity of illness scores and mortality prediction models were compared (UK Acute Physiology and Chronic Health Evaluation [APACHE] II, Stuivenberg Hospital Acute Renal Failure [SHARF] T0, SHARF II0 and the Mehta model). Results Severe AKI occurred in 17,326 out of 276,731 admissions (6.3%). The source of admission was nonsurgical in 83.7%. Sepsis was present in 47.3% and AKI was nonoliguric in 63.9% of cases. Admission to ICU with severe AKI accounted for 9.3% of all ICU bed-days. Oliguric AKI was associated with longer length of stay for survivors and shorter length of stay for nonsurvivors compared with nonoliguric AKI. Oliguric AKI was associated with significantly greater ICU and hospital mortality (55.8% and 77.3%, respectively) compared with nonoliguric AKI (33.4% and 49.3%, respectively). Surgery during the 1 week before admission or during the first week in the CMP unit was associated with decreased odds of mortality. UK APACHE II and the Mehta scores under-predicted the number of deaths, whereas SHARF T0 and SHARF II0 over-predicted the number of deaths. Conclusions Severe AKI accounts for over 9% of all bed-days in adult, general ICUs, representing a considerable drain on resources. Although nonoliguric AKI continues to confer a survival benefit, overall survival from AKI in the ICU and survival to leave hospital remains poor. The use of APACHE II score measured during the first 24 hours of ICU stay performs well as compared with SHARF T0, SHARF II0 and the Mehta score, but it lacks perfect calibration. PMID:19105800

Bleeding complications after endovascular therapy of cerebral arteriovenous malformations.

PubMed

Heidenreich, J O; Hartlieb, S; Stendel, R; Pietilä, T A; Schlattmann, P; Wolf, K-J; Schilling, A M

2006-02-01

Intracerebral hemorrhages after embolization of arteriovenous malformations (AVMs) are the most dreaded complications of this well-established therapy. Apart from the known risk factors, our center noticed a high incidence of complications during postinterventional monitoring in medical intensive care units (ICUs) and stroke units. We report 125 consecutive interventions performed on 66 patients by using flow-dependent microcatheters and n-butyl cyanoacrylate as the embolic agent. Postinterventional intensive care monitoring was performed in an interdisciplinary operative ICU, a stroke unit, or a medical ICU. Patients were compared with regard to bleeding complications, AVM morphology, embolization result, postinterventional monitoring, and demographic factors. Intracerebral hemorrhages occurred in 7 patients. Significant differences in outcome were found between 66 patients monitored in the interdisciplinary operative ICU from medical ICU or stroke unit. This was also true when adjusted for age and extent of AVM reduction by using exact logistic regression. A partial AVM reduction of >60% was a considerable risk factor for hemorrhage (odds ratio [OR] = 18.8; 95% confidence interval [CI] [1.341, not available]. Age was also an essential risk factor. An age difference of 10 years leads to an OR of 2.545 (95% CI [1.56, 7.35]). A considerable AVM reduction in one session appears to increase the risk of hemorrhage technically. This suggests a distribution of the interventions in many partial steps.

Crew resource management training in the intensive care unit. A multisite controlled before-after study.

PubMed

Kemper, Peter F; de Bruijne, Martine; van Dyck, Cathy; So, Ralph L; Tangkau, Peter; Wagner, Cordula

2016-08-01

There is a growing awareness today that adverse events in the intensive care unit (ICU) are more often caused by problems related to non-technical skills than by a lack of technical, or clinical, expertise. Team training, such as crew resource management (CRM), aims to improve these non-technical skills. The present study evaluated the effectiveness of CRM in the ICU. Six ICUs participated in a paired controlled trial, with one pretest and two post-test measurements (after 3 and 12 months). Three ICUs received CRM training and were compared with a matched control unit. The 2-day classroom-based training was delivered to multidisciplinary groups (ie, ICU physicians, nurses, managers). All levels of Kirkpatrick's evaluation framework were assessed using a mixed method design, including questionnaires, observations and routinely administered patient outcome data. Level I-reaction: participants were very positive directly after the training. Level II-learning: attitudes towards behaviour aimed at optimising situational awareness were relatively high at baseline and remained stable. Level III-behaviour: self-reported behaviour aimed at optimising situational awareness improved in the intervention group. No changes were found in observed explicit professional oral communication. Level IV-organisation: patient outcomes were unaffected. Error management culture and job satisfaction improved in the intervention group. Patient safety culture improved in both control and intervention units. We can conclude that CRM, as delivered in the present study, does not change behaviour or patient outcomes by itself, yet changes how participants think about errors and risks. This indicates that CRM requires a combination with other initiatives in order to improve clinical outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Acid Sphingomyelinase Serum Activity Predicts Mortality in Intensive Care Unit Patients after Systemic Inflammation: A Prospective Cohort Study

PubMed Central

Reinicke, Maike; Winoto-Morbach, Supandi; Schädler, Dirk; Zick, Günther; Frerichs, Inéz; Weiler, Norbert; Schütze, Stefan

2014-01-01

Introduction Acid sphingomyelinase is involved in lipid signalling pathways and regulation of apoptosis by the generation of ceramide and plays an important role during the host response to infectious stimuli. It thus has the potential to be used as a novel diagnostic marker in the management of critically ill patients. The objective of our study was to evaluate acid sphingomyelinase serum activity (ASM) as a diagnostic and prognostic marker in a mixed intensive care unit population before, during, and after systemic inflammation. Methods 40 patients admitted to the intensive care unit at risk for developing systemic inflammation (defined as systemic inflammatory response syndrome plus a significant procalcitonin [PCT] increase) were included. ASM was analysed on ICU admission, before (PCTbefore), during (PCTpeak) and after (PCTlow) onset of SIRS. Patients undergoing elective surgery served as control (N = 8). Receiver-operating characteristics curves were computed. Results ASM significantly increased after surgery in the eight control patients. Patients from the intensive care unit had significantly higher ASM on admission than control patients after surgery. 19 out of 40 patients admitted to the intensive care unit developed systemic inflammation and 21 did not, with no differences in ASM between these two groups on admission. In patients with SIRS and PCT peak, ASM between admission and PCTbefore was not different, but further increased at PCTpeak in non-survivors and was significantly higher at PCTlow compared to survivors. Survivors exhibited decreased ASM at PCTpeak and PCTlow. Receiver operating curve analysis on discrimination of ICU mortality showed an area under the curve of 0.79 for ASM at PCTlow. Conclusions In summary, ASM was generally higher in patients admitted to the intensive care unit compared to patients undergoing uncomplicated surgery. ASM did not indicate onset of systemic inflammation. In contrast to PCT however, it remained high in non-surviving ICU patients after systemic inflammation. PMID:25384060

Methicillin-resistant Staphylococcus aureus prolongs intensive care unit stay in ventilator-associated pneumonia, despite initially appropriate antibiotic therapy.

PubMed

Shorr, Andrew F; Combes, Alain; Kollef, Marin H; Chastre, Jean

2006-03-01

To determine the impact of methicillin-resistant Staphylococcus aureus (MRSA) on length of stay in the intensive care unit (ICU) for patients with ventilator-associated pneumonia (VAP) and to control for the effect of initially inappropriate antibiotic treatment on outcomes by focusing only on persons who were given appropriate antibiotic therapy for their infection. Retrospective analysis of pooled, patient-level data from multiple clinical trials in VAP. Multiple ICUs in France. Persons with bronchoscopically confirmed VAP due to either MRSA or methicillin-susceptible S. aureus (MSSA) and who received initially appropriate antibiotic treatment. All persons with MRSA VAP received vancomycin (15 mg/kg intravenously, twice daily). None. We compared patients with MRSA VAP to persons with MSSA VAP. ICU length of stay represented the primary end point and ICU-free days served as a secondary end point. We recorded information regarding multiple confounders, including demographics, reasons for ICU admission and mechanical ventilation (MV), severity of illness at both ICU admission and time of diagnosis of VAP, and duration of mechanical ventilation before and following the onset of VAP. The final cohort included 107 patients, and one third of cases were due to MRSA. Despite receiving initially appropriate antibiotic treatment, median ICU length of stay was significantly longer for persons with MRSA infection (33 days vs. 22 days; p=.047). The median number of ICU-free days was concomitantly lower in MRSA VAP (0 days vs. 5 days; p=.011). Survival analysis employing a Cox proportional hazards model identified several predictors of remaining in the ICU: Pao2/Fio2 ratio at diagnosis of VAP, duration of MV before VAP, duration of MV after diagnosis of VAP, and reason for MV. Additionally, infection with MRSA as opposed MSSA doubled the probability of needing continued ICU care (hazard ratio, 2.08; 95% confidence interval, 1.09-3.95; p=.025). MRSA VAP independently prolongs the duration of ICU hospitalization, and in turn, increases overall costs, even for patients initially given appropriate antibiotic treatment. Confronting the adverse impact of MRSA will require efforts that address more than the initial antibiotic prescription.

Characteristics and outcomes of patients reviewed by intensive care unit liaison nurses in Australia: a prospective multicentre study.

PubMed

Green, Anna; Jones, Daryl; McIntyre, Tammie; Taylor, Carmel; Chaboyer, Wendy; Bailey, Michael

2015-12-01

Intensive care unit liaison nurse (ICU LN) services are one strategy to manage deteriorating hospital patients. Studies on the characteristics and outcomes of patients reviewed by ICU LNs have been from single centres and surveys. To conduct a 20-hospital, prospective observational study on the characteristics and outcomes of patients reviewed by Australian ICU LNs over 2 months. All patients screened by ICU LNs over the study period were included. Details included the source of initial review, patient demographics and initial physiological parameters, case load, interventions and patient outcome. Only two hospitals provided a 24-hour, 7-day service, and in 14 hospitals, an ICU LN participated in the rapid response team (RRT). There were 3799 patients screened (54.6% men, mean age 62.9 years [SD, 19.4 years]), of whom 1330 (35%) had no interventions (were screened only). The remaining 2469 patients received interventions; 978 (39.6%) were reviewed once, and 1491 (60.4%) were reviewed multiple times. The three commonest reasons for screening patients were after ICU discharge (1734 [45.6%]), as part of the RRT review (914 [24.1%]), or for a ward patient review meeting with a "worried" criterion (412 [10.8%]). Patients who did not receive interventions were younger, more likely to be surgical patients, less likely to have dementia, less likely to be seen during an RRT review, had more favourable vital signs and were less likely to be discharged to a nursing home or die in hospital. The commonest interventions included ordering a diagnostic test, administration of medication, initiating an interprofessional referral and increasing limitations of therapy. The inhospital mortality was 10.2% overall, and 4.6% in patients who were screened but did not receive any interventions. Several predictors of inhospital mortality were identified. Most ICU LN reviews occur after ICU discharge or in association with an RRT review. The inhospital mortality of ICU LN-reviewed patients is high (about 10%). ICU LNs effectively screen patients and often participate in end-of-life care planning.

Do intensive care data on respiratory infections reflect influenza epidemics?

PubMed

Koetsier, Antonie; van Asten, Liselotte; Dijkstra, Frederika; van der Hoek, Wim; Snijders, Bianca E; van den Wijngaard, Cees C; Boshuizen, Hendriek C; Donker, Gé A; de Lange, Dylan W; de Keizer, Nicolette F; Peek, Niels

2013-01-01

Severe influenza can lead to Intensive Care Unit (ICU) admission. We explored whether ICU data reflect influenza like illness (ILI) activity in the general population, and whether ICU respiratory infections can predict influenza epidemics. We calculated the time lag and correlation between ILI incidence (from ILI sentinel surveillance, based on general practitioners (GP) consultations) and percentages of ICU admissions with a respiratory infection (from the Dutch National Intensive Care Registry) over the years 2003-2011. In addition, ICU data of the first three years was used to build three regression models to predict the start and end of influenza epidemics in the years thereafter, one to three weeks ahead. The predicted start and end of influenza epidemics were compared with observed start and end of such epidemics according to the incidence of ILI. Peaks in respiratory ICU admissions lasted longer than peaks in ILI incidence rates. Increases in ICU admissions occurred on average two days earlier compared to ILI. Predicting influenza epidemics one, two, or three weeks ahead yielded positive predictive values ranging from 0.52 to 0.78, and sensitivities from 0.34 to 0.51. ICU data was associated with ILI activity, with increases in ICU data often occurring earlier and for a longer time period. However, in the Netherlands, predicting influenza epidemics in the general population using ICU data was imprecise, with low positive predictive values and sensitivities.

Serial evaluation of the MODS, SOFA and LOD scores to predict ICU mortality in mixed critically ill patients.

PubMed

Khwannimit, Bodin

2008-09-01

To perform a serial assessment and compare ability in predicting the intensive care unit (ICU) mortality of the multiple organ dysfunction score (MODS), sequential organ failure assessment (SOFA) and logistic organ dysfunction (LOD) score. The data were collected prospectively on consecutive ICU admissions over a 24-month period at a tertiary referral university hospital. The MODS, SOFA, and LOD scores were calculated on initial and repeated every 24 hrs. Two thousand fifty four patients were enrolled in the present study. The maximum and delta-scores of all the organ dysfunction scores correlated with ICU mortality. The maximum score of all models had better ability for predicting ICU mortality than initial or delta score. The areas under the receiver operating characteristic curve (AUC) for maximum scores was 0.892 for the MODS, 0.907 for the SOFA, and 0.92for the LOD. No statistical difference existed between all maximum scores and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Serial assessment of organ dysfunction during the ICU stay is reliable with ICU mortality. The maximum scores is the best discrimination comparable with APACHE II score in predicting ICU mortality.

Saudi Arabian ICU safety culture and nurses' attitudes.

PubMed

Alayed, Abdulrahman S; Lööf, Helena; Johansson, Unn-Britt

2014-01-01

The purpose of this paper is to examine nurses' attitudes towards safety culture in six Saudi Arabian intensive care units (ICUs). The study is descriptive with a cross-sectional design. The Safety Attitude Questionnaire (SAQ)-ICU version was distributed and 216 completed questionnaires were returned. The findings provide a basis for further research on Saudi Arabian ICU safety culture. This study showed that the SAQ-ICU can be used to measure safety climate to identify areas for improvement according to nurse attitudes and perceptions. Findings indicate that ICU safety culture is an important issue that hospital managers should prioritise. The SAQ-ICU questionnaire, used to measure safety climate in Saudi Arabian ICUs, identifies service strengths and improvement areas according to attitudes and perceptions. To the knowledge, this is the first study to use SAQ to examine nurses' safety culture attitudes in Saudi Arabian ICUs. The present findings provide a baseline and further details about Saudi Arabian ICU safety. Study participants represented nine nationalities, indicating the nursing workforce's diversity, which is expected to continue in the future. Such a nursing cultural heterogeneity calls for further studies to examine and evaluate attitudes and values to improve ICU safety culture.

Increased Incidence of Critical Illness in Psoriasis.

PubMed

Marrie, Ruth Ann; Bernstein, Charles N; Peschken, Christine A; Hitchon, Carol A; Chen, Hui; Garland, Allan

Psoriasis is associated with an increased risk of comorbid disease. Despite the recognition of increased morbidity in psoriasis, the effects on health care utilisation remain incompletely understood. Little is known about the risk of intensive care unit (ICU) admission in persons with psoriasis. To compare the incidence of ICU admission and post-ICU mortality rates in a psoriasis population compared with a matched population without psoriasis. Using population-based administrative data from Manitoba, Canada, we identified 40 930 prevalent cases of psoriasis and an age-, sex-, and geographically matched cohort from the general population (n = 150 210). We compared the incidence of ICU admission between populations using incidence rates and Cox regression models adjusted for age, sex, socioeconomic status, and comorbidity and compared mortality after ICU admission. Among incident psoriasis cases (n = 30 150), the cumulative 10-year incidence of ICU admission was 5.6% (95% confidence interval [CI], 5.3%-5.8%), 21% higher than in the matched cohort (incidence rate ratio, 1.21; 95% CI, 1.15-1.27). In the prevalent psoriasis cohort, crude mortality in the ICU was 11.5% (95% CI, 9.9%-13.0%), 32% higher than observed in the matched population admitted to the ICU (8.7%; 95% CI, 8.3%-9.1%). Mortality rates after ICU admission remained elevated at all time points in the psoriasis cohort compared with the matched cohort. Psoriasis is associated with an increased risk for ICU admission and with an increased risk of mortality post-ICU admission.

Impact of hospital care on incidence of bloodstream infection: the evaluation of processes and indicators in infection control study.

PubMed Central

Kritchevsky, S. B.; Braun, B. I.; Wong, E. S.; Solomon, S. L.; Steele, L.; Richards, C.; Simmons, B. P.

2001-01-01

The Evaluation of Processes and Indicators in Infection Control (EPIC) study assesses the relationship between hospital care and rates of central venous catheter-associated primary bacteremia in 54 intensive-care units (ICUs) in the United States and 14 other countries. Using ICU rather than the patient as the primary unit of statistical analysis permits evaluation of factors that vary at the ICU level. The design of EPIC can serve as a template for studies investigating the relationship between process and event rates across health-care institutions. PMID:11294704

A step ahead: strategies for excellence in critical care nursing practice.

PubMed

Albano, Amy; Elliott, Sheila; Lusardi, Paula; Scott, Susan; Thomas, Diane

2005-06-01

The adult intensive care unit (ICU) at Baystate Medical Center is a 24-bed medical-surgical-trauma ICU that provides high-quality care to critically ill patients. Collaboration and expertise among the nursing staff, intensivists, and interdisciplinary colleagues have contributed to its development into a Beacon Award-winning unit. Its primary goal is reflected in the unit's mission: "Care for our patients is guided by knowledge, motivated by compassion, and performed in collaboration with others." Common interests, values, and purposes have created an environment of communication that supports the delivery of exceptional critical care to patients and their families.

Questionnaire survey on the use of a novel artificial pancreas by intensive care unit nurses.

PubMed

Mibu, Kiyo; Yatabe, Tomoaki; Yamasaki, Fumiyasu; Kitagawa, Hiroyuki; Munekage, Masaya; Namikawa, Tsutomu; Hanazaki, Kazuhiro

2015-06-01

The introduction of a color liquid-crystal display (LCD) on a novel artificial pancreas (STG-55, Nikkiso Co. Ltd. Tokyo, Japan) allowed nurses to more easily monitor changes in patients' blood glucose levels, compared to the previous model (STG-22). This study was conducted to examine the hypothesis that the STG-55 provided nurses with a feeling of security due to the introduction of the LCD screen. A questionnaire survey was conducted 6 months after the STG-55 was introduced (Survey 2012), among intensive care unit (ICU) nurses who had used both the STG-22 and the STG-55 for patient glycemic control. The results were then compared with the results from a questionnaire survey that was conducted after the STG-22 was introduced (Survey 2006). All ICU nurses (n = 19) responded to Survey 2012, and 95% of these nurses had responded to Survey 2006 (n = 19). After the introduction of the STG-22, 11 nurses (58%) reported becoming conscious of anxiety regarding hypoglycemia when they performed conventional glucose control with the sliding scale method. This anxiety awareness increased significantly (19 nurses, 100%; p < 0.01) after the STG-55 was introduced. However, there were no significant differences in the proportion of respondents who requested improvements in the blood withdrawal process. In conclusion, the results of our survey indicate that all ICU nurses became conscious of anxiety regarding the risk of hypoglycemia when using the conventional sliding scale method after the introduction of the STG-55. However, the respondents were not satisfied with the STG-55, due to difficulties encountered during blood withdrawal.

Physical and Visual Accessibilities in Intensive Care Units: A Comparative Study of Open-Plan and Racetrack Units.

PubMed

Rashid, Mahbub; Khan, Nayma; Jones, Belinda

2016-01-01

This study compared physical and visual accessibilities and their associations with staff perception and interaction behaviors in 2 intensive care units (ICUs) with open-plan and racetrack layouts. For the study, physical and visual accessibilities were measured using the spatial analysis techniques of Space Syntax. Data on staff perception were collected from 81 clinicians using a questionnaire survey. The locations of 2233 interactions, and the location and length of another 339 interactions in these units were collected using systematic field observation techniques. According to the study, physical and visual accessibilities were different in the 2 ICUs, and clinicians' primary workspaces were physically and visually more accessible in the open-plan ICU. Physical and visual accessibilities affected how well clinicians' knew their peers and where their peers were located in these units. Physical and visual accessibilities also affected clinicians' perception of interaction and communication and of teamwork and collaboration in these units. Additionally, physical and visual accessibilities showed significant positive associations with interaction behaviors in these units, with the open-plan ICU showing stronger associations. However, physical accessibilities were less important than visual accessibilities in relation to interaction behaviors in these ICUs. The implications of these findings for ICU design are discussed.

A software communication tool for the tele-ICU.

PubMed

Pimintel, Denise M; Wei, Shang Heng; Odor, Alberto

2013-01-01

The Tele Intensive Care Unit (tele-ICU) supports a high volume, high acuity population of patients. There is a high-volume of incoming and outgoing calls, especially during the evening and night hours, through the tele-ICU hubs. The tele-ICU clinicians must be able to communicate effectively to team members in order to support the care of complex and critically ill patients while supporting and maintaining a standard to improve time to intervention. This study describes a software communication tool that will improve the time to intervention, over the paper-driven communication format presently used in the tele-ICU. The software provides a multi-relational database of message instances to mine information for evaluation and quality improvement for all entities that touch the tele-ICU. The software design incorporates years of critical care and software design experience combined with new skills acquired in an applied Health Informatics program. This software tool will function in the tele-ICU environment and perform as a front-end application that gathers, routes, and displays internal communication messages for intervention by priority and provider.

Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews

PubMed Central

Connolly, Bronwen; O'Neill, Brenda; Salisbury, Lisa; Blackwood, Bronagh

2016-01-01

Background Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery. Methods Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence. Results Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge. Conclusions Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for design of future interventional trials and SR. Trial registration number CRD42015001068. PMID:27220357

Efficient and sparse feature selection for biomedical text classification via the elastic net: Application to ICU risk stratification from nursing notes.

PubMed

Marafino, Ben J; Boscardin, W John; Dudley, R Adams

2015-04-01

Sparsity is often a desirable property of statistical models, and various feature selection methods exist so as to yield sparser and interpretable models. However, their application to biomedical text classification, particularly to mortality risk stratification among intensive care unit (ICU) patients, has not been thoroughly studied. To develop and characterize sparse classifiers based on the free text of nursing notes in order to predict ICU mortality risk and to discover text features most strongly associated with mortality. We selected nursing notes from the first 24h of ICU admission for 25,826 adult ICU patients from the MIMIC-II database. We then developed a pair of stochastic gradient descent-based classifiers with elastic-net regularization. We also studied the performance-sparsity tradeoffs of both classifiers as their regularization parameters were varied. The best-performing classifier achieved a 10-fold cross-validated AUC of 0.897 under the log loss function and full L2 regularization, while full L1 regularization used just 0.00025% of candidate input features and resulted in an AUC of 0.889. Using the log loss (range of AUCs 0.889-0.897) yielded better performance compared to the hinge loss (0.850-0.876), but the latter yielded even sparser models. Most features selected by both classifiers appear clinically relevant and correspond to predictors already present in existing ICU mortality models. The sparser classifiers were also able to discover a number of informative - albeit nonclinical - features. The elastic-net-regularized classifiers perform reasonably well and are capable of reducing the number of features required by over a thousandfold, with only a modest impact on performance. Copyright © 2015 Elsevier Inc. All rights reserved.

Redesigning the ICU nursing discharge process: a quality improvement study.

PubMed

Chaboyer, Wendy; Lin, Frances; Foster, Michelle; Retallick, Lorraine; Panuwatwanich, Kriengsak; Richards, Brent

2012-02-01

To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality, and ICU readmission within 72 hours. A quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, and designing a daily ICU discharge alert sheet that included an expected date of discharge. A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention). Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed the new process into practice. ©2011 Sigma Theta Tau International.

Emergency Manuals Improved Novice Physician Performance During Simulated ICU Emergencies

PubMed Central

Wang, Jacob; Stiegler, Marjorie P.; Nguyen, Dung; Rebel, Annette; Isaak, Robert S.

2017-01-01

Background Emergency manuals, which are safety essentials in non-medical high-reliability organizations (e.g., aviation), have recently gained acceptance in critical medical environments. Of the existing emergency manuals in anesthesiology, most are geared towards intraoperative settings. Additionally, most evidence supporting their efficacy focuses on the study of physicians with at least some meaningful experience as a physician. Our aim was to evaluate whether an emergency manual would improve the performance of novice physicians (post-graduate year [PGY] 1 or first year resident) in managing a critical event in the intensive care unit (ICU). Methods PGY1 interns (n=41) were assessed on the management of a simulated critical event (unstable bradycardia) in the ICU. Participants underwent a group allocation process to either a control group (n=18) or an intervention group (emergency manual provided, n=23). The number of successfully executed treatment and diagnostic interventions completed was evaluated over a ten minute (600 seconds) simulation for each participant. Results The participants using the emergency manual averaged 9.9/12 (83%) interventions, compared to an average of 7.1/12 (59%) interventions (p < 0.01) in the control group. Conclusions The use of an emergency manual was associated with a significant improvement in critical event management by individual novice physicians in a simulated ICU patient (23% average increase). PMID:29600255

Correlation between workplace and occupational burnout syndrome in nurses

PubMed Central

Ahmadi, Omid; Azizkhani, Reza; Basravi, Monem

2014-01-01

Background: This study was conducted to determine the effect of nurses’ workplace on burnout syndrome among nurses working in Isfahan's Alzahra Hospital as a reference and typical university affiliated hospital, in 2010. Materials and Methods: In this cross-sectional study, 100 nurses were randomly selected among those working in emergency, orthopedic, dialysis wards and intensive care unit (ICU). Required data on determination of occupational burnout rate among the nurses of these wards were collected using Maslach Burnout Inventory (MBI) standard and validated questionnaire. Nurses were selected using simple random sampling. Results: The multivariate ANOVA analysis showed that occupational burnout mean values of nurses working in orthopedic and dialysis wards were significantly less than those of nurses working in emergency ward and ICU (P = 0.01). There was also no significant difference between occupational burnout mean values of nurses working in emergency ward and ICU (P > 0.05). t-test showed that there was a difference between occupational burnout values of men and women, as these values for women were higher than those of men (P = 0.001). Conclusion: Results showed that occupational burnout mean values of nurses working in emergency ward and ICU were significantly more than those of nurses working in orthopedic and dialysis wards. PMID:24627852

Molecular characterisation and control of Acinetobacter baumannii isolates resistant to multi-drugs emerging in inter-intensive care units.

PubMed

Ertürk, Ayşe; Çiçek, Ayşegül Çopur; Gümüş, Aziz; Cüre, Erkan; Şen, Ahmet; Kurt, Aysel; Karagöz, Alper; Aydoğan, Nebahat; Sandallı, Cemal; Durmaz, Rıza

2014-07-22

A nosocomial outbreak of Acinetobacter baumannii (AB) infections occurred among intensive care units (ICU) (surgery, medical, cardiovascular surgery, coronary unit) of Recep Tayyip Erdogan University Medical School (Rize, Turkey) between January 2011 and May 2012. The identification of isolates and clonal relation among them were investigated by molecular techniques. A total of 109 AB isolates were obtained from 64 clinical materials from 54 ICU patients and 3 from the hands of healthcare workers (HCWs) of 42 environmental samples. The isolates were identified by 16S rDNA sequencing and OXA- specific PCR. The clonal relation between isolates was investigated by PFGE methods using ApaI restriction enzyme. All isolates were determined as AB by 16S rDNA sequencing and OXA-spesific PCR. While the blaOXA-51-like gene was amplified in all isolates, the blaOXA-23-like gene was amplified from 103 isolates. The PFGE pattern generated 9 pulsotypes and showed that the isolates from patients, HCWs, and the environment were genetically related. In 7 of these pulsotypes, there were 107 strains (98%) showing similar PFGE profiles that cannot be distinguished from each other, ranging from 2 to 53. The remaining 2 pulsotypes were comprised of strains closely associated with the main cluster. Two major groups were discovered with similarity coefficient of 85% and above. The first group consisted of 97 strains that are similar to each other at 92.7% rate, and the second group consisted of 12 strains that are 100% identical. The common utilization of the blood gas device among ICU was the reason for the contamination. AB strains can remain stable for a long period of time, although due to the disinfection procedures applied in hospitals, there is a small chance that the same clone might reappear and cause another epidemic. For that reason, the resistance profiles of the strains must be continuously followed with amplification-based methods, and these methods should be used to support the PFGE method in the short term.

Description of inpatient medication management using cognitive work analysis.

PubMed

Pingenot, Alleene Anne; Shanteau, James; Sengstacke, L T C Daniel N

2009-01-01

The purpose of this article was to describe key elements of an inpatient medication system using the cognitive work analysis method of Rasmussen et al (Cognitive Systems Engineering. Wiley Series in Systems Engineering; 1994). The work of nurses and physicians were observed in routine care of inpatients on a medical-surgical unit and attached ICU. Interaction with pharmacists was included. Preoperative, postoperative, and medical care was observed. Personnel were interviewed to obtain information not easily observable during routine work. Communication between healthcare workers was projected onto an abstraction/decomposition hierarchy. Decision ladders and information flow charts were developed. Results suggest that decision making on an inpatient medical/surgical unit or ICU setting is a parallel, distributed process. Personnel are highly mobile and often are working on multiple issues concurrently. In this setting, communication is key to maintaining organization and synchronization for effective care. Implications for research approaches to system and interface designs and decision support for personnel involved in the process are discussed.

Sleep Deprivation in Critical Illness: Its Role in Physical and Psychological Recovery

PubMed Central

Kamdar, Biren B.; Needham, Dale M.; Collop, Nancy A.

2012-01-01

Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity of time spent in restorative sleep stages. Factors that are associated with sleep disruption in the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient care interactions, and environmental noise and light. As the field of critical care increasingly focuses on patients' physical and psychological outcomes following critical illness, understanding the potential contribution of ICU-related sleep disruption on patient recovery is an important area of investigation. This review article summarizes the literature regarding sleep architecture and measurement in the critically ill, causes of ICU sleep fragmentation, and potential implications of ICU-related sleep disruption on patients' recovery from critical illness. With this background information, strategies to optimize sleep in the ICU are also discussed. PMID:21220271

How to develop a tele-ICU model?

PubMed

Rogove, Herb

2012-01-01

The concept of the tele-ICU (intensive care unit) is about 30 years old and more hospitals are utilizing it to cover multiple hospitals in their system or for hospitals that lack on-site critical care coverage such as in the rural setting. Doing a needs analysis, picking the appropriate committee to oversee development of the correct model, choosing quality metrics to measure, and designing an implementation plan that has a timeline is how the process should begin. Research including visitation to established programs and connecting with professional societies are helpful. Developing both a business and financial plan will optimize the value of a tele-ICU program. The innovative ICU nursing director will help to integrate a telemedicine program seamlessly with the on-site program to insure a successful program that benefits patients, their families, the ICU staff, and the hospital.

Sedation in the neurologic intensive care unit.

PubMed

Keegan, Mark T

2008-03-01

Providing adequate sedation in the neurologic intensive care unit (ICU) depends on determination of proper goals for sedation, adequate assessment of the level of sedation, and appropriate choice of drug based on the patient's physiology. The management of sedation in the ICU will influence long-term outcome. Delirium, anxiety, and pain must be identified and treated separately. The use of protocols can improve compliance with published evidence-based recommendations. Propofol and dexmedetomidine may be used for rapidly titratable sedation, benzodiazepines for anxiolysis, neuroleptics for treatment of delirium, and opiates for analgesia. Unique aspects of patients with acute brain disease, such as elevated intracranial pressure or status epilepticus, require adaptation of sedative regimens. Processed EEG monitoring and volatile anesthetic agents have not yet proven beneficial or practical for use in the ICU.

The boot software of the control unit of the near infrared spectrograph of the Euclid space mission: technical specification

NASA Astrophysics Data System (ADS)

Gómez-Sáenz-de-Tejada, Jaime; Toledo-Moreo, Rafael; Colodro-Conde, Carlos; Pérez-Lizán, David; Fernández-Conde, Jesús; Sánchez-Prieto, Sebastián.

2016-07-01

The Near Infrared Spectrograph and Photometer (NISP) is one of the instruments on board the ESA EUCLID mission. The Boot Software (BSW) is in charge of initialization and communications after a reset occurs at hard- ware level. The Universidad Politecnica de Cartagena and Instituto de Astrofisica de Canarias are responsible of the Instrument Control Unit of the NISP (NI-ICU) in the Euclid Consortium. The NI-ICU BSW is developed by Universidad de Alcaĺa, and its main functions are: communication with the S/C for memory management, self-tests and start of a patchable Application Software (ASW). This paper presents the NI-ICU BSW status of definition and design at the end of the Technical Specification phase.

Daily bathing with octenidine on an intensive care unit is associated with a lower carriage rate of meticillin-resistant Staphylococcus aureus.

PubMed

Spencer, C; Orr, D; Hallam, S; Tillmanns, E

2013-02-01

Routine daily bathing of intensive care (ICU) patients with topical chlorhexidine reduces meticillin-resistant Staphylococcus aureus (MRSA) acquisition. The aim of this study was to investigate whether repeated five-day cycles of daily topical octenidine could result in a similar effect. This was a two-year retrospective, uncontrolled study in a mixed medical and surgical ICU/high dependency unit, demonstrating a 76% reduction in MRSA acquisition but no significant reduction in all ICU-acquired bacteraemias. Chlorhexidine use is increasing but resistance is being reported. This pilot study found a similar reduction in MRSA acquisition with octenidine as an alternative to chlorhexidine. Further study is required to establish causality. Copyright © 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Perme Intensive Care Unit Mobility Score and ICU Mobility Scale: translation into Portuguese and cross-cultural adaptation for use in Brazil

PubMed Central

Kawaguchi, Yurika Maria Fogaça; Nawa, Ricardo Kenji; Figueiredo, Thais Borgheti; Martins, Lourdes; Pires-Neto, Ruy Camargo

2016-01-01

ABSTRACT Objective: To translate the Perme Intensive Care Unit Mobility Score and the ICU Mobility Scale (IMS) into Portuguese, creating versions that are cross-culturally adapted for use in Brazil, and to determine the interobserver agreement and reliability for both versions. Methods: The processes of translation and cross-cultural validation consisted in the following: preparation, translation, reconciliation, synthesis, back-translation, review, approval, and pre-test. The Portuguese-language versions of both instruments were then used by two researchers to evaluate critically ill ICU patients. Weighted kappa statistics and Bland-Altman plots were used in order to verify interobserver agreement for the two instruments. In each of the domains of the instruments, interobserver reliability was evaluated with Cronbach's alpha coefficient. The correlation between the instruments was assessed by Spearman's correlation test. Results: The study sample comprised 103 patients-56 (54%) of whom were male-with a mean age of 52 ± 18 years. The main reason for ICU admission (in 44%) was respiratory failure. Both instruments showed excellent interobserver agreement (κ > 0.90) and reliability (α > 0.90) in all domains. Interobserver bias was low for the IMS and the Perme Score (−0.048 ± 0.350 and −0.06 ± 0.73, respectively). The 95% CIs for the same instruments ranged from −0.73 to 0.64 and −1.50 to 1.36, respectively. There was also a strong positive correlation between the two instruments (r = 0.941; p < 0.001). Conclusions: In their versions adapted for use in Brazil, both instruments showed high interobserver agreement and reliability. PMID:28117473

Impact of active screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization on MRSA infections, mortality and medical cost: a quasi-experimental study in surgical intensive care unit.

PubMed

Lee, Yuarn-Jang; Chen, Jen-Zon; Lin, Hsiu-Chen; Liu, Hsin-Yi; Lin, Shyr-Yi; Lin, Hsien-Ho; Fang, Chi-Tai; Hsueh, Po-Ren

2015-04-08

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading pathogen of healthcare-associated infections in intensive care units (ICUs). Prior studies have shown that decolonization of MRSA carriers is an effective method to reduce MRSA infections in ICU patients. However, there is currently a lack of data on its effect on mortality and medical cost. Using a quasi-experimental, interrupted time-series design with re-introduction of intervention, we evaluated the impact of active screening and decolonization on MRSA infections, mortality and medical costs in the surgical ICU of a university hospital in Taiwan. Regression models were used to adjust for effects of confounding variables. MRSA infection rate decreased from 3.58 (baseline) to 0.42‰ (intervention period) (P <0.05), re-surged to 2.21‰ (interruption period) and decreased to 0.18‰ (re-introduction of intervention period) (P <0.05). Patients admitted to the surgical ICU during the intervention periods had a lower in-hospital mortality (13.5% (155 out of 1,147) versus 16.6% (203 out of 1,226), P = 0.038). After adjusting for effects of confounding variables, the active screening and decolonization program was independently associated with a decrease in in-hospital MRSA infections (adjusted odds ratio: 0.3; 95% CI: 0.1 to 0.8) and 90-day mortality (adjusted hazard ratio: 0.8; 95% CI: 0.7 to 0.99). Cost analysis showed that $22 medical costs can be saved for every $1 spent on the intervention. Active screening for MRSA and decolonization in ICU settings is associated with a decrease in MRSA infections, mortality and medical cost.

Developing a Simulation to Study Conflict in Intensive Care Units

PubMed Central

Chiarchiaro, Jared; Schuster, Rachel A.; Ernecoff, Natalie C.; Barnato, Amber E.; Arnold, Robert M.

2015-01-01

Rationale: Although medical simulation is increasingly being used in healthcare education, there are few examples of how to rigorously design a simulation to evaluate and study important communication skills of intensive care unit (ICU) clinicians. Objectives: To use existing best practice recommendations to develop a medical simulation to study conflict management in ICUs, then assess the feasibility, acceptability, and realism of the simulation among ICU clinicians. Methods: The setting was a medical ICU of a tertiary care, university hospital. Participants were 36 physicians who treat critically ill patients: intensivists, palliative medicine specialists, and trainees. Using best-practice guidelines and an iterative, multidisciplinary approach, we developed and refined a simulation involving a critically ill patient, in which the patient had a clear advance directive specifying no use of life support, and a surrogate who was unwilling to follow the patient’s preferences. ICU clinicians participated in the simulation and completed surveys and semistructured interviews to assess the feasibility, acceptability, and realism of the simulation. Measurements and Main Results: All participants successfully completed the simulation, and all perceived conflict with the surrogate (mean conflict score, 4.2 on a 0–10 scale [SD, 2.5; range, 1–10]). Participants reported high realism of the simulation across a range of criteria, with mean ratings of greater than 8 on a 0 to 10 scale for all domains assessed. During semistructured interviews, participants confirmed a high degree of realism and offered several suggestions for improvements. Conclusions: We used existing best practice recommendations to develop a simulation model to study physician–family conflict in ICUs that is feasible, acceptable, and realistic. PMID:25643166

Technology that achieves the Triple Aim: an economic analysis of the BrainPath™ approach in neurosurgery

PubMed Central

Norton, Sidney P; Dickerson, Evan M; Kulwin, Charles G; Shah, Mitesh V

2017-01-01

Background The Triple Aim is defined as: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. The purpose of this analysis was to evaluate the economic value of a new neurosurgical technique, the BrainPath™ approach, for use in patients with subcortical tumors and intracerebral hemorrhage (ICH). Methods Inpatient length of stay (LOS) data were collected for ICH and brain tumor surgical patient cases between August 2013 and November 2015. Patient cases were separated into two groups; BrainPath approach (n = 28) and conventional techniques, such as craniotomy, (n = 208). The average intensive care unit (ICU) LOS was calculated for each group by diagnosis-related group and compared between groups. Results The new surgical technology resulted in surgical intervention in 14 ICH cases which otherwise would have been medically managed due to the hemorrhage location or size of the ICH. A reduction in ICU LOS was seen in this group. Based on the variable direct cost per day in the neuro critical care unit at this academic medical center, 14 patient cases incurred ~ US$210,000 less in direct ICU costs. Surgical resection was possible in two tumor patient cases which would have been biopsied, rather than surgically resected, also due to location of the abnormalities. A total net value of > US$329,000 is attributable to the analyzed approach over a 28-month period. Conclusion This analysis shows positive economic value for the new technology group when ICU LOS and reimbursement are considered against equipment costs, thus achieving Triple Aim objectives. PMID:28894384

Defining the Role of the Environment in the Emergence and Persistence of vanA Vancomycin-Resistant Enterococcus (VRE) in an Intensive Care Unit: A Molecular Epidemiological Study.

PubMed

Lee, Andie S; White, Elizabeth; Monahan, Leigh G; Jensen, Slade O; Chan, Raymond; van Hal, Sebastiaan J

2018-06-01

OBJECTIVETo describe the transmission dynamics of the emergence and persistence of vanA vancomycin-resistant enterococcus (VRE) in an intensive care unit (ICU) using whole-genome sequencing of patient and environmental isolates.DESIGNRetrospective cohort study.SETTINGICU in a tertiary referral center.PARTICIPANTSPatients admitted to the ICU over an 11-month period.METHODS VanA VRE isolated from patients (n=31) were sequenced using the Illumina MiSeq platform. Environmental samples from bed spaces, equipment, and waste rooms were collected. All vanA VRE-positive environmental samples (n=14) were also sequenced. Data were collected regarding patient ward and bed movements.RESULTSThe 31 patient vanA VRE isolates were from screening (n=19), urine (n=4), bloodstream (n=3), skin/wound (n=3), and intra-abdominal (n=2) sources. The phylogeny from sequencing data confirmed several VRE clusters, with 1 group accounting for 38 of 45 isolates (84%). Within this cluster, cross-transmission was extensive and complex across the ICU. Directionality indicated that colonized patients contaminated environmental sites. Similarly, environmental sources not only led to patient colonization but also to infection. Notably, shared equipment acted as a conduit for transmission between different ICU areas. Infected patients, however, were not linked to further VRE transmission.CONCLUSIONSGenomic sequencing confirmed a predominantly clonal outbreak of VRE with complex transmission dynamics. The environmental reservoir, particularly from shared equipment, played a key role in ongoing VRE spread. This study provides evidence to support the use of multifaceted strategies, with an emphasis on measures to reduce bacterial burden in the environment, for successful VRE control.Infect Control Hosp Epidemiol 2018;39:668-675.

Preoperative prediction of intensive care unit stay following cardiac surgery.

PubMed

De Cocker, Jeroen; Messaoudi, Nouredin; Stockman, Bernard A; Bossaert, Leo L; Rodrigus, Inez E R

2011-01-01

Following cardiac surgery, a great variety in intensive care unit (ICU) stay is observed, making it often difficult to adequately predict ICU stay preoperatively. Therefore, a study was conducted to investigate, which preoperative variables are independent risk factors for a prolonged ICU stay and whether a patient's risk of experiencing an extended ICU stay can be estimated from these predictors. The records of 1566 consecutive adult patients who underwent cardiac surgery at our institution were analysed retrospectively over a 2-year period. Procedures included in the analyses were coronary artery bypass grafting, valve replacement or repair, ascending and aortic arch surgery, ventricular rupture and aneurysm repair, septal myectomy and cardiac tumour surgery. For this patient group, ICU stay was registered and 57 preoperative variables were collected for analysis. Descriptives and log-rank tests were calculated and Kaplan-Meier curves drawn for all variables. Significant predictors in the univariate analyses were included in a Cox proportional hazards model. The definitive model was validated on an independent sample of 395 consecutive adult patients who underwent cardiac surgery at our institution over an additional 6-month period. In this patient group, the accuracy and discriminative abilities of the model were evaluated. Twelve independent preoperative predictors of prolonged ICU stay were identified: age at surgery>75 years, female gender, dyspnoea status>New York Heart Association class II (NYHA II), unstable symptoms, impaired kidney function (estimated glomerular filtration rate (eGFR)<60 ml min(-1)), extracardiac arterial disease, presence of arrhythmias, mitral insufficiency>colour flow mapping (CFM) grade II, inotropic support, intra-aortic balloon pumping (IABP), non-elective procedures and aortic surgery. The individual effect of every predictor on ICU stay was quantified and inserted into a mathematical algorithm (called the Morbidity Defining Cardiosurgical (MDC) index), making it possible to calculate a patient's risk of having an extended ICU stay. The model showed very good calibration and very good to excellent discriminative ability in predicting ICU stay >2, >5 and >7 days (C-statistic of 0.78; 0.82 and 0.85, respectively). Twelve independent preoperative risk factors for a prolonged ICU stay following cardiac surgery were identified and constructed into a proportional hazards model. Using this risk model, one can predict whether a patient will have a prolonged ICU stay or not. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Surveillance for vancomycin-resistant enterococci: type, rates, costs, and implications.

PubMed

Shadel, Brooke N; Puzniak, Laura A; Gillespie, Kathleen N; Lawrence, Steven J; Kollef, Marin; Mundy, Linda M

2006-10-01

To evaluate 2 active surveillance strategies for detection of enteric vancomycin-resistant enterococci (VRE) in an intensive care unit (ICU). Thirty-month prospective observational study. ICU at a university-affiliated referral center. All patients with an ICU stay of 24 hours or more were eligible for the study. Clinical active surveillance (CAS), involving culture of a rectal swab specimen for detection of VRE, was performed on admission, weekly while the patient was in the ICU, and at discharge. Laboratory-based active surveillance (LAS), involving culture of a stool specimen for detection of VRE, was performed on stool samples submitted for Clostridium difficile toxin detection. Enteric colonization with VRE was detected in 309 (17%) of 1,872 patients. The CAS method initially detected 280 (91%) of the 309 patients colonized with VRE, compared with 25 patients (8%) detected by LAS; colonization in 4 patients (1%) was initially detected by analysis of other clinical specimens. Most patients with colonization (76%) would have gone undetected by LAS alone, whereas use of the CAS method exclusively would have missed only 3 patients (1%) who were colonized. CAS cost Dollars 1,913 per month, or Dollars 57,395 for the 30-month study period. Cost savings of CAS from preventing cases of VRE colonization and bacteremia were estimated to range from Dollars 56,258 to Dollars 303,334 per month. A patient-based CAS strategy for detection of enteric colonization with VRE was superior to LAS. In this high-risk setting, CAS appeared to be the most efficient and cost-effective surveillance method. The modest costs of CAS were offset by the averted costs associated with the prevention of VRE colonization and bacteremia.

Detecting organisational innovations leading to improved ICU outcomes: a protocol for a double-blinded national positive deviance study of critical care delivery

PubMed Central

Jopling, Jeffrey K; Scott, Jennifer Yang; Ramsey, Meghan; Vranas, Kelly; Wagner, Todd H; Milstein, Arnold

2017-01-01

Introduction There is substantial variability in intensive care unit (ICU) utilisation and quality of care. However, the factors that drive this variation are poorly understood. This study uses a novel adaptation of positive deviance approach—a methodology used in public health that assumes solutions to challenges already exist within the system to detect innovations that are likely to improve intensive care. Methods and analysis We used the Philips eICU Research Institute database, containing 3.3 million patient records from over 50 health systems across the USA. Acute Physiology and Chronic Health Evaluation IVa scores were used to identify the study cohort, which included ICU patients whose outcomes were felt to be most sensitive to organisational innovations. The primary outcomes included mortality and length of stay. Outcome measurements were directly standardised, and bootstrapped CIs were calculated with adjustment for false discovery rate. Using purposive sampling, we then generated a blinded list of five positive outliers and five negative comparators. Using rapid qualitative inquiry (RQI), blinded interdisciplinary site visit teams will conduct interviews and observations using a team ethnography approach. After data collection is completed, the data will be unblinded and analysed using a cross-case method to identify themes, patterns and innovations using a constant comparative grounded theory approach. This process detects the innovations in intensive care and supports an evaluation of how positive deviance and RQI methods can be adapted to healthcare. Ethics and dissemination The study protocol was approved by the Stanford University Institutional Review Board (reference: 39509). We plan on publishing study findings and methodological guidance in peer-reviewed academic journals, white papers and presentations at conferences. PMID:28615274

Do sedation and analgesia contribute to long-term cognitive dysfunction in critical care survivors?

PubMed

Fernandez-Gonzalo, S; Turon, M; De Haro, C; López-Aguilar, J; Jodar, M; Blanch, L

2018-03-01

Deep sedation during stay in the Intensive Care Unit (ICU) may have deleterious effects upon the clinical and cognitive outcomes of critically ill patients undergoing mechanical ventilation. Over the last decade a vast body of literature has been generated regarding different sedation strategies, with the aim of reducing the levels of sedation in critically ill patients. There has also been a growing interest in acute brain dysfunction, or delirium, in the ICU. However, the effect of sedation during ICU stay upon long-term cognitive deficits in ICU survivors remains unclear. Strategies for reducing sedation levels in the ICU do not seem to be associated with worse cognitive and psychological status among ICU survivors. Sedation strategy and management efforts therefore should seek to secure the best possible state in the mechanically ventilated patient and lower the prevalence of delirium, in order to prevent long-term cognitive alterations. Copyright © 2017 Elsevier España, S.L.U. y SEMNIM. All rights reserved.

Post-Traumatic Stress Symptoms in Post-ICU Family Members: Review and Methodological Challenges.

PubMed

Petrinec, Amy B; Daly, Barbara J

2016-01-01

Family members of intensive care unit (ICU) patients are at risk for symptoms of post-traumatic stress disorder (PTSD) following ICU discharge. The aim of this systematic review is to examine the current literature regarding post-ICU family PTSD symptoms with an emphasis on methodological issues in conducting research on this challenging phenomenon. An extensive review of the literature was performed confining the search to English language studies reporting PTSD symptoms in adult family members of adult ICU patients. Ten studies were identified for review published from 2004 to 2012. Findings demonstrate a significant prevalence of family PTSD symptoms in the months following ICU hospitalization. However, there are several methodological challenges to the interpretation of existing studies and to the conduct of future research including differences in sampling, identification of risk factors and covariates of PTSD, and lack of consensus regarding the most appropriate PTSD symptom measurement tools and timing. © The Author(s) 2014.

[Ten-year evolution of mechanical ventilation in acute respiratory failure in the hematogical patient admitted to the intensive care unit].

PubMed

Belenguer-Muncharaz, A; Albert-Rodrigo, L; Ferrandiz-Sellés, A; Cebrián-Graullera, G

2013-10-01

A comparison was made between invasive mechanical ventilation (IMV) and noninvasive positive pressure ventilation (NPPV) in haematological patients with acute respiratory failure. A retrospective observational study was made from 2001 to December 2011. A clinical-surgical intensive care unit (ICU) in a tertiary hospital. Patients with hematological malignancies suffering acute respiratory failure (ARF) and requiring mechanical ventilation in the form of either IMV or NPPV. Analysis of infection and organ failure rates, duration of mechanical ventilation and ICU and hospital stays, as well as ICU, hospital and mortality after 90 days. The same variables were analyzed in the comparison between NPPV success and failure. Forty-one patients were included, of which 35 required IMV and 6 NPPV. ICU mortality was higher in the IMV group (100% vs 37% in NPPV, P=.006). The intubation rate in NPPV was 40%. Compared with successful NPPV, failure in the NPPV group involved more complications, a longer duration of mechanical ventilation and ICU stay, and greater ICU and hospital mortality. Multivariate analysis of mortality in the NPPV group identified NPPV failure (OR 13 [95%CI 1.33-77.96], P=.008) and progression to acute respiratory distress syndrome (OR 10 [95%CI 1.95-89.22], P=.03) as prognostic factors. The use of NPPV reduced mortality compared with IMV. NPPV failure was associated with more complications. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Neurocritical care education during neurology residency: AAN survey of US program directors.

PubMed

Sheth, K N; Drogan, O; Manno, E; Geocadin, R G; Ziai, W

2012-05-29

Limited information is available regarding the current state of neurocritical care education for neurology residents. The goal of our survey was to assess the need and current state of neurocritical care training for neurology residents. A survey instrument was developed and, with the support of the American Academy of Neurology, distributed to residency program directors of 132 accredited neurology programs in the United States in 2011. A response rate of 74% (98 of 132) was achieved. A dedicated neuroscience intensive care unit (neuro-ICU) existed in 64%. Fifty-six percent of residency programs offer a dedicated rotation in the neuro-ICU, lasting 4 weeks on average. Where available, the neuro-ICU rotation was required in the vast majority (91%) of programs. Neurology residents' exposure to the fundamental principles of neurocritical care was obtained through a variety of mechanisms. Of program directors, 37% indicated that residents would be interested in performing away rotations in a neuro-ICU. From 2005 to 2010, the number of programs sending at least one resident into a neuro-ICU fellowship increased from 14% to 35%. Despite the expansion of neurocritical care, large proportions of US neurology residents have limited exposure to a neuro-ICU and neurointensivists. Formal training in the principles of neurocritical care may be highly variable. The results of this survey suggest a charge to address the variability of resident education and to develop standardized curricula in neurocritical care for neurology residents.

Bench-to-bedside review: Leadership and conflict management in the intensive care unit

PubMed Central

Strack van Schijndel, Rob JM; Burchardi, Hilmar

2007-01-01

In the management of critical care units, leadership and conflict management are vital areas for the successful performance of the unit. In this article a practical approach to define competencies for leadership and principles and practices of conflict management are offered. This article is, by lack of relevant intensive care unit (ICU) literature, not evidence based, but it is the result of personal experience and a study of literature on leadership as well on conflicts and negotiations in non-medical areas. From this, information was selected that was recognisable to the authors and, thus, also seems to be useful knowledge for medical doctors in the ICU environment. PMID:18086322

Bench-to-bedside review: leadership and conflict management in the intensive care unit.

PubMed

Strack van Schijndel, Rob J M; Burchardi, Hilmar

2007-01-01

In the management of critical care units, leadership and conflict management are vital areas for the successful performance of the unit. In this article a practical approach to define competencies for leadership and principles and practices of conflict management are offered. This article is, by lack of relevant intensive care unit (ICU) literature, not evidence based, but it is the result of personal experience and a study of literature on leadership as well on conflicts and negotiations in non-medical areas. From this, information was selected that was recognisable to the authors and, thus, also seems to be useful knowledge for medical doctors in the ICU environment.

Aiming for zero: decreasing central line associated bacteraemia in the intensive care unit.

PubMed

Seddon, Mary E; Hocking, Catherine J; Mead, Pat; Simpson, Catherine

2011-07-29

To eliminate Central Line Associated Bacteraemia (CLAB) in the Critical Care Complex (CCC)-Intensive Care Unit (ICU) and High Dependency Unit (HDU)-Middlemore Hospital. Multifaceted quality improvement programme that included: engagement with ICU leadership and education of ICU staff; the introduction of a CLAB prevention bundle of care through standardised checklists for central line insertion (December 2008) and line maintenance (July 2009); the development of a central line pack; and rapid, visual feedback of results. Absolute numbers of CLAB in the CCC decreased from 14 in 2008, to 4 in 2009 and 1 in the first 6 months of 2010 (despite increase in bed census and a doubling of admissions). The CLAB rate per 1,000 line days decreased from 6.6 to 0.9. The days between CLAB increased from a median of 30 to >100 days, with zero CLAB for 5 of the last 6 months. Mortality for patients with CLAB was 37%, compared with mortality of 13% for all other ICU patients. The conservative cost savings were $200,000 in 2009 and $260,000 in 2010. Using an evidenced-based quality improvement approach, it is possible to significantly decrease Central Line Associated Bacteraemia in the Critical Care Complex. In doing so patient morbidity and mortality are reduced and money is saved for other healthcare needs.

A Systematic Review of the Liaison Nurse Role on Patient's Outcomes after Intensive Care Unit Discharge.

PubMed

Tabanejad, Zeinab; Pazokian, Marzieh; Ebadi, Abbas

2014-10-01

This review focuses on the impact of liaison nurse in nursing care of patient after ICU discharge on patient's outcomes, compared with patients that are not taken care of by liaison nurses. The role of the ICU liaison nurse has transpired to solve the gap between intensive care unit and wards. Therefore, we aimed to review the outcomes of all studies in this field. A systematic review of intervention studies between 2004 and 2013 was undertaken using standard and sensitive keywords such as liaison nurse, intensive care unit, and patient outcomes in the following databases: Science direct, PubMed, Scopus, Ovid, Oxford, Wiley, Scholar, and Mosby. Then, the articles which had the inclusion criteria after quality control were selected for a systematic review. From 662 retrieved articles, six articles were analyzed in a case study and four articles showed a statistically significant effect of the liaison nurse on the patient's outcomes such as reducing delays in patient discharge, effective discharge planning, improvement in survival for patients at the risk for readmission. Liaison nurses have a positive role on the outcomes of patients who are discharged from the ICU and more research should be done to examine the exact function of liaison nurses and other factors that influence outcomes in patients discharged from ICU.

Chapter 3. Coordination and collaboration with interface units

PubMed Central

Joynt, Gavin M.; Loo, Shi; Taylor, Bruce L.; Margalit, Gila; Christian, Michael D.; Sandrock, Christian; Danis, Marion; Leoniv, Yuval

2016-01-01

Purpose To provide recommendations and standard operating procedures (SOPs) for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on enhancing coordination and collaboration between the ICU and other key stakeholders. Methods Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including coordination and collaboration. Results Key recommendations include: (1) establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resource use and communications; (2) develop a system of communication, coordination and collaboration between the ICU and key interface departments within the hospital; (3) identify key functions or processes requiring coordination and collaboration, the most important of these being manpower and resources utilization (surge capacity) and re-allocation of personnel, equipment and physical space; (4) develop processes to allow smooth inter-departmental patient transfers; (5) creating systems and guidelines is not sufficient, it is important to: (a) identify the roles and responsibilities of key individuals necessary for the implementation of the guidelines; (b) ensure that these individuals are adequately trained and prepared to perform their roles; (c) ensure adequate equipment to allow key coordination and collaboration activities; (d) ensure an adequate physical environment to allow staff to properly implement guidelines; (6) trigger events for determining a crisis should be defined. Conclusions Judicious planning and adoption of protocols for coordination and collaboration with interface units are necessary to optimize outcomes during a pandemic. PMID:20213418

Effectiveness of classroom based crew resource management training in the intensive care unit: study design of a controlled trial.

PubMed

Kemper, Peter F; de Bruijne, Martine; van Dyck, Cathy; Wagner, Cordula

2011-11-10

Crew resource management (CRM) has the potential to enhance patient safety in intensive care units (ICU) by improving the use of non-technical skills. However, CRM evaluation studies in health care are inconclusive with regard to the effect of this training on behaviour and organizational outcomes, due to weak study designs and the scarce use of direct observations. Therefore, the aim of this study is to determine the effectiveness and cost-effectiveness of CRM training on attitude, behaviour and organization after one year, using a multi-method approach and matched control units. The purpose of the present article is to describe the study protocol and the underlying choices of this evaluation study of CRM in the ICU in detail. Six ICUs participated in a paired controlled trial, with one pre-test and two post test measurements (respectively three months and one year after the training). Three ICUs were trained and compared to matched control ICUs. The 2-day classroom-based training was delivered to multidisciplinary groups. Typical CRM topics on the individual, team and organizational level were discussed, such as situational awareness, leadership and communication. All levels of Kirkpatrick's evaluation framework (reaction, learning, behaviour and organisation) were assessed using questionnaires, direct observations, interviews and routine ICU administration data. It is expected that the CRM training acts as a generic intervention that stimulates specific interventions. Besides effectiveness and cost-effectiveness, the assessment of the barriers and facilitators will provide insight in the implementation process of CRM. Netherlands Trial Register (NTR): NTR1976.

Family participation in intensive care unit rounds: Comparing family and provider perspectives.

PubMed

Au, Selena S; Roze des Ordons, Amanda; Soo, Andrea; Guienguere, Simon; Stelfox, Henry T

2017-04-01

To describe and compare intensive care unit (ICU) patient family member and provider experiences, preferences, and perceptions of family participation in ICU rounds. Cross-sectional survey of ICU family members and providers of patients admitted to 4 medical-surgical ICUs from September 2014 to March 2015. Surveys were completed by 63 (62%) family members and 258 (43%) providers. Provider respondents included physicians (9%), nurses (56%), respiratory therapists (24%), and other ICU team members (11%). Although 38% of providers estimated only moderate family member interest in participating in rounds, 97% of family members expressed high interest. Family members and providers reported listening (95% vs 96%; P=.594) and sharing information about the patient (82% vs 82%; P=.995) as appropriate roles for family members during rounds, but differed in their perceptions on asking questions (75% vs 86%; P=.043) and participating in decision making (36% vs 59%; P=.003). Compared with family members, providers were more likely to perceive family participation in rounds to cause family stress (7% vs 22%; P=.020) and confusion (0% vs 28%; P<.001). Family members and providers share some perspectives on family participation in ICU rounds although other perspectives are discordant, with implications for communication strategies and collaborative decision making. Copyright © 2016 Elsevier Inc. All rights reserved.

An evaluation of hand hygiene in an intensive care unit: Are visitors a potential vector for pathogens?

PubMed

Birnbach, David J; Rosen, Lisa F; Fitzpatrick, Maureen; Arheart, Kristopher L; Munoz-Price, L Silvia

2015-01-01

Patients in an intensive care unit (ICU) are frequently immunocompromised and might be highly susceptible to infection. Visitors to an ICU who do not adequately clean their hands could carry pathogenic organisms, resulting in risk to a vulnerable patient population. This observational study identifies pathogens carried on the hands of visitors into an ICU and investigates the effect of hand hygiene. Two observers, one stationed outside and one inside the ICU, evaluated whether visitors performed hand hygiene at any of the wall-mounted alcohol-based hand sanitizer dispensers prior to reaching a patient's room. Upon reaching a patient's room, the dominant hand of all of the participants was cultured. Of the 55 participating visitors, 35 did not disinfect their hands. Among the cultures of those who failed to perform hand hygiene, eight cultures grew Gram-negative rods and one grew methicillin-resistant Staphylococcus aureus. Of the cultures of the 20 individuals who performed hand hygiene, 14 (70%) had no growth on the cultures, and the remaining six (30%) showed only the usual skin flora. The visitors who do not perform hand hygiene might carry pathogens that pose a risk to ICU patients. Copyright © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

Care and caring in the intensive care unit: Family members' distress and perceptions about staff skills, communication, and emotional support.

PubMed

Carlson, Eve B; Spain, David A; Muhtadie, Luma; McDade-Montez, Liz; Macia, Kathryn S

2015-06-01

Family members of intensive care unit (ICU) patients are sometimes highly distressed and report lower satisfaction with communication and emotional support from staff. Within a study of emotional responses to traumatic stress, associations between family distress and satisfaction with aspects of ICU care were investigated. In 29 family members of trauma patients who stayed in an ICU, we assessed symptoms of depression and posttraumatic stress disorder (PTSD) during ICU care. Later, family members rated staff communication, support, and skills and their overall satisfaction with ICU care. Ratings of staff competence and skills were significantly higher than ratings of frequency of communication, information needs being met, and support. Frequency of communication and information needs being met were strongly related to ratings of support (rs = .75-.77) and staff skills (rs = .77-.85), and aspects of satisfaction and communication showed negative relationships with symptoms of depression (rs = -.31 to -.55) and PTSD (rs = -.17 to -.43). Although satisfaction was fairly high, family member distress was negatively associated with several satisfaction variables. Increased understanding of the effects of traumatic stress on family members may help staff improve communication and increase satisfaction of highly distressed family members. Published by Elsevier Inc.

Consistency of communication among intensive care unit staff as perceived by family members of patients surviving to discharge.

PubMed

Hwang, David Y; Yagoda, Daniel; Perrey, Hilary M; Tehan, Tara M; Guanci, Mary; Ananian, Lillian; Currier, Paul F; Cobb, J Perren; Rosand, Jonathan

2014-02-01

We hypothesize that intensive care unit (ICU) families frequently perceive that they have received inconsistent information from staff about their relatives and that these inconsistencies influence abilities to make medical decisions, as well as satisfaction. We performed a prospective cohort study in the neurosciences and medical ICU at a university hospital. One hundred twenty-four family members of adult patients surviving to ICU discharge completed a questionnaire regarding perceptions of inconsistent information. Of 193 eligible patients, 64.2% had family complete the survey. Thirty-one respondents (25.0%; 95% confidence interval, 7.7) reported at least 1 instance of inconsistent information during their family member's admission, with no difference between the neurosciences ICU (21.5%; 9.3) and the medical ICU (31.1%; 14.1; P = .28). Of those who did receive inconsistent information, 38.7% (95% confidence interval, 18.2) reported multiple episodes and 74.2% (16.3) indicated that episodes occurred within the first 48 hours of admission. These episodes had an adverse effect, with 19.4% (14.7) indicating that they affected satisfaction and 9.7% (11.0) indicating that they made decision making difficult. Episodes involving inconsistent information from staff as perceived by families may be quite prevalent and may influence decision-making abilities and satisfaction.

Needs of Patients' Family Members in an Intensive Care Unit With Continuous Visitation.

PubMed

Jacob, Mini; Horton, Cynthia; Rance-Ashley, Sharon; Field, Tera; Patterson, Robbie; Johnson, Claudette; Saunders, Holly; Shelton, Tracy; Miller, Jessica; Frobos, Carmen

2016-03-01

Although many critical care experts and national organizations support open visitation in intensive care units (ICUs), most ICU visiting policies do not allow unrestricted presence of patients' family members. To describe how well the needs of family members were met in an adult neuroscience ICU with a continuous visitation policy and an adjoining private suite for patients' family members. An exploratory, descriptive study design was used to identify the effects of continuous family visitation in the neuroscience ICU on patients' family members and their needs and experiences during their time in the unit. A convenience sample of consenting family members completed a survey of family need items 72 hours after the patient was admitted to the unit. The most important needs identified by the 45 family members surveyed were items relating to information about the patient, visiting the patient, being given hope, talking with a doctor each day, and being assured that the best care is being given to the patient. Least important items were related to physical comforts for the family members. The vast majority of family members rated their needs as being met for all of the items in the survey and reported a high level of satisfaction with care. In a neuroscience ICU with an open visitation policy and a private suite for patients' family members, family members rated their needs as being met at a high level, unlike in prior studies in units with limitations on family visitation. The rank order of the importance of each need in the survey was similar to rankings in prior studies in a variety of critical care units. ©2016 American Association of Critical-Care Nurses.

Acute exacerbations of chronic obstructive pulmonary disease: diagnosis, management, and prevention in critically ill patients.

PubMed

Dixit, Deepali; Bridgeman, Mary Barna; Andrews, Liza Barbarello; Narayanan, Navaneeth; Radbel, Jared; Parikh, Amay; Sunderram, Jag

2015-06-01

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death and is a substantial source of disability in the United States. Moderate-to-severe acute exacerbations of COPD (AECOPD) can progress to respiratory failure, necessitating ventilator assistance in patients in the intensive care unit (ICU). Patients in the ICU with AECOPD requiring ventilator support have higher morbidity and mortality rates as well as costs compared with hospitalized patients not in the ICU. The mainstay of management for patients with AECOPD in the ICU includes ventilator support (noninvasive or invasive), rapid-acting inhaled bronchodilators, systemic corticosteroids, and antibiotics. However, evidence supporting these interventions for the treatment of AECOPD in critically ill patients admitted to the ICU is scant. Corticosteroids have gained widespread acceptance in the management of patients with AECOPD necessitating ventilator assistance, despite their lack of evaluation in clinical trials as well as controversies surrounding optimal dosage regimens and duration of treatment. Recent studies evaluating the safety and efficacy of corticosteroids have found that higher doses are associated with increased adverse effects, which therefore support lower dosing strategies, particularly for patients admitted to the ICU for COPD exacerbations. This review highlights recent findings from the current body of evidence on nonpharmacologic and pharmacologic treatment and prevention of AECOPD in critically ill patients. In addition, the administration of bronchodilators using novel delivery devices in the ventilated patient and the conflicting evidence surrounding antibiotic use in AECOPD in the critically ill is explored. Further clinical trials, however, are warranted to clarify the optimal pharmacotherapy management for AECOPD, particularly in critically ill patients admitted to the ICU. © 2015 Pharmacotherapy Publications, Inc.

Control of extended-spectrum β-lactamase-producing Enterobacteriaceae nosocomial acquisition in an intensive care unit: A time series regression analysis.

PubMed

Boyer, Alexandre; Couallier, Vincent; Clouzeau, Benjamin; Lasheras, Agnes; M'zali, Fatima; Kann, Michael; Rogues, Anne-Marie; Gruson, Didier

2015-12-01

This study was undertaken to determine the temporal relationship between implementation of different interventions in an intensive care unit (ICU) and control of endemic nosocomial acquisition of extended-spectrum β-lactamase Enterobacteriaceae (ESBLE). This was a prospective observational study with time-series analysis of the monthly incidence of ESBLE and its predictors. In November 2007, after a 14-month baseline period, an intervention consisting of restriction of third-generation cephalosporins (3 GC) and increased use of alcohol-based hand rubs was implemented. In January 2008, an increased health care worker (HCW):patient ratio was also implemented. In March 2010, the ICU was closed, and patients were moved to a clean ICU. The first intervention resulted in global reduction in 3 GC and increased use of alcohol-based hand rub. A significant change in ESBLE incidence was observed in a full segmented univariate regression analysis (mean change in level, -0.91 ± 0.19; P < .0001). After ICU closure, there was a dramatic reduction in ESBLE acquisition. According to the multivariate model, the ICU closure was the main protective factor. Before ICU closure, an increase in the HCW:patient ratio of 0.1 point tended to be associated with a decreased risk of ESBLE acquisition (relative risk, 0.28; 95% confidence interval, 0.06-1.25; P = .09). This study shows that ICU closure was associated with, but not necessarily the reason for, control of ESBLE cross-transmission in a nonoutbreak setting. Environmental ESBE sources may play a role in cross-transmission. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Inflammation responses in patients with pulmonary tuberculosis in an intensive care unit

PubMed Central

Liu, Qiu-Yue; Han, Fen; Pan, Li-Ping; Jia, Hong-Yan; Li, Qi; Zhang, Zong-De

2018-01-01

Pulmonary tuberculosis caused by Mycobacterium tuberculosis remains a global problem. Inflammatory responses are the primary characteristics of patients with pulmonary tuberculosis in intensive care units (ICU). The aim of the present study was to investigate the clinical importance of inflammatory cells and factors for patients with pulmonary tuberculosis in ICU. A total of 124 patients with pulmonary tuberculosis in ICU were recruited for the present study. The inflammatory responses in patients with pulmonary tuberculosis in ICU were examined by changes in inflammatory cells and factors in the serum. The results indicated that serum levels of lymphocytes, plasma cells, granulocytes and monocytes were increased in patients with pulmonary tuberculosis in ICU compared with healthy controls. The serum levels of inflammatory factors interleukin (IL)-1, IL-6, IL-10, IL-12, and IL-4 were upregulated in patients with pulmonary tuberculosis in ICU. Lower plasma concentrations of IL-2, IL-15 and interferon-γ were detected in patients with pulmonary tuberculosis compared with healthy controls. It was demonstrated that high mobility group box-1 protein expression levels were higher in the serum of patients with pulmonary tuberculosis compared with healthy controls. Notably, an imbalance of T-helper cell (Th)1/Th2 cytokines was observed in patients with pulmonary tuberculosis. Pulmonary tuberculosis caused by M. tuberculosis also upregulated expression of matrix metalloproteinase (MMP)-1 and MMP-9 in hPMCs. In conclusion, these outcomes demonstrated that inflammatory responses and inflammatory factors are associated with the progression of pulmonary tuberculosis, suggesting that inhibition of inflammatory responses and inflammatory factors may be beneficial for the treatment of patients with pulmonary tuberculosis in ICU. PMID:29456674

Lived experiences of parents of premature babies in the intensive care unit in a private hospital in Johannesburg, South Africa.

PubMed

Steyn, Erika; Poggenpoel, Marie; Myburgh, Chris

2017-02-28

Many of the 15 million premature babies born worldwide every year survive because of advanced medical interventions. Their parents have intense experiences when their babies are in the intensive care unit (ICU), and these have an impact on their thoughts, feelings and relationships, including their relationships with their premature babies. The aim of the study was to explore and describe the lived experiences of parents of premature babies in an ICU. Research design was qualitative, exploratory, descriptive and contextual. A purposive sample of parents with premature babies in an ICU in a private hospital in Johannesburg Gauteng in South Africa was used. Eight parents, four mothers and four fathers, married and either Afrikaans or English-speaking, were included in the study. Data were collected by conducting in-depth phenomenological interviews with them and making use of field notes. Trustworthiness was ensured by implementing the strategies of credibility, transferability, dependability and confirmability. Ethical principles such as autonomy, beneficence, nonmaleficence and justice were adhered to throughout the research process. Thematic analyses were utilised to analyse the data. Two themes in the experiences of parents with premature babies in ICU became apparent. Parents experienced thoughts, emotions and hope while their premature babies were in the ICU as well as challenges in their relationships and these challenges influenced their experiences. Mindfulness of intensive care nurses should be facilitated so that intensive care nurses can promote the mental health of parents with premature babies in the ICU. Parents with premature babies in the ICU have thoughts and emotional experiences which include hope and they affect parents' relationships.

Relationship between volume and survival in closed intensive care units is weak and apparent only in mechanically ventilated patients.

PubMed

Fernández, Rafael; Altaba, Susana; Cabre, Lluis; Lacueva, Victoria; Santos, Antonio; Solsona, Jose-Felipe; Añon, Jose-Manuel; Catalan, Rosa-Maria; Gutierrez, Maria-Jose; Fernandez-Cid, Ramon; Gomez-Tello, Vicente; Curiel, Emilio; Fernandez-Mondejar, Enrique; Oliva, Joan-Carles; Tizon, Ana Isabel; Gonzalez, Javier; Monedero, Pablo; Sanchez, Manuela Garcia; de la Torre, M Victoria; Ibañez, Pedro; Frutos, Fernando; Del Nogal, Frutos; Gomez, M Jesus; Marcos, Alfredo; Vera, Paula; Serrano, Jose Manuel; Umaran, Isabel; Carrillo, Andres; Lopez-Pueyo, M-Jose; Rascado, Pedro; Balerdi, Begoña; Suberviola, Borja; Hernandez, Gonzalo

2013-10-01

Recent studies have found an association between increased volume and increased intensive care unit (ICU) survival; however, this association might not hold true in ICUs with permanent intensivist coverage. Our objective was to determine whether ICU volume correlates with survival in the Spanish healthcare system. Post hoc analysis of a prospective study of all patients admitted to 29 ICUs during 3 months. At ICU discharge, the authors recorded demographic variables, severity score, and specific ICU treatments. Follow-up variables included ICU readmission and hospital mortality. Statistics include logistic multivariate analyses for hospital mortality according to quartiles of volume of patients. The authors studied 4,001 patients with a mean predicted risk of death of 23% (range at hospital level: 14-46%). Observed hospital mortality was 19% (range at hospital level: 11-35%), resulting in a standardized mortality ratio of 0.81 (range: 0.5-1.3). Among the 1,923 patients needing mechanical ventilation, the predicted risk of death was 32% (14-60%) and observed hospital mortality was 30% (12-61%), resulting in a standardized mortality ratio of 0.96 (0.5-1.7). The authors found no correlation between standardized mortality ratio and ICU volume in the entire population or in mechanically ventilated patients. Only mechanically ventilated patients in very low-volume ICUs had slightly worse outcome. In the currently studied healthcare system characterized by 24/7 intensivist coverage, the authors found wide variability in outcome among ICUs even after adjusting for severity of illness but no relationship between ICU volume and outcome. Only mechanically ventilated patients in very low-volume centers had slightly worse outcomes.

Exploring bacterial diversity in hospital environments by GS-FLX Titanium pyrosequencing.

PubMed

Poza, Margarita; Gayoso, Carmen; Gómez, Manuel J; Rumbo-Feal, Soraya; Tomás, María; Aranda, Jesús; Fernández, Ana; Bou, Germán

2012-01-01

Understanding microbial populations in hospital environments is crucial for improving human health. Hospital-acquired infections are an increasing problem in intensive care units (ICU). In this work we present an exploration of bacterial diversity at inanimate surfaces of the ICU wards of the University Hospital A Coruña (Spain), as an example of confined hospital environment subjected to selective pressure, taking the entrance hall of the hospital, an open and crowded environment, as reference. Surface swab samples were collected from both locations and recovered DNA used as template to amplify a hypervariable region of the bacterial 16S rRNA gene. Sequencing of the amplicons was performed at the Roche 454 Sequencing Center using GS-FLX Titanium procedures. Reads were pre-processed and clustered into OTUs (operational taxonomic units), which were further classified. A total of 16 canonical bacterial phyla were detected in both locations. Members of the phyla Firmicutes (mainly Staphylococcus and Streptococcus) and Actinobacteria (mainly Micrococcaceae, Corynebacteriaceae and Brevibacteriaceae) were over-represented in the ICU with respect to the Hall. The phyllum Proteobacteria was also well represented in the ICU, mainly by members of the families Enterobacteriaceae, Methylobacteriaceae and Sphingomonadaceae. In the Hall sample, the phyla Proteobacteria, Bacteroidetes, Deinococcus-Thermus and Cyanobacteria were over-represented with respect to the ICU. Over-representation of Proteobacteria was mainly due to the high abundance of Enterobacteriaceae members. The presented results demonstrate that bacterial diversity differs at the ICU and entrance hall locations. Reduced diversity detected at ICU, relative to the entrance hall, can be explained by its confined character and by the existence of antimicrobial selective pressure. This is the first study using deep sequencing techniques made in hospital wards showing substantial hospital microbial diversity.

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery.

PubMed

Johnson, Joyce T; Wilkes, Jacob F; Menon, Shaji C; Tani, Lloyd Y; Weng, Hsin-Yi; Marino, Bradley S; Pinto, Nelangi M

2018-06-01

Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Organizational culture and climate for patient safety in Intensive Care Units.

PubMed

Santiago, Thaiana Helena Roma; Turrini, Ruth Natalia Teresa

2015-02-01

Objective To assess the perception of health professionals about patient safety climate and culture in different intensive care units (ICUs) and the relationship between scores obtained on the Hospital Survey on Patient Safety Culture (HSOPSC) and the Safety Attitudes Questionnaire (SAQ). Method A cross-sectional study conducted at a teaching hospital in the state of São Paulo, Brazil, in March and April 2014. As data gathering instruments, the HSOPSC, SAQ and a questionnaire with sociodemographic and professional information about the staff working in an adult, pediatric and neonatal ICU were used. Data analysis was conducted with descriptive statistics. Results The scales presented good reliability. Greater weaknesses in patient safety were observed in the Working conditions andPerceptions of management domains of the SAQ and in the Nonpunitive response to error domain of the HSOPSC. The strengths indicated by the SAQ wereTeamwork climate and Job satisfactionand by the HSOPC, Supervisor/manager expectations and actions promoting safety and Organizational learning-continuous improvement. Job satisfaction was higher among neonatal ICU workers when compared with the other ICUs. The adult ICU presented lower scores for most of the SAQ and HSOPSC domains. The scales presented moderate correlation between them (r=0.66). Conclusion There were differences in perception regarding patient safety among ICUs, which corroborates the existence of local microcultures. The study did not demonstrate equivalence between the SAQ and the HSOPSC.

Satisfaction with care and decision making among parents/caregivers in the pediatric intensive care unit: a comparison between English-speaking whites and Latinos.

PubMed

Epstein, David; Unger, Jennifer B; Ornelas, Beatriz; Chang, Jennifer C; Markovitz, Barry P; Dodek, Peter M; Heyland, Daren K; Gold, Jeffrey I

2015-04-01

Because of previously documented health care disparities, we hypothesized that English-speaking Latino parents/caregivers would be less satisfied with care and decision making than English-speaking non-Latino white (NLW) parents/caregivers. An intensive care unit (ICU) family satisfaction survey, Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version), was completed by English-speaking parents/caregivers of children in a cardiothoracic ICU at a university-affiliated children's hospital in 2011. English-speaking NLW and Latino parents/caregivers of patients, younger than 18 years, admitted to the ICU were approached to participate on hospital day 3 or 4 if they were at the bedside for greater than or equal to 2 days. Analysis of variance, χ(2), and Student t tests were used. Cronbach αs were calculated. Fifty parents/caregivers completed the survey in each group. Latino parents/caregivers were younger, more often mothers born outside the United States, more likely to have government insurance or no insurance, and had less education and income. There were no differences between the groups' mean overall satisfaction scores (92.6 ± 8.3 and 93.0 ± 7.1, respectively; P = .80). The Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version) showed high internal consistency reliability (α = .95 and .91 for NLW and Latino groups, respectively). No disparities in ICU satisfaction with care and decision making between English-speaking NLW and Latino parents/caregivers were found. Copyright © 2014 Elsevier Inc. All rights reserved.

Comparison of European ICU patients in 2012 (ICON) versus 2002 (SOAP).

PubMed

Vincent, Jean-Louis; Lefrant, Jean-Yves; Kotfis, Katarzyna; Nanchal, Rahul; Martin-Loeches, Ignacio; Wittebole, Xavier; Sakka, Samir G; Pickkers, Peter; Moreno, Rui; Sakr, Yasser

2018-03-01

To evaluate differences in the characteristics and outcomes of intensive care unit (ICU) patients over time. We reviewed all epidemiological data, including comorbidities, types and severity of organ failure, interventions, lengths of stay and outcome, for patients from the Sepsis Occurrence in Acutely ill Patients (SOAP) study, an observational study conducted in European intensive care units in 2002, and the Intensive Care Over Nations (ICON) audit, a survey of intensive care unit patients conducted in 2012. We compared the 3147 patients from the SOAP study with the 4852 patients from the ICON audit admitted to intensive care units in the same countries as those in the SOAP study. The ICON patients were older (62.5 ± 17.0 vs. 60.6 ± 17.4 years) and had higher severity scores than the SOAP patients. The proportion of patients with sepsis at any time during the intensive care unit stay was slightly higher in the ICON study (31.9 vs. 29.6%, p = 0.03). In multilevel analysis, the adjusted odds of ICU mortality were significantly lower for ICON patients than for SOAP patients, particularly in patients with sepsis [OR 0.45 (0.35-0.59), p < 0.001]. Over the 10-year period between 2002 and 2012, the proportion of patients with sepsis admitted to European ICUs remained relatively stable, but the severity of disease increased. In multilevel analysis, the odds of ICU mortality were lower in our 2012 cohort compared to our 2002 cohort, particularly in patients with sepsis.

Conceptual design of the X-IFU Instrument Control Unit on board the ESA Athena mission

NASA Astrophysics Data System (ADS)

Corcione, L.; Ligori, S.; Capobianco, V.; Bonino, D.; Valenziano, L.; Guizzo, G. P.

2016-07-01

Athena is one of L-class missions selected in the ESA Cosmic Vision 2015-2025 program for the science theme of the Hot and Energetic Universe. The Athena model payload includes the X-ray Integral Field Unit (X-IFU), an advanced actively shielded X-ray microcalorimeter spectrometer for high spectral resolution imaging, utilizing cooled Transition Edge Sensors. This paper describes the preliminary architecture of Instrument Control Unit (ICU), which is aimed at operating all XIFU's subsystems, as well as at implementing the main functional interfaces of the instrument with the S/C control unit. The ICU functions include the TC/TM management with S/C, science data formatting and transmission to S/C Mass Memory, housekeeping data handling, time distribution for synchronous operations and the management of the X-IFU components (i.e. CryoCoolers, Filter Wheel, Detector Readout Electronics Event Processor, Power Distribution Unit). ICU functions baseline implementation for the phase-A study foresees the usage of standard and Space-qualified components from the heritage of past and current space missions (e.g. Gaia, Euclid), which currently encompasses Leon2/Leon3 based CPU board and standard Space-qualified interfaces for the exchange commands and data between ICU and X-IFU subsystems. Alternative architecture, arranged around a powerful PowerPC-based CPU, is also briefly presented, with the aim of endowing the system with enhanced hardware resources and processing power capability, for the handling of control and science data processing tasks not defined yet at this stage of the mission study.

Factors influencing when intensive care unit nurses go to the bedside to investigate patient related alarms: A descriptive qualitative study.

PubMed

Despins, Laurel A

2017-12-01

This study examines what prompts the intensive care unit (ICU) nurse to go to the patient's bedside to investigate an alarm and the influences on the nurse's determination regarding how quickly this needs to occur. A qualitative descriptive design guided data collection and analysis. Individual semi-structured interviews were conducted. Thematic analysis guided by the Patient Risk Detection Theoretical Framework was applied to the data. Four specialty intensive care units in an academic medical center. ICU nurses go the patient's bedside in response to an alarm to catch patient deterioration and avert harm. Their determination of the immediacy of patient risk and their desire to prioritize their bedside investigations to true alarms influences how quickly they proceed to the bedside. Ready visual access to physiological data and waveform configurations, experience, teamwork, and false alarms are important determinants in the timing of ICU nurses' bedside alarm investigations. Copyright © 2017 Elsevier Ltd. All rights reserved.

Safety and Security Concerns of Nurses Working in the Intensive Care Unit: A Qualitative Study.

PubMed

Keys, Yolanda; Stichler, Jaynelle F

Intensive care units (ICUs) exist to serve as a safe place for critically ill patients to receive care from skilled practitioners. In this qualitative study, ICU nurses shared their perspectives on elements that promote safety and security on their units. After obtaining institutional review board approval, participants participated in telephone interviews with a nurse researcher who has experience as a bedside ICU nurse. Five categories and 14 themes were identified and then confirmed using member checking. Results indicate that participants prefer to provide care in ICUs with no more than 12 to 14 beds and provide the following: visibility of patients and coworkers; more than 1 way to exit; and can be locked in case of emergency or threat. Nearly all respondents mentioned adequate staffing as the most important attribute of a safe, secure care environment for patients and families. More research is needed to identify design features that make the most impact on providing a safe, secure ICU environment.

Value and role of intensive care unit outcome prediction models in end-of-life decision making.

PubMed

Barnato, Amber E; Angus, Derek C

2004-07-01

In the United States, intensive care unit (ICU) admission at the end of life is commonplace. What is the value and role of ICU mortality prediction models for informing the utility of ICU care?In this article, we review the history, statistical underpinnings,and current deployment of these models in clinical care. We conclude that the use of outcome prediction models to ration care that is unlikely to provide an expected benefit is hampered by imperfect performance, the lack of real-time availability, failure to consider functional outcomes beyond survival, and physician resistance to the use of probabilistic information when death is guaranteed by the decision it informs. Among these barriers, the most important technical deficiency is the lack of automated information systems to provide outcome predictions to decision makers, and the most important research and policy agenda is to understand and address our national ambivalence toward rationing care based on any criterion.

Early treatment of imported falciparum malaria in the intermediate and intensive care unit setting: an 8-year single-center retrospective study.

PubMed

Schwake, Lukas; Streit, Judith Pamela; Edler, Lutz; Encke, Jens; Stremmel, Wolfgang; Junghanss, Thomas

2008-01-01

Imported falciparum malaria is characterized by a broad spectrum of potentially life-threatening complications that may arise even after initiation of appropriate antimalarial drug therapy. Hence, at Heidelberg University Hospital, all patients with newly diagnosed falciparum malaria are initially treated in the intermediate care unit (IMC) or intensive care unit (ICU). The present study was undertaken to evaluate critically the benefit of this strategy, which includes daily consultation with senior specialists in tropical medicine. We conducted a retrospective cohort study at the 14-bed combined IMC/ICU of a 1,685-bed university hospital. A cohort of 122 patients with imported falciparum malaria admitted from 1 January 1996 to 31 December 2003 was included. Thirty-four patients (27.9%) developed complications, defined according to the current World Health Organization classification. Most patients (80.3%) studied did not take the recommended chemoprophylaxis against malaria. The majority of patients (89.3% [n = 109]) could be adequately treated in the IMC. Life-threatening complications requiring ICU support occurred in 13 patients (10.7%). All complications were successfully managed. Fifty-five patients (45.1%) fulfilling recently published criteria for outpatient treatment had an excellent therapeutic response and did not require ICU support. This retrospective evaluation demonstrated favourable therapeutic results in hospitalized patients with imported falciparum malaria. Both initial treatment in the medical IMC/ICU and close collaboration between intensivists and specialists in tropical medicine may improve disease outcome among affected patients. Prospective studies are needed to confirm these preliminary findings.

Ward nurses' experiences of the discharge process between intensive care unit and general ward.

PubMed

Kauppi, Wivica; Proos, Matilda; Olausson, Sepideh

2018-05-01

Intensive care unit (ICU) discharges are challenging practices that carry risks for patients. Despite the existing body of knowledge, there are still difficulties in clinical practice concerning unplanned ICU discharges, specifically where there is no step-down unit. The aim of this study was to explore general ward nurses' experiences of caring for patients being discharged from an ICU. Data were collected from focus groups and in-depth interviews with a total of 16 nurses from three different hospitals in Sweden. An inductive qualitative design was chosen. The analysis revealed three themes that reflect the challenges in nursing former ICU patients: a vulnerable patient, nurses' powerlessness and organizational structure. The nurses described the challenge of nursing a fragile patient based on several aspects. They expressed feeling unrealistic demands when caring for a fragile former ICU patient. The demands were related to their own profession and knowledge regarding how to care for this group of patients. The organizational structure had an impact on how the nurses' caring practice could be realized. This evoked ethical concerns that the nurses had to cope with as the organization's care guidelines did not always favour the patients. The structure of the organization and its leadership appear to have a significant impact on the nurses' ability to offer patients the care they need. This study sheds light on the need for extended outreach services and intermediate care in order to meet the needs of patients after the intensive care period. © 2018 British Association of Critical Care Nurses.

Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Adult Intensive Care Unit Patients Following State-Mandated Active Surveillance.

PubMed

Lin, Michael Y; Hayden, Mary K; Lyles, Rosie D; Lolans, Karen; Fogg, Louis F; Kallen, Alexander J; Weber, Stephen G; Weinstein, Robert A; Trick, William E

2018-05-02

In 2007, Illinois became the first state in the United States to mandate active surveillance of methicillin-resistant Staphylococcus aureus (MRSA). The Illinois law applies to intensive care unit (ICU) patients; contact precautions are required for patients found to be MRSA colonized. However, the effectiveness of a legislated "search and isolate" approach to reduce MRSA burden among critically ill patients is uncertain. We evaluated whether the prevalence of MRSA colonization declined in the 5 years after the start of mandatory active surveillance. All hospitals with an ICU having ≥10 beds in Chicago, Illinois, were eligible to participate in single-day serial point prevalence surveys. We assessed MRSA colonization among adult ICU patients present at time of survey using nasal and inguinal swab cultures. The primary outcome was region-wide MRSA colonization prevalence over time. All 25 eligible hospitals (51 ICUs) participated in serial point prevalence surveys over 8 survey periods (2008-2013). A total of 3909 adult ICU patients participated in the point prevalence surveys, with 432 (11.1%) found to be colonized with MRSA (95% confidence interval [CI], 10.1%-12.0%). The MRSA colonization prevalence among patients was unchanged during the study period; year-over-year relative risk for MRSA colonization was 0.97 (95% CI, .89-1.05; P = .48). MRSA colonization prevalence among critically ill adult patients did not decline during the time period following legislatively mandated MRSA active surveillance. Our findings highlight the limits of legislated MRSA active surveillance as a strategy to reduce MRSA colonization burden among ICU patients.

Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad.

PubMed

Angue, Marion; Allou, Nicolas; Belmonte, Olivier; Lefort, Yannick; Lugagne, Nathalie; Vandroux, David; Montravers, Philippe; Allyn, Jérôme

2015-01-01

Few national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with ("Abroad") or without ("Local") a recent stay abroad, and then identify the risk factors in "Abroad" patients. In this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad ("Abroad") within 6 months prior to ICU admission. Of 1,842 ICU patients, 129 (7%) "Abroad" patients were reported. In the "Abroad" group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in "Local" patients. Risk factors associated with MDR bacteria carriage at admission in "Abroad" patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and "hospitalization abroad with antibiotic treatment" [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor. The main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of "Abroad" patients should be recommended, even in case of a first negative screening. © 2015 International Society of Travel Medicine.

Problematic Dichotomization of Risk for Intensive Care Unit (ICU)-Acquired Invasive Candidiasis: Results Using a Risk-Predictive Model to Categorize 3 Levels of Risk From a Multicenter Prospective Cohort of Australian ICU Patients.

PubMed

Playford, E Geoffrey; Lipman, Jeffrey; Jones, Michael; Lau, Anna F; Kabir, Masrura; Chen, Sharon C-A; Marriott, Deborah J; Seppelt, Ian; Gottlieb, Thomas; Cheung, Winston; Iredell, Jonathan R; McBryde, Emma S; Sorrell, Tania C

2016-12-01

 Delayed antifungal therapy for invasive candidiasis (IC) contributes to poor outcomes. Predictive risk models may allow targeted antifungal prophylaxis to those at greatest risk.  A prospective cohort study of 6685 consecutive nonneutropenic patients admitted to 7 Australian intensive care units (ICUs) for ≥72 hours was performed. Clinical risk factors for IC occurring prior to and following ICU admission, colonization with Candida species on surveillance cultures from 3 sites assessed twice weekly, and the occurrence of IC ≥72 hours following ICU admission or ≤72 hours following ICU discharge were measured. From these parameters, a risk-predictive model for the development of ICU-acquired IC was then derived.  Ninety-six patients (1.43%) developed ICU-acquired IC. A simple summation risk-predictive model using the 10 independently significant variables associated with IC demonstrated overall moderate accuracy (area under the receiver operating characteristic curve = 0.82). No single threshold score could categorize patients into clinically useful high- and low-risk groups. However, using 2 threshold scores, 3 patient cohorts could be identified: those at high risk (score ≥6, 4.8% of total cohort, positive predictive value [PPV] 11.7%), those at low risk (score ≤2, 43.1% of total cohort, PPV 0.24%), and those at intermediate risk (score 3-5, 52.1% of total cohort, PPV 1.46%).  Dichotomization of ICU patients into high- and low-risk groups for IC risk is problematic. Categorizing patients into high-, intermediate-, and low-risk groups may more efficiently target early antifungal strategies and utilization of newer diagnostic tests. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

African Americans Are Less Likely to Receive Care by a Cardiologist During an Intensive Care Unit Admission for Heart Failure.

PubMed

Breathett, Khadijah; Liu, Wenhui G; Allen, Larry A; Daugherty, Stacie L; Blair, Irene V; Jones, Jacqueline; Grunwald, Gary K; Moss, Marc; Kiser, Tyree H; Burnham, Ellen; Vandivier, R William; Clark, Brendan J; Lewis, Eldrin F; Mazimba, Sula; Battaglia, Catherine; Ho, P Michael; Peterson, Pamela N

2018-05-01

This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race. Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting. Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality. Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32). Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Resistance patterns and outcomes in intensive care unit (ICU)-acquired pneumonia. Validation of European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC) classification of multidrug resistant organisms.

PubMed

Martin-Loeches, Ignacio; Torres, Antonio; Rinaudo, Mariano; Terraneo, Silvia; de Rosa, Francesca; Ramirez, Paula; Diaz, Emili; Fernández-Barat, Laia; Li Bassi, Gian Luigi; Ferrer, Miquel

2015-03-01

Bacterial resistance has become a major public health problem. To validate the definition of multidrug-resistant organisms (MDRO) based on the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC) classification. Prospective, observational study in six medical and surgical Intensive-Care-Units (ICU) of a University hospital. Three-hundred-and-forty-three patients with ICU-acquired pneumonia (ICUAP) were prospectively enrolled, 140 patients had no microbiological confirmation (41%), 82 patients (24%) developed ICUAP for non-MDRO, whereas 121 (35%) were MDROs. Non-MDRO, MDRO and no microbiological confirmation patients did not present either a significant different previous antibiotic use (p 0.18) or previous hospital admission (p 0.17). Appropriate antibiotic therapy was associated with better ICU survival (105 [92.9%] vs. 74 [82.2%]; p = 0.03). An adjusted multivariate regression logistic analysis identified that only MDRO had a higher ICU-mortality than non-MDRO and no microbiological confirmation patients (OR 2.89; p < 0.05; 95% CI for Exp [β]. 1.02-8.21); Patients with MDRO ICUAP remained in ICU for a longer period than MDRO and no microbiological confirmation respectively (p < 0.01) however no microbiological confirmation patients had more often antibiotic consumption than culture positive ones. Patients who developed ICUAP due to MDRO showed a higher ICU-mortality than non-MDRO ones and use of ICU resources. No microbiological confirmation patients had more often antibiotic consumption than culture positive patients. Risk factors for MDRO may be important for the selection of initial antimicrobial therapy, in addition to local epidemiology. Copyright © 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Clinician Perspectives on an Electronic Portal to Improve Communication with Patients and Families in the Intensive Care Unit.

PubMed

Bell, Sigall K; Roche, Stephanie D; Johansson, Anna C; O'Reilly, Kristin P; Lee, Barbara S; Sands, Kenneth E; Talmor, Daniel S; Brown, Samuel M

2016-12-01

Communication in the intensive care unit (ICU) often falls short of patient and family needs, putting them at risk for significant physical and emotional harm. As electronic patient portals rapidly evolve, one designed specifically for the ICU might potentially enhance communication among patients, family members, and clinicians; however, the views of frontline ICU staff on such technology are unknown. To identify clinician perspectives on the current state of communication among patients, families, and clinicians in the ICU, and assess their views on whether and how an electronic portal may address existing communication deficits and improve care. Three focus groups comprised altogether of 26 clinicians from 6 ICUs, representing several disciplines in an academic medical center in Boston, Massachusetts. Transcripts were analyzed inductively for major themes using grounded theory. We identified seven themes reflecting clinician perspectives on communication challenges and desired portal functionality: (1) comprehension and literacy; (2) results and updates; (3) patient and family preferences; (4) interclinician communication; (5) family informational needs; (6) the ICU as an unfamiliar environment; and (7) enhancing humanism through technology. Each theme included current gaps in practice, potential benefits and concerns related to an ICU communication portal, and participant recommendations. Benefits included enhanced education, patient/family engagement, and clinician workflow. Challenges included the stress and uncertainty of ICU care, fear of technology replacing human connection, existing interclinician communication failures, and the tension between informing families without overwhelming them. Overall, clinicians were cautiously supportive of an electronic portal to enhance communication in the ICU and made several specific recommendations for design and implementation. As new technologies expand opportunities for greater transparency and participation in care, clinician buy-in and positive impact will depend, in large part, on the extent to which the concerns of stakeholders are addressed. At the same time, clinicians anticipate several potential benefits that could help support provider workflow and engage patients and families through enhanced communication and humanism.

ICU telemedicine and critical care mortality: a national effectiveness study

PubMed Central

Kahn, Jeremy M; Le, Tri Q.; Barnato, Amber E.; Hravnak, Marilyn; Kuza, Courtney C.; Pike, Francis; Angus, Derek C.

2015-01-01

Background Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. Objectives To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals. Research design We performed a multi-center retrospective case-control study using 2001–2010 Medicare claims data linked to a national survey identifying United States hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 non-adopting hospitals (controls) based on size, case-mix and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach. Results 132 adopting case hospitals were matched to 389 similar non-adopting control hospitals. The pre- and post-adoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, p=0.07) and control hospitals (23.5% vs. 23.7%, p<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios: 0.96, 95% CI = 0.95–0.98, p<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios: 1.01; interquartile range 0.85–1.12; range 0.45–2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions post-adoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (p<0.001) and be located in urban areas (p=0.04) compared to other hospitals. Conclusions Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions. PMID:26765148

Perceptions of safety culture vary across the intensive care units of a single institution.

PubMed

Huang, David T; Clermont, Gilles; Sexton, J Bryan; Karlo, Crystal A; Miller, Rachel G; Weissfeld, Lisa A; Rowan, Kathy M; Angus, Derek C

2007-01-01

To determine whether safety culture factors varied across the intensive care units (ICUs) of a single hospital, between nurses and physicians, and to explore ICU nursing directors' perceptions of their personnel's attitudes. Cross-sectional surveys using the Safety Attitudes Questionnaire-ICU version, a validated, aviation industry-based safety culture survey instrument. It assesses culture across six factors: teamwork climate, perceptions of management, safety climate, stress recognition, job satisfaction, and work environment. Four ICUs in one tertiary care hospital. All ICU personnel. We conducted the survey from January 1 to April 1, 2003, and achieved a 70.2% response rate (318 of 453). We calculated safety culture factor mean and percent-positive scores (percentage of respondents with a mean score of > or =75 on a 0-100 scale for which 100 is best) for each ICU. We compared mean ICU scores by ANOVA and percent-positive scores by chi-square. Mean and percent-positive scores by job category were modeled using a generalized estimating equations approach and compared using Wald statistics. We asked ICU nursing directors to estimate their personnel's mean scores and generated ratios of their estimates to the actual scores.Overall, factor scores were low to moderate across all factors (range across ICUs: 43.4-74.9 mean scores, 8.6-69.4 percent positive). Mean and percent-positive scores differed significantly (p < .0083, Bonferroni correction) across ICUs, except for stress recognition, which was uniformly low. Compared with physicians, nurses had significantly lower mean working conditions and perceptions of management scores. ICU nursing directors tended to overestimate their personnel's attitudes. This was greatest for teamwork, for which all director estimates exceeded actual scores, with a mean overestimate of 16%. Significant safety culture variation exists across ICUs of a single hospital. ICU nursing directors tend to overestimate their personnel's attitudes, particularly for teamwork. Culture assessments based on institutional level analysis or director opinion may be flawed.

Palliative Care Consultations in the Neuro-ICU: A Qualitative Study.

PubMed

Tran, Len N; Back, Anthony L; Creutzfeldt, Claire J

2016-10-01

Integration of palliative care (PC) into the neurological intensive care unit (neuro-ICU) is increasingly recommended, but evidence regarding the best practice is lacking. We conducted a qualitative analysis exploring current practices and key themes of specialist PC consultations in patients admitted to a single neuro-ICU. We retrospectively identified all patients who were admitted to the neuro-ICU for ≥24 h and received a PC consultation between January and August 2014. We reviewed PC consultation notes and neuro-ICU progress notes from the electronic health records of these patients. We performed content analysis on the PC notes. Twenty-five neuro-ICU patients (4 %) received a PC consultation over 8 months with the most prevalent reason of clarifying goals of care. The main distinctions between patients with and those without (n = 580) a PC consultation were ICU length of stay (median 8.2 vs. 2.8 days) and death in the neuro-ICU (56 % vs. 11 %). The most prevalent themes addressed in the PC consultation notes were (1) discussing prognosis, (2) eliciting patient and family values, (3) understanding medical options, and (4) identifying conflict. PC consultations in the neuro-ICU emphasize family coping and decision-making by helping discuss prognosis and exploring patient and family values as well as their ability to understand the medical information. Several features suggest that earlier integration of PC into neuro-ICU care may enhance both coping and the decision-making process.

Palliative Care Needs Assessment in the Neuro-ICU: Effect on Family.

PubMed

Creutzfeldt, Claire J; Hanna, Marina G; Cheever, C Sherry; Lele, Abhijit V; Spiekerman, Charles; Engelberg, Ruth A; Curtis, J Randall

2017-10-01

Examine the association of a daily palliative care needs checklist on outcomes for family members of patients discharged from the neurosciences intensive care unit (neuro-ICU). We conducted a prospective, longitudinal cohort study in a single, thirty-bed neuro-ICU in a regional comprehensive stroke and level 1 trauma center. One of two neuro-ICU services that admit patients to the same ICU on alternating days used a palliative care needs checklist during morning work rounds. Between March and October, 2015, surveys were mailed to family members of patients discharged from the neuro-ICU. Nearly half of surveys (n = 91, 48.1%) were returned at a median of 4.7 months. At the time of survey completion, mean Modified rankin scale score (mRS) of neuro-ICU patients was 3.1 (SD 2). Overall ratings of quality of care were relatively high (82.2 on a 0-100 scale) with 32% of family members meeting screening criteria for depressive syndrome. The primary outcome measuring family satisfaction, consisting of eight items from the Family Satisfaction in the ICU questionnaire, did not differ significantly between families of patients from either ICU service nor did family ratings of depression (PHQ-8) and post-traumatic stress (PCL-17). Among families of patients discharged from the neuro-ICU, the daily use of a palliative care needs checklist had no measurable effect on family satisfaction scores or long-term psychological outcomes. Further research is needed to identify optimal interventions to meet the palliative care needs specific to family members of patients treated in the neuro-ICU.

Estimating ICU bed capacity using discrete event simulation.

PubMed

Zhu, Zhecheng; Hen, Bee Hoon; Teow, Kiok Liang

2012-01-01

The intensive care unit (ICU) in a hospital caters for critically ill patients. The number of the ICU beds has a direct impact on many aspects of hospital performance. Lack of the ICU beds may cause ambulance diversion and surgery cancellation, while an excess of ICU beds may cause a waste of resources. This paper aims to develop a discrete event simulation (DES) model to help the healthcare service providers determine the proper ICU bed capacity which strikes the balance between service level and cost effectiveness. The DES model is developed to reflect the complex patient flow of the ICU system. Actual operational data, including emergency arrivals, elective arrivals and length of stay, are directly fed into the DES model to capture the variations in the system. The DES model is validated by open box test and black box test. The validated model is used to test two what-if scenarios which the healthcare service providers are interested in: the proper number of the ICU beds in service to meet the target rejection rate and the extra ICU beds in service needed to meet the demand growth. A 12-month period of actual operational data was collected from an ICU department with 13 ICU beds in service. Comparison between the simulation results and the actual situation shows that the DES model accurately captures the variations in the system, and the DES model is flexible to simulate various what-if scenarios. DES helps the healthcare service providers describe the current situation, and simulate the what-if scenarios for future planning.

Intensive Care in Critical Access Hospitals

ERIC Educational Resources Information Center

Freeman, Victoria A.; Walsh, Joan; Rudolf, Matthew; Slifkin, Rebecca T.; Skinner, Asheley Cockrell

2007-01-01

Context: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. Purpose: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of…

Performance of a Modern Glucose Meter in ICU and General Hospital Inpatients: 3 Years of Real-World Paired Meter and Central Laboratory Results.

PubMed

Zhang, Ray; Isakow, Warren; Kollef, Marin H; Scott, Mitchell G

2017-09-01

Due to accuracy concerns, the Food and Drug Administration issued guidances to manufacturers that resulted in Center for Medicare and Medicaid Services stating that the use of meters in critically ill patients is "off-label" and constitutes "high complexity" testing. This is causing significant workflow problems in ICUs nationally. We wished to determine whether real-world accuracy of modern glucose meters is worse in ICU patients compared with non-ICU inpatients. We reviewed glucose results over the preceding 3 years, comparing results from paired glucose meter and central laboratory tests performed within 60 minutes of each other in ICU versus non-ICU settings. Seven ICU and 30 non-ICU wards at a 1,300-bed academic hospital in the United States. A total of 14,763 general medicine/surgery inpatients and 20,970 ICU inpatients. None. Compared meter results with near simultaneously performed laboratory results from the same patient by applying the 2016 U.S. Food and Drug Administration accuracy criteria, determining mean absolute relative difference and examining where paired results fell within the Parkes consensus error grid zones. A higher percentage of glucose meter results from ICUs than from non-ICUs passed 2016 Food and Drug Administration accuracy criteria (p < 10) when comparing meter results with laboratory results. At 1 minute, no meter result from ICUs posed dangerous or significant risk by error grid analysis, whereas at 10 minutes, less than 0.1% of ICU meter results did, which was not statistically different from non-ICU results. Real-world accuracy of modern glucose meters is at least as accurate in the ICU setting as in the non-ICU setting at our institution.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process.

PubMed

Schmidt, Matthieu; Demoule, Alexandre; Deslandes-Boutmy, Emmanuelle; Chaize, Marine; de Miranda, Sandra; Bèle, Nicolas; Roche, Nicolas; Azoulay, Elie; Similowski, Thomas

2014-06-04

ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation. Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation. The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.

Amoxicillin/clavulanate (Augmentin) resistant Escherichia coli in bacterial peritonitis after abdominal surgery--clinical outcome in ICU patients.

PubMed

Rahnama'i, M S; Wagenvoort, J H T; van der Linden, C J

2009-05-01

Bacterial resistance to antimicrobial agents is of great concern to clinicians. Patient outcome after infection is mainly dependent on the sensitivity of the bacterium to the agent used. We retrospectively studied 89 postoperative intensive care unit (ICU) patients with proven Escherichia coli peritonitis and investigated the clinical consequences of the E. coli resistance to amoxicillin/clavulanate. Significantly increased mortality, days of ventilation and ICU stay were noted in the co-amoxicillin/clavulanate resistant group. Furthermore, our results demonstrate that the sensitivity of E. coli to amoxicillin/clavulanate in the postoperative ICU setting has decreased in recent years. We can conclude that the current antibiotic regimen for the empirical treatment of ICU patients with peritonitis, as used in our hospital, needs to be changed. A switch, for instance, to ceftriaxone (Rocephin) in combination with metronidazole and gentamicin, instead of the present regimen of amoxicillin/clavulanate in combination with gentamicin, seems preferable.

The clinical relevance of the Waterlow pressure sore risk scale in the ICU.

PubMed

Weststrate, J T; Hop, W C; Aalbers, A G; Vreeling, A W; Bruining, H A

1998-08-01

To evaluate whether the Waterlow pressure sore risk (PSR) scale has prognostic significance for intensive care patients. A prospective study. The surgical intensive care unit (ICU) of the University Hospital Rotterdam. Data were evaluated from 594 patients who had been admitted to the ICU during the year 1994. Each patient was assessed daily with respect to their Waterlow PSR score and the development of pressure sores in the sacral region. Actuarial statistical methods were used to analyse the predictive value of the risk score. When a patient had a Waterlow PSR score > 25 on admission, the risk of developing a pressure sore was significantly increased compared to patients with a PSR score < 25. After admission, the daily Waterlow PSR scores obtained were significantly associated with the risk of developing a pressure sore. For each additional point this risk increased by 23% (95% confidence interval 17 to 28%). The Waterlow PSR scale provides the medical and nursing staff at an early stage with reliable information about the risk patients have in developing a pressure sore.

Visiting hours policies in New England intensive care units: strategies for improvement.

PubMed

Lee, Melissa D; Friedenberg, Allison S; Mukpo, David H; Conray, Kayla; Palmisciano, Amy; Levy, Mitchell M

2007-02-01

Dying patients often feel isolated and alone, and restricted visiting hours in the intensive care unit (ICU) has been shown to increase anxiety and dissatisfaction in both critically ill patients and their families. Unrestricted visiting has been identified as a top-ten need by families of patients in the ICU. Because emotional distress experienced by patients and families may persist well beyond the ICU stay, an open visiting policy, by meeting the needs of patients and families, may improve the quality of end-of-life care in the ICU. This two-part study included a survey to determine the visiting hours policies of New England-area hospital ICUs, and nursing focus groups to describe challenges and barriers that nursing staff working in an open ICU have experienced and to provide solutions that will facilitate implementation of an open visiting hours policy. Two-part study: survey and focus groups. ICUs in New England and one medical ICU in a tertiary care hospital. Registered nurses employed in medical ICUs. Adult ICUs in the six New England states were located using a library listing of all regional hospitals. A telephone questionnaire interview was used to ascertain visiting hours policies in each ICU. Six focus-group sessions were conducted with nursing staff who work in an urban, northeastern ICU with 8 yrs of experience with an unrestricted visiting hours policy. A total of 171 hospitals completed the questionnaire (96%). From all ICUs surveyed, 62 (32%) had unrestricted, open visiting hours. Out of these, 57 (92%) were medical ICUs or mixed medical/surgical ICUs. Nursing staff identified three major areas of concern with an open visiting hours policy: space, conflict, and burden. Strategies for resolution that are either employed or advocated by nursing staff are described. The majority of ICUs in New England have restricted visiting hours. Only one third of ICUs have open visiting policies. Nursing concerns with an unrestricted ICU were identified and solutions were offered that may provide guidance for other ICUs considering adopting an open visiting hours policy.

Diffusion of Evidence-based Intensive Care Unit Organizational Practices. A State-Wide Analysis.

PubMed

Kohn, Rachel; Madden, Vanessa; Kahn, Jeremy M; Asch, David A; Barnato, Amber E; Halpern, Scott D; Kerlin, Meeta Prasad

2017-02-01

Several intensive care unit (ICU) organizational practices have been associated with improved patient outcomes. However, the uptake of these evidence-based practices is unknown. To assess diffusion of ICU organizational practices across the state of Pennsylvania. We conducted two web-based, cross-sectional surveys of ICU organizational practices in Pennsylvania acute care hospitals, in 2005 (chief nursing officer respondents) and 2014 (ICU nurse manager respondents). Of 223 eligible respondents, nurse managers from 136 (61%) medical, surgical, mixed medical-surgical, cardiac, and specialty ICUs in 98 hospitals completed the 2014 survey, compared with 124 of 164 (76%) chief nursing officers in the 2005 survey. In 2014, daytime physician staffing models varied widely, with 23 of 136 (17%) using closed models and 33 (24%) offering no intensivist staffing. Nighttime intensivist staffing was used in 37 (27%) ICUs, 38 (28%) used nonintensivist attending staffing, and 24 (18%) had no nighttime attending physicians. Daily multidisciplinary rounds occurred in 93 (68%) ICUs. Regular participants included clinical pharmacists in 68 of 93 (73%) ICUs, respiratory therapists in 62 (67%), and advanced practitioners in 37 (39%). Patients and family members participated in rounds in 36 (39%) ICUs. Clinical protocols or checklists for mechanically ventilated patients were available in 128 of 133 (96%) ICUs, low tidal volume ventilation for acute respiratory distress syndrome in 54 of 132 (41%) ICUs, prone positioning for severe acute respiratory distress syndrome in 37 of 134 (28%) ICUs, and family meetings in 19 of 134 (14%) ICUs. Among 61 ICUs that responded to both surveys, there was a significant increase in the proportion of ICUs using nighttime in-ICU attending physicians (23 [38%] in 2005 vs. 30 [49%] in 2014; P = 0.006). The diffusion of evidence-based ICU organizational practices has been variable across the state of Pennsylvania. Only half of Pennsylvania ICUs have intensivists dedicated to the ICU. Variable numbers use clinical protocols for life-saving therapies, and few use structured family engagement strategies. In contrast, the diffusion of non-evidence-based practices, including overnight ICU attending physician staffing, is increasing. Future research should focus on promoting implementation of organizational evidence to promote high-quality ICU care.

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST-Segment-Elevation Myocardial Infarction.

PubMed

Fanaroff, Alexander C; Chen, Anita Y; Thomas, Laine E; Pieper, Karen S; Garratt, Kirk N; Peterson, Eric D; Newby, L Kristin; de Lemos, James A; Kosiborod, Mikhail N; Amsterdam, Ezra A; Wang, Tracy Y

2018-05-25

Intensive care unit (ICU) use for initially stable patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high-risk patients with NSTEMI for ICU admission. Using the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high-grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU-level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST-segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C-statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU. The ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

A Novel Picture Guide to Improve Spiritual Care and Reduce Anxiety in Mechanically Ventilated Adults in the Intensive Care Unit

PubMed Central

Berning, Joel N.; Poor, Armeen D.; Buckley, Sarah M.; Patel, Komal R.; Lederer, David J.; Goldstein, Nathan E.; Brodie, Daniel

2016-01-01

Rationale: Hospital chaplains provide spiritual care that helps patients facing serious illness cope with their symptoms and prognosis, yet because mechanically ventilated patients cannot speak, spiritual care of these patients has been limited. Objectives: To determine the feasibility and measure the effects of chaplain-led picture-guided spiritual care for mechanically ventilated adults in the intensive care unit (ICU). Methods: We conducted a quasi-experimental study at a tertiary care hospital between March 2014 and July 2015. Fifty mechanically ventilated adults in medical or surgical ICUs without delirium or dementia received spiritual care by a hospital chaplain using an illustrated communication card to assess their spiritual affiliations, emotions, and needs and were followed until hospital discharge. Feasibility was assessed as the proportion of participants able to identify spiritual affiliations, emotions, and needs using the card. Among the first 25 participants, we performed semistructured interviews with 8 ICU survivors to identify how spiritual care helped them. For the subsequent 25 participants, we measured anxiety (on 100-mm visual analog scales [VAS]) immediately before and after the first chaplain visit, and we performed semistructured interviews with 18 ICU survivors with added measurements of pain and stress (on ±100-mm VAS). Measurements and Main Results: The mean (SD) age was 59 (±16) years, median mechanical ventilation days was 19.5 (interquartile range, 7–29 d), and 15 (30%) died in-hospital. Using the card, 50 (100%) identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Anxiety after the first visit decreased 31% (mean score change, −20; 95% confidence interval, −33 to −7). Among 28 ICU survivors, 26 (93%) remembered the intervention and underwent semistructured interviews, of whom 81% felt more capable of dealing with their hospitalization and 0% felt worse. The 18 ICU survivors who underwent additional VAS testing during semistructured follow-up interviews reported a 49-point reduction in stress (95% confidence interval, −72 to −24) and no significant change in physical pain that they attributed to picture-guided spiritual care. Conclusions: Chaplain-led picture-guided spiritual care is feasible among mechanically ventilated adults and shows potential for reducing anxiety during and stress after an ICU admission. PMID:27097049

Quality of care in the intensive care unit from the perspective of patient's relatives: development and psychometric evaluation of the consumer quality index 'R-ICU'.

PubMed

Rensen, Ans; van Mol, Margo M; Menheere, Ilse; Nijkamp, Marjan D; Verhoogt, Ellen; Maris, Bea; Manders, Willeke; Vloet, Lilian; Verharen, Lisbeth

2017-01-24

The quality standards of the Dutch Society of Intensive Care require monitoring of the satisfaction of patient's relatives with respect to care. Currently, no suitable instrument is available in the Netherlands to measure this. This study describes the development and psychometric evaluation of the questionnaire-based Consumer Quality Index 'Relatives in Intensive Care Unit' (CQI 'R-ICU'). The CQI 'R-ICU' measures the perceived quality of care from the perspective of patients' relatives, and identifies aspects of care that need improvement. The CQI 'R-ICU' was developed using a mixed method design. Items were based on quality of care aspects from earlier studies and from focus group interviews with patients' relatives. The time period for the data collection of the psychometric evaluation was from October 2011 until July 2012. Relatives of adult intensive care patients in one university hospital and five general hospitals in the Netherlands were approached to participate. Psychometric evaluation included item analysis, inter-item analysis, and factor analysis. Twelve aspects were noted as being indicators of quality of care, and were subsequently selected for the questionnaire's vocabulary. The response rate of patients' relatives was 81% (n = 455). Quality of care was represented by two clusters, each showing a high reliability: 'Communication' (α = .80) and 'Participation' (α = .84). Relatives ranked the following aspects for quality of care as most important: no conflicting information, information from doctors and nurses is comprehensive, and health professionals take patients' relatives seriously. The least important care aspects were: need for contact with peers, nuisance, and contact with a spiritual counsellor. Aspects that needed the most urgent improvement (highest quality improvement scores) were: information about how relatives can contribute to the care of the patient, information about the use of meal-facilities in the hospital, and involvement in decision-making on the medical treatment of the patient. The CQI 'R-ICU' evaluates quality of care from the perspective of relatives of intensive care patients and provides practical information for quality assurance and improvement programs. The development and psychometric evaluation of the CQI 'R-ICU' led to a draft questionnaire, sufficient to justify further research into the reliability, validity, and the discriminative power of the questionnaire.

Mechanical ventilation strategies for intensive care unit patients without acute lung injury or acute respiratory distress syndrome: a systematic review and network meta-analysis.

PubMed

Guo, Lei; Wang, Weiwei; Zhao, Nana; Guo, Libo; Chi, Chunjie; Hou, Wei; Wu, Anqi; Tong, Hongshuang; Wang, Yue; Wang, Changsong; Li, Enyou

2016-07-22

It has been shown that the application of a lung-protective mechanical ventilation strategy can improve the prognosis of patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). However, the optimal mechanical ventilation strategy for intensive care unit (ICU) patients without ALI or ARDS is uncertain. Therefore, we performed a network meta-analysis to identify the optimal mechanical ventilation strategy for these patients. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, MEDLINE, CINAHL, and Web of Science for studies published up to July 2015 in which pulmonary compliance or the partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FIO2) ratio was assessed in ICU patients without ALI or ARDS, who received mechanical ventilation via different strategies. The data for study characteristics, methods, and outcomes were extracted. We assessed the studies for eligibility, extracted the data, pooled the data, and used a Bayesian fixed-effects model to combine direct comparisons with indirect evidence. Seventeen randomized controlled trials including a total of 575 patients who received one of six ventilation strategies were included for network meta-analysis. Among ICU patients without ALI or ARDS, strategy C (lower tidal volume (VT) + higher positive end-expiratory pressure (PEEP)) resulted in the highest PaO2/FIO2 ratio; strategy B (higher VT + lower PEEP) was associated with the highest pulmonary compliance; strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay; and strategy D (lower VT + zero end-expiratory pressure (ZEEP)) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance. For ICU patients without ALI or ARDS, strategy C (lower VT + higher PEEP) was associated with the highest PaO2/FiO2 ratio. Strategy B (higher VT + lower PEEP) was superior to the other strategies in improving pulmonary compliance. Strategy A (lower VT + lower PEEP) was associated with a shorter length of ICU stay, whereas strategy D (lower VT + ZEEP) was associated with the lowest PaO2/FiO2 ratio and pulmonary compliance.

Effect of Early Rehabilitation during Intensive Care Unit Stay on Functional Status: Systematic Review and Meta-Analysis

PubMed Central

Castro-Avila, Ana Cristina; Serón, Pamela; Fan, Eddy; Gaete, Mónica; Mickan, Sharon

2015-01-01

Background and Aim Critically ill survivors may have functional impairments even five years after hospital discharge. To date there are four systematic reviews suggesting a beneficial impact for mobilisation in mechanically ventilated and intensive care unit (ICU) patients, however there is limited information about the influence of timing, frequency and duration of sessions. Earlier mobilisation during ICU stay may lead to greater benefits. This study aims to determine the effect of early rehabilitation for functional status in ICU/high-dependency unit (HDU) patients. Design Systematic review and meta-analysis. MEDLINE, EMBASE, CINALH, PEDro, Cochrane Library, AMED, ISI web of science, Scielo, LILACS and several clinical trial registries were searched for randomised and non-randomised clinical trials of rehabilitation compared to usual care in adult patients admitted to an ICU/HDU. Results were screened by two independent reviewers. Primary outcome was functional status. Secondary outcomes were walking ability, muscle strength, quality of life, and healthcare utilisation. Data extraction and methodological quality assessment using the PEDro scale was performed by primary reviewer and checked by two other reviewers. The authors of relevant studies were contacted to obtain missing data. Results 5733 records were screened. Seven articles were included in the narrative synthesis and six in the meta-analysis. Early rehabilitation had no significant effect on functional status, muscle strength, quality of life, or healthcare utilisation. However, early rehabilitation led to significantly more patients walking without assistance at hospital discharge (risk ratio 1.42; 95% CI 1.17-1.72). There was a non-significant effect favouring intervention for walking distance and incidence of ICU-acquired weakness. Conclusions Early rehabilitation during ICU stay was not associated with improvements in functional status, muscle strength, quality of life or healthcare utilisation outcomes, although it seems to improve walking ability compared to usual care. Results from ongoing studies may provide more data on the potential benefits of early rehabilitation in critically ill patients. PMID:26132803

Touch: a nursing strategy in the intensive care unit.

PubMed

Estabrooks, C A

1989-07-01

In this article findings are reported from a qualitative study that examined touch from the perspective of intensive care (ICU) nurses. In-depth interviews with eight experienced ICU nurses and participant observation were used to collect data. Three distinct kinds of touch were identified, as well as normative patterns of touch among ICU nurses. The findings indicate that an understanding of touch is predicated on knowledge about the structural components of touch and the contextual variables and conditions that determine norms of touching. Touch is described as a multipurpose nursing strategy in the ICU. A need was identified to study a wider range of potential therapeutic and nontherapeutic touch meanings for nurses and patients than has previously been reported.

Predicting Length of Stay in Intensive Care Units after Cardiac Surgery: Comparison of Artificial Neural Networks and Adaptive Neuro-fuzzy System.

PubMed

Maharlou, Hamidreza; Niakan Kalhori, Sharareh R; Shahbazi, Shahrbanoo; Ravangard, Ramin

2018-04-01

Accurate prediction of patients' length of stay is highly important. This study compared the performance of artificial neural network and adaptive neuro-fuzzy system algorithms to predict patients' length of stay in intensive care units (ICU) after cardiac surgery. A cross-sectional, analytical, and applied study was conducted. The required data were collected from 311 cardiac patients admitted to intensive care units after surgery at three hospitals of Shiraz, Iran, through a non-random convenience sampling method during the second quarter of 2016. Following the initial processing of influential factors, models were created and evaluated. The results showed that the adaptive neuro-fuzzy algorithm (with mean squared error [MSE] = 7 and R = 0.88) resulted in the creation of a more precise model than the artificial neural network (with MSE = 21 and R = 0.60). The adaptive neuro-fuzzy algorithm produces a more accurate model as it applies both the capabilities of a neural network architecture and experts' knowledge as a hybrid algorithm. It identifies nonlinear components, yielding remarkable results for prediction the length of stay, which is a useful calculation output to support ICU management, enabling higher quality of administration and cost reduction.

Efficacy of a high-observation protocol in major head and neck cancer surgery: A prospective study.

PubMed

Barber, Brittany; Harris, Jeffrey; Shillington, Cameron; Rychlik, Shannon; Dort, Joseph; Meier, Michael; Estey, Angela; Elwi, Adam; Wickson, Patty; Buss, Michael; Zygun, David; Ansari, Kal; Biron, Vincent; O'Connell, Daniel; Seikaly, Hadi

2017-08-01

The purpose of this study was to optimize an existing clinical care pathway (CCP) for head and neck cancer with a high-observation protocol (HOP) and to determine the effect on length of intensive care unit (ICU) admission and length of stay in hospital (LOS). The HOP mandated initiation of spontaneous breathing trials before the conclusion of the surgery, weaning of sedation, and limiting mechanical ventilation. All patients with head and neck cancer undergoing primary surgery on the HOP were compared to a historical cohort regarding length of ICU admission, ICU readmissions, and LOS. Ninety-six and 52 patients were observed in "historical" and "HOP" cohorts. The length of ICU admission (1.9 vs 1.2 days; p = .021), LOS (20.3 vs 14.1 days; p = .020), and ICU readmissions (10.4% vs 1.9%; p = .013) were significantly decreased in the "HOP" cohort. Rapid weaning of sedation and limiting mechanical ventilation may contribute to a shorter length of ICU admission and LOS, as well as decreased ICU readmissions. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1689-1695, 2016. © 2017 Wiley Periodicals, Inc.

Reasons for refusal of admission to intensive care and impact on mortality.

PubMed

Iapichino, Gaetano; Corbella, Davide; Minelli, Cosetta; Mills, Gary H; Artigas, Antonio; Edbooke, David L; Pezzi, Angelo; Kesecioglu, Jozef; Patroniti, Nicolò; Baras, Mario; Sprung, Charles L

2010-10-01

To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward. A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality. Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in patients with greater severity of illness. We suggest that intensivists take great care to avoid ICU admission of patients judged not severe enough for ICU or with low performance status, and they tend to admit surgical patients more readily than medical patients. Interestingly, they do not judge age per se as a reason for refusal of ICU admission. Admission to ICU was associated with a reduction of both 28- and 90-day mortality, particularly in patients with greater severity of illness at time of triage.

Prognostic Factors for Hospital Mortality and ICU Admission in Patients With ANCA-Related Pulmonary Vasculitis

PubMed Central

Holguin, Fernando; Ramadan, Bassel; Gal, Anthony A.; Roman, Jesse

2015-01-01

Background The objective of this study was to evaluate the factors predictive of 28-day mortality and admission to Intensive Care Unit (ICU) in patients with ANCA-related pulmonary vasculitis. Methods We reviewed the medical records and imaging studies of 65 patients diagnosed with ANCA-related vasculitis hospitalized with pulmonary complications between February 1985 and November 2002. All patients underwent open or video-assisted thoracoscopic lung biopsy, had a positive ANCA serology, and were negative for glomerular basement membrane antibodies. Results At presentation, 72% had dyspnea, 68% fever, 47% cough, 45% elevated blood pressure, 32.3% hemoptysis, 26.1% sinus involvement, 15% renal failure, and 4.6% scleritis. Pathological findings included alveolar hemorrhage (60%), granulomatous inflammation (46%), and capillaritis (38%). A significant number required mechanical ventilation (27.7%), hemodialysis (24.6%), continuous renal replacement therapy (3.1%), and plasmapheresis (3.1%). The 28-day mortality was 16.9% (11/65). Mechanical ventilation (OR 68, P < 0.005), admission to ICU (OR 18.5, P < 0.01), and blood transfusion (OR 22.4, P < 0.004) were strong predictors of increased mortality within 28 days after admission. Respiratory failure (OR 31, P < 0.0007), hemoptysis (OR 2.9, P < 0.06), smoking (OR 5.9, P < 0.02), and acute renal failure (OR 7.8, P < 0.01) were also predictors for admission to the ICU. Conclusion In patients with ANCA-related pulmonary vasculitis several clinical factors, but not pathologic findings or ANCA titers, are associated with ICU admission and/or 28-day mortality. PMID:18854674

Use of Augmentative and Assistive Communication Strategies by Family Members in the ICU

PubMed Central

Broyles, Lauren M.; Tate, Judith A.; Happ, Mary Beth

2013-01-01

Background Very little is known about patient-family communication during critical illness and mechanical ventilation in the intensive care unit (ICU), including the use of augmentative and alternative communication (AAC) tools and strategies during patient-family communication. Objectives The study objectives were to identify (1) which AAC tools families use with nonspeaking ICU patients and how they are used, and (2) what families and nurses say about patient-family communication with nonspeaking patients in the ICU. Methods A qualitative secondary analysis was conducted of existing data from a clinical trial testing interventions to improve nurse-patient communication in the ICU. Narrative study data (field notes, intervention logs, nurse interviews) from 127 critically ill adults were reviewed for evidence of family involvement with AAC tools. Qualitative content analysis was applied for thematic description of family and nurse accounts of patient-family communication. Results Family involvement with AAC tools was evident in 44% (n= 41/93) of the patients completing the parent study protocol. Spouses/significant others communicated with patients most often. Writing was the most frequently used tool. Main themes describing patient-family communication included: (1) Families as unprepared and unaware; (2) Family perceptions of communication effectiveness; (3) Nurses deferring to or guiding patient-family communication; (4) Patient communication characteristics; and (5) Family experience and interest with AAC tools. Conclusions Families are typically unprepared for the communication challenges of critical illness, and often “on their own” in confronting them. Assessment by skilled bedside clinicians can reveal patient communication potential and facilitate useful AAC tools and strategies for patients and families. PMID:22381993

Clinical and Biological Predictors of Plasma Levels of Soluble RAGE in Critically Ill Patients: Secondary Analysis of a Prospective Multicenter Observational Study

PubMed Central

Pranal, Thibaut; Pereira, Bruno; Berthelin, Pauline; Roszyk, Laurence; Chabanne, Russell; Eisenmann, Nathanael; Lautrette, Alexandre; Belville, Corinne; Blondonnet, Raiko; Gillart, Thierry; Skrzypczak, Yvan; Souweine, Bertrand; Bouvier, Damien; Constantin, Jean-Michel

2018-01-01

Rationale Although soluble forms of the receptor for advanced glycation end products (RAGE) have been recently proposed as biomarkers in multiple acute or chronic diseases, few studies evaluated the influence of usual clinical and biological parameters, or of patient characteristics and comorbidities, on circulating levels of soluble RAGE in the intensive care unit (ICU) setting. Objectives To determine, among clinical and biological parameters that are usually recorded upon ICU admission, which variables, if any, could be associated with plasma levels of soluble RAGE. Methods Data for this ancillary study were prospectively obtained from adult patients with at least one ARDS risk factor upon ICU admission enrolled in a large multicenter observational study. At ICU admission, plasma levels of total soluble RAGE (sRAGE) and endogenous secretory (es)RAGE were measured by duplicate ELISA and baseline patient characteristics, comorbidities, and usual clinical and biological indices were recorded. After univariate analyses, significant variables were used in multivariate, multidimensional analyses. Measurements and Main Results 294 patients were included in this ancillary study, among whom 62% were admitted for medical reasons, including septic shock (11%), coma (11%), and pneumonia (6%). Although some variables were associated with plasma levels of RAGE soluble forms in univariate analysis, multidimensional analyses showed no significant association between admission parameters and baseline plasma sRAGE or esRAGE. Conclusions We found no obvious association between circulating levels of soluble RAGE and clinical and biological indices that are usually recorded upon ICU admission. This trial is registered with NCT02070536. PMID:29861796

Midodrine as adjunctive support for treatment of refractory hypotension in the intensive care unit: a multicenter, randomized, placebo controlled trial (the MIDAS trial).

PubMed

Anstey, Matthew H; Wibrow, Bradley; Thevathasan, Tharusan; Roberts, Brigit; Chhangani, Khushi; Ng, Pauline Yeung; Levine, Alexander; DiBiasio, Alan; Sarge, Todd; Eikermann, Matthias

2017-03-21

Patients admitted to intensive care units (ICU) are often treated with intravenous (IV) vasopressors. Persistent hypotension and dependence on IV vasopressors in otherwise resuscitated patients lead to delay in discharge from ICU. Midodrine is an oral alpha-1 adrenergic agonist approved for treatment of symptomatic orthostatic hypotension. This trial aims to evaluate whether oral administration of midodrine is an effective adjunct to standard therapy to reduce the duration of IV vasopressor treatment, and allow earlier discharge from ICU and hospital. The MIDAS trial is an international, multicenter, randomized, double-blind, placebo-controlled clinical trial being conducted in the USA and Australia. We are targeting 120 patients. Adult patients admitted to the ICU who are resuscitated and otherwise stable on low dose IV vasopressors for at least 24 h will be considered for recruitment. Participants will be randomized to receive midodrine (20 mg) or placebo three times a day, in addition to standard care. The primary outcome is time (hours) from initiation of midodrine or placebo to discontinuation of IV vasopressors. Secondary outcomes include time (hours) from ICU admission to discharge readiness, ICU length of stay (LOS) (days), hospital LOS (days), rates of ICU readmission, and rates of adverse events related to midodrine administration. Midodrine is approved by the Food and Drug Administration (FDA) for the treatment of symptomatic orthostatic hypotension. In August 2010, FDA proposed to withdraw approval of midodrine because of lack of studies that verify the clinical benefit of the drug. We obtained Investigational New Drug (IND 113,330) approval to study its effects in critically ill patients who require IV vasopressors but are otherwise ready for discharge from the ICU. A pilot observational study in a cohort of surgical ICU patients showed that the rate of decline in vasopressor requirements increased after initiation of midodrine treatment. We hypothesize that midodrine administration is effective to wean IV vasopressors and shorten ICU and hospital LOS. This trial may have significant implications on lowering costs of hospital care and obtaining FDA approval for new indications for midodrine. This study has been registered at clinicaltrials.gov on 02/09/2012 (NCT01531959).

Chapter 7. Critical care triage. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster.

PubMed

Christian, Michael D; Joynt, Gavin M; Hick, John L; Colvin, John; Danis, Marion; Sprung, Charles L

2010-04-01

To provide recommendations and standard operating procedures for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on critical care triage. Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including critical care triage. Key recommendations include: (1) establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resources; (2) developing fair and equitable policies may require restricting ICU services to patients most likely to benefit; (3) usual treatments and standards of practice may be impossible to deliver; (4) ICU care and treatments may have to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who do not improve or deteriorate; (5) triage criteria should be objective, ethical, transparent, applied equitably and be publically disclosed; (6) trigger triage protocols for pandemic influenza only when critical care resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts to extend resources or obtain additional resources; (7) triage of patients for ICU should be based on those who are likely to benefit most or a 'first come, first served' basis; (8) a triage officer should apply inclusion and exclusion criteria to determine patient qualification for ICU admission. Judicious planning and adoption of protocols for critical care triage are necessary to optimize outcomes during a pandemic.

Intensive care unit readmission during childhood after preterm birth with respiratory failure.

PubMed

Mourani, Peter M; Kinsella, John P; Clermont, Gilles; Kong, Lan; Perkins, Amy M; Weissfeld, Lisa; Cutter, Gary; Linde-Zwirble, Walter T; Abman, Steven H; Angus, Derek C; Watson, R Scott

2014-04-01

To determine the incidence and risk factors for readmission to the intensive care unit (ICU) among preterm infants who required mechanical ventilation at birth. We studied preterm newborns (birth weight 500-1250 g) who required mechanical ventilation at birth and were enrolled in a multicenter trial of inhaled nitric oxide therapy. Patients were assessed up to 4.5 years of age via annual in-person evaluations and structured telephone interviews. Univariate and multivariable analyses of baseline and birth hospitalization predictors of ICU readmission were performed. Of 512 subjects providing follow-up data, 58% were readmitted to the hospital (51% of these had multiple readmissions, averaging 3.9 readmissions per subject), 19% were readmitted to an ICU, and 12% required additional mechanical ventilation support. In univariate analyses, ICU readmission was more common among male subjects (OR 2.01; 95% CI 1.27-3.18), infants with grade 3-4 intracranial hemorrhage (OR 2.13; 95% CI 1.23-3.69), increasing duration of birth hospitalization (OR 1.01 per day; 95% CI 1.00-1.02), and prolonged oxygen therapy (OR 1.01 per day; 95% CI 1.00-1.01). In the first year after birth hospitalization, children readmitted to an ICU incurred greater health care costs (median $69,700 vs $30,200 for subjects admitted to the ward and $9600 for subjects never admitted). Small preterm infants who were mechanically ventilated at birth have substantial risk for readmission to an ICU and late mechanical ventilation, require extensive health care resources, and incur high treatment costs. Copyright © 2014 Mosby, Inc. All rights reserved.

Intensive Care Unit Admission and Death Rates of Infants Admitted With Respiratory Syncytial Virus Lower Respiratory Tract Infection in Mexico.

PubMed

Vizcarra-Ugalde, Sergio; Rico-Hernández, Montserrat; Monjarás-Ávila, César; Bernal-Silva, Sofía; Garrocho-Rangel, Maria E; Ochoa-Pérez, Uciel R; Noyola, Daniel E

2016-11-01

Respiratory syncytial virus (RSV) is the most common etiology for acute respiratory infection hospital admissions in young children. Case fatality rates for hospitalized patients range between 0% and 3.4%. Recent reports indicate that deaths associated with RSV are uncommon in developed countries. However, the role of this virus as a current cause of mortality in other countries requires further examination. Children with RSV infection admitted between May 2003 and December 2014 to a level 2 specialty hospital in Mexico were included in this analysis. Underlying risk factors, admission to the intensive care unit (ICU) and condition on discharge were assessed to determine the ICU admission and death rates associated to RSV infection. We analyzed data of 1153 patients with RSV infection in whom information regarding underlying illnesses and discharge status was available. Sixty patients (5.2 %) were admitted to the ICU and 12 (1.04 %) died. Relevant underlying conditions were present in 320 (27.7%) patients. Infants with underlying respiratory disorders (excluding asthma) and a history of prematurity had high ICU admission rates (17.1% and 13.8%, respectively). Mortality rates were highest for infants with respiratory disease (excluding asthma) (7.3%), cardiovascular diseases (5.9%) and neurologic disorders (5.3%). The ICU admission and death rates were higher in infants <6 months of age than in other age groups. The ICU admission rate and mortality rate in Mexican infants hospitalized with RSV infection were 5.2% and 1%, respectively. Mortality rates were high in infants with respiratory, cardiovascular and neurologic disorders.

Impact of a communication strategy on family satisfaction in the intensive care unit.

PubMed

Pagnamenta, Alberto; Bruno, Roberta; Gemperli, Armin; Chiesa, Alessandro; Previsdomini, Marco; Corti, Fabio; Merlani, Paolo; Cottini, Silvia; Llamas, Michael; Rothen, Hans Ulrich

2016-07-01

Family satisfaction of critically ill patients has gained increased interest as important indicator to evaluate the quality of care in the intensive care unit (ICU). The family satisfaction in the ICU questionnaire (FS-ICU 24) is a well-established tool to assess satisfaction in such settings. We tested the hypothesis that an intervention, aiming at improved communication between health professionals and patients' next of kin in the ICU improves family satisfaction, as assessed by FS-ICU 24. Using a multicenter before-and-after study design, we evaluated medium-term effectiveness of VALUE, a recently proposed strategy aiming at improved communication. Satisfaction was assessed using the FS-ICU 24 questionnaire. Performance-importance plots were generated in order to identify items highly correlated with overall satisfaction but with low individual score. A total of 163 completed family questionnaires in the pre-intervention and 118 in the post-intervention period were analyzed. Following the intervention, we observed: (1) a non-significant increase in family satisfaction summary score and sub-scores; (2) no decline in any individual family satisfaction item, and (3) improvement in items with high overall impact on satisfaction but quoted with low degree of satisfaction. No significant improvement in family satisfaction of critically ill adult patients could be found after implementing the VALUE strategy. Whether these results are due to insufficient training of the new strategy or a missing effect of the strategy in our socio-economic environment remains to be shown. © 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Potential Adverse Effects of Broad-Spectrum Antimicrobial Exposure in the Intensive Care Unit

PubMed Central

Wiens, Jenna; Finlayson, Samuel; Mahoney, Monica V; Celi, Leo Anthony

2018-01-01

Abstract Background The potential adverse effects of empiric broad-spectrum antimicrobial use among patients with suspected but subsequently excluded infection have not been fully characterized. We sought novel methods to quantify the risk of adverse effects of broad-spectrum antimicrobial exposure among patients admitted to an intensive care unit (ICU). Methods Among all adult patients admitted to ICUs at a single institution, we selected patients with negative blood cultures who also received ≥1 broad-spectrum antimicrobials. Broad-spectrum antimicrobials were categorized in ≥1 of 5 categories based on their spectrum of activity against potential pathogens. We performed, in serial, 5 cohort studies to measure the effect of each broad-spectrum category on patient outcomes. Exposed patients were defined as those receiving a specific category of broad-spectrum antimicrobial; nonexposed were all other patients in the cohort. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay and nosocomial acquisition of antimicrobial-resistant bacteria (ARB) or Clostridium difficile within 30 days of admission. Results Among the study cohort of 1918 patients, 316 (16.5%) died within 30 days, 821 (42.8%) had either a length of hospital stay >7 days or an ICU length of stay >3 days, and 106 (5.5%) acquired either a nosocomial ARB or C. difficile. The short-term use of broad-spectrum antimicrobials in any of the defined broad-spectrum categories was not significantly associated with either primary or secondary outcomes. Conclusions The prompt and brief empiric use of defined categories of broad-spectrum antimicrobials could not be associated with additional patient harm. PMID:29479546

Incidence of pulmonary aspergillosis and correlation of conventional diagnostic methods with nested PCR and real-time PCR assay using BAL fluid in intensive care unit patients.

PubMed

Zarrinfar, Hossein; Makimura, Koichi; Satoh, Kazuo; Khodadadi, Hossein; Mirhendi, Hossein

2013-05-01

Although the incidence of invasive aspergillosis in the intensive care unit (ICU) is scarce, it has emerged as major problems in critically ill patients. In this study, the incidence of pulmonary aspergillosis (PA) in ICU patients has evaluated and direct microscopy and culture has compared with nested polymerase chain reaction (PCR) and real-time PCR for detection of Aspergillus fumigatus and A. flavus in bronchoalveolar lavage (BAL) samples of the patients. Thirty BAL samples obtained from ICU patients during a 16-month period were subjected to direct examinations on 20% potassium hydroxide (KOH) and culture on two culture media. Nested PCR targeting internal transcribed spacer ribosomal DNA and TaqMan real-time PCR assay targeting β-tubulin gene were used for the detection of A. fumigatus and A. flavus. Of 30 patients, 60% were men and 40% were women. The diagnosis of invasive PA was probable in 1 (3%), possible in 11 (37%), and not IPA in 18 (60%). Nine samples were positive in nested PCR including seven samples by A. flavus and two by A. fumigatus specific primers. The lowest amount of DNA that TaqMan real-time PCR could detect was ≥40 copy numbers. Only one of the samples had a positive result of A. flavus real-time PCR with Ct value of 37.5. Although a significant number of specimens were positive in nested PCR, results of this study showed that establishment of a correlation between the conventional methods with nested PCR and real-time PCR needs more data confirmed by a prospective study with a larger sample group. © 2013 Wiley Periodicals, Inc.

Intensive care unit patients with 2009 pandemic influenza A (H1N1pdm09) virus infection - United States, 2009.

PubMed

Bramley, Anna M; Dasgupta, Sharoda; Skarbinski, Jacek; Kamimoto, Laurie; Fry, Alicia M; Finelli, Lyn; Jain, Seema

2012-11-01

The influenza A (H1N1pdm09) [pH1N1] virus resulted in intensive care unit (ICU) admissions, acute respiratory distress syndrome (ARDS), and death.   To describe the characteristics of ICU patients with pH1N1 virus infection in the United States during the spring and fall of 2009 and to describe the factors associated with severe complications including ARDS and death.   Through two national case-series conducted during spring and fall of 2009, medical charts were reviewed on ICU patients with laboratory-confirmed pH1N1 infection by real-time reverse-transcriptase polymerase chain reaction.   The majority (77%) of 154 patients hospitalized in an ICU were <50 years of age, and 65% had at least one underlying medical condition. One hundred and twenty-eight (83%) patients received influenza antiviral agents; 29% received treatment ≤ 2 days after illness onset. Forty-eight (38%) patients developed ARDS and 37 (24%) died. Patients with ARDS were more likely to be morbidly obese (36% versus 19%, P=0.04) and patients who died were less likely to have asthma (11% versus 28%, P=0.05). Compared with patients who received treatment ≥ 6 days after illness onset, patients treated ≤ 2 days after illness onset were less likely to develop ARDS (17% versus 37%, P<0.01) or die (7% versus 35%, P<0.01). Among patients hospitalized in an ICU with pH1N1 virus infection, ARDS was a common complication, and one-quarter of patients died. Patients with asthma had less severe outcomes. Early treatment with influenza antiviral agents was likely beneficial, especially when initiated ≤ 2 days after illness onset. Published 2012. This article is a US Government work and is in the public domain in the USA.

Experiences of ICU survivors in a low middle income country- a multicenter study.

PubMed

Pieris, Lalitha; Sigera, Ponsuge Chathurani; De Silva, Ambepitiyawaduge Pubudu; Munasinghe, Sithum; Rashan, Aasiyah; Athapattu, Priyantha Lakmini; Jayasinghe, Kosala Saroj Amarasiri; Samarasinghe, Kerstein; Beane, Abi; Dondorp, Arjen M; Haniffa, Rashan

2018-03-21

Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC. This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors' experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright. Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%). The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be "very satisfactory" (93.8%, n = 411) with none of the survivors stating they were either "dissatisfied" or "very dissatisfied". In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns.

Long-term outcome of elderly patients requiring intensive care admission for abdominal pathologies: survival and quality of life.

PubMed

Merlani, P; Chenaud, C; Mariotti, N; Ricou, B

2007-05-01

Medical developments have allowed the management of patients aged over 70 years with severe abdominal pathologies requiring intensive care unit (ICU) admission. These patients require enhanced life support and present a high ICU mortality. We investigated the outcome and quality of life (QOL) of elderly patients 2 years after their ICU stay for abdominal pathologies. Patients aged 70 years or over with abdominal pathologies, admitted to our ICU over a period of 2 years, were included. Two years following their ICU stay, a letter informed the patients about the present study. Consent to participate was obtained by telephone. QOL was assessed by the Euro-QOL and Short Form-36 questionnaires. Other patient-centered outcomes were evaluated. Overall, 2780 patients were admitted to the ICU during the study period; 141 (5%) patients were eligible; 112 of the 141 (79%) survived their ICU stay, 95 (67%) survived their hospital stay and 52 (37%) were alive 2 years after their ICU stay; 36 of the 52 survivors (69%) answered the questionnaire. Their QOL 2 years after their ICU stay was decreased in comparison with an age-matched population. Eighty-one per cent of patients lived at home and 57% were totally independent. They perceived their ICU stay as positive and 75% stated that they would agree to go through intensive care again. Factors associated with 2-year survival were the absence of co-morbidity, absence of malignancy and a lower Simplified Acute Physiology II score on ICU admission. A high mortality rate and a decrease in QOL were observed in elderly patients with severe abdominal pathologies. Nonetheless, these patients were able to adapt well to their physical disabilities.

Severity of acidosis affects long-term survival in COPD patients with hypoxemia after intensive care unit discharge.

PubMed

Gungor, Sinem; Kargin, Feyza; Irmak, Ilim; Ciyiltepe, Fulya; Acartürk Tunçay, Eylem; Atagun Guney, Pinar; Aksoy, Emine; Ocakli, Birsen; Adiguzel, Nalan; Karakurt, Zuhal

2018-01-01

Patients admitted to the intensive care unit (ICU) with acute respiratory failure (ARF) due to COPD have high mortality and morbidity. Acidosis has several harmful effects on hemodynamics and metabolism, and the current knowledge regarding the relationship between respiratory acidosis severity on the short- and long-term survival of COPD patients is limited. We hypothesized that COPD patients with severe acidosis would have a poorer short- and long-term prognosis compared with COPD patients with mild-to-moderate acidosis. This retrospective observational cohort study was conducted in a level III respiratory ICU of a tertiary teaching hospital for chest diseases between December 1, 2013, and December 30, 2014. Subject characteristics, comorbidities, ICU parameters, duration of mechanical ventilation, length of ICU stay, ICU mortality, use of domiciliary noninvasive mechanical ventilation (NIMV) and long-term oxygen therapy (LTOT), and short- and long-term mortality were recorded. Patients were grouped according to their arterial blood gas (ABG) values during ICU admission: severe acidotic (pH≤7.20) and mild-to-moderate acidotic (pH 7.21-7.35). These groups were compared with the recorded data. The mortality predictors were analyzed by logistic regression test in the ICU and the Cox regression test for long-term mortality predictors. During the study period, a total of 312 COPD patients admitted to the ICU with ARF, 69 (72.5% male) in the severe acidosis group and 243 (79% male) in the mild-to-moderate acidosis group, were enrolled. Group demographics, comorbidities, duration of mechanical ventilation, and length of ICU stay were similar in the two groups. The severe acidosis group had a significantly higher rate of NIMV failure (60.7% vs 40%) in the ICU. Mild-to-moderate acidotic COPD patients using LTOT had longer survival after ICU discharge than those without LTOT. On the other hand, severely acidotic COPD patients without LTOT showed shorter survival than those with LTOT. Kaplan-Meier cumulative survival analysis showed that the 28-day and 1-, 2-, and 3-year mortality rates were 12.2%, 36.2%, 52.6%, 63.3%, respectively ( p =0.09). The Cox regression analyses showed that older age, PaO 2 /FiO 2 <300 mmHg, and body mass index ≤20 kg/m 2 was associated with mortality of all patients after 3 years. Severely acidotic COPD patients had a poorer short- and long-term prognosis compared with mild-to-moderate acidotic COPD patients if acute and chronic hypoxemia was predominant.

Economic outcomes of influenza in hospitalized elderly with and without ICU admission.

PubMed

Chan, Yik-Kei; Wong, Rity Yk; Ip, Margaret; Lee, Nelson Ls; You, Joyce Hs

2017-01-01

To describe direct medical costs of influenza in hospitalized elderly, with and without intensive care unit (ICU) admission, during the 2014-2015 season in Hong Kong. A retrospective study was conducted in 110 inpatients aged ≥65 years with laboratory-confirmed influenza treated by antiviral therapy during season 2014-2015 in a tertiary hospital. Resource utilization of influenza-related diagnostic and laboratory tests, medications for influenza treatment, usage of general medical ward and ICU during the influenza-related length of hospital stay (IR-LOS) were collected. There were 18 (16.4%) and 92 (83.4%) cases with and without ICU admission, respectively. The difference in influenza-related mortality rates between patients with (11.1%) and without ICU admission (2.2%) was not statistically significant (P=0.064). Patients with ICU admission reported longer IR-LOS (12.7 ±6.0 days versus 5.5 ±2.7 days; P<0.001) and higher direct costs (36,588 USD ±21,482 versus 5,773 USD ±2,017; P<0.001; 1 USD=7.8 HKD). Male gender (OR=14.50; 95% CI 1.68, 125.07) and respiratory complications (OR=9.61; 95% CI 1.90, 48.50) were positive predictors of ICU admission. Age ≥70 years (OR=0.09; 95% CI 0.02, 0.46) and antiviral therapy initiation within 7 days (OR=0.05; 95% CI 0.003, 0.79) were negative predictors of ICU admission. Influenza B was a positive predictor of high-cost hospitalization in non-ICU survivors (OR=7.33; 95% CI 1.24, 43.29). No predictor of mortality was identified. Hospitalization cost in elderly for seasonal influenza was substantial in Hong Kong. The cost in patients with ICU admission was significantly higher than those without ICU care. Respiratory complications and male gender predicted ICU admission. Influenza B infection predicted high-cost hospitalization in non-ICU survivors.

MIMIC II: a massive temporal ICU patient database to support research in intelligent patient monitoring

NASA Technical Reports Server (NTRS)

Saeed, M.; Lieu, C.; Raber, G.; Mark, R. G.

2002-01-01

Development and evaluation of Intensive Care Unit (ICU) decision-support systems would be greatly facilitated by the availability of a large-scale ICU patient database. Following our previous efforts with the MIMIC (Multi-parameter Intelligent Monitoring for Intensive Care) Database, we have leveraged advances in networking and storage technologies to develop a far more massive temporal database, MIMIC II. MIMIC II is an ongoing effort: data is continuously and prospectively archived from all ICU patients in our hospital. MIMIC II now consists of over 800 ICU patient records including over 120 gigabytes of data and is growing. A customized archiving system was used to store continuously up to four waveforms and 30 different parameters from ICU patient monitors. An integrated user-friendly relational database was developed for browsing of patients' clinical information (lab results, fluid balance, medications, nurses' progress notes). Based upon its unprecedented size and scope, MIMIC II will prove to be an important resource for intelligent patient monitoring research, and will support efforts in medical data mining and knowledge-discovery.

Exploring performance obstacles of intensive care nurses.

PubMed

Gurses, Ayse P; Carayon, Pascale

2009-05-01

High nursing workload, poor patient safety, and poor nursing quality of working life (QWL) are major issues in intensive care units (ICUs). Characteristics of the ICU and performance obstacles may contribute to these issues. The goal of this study was to comprehensively identify the performance obstacles perceived by ICU nurses. We used a qualitative research design and conducted semi-structured interviews with 15 ICU nurses of a medical-surgical ICU. Based on this qualitative study and a previously reported quantitative study, we identified seven main types of performance obstacles experienced by ICU nurses. Obstacles related to the physical environment (e.g., noise, amount of space), family relations (e.g., distractions caused by family, lack of time to spend with family), and equipment (e.g., unavailability, misplacement) were the most frequently experienced performance obstacles. The qualitative interview data provided rich information regarding the factors contributing to the performance obstacles. Overall, ICU nurses experience a variety of performance obstacles in their work on a daily basis. Future research is needed to understand the impact of performance obstacles on nursing workload, nursing QWL, and quality and safety of care.

Assessing organizational performance in intensive care units: a French experience.

PubMed

Minvielle, Etienne; Aegerter, Philippe; Dervaux, Benoît; Boumendil, Ariane; Retbi, Aurélia; Jars-Guincestre, Marie Claude; Guidet, Bertrand

2008-06-01

The objective of the study was to assess and to explain variation of organizational performance in intensive care units (ICUs). This was a prospective multicenter study. The study involved 26 ICUs located in the Paris area, France, participating in a regional database. Data were collected through answers of 1000 ICU personnel to the Culture, Organization, and Management in Intensive Care questionnaire and from the database. Organizational performance was assessed through a composite score related to 5 dimensions: coordination and adaptation to uncertainty, communication, conflict management, organizational change, and organizational learning, Skills developed in relationship with patients and their families. Statistical comparisons between ICUs were performed by analysis of variance with a Scheffé pairwise procedure. A multilevel regression model was used to analyze both individual and structural variables explaining differences of ICU's organizational performance. The organizational performance score differed among ICUs. Some cultural values were negatively correlated with a high level of organizational performance, suggesting improvement potential. Several individual and structural factors were also related to the quality of ICU organization, including absence of burnout, older staff, satisfaction to work, and high workload (P < .02 for each). A benchmarking approach can be used by ICU managers to assess the organizational performance of their ICU based on a validated questionnaire. Differences are mainly explained by cultural values and individual well-being factors, introducing new requirements for managing human resources in ICUs.

Anaerobic antibiotic usage for pneumonia in the medical intensive care unit.

PubMed

Kioka, Mutsumi J; DiGiovine, Bruno; Rezik, Mohamed; Jennings, Jeffrey H

2017-11-01

Pneumonia is a common admitting diagnosis in the intensive care unit (ICU). When aspiration is suspected, antibiotics to cover anaerobes are frequently used, but in the absence of clear risk factors, current guidelines have questioned their role. It is unknown how frequently these guidelines are followed. We conducted a single-centre observational study on practice patterns of anaerobic antibiotic use in consecutive patients admitted to the ICU with aspiration pneumonia (Asp), community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP). A total of 192 patients were studied (Asp: 20, HCAP: 107, CAP: 65). Overall, 59 patients received anaerobic antibiotics (Asp: 90%, HCAP: 28%, CAP 17%) but a significant proportion of these patients did not meet criteria to receive them. Inappropriate anaerobic antibiotic use was 12/20 for Asp, 27/107 for HCAP and 9/65 for CAP. Mortality probability model III at zero hours (MPM0) score and a diagnosis of Asp were predictors of receiving inappropriate anaerobic antibiotics. Receiving inappropriate anaerobic antibiotics was associated with a longer ICU length of stay (LOS; 7 days (interquartile range (IQR): 7-21) vs 4 days (IQR:2-9), P = 0.017). For patients in the ICU admitted with pneumonia, there is a high occurrence of inappropriately prescribed anaerobic antibiotics, the use of which was associated with a longer ICU LOS. © 2017 Asian Pacific Society of Respirology.

The management of Convulsive Refractory Status Epilepticus in adults in the UK: No consistency in practice and little access to continuous EEG monitoring.

PubMed

Patel, Mitesh; Bagary, Manny; McCorry, Dougall

2015-01-01

Convulsive Status Epilepticus (CSE) is a common neurological emergency with patients presenting with prolonged epileptic activity. Sub-optimal management is coupled with high morbidity and mortality. Continuous electroencephalogram (EEG) monitoring is considered essential by the National Institute for Health and Care Excellence (NICE) in the management of Convulsive Refractory Status Epilepticus (CRSE). The aim of this research was to determine current clinical practice in the management of CRSE amongst adults in intensive care units (ICU) in the UK and establish if the use of a standardised protocol requires re-enforcement within trusts. 75 randomly selected UK NHS Trusts were contacted and asked to complete a questionnaire in addition to providing their protocol for CRSE management in ICU. 55 (73%) trusts responded. While 31 (56% of responders) had a protocol available in ICU for early stages of CSE, just 21 (38%) trusts had specific guidelines if CRSE occurred. Only 23 (42%) trusts involved neurologists at any stage of management and just 18 (33%) have access to continuous EEG monitoring. This study identifies significant inconsistency in the management of CSE in ICU's across the UK. A minority of ICU units have a protocol for CRSE or access to continuous EEG monitoring despite it being considered fundamental for management and supported by NICE guidance. Copyright © 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.