Granholm, A.; Perner, A.; Krag, M.
Background: Intensive care unit (ICU) mortality prediction scores deteriorate over time, and their complexity decreases clinical applicability and commonly causes problems with missing data. We aimed to develop and internally validate a new and simple score that predicts 90-day mortality in adults...... upon acute admission to the ICU: the Simplified Mortality Score for the Intensive Care Unit (SMS-ICU). Methods: We used data from an international cohort of 2139 patients acutely admitted to the ICU and 1947 ICU patients with severe sepsis/septic shock from 2009 to 2016. We performed multiple...... imputations for missing data and used binary logistic regression analysis with variable selection by backward elimination, followed by conversion to a simple point-based score. We assessed the apparent performance and validated the score internally using bootstrapping to present optimism-corrected performance...
Full Text Available Abstract Background Accurate cost estimate and a profit and loss analysis are necessary for health care practice. We performed an actual financial analysis for an intensive care unit (ICU of a university hospital in Japan, and tried to discuss the health care policy and resource allocation decisions that have an impact on critical intensive care. Methods The costs were estimated by a department level activity based costing method, and the profit and loss analysis was based on a break-even point analysis. The data used included the monthly number of patients, the revenue, and the direct and indirect costs of the ICU in 2003. Results The results of this analysis showed that the total costs of US$ 2,678,052 of the ICU were mainly incurred due to direct costs of 88.8%. On the other hand, the actual annual total patient days in the ICU were 1,549 which resulted in revenues of US$ 2,295,044. However, it was determined that the ICU required at least 1,986 patient days within one fiscal year based on a break-even point analysis. As a result, an annual deficit of US$ 383,008 has occurred in the ICU. Conclusion These methods are useful for determining the profits or losses for the ICU practice, and how to evaluate and to improve it. In this study, the results indicate that most ICUs in Japanese hospitals may not be profitable at the present time. As a result, in order to increase the income to make up for this deficit, an increase of 437 patient days in the ICU in one fiscal year is needed, and the number of patients admitted to the ICU should thus be increased without increasing the number of beds or staff members. Increasing the number of patients referred from cooperating hospitals and clinics therefore appears to be the best strategy for achieving these goals.
Mansoor, F.; Akhtar, A.; Qadeer, A.; Ali, Z.; Kaleem, B.; Sikandar, I.
Objective: To identity the risk factors on intensive care unit (ICU) admission that are linked with ICU mortality in patients with severe pneumonia. Study Design: A retrospective observational study. Place and Duration of Study: Patients admitted to the medical ICU in Shifa International Hospital, Islamabad, between October 2013 and March 2014. Material and Methods: Adult patients admitted to the ICU with the suspected diagnosis of severe pneumonia were studied. In addition to the co-morbidities, presence or absence of septic shock and acute kidney injury, PaO/sub 2//FiO/sub 2/ ratio and type of mechanical ventilation were recorded on ICU admission. This data was initially recorded on paper forms and latter entered in the SPSS. Bivariate analysis was performed to study the relationship between these risk factors and their effect on the ICU mortality. Results: We evaluated a total number of 82 patients with severe pneumonia. ICU mortality was 14.8 percent (12 patients). Statistical analysis showed that patients with severe acute respiratory distress syndrome (ARDS), septic shock, history of chronic liver disease and human immunodeficiency virus (HIV) neutropenic sepsis and those who received invasive mechanical ventilation were at higher risk of mortality. We did not find any direct correlation between age, presence of acute kidney injury, history of diabetes mellitus and risk of death in the ICU. Conclusion: In adult patients, septic shock, severe ARDS, history of chronic liver disease, neutropenic sepsis and presence of HIV, and invasive mechanical ventilation are associated with a higher risk of ICU mortality in patients admitted with severe pneumonia. (author)
Full Text Available Tanyong Pipanmekaporn,1 Nahathai Wongpakaran,2 Sirirat Mueankwan,3 Piyawat Dendumrongkul,2 Kaweesak Chittawatanarat,3 Nantiya Khongpheng,3 Nongnut Duangsoy31Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 2Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; 3Division of Surgical Critical Care and Trauma, Department of Surgery, Chiang Mai University Hospital, Chiang Mai, ThailandPurpose: The purpose of this study was to determine the validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU, when compared to the diagnoses made by delirium experts.Patients and methods: This was a cross-sectional study conducted in both surgical intensive care and subintensive care units in Thailand between February–June 2011. Seventy patients aged 60 years or older who had been admitted to the units were enrolled into the study within the first 48 hours of admission. Each patient was randomly assessed as to whether they had delirium by a nurse using the Thai version of the CAM-ICU algorithm (Thai CAM-ICU or by a delirium expert using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.Results: The prevalence of delirium was found to be 18.6% (n=13 by the delirium experts. The sensitivity of the Thai CAM-ICU’s algorithms was found to be 92.3% (95% confidence interval [CI] =64.0%-99.8%, while the specificity was 94.7% (95% CI =85.4%-98.9%. The instrument displayed good interrater reliability (Cohen’s κ=0.81; 95% CI =0.64-0.99. The time taken to complete the Thai CAM-ICU was 1 minute (interquatile range, 1-2 minutes.Conclusion: The Thai CAM-ICU demonstrated good validity, reliability, and ease of use when diagnosing delirium in a surgical intensive care unit setting. The use of this diagnostic tool should be encouraged for daily, routine use, so as to promote the early detection
Lefrant, Jean-Yves; Garrigues, Bernard; Pribil, Céline; Bardoulat, Isabelle; Courtial, Frédéric; Maurel, Frédérique; Bazin, Jean-Étienne
To estimate the daily cost of intensive care unit (ICU) stays via micro-costing. A multicentre, prospective, observational, cost analysis study was carried out among 21 out of 23 French ICUs randomly selected from French National Hospitals. Each ICU randomly enrolled 5 admitted adult patients with a simplified acute physiology II score ≥ 15 and with at least one major intensive care medical procedure. All health-care human resources used by each patient over a 24-hour period were recorded, as well as all medications, laboratory analyses, investigations, tests, consumables and administrative expenses. All resource costs were estimated from the hospital's perspective (reference year 2009) based on unitary cost data. One hundred and four patients were included (mean age: 62.3 ± 14.9 years, mean SAPS II: 51.5 ± 16.1, mean SOFA on the study day: 6.9 ± 4.3). Over 24 hours, 29 to 186 interventions per patient were performed by different caregivers, leading to a mean total time spent for patient care of 13:32 ± 05:00 h. The total daily cost per patient was € 1425 ± € 520 (95% CI = € 1323 to € 1526). ICU human resources represented 43% of total daily cost. Patient-dependent expenses (€ 842 ± € 521) represented 59% of the total daily cost. The total daily cost was correlated with the daily SOFA score (r = 0.271, P = 0.006) and the bedside-time given by caregivers (r = 0.716, P average cost of one day of ICU care in French National Hospitals is strongly correlated with the duration of bedside-care carried out by human resources. Copyright © 2015. Published by Elsevier Masson SAS.
Sasaki, Hatoko; Yonemoto, Naohiro; Mori, Rintaro; Nishida, Toshihiko; Kusuda, Satoshi; Nakayama, Takeo
Although communication among health providers has become a critical part of improving quality of care, few studies on this topic have been conducted in Japan. This study aimed to examine the reliability and validity of the Intensive Care Unit Nurse-Physician Questionnaire (ICU N-P-Q) for use among nurses and physicians in neonatal ICUs (NICUs) in Japan. A Japanese translation of the ICU N-P-Q was administered to physicians and nurses working at 40 NICUs across Japan, which were participating in the Improvement of NICU Practice and Team Approach Cluster randomized controlled trial (INTACT). We used the principal components analysis to evaluate the factor structure of the instruments. Convergent validity was assessed by examining correlations between the subscales of Communication and Conflict Management of the ICU N-P-Q and the subscales and total score of the Nurse-Physician Collaboration Scale (NPCS). Correlations between the subscales of Communication and Conflict Management by correlation with scales that refer to performance, including Job Satisfaction and Unit Effectiveness, were calculated to test the criterion validity. In total, 2006 questionnaires were completed by 316 physicians and 1690 nurses. The exploratory factor analysis revealed 15 factors in the physicians' questionnaire and 12 in the nurses' questionnaire. Convergent validity was confirmed, except for 'Between-group Accuracy' and 'Cooperativeness' in the physicians' scale, and for 'Between-group Accuracy' and 'Sharing of Patient Information' in the nurses' scale. Correlations between the subscales of communication and outcomes were confirmed in the nurses' questionnaire but were not fully supported in the physicians' questionnaire. Although the psychometric property behaved somewhat differently by occupation, the present findings provide preliminary support for the utility of the common item structure with the original scale, to measure the degree and quality of communication and collaboration
Mitasova, Adela; Kostalova, Milena; Bednarik, Josef; Michalcakova, Radka; Kasparek, Tomas; Balabanova, Petra; Dusek, Ladislav; Vohanka, Stanislav; Ely, E Wesley
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
Granholm, Anders; Perner, Anders; Krag, Mette
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...
Baddley John W
Full Text Available Abstract Background Few data are available regarding the epidemiology of invasive aspergillosis (IA in ICU patients. The aim of this study was to examine epidemiology and economic outcomes (length of stay, hospital costs among ICU patients with IA who lack traditional risk factors for IA, such as cancer, transplants, neutropenia or HIV infection. Methods Retrospective cohort study using Premier Inc. Perspective™ US administrative hospital database (2005–2008. Adults with ICU stays and aspergillosis (ICD-9 117.3 plus 484.6 who received initial antifungal therapy (AF in the ICU were included. Patients with traditional risk factors (cancer, transplant, neutropenia, HIV/AIDS were excluded. The relationship of antifungal therapy and co-morbidities to economic outcomes were examined using Generalized linear models. Results From 6,424 aspergillosis patients in the database, 412 (6.4% ICU patients with IA were identified. Mean age was 63.9 years and 53% were male. Frequent co-morbidities included steroid use (77%, acute respiratory failure (76% and acute renal failure (41%. In-hospital mortality was 46%. The most frequently used AF was voriconazole (71% received at least once. Mean length of stay (LOS was 26.9 days and mean total hospital cost was $76,235. Each 1 day lag before initiating AF therapy was associated with 1.28 days longer hospital stay and 3.5% increase in costs (p Conclusions Invasive aspergillosis in ICU patients is associated with high mortality and hospital costs. Antifungal timing impacts economic outcomes. These findings underscore the importance of timely diagnosis, appropriate treatment, and consideration of Aspergillus as a potential etiology in ICU patients.
Full Text Available Objectives: The aim of the research was to determine prevalence of potential drug interactions among elderly patients in the Shahid Bahonar ICU in Kerman. Methods & Materials: In this cross sectional study, data about all elderly patients who were admitted in the intensive care unit from 1/4/2009 to 1/4/2010 were retrieved from medical records and evaluated with regard to the number and type of drug interactions, the number of drugs administered, age, sex, length of stay in the ICU, and the number of doctors prescribing medications of medications administered. The extent and number of drug interactions were investigated based on the reference textbook Drug Interaction Facts and in order to analyze the data collected, using SPSS 18 and according to study goals, a descriptive test, Pierson's correlation test, an independent T-test and a one-way ANOVA were used. Results: In total, 77 types of drugs and 394 drugs were prescribed with a mean of 5.6(SD=1.5 drugs per patient. A total of 108 potential drug interactions were found related to drugs prescribed during the first twenty-four hours. In terms of the type of drug interactions, delayed, moderate and possible types comprised the highest proportion of drug interactions. The four major interactions were between cimetidine and methadone, furosemide and amikacine, phenytoin and dopamine, and heparin and aspirin. The results of Pierson's correlation test were inicative of a positive correlation between the number of potential drug interactions and that of the drugs prescribed (r=0.563, P<0.05. Results of a one-way ANOVA showed that the mean number of potential drug interaction were significantly higher in those who died than in other patients (P<0.05. Conclusion: Elderly patients who are admitted to the intensive care unit are at a high risk of developing drug interactions and better care must be taken by medical team members.
Rensen, Ans; van Mol, Margo M; Menheere, Ilse; Nijkamp, Marjan D; Verhoogt, Ellen; Maris, Bea; Manders, Willeke; Vloet, Lilian; Verharen, Lisbeth
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
Full Text Available Background Peripheral catheters are the most common invasive procedures in patients, and have several therapeutic uses, yet result in infectious and non-infectious complications as well as problems such as pain and bruising, drug and fluid leakage out of the vessels, ecchymosis, hematoma, thrombosis, embolism, infection and phlebitis. Objectives The aim of this study was to evaluate the complications of peripheral veins catheterization and some related factors at an intensive care unit (ICU of Susa city. Methods This descriptive cross sectional study was conducted on 224 catheters in patients, who were hospitalized for at least 48 hours at the intensive care unit. Data was collected through a questionnaire (demographic information, medications, catheter number, catheter site and placement and a checklist of catheter mechanical complications and phlebitis checklist. Review of the catheter site was done as well (at first, second, third and fourth, twelfth hour. To analyze the data, descriptive and analytical statistics (chi-square and Mann-Whitney were used, and the significance level was considered as P 0.05. A significant correlation was reported between variables such as type of drugs, catheter survival time, and work shift (P < 0.05. Conclusions Due to mechanical problems and phlebitis caused by peripheral catheters, choosing the right location and proper care and management of catheters can reduce the risk of complications and prevent overload to the patient and system due to increased skills by using educational programs.
BACKGROUND The demand for critical care services among elderly with dementia outpaces that of their non-dementia elderly counterparts. However, there are scarce data on the corresponding attributes among ICU-managed patients with dementia. MATERIAL AND METHODS We used the Texas Inpatient Public Use Data File to examine temporal trends of the demographics, burden of comorbidities, measures of severity of illness, use of healthcare resources, and short-term outcomes among hospitalizations aged 65 years or older with a reported diagnosis of dementia, who were admitted to ICU (D-ICU hospitalizations) between 2001 and 2010. Average annual percent changes (AAPC) were derived. RESULTS D-ICU hospitalizations (n=276,056) had increasing mean (SD) Charlson comorbidity index [1.7 (1.5) vs. 2.6 (1.9)], with reported organ failure (OF) nearly doubling from 25% to 48.5%, between 2001–2001 and 2009–2010, respectively. Use of life support interventions was infrequent, but rose in parallel with corresponding changes in respiratory and renal failure. Median total hospital charges increased from $26,442 to $36,380 between 2001–2002 and 2009–2010. Routine home discharge declined (–5.2%/year [–6.2%– –4.1%]) with corresponding rising use of home health services (+7.2%/year [4.4–10%]). Rates of discharge to another hospital or a nursing facility remained unchanged, together accounting for 60.4% of discharges of hospital survivors in 2010. Transfers to a long-term acute care hospital increased 9.2%/year (6.9–11.5%). Hospital mortality (7.5%) remained unchanged. CONCLUSIONS Elderly D-ICU hospitalizations have increasing comorbidity burden, with rising severity of illness, and increasing use of health care resources. Though the majority survived hospitalization, most D-ICU hospitalizations were discharged to another facility.
Background The demand for critical care services among elderly with dementia outpaces that of their non-dementia elderly counterparts. However, there are scarce data on the corresponding attributes among ICU-managed patients with dementia. Material/Methods We used the Texas Inpatient Public Use Data File to examine temporal trends of the demographics, burden of comorbidities, measures of severity of illness, use of healthcare resources, and short-term outcomes among hospitalizations aged 65 years or older with a reported diagnosis of dementia, who were admitted to ICU (D-ICU hospitalizations) between 2001 and 2010. Average annual percent changes (AAPC) were derived. Results D-ICU hospitalizations (n=276,056) had increasing mean (SD) Charlson comorbidity index [1.7 (1.5) vs. 2.6 (1.9)], with reported organ failure (OF) nearly doubling from 25% to 48.5%, between 2001–2001 and 2009–2010, respectively. Use of life support interventions was infrequent, but rose in parallel with corresponding changes in respiratory and renal failure. Median total hospital charges increased from $26,442 to $36,380 between 2001–2002 and 2009–2010. Routine home discharge declined (−5.2%/year [−6.2%– −4.1%]) with corresponding rising use of home health services (+7.2%/year [4.4–10%]). Rates of discharge to another hospital or a nursing facility remained unchanged, together accounting for 60.4% of discharges of hospital survivors in 2010. Transfers to a long-term acute care hospital increased 9.2%/year (6.9–11.5%). Hospital mortality (7.5%) remained unchanged. Conclusions Elderly D-ICU hospitalizations have increasing comorbidity burden, with rising severity of illness, and increasing use of health care resources. Though the majority survived hospitalization, most D-ICU hospitalizations were discharged to another facility. PMID:27764074
The CAM-ICU has now a French "official" version. The translation process of the 2014 updated Complete Training Manual of the Confusion Assessment Method for the Intensive Care Unit in French (CAM-ICU.fr).
Chanques, Gérald; Garnier, Océane; Carr, Julie; Conseil, Matthieu; de Jong, Audrey; Rowan, Christine M; Ely, E Wesley; Jaber, Samir
Delirium is common in Intensive-Care-Unit (ICU) patients but under-recognized by bed-side clinicians when not using validated delirium-screening tools. The Confusion-Assessment-Method for the ICU (CAM-ICU) has demonstrated very good psychometric properties, and has been translated into many different languages though not into French. We undertook this opportunity to describe the translation process. The translation was performed following recommended guidelines. The updated method published in 2014 including introduction letters, worksheet and flowsheet for bed-side use, the method itself, case-scenarios for training and Frequently-Asked-Questions (32 pages) was translated into French language by a neuropsychological researcher who was not familiar with the original method. Then, the whole method was back-translated by a native English-French bilingual speaker. The new English version was compared to the original one by the Vanderbilt University ICU-delirium-team. Discrepancies were discussed between the two teams before final approval of the French version. The entire process took one year. Among the 3692 words of the back-translated version of the method itself, 18 discrepancies occurred. Eight (44%) lead to changes in the final version. Details of the translation process are provided. The French version of CAM-ICU is now available for French-speaking ICUs. The CAM-ICU is provided with its complete training-manual that was challenging to translate following recommended process. While many such translations have been done for other clinical tools, few have published the details of the process itself. We hope that the availability of such teaching material will now facilitate a large implementation of delirium-screening in French-speaking ICUs. Copyright © 2017 Société française d'anesthésie et de réanimation (Sfar). All rights reserved.
Guørit, J.M.; Amantini, A.; Amodio, P.
STUDY AIM: To provide a consensus of European leading authorities about the optimal use of clinical neurophysiological (CN) tests (electroencephalogram [EEG]; evoked potentials [EP]; electroneuromyography [ENMG]) in the intensive care unit (ICU) and, particularly, about the way to make these tests...... contribution to all other experts. A complete consensus has been reached when submitting the manuscript. RESULTS: What the group considered as the best classification systems for EEG and EP abnormalities in the ICU is first presented. CN tests are useful for diagnosis (epilepsy, brain death, and neuromuscular...
Ayush Kumar Jayaswal
Full Text Available BACKGROUND Delirium, a common neuropsychiatric syndrome in intensive care settings is a distressing experience for the patient, caregivers and nursing staff. Research on delirium experience has been scant and unsystematic. We set out to explore the extent of recall of delirium, differential distress it had on patients, caregivers and nursing staff and the extent to which it impacted recognition across the motoric subtypes. MATERIALS AND METHODS A prospective study was carried out on all consecutively admitted patients in the medical ICU of a tertiary care teaching hospital. Patients diagnosed with delirium using Confusion Assessment Method for ICU (CAM-ICU were administered the Richmond Agitation Sedation Scale (RASS for differentiating the motor subtypes (hypoactive, hyperactive, mixed. Distress was assessed using the Delirium Experience Questionnaire (DEQ. RESULTS Of the 88 patients (31.43% who developed delirium, 60.2% recalled their experience. Recall was highest in the hyperactive subtype. 76% of patients, 94.3% of caregivers and 31.8% of nursing staff reported severe levels of distress. Motoric subtypes did not impact on the distress levels experienced by the patients or their caregivers, but influenced it significantly in the nursing staff (highest in hyperactive, least in hypoactive. Identification of delirium by nursing staff (13.4% was significantly influenced by the motor subtypes (highest in hyperactive, least in hypoactive. Linear regression analysis revealed that distress of ICU staff (F=1.36, p=0.018 and not the motoric subtypes (F=1.36, p=0.262 significantly predicted recognition of delirium. CONCLUSIONS Most patients who develop delirium and their caregivers experience high levels of distress. Under-recognition is significantly influenced by the distress it causes the ICU staff than the motor subtype of delirium.
Donovan, Anne L; Aldrich, J Matthew; Gross, A Kendall; Barchas, Denise M; Thornton, Kevin C; Schell-Chaple, Hildy M; Gropper, Michael A; Lipshutz, Angela K M
We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success. Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles. Original articles, review articles, and systematic reviews were considered. Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles. "Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils
Miller, Anne; Buerhaus, Peter I
Recent findings that variations in nursing workload may affect inpatient outcomes now highlight nurse workload management and the need for an updated analysis of the role of the charge nurse (CN). Observational data for eight CNs, each at one of eight ICUs in a not-for-profit Level 1 Trauma Center, coded to capture interprofessional interactions, decision making, team coordination phases, and support tools. A researcher shadowed each participant for 12 hours. Each shift began and ended with a face-to-face handoff that included summaries of each patient's condition; the current bed census; anticipated admissions, discharges, and transfers; and the number of nurses available to work the current and coming two shifts. The researcher, using a notebook, recorded the substantive content of all work conversations initiated by or directed to the CN from physicians, staff nurses, allied health workers, other employees, and patients/families. The tools used to support conversations were collected as blank forms or computer screen prints and annotated to describe how they were used, when, and for what purpose. Statistically significant three-way interactions suggest that CNs' conversations with colleagues depend on the team coordination phase and the decision-making level, and that the support tools that CNs use when talking to colleagues depend on the decision-making level and the team coordination phase. The role of ICU CNs appears to be continuing to evolve, now encompassing unit resource management in addition to supervising care delivery. Effective support tools, together with education that would enhance communication and resource management skills, will be essential to CNs' ability to support unit resilience and adaptability in an increasingly complex environment.
Mehrholz, Jan; Thomas, Simone; Burridge, Jane H.; Schmidt, Andr?; Scheffler, Bettina; Schellin, Ralph; R?ckriem, Stefan; Mei?ner, Daniel; Mehrholz, Katja; Sauter, Wolfgang; Bodechtel, Ulf; Elsner, Bernhard
Background Critical illness myopathy (CIM) and polyneuropathy (CIP) are a common complication of critical illness. Both cause intensive-care-unit-acquired (ICU-acquired) muscle weakness (ICUAW) which increases morbidity and delays rehabilitation and recovery of activities of daily living such as walking ability. Focused physical rehabilitation of people with ICUAW is, therefore, of great importance at both an individual and a societal level. A recent systematic Cochrane review found no random...
Clemens de Grahl
Full Text Available Purpose: To date there are only a few studies published, dealing with delirium in critically ill patients. The problem with these studies is that prevalence rates of delirium could only be estimated because of the lack of validated delirium assessment tools for the paediatric intensive care unit (PICU. The paediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU was specifically developed and validated for the detection of delirium in PICU patients. The purpose of this study was the translation of the English pCAM-ICU into German according to international validated guidelines. Methods: The translation process was performed according to the principles of good practice for the translation and cultural adaptation process for patient reported outcomes measures: From three independently created German forward-translation versions one preliminary German version was developed, which was then retranslated to English by a certified, state-approved translator. The back-translated version was submitted to the original author for evaluation. The German translation was evaluated by clinicians and specialists anonymously (German grades in regards to language and content of the translation. Results: The results of the cognitive debriefing revealed good to very good results. After that the translation process was successfully completed and the final version of the German pCAM-ICU was adopted by the expert committee. Conclusion: The German version of the pCAM-ICU is a result of a translation process in accordance with internationally acknowledged guidelines. Particularly, with respect to the excellent results of the cognitive debriefing, we could finalise the translation and cultural adaptation process for the German pCAM-ICU.
Lau, Vincent I; Priestap, Fran A; Lam, Joyce N H; Ball, Ian M
To evaluate the relationship between rates of discharge directly to home (DDH) from the intensive care unit (ICU) and bed availability (ward and ICU). Also to identify patient characteristics that make them candidates for safe DDH and describe transfer delay impact on length of stay (LOS). Retrospective cohort study of all adult patients who survived their stay in our medical-surgical-trauma ICU between April 2003 and March 2015. Median age was 49 years (interquartile range [IQR]: 33.5-60.4), and the majority of the patients were males (54.8%). Median number of preexisting comorbidities was 5 (IQR: 2-7) diagnoses. Discharge directly to home increased from 28 (3.1% of all survivors) patients in 2003 to 120 (12.5%) patients in 2014. The mean annual rate of DDH was between 11% and 12% over the last 6 years. Approximately 62% (n = 397) of patients waited longer than 4 hours for a ward bed, with a median delay of 2.0 days (IQR: 0.5-4.7) before being DDH. There was an inverse correlation between ICU occupancy and DDH rates ( r P = -.55, P < .0001, 95% confidence interval [CI] = -0.36 to -0.69, R 2 = .29). There was no correlation with ward occupancy and DDH rates ( r s = -.055, P = .64, 95% CI = -0.25 to 0.21). The DDH rates have been increasing over time at our institution and were inversely correlated with ICU bed occupancy but were not associated with ward occupancy. The DDH patients are young, have few comorbidities on admission, and few discharge diagnoses, which are usually reversible single system problems with low disease burden. Transfers to the ward are delayed in a majority of cases, leading to increased ICU LOS and likely increased overall hospital LOS as well.
The effect of the TIM program (Transfer ICU Medication reconciliation) on medication transfer errors in two Dutch intensive care units : Design of a prospective 8-month observational study with a before and after period
B.E. Bosma (Bertha); E. Meuwese (Edmé); S.S. Tan (Siok Swan); J. van Bommel (Jasper); Melief, P.H.G.J. (Piet Herman Gerard Jan); N.G.M. Hunfeld (Nicola); P.M.L.A. van den Bemt (Patricia)
markdownabstract__Background:__ The transfer of patients to and from the Intensive Care Unit (ICU) is prone to medication errors. The aim of the present study is to determine whether the number of medication errors at ICU admission and discharge and the associated potential harm and costs are
Damiani, Lucas P; Cavalcanti, Alexandre B; Moreira, Frederico R; Machado, Flavia; Bozza, Fernando A; Salluh, Jorge I F; Campagnucci, Valquiria P; Normilio-Silva, Karina; Chiattone, Viviane C; Angus, Derek C; Berwanger, Otavio; Chou H Chang, Chung-
The Checklist During Multidisciplinary Visits for Reduction of Mortality in Intensive Care Units (Checklist- ICU) trial is a pragmatic, two-arm, cluster-randomised trial involving 118 intensive care units in Brazil, with the primary objective of determining if a multifaceted qualityimprovement intervention with a daily checklist, definition of daily care goals during multidisciplinary daily rounds and clinician prompts can reduce inhospital mortality. To describe our trial statistical analysis plan (SAP). This is an ongoing trial conducted in two phases. In the preparatory observational phase, we collect three sets of baseline data: ICU characteristics; patient characteristics, processes of care and outcomes; and completed safety attitudes questionnaires (SAQs). In the randomised phase, ICUs are assigned to the experimental or control arms and we collect patient data and repeat the SAQ. Our SAP includes the prespecified model for the primary and secondary outcome analyses, which account for the cluster-randomised design and availability of baseline data. We also detail the multiple mediation models that we will use to assess our secondary hypothesis (that the effect of the intervention on inhospital mortality is mediated not only through care processes targeted by the checklist, but also through changes in safety culture). We describe our approach to sensitivity and subgroup analyses and missing data. We report our SAP before closing our study database and starting analysis. We anticipate that this should prevent analysis bias and enhance the utility of results.
Denehy, Linda; de Morton, Natalie A; Skinner, Elizabeth H; Edbrooke, Lara; Haines, Kimberley; Warrillow, Stephen; Berney, Sue
Several tests have recently been developed to measure changes in patient strength and functional outcomes in the intensive care unit (ICU). The original Physical Function ICU Test (PFIT) demonstrates reliability and sensitivity. The aims of this study were to further develop the original PFIT, to derive an interval score (the PFIT-s), and to test the clinimetric properties of the PFIT-s. A nested cohort study was conducted. One hundred forty-four and 116 participants performed the PFIT at ICU admission and discharge, respectively. Original test components were modified using principal component analysis. Rasch analysis examined the unidimensionality of the PFIT, and an interval score was derived. Correlations tested validity, and multiple regression analyses investigated predictive ability. Responsiveness was assessed using the effect size index (ESI), and the minimal clinically important difference (MCID) was calculated. The shoulder lift component was removed. Unidimensionality of combined admission and discharge PFIT-s scores was confirmed. The PFIT-s displayed moderate convergent validity with the Timed "Up & Go" Test (r=-.60), the Six-Minute Walk Test (r=.41), and the Medical Research Council (MRC) sum score (rho=.49). The ESI of the PFIT-s was 0.82, and the MCID was 1.5 points (interval scale range=0-10). A higher admission PFIT-s score was predictive of: an MRC score of ≥48, increased likelihood of discharge home, reduced likelihood of discharge to inpatient rehabilitation, and reduced acute care hospital length of stay. Scoring of sit-to-stand assistance required is subjective, and cadence cutpoints used may not be generalizable. The PFIT-s is a safe and inexpensive test of physical function with high clinical utility. It is valid, responsive to change, and predictive of key outcomes. It is recommended that the PFIT-s be adopted to test physical function in the ICU.
Eftekharian, Hamidreza; Zamiri, Barbad; Ahzan, Shamseddin; Talebi, Mohamad; Zarei, Kamal
Statement of the Problem: Due to shortage of ICU beds in hospitals, knowing what kind of orthognathic surgery patients more need ICU care after surgery would be important for surgeons and hospitals to prevent unnecessary ICU bed reservation. Purpose: The aim of the present study was to determine what kinds of orthognathic surgery patients would benefit more from ICU care after surgery. Materials and Method: 210 patients who were admitted to Chamran Hospital, Shiraz, for bimaxillary orthognathic surgery (2008-2013) were reviewed based on whether they had been admitted to ICU or maxillofacial surgery ward. Operation time, sex, intraoperative Estimated Blood Loss (EBL), postoperative complications, ICU admission, and unwanted complications resulting from staying in ICU were assessed. Results: Of 210 patients undergoing bimaxillary orthognathic surgery, 59 patients (28.1%) were postoperatively admitted to the ICU and 151 in the maxillofacial ward (71.9%). There was not statistically significant difference in age and sex between the two groups (p> 0.05). The groups were significantly different in terms of operation time (pOrthognathic surgery patients (maxillary impaction and setback plus mandibular advancement plus genioplasty) due to more intraoperative bleeding and postoperative nausea and pain would benefit from ICU admission after surgery. PMID:26106634
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.
Jensen, Hanne Irene; Gerritsen, Rik T; Koopmans, Matty
as reflective indicators was supported by analysis of a factor representing satisfaction with communication, measured with a combination of causal and reflective indicators. CONCLUSIONS: Most family members were moderately or very satisfied with patient care, family care, information and decision-making...... in and support during decision-making processes. Exploratory factor analysis suggested four underlying factors, but confirmatory factor analysis failed to yield a multi-factor model with between-country measurement invariance. A hypothesis that this failure was due to misspecification of causal indicators......BACKGROUND: Families' perspectives are of great importance in evaluating quality of care in the intensive care unit (ICU). This Danish-Dutch study tested a European adaptation of the "Family Satisfaction in the ICU" (euroFS-ICU). The aim of the study was to examine assessments of satisfaction...
Khan, Anjum; Lampitoc, Marianita; Salaripour, Maryam; McKernan, Patricia; Devlin, Roslyn; Muller, Matthew P
Outbreaks of methicillin resistant Staphylococcus aureus in the intensive care unit setting can be prolonged and difficult to control. This report describes the rapid control of an outbreak of methicillin resistant Staphylococcus aureus in a 24-bed open-concept medical surgical intensive care unit with a baseline methicillin resistant Staphylococcus aureus acquisition rate of 1.5 cases per 1000 patient days. This institution's infection control policy mandates an outbreak investigation if two cases of hospital-acquired methicillin resistant Staphylococcus aureus colonization or infection are identified in an intensive care unit within a four-week period. In July 2007, methicillin resistant Staphylococcus aureus was identified in the sputum of two patients within a one-week period. Screening of all patients in the intensive care unit identified one additional case and a fourth case was identified from a clinical specimen before control measures were implemented. Initial control measures included healthcare worker education, enhanced surveillance, patient cohorting, and enhanced environmental cleaning. Despite these measures, three more cases occurred. All patients were then placed in contact isolation, healthcare workers were screened, and the nursing staff was cohorted. After two weeks without a case, two additional cases were identified. Decolonization of all positive patients was initiated. No further cases occurred over a five-week period and the outbreak was declared over. The outbreak resulted in nine cases of methicillin resistant Staphylococcus aureus colonization (n = 8) or infection (n = 1) over an 11-week period. Only one of 175 healthcare workers was colonized and it was not the outbreak strain. Early detection and the stepwise addition of infection control measures resulted in the rapid control of an outbreak of methicillin resistant Staphylococcus aureus in a medical surgical intensive care unit without unit closure. A low threshold of suspicion and
Kawaguchi, Yurika Maria Fogaça; Nawa, Ricardo Kenji; Figueiredo, Thais Borgheti; Martins, Lourdes; Pires-Neto, Ruy Camargo
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
Edgeworth, Jonathan D; Chis Ster, Irina; Wyncoll, Duncan; Shankar-Hari, Manu; McKenzie, Catherine A
To determine long-term adherence to a 5 day antibiotic course guideline for treating intensive care unit (ICU)-acquired Gram-negative bacteria (GNB) infections. Descriptive analysis of patient-level data on all GNB-active antibiotics prescribed from day 3 and all GNB identified in clinical samples in 5350 patients admitted to a 30 bed general ICU between 2002 and 2009. Four thousand five hundred and eleven of 5350 (84%) patients were treated with one or more antibiotics active against GNB commenced from day 3. Gentamicin was the most frequently prescribed antibiotic (92.2 days of therapy/1000 patient-days). Only 6% of courses spanned >6 days of therapy and 89% of antibiotic therapy days were with a single antibiotic active against GNB. There was no significant difference between gentamicin and meropenem in the number of first courses in which a resistant GNB was identified in blood cultures [11/1177 (0.9%) versus 5/351 (1.4%); P = 0.43] or respiratory tract specimens [59/951 (6.2%) versus 17/246 (6.9%); P = 0.68] at the time of starting therapy. This study demonstrates long-term adherence to a 5 day course antibiotic guideline for treatment of ICU-associated GNB infections. This guideline is a potential antibiotic-sparing alternative to currently recommended dual empirical courses extending to ≥7 days. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: email@example.com.
Yurika Maria Fogaça Kawaguchi
Full Text Available 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 ( > 0.90 and reliability ( > 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.
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).
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
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
Kawaguchi, Yurika Maria Fogaça; Nawa, Ricardo Kenji; Figueiredo, Thais Borgheti; Martins, Lourdes; Pires-Neto, Ruy Camargo
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. 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. 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 ( > 0.90) and reliability ( > 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 composta por 103 pacientes, sendo a maioria homens (n = 56; 54%), com média de idade = 52 ± 18 anos. O principal motivo de internação nas UTIs foi insuficiência respiratória (em 44%). Os dois instrumentos apresentaram excelente concordância interobservador (> 0,90) e confiabilidade ( > 0,90) em todos os domínios. Constatou-se um baixo viés interobservador na EMU e no Perme Escore (-0,048 ± 0,350 e -0,06 ± 0,73, respectivamente). Os IC95% para os mesmos instrumentos variaram
Pouline M. P. van Oort
Full Text Available The diagnosis of hospital-acquired pneumonia remains challenging. We hypothesized that analysis of volatile organic compounds (VOCs in exhaled breath could be used to diagnose pneumonia or the presence of pathogens in the respiratory tract in intubated and mechanically-ventilated intensive care unit patients. In this prospective, single-centre, cross-sectional cohort study breath from mechanically ventilated patients was analysed using gas chromatography-mass spectrometry. Potentially relevant VOCs were selected with a p-value < 0.05 and an area under the receiver operating characteristics curve (AUROC above 0.7. These VOCs were used for principal component analysis and partial least square discriminant analysis (PLS-DA. AUROC was used as a measure of accuracy. Ninety-three patients were included in the study. Twelve of 145 identified VOCs were significantly altered in patients with pneumonia compared to controls. In colonized patients, 52 VOCs were significantly different. Partial least square discriminant analysis classified patients with modest accuracy (AUROC: 0.73 (95% confidence interval (CI: 0.57–0.88 after leave-one-out cross-validation. For determining the colonization status of patients, the model had an AUROC of 0.69 (95% CI: 0.57–0.82 after leave-one-out cross-validation. To conclude, exhaled breath analysis can be used to discriminate pneumonia from controls with a modest to good accuracy. Furthermore breath profiling could be used to predict the presence and absence of pathogens in the respiratory tract. These findings need to be validated externally.
Medlock, Stephanie; Eslami, Saeid; Askari, Marjan; van Lieshout, Erik Jan; Dongelmans, Dave A.; Abu-Hanna, Ameen
The discharge letter is the primary means of communication at patient discharge, yet discharge letters are often not completed on time. A multifaceted intervention was performed to improve communication in patient hand-off from the intensive care unit (ICU) to the wards by improving the timeliness
Medlock, S.; Eslami, S.; Askari, M.; van Lieshout, E.J.; Dongelmans, D.A.; Abu-Hanna, A.
Background: The discharge letter is the primary means of communication at patient discharge, yet discharge letters are often not completed on time. A multifaceted intervention was performed to improve communication in patient hand-off from the intensive care unit (ICU) to the wards by improving the
Radtke, Anne; Pfister, Roman; Kuhr, Kathrin; Kochanek, Matthias; Michels, Guido
The aim of the FEELING-ON-ICU study was to compare mortality estimations of critically ill patients based on 'gut feeling' of medical staff and by Acute Physiology And Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II and Sequential Organ Failure Assessment (SOFA). Medical staff estimated patients' mortality risks via questionnaires. APACHE II, SAPS II and SOFA were calculated retrospectively from records. Estimations were compared with actual in-hospital mortality using receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC). 66 critically ill patients (60.6% male, mean age 63±15years (range 30-86)) were evaluated each by a nurse (n=66, male 32.4%) and a physician (n=66, male 67.6%). 15 (22.7%) patients died on the intensive care unit. AUC was largest for estimations by physicians (AUC 0.814 (95% CI 0.705-0.923)), followed by SOFA (AUC 0.749 (95% CI 0.629-0.868)), SAPS II (AUC 0.723 (95% CI 0.597-0.849)), APACHE II (AUC 0.721 (95% CI 0.595-0.847)) and nursing staff (AUC 0.669 (95% CI 0.529-0.810)) (p<0.05 for all results). The concept of physicians' 'gut feeling' was comparable to classical objective scores in mortality estimations of critically ill patients. Concerning practicability physicians' evaluations were advantageous to complex score calculation. Copyright © 2017 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.
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
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.
Kahn, Jeremy M; Le, Tri Q.; Barnato, Amber E.; Hravnak, Marilyn; Kuza, Courtney C.; Pike, Francis; Angus, Derek C.
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%, ptelemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios: 0.96, 95% CI = 0.95–0.98, ptelemedicine 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 (ptelemedicine 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
Zariquiey-Esteva, G; Galeote-Cózar, D; Santa-Candela, P; Castanera-Duro, A
Botulism is a rare disease in Europe, caused by the bacterium Clostridium botulinum, notifiable, non-transmissible person-to-person and potentially fatal (between 5 and 10%) if not treated quickly. The favourable opinion of the Clinical Research Ethics Committee was obtained. We present the nursing care plan of a 49-year-old man with a diagnosis of bacterial intoxication caused by Clostridium botulinum, secondary to ingestion of beans in poor condition, who was admitted to the ICU for a total of 35 days. Holistic nursing evaluation during the first 24hours, with prioritisation of the systems that were deteriorating fastest: neurological and respiratory. Nine diagnoses were prioritised according to the NANDA taxonomy: Risk for allergy response, Ineffective breathing pattern, impaired oral mucous membrane, Impaired physical mobility, Risk for disuse syndrome, Risk for dysfunctional gastrointestinal motility, Impaired urinary elimination, Risk for acute confusion and Risk for caregiver role strain. The nursing care plan, standardised and organised with the NANDA taxonomy and prioritised with the outcome-present state-test (OPT) model, guaranteed the best care based on evidence, as the NOC scores improvement demonstrated. It was impossible to compare the nursing intervention with other case reports. Copyright © 2017 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.
Creutzfeldt, Claire J; Hanna, Marina G; Cheever, C Sherry; Lele, Abhijit V; Spiekerman, Charles; Engelberg, Ruth A; Curtis, J Randall
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.
Mahmoudian-Dehkordi, Amin; Sadat, Somayeh
Intensive Care Units (ICU) are costly yet critical hospital departments that should be available to care for patients needing highly specialized critical care. Shortage of ICU beds in many regions of the world and the constant fire-fighting to make these beds available through various ICU management policies motivated this study. The paper discusses the application of a generic system dynamics model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to explore the dynamics of intended and unintended consequences of such ICU management policies under a natural disaster crisis scenario. ICU management policies that can be implemented by a single hospital on short notice, namely premature transfer from ICU, boarding in ward, and general ward admission control, along with their possible combinations, are modeled and their impact on managerial and health outcome measures are investigated. The main insight out of the study is that the general ward admission control policy outperforms the rest of ICU management policies under such crisis scenarios with regards to reducing total mortality, which is counter intuitive for hospital administrators as this policy is not very effective at alleviating the symptoms of the problem, namely high ED and ICU occupancy rates that are closely monitored by hospital management particularly in times of crisis. A multivariate sensitivity analysis on parameters with diverse range of values in the literature found the superiority of the general ward admission control to hold true in every scenario.
Full Text Available Background: Futile care is provided many complicated challenges for nursing in intensive care units in Iran. Objective: This study aimed to study prevalence of futile care from the viewpoints of nurses that working ICU. Methods: This descriptive-analytical study was conducted on totally 210 nurses working in all ICU of academic, public, and private hospitals of Qazvin city in 2014. Data were analyzed using Chi-square, independent t-test, one-way ANOVA and Friedman tests. Findings: The most prevalence of providing futile care was in teaching hospital (51.98±23.2, and the least prevalence was in charity hospital (37.3±12.77. There was significant difference between mean of futile care in different hospitals (P<0.007. Conclusion: As the key role of nurses in the managing futile care, awareness about prevalence of this kind of care, could be initial step for providing benefit care plans in ICU.
Nurul Huda Razalli
Full Text Available Compartment syndrome occurs when pressure within a closed muscle or bone compartment builds to dangerous levels. This pressure can decrease blood flow to nerve and muscle cells, leading to ischemia and organ dysfunction. Challenges in providing enteral nutrition for abdominal compartment syndrome (ACS patients include the increase risk for developing gastrointestinal symptoms such as diarrhea, constipation and distention. There are limited reports available on the nutritional management of ACS patients in the ICU especially those with morbid obesity condition to guide dietitians in providing nutritional support for these patients. Here, we report the enteral nutrition management of a mechanically ventilated, morbidly obese patient with ACS in a critical care setting by adopting postpyloric feeding, using prokinetic agents and implementing PO2/FiO2 ratio calculation for prescription of most suitable enteral formula.
Medlock, Stephanie; Eslami, Saeid; Askari, Marjan; van Lieshout, Erik Jan; Dongelmans, Dave A; Abu-Hanna, Ameen
The discharge letter is the primary means of communication at patient discharge, yet discharge letters are often not completed on time. A multifaceted intervention was performed to improve communication in patient hand-off from the intensive care unit (ICU) to the wards by improving the timeliness of discharge letters. A management directive was operationalised by a working group of ICU staff in a longitudinal before-after study. The intervention consisted of (a) changing policy to require a letter for use as a transfer note at the time of ICU discharge, (b) changing the assignment of responsibility to an automatic process, (c) leveraging positive peer pressure by making the list of patients in need of letters visible to colleagues and (d) provision of decision support, through automatic copying of important content from the patient record to the letter and email reminders if letters were not written on time. Statistical process control charts were used to monitor the longitudinal effect of the intervention. The intervention resulted in a 77.9% absolute improvement in the proportion of patients with a complete transfer note at the time of discharge, and an 85.2% absolute improvement in the number of discharge letters written. Statistical process control shows that the effect was sustained over time. A multifaceted intervention can be highly effective for improving discharge communication from the ICU.
Shola Usha Rani
Full Text Available An interoperable telehealth system provides an independent healthcare solution for better management of health and wellness. It allows people to manage their heart disease and diabetes etc. by sending their health parameters like blood pressure, heart rate, glucose levels, temperature, weight, respiration from remote place to health professional, and get real-time feedback on their condition. Here different medical devices are connected to the patient for monitoring. Each kind of device is manufactured by different vendors. And each device information and communication requires different installation and network design. It causes design complexities and network overheads when moving patients for diagnosis examinations. This problem will be solved by interoperability among devices. The ISO/IEEE 11073 is an international standard which produces interoperable hospital information system solution to medical devices. One such type of integrated environment that requires the integration of medical devices is ICU (Intensive Care Unit. This paper presents the issues for ICU monitoring system and framework solution for it.
Zampieri, Fernando Godinho; Soares, Márcio; Borges, Lunna Perdigão; Salluh, Jorge Ibrain Figueira; Ranzani, Otávio Tavares
To describe the Epimed Monitor Database®, a Brazilian intensive care unit quality improvement database. We described the Epimed Monitor® Database, including its structure and core data. We presented aggregated informative data from intensive care unit admissions from 2010 to 2016 using descriptive statistics. We also described the expansion and growth of the database along with the geographical distribution of participating units in Brazil. The core data from the database includes demographic, administrative and physiological parameters, as well as specific report forms used to gather detailed data regarding the use of intensive care unit resources, infectious episodes, adverse events and checklists for adherence to best clinical practices. As of the end of 2016, 598 adult intensive care units in 318 hospitals totaling 8,160 intensive care unit beds were participating in the database. Most units were located at private hospitals in the southeastern region of the country. The number of yearly admissions rose during this period and included a predominance of medical admissions. The proportion of admissions due to cardiovascular disease declined, while admissions due to sepsis or infections became more common. Illness severity (Simplified Acute Physiology Score - SAPS 3 - 62 points), patient age (mean = 62 years) and hospital mortality (approximately 17%) remained reasonably stable during this time period. A large private database of critically ill patients is feasible and may provide relevant nationwide epidemiological data for quality improvement and benchmarking purposes among the participating intensive care units. This database is useful not only for administrative reasons but also for the improvement of daily care by facilitating the adoption of best practices and use for clinical research.
Rajamani, A; Barrett, E; Weisbrodt, L; Bourne, J; Palejs, P; Gresham, R; Huang, S
International literature on end-of-life care in intensive care units (ICUs) supports the use of 'protocol bundles', which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had 'withdrawal' of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.
Rozaidi, S W; Sukro, J; Dan, A
CU-acquired nosocomial infection (NI) remains one of the major causes of ICU mortality. This study presents the incidence of ICU-acquired nosocomial infection in ICU HUKM for the years 1998 and 1999, as part of the ongoing ICU-acquired nosocomial infection surveillance program. The overall incidence was 23%. The main types of NI was lower respiratory tract infection (15.3%), primary bacteraemia (8.1%), ventilator associated pneumonia (5.4%), urinary tract infection (2.0%), skin infection (1.6%) central venous catheter sepsis (1.2%) and surgical skin infection (0.8%). The overall culture positive nosocomial infection rate was only 12.1%, majority from the lungs (12.6%), blood (7.3%), skin swabs (2.0%), and urine (1.6%). The main gram-negative organism cultured was Acinetobacter sp. (19%) and Staph. aureus (8.5%) was the gram-positive organism. The overall ICU mortality rate was 27.5% of which 60.9% of patients who died were attributed directly to sepsis.
Guérit, J-M; Amantini, A; Amodio, P
disorders), prognosis (anoxic ischemic encephalopathy, head trauma, and neurologic disturbances of metabolic and toxic origin), and follow-up, in the adult, paediatric, and neonatal ICU. Regarding prognosis, a clear distinction is made between these tests whose abnormalities are indicative of an ominous...
Full Text Available Delirium is described as a manifestation of acute brain injury and recognized as one of the most common complications in intensive care unit (ICU patients. Although the causes of delirium vary widely among patients, delirium increases the risk of longer ICU and hospital length of stay, death, cost of care, and post-ICU cognitive impairment. Prevention and early detection are therefore crucial. However, the clinical approach toward delirium is not sufficiently aggressive, despite the condition’s high incidence and prevalence in the ICU setting. While the underlying pathophysiology of delirium is not fully understood, many risk factors have been suggested. As a way to improve delirium-related clinical outcome, high-risk patients can be identified. A valid and reliable bedside screening tool is also needed to detect the symptoms of delirium early. Delirium is commonly treated with medications, and haloperidol and atypical antipsychotics are commonly used as standard treatment options for ICU patients although their efficacy and safety have not been established. The approaches for the treatment of delirium should focus on identifying the underlying causes and reducing modifiable risk factors to promote early mobilization.
Bhatia, Munish; Sood, Sandeep K
The rapid introduction of Internet of Things (IoT) Technology has boosted the service deliverance aspects of health sector in terms of m-health, and remote patient monitoring. IoT Technology is not only capable of sensing the acute details of sensitive events from wider perspectives, but it also provides a means to deliver services in time sensitive and efficient manner. Henceforth, IoT Technology has been efficiently adopted in different fields of the healthcare domain. In this paper, a framework for IoT based patient monitoring in Intensive Care Unit (ICU) is presented to enhance the deliverance of curative services. Though ICUs remained a center of attraction for high quality care among researchers, still number of studies have depicted the vulnerability to a patient's life during ICU stay. The work presented in this study addresses such concerns in terms of efficient monitoring of various events (and anomalies) with temporal associations, followed by time sensitive alert generation procedure. In order to validate the system, it was deployed in 3 ICU room facilities for 30 days in which nearly 81 patients were monitored during their ICU stay. The results obtained after implementation depicts that IoT equipped ICUs are more efficient in monitoring sensitive events as compared to manual monitoring and traditional Tele-ICU monitoring. Moreover, the adopted methodology for alert generation with information presentation further enhances the utility of the system.
Li, Y.; Albayrak, A.; Goossens, R.H.M.; Xiao, D.; Jakimowicz, J.J.
Because of high risk and instability of the patients in Intensive care unit(ICU), the design of ICU is very difficult. ICU design, auxiliary building design, lighting design, noise control and other aspects can also enhance its management. In this paper, we compare ICU design in China and Holland based on related standards. We also premeditate the indoor environment from planning perspective, analyze patients, their families, medical staff and space requirement to conduct research in ICU desi...
The REAnimation Low Immune Status Markers (REALISM) project: a protocol for broad characterisation and follow-up of injury-induced immunosuppression in intensive care unit (ICU) critically ill patients.
Rol, Mary-Luz; Venet, Fabienne; Rimmele, Thomas; Moucadel, Virginie; Cortez, Pierre; Quemeneur, Laurence; Gardiner, David; Griffiths, Andrew; Pachot, Alexandre; Textoris, Julien; Monneret, Guillaume
The host response to septic shock is dynamic and complex. A sepsis-induced immunosuppression phase has recently been acknowledged and linked to bad outcomes and increased healthcare costs. Moreover, a marked suppression of the immune response has also been partially described in patients hospitalized in intensive care unit (ICU) for severe trauma or burns. It has been hypothesized that immune monitoring could enable identification of patients who might most benefit from novel, adjunctive immune-stimulating therapies. However, there is currently neither a clear definition for such injury-induced immunosuppression nor a stratification biomarker compatible with clinical constraints. We set up a prospective, longitudinal single-centre clinical study to determine the incidence, severity and persistency of innate and adaptive immune alterations in ICU patients. We optimized a workflow to describe and follow the immunoinflammatory status of 550 patients (septic shock, severe trauma/burn and major surgery) during the first 2 months after their initial injury. On each time point, two immune functional tests will be performed to determine whole-blood TNF-α production in response to ex vivo lipopolysaccharide stimulation and the T lymphocyte proliferation in response to phytohaemagglutinin. In addition, a complete immunophenotyping using flow cytometry including monocyte HLA-DR expression and lymphocyte subsets will be obtained. New markers (ie, levels of expression of host mRNA and viral reactivation) will be also evaluated. Reference intervals will be determined from a cohort of 150 age-matched healthy volunteers. This clinical study will provide, for the first time, data describing the immune status of severe ICU patients over time. Ethical approval has been obtained from the institutional review board (no 69HCL15_0379) and the French National Security agency for drugs and health-related products. Results will be disseminated through presentations at scientific meetings
Gaíva, Maria Aparecida Munhoz; Scochi, Carmen Gracinda Silvan
This study aimed at analyzing the family participation in the premature assistance in a university hospital neonatal ICU. Data were collected from the participant observation. Results showed that despite of the mother's presence in the daily life of their premature children placed in a hospital, family isn't inserted in the work process and mothers are the only ones who take part of the cares. This participation basically happens in the execution of maternity care, especially at the medium risk unity, the mother and premature family are less welcomed and there isn't any partnership between the care team and the family, there aren't team interventions in order to turn premature family in autonomous subject to promote health and life quality to baby's life.
Anderson, Wendy G; Puntillo, Kathleen; Boyle, Deborah; Barbour, Susan; Turner, Kathleen; Cimino, Jenica; Moore, Eric; Noort, Janice; MacMillan, John; Pearson, Diana; Grywalski, Michelle; Liao, Solomon; Ferrell, Bruce; Meyer, Jeannette; O'Neil-Page, Edith; Cain, Julia; Herman, Heather; Mitchell, William; Pantilat, Steven
Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses. To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication. A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S. The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%). ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
DeKeyser Ganz, Freda; Fink, Naomi Farkash; Raanan, Ofra; Asher, Miriam; Bruttin, Madeline; Nun, Maureen Ben; Benbinishty, Julie
The purpose of this study was to describe the oral-care practices of ICU nurses, to compare those practices with current evidence-based practice, and to determine if the use of evidence-based practice was associated with personal demographic or professional characteristics. A national survey of oral-care practices of ICU nurses was conducted using a convenience sample of 218 practicing ICU nurses in 2004-05. The survey instrument included questions about demographic and professional characteristics and a checklist of oral-care practices. Nurses rated their perceived level of priority concerning oral care on a scale from 0 to 100. A score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the current best evidence. This score was then statistically analyzed using ANOVA to determine differences of EBP based on demographic and professional characteristics. The most commonly used equipment was gauze pads (84%), followed by tongue depressors (55%), and toothbrushes (34%). Chlorhexidine was the most common solution used (75%). Less than half (44%) reported brushing their patients' teeth. The majority performed an oral assessment before beginning oral care (71%); however, none could describe what assessment tool was used. Only 57% of nurses reported documenting their oral care. Nurses rated oral care of intubated patients with a priority of 67+/-27.1. Wide variations were noted within and between units in terms of which techniques, equipment, and solutions were used. No significant relationships were found between the use of an evidence-based protocol and demographic and professional characteristics or with the priority given to oral care. While nurses ranked oral care a high priority, many did not implement the latest evidence into their current practice. The level of research utilization was not related to personal or professional characteristics. Therefore attempts should be made to encourage all
Objectives:The Intensive Care Unit (ICU) has improved patient outcome in complex surgeries while the costs of maintaining services are high. ICU services in developing countries are often inadequate due to lack of funds. This study reviews the pattern and outcomes of General Surgical patients admitted to the ICU of our ...
Delirium poses a significant burden on our healthcare, with patients in the intensive care unit (ICU) at an increased risk for developing this disorder. In addition, the ICU environment poses unique challenges in the assessment of delirium. It is paramount that the healthcare provider has an understanding of delirium in ICU, ...
Full Text Available Background: The Lagos University Teaching Hospital's Intensive Care Unit (ICU was founded in 1975. It was designed as an eight-bedded ICU, a previous review of outcome of surgical admissions in the ICU in 2002 placed mortality at 40.3%, however, presently run as a five-bed unit with new ICU equipment procured in 2012, arterial blood gas machines, patient monitors, and ventilators with sustained multidisciplinary approach to patient management. We compared the number of admissions, mortality, and discharges to the ward 1 year before (Period I and after the upgrade of the ICU facilities (Period II. Methods: This was a retrospective study of all patients admitted into the ICU between June 2011 and May 2013. We looked at the admission register of the ICU and retrieved biometric data, diagnosis, age, pattern of units admitting patients into ICU, length of stay (LOS, and outcome of ICU care whether the patient died in ICU or was discharged to the ward. Results: There were 122 patients admitted into the ICU in Period I and 156 patients were admitted in Period II with a mean LOS of 6.3 ± 5.4 days and 7.8 ± 7.3 days, respectively. Mortality rate in Period I was 74.6% while mortality fell to 57.7% in Period II (P = 0.005. Conclusion: There was a significant improvement in the ICU outcome with the upgrade of the ICU facilities.
Venditti, Angelo; Ronk, Chanda; Kopenhaver, Tracey; Fetterman, Susan
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.
Seyedeh Toktam Masoumian Hoseini
Full Text Available Introduction: Nowadays, Intensive Care Unit (ICU nurses play a significant and key role in the care of brain dead patients and their families, therefore their Practice extremely important to the success of organ donation. To assess ICU nurse's practice in relation to nurse's role in the organ donation process from brain dead patients in Iran. Materials and Methods:In a cross-sectional analytical study 90 ICU nurses in Ghaem and Imam Reza Hospitals in Mashhad through stratified random sampling allocation method were selected. Data collection tools included a questionnaire on demographic information, factors influencing nurse's practice during the organ donation process and surveying "nurse's practice in relation to their roles in the organ donation process." Results: 90 nurses participated in this study. (70.0% of the research subjects had spoken with their own families about organ donation, and (20.0% had organ donation cards. Practice scores were calculated on a scale of 100. The mean score of nurses' practice was (6.04± 3.66. 96.7% of nurses’ weak practice in terms of their roles in the organ donation process. Conclusion: As a result, they do not have adequate practice regard nurse's role in organ donation process and in relation to brain death patient and their families. Therefore it is suggested to include nursing courses in the organ donation process and organ transplantation as well as educational programs to acquaint nurses with their roles in the process to improve their practice by different training methods.
Wu, Tammy W; Oliffe, John L; Bungay, Vicky; Johnson, Joy L
Male intensive care unit (ICU) nurses bring energy and expertise along with an array of beliefs and practices to their workplace. This article investigates the experiences of male ICU nurses in the context of caring for dying patients and their families. Applying a gender analysis, distilled are insights to how masculinities inform and influence the participants' practices and coping strategies. The findings reveal participants draw on masculine ideals of being a protector and rational in their decisive actions toward meeting the comfort needs of dying patients and their families. Somewhat paradoxically, most participants also transgressed masculine norms by outwardly expressing their feelings and talking about emotions related to these experiences. Participants also reported renewed appreciation of their life and their families and many men chronicled recreational activities and social connectedness as strategies for coping with workplace induced stresses. The findings drawn from this study can guide both formal and informal support services for men who are ICU nurses, which in turn might aid retention of this subgroup of workers. © The Author(s) 2014.
Ho, Jim Q; Nguyen, Christopher D; Lopes, Richard; Ezeji-Okoye, Stephen C; Kuschner, Ware G
Spiritual care is an important component of high-quality health care, especially for critically ill patients and their families. Despite evidence of benefits from spiritual care, physicians and other health-care providers commonly fail to assess and address their patients' spiritual care needs in the intensive care unit (ICU). In addition, it is common that spiritual care resources that can improve both patient outcomes and family member experiences are underutilized. In this review, we provide an overview of spiritual care and its role in the ICU. We review evidence demonstrating the benefits of, and persistent unmet needs for, spiritual care services, as well as the current state of spiritual care delivery in the ICU setting. Furthermore, we outline tools and strategies intensivists and other critical care medicine health-care professionals can employ to support the spiritual well-being of patients and families, with a special focus on chaplaincy services.
Wiegand, Debra L; Grant, Marian S; Cheon, Jooyoung; Gergis, Mary A
Families of older adults are intricately involved in the end-of-life decision-making process for a family member with a serious illness in the intensive care unit (ICU) setting. However, families are not always as involved and as informed as they would like to be. Creating a culture that assesses family needs and supports families is an important component of family-centered care. There are several strategies that nurses and other members of the interdisciplinary team can use to promote family-centered end-of-life care in the ICU. Nurses can get to know the family by spending time talking with them, assessing them, seeking to understand their perspectives on their family member's condition, and discussing previously verbalized patient wishes for care. This article offers strategies nurses can use to help guide the family through the end-of-life decision-making process, support families as difficult and complex decisions are made in collaboration with the health care team, and prepare families for the dying process. Copyright 2013, SLACK Incorporated.
Lykkegaard, Kristina; Delmar, Charlotte
This study explores the perceived meaning of dependency on care as experienced by intensive care patients. Research from non-intensive settings shows that dependency is often experienced negatively, but literature on the subject experienced by patients in the ICU is sparse. The study is based on in-depth qualitative semi-structured interviews of lived experience with three former patients admitted to an intensive care unit at a Danish university hospital. The in-depth interviews have been characterized as narratives. The main inspiration for the analysis method is Ricoeur's phenomenological hermeneutical interpretation theory. The study has found that dependency is experienced as difficult, and the relationship with the nurses seems to be ambivalent. The good relationship is experienced to make dependency easier, whereas negative experiences make it harder to cope with dependency. The participants deal with dependency by accepting negative experiences in gratitude for having recovered from critical illness. The findings might be influenced by studies being conducted in a western country setting where independence is valued. They can be used as means of reflection on nursing practice and matters such as communication and patient participation.
Full Text Available Introduction: The intensive care unit (ICU represents a special environment for patients. We analyzed patients in the ICU/ high care unit (HCU with respect to dermatology counselling and skin problems.Setting: Academic Teaching Hospital over a 10 month period.Methods: The total number of patients of the ICU was 1,208 with a mean stay of 4.1 days. In the HCU the mean stay was 16 days. Diagnosis leading to admission were analyzed. All files of dermatological counselling were evaluated in detail.Results: Fifty-five patients with dermatologic problems were identified: 19 women and 26 males. The age ranged from 22 to 90 years of life (mean ± standard deviation: 67.2 ± 17.4 years. The total number of consultations were 85. The range of repeated dermatological consultation ranged from two to ten. The major reasons were skin and soft tissue infections, adverse drug reactions, chronic wounds including pressure sores and skin irritation or dermatitis. Pre-existing skin conditions may complicate the treatment and care during ICU/HCU stay.Conclusion: A tight collaboration between of the medical staff of ICU/HCU and dermatology department will ensure a rapid diagnosis and treatment of various skin conditions in the ICU, without increasing the costs significantly. Interdisciplinary education of nursing staff contributes to improved skin care in the ICU/HCU and helps to prevent acute skin failure.
J.A. Calvache (Jose Andrés); R.A. Molina García (Rodrigo); A.L. Trochez (Adolfo); J. Benitez (Javier); L.A. Flga (Lucía Arroyo)
textabstractBackground: The development of percutaneous dilatational tracheostomy techniques (PDT) has facilitated the procedure in Intensive Care Units (ICU). Objective: To describe the early intra and post-operative complications in ICU patients requiring percutaneous dilatational tracheostomy
Chen, Robert; Kumar, Vikas; Fitch, Natalie; Jagadish, Jitesh; Lifan Zhang; Dunn, William; Duen Horng Chau
Preventing mortality in intensive care units (ICUs) has been a top priority in American hospitals. Predictive modeling has been shown to be effective in prediction of mortality based upon data from patients' past medical histories from electronic health records (EHRs). Furthermore, visualization of timeline events is imperative in the ICU setting in order to quickly identify trends in patient histories that may lead to mortality. With the increasing adoption of EHRs, a wealth of medical data is becoming increasingly available for secondary uses such as data exploration and predictive modeling. While data exploration and predictive modeling are useful for finding risk factors in ICU patients, the process is time consuming and requires a high level of computer programming ability. We propose explICU, a web service that hosts EHR data, displays timelines of patient events based upon user-specified preferences, performs predictive modeling in the back end, and displays results to the user via intuitive, interactive visualizations.
Mar 4, 2013 ... care unit research: a South African perspective. De Roubaix JAM, MBChB, .... (g) the development of new applications of health technology. The last two items .... Consent in emergency and ICU care: SA regulatory guidelines.
Osman, Mohamed F; Askari, Reza
It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research. Copyright © 2014 Elsevier Inc. All rights reserved.
Ogbu, Ogbonna C.; Coopersmith, Craig M.
Improving value within critical care remains a priority because it represents a significant portion of health-care spending, faces high rates of adverse events, and inconsistently delivers evidence-based practices. ICU directors are increasingly required to understand all aspects of the value provided by their units to inform local improvement efforts and relate effectively to external parties. A clear understanding of the overall process of measuring quality and value as well as the strengths, limitations, and potential application of individual metrics is critical to supporting this charge. In this review, we provide a conceptual framework for understanding value metrics, describe an approach to developing a value measurement program, and summarize common metrics to characterize ICU value. We first summarize how ICU value can be represented as a function of outcomes and costs. We expand this equation and relate it to both the classic structure-process-outcome framework for quality assessment and the Institute of Medicine’s six aims of health care. We then describe how ICU leaders can develop their own value measurement process by identifying target areas, selecting appropriate measures, acquiring the necessary data, analyzing the data, and disseminating the findings. Within this measurement process, we summarize common metrics that can be used to characterize ICU value. As health care, in general, and critical care, in particular, changes and data become more available, it is increasingly important for ICU leaders to understand how to effectively acquire, evaluate, and apply data to improve the value of care provided to patients. PMID:25846533
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
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
Zalenski, Robert J; Jones, Spencer S; Courage, Cheryl; Waselewsky, Denise R; Kostaroff, Anna S; Kaufman, David; Beemath, Afzal; Brofman, John; Castillo, James W; Krayem, Hicham; Marinelli, Anthony; Milner, Bradley; Palleschi, Maria Teresa; Tareen, Mona; Testani, Sheri; Soubani, Ayman; Walch, Julie; Wheeler, Judy; Wilborn, Sonali; Granovsky, Hanna; Welch, Robert D
There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to "do not resuscitate" (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR-adjusted odds ratio (AOR) = 7.5; 95% CI 5.6-9.9) and hospice referrals-(AOR = 7.6; 95% CI 5.0-11.7). They had slightly lower 30-day readmissions-(AOR = 0.7; 95% CI 0.5-1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation-by Day 4 of admission-was associated with reductions in LOS (1.7 days [95% CI -3.1, -1.2]) and average direct variable costs (-$1815 [95% CI -$3322, -$803]) compared to those who received no PCC. Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Boyko, Yuliya; Jennum, Poul; Nikolic, Miki
PURPOSE: To determine if improving intensive care unit (ICU) environment would enhance sleep quality, assessed by polysomnography (PSG), in critically ill mechanically ventilated patients. MATERIALS AND METHODS: Randomized controlled trial, crossover design. The night intervention "quiet routine...... Medicine) sleep scoring criteria were insufficient for the assessment of polysomnograms. Modified classification for sleep scoring in critically ill patients, suggested by Watson et al. (Crit Care Med 2013;41:1958-1967), was used. RESULTS: Sound level analysis showed insignificant effect...... patients. We were not able to further reduce the already existing low noise levels in the ICU and did not find any association between the environmental intervention and the presence of normal sleep characteristics in the PSG....
Interventions to assess therapy ... and trauma intensive care unit (ICU) at Steve Biko Academic Hospital. ... of programme success, such as improving the quality of service by .... saving and extra quality assurance opportunity for the unit..
van de Leur, JP; van der Schans, CP; Loef, BG; Deelman, BG; Geertzen, JHB; Zwaveling, JH
Introduction A stay in the intensive care unit (ICU), although potentially life-saving, may cause considerable discomfort to patients. However, retrospective assessment of discomfort is difficult because recollection of stressful events may be impaired by sedation and severe illness during the ICU
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.
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 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
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
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). 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. 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 often trauma/emergency surgery patients. Compared with in-HU patients, the incidence of aspiration pneumonia (2.2% vs. 3.6%, p 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. Epidemiologic study, level III. Therapeutic study, level IV.
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
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 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.
achieving the optimal physical structure that facilitates the care of ... patients with varying levels of need in terms of ICU equipment. As part of .... Prevention and Control Unit and is based on the R158 regulations, ..... and organizational aspects.
Kuschner, Ware G; Gruenewald, David A; Clum, Nancy; Beal, Alice; Ezeji-Okoye, Stephen C
Ethical conflicts are commonly encountered in the course of delivering end-of-life care in the ICU. Some ethical concerns have legal dimensions, including concerns about inappropriate hastening of death. Despite these concerns, many ICUs do not have explicit policies and procedures for withdrawal of life-sustaining treatments. We describe a US Office of Inspector General (OIG) investigation of end-of-life care practices in our ICU. The investigation focused on care delivered to four critically ill patients with terminal diseases and an ICU nurse's concern that the patients had been subjected to euthanasia. The OIG investigation also assessed the validity of allegations that patient flow in and out of our ICU was inappropriately influenced by scheduled surgeries and that end-of-life care policies in our ICU were not clear. Although the investigation did not substantiate the allegations of euthanasia or inappropriate ICU patient flow, it did find that the policies that discuss end-of-life care issues were not clear and allowed for wide-ranging interpretations. Acting on the OIG recommendations, we developed a quality improvement initiative addressing end-of-life care in our ICU, intended to enhance communication and understanding about palliative care practices in our ICU, to prevent ethical conflicts surrounding end-of-life care, and to improve patient care. The initiative included the introduction of newly developed ICU comfort care guidelines, a physician order set, and a physician template note. Additionally, we implemented an educational program for ICU staff. Staff feedback regarding the initiative has been highly favorable, and the nurse whose concerns led to the investigation was satisfied not only with the investigation but also the policies and procedures that were subsequently introduced in our ICU.
Lykkegaard, Kristina; Delmar, Charlotte
This study explores the perceived meaning of dependency on care as experienced by intensive care patients. Research from non-intensive settings shows that dependency is often experienced negatively, but literature on the subject experienced by patients in the ICU is sparse. The study is based on in-depth qualitative semi-structured interviews of lived experience with three former patients admitted to an intensive care unit at a Danish university hospital. The in-depth interviews have been characterized as narratives. The main inspiration for the analysis method is Ricoeur's phenomenological hermeneutical interpretation theory. The study has found that dependency is experienced as difficult, and the relationship with the nurses seems to be ambivalent. The good relationship is experienced to make dependency easier, whereas negative experiences make it harder to cope with dependency. The participants deal with dependency by accepting negative experiences in gratitude for having recovered from critical illness. The findings might be influenced by studies being conducted in a western country setting where independence is valued. They can be used as means of reflection on nursing practice and matters such as communication and patient participation. PMID:25765881
Madsen, Kristian Rørbaek; Lorentzen, Kristian; Clausen, Niels
Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU), and is recommended in the Surviving Sepsis Campaign guidelines 2012. The present guideline from the Danish Society of Intensive Care Medicine and the Danish Society of Anesthesiology and Intensive Care Medicine sums...... critically ill patients in the ICU outside the context of randomized controlled trials (GRADE 1C). No robust evidence supports recommendations for subpopulations in the ICU such as septic, burn, trauma, cardiothoracic or enterally fed patients. However, if SUP is considered clinically indicated in individual...
Full Text Available The drug related complications are on the rise warranting special attention towards patient safety in Intensive Care Unit (ICU setup. Pharmacovigilance is the science about the detection, assessment and prevention of drug related problems. This review is aimed to highlight significant problems arising from medication errors with emphasis on special drugs used in ICU (oxygen, antibiotics, sedatives, analgesics and neuromuscular blocking drugs and their risk reduction strategies in ICU utilizing practice of pharmacovigilance. Human error, lack of communication among various health providers, inadequate knowledge about drugs, failure to follow protocols or recommended guidelines are important causes of drug related problems in ICU. It is imperative that ICU administrators and medical directors of hospitals consider adverse drug events (ADEs as system failures. Pharmacovigilance, an observational science is the need of the hour for patients admitted in ICUs. We need to give more emphasis on prevention rather than treating the potentially fatal complications arising from ADEs. Eternal vigilance is the key. Protocol based management, improvement of medication system, frequent audits, improved communication, good team work, a blame free environ-ment, inclusion of a pharmacist, leadership involvement and use of information technology in the ICU are possible solutions.
Full Text Available Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.
Matlakala, Mokgadi C; Bezuidenhout, Martie C; Botha, Annali D H
Nurses in intensive care units (ICUs) are exposed regularly to huge demands interms of fulfilling the many roles that are placed upon them. Unit managers, in particular, are responsible for the efficient management of the units and have the responsibilities of planning, organising, leading and controlling the daily activities in order to facilitate the achievement of the unit objectives. The objective of this study was to explore and present the challenges encountered by ICU managers in the management of large ICUs. A qualitative, exploratory and descriptive study was conducted at five hospital ICUs in Gauteng province, South Africa. Data were collected through individual interviews from purposively-selected critical care unit managers, then analysed using the matic coding. Five themes emerged from the data: challenges related to the layout and structure of the unit, human resources provision and staffing, provision of material resources, stressors in the unit and visitors in the ICU. Unit managers in large ICUs face multifaceted challenges which include the demand for efficient and sufficient specialised nurses; lack of or inadequate equipment that goes along with technology in ICU and supplies; and stressors in the ICU that limit the efficiency to plan, organise, lead and control the daily activities in the unit. The challenges identified call for multiple strategies to assist in the efficient management of large ICUs.
Mokgadi C. Matlakala
Full Text Available Background: Nurses in intensive care units (ICUs are exposed regularly to huge demands interms of fulfilling the many roles that are placed upon them. Unit managers, in particular, are responsible for the efficient management of the units and have the responsibilities of planning, organising, leading and controlling the daily activities in order to facilitate the achievement of the unit objectives. Objectives: The objective of this study was to explore and present the challenges encountered by ICU managers in the management of large ICUs. Method: A qualitative, exploratory and descriptive study was conducted at five hospital ICUs in Gauteng province, South Africa. Data were collected through individual interviews from purposively-selected critical care unit managers, then analysed using the matic coding. Results: Five themes emerged from the data: challenges related to the layout and structure of the unit, human resources provision and staffing, provision of material resources, stressors in the unit and visitors in the ICU. Conclusion: Unit managers in large ICUs face multifaceted challenges which include the demand for efficient and sufficient specialised nurses; lack of or inadequate equipment that goes along with technology in ICU and supplies; and stressors in the ICU that limit the efficiency to plan, organise, lead and control the daily activities in the unit. The challenges identified call for multiple strategies to assist in the efficient management of large ICUs.
Kvande, Monica; Lykkeslet, Else; Storli, Sissel Lisa
Nurses and physicians work side-by-side in the intensive care unit (ICU). Effective exchanges of patient information are essential to safe patient care in the ICU. Nurses often rate nurse-physician communication lower than physicians and report that it is difficult to speak up, that disagreements are not resolved and that their input is not well received. Therefore, this study explored nurses' dialogue with physicians regarding patients' clinical status and the prerequisites for effective and accurate exchanges of information. We adopted a qualitative approach, conducting three focus group discussions with five to six nurses and physicians each (14 total). Two themes emerged. The first theme highlighted nurses' contributions to dialogues with physicians; nurses' ongoing observations of patients were essential to patient care discussions. The second theme addressed the prerequisites of accurate and effective dialogue regarding care options, comprising three subthemes: nurses' ability to speak up and present clinical changes, establishment of shared goal and clinical understanding, and open dialogue and willingness to listen to each other. Nurses should understand their essential role in conducting ongoing observations of patients and their right to be included in care-related decision-making processes. Physicians should be willing to listen to and include nurses' clinical observations and concerns.
Hester, Marisa; Ingalls, Nichole K; Hatzfeld, Jennifer J
Severely injured patients have difficulty recalling their intensive care unit (ICU) experience which may contribute to emotional trauma. An ICU patient journal contains a short summary of key events during the ICU stay, and has been shown to improve emotional well-being. This project evaluated the feasibility and perceptions of ICU journals in a combat ICU. A one-page survey was distributed to ICU nursing staff at Craig Joint Theater Hospital before and after the use of ICU journals as a process improvement initiative. 16 preimplementation and 10 postimplementation surveys were collected to determine the perception of the utility and feasibility of ICU journals, as well as changes to nursing job satisfaction. Overall, nurses had positive perceptions of ICU journaling; after implementation they felt it could also benefit nurses (31% vs. 80%, p = 0.002). ICU nurses that used journals were also more likely to feel their work makes a difference (90%, p = 0.012) and they could connect with their patient on a personal level (50%, p = 0.037). Primary barriers were time to journal and legal concerns. This study demonstrates with the right guidance, ICU journals can be incorporated into an ICU in a deployed environment and nursing staff feel they benefit the patient, family, unit, and staff. Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.
Chiarchiaro, Jared; White, Douglas B; Ernecoff, Natalie C; Buddadhumaruk, Praewpannarai; Schuster, Rachel A; Arnold, Robert M
Conflict is common between physicians and surrogate decision makers around end-of-life care in ICU. Involving experts in conflict management improve outcomes, but little is known about what differences in conflict management styles may explain the benefit. We used simulation to examine potential differences in how palliative care specialists manage conflict with surrogates about end-of-life treatment decisions in ICUs compared with intensivists. Subjects participated in a high-fidelity simulation of conflict with a surrogate in an ICU. In this simulation, a medical actor portrayed a surrogate decision maker during an ICU family meeting who refuses to follow an advance directive that clearly declines advanced life-sustaining therapies. We audiorecorded the simulation encounters and applied a coding framework to quantify conflict management behaviors, which was organized into two categories: task-focused communication and relationship building. We used negative binomial modeling to determine whether there were differences between palliative care specialists' and intensivists' use of task-focused communication and relationship building. Single academic medical center ICU. Palliative care specialists and intensivists. None. We enrolled 11 palliative care specialists and 25 intensivists. The palliative care specialists were all attending physicians. The intensivist group consisted of 11 attending physicians, 9 pulmonary and critical care fellows, and 5 internal medicine residents rotating in the ICU. We excluded five residents from the primary analysis in order to reduce confounding due to training level. Physicians' mean age was 37 years with a mean of 8 years in practice. Palliative care specialists used 55% fewer task-focused communication statements (incidence rate ratio, 0.55; 95% CI, 0.36-0.83; p = 0.005) and 48% more relationship-building statements (incidence rate ratio, 1.48; 95% CI, 0.89-2.46; p = 0.13) compared with intensivists. We found that palliative care
Full Text Available Nurses have the most important role among health care workers (HCWs in each hospital (Aiken et al., 2008 . Nurses education can lead to the improvement of nursing care If is implemented and designed based on nurses’ needs and proper principles (Aiken et al., 2008 . Nowadays, increased quality of the treatment and increase the chances of survival of patients with acute respiratory failure are very important (Teixeira et al., 2013 . Nursing care plan in ICU patients is one of the important elements in nursing care, and one of the main strategies is promotion of education level. Nurses due to longtime relationship with nursing staff in 24 hours and use of multiple roles of education have excellent position in evaluating educational needs and performing clinical educator roles. The effect of education on the nursing care quality of patients who were under mechanical ventilation (UMV in intensive care unit (ICU ward of Razi hospital is evaluated during 2015. The present study is descriptive-analytical and semi experimental research. Research statistical population included 30 nurses. In this paper, the effects of communication with the patient, correct suctioning, compliance of aseptic techniques, the correct discharge of tube cuff, chest physiotherapy, the correct change positions, health food gavage, prevent of foot drop, oral hygiene, the eyes hygiene and protect the cornea have been studied. After completion of the questionnaires by patients, the obtained coded data were fed into EXCEL. Reliability was confirmed with coefficient Alfa 0.86 and the result of software and techniques were entered to SPSS for statistics and analysis. Keywords: Education, Nurse, Intensive care unit, Mechanical ventilation, Nursing care, Iran
Crippen, David; Burrows, Dick; Stocchetti, Nino; Mayer, Stephan A; Andrews, Peter; Bleck, Tom; Whetstine, Leslie
The patient is a 27-year-old previously healthy male with a diagnosis of viral encephalitis with a lymphocytic pleocytosis on cerebrospinal fluid examination. For 3 months, he has been in status epilepticus (SE) on high doses of barbiturates, benzodiazepines, and ketamine and a ketogenic feeding-tube formula. He remains in burst suppression on continuous electroencephalography (EEG). He is trached and has a percutaneous endoscopic gastrostomy (PEG) feeding tube. He has been treated several times for pneumonia, and he is on a warming blanket and is on vasopressors to maintain his blood pressure. His vitals are stable and his lab work is within limits. The sedation is decreased under EEG guidance every 72 hours, after which he goes back into SE and heavy sedation is resumed. The latest magnetic resonance imaging (MRI) shows edema but otherwise no obvious permanent cortical damage. The family wants a realistic assessment of the likely outcome. The neurologist tells them the literature suggests the outlook is poor but not 100% fatal. As long as all of his other organs are functioning on life support, there is always a chance the seizures will stop at some time in the future, and so the neurologist recommends an open-ended intensive care unit (ICU) plan and hopes for that outcome.
Full Text Available Introduction: The intensive care unit is one of the specialized units in hospitals where head nurses are responsible for both motivating the personnel and providing high quality care. Understanding of the lived experiences of head nurses could help develop new assumptions of the ICU. The present study was therefore conducted to describe the lived experiences of head nurses working in ICU. Methods: In this phenomenological study, data were collected through unstructured in-depth interviews with 5 ICU head nurses in Northern Iran and then analyzed using 7 steps Colaizzi’s method. Results: Despite the "distressing atmosphere of the ICU", the "difficulty of managing the ICU" and the "difficulty of communication in the ICU", which encourages the "desire to leave the unit" among ICU head nurses, the "desire to stay in the unit" is stronger and head nurses are highly motivated to stay in the unit because the unit "develops a feeling of being extraordinary", "creates an interest in providing complicated care to special patients", "facilitates the spiritual bond", "develops a professional dynamism" and "creates an awareness about the nature of intensive care" among them. Conclusion: According to the result, ICU head nurses are still inclined to work in the unit and achieve success in spite of the problems that persist in working in the ICU. As the individuals’ motivation can be the backbone of organizations, and given that individuals with a high enthusiasm for success are productive, hospital managers can take advantage of this strength in choosing their head nurses.
Mador, Rebecca L; Shaw, Nicola T
The introduction of a Critical Care Information System (CCIS) into an intensive care unit (ICU) is purported to reduce the time health care providers (HCP) spend on documentation and increase the time available for direct patient care. However, there is a paucity of rigorous empirical research that has investigated these assertions. Moreover, those studies that have sought to elucidate the relationship between the introduction of a CCIS and the time spent by staff on in/direct patient care activities have published contradictory findings. The objective of this literature review is to establish the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU. Five electronic databases were searched including PubMed Central, EMBASE, CINAHL, IEEE Xplore, and the Cochrane Database of Systematic Reviews. Reference lists of all published papers were hand searched, and citations reviewed to identify extra papers. We included studies that were empirical articles, published in English, and provided original data on the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU. In total, 12 articles met the inclusion criteria. Workflow analysis (66%) and time-and-motion analysis (25%) were the most common forms of data collection. Three (25%) studies found an increase in time spent charting, five (42%) found no difference, and four (33%) studies reported a decrease. Results on the impact of a CCIS on direct patient care were similarly inconclusive. Due to the discrepant findings and several key methodological issues, the impact of a CCIS on time spent charting and in direct patient care remains unclear. This review highlights the need for an increase in rigorous empirical research in this area and provides recommendations for the design and implementation of future studies.
McLaughlin, Anne Marie
To prospectively assess the cost of patients in an adult intensive care unit (ICU) using bottom-up costing methodology and evaluate the usefulness of "severity of illness" scores in estimating ICU cost.
King, Mary A; Niven, Alexander S; Beninati, William; Fang, Ray; Einav, Sharon; Rubinson, Lewis; Kissoon, Niranjan; Devereaux, Asha V; Christian, Michael D; Grissom, Colin K
Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided. Successful ICU evacuation during a disaster requires active preparation, participation
Full Text Available In Mongolia, a Central Asian lower-middle income country, intensive care medicine is an under-resourced and-developed medical specialty. The burden of critical illness and capacity of intensive care unit (ICU services in the country is unknown. In this nationwide census, we collected data on adult and pediatric/neonatal ICU capacities and the number of ICU admissions in 2014. All hospitals registered to run an ICU service in Mongolia were surveyed. Data on the availability of an adult and/or pediatric/neonatal ICU service, the number of available ICU beds, the number of available functional mechanical ventilators, the number of patients admitted to the ICU, and the number of patients admitted to the study hospital were collected. In total, 70 ICUs with 349 ICU beds were counted in Mongolia (11.7 ICU beds/100,000 inhabitants; 1.7 ICU beds/100 hospital beds. Of these, 241 (69% were adult and 108 (31% pediatric/neonatal ICU beds. Functional mechanical ventilators were available for approximately half of the ICU beds (5.1 mechanical ventilators/100,000 inhabitants. While all provincial hospitals ran a pediatric/neonatal ICU, only dedicated pediatric hospitals in Ulaanbaatar did so. The number of adult and pediatric/neonatal ICU admissions varied between provinces. The number of adult ICU beds and adult ICU admissions per 100,000 inhabitants correlated (r = 0.5; p = 0.02, while the number of pediatric/neonatal ICU beds and pediatric/neonatal ICU admissions per 100,000 inhabitants did not (r = 0.25; p = 0.26. In conclusion, with 11.7 ICU beds per 100,000 inhabitants the ICU capacity in Mongolia is higher than in other low- and lower-middle-income countries. Substantial heterogeneities in the standardized ICU capacity and ICU admissions exist between Mongolian provinces. Functional mechanical ventilators are available for only half of the ICU beds. Pediatric/neonatal ICU beds make up one third of the national ICU capacity and appear to meet or even
Madsen, Kristian Rørbaek; Lorentzen, Kristian; Clausen, Niels
Stress ulcer prophylaxis (SUP) is commonly used in the intensive care unit (ICU), and is recommended in the Surviving Sepsis Campaign guidelines 2012. The present guideline from the Danish Society of Intensive Care Medicine and the Danish Society of Anesthesiology and Intensive Care Medicine sums...
Svenningsen, Helle; Egerod, I; Videbech, Poul
Delirium in patients admitted to the intensive care unit (ICU) is a serious complication potentially increasing morbidity and mortality. The aim of this study was to investigate the impact of fluctuating sedation levels on the incidence of delirium in ICU.......Delirium in patients admitted to the intensive care unit (ICU) is a serious complication potentially increasing morbidity and mortality. The aim of this study was to investigate the impact of fluctuating sedation levels on the incidence of delirium in ICU....
Andrew M. Harrison
Full Text Available Background Electronic Health Record (EHR-based sepsis alert systems have failed to demonstrate improvements in clinically meaningful endpoints. However, the effect of implementation barriers on the success of new sepsis alert systems is rarely explored. Objective To test the hypothesis time to severe sepsis alert acknowledgement by critical care clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement system compared to a text paging-based system. Study Design In one arm of this simulation study, real alerts for patients in the medical ICU were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts were delivered through text paging. The primary outcome was time to alert acknowledgement. The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal group interview. Results The alert acknowledgement rate from the severe sepsis alert system was 3% (N = 148 and 51% (N = 156 from simulated severe sepsis alerts through traditional text paging. Time to alert acknowledgement from the severe sepsis alert system was median 274 min (N = 5 and median 2 min (N = 80 from text paging. The response rate from the EHR-based alert system was insufficient to compare primary measures. However, secondary measures revealed important barriers. Conclusion Alert fatigue, interruption, human error, and information overload are barriers to alert and simulation studies in the ICU setting.
Obel, N; Schierbeck, J; Pedersen, L
BACKGROUND: As a result of a shortage of intensive care capacity, patients may be discharged prematurely early during weekends which may lead to an increased mortality and risk of readmission to intensive care units (ICU). We examined whether discharge from the ICU during the first part...
Matlakala, M C; Bezuidenhout, M C; Botha, A D H
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.
Weinreich, Mark; Herman, Jennifer; Dickason, Stephanie; Mayo, Helen
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.
Full Text Available BACKGROUND: Resistance to antibiotics among Enterobacteriacae represents a serious therapeutic and infection control challenge. The objective of this study was to determine the frequency of carbapenem, colistin and tigecycline resistant Enterobacteriaceae isolates obtained from patients admitted in medical intensive care unit (ICU of a tertiary care hospital in Karachi, Pakistan. METHODS: This was a descriptive cross sectional study that was conducted at Liaquat National Postgraduate Medical Centre, Karachi, Pakistan during December 2015 to May 2016. Patients admitted in the medical ICU with systemic inflammatory response syndrome were included. The culture positive samples were analyzed for further identification and antimicrobial sensitivity was performed according to clinical laboratory standard institute (CLSI 2014 guidelines. RESULTS: Of the 748 samples, 177 were positive for Enterobactericae. Most samples were taken from blood 75(42.2% or tracheal secretions 67(37.9%. Most common organism isolated were Klebsiella pneumoniae 77(43.5% and Escherichia coli 71(40.1%. Out of these 10.7% organisms were resistant to meropenem, while 2.8% and 20.3% were resistant to colistin and tigecycline respectively. CONCLUSION: Increasing spread of drug resistance among Enterobacteriacae reflects an important problem that can be controlled with effective policies of infection control, surveillance and antimicrobial stewardship.
Andersen, J H; Boesen, Hans Christian Toft; Olsen, Karsten Skovgaard
Sleep deprivation has deleterious effects on most organ systems. Patients in the Intensive care unit (ICU) report sleep deprivation as the second worst experience during their stay only superseded by pain. The aim of the review is to provide the clinician with knowledge of the optimal sleep-frien......-friendly care and environment.......Sleep deprivation has deleterious effects on most organ systems. Patients in the Intensive care unit (ICU) report sleep deprivation as the second worst experience during their stay only superseded by pain. The aim of the review is to provide the clinician with knowledge of the optimal sleep...
Bosma, L.B.E. (Liesbeth B. E.); N.G.M. Hunfeld (Nicola); R.A.M. Quax; E. Meuwese (Edmé); Melief, P.H.G.J. (Piet H. G. J.); J. van Bommel (Jasper); S.S. Tan (Siok Swan); van Kranenburg, M.J. (Maaike J.); P.M.L.A. van den Bemt (Patricia)
textabstractBackground: Medication errors occur frequently in the intensive care unit (ICU) and during care transitions. Chronic medication is often temporarily stopped at the ICU. Unfortunately, when the patient improves, the restart of this medication is easily forgotten. Moreover, temporal ICU
Kubicki, Mark A; McGain, Forbes; O'Shea, Catherine J; Bates, Samantha
The provision of health care has significant direct environmental effects such as energy and water use and waste production, and indirect effects, including manufacturing and transport of drugs and equipment. Recycling of hospital waste is one strategy to reduce waste disposed of as landfill, preserve resources, reduce greenhouse gas emissions, and potentially remain fiscally responsible. We began an intensive care unit recycling program, because a significant proportion of ICU waste was known to be recyclable. To determine the weight and proportion of ICU waste recycled, the proportion of incorrect waste disposal (including infectious waste contamination), the opportunity for further recycling and the financial effects of the recycling program. We weighed all waste and recyclables from an 11-bed ICU in an Australian metropolitan hospital for 7 non-consecutive days. As part of routine care, ICU waste was separated into general, infectious and recycling streams. Recycling streams were paper and cardboard, three plastics streams (polypropylene, mixed plastics and polyvinylchloride [PVC]) and commingled waste (steel, aluminium and some plastics). ICU waste from the waste and recycling bins was sorted into those five recycling streams, general waste and infectious waste. After sorting, the waste was weighed and examined. Recycling was classified as achieved (actual), potential and total. Potential recycling was defined as being acceptable to hospital protocol and local recycling programs. Direct and indirect financial costs, excluding labour, were examined. During the 7-day period, the total ICU waste was 505 kg: general waste, 222 kg (44%); infectious waste, 138 kg (27%); potentially recyclable waste, 145 kg (28%). Of the potentially recyclable waste, 70 kg (49%) was actually recycled (14% of the total ICU waste). In the infectious waste bins, 82% was truly infectious. There was no infectious contamination of the recycling streams. The PVC waste was 37% contaminated
K Taylor A Blair BA, RN
Full Text Available The critical care literature in the US has recently brought attention to the impact an ICU experience can have long after the patient survives critical illness, particularly if delirium was present. Current recommendations to mitigate post-intensive care syndrome (PICS are embedded in patient and family-centered care and aim to promote family presence in the ICU, provide support for decision-making, and enhance communication with the health-care team. Evidence-based interventions are few in number but include use of an ICU diary to minimize the psychological and emotional sequelae affecting patients and family members in the months following the ICU stay. In this paper we describe our efforts to implement an ICU diary and solicit feedback on its role in fostering teamwork and communication between patients, family members, and ICU staff. Next steps will involve a PICS follow-up clinic where trained staff will coordinate specialty referrals and perform long-term monitoring of mental health and other quality of life outcomes.
Blair, K Taylor A; Eccleston, Sarah D; Binder, Hannah M; McCarthy, Mary S
The critical care literature in the US has recently brought attention to the impact an ICU experience can have long after the patient survives critical illness, particularly if delirium was present. Current recommendations to mitigate post-intensive care syndrome (PICS) are embedded in patient and family-centered care and aim to promote family presence in the ICU, provide support for decision-making, and enhance communication with the health-care team. Evidence-based interventions are few in number but include use of an ICU diary to minimize the psychological and emotional sequelae affecting patients and family members in the months following the ICU stay. In this paper we describe our efforts to implement an ICU diary and solicit feedback on its role in fostering teamwork and communication between patients, family members, and ICU staff. Next steps will involve a PICS follow-up clinic where trained staff will coordinate specialty referrals and perform long-term monitoring of mental health and other quality of life outcomes.
Rudy, E B; Daly, B J; Douglas, S; Montenegro, H D; Song, R; Dyer, M A
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.
Full Text Available The antimicrobial management of patients in the Intensive Care Units are complex. Antimicrobial resistance is an increasing problem. Effective strategies for the prevention of antimicrobial resistance in ICUs have focused on limiting the unnecessary use of antibiotics and increasing compliance with infection control practices. Antibiotic policies have been implemented to modify antibiotic use, including national or regional formulary manipulations, antibiotic restriction forms, care plans, antibiotic cycling and computer assigned antimicrobial therapy. Moreover, infectious diseases consultation is a simple way to limit antibiotic use in ICU units. To improve rational antimicrobial using a multidisiplinary approach is suggested. [Archives Medical Review Journal 2003; 12(4.000: 299-309
Noome, M.; Beneken genaamd Kolmer, D.M.; Leeuwen, E. van; Dijkstra, B.M.; Vloet, L.C.M.
AIM: 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). METHOD: Three electronic databases, PubMed, CINAHL and EMBASE, and
Noome, M.; Beneken genaamd Kolmer, D.M.; van Leeuwen, E.; Dijkstra, B.M.; Vloet, L.
Aim 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). Method Three electronic databases, PubMed, CINAHL and EMBASE, and reference
Chuang, Chien-Huai; Tseng, Pei-Chi; Lin, Chun-Yu; Lin, Kuan-Han; Chen, Yen-Yuan
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
Gershengorn, Hayley B; Garland, Allan; Gong, Michelle N
Published studies suggest hospital costs on Day 1 in the intensive care unit (ICU) far exceed those of subsequent days, when costs are relatively stable. Yet, no study stratified patients by ICU type. To determine whether daily cost patterns differ by ICU type. We performed a retrospective study of adults admitted to five ICUs (two surgical: quaternary surgical ICU [SICU quat] and quaternary cardiac surgical ICU [CSICU quat]; two medical: tertiary medical ICU [MICU tertiary] and quaternary medical ICU [MICU quat]; one general: community medical surgical ICU [MSICU comm]) at Montefiore Medical Center in the Bronx, New York during 2013. After excluding costs clearly accrued outside the ICU, daily hospital costs were merged with clinical data. Patterns of daily unadjusted costs were evaluated in each ICU using median regression. Generalized estimating equations with first-order autocorrelation were used to identify factors independently associated with daily costs. Unadjusted daily costs were higher on Day 1 than on subsequent days only for surgical ICUs-SICU quat (median [interquartile range], $2,636 [$1,834-$4,282] on Day 1 vs. $1,840 [$1,501-$2,332] on Day 2; P cost from Days 1 to 2. After multivariate adjustment, there remained a significant decrease in cost from ICU Day 1 to 2 in surgical units with statistically similar Day 1 and 2 costs for other ICUs. Higher Day 1 costs are not seen in patients admitted to medical/nonsurgical ICUs.
Bellani, Giacomo; Laffey, John G.; Pham, Tài; Fan, Eddy; Brochard, Laurent; Esteban, Andres; Gattinoni, Luciano; van Haren, Frank; Larsson, Anders; McAuley, Daniel F.; Ranieri, Marco; Rubenfeld, Gordon; Thompson, B. Taylor; Wrigge, Hermann; Slutsky, Arthur S.; Pesenti, Antonio; Francois, Guy M.; Rabboni, Francesca; Madotto, Fabiana; Conti, Sara; Sula, Hektor; Nunci, Lordian; Cani, Alma; Zazu, Alan; Dellera, Christian; Insaurralde, Carolina S.; Alejandro, Risso V.; Daldin, Julio; Vinzio, Mauricio; Fernandez, Ruben O.; Cardonnet, Luis P.; Bettini, Lisandro R.; Bisso, Mariano Carboni; Osman, Emilio M.; Setten, Mariano G.; Lovazzano, Pablo; Alvarez, Javier; Villar, Veronica; Pozo, Norberto C.; Grubissich, Nicolas; Plotnikow, Gustavo A.; Vasquez, Daniela N.; Ilutovich, Santiago; Tiribelli, Norberto; Chena, Ariel; Pellegrini, Carlos A.; Saenz, María G.; Estenssoro, Elisa; Simonis, Fabienne D.; Schultz, Marcus J.
IMPORTANCE Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS). OBJECTIVES To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation
Yaqub, K.M.; Usman, J.; Zaidi, S.B.H.; Khalil, A.; Noor, N.; Gill, M.M.
Objective: To determine the frequency of fungal infections in intensive care unit (ICU) of Military Hospital, Rawalpindi, a tertiary care health facility. Study Design: Cross sectional study. Place and Duration of Study: Intensive Care Department of Military Hospital Rawalpindi from 01 Jan 2012 to 30 Jun 2012. Methodology: A total of 89 patients were screened with stay of more than 5 days in intensive care unit. Thirty cases were enrolled in the study for investigation of fungal infections that had fever even after 05 days of being on broad spectrum antibiotics. Culture was done on blood, urine and catheter tip samples as per clinical condition of a patient. Results: Candida infection was found in 23.4% of study cases. The mean age of study patients was 41.2 +- 20.0 years while 63.4% were female patients as compared to 36.7% males. Conclusion: Fungal infections especially candidemias are quite frequent in the intensive care units. (author)
Intensive care units (ICUs) provides intensive treatment medicine to avoid complications such as malnutrition, infection and even death. As very little is currently known about the nutritional practices in Iranian ICUs, this study attempted to assess the various aspects of current nutrition support practices in Iranian ICUs. We conducted a cross-sectional study on 150 critically ill patients at 18 ICUs in 12 hospitals located in 2 provinces of Iran from February 2015 to March 2016. Data were collected through interview with supervisors of ICUs, medical record reviews and direct observation of patients during feeding. Our study showed that hospital-prepared enteral tube feeding formulas are the main formulas used in Iranian hospitals. None of the dietitians worked exclusively an ICU and only 30% of patients received diet counselling. Regular monitoring of nutritional status, daily energy and protein intake were not recorded in any of the participating ICUs. Patients were not monitored for anthropometric measurements such as mid-arm circumference (MAC) and electrolyte status. The nasogastric tube was not switched to percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEGJ) in approximately 85% of patients receiving long-term enteral nutrition (EN) support. Our findings demonstrated that the quality of nutritional care was inappropriate in Iranian ICUs and improvement of nutritional care services within Iranian ICUs is necessary. PMID:29713622
Full Text Available Intensive care is a critical area of medicine having a multidisciplinary nature requiring all types of healthcare professionals. Given the critical environment of intensive care units (ICUs, the need to use information technologies, like decision support systems, to improve healthcare services and ICU management is evident. It is proven that unplanned and prolonged admission to the ICU is not only prejudicial to a patient's health, but also such a situation implies a readjustment of ICU resources, including beds, doctors, nurses, financial resources, among others. By discovering the common characteristics of the admitted patients, it is possible to improve these outcomes. In this study clustering techniques were applied to data collected from admitted patients in an intensive care unit. The best results presented a silhouette of 1, with a distance to centroids of 6.2 × 10−17 and a Davies–Bouldin index of −0.652.
de Rooij, Sophia E.; Abu-Hanna, Ameen; Levi, Marcel; de Jonge, Evert
INTRODUCTION: Current prognostic models for intensive care unit (ICU) patients have not been specifically developed or validated in the very elderly. The aim of this study was to develop a prognostic model for ICU patients 80 years old or older to predict in-hospital mortality by means of data
Phillips, Stuart M.; Dickerson, Roland N.; Moore, Frederick A.; Paddon-Jones, Douglas; Weijs, Peter J. M.
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)
This thesis covers several topics including studies on the accuracy of continuous glucose measurement (CGM) devices in the Intensive Care Unit (ICU). In addition, it is investigated whether an electronic nose (eNose) can be used to predict blood glucose levels in mechanically ventilated ICU
Background. The admission of a relative to an intensive care unit (ICU) is a stressful experience for family members. There has been limited research addressing this issue in Kigali, Rwanda. Objective. To explore the needs of patient family members admitted into an ICU in Kigali, Rwanda. Methods. This study used a ...
De Bock, Ben A.; Willems, Dick L.; Weinstein, Henry C.
How to clarify the implications of complexity thinking for decision making in the intensive care unit (ICU)? Retrospective qualitative empirical research. Practitioners in an ICU were interviewed on how their decisions were made regarding a particular patient in a difficult, clinical situation.
Dettling-Ihnenfeldt, Daniela S.; de Graaff, Aafke E.; Beelen, Anita; Nollet, Frans; van der Schaaf, Marike
The purpose of this study was to explore coping styles among intensive care unit (ICU) survivors and investigate the association between coping style and quality of life (QOL). In this cross-sectional multicenter study, 150 adult patients who were mechanically ventilated in an ICU for ≥2 days and
Forte, Daniel Neves; Vincent, Jean Louis; Velasco, Irineu Tadeu; Park, Marcelo
This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics. The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.
Lindgaard, Sidsel Christy; Nielsen, Jonas; Lindmark, Anders
BACKGROUND: Allogeneic haematopoietic stem cell transplantation (HSCT) is a procedure with inherent complications and intensive care may be necessary. We evaluated the short- and long-term outcomes of the HSCT recipients requiring admission to the intensive care unit (ICU). METHODS: We...... ventilation had a statistically significant effect on in-ICU (p = 0.02), 6-month (p = 0.049) and 1-year (p = 0.014) mortality. Renal replacement therapy also had a statistically significant effect on in-hospital (p = 0.038) and 6-month (p = 0.026) mortality. Short ICU admissions, i.e. ... to the ICU was confirmed in our study. Mechanical ventilation, renal replacement therapy and an ICU admission of ≥10 days were each risk factors for mortality in the first year after ICU admission....
Zaforteza, Concha; Gastaldo, Denise; Moreno, Cristina; Bover, Andreu; Miró, Rosa; Miró, Margalida
This study focuses on change strategies generated through a dialogical-reflexive-participatory process designed to improve the care of families of critically ill patients in an intensive care unit (ICU) using a participatory action research in a tertiary hospital in the Balearic Islands (Spain). Eleven professionals (representatives) participated in 11 discussion groups and five in-depth interviews. They represented the opinions of 49 colleagues (participants). Four main change strategies were created: (i) Institutionally supported practices were confronted to make a shift from professional-centered work to a more inclusive, patient-centered approach; (ii) traditional power relations were challenged to decrease the hierarchical power differences between physicians and nurses; (iii) consensus was built about the need to move from an individual to a collective position in relation to change; and (iv) consensus was built about the need to develop a critical attitude toward the conservative nature of the unit. The strategies proposed were both transgressive and conservative; however, when compared with the initial situation, they enhanced the care offered to patients' relatives and patient safety. Transforming conservative settings requires capacity to negotiate positions and potential outcomes. However, when individual critical capacities are articulated with a new approach to micropolitics, transformative proposals can be implemented and sustained. © 2015 John Wiley & Sons Ltd.
Polmear, C M; Nathan, H; Bates, S; French, C; Odisho, J; Skinner, E; Karahalios, A; McGain, F
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.
Østergaard, Kija Lin; Brandrup, Morten
-ended dry-erase whiteboard (make-up-your-own-sentences). In conclusion the primary feature in the two subjects is to optimize communication/collaboration and information between ICU and general wards in the transition. To make it a long term solution the content of such a support would need involvement...... of the end-users in the design process (Participatory Design). Hence these two findings, this review is setting the stage for further research on how electronic whiteboards can support the initial follow up when patients are transferred from an ICU to a general ward.......This paper is reviewing the existing literature on Intensive Care Unit (ICU) Outreach, in-hospital follow up 24 hours after the transition to a general ward from an ICU. It also touches upon the use of Electronic Whiteboards in a hospital setting and how the electronic whiteboards might support...
Objective. To document the outcome of patients discharged from the intensive care unit (ICU) with tracheostomies. Design and setting. This was a retrospective study conducted in the ICU of Dr George Mukhari Hospital, Pretoria. Patients. All patients discharged from the ICU with tracheostomies over a period of 1 year from 1 ...
Full Text Available The aim of intensive care is to support the physiology of the body till the treatment or the reparative process of the body kicks in to the rescue. Maintaining an adequate nutrition during this period is of vital importance to counteract the catabolic effect of the critical disease process. The guidelines for nutritional care in the neuro intensive care unit (ICU are sparse. This article collates the current evidence and best practice recommendations as applicable to the critically ill patient in the neuro ICU. The use of screening tests to identify patients at a risk of malnutrition and related complications is presently recommended for all patients with an emphasis on early initiation of caloric support. Over-aggressive feeding in an attempt to revert the catabolic effects of critical illness have not proven beneficial, just as the attempts to improve patient outcomes by altering the routes of nutrition administration. Special patient population such as traumatic brain injury, stroke, subarachnoid haemorrhage or spinal cord injury may have varying nutritional requirements; individualised approach in the neurocritical ICU with the help of the intensivist, nutritionist and pharmacology team may be of benefit.
Pouwels, K B; Van Kleef, E; Vansteelandt, S; Batra, R; Edgeworth, J D; Smieszek, T; Robotham, J V
BACKGROUND: 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. AIM: To evaluate these associations while adjusting for potential time-varying
Hui Siu L
Full Text Available Abstract 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
Ponzoni, Carolina R; Corrêa, Thiago D; Filho, Roberto R; Serpa Neto, Ary; Assunção, Murillo S C; Pardini, Andreia; Schettino, Guilherme P P
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 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
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
Jackson, James C.; Santoro, Michael J.; Ely, Taylor M.; Boehm, Leanne; Kiehl, Amy L; Anderson, Lindsay S.; Ely, E. Wesley
The Intensive Care Unit is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and, while the overall number of hospital beds remains stable in the U.S., the percentage of that total devoted to ICU beds is rising. These two realities engender a demographic imperative to address patient safety in the critical care setting. This manuscr...
Altawalbeh, Shoroq M; Saul, Melissa I; Seybert, Amy L; Thorpe, Joshua M; Kane-Gill, Sandra L
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.
Silvia Helena Henriques Camelo
Full Text Available Objective. The aim in this study was to identify how Intensive Care Unit nurses perceive professional competences in thecare team. Methodology. Qualitative multiple case study with an exploratory focus. The sample consisted of 24 nurses from Intensive Care Units (ICU at two large hospitals. To collect the information, direct observation and - structured, non-structuredand participant - interviews were used. Results. Ninety-six percent of the participants were women, 79% were less than 40 years old, and 63% possessed less than five years of professional experience in ICU. Data analysis revealed three study categories: teamwork as a nursing management tool, improving teamwork, and interpersonal communication for teamwork. Conclusion. At the ICU where the nurses work, a teamwork strategy is observed, which demands cooperation and participation by other disciplines.
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.
Al-Kashmiri, Ammar M; Al-Shaqsi, Sultan Z; Al-Kharusi, Adil S; Al-Tamimi, Laila A
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.
M.M.C. van Mol (Margo); E.J.O. Kompanje (Erwin); D.D. Benoit (Dominique); J. Bakker (Jan); M.D. Nijkamp (Marjan); S. Seedat (Soraya)
textabstractBackground: 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
Veelo, Denise P.; Schultz, Marcus J.; Phoa, Kai Y. N.; Dongelmans, Dave A.; Binnekade, Jan M.; Spronk, Peter E.
OBJECTIVE: To determine tracheostomy-management practices in Dutch intensive care units (ICUs) and post-ICU step-down facilities. METHODS: We surveyed the physician medical directors of all Dutch nonpediatric ICUs that have : 5 beds suitable for mechanical ventilation. The survey asked for
Life-threatening attacks of asthma requiring intensive care unit (ICU) management at Red Cross War Memorial Children's Hospital in Cape Town were noted to occur in some patients in the same or adjacent months of different years. A retrospective case-controlled study was performed of 21 such 'seasonal' patients who ...
It is, however, potentially preventable. Objective. To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication. Method. A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May ...
Full Text Available Abstract Background Medication administration errors in patient care have been shown to be frequent and serious. Such errors are particularly prevalent in highly technical specialties such as the intensive care unit (ICU. In Ethiopia, the prevalence of medication administration errors in the ICU is not studied. Objective To assess medication administration errors in the intensive care unit of Jimma University Specialized Hospital (JUSH, Southwest Ethiopia. Methods Prospective observation based cross-sectional study was conducted in the ICU of JUSH from February 7 to March 24, 2011. All medication interventions administered by the nurses to all patients admitted to the ICU during the study period were included in the study. Data were collected by directly observing drug administration by the nurses supplemented with review of medication charts. Data was edited, coded and entered in to SPSS for windows version 16.0. Descriptive statistics was used to measure the magnitude and type of the problem under study. Results Prevalence of medication administration errors in the ICU of JUSH was 621 (51.8%. Common administration errors were attributed to wrong timing (30.3%, omission due to unavailability (29.0% and missed doses (18.3% among others. Errors associated with antibiotics took the lion's share in medication administration errors (36.7%. Conclusion Medication errors at the administration phase were highly prevalent in the ICU of Jimma University Specialized Hospital. Supervision to the nurses administering medications by more experienced ICU nurses or other relevant professionals in regular intervals is helpful in ensuring that medication errors don’t occur as frequently as observed in this study.
Weled, Barry J; Adzhigirey, Lana A; Hodgman, Tudy M; Brilli, Richard J; Spevetz, Antoinette; Kline, Andrea M; Montgomery, Vicki L; Puri, Nitin; Tisherman, Samuel A; Vespa, Paul M; Pronovost, Peter J; Rainey, Thomas G; Patterson, Andrew J; Wheeler, Derek S
In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.
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.
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
Yeliz İrem Tunçel
Full Text Available Objective: Burnout is common in intensive care units (ICU because of high demands and difficult working conditions. The aim of this study was to analyse nurses’ burnout in our oncology ICU and to determine which factors are associated with. Material and Method: The study was carried out in Ankara Oncology Hospital ICU. A self- reporting questionnaire in an envelope was used for the evaluation of burnout (Turkish- language version of Maslach Burnout Inventory and depression (Beck Depression Scale. Results: From a total of 37 ICU nurses, 35 participated in the study (%94,5 response rate. High levels of emotional exhaustion in 82% and depersonalization in 51,4% of nurses was determined. Personal accomplishment was higher at 80%. Mild to moderate emotional state and mild anxiety was revealed. Years in profession,finding salary insufficient, finding the profession in its proper, choosing the profession of his own accord, work environment satisfaction and finding the social activity adequate were associated with burnout (p≤0.05. Conclusion: In our study, intensive care unit nurses’ burnout scores were found to be higher. Burnout was rare in nurses that choose the profession of his own accord, find the nursing profession in its proper, and social activity adequate and are satisfied with the work environment. Therefore, we believe that attention should be given to individual needs and preferences in the selection of ICU staff.
van Beest, Paul A.; Brander, Lukas; Jansen, Sebastiaan P. A.; Rommes, Johannes H.; Kuiper, Michael A.; Spronk, Peter E.
Background: Both hyperlactatemia and persistence of hyperlactatemia have been associated with bad outcome. We compared lactate and lactate-derived variables in outcome prediction. Methods: Retrospective observational study. Case records from 2,251 consecutive intensive care unit (ICU) patients
Al Saleem, Nouf; Al Harthy, Abdulrahman
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.
Smith, Judith M; Van Aman, M Nancy; Schneiderhahn, Mary Elizabeth; Edelman, Robin; Ercole, Patrick M
Delirium is an acute brain dysfunction associated with poor outcomes in intensive care unit (ICU) patients. Critical care nurses play an important role in the prevention, detection, and management of delirium, but they must be able to accurately assess for it. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument is a reliable and valid method to assess for delirium, but research reveals most nurses need practice to use it proficiently. A pretest-posttest design was used to evaluate the success of a multimodal educational strategy (i.e., online learning module coupled with standardized patient simulation experience) on critical care nurses' knowledge and confidence to assess and manage delirium using the CAM-ICU. Participants (N = 34) showed a significant increase (p education. No statistical change in knowledge of delirium existed following the education. A multimodal educational strategy, which included simulation, significantly added confidence in critical care nurses' performance using the CAM-ICU. J Contin Nurs Educ. 2017;48(5):239-244. Copyright 2017, SLACK Incorporated.
Chapter 3. Coordination and collaboration with interface units. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster
Joynt, Gavin M.; Loo, Shi; Taylor, Bruce L.; Margalit, Gila; Christian, Michael D.; Sandrock, Christian; Danis, Marion; Leoniv, Yuval; Sprung, Charles L.; Camargo, Ruben; Ceraso, Daniel; Azoulay, Elie; Duguet, Alexandre; Guery, Benoit; Reinhart, Konrad; Adini, Bruria; Barlavie, Yaron; Benin-Goren, Odeda; Cohen, Robert; Klein, Motti; Rubinovitch, Bina; Sonnenblick, Moshe; Steinberg, Avraham; Weissman, Charles; Wolff, Donna; Kesecioglu, Jozef; de Jong, Menno; Moreno, Rui; An, Youzhong; Du, Bin; Joyng, Gavin M.; Colvin, John; Richards, Guy; Artigas, Antonio; Pugin, Jerome; Amundson, Dennis; Devereaux, Asha; Beigel, John; Farmer, Chris; Hick, John L.; Maki, Dennis; Masur, Henry; Rubinson, Lewis; Talmor, Daniel; Truog, Robert; Zimmerman, Janice; Brett, Steve; Montgomery, Hugh; Rhodes, Andrew; Sanderson, Frances
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. Based on a literature
Singhi, Sunit; Deep, Akash
Candidemia and disseminated candidiasis are major causes of morbidity and mortality in hospitalized patients especially in the intensive care units (ICU). The incidence of invasive candidasis is on a steady rise because of increasing use of multiple antibiotics and invasive procedures carried out in the ICUs. Worldwide there is a shifting trend from C. albicans towards non albicans species, with an associated increase in mortality and antifungal resistance. In the ICU a predisposed host in one who is on broad spectrum antibiotics, parenteral nutrition, and central venous catheters. There are no pathognomonic signs or symptoms. The clinical clues are: unexplained fever or signs of severe sepsis or septic shock while on antibiotics, multiple, non-tender, nodular erythematous cutaneous lesions. The spectrum of infection with candida species range from superficial candidiasis of the skin and mucosa to more serious life threatening infections. Treatment of candidiasis involves removal of the most likely source of infection and drug therapy to speed up the clearance of infection. Amphotericin B remains the initial drug of first choice in hemodynamically unstable critically ill children in the wake of increasing resistance to azoles. Evaluation of newer antifungal agents and precise role of prophylactic therapy in ICU patients is needed.
Bakhru, Rita N; McWilliams, David J; Wiebe, Douglas J; Spuhler, Vicki J; Schweickert, William D
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 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.
Jackson, James C.; Santoro, Michael J.; Ely, Taylor M.; Boehm, Leanne; Kiehl, Amy L; Anderson, Lindsay S.; Ely, E. Wesley
The Intensive Care Unit is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and, while the overall number of hospital beds remains stable in the U.S., the percentage of that total devoted to ICU beds is rising. These two realities engender a demographic imperative to address patient safety in the critical care setting. This manuscript addresses the medical community’s resistance to adopting a culture of safety in critical care with regard to issues surrounding sedation, delirium, and early mobility. Although there is currently much research and quality improvement in this area, most of what we know from these data and published guidelines has not become reality in the day-to-day management of ICU patients. This manuscript is not intended to provide a comprehensive review of the literature, but rather a framework to rethink our currently outdated culture of critical care by employing Maslow’s Hierarchy of Needs, along with a few novel analogies. Application of Maslow’s Hierarchy will help propel healthcare professionals toward comprehensive care of the whole person, not merely for survival, but toward restoration of pre-illness function of mind, body, and spirit. PMID:24636724
Eddelien, Heidi Shil; Hoffmeyer, Henrik Westy; Lund, Eva Charlotte Løbner
Glucocorticoids (GC) are used for intensive care unit (ICU) patients on several indications. We present a patient who was admitted to the ICU due to severe respiratory failure caused by bronchospasm requiring mechanical ventilation and treated with methylprednisolone 240 mg/day in addition...... to antibiotics and bronchiolytics. When the sedation was lifted on day 10, the patient was awake but quadriplegic. Blood samples revealed elevated muscle enzymes, electromyography showed myopathy, and a muscle biopsy was performed. Glucocorticoid-induced myopathy was suspected, GC treatment was tapered...
Evans, Jessica; Kobewka, Daniel; Thavorn, Kednapa; D'Egidio, Gianni; Rosenberg, Erin; Kyeremanteng, Kwadwo
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.
Gajic, Ognjen; Malinchoc, Michael; Comfere, Thomas B.; Harris, Marcelline R.; Achouiti, Ahmed; Yilmaz, Murat; Schultz, Marcus J.; Hubmayr, Rolf D.; Afessa, Bekele; Farmer, J. Christopher
OBJECTIVE: Unplanned readmission of hospitalized patients to an intensive care unit (ICU) is associated with a worse outcome, but our ability to identify who is likely to deteriorate after ICU dismissal is limited. The objective of this study is to develop and validate a numerical index, named the
Guery, B.P.; Arendrup, M.C.; Auzinger, G.; Azoulay, E.; Borges Sa, M.; Johnson, E.M.; Muller, E.; Putensen, C.; Rotstein, C.; Sganga, G.; Venditti, M.; Zaragoza Crespo, R.; Kullberg, B.J.
BACKGROUND: Invasive candidiasis and candidemia are frequently encountered in the nosocomial setting particularly in the intensive care unit (ICU). OBJECTIVE AND METHODS: To review the current management of invasive candidiasis and candidemia in non-neutropenic adult ICU patients based on a review
Halaby, Teysir; Al Naiemi, Nashwan; Beishuizen, Bert; Verkooijen, Roel; Ferreira, José A; Klont, Rob; Vandenbroucke-Grauls, Christina
Cross-transmission of nosocomial pathogens occurs frequently in intensive care units (ICU). The aim of this study was to investigate whether the introduction of a single room policy resulted in a decrease in transmission of multidrug-resistant (MDR) bacteria in an ICU.
Ruiz-Garbajosa, Patricia; del Campo, Rosa; Coque, Teresa M.; Asensio, Angel; Bonten, Marc; Willems, Rob; Baquero, Fernando; Canton, Rafael
The dynamics of intestinal colonization with enterococcal clones in intensive-care-unit (ICU) patients was evaluated. Eight patients admitted directly to the neurosurgical ICU at the Ramon y Cajal University Hospital (Madrid, Spain) from the community and with no overlapping stay during a 10-month
Bloomer, Melissa J; Morphet, Julia; O'Connor, Margaret; Lee, Susan; Griffiths, Debra
This qualitative descriptive study was undertaken in two metropolitan ICUs utilising focus groups to describe the ways in which ICU nurses care for the families of dying patients during and after the death. Participants shared their perspectives on how they care for families, their concerns about care, and detailed the strategies they use to provide timely and person-centred family care. Participants identified that their ICU training was inadequate in equipping them to address the complex care needs of families leading up to and following patient deaths, and they relied on peer mentoring and role-modelling to improve their care. Organisational constraints, practices and pressures impacting on the nurse made 'ideal' family care difficult. They also identified that a lack of access to pastoral care and social work after hours contributed to their concerns about family care. Participants reported that they valued the time nurses spent with families, and the importance of ensuring families spent time with the patient, before and after death. Copyright © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
Ratzer, Mette; Brink, Ole; Knudsen, Linda
Aims: This study aimed to estimate the prevalence of severe Posttraumatic Stress Disorder (PTSD) symptoms and to identify factors associated with PTSD in survivors of intensive care unit (ICU) treatment following traumatic injury. Methods: Fifty-two patients who were admitted to an ICU through...... the emergency ward following traumatic injury were prospectively followed. Information on injury severity and ICU treatment were obtained through medical records. Demographic information and measures of acute stress symptoms, experienced social support, coping style, sense of coherence (SOC) and locus...... of control were assessed within one-month post-accident (T1). At the six months follow-up (T2), PTSD was assessed with the Harvard Trauma Questionnaire (HTQ). Results: In the six months follow-up, 10 respondents (19.2%) had HTQ total scores reaching a level suggestive of PTSD (N = 52), and 11 respondents (21...
Krag, M; Perner, A; Wetterslev, J
BACKGROUND: Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection...... for SUP varies both within and between countries. METHODS: Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about...... adverse effects. Fisher's exact test was used to assess differences between groups. RESULTS: Ninety-seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP...
Jensen, Hanne Irene
be interdisciplinary, but the literature shows that this is not always the case. Research on end-of-life issues in Danish ICUs is limited. Aim The aims of this thesis were to • Examine Danish practices regarding end-of-life decisions in the ICU. • Examine the opinions of nurses and physicians who work in Danish ICUs...... and decision-making. Hypotheses • Nurses, intensivists, and primary physicians have different experiences of interdisciplinary collaboration regarding end-of-life decision-making in the ICU. • Specific interventions targeting end-of-life decision-making in the ICU, such as interdisciplinary audits......Background When making end-of-life decisions in intensive care units, the different staff groups have different roles in the decision-making process and may not always assess the situation identically. Practice recommendations for withholding or withdrawing therapy state that decisions should...
Carlson, Eve B; Spain, David A; Muhtadie, Luma; McDade-Montez, Liz; Macia, Kathryn S
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.
Moon, Kyoung-Ja; Lee, Sun-Mi
A decreased incidence of delirium following the application of non-pharmacologic intervention protocols to several patient populations has been previously reported. However, few studies have been conducted to examine the effects of their application to intensive care unit (ICU) patients. To examine the effects of applying a tailored delirium preventive protocol, developed by the authors, to ICU patients by analyzing its effects on delirium incidence, in-hospital mortality, ICU readmission, and length of ICU stay in a Korean hospital. A single-blind randomized controlled trial. A 1049-bed general hospital with a 105-bed ICU. Sixty and 63 ICU patients were randomly assigned to the intervention and control groups, respectively. The researchers applied the delirium prevention protocol to the intervention group every day for the first 7 days of ICU hospitalization. Delirium incidence, mortality, and re-admission to the ICU during the same hospitalization period were analyzed by logistic regression analysis; the 7- and 30-day in-hospital mortality by Kaplan-Meier survival and Cox proportional hazard regression analysis; and length of ICU stay was assessed by linear regression analysis. Application of the protocol had no significant effect on delirium incidence, in-hospital mortality, re-admission to the ICU, or length of ICU stay. Whereas the risk of 30-day in-hospital mortality was not significantly lower in the intervention than in the control group (OR: 0.33; 95% CI: 0.10-1.09), we found a significantly decreased 7-day in-hospital mortality in the intervention group after protocol application (HR: 0.09; 95% CI: 0.01-0.72). Application of a tailored delirium prevention protocol to acute stage patients during the first 7 days of ICU hospitalization appeared to reduce the 7-day in-hospital risk of mortality only for this patient population. Copyright © 2015 Elsevier Ltd. All rights reserved.
Lei, Jin'e; Han, Shaoshan; Wu, Wenjing; Wang, Xue; Xu, Jiru; Han, Lei
Extensively drug-resistant Acinetobacter baumannii (XDRAB) is a great threat in intensive care units (ICUs). The aim of this study was to describe an XDRAB outbreak which was cross-transmitted in the ICU and respiratory intensive care unit (RICU) in a tertiary care hospital from January-March 2013. Patient and environmental surveillances were performed. Isolates were tested for antimicrobial susceptibility. Genotypes were analyzed by multilocus sequence typing (MLST). A series of enhanced strategies were implemented to control the outbreak. A total of 11 patients were infected by XDRAB strains during this outbreak. Three patients in the ICU were found positive for XDRAB at the onset of the outbreak. Thereafter, infections were detected in 6 patients in the RICU, followed by reappearance of this strain in the ICU in 2 patients. All A baumannii strains isolated from patients and the environment were extensively drug resistant. MLST revealed them as ST368. After 3 rounds of environmental screening and cleaning, the laminar flow system connecting the ICU and RICU was found as the source of transmission. Successful control of this outbreak was achieved through multifaceted intervention measures. This study suggested the importance of thorough surveillance and disinfection of the environment, including concealed devices, in preventing the transmission of an outbreak. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Strandberg, Sandra; Vesterlund, Lisa; Engström, Åsa
The aim of this study was to describe the contents of a patient diary and its significance for persons cared for in an ICU. An empirical study with a qualitative design. Eight telephone interviews and one face-to-face interview were conducted with nine persons previously been treated in an ICU and been given a patient diary. In addition, the person would have read his/her diary. The data have been analysed with qualitative content analysis. The study identified one overarching theme; Gaining understanding, and four categories; The diary is written for me, Creating memories from the time of care, Who writes in the diary and, The ability to return to the diary. The diary meant that participants gained an understanding of their time in the ICU while they were critically ill and the diary was important to be able to return to. What formerly critically ill patients appreciate most about the diary is that the diary is personally written, which makes them feel confirmed and valuable as a person. Guidelines for how and when a diary should be written and used would likely encourage critical care nurses and relatives to write in it. Copyright © 2017 Elsevier Ltd. All rights reserved.
Mariama Amaral Michels
Full Text Available Rationale and objective: currently, Healthcare-associated Infections (HAIs constitute a serious public health problem. It is estimated that for every ten hospitalized patients, one will have infection after admission, generating high costs resulting from increased length of hospitalization, additional diagnostic and therapeutic interventions. The intensive care unit (ICU, due to its characteristics, is one of the most complex units of the hospital environment, a result of the equipment, the available technology, the severity of inpatients and the invasive procedures the latter are submitted to. The aim of the study was to evaluate the adherence to specifi c HAI prevention measures in invasive ICU procedures. Methods: This study had a quantitative, descriptive and exploratory approach. Among the risk factors for HAIs are the presence of central venous access, indwelling vesical catheter and mechanical ventilation, and, therefore, the indicators were calculated for patients undergoing these invasive procedures, through a questionnaire standardized by the Hospital Infection Control Commission (HICC. Results: For every 1,000 patients, 15 had catheter-related bloodstream infection, 6.85 had urinary tract infection associated with indwelling catheter in the fi rst half of 2010. Conclusion: most HAIs cannot be prevented, for reasons inherent to invasive procedures and the patients. However, their incidence can be reduced and controlled. The implementation of preventive measures based on scientifi c evidence can reduce HAIs signifi cantly and sustainably, resulting in safer health care services and reduced costs. The main means of prevention include the cleaning of hands, use of epidemiological block measures, when necessary, and specifi c care for each infection site. KEYWORDS Nosocomial infection. Intensive care units.
Mol, Meriel; van Kan, H. J. M.; Schultz, Marcus J.; de Jonge, Evert
OBJECTIVE: To study whether selective decontamination of the digestive tract (SDD) results in detectable serum tobramycin concentrations in intensive care unit (ICU) patients with acute renal failure treated with continuous venovenous hemofiltration (CVVH). DESIGN AND SETTING: Prospective,
Ten Have, Elsbeth C M; Nap, Raoul E; Tulleken, Jaap E
The implementation of interdisciplinary teams in the intensive care unit (ICU) has focused attention on leadership behavior. A daily recurrent situation in ICUs in which both leadership behavior and interdisciplinary teamwork are integrated concerns the interdisciplinary rounds (IDRs). Although IDRs
Khandelwal, Nita; Benkeser, David; Coe, Norma B; Engelberg, Ruth A; Curtis, J Randall
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.
Christensen, Martin; Probst, Barbara
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.
Seaman, Jennifer B; Evans, Anna C; Sciulli, Andrea M; Barnato, Amber E; Sereika, Susan M; Happ, Mary Beth
The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen's kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.
L. K. Moshetova
Full Text Available Aim. To describe eye injuries in intensive care unit (ICU patients with multitrauma, to study conjunctival microflora in these patients, and to develop etiologically and pathogenically targeted treatment and prevention of wound complications.Materials and methods. Study group included 50 patients (54 eyes with combined mechanical cerebral and eye injury. All patients underwent possible ophthalmological examination (biomicroscopy, ophthalmoscopy and ocular fundus photographing with portative fundus camera, tonometry, cranial CT and MRT, and bacteriological study of conjunctival smears. Results. Modern methods of ophthalmological examination of ICU patients provided correct diagnosis and prediction of wound healing. Eye injury treatment schedule provided maximum possible results in all ICU patients. Hospitalacquired infection results in asymptomatic dissemination of pathogenic microbes on ocular surface. Conclusions. 14-day topical treatment with antimicrobials, steroids, and NSAIDs reduces posttraumatic inflammation caused by mechanical eye injuries in ICU patients. Bacteriological studies of conjunctival smears demonstrate the presence of pathogenic flora in ICU patients. In these patients, the most effective antibacterial agents are third-generation fluoroquinolones.
Kauppi, Wivica; Proos, Matilda; Olausson, Sepideh
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.
Khandelwal, Nita; Benkeser, David; Coe, Norma B; Engelberg, Ruth A; Teno, Joan M; Curtis, J Randall
Terminal intensive care unit (ICU) stays represent an important target to increase value of care. 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. Secondary analysis of an intervention study to improve quality of care for critically ill patients. 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. 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. 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. 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.
Battle, Emma; Bates, Lucy; Liderth, Emma; Jones, Samantha; Sheen, Sheryl; Ginty, Andrew; Northmore, Melanie
There is often an overlap between intensive care medicine and palliative medicine. When all curative treatment options have been explored, keeping the patient comfortable and free from pain is the main concern for healthcare practitioners. Patient autonomy in end of life decisions has not been encouraged in the intensive care unit (ICU), until now, because of its specialised and technical nature. Staff at the Royal Bolton Hospital have broken down the barriers to enabling ICU patients to die in their own homes, and have developed a system of collaborative working that can help to fulfil a patient's final wish to go home. This article describes how ICU staff developed a process that enabled two ventilated patients to be transferred home for end of life care.
Merino, P; Martín, M C; Alonso, A; Gutiérrez, I; Alvarez, J; Becerril, F
To estimate the incidence of medication errors in Spanish intensive care units. Post hoc study of the SYREC trial. A longitudinal observational study carried out during 24 hours in patients admitted to the ICU. Spanish intensive care units. Patients admitted to the intensive care unit participating in the SYREC during the period of study. Risk, individual risk, and rate of medication errors. The final study sample consisted of 1017 patients from 79 intensive care units; 591 (58%) were affected by one or more incidents. Of these, 253 (43%) had at least one medication-related incident. The total number of incidents reported was 1424, of which 350 (25%) were medication errors. The risk of suffering at least one incident was 22% (IQR: 8-50%) while the individual risk was 21% (IQR: 8-42%). The medication error rate was 1.13 medication errors per 100 patient-days of stay. Most incidents occurred in the prescription (34%) and administration (28%) phases, 16% resulted in patient harm, and 82% were considered "totally avoidable". Medication errors are among the most frequent types of incidents in critically ill patients, and are more common in the prescription and administration stages. Although most such incidents have no clinical consequences, a significant percentage prove harmful for the patient, and a large proportion are avoidable. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.
Full Text Available Regulation of the Minister of Health dated 20/12/2012 on medical standards of conduct in the field of Anaesthesiology and intensive therapy, for carrying out the activities of healing in section § 2.2 intense therapy defines as: "any proceedings to maintain vital functions, and treatment of patients in life-threatening States, caused by potentially reversible renal failure one or more basic body systems, in particular the respiration, cardiovascular, central nervous system". However, in point § 12.1. We read that "Treatment of patients under intensive care in the hospital is an interdisciplinary". Annex 1 to this regulation refers to the work of physiotherapist in the ICU (INTENSIVE CARE UNITS and reads as follows: "the equivalent of at least 0.5 FTE-physical therapist-up to a range of benefits to be performed (the third reference level". [6
Tricyclic antidepressant (TCA) overdose necessitating intensive care unit (ICU) admission remains a significant problem in the Western Cape. In this retrospective study, we reviewed the course of life-threatening TCA overdose in our centre to identify potential prognostic indicators. TCA levels >1 000 ng/ml were associated ...
Kumar, Parmeshwar; Jithesh, Vishwanathan; Gupta, Shakti Kumar
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.
Jensen, Hanne Irene; Gerritsen, Rik T; Koopmans, Matty
PURPOSE: The purpose of the study is to adapt and provide preliminary validation for questionnaires evaluating families' experiences of quality of care for critically ill patients in the intensive care unit (ICU). MATERIALS AND METHODS: This study took place in 2 European ICUs. Based on literature...... validity. RESULTS: A total of 110 family members participated. Response rate was 87%. For all questions, a median of 97% (94%-99%) was assessed as relevant, and a median of 98% (97%-100%), as understandable. Median ceiling effect was 41% (30%-47%). There was a median of 0% missing data (0%-1%). Test......-retest reliability showed a median weighted κ of 0.69 (0.53-0.83). Validation showed significant correlation between total scores and key questions. CONCLUSIONS: The questions were assessed as relevant and understandable, providing high face and content validity. Ceiling effects were comparable to similar...
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
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 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.
Foglia, Elizabeth; Meier, Mary Dawn; Elward, Alexis
Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is as...
Padar, Martin; Uusvel, Gerli; Starkopf, Liis
AIM: To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients. METHODS: An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013......, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population...... the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher...
Bloomer, Melissa J; Al-Mutair, Abbas
Australia is a diverse and multicultural nation, made up of a population with a predominant Christian faith. Islam, the second largest religion in the world, has demonstrated significant growth in Australia in the last decade. Coming from various countries of origin and cultural backgrounds, Muslim beliefs can range from what is considered 'traditional' to very 'liberal'. It is neither possible nor practical for every intensive care clinician to have an intimate understanding of Islam and Muslim practices, and cultural variations amongst Muslims will mean that not all beliefs/practices will be applicable to all Muslims. However, being open and flexible in the way that care is provided and respectful of the needs of Muslim patients and their families is essential to providing culturally sensitive care. This discussion paper aims to describe the Islamic faith in terms of Islamic teachings, beliefs and common practices, considering how this impacts upon the perception of illness, the family unit and how it functions, decision-making and care preferences, particularly at the end of life in the intensive care unit. Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
Curcio, D; Belloni, R
There is a general consensus that antimicrobial use in intensive care units (ICU) is greater than that in general wards. By implementing a strategy of systematic infectious disease consultations in agreement with the ICU chief, we have modified the antibiotic prescription habits of the ICU physician. A reduction was observed in the use of selected antibiotics (third-generation cephalosporins, vancomycin, carbapenems and piperacillin-tazobactam), with a significant reduction in the length of hospital stay for ICU patients and lower antibiotic costs without negative impact on patient mortality. Leadership by the infectious diseases consultant in combination with commitment by ICU physicians is a simple and effective method to change antibiotic prescription habits in the ICU.
Wasserfallen, Jean-Blaise; Bütschi, Anne-Joëlle; Muff, Patrik; Biollaz, Jérôme; Schaller, Marie-Denise; Pannatier, André; Revelly, Jean-Pierre; Chiolero, René
To assess whether formatting the medical order sheet has an effect on the accuracy and security of antibiotics prescription. Prospective assessment of antibiotics prescription over time, before and after the intervention, in comparison with a control ward. The medical and surgical intensive care unit (ICU) of a university hospital. All patients hospitalized in the medical or surgical ICU between February 1 and April 30, 1997, and July 1 and August 31, 2000, for whom antibiotics were prescribed. Formatting of the medical order sheet in the surgical ICU in 1998. Compliance with the American Society of Hospital Pharmacists' criteria for prescription safety was measured. The proportion of safe orders increased in both units, but the increase was 4.6 times greater in the surgical ICU (66% vs. 74% in the medical ICU and 48% vs. 74% in the surgical ICU). For unsafe orders, the proportion of ambiguous orders decreased by half in the medical ICU (9% vs. 17%) and nearly disappeared in the surgical ICU (1% vs. 30%). The only missing criterion remaining in the surgical ICU was the drug dose unit, which could not be preformatted. The aim of antibiotics prescription (either prophylactic or therapeutic) was indicated only in 51% of the order sheets. Formatting of the order sheet markedly increased security of antibiotics prescription. These findings must be confirmed in other settings and with different drug classes. Formatting the medical order sheet decreases the potential for prescribing errors before full computerized prescription is available.
Laporta, Denny P; Burns, Judy; Doig, Chip J
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
Strack van Schijndel, Rob J M; Burchardi, Hilmar
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.
Landry, Elizabeth K; Gabriel, Rodney A; Beutler, Sascha; Dutton, Richard P; Urman, Richard D
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 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.
Sara Bermejo de las Heras
Full Text Available Introduction: Malnutrition is particularly prevalent in Intensive Care Units (ICU and associated with poor clinical outcomes. Enteral nutrition (EN has multiple benefits in critically ill patients, particularly when started early at the ICU. A series of studies corroborate this fact; however, other studies present conflicting results. Objective: To assess the clinical results of ICU patients receiving EN, according to EN starting time (early versus late. Patients and method: Basic variables were recorded in all ICU patients who received NE along the study period, as well as time from ICU admission to the start of EN, ICU length of stay, characteristic gastrointestinal complications of EN (gastric residue, constipation, diarrhea, vomiting, regurgitation, abdominal distension and bronchoaspiration and mortality. Results: There was a significant association between early EN and mortality reduction. However, there were no differences in ICU length of stay according to EN starting time. The most frequent complications in the sample were high gastric residue (17.9%, abdominal distension (22.5% and constipation (42.2%. However, no significant differences were observed as a function of the EN starting time. Discussion: Our results, although discrepant at times, do not contradict with those of other studies. EN has shown to be effective as a therapeutic strategy. Therefore, it is recommended the early start of EN in the ICU.
Aslakson, Rebecca A; Wyskiel, Rhonda; Thornton, Imani; Copley, Christina; Shaffer, Dauryne; Zyra, Marylou; Nelson, Judith; Pronovost, Peter J
Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting. We developed a focus group guide to identify barriers to two key components of palliative care-optimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses. Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care. Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.
C. L. Gonçalves
Full Text Available Abstract The presence of airborne fungi in Intensive Care Unit (ICUs is associated with increased nosocomial infections. The aim of this study was the isolation and identification of airborne fungi presented in an ICU from the University Hospital of Pelotas – RS, with the attempt to know the place’s environmental microbiota. 40 Petri plates with Sabouraud Dextrose Agar were exposed to an environment of an ICU, where samples were collected in strategic places during morning and afternoon periods for ten days. Seven fungi genera were identified: Penicillium spp. (15.18%, genus with the higher frequency, followed by Aspergillus spp., Cladosporium spp., Fusarium spp., Paecelomyces spp., Curvularia spp., Alternaria spp., Zygomycetes and sterile mycelium. The most predominant fungi genus were Aspergillus spp. (13.92% in the morning and Cladosporium spp. (13.92% in the afternoon. Due to their involvement in different diseases, the identified fungi genera can be classified as potential pathogens of inpatients. These results reinforce the need of monitoring the environmental microorganisms with high frequency and efficiently in health institutions.
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
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 ratiobedridden 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.
Lilly, Craig M; Motzkus, Christine; Rincon, Teresa; Cody, Shawn E; Landry, Karen; Irwin, Richard S
ICU telemedicine improves access to high-quality critical care, has substantial costs, and can change financial outcomes. Detailed information about financial outcomes and their trends over time following ICU telemedicine implementation and after the addition of logistic center function has not been published to our knowledge. Primary data were collected for consecutive adult patients of a single academic medical center. We compared clinical and financial outcomes across three groups that differed regarding telemedicine support: a group without ICU telemedicine support (pre-ICU intervention group), a group with ICU telemedicine support (ICU telemedicine group), and an ICU telemedicine group with added logistic center functions and support for quality-care standardization (logistic center group). The primary outcome was annual direct contribution margin defined as aggregated annual case revenue minus annual case direct costs (including operating costs of ICU telemedicine and its related programs). All monetary values were adjusted to 2015 US dollars using Producer Price Index for Health-Care Facilities. Annual case volume increased from 4,752 (pre-ICU telemedicine) to 5,735 (ICU telemedicine) and 6,581 (logistic center). The annual direct contribution margin improved from $7,921,584 (pre-ICU telemedicine) to $37,668,512 (ICU telemedicine) to $60,586,397 (logistic center) due to increased case volume, higher case revenue relative to direct costs, and shorter length of stay. The ability of properly modified ICU telemedicine programs to increase case volume and access to high-quality critical care with improved annual direct contribution margins suggests that there is a financial argument to encourage the wider adoption of ICU telemedicine. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
Full Text Available Objective: To investigate the role of acute kidney injury (AKI classification system for kidney injury outcome in neuro-Intensive care unit (ICU patients. Material and Method: Total 432 patients who admitted to ICU between 2005 and 2009 evaluated in this study. All patients’ AKI stage, Acute Physiology and Chronic Health Evaluation (APACHE-II, Sequential Organ Failure Assessment Score (SOFA, Glasgow Coma Score (GCS, Glasgow Outcome Score (GOS, mortality rate, length of ICU stay, need for intubation, and mechanical ventilation were recorded. Results: AKI was found in 24 of all 432 patents’ (5.5%. We found that, patients with AKI had higher APHACE-II score, SOFA score and mortality rates; longer ICU stay, duration of mechanical ventilation and intubation and lower GCS and GOS than without AKI group. Conclusion: Length of ICU stay and mortality rate were higher in AKI positive group.
Luo, H B; Wang, X T; Tang, B; Zhu, Z N; Guo, H L; Li, Z Z; Sun, J H; Liu, D W
Objective: To investigate doctors' and nurses' perceptions and implementation of delirium management in intensive care unit. Methods: A total of 197 doctors and nurses in 2 general ICUs and 3 special ICUs at Peking Union Medical College Hospital finished a self-designed questionnaire of delirium management. Results: There were 47 males and 150 females, 43 doctors and 154 nurses who participated in the survey.One hundred and twenty five participators were from general ICU and the others from special ICU. The ICU staff had a significant difference on the perceptions and implementation of delirium management( P delirium assessment" ( P delirium management,especially in special ICUs. Delirium management should be included as a routine care in ICU to improve patients' outcome.
Full Text Available To survey the recent medical literature reporting effects of intensive care unit (ICU design on patients’ and family members’ well-being, safety and functionality. Features of ICU design linked to the needs of patients and their family are single-rooms, privacy, quiet surrounding, exposure to daylight, views of nature, prevention of infection, a family area and open visiting hours. Other features such as safety, working procedures, ergonomics and logistics have a direct impact on the patient care and the nursing and medical personnel. An organization structured on the needs of the patient and their family is mandatory in designing a new intensive care. The main aims in the design of a new department should be patient centered care, safety, functionality, innovation and a future-proof concept.
Choi, JiYeon; Tate, Judith A; Hoffman, Leslie A; Schulz, Richard; Ren, Dianxu; Donahoe, Michael P; Given, Barbara A; Sherwood, Paula R
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. To describe self-reported fatigue in caregivers of ICU survivors from patients' ICU admission to ≤ 2 weeks, two- and four-months post-ICU discharge. 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). Forty-seven patient-caregiver pairs were initially enrolled. Clinically significant fatigue (SF-36 Vitality ≤ 45) was reported by 43%-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. 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. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
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.
Ahmad, Danish; Moeller, Katherine; Chowdhury, Jared; Patel, Vishal; Yoo, Erika J
To evaluate the impact of outlier status, or the practice of boarding ICU patients in distant critical care units, on clinical and utilization outcomes. Retrospective observational study of all consecutive admissions to the MICU service between April 1, 2014-January 3, 2016, at an urban university hospital. Of 1931 patients, 117 were outliers (6.1%) for the entire duration of their ICU stay. In adjusted analyses, there was no association between outlier status and hospital (OR 1.21, 95% CI 0.72-2.05, p=0.47) or ICU mortality (OR 1.20, 95% CI 0.64-2.25, p=0.57). Outliers had shorter hospital and ICU lengths of stay (LOS) in addition to fewer ventilator days. Crossover patients who had variable outlier exposure also had no increase in hospital (OR 1.61; 95% CI 0.80-3.23; p=0.18) or ICU mortality (OR 1.05; 95% CI 0.43-2.54; p=0.92) after risk-adjustment. Boarding of MICU patients in distant units during times of bed nonavailability does not negatively influence patient mortality or LOS. Increased hospital and ventilator utilization observed among non-outliers in the home unit may be attributable, at least in part, to differences in patient characteristics. Prospective investigation into the practice of ICU boarding will provide further confirmation of its safety. Copyright © 2017 Elsevier Inc. All rights reserved.
De Gaetano, Andrea; Cortese, Giuliana; Pedersen, Morten Gram
Serum creatinine is a metabolite assumed to be constantly produced by the normally functioning muscle mass and is a good measure for monitoring daily renal function in the intensive care unit (ICU). High serum creatinine levels or an abnormal departure from normal pre-disease basal levels....... The present work details the structure of a model describing observed creatinine serum concentration (CSC) variations, depending on the time-varying septic insult to renal function in ICU patients, as well as the estimation of its parameters. CSC determinations were routinely obtained from 12 patients...
Lin, Frances; Chaboyer, Wendy; Wallis, Marianne
It is everyday news that we need more intensive care unit (ICU) beds, thus effective use of existing resources is imperative. The aim of this literature review was to critically analyse current literature on how organizational factors, individual factors and teamwork factors influence the ICU discharge process. A better understanding of discharge practices has the potential to ultimately influence ICU resource availability. Databases including CINAHL, MEDLINE, PROQUEST, SCIENCE DIRECT were searched using key terms such as ICU discharge, discharge process, ICU guidelines and policies, discharge decision-making, ICU organisational factors, ICU and human factors, and ICU patient transfer. Articles' reference lists were also used to locate relevant literature. A total of 21 articles were included in the review. Only a small number of ICUs used written patient discharge guidelines. Consensus, rather than empirical evidence, dictates the importance of guidelines and policies. Premature discharge, discharge after hours and discharge by triage still exist due to resources constraints, even though the literature suggests these are associated with increased mortality. Teamwork and team training appear to be effective in improving efficiency and communication between professions or between clinical areas. However, this aspect has rarely been researched in relation to ICU patient discharge. Intensive care patient discharge is influenced by organisational factors, individual factors and teamwork factors. Organisational interventions are effective in reducing ICU discharge delay and shortening patient hospital stay. More rigorous research is needed to discover how these factors influence the ICU discharge process.
Paonessa, Joseph R; Brennan, Thomas; Pimentel, Marco; Steinhaus, Daniel; Feng, Mengling; Celi, Leo Anthony
Limited information exists on the etiology, prevalence, and significance of hyperdynamic left ventricular ejection fraction (HDLVEF) in the intensive care unit (ICU). Our aim in the present study was to compare characteristics and outcomes of patients with HDLVEF with those of patients with normal left ventricular ejection fraction in the ICU using a large, public, deidentified critical care database. We conducted a longitudinal, single-center, retrospective cohort study of adult patients who underwent echocardiography during a medical or surgical ICU admission at the Beth Israel Deaconess Medical Center using the Multiparameter Intelligent Monitoring in Intensive Care II database. The final cohort had 2867 patients, of whom 324 had HDLVEF, defined as an ejection fraction >70%. Patients with an ejection fraction <55% were excluded. Compared with critically ill patients with normal left ventricular ejection fraction, the finding of HDLVEF in critically ill patients was associated with female sex, increased age, and the diagnoses of hypertension and cancer. Patients with HDLVEF had increased 28-day mortality compared with those with normal ejection fraction in multivariate logistic regression analysis adjusted for age, sex, Sequential Organ Failure Assessment score, Elixhauser score for comorbidities, vasopressor use, and mechanical ventilation use (odds ratio 1.38, 95% confidence interval 1.039-1.842, p =0.02). The presence of HDLVEF portended increased 28-day mortality, and may be helpful as a gravity marker for prognosis in patients admitted to the ICU. Further research is warranted to gain a better understanding of how these patients respond to common interventions in the ICU and to determine if pharmacologic modulation of HDLVEF improves outcomes.
Carbajal, Ricardo; Eriksson, Mats; Courtois, Emilie; Boyle, Elaine; Avila-Alvarez, Alejandro; Andersen, Randi Dovland; Sarafidis, Kosmas; Polkki, Tarja; Matos, Cristina; Lago, Paola; Papadouri, Thalia; Montalto, Simon Attard; Ilmoja, Mari-Liis; Simons, Sinno; Tameliene, Rasa; van Overmeire, Bart; Berger, Angelika; Dobrzanska, Anna; Schroth, Michael; Bergqvist, Lena; Lagercrantz, Hugo; Anand, Kanwaljeet J. S.; Kiechl-Kohlendorfer, Ursula; Trinkl, Anna; Deindl, Philipp; Wald, Martin; Rigo, Vincent; Dussart, Anneliese; Dierckx, Elke; Coppens, Sophie; Kiilsapaa, Birgit; Metsvaht, Tuuli; Metsäranta, Marjo; Nikolajev, Kari; Saarela, Timo; Peltoniemi, Outi; Tammela, Outi; Lehtonen, Liisa; Savagner, Christophe; Sevestre, Anna; Alexandre, Cénéric; Bouchon-Guedj, Nathalie; Saumureau, Simone; Grosse, Camille; Jouvencel, Philippe; Ramful, Duksha; Clamadieu, Catherine; Mourdie, Julien; Montcho, Yannis; Cambonie, Gilles; Di Maio, Massimo; Patural, Hugues; Asrtuc, Dominique; Norbert, Karine; Bouchera, Kassis; Lang, Mathieu; Galene Gromez, Sophie; Hamon, Isabelle; Nolent, Paul; Ntwari, René-Christian; Lallemant, Carine; Chary Tardy, Anne Cécile; Pelluau, Sonia; Roue, Jean Michel; Picaud, Jean Charles; Camelio, Aurélie; Tourneux, Pierre; Saint-Faust, Marie; Morville, Patrice; David, Alexandra; Theret, Bernard; Frédérique, Martin; Topf, Georg; Menendez-Castro, Ricardo; Fujiwara-Pichler, Erhard; Deeg, Karl Heinz; Anatolitou, Fani; Baroutis, George; Papazafeiratou, Chrissoulan; Giannakopoulou, Christine; Baltogianni, Maria; Delivoria, Varvara; Sterpi, Magdalena; Saklamaki-Kontou, Melpomeni; Dimitriou, Gabriel; Charitou, Antonia; Thomaidou, Agathi; Chatziioannidis, Ilias; Salvanos, Iraklis; Pirelli, Anna; Poggiani, Carlo; Fasolato, Valeria; Cristofori, Gloria; Gomirato, Serena; Allegro, Antonella; Alfiero, Michela; Biban, Paolo; Bertolini, Alessandra; Golin, Rosanna; Franco, Elena; Molinaro, Grazia; Federica, Visintini; Rossini, Roberto; Garetti, Elisabetta; Faraoni, Maddalena; Dani, Carlo; Germini, Cristina; Braguglia, Annabella; Benigni, Gina; Azzali, Adriano; Santa, Barresi; Romoli, Raffaella; Carrera, Giuseppe; Miria, Natile; Savant, Patrizia; Cossu, Maria Antonia; Giancarlo, Gargano; Cassar, Robert; Bos, Annelis; van Kaam, Anton; Brouwer, Mieke; van Lingen, Richard; Bambang Oetomo, Sidarto; Sivertsen, Wiebke; Nakstad, Britt; Solhjell, Kari; Flagstad, Gro; Salvesen, Bodil; Nessestrand, Ingunn A. M.; Nordhov, Marianne; Anderssen, Sven-Harald; Wasland, Kristin; Danielsen, Kåre; Kristoffersen, Laila Marie; Ytterdahl Bergland, Unni; Borghild Stornes, Randi; Andresen, Jannicke; Solberg, Rønnaug; Hochnowski, Kristoffer; Terpinska, Ewa; Kociszewska-Najman, Bozena; Melka, Andrzej; Głuszczak, Ewa; Niezgoda, Anna; Borszewska-Kornacka, Maria Katarzyna; Witwicki, Jacek M.; Korbal, Piotr; Ramos, Helena; Garcia, Pedro; Machado, Cidália; Clemente, Fátima; Costa, Miguel; Trindade, Cristina; Salazar, Anabela; Martins Barroso, Laura; Resende, Cristine; Afonso, Maria Eulàlia; Torres, Jacinto; Maciel, Paula; Nunes, José Luis; Neve Dos Santos, Vera Alexandra; Melgar Bonis, Ana; Euba Lopez, Aintzane; Tapia Collados, Caridad; Jesus Ripalda, María; Solis Sanchez, Gonzalo; Martin Parra, Belén; Botet, Francesc; Fernandez Trisac, Jose Luis; Elorza Fernandez, María Dolores; Arriaga Redondo, María; Bargallo Ailagas, Eva; Saenz, Pilar; Lopez Ortego, Paloma; Ventura, Purificación; Galve, Zenaida; Perez Ocon, Amaya; Crespo Suarez, Pilar; Dianez Vega, Gloria; San Feliciano, Laura; Herranz Carillo, Gloria; Esteban Diez, Inés; Reyné, Mar; Garcia Borau, María José; de Las Cuevas, Isabel; Couce, María L.; González Carrasco, Ersilia; Montoro Exposito, Aurora; Concheiro Guisan, Ana; Luna Lagares, Salud; Sanchez Redondo, Maria Dolores; Hellström Westas, Lena; Moren, Stefan; Norman, Elisabeth; Olsson, Emma; Åberg, Emma; Printz, Gordana; Turner, Mark; McBride, Tim; Bomont, Robert; Webb, Delyth; Saladi, Murthy; Thirumurugan, Arumugavelu; Brooke, Nigel; Skene, Caryl; Bilolikar, Harsha; Noble, Vibert; Vora, Amish; Thompson, Fiona; Deorukhkar, Anjum; El-Refee, Sherif; McIntyre, John; Millman, Guy; Reed, Joanne; Babirecki, Matthew; Kumar, Dev; Yadav, Mahesh; O'Brien, Margaret; Gasiorowski, Edward Robert; Rawlingson, Chris; Shastri, Aravind; Tibby, Shane; Walsh, Sandra; Azzopardi, Denis; Soe, Aung; MaCrae, Duncan; Eyre, Elizabeth; Menon, Gopi; Gupta, Samir; James, Anitha; Surana, Pinki; Adams, Eleri; Wolf, Andrew; Maxwell, Nicola; Wagstaff, Miles; Mann, Rebecca; Kumar, Yadlapalli; Quinn, Michael; Jones Dyson, Steve; Mannix, Paul; Morris, Kevin; Ewer, Andrew; Gurusamy, Kalyana; Deshpande, Sanjeev; Alexander, John; Blake, Kathryn; Kumar, Siva; Oddie, Sam; Ohadike, Pamela; McKechnie, Liz; Gibson, David; Shirsalkar, Anand; Suryanarayanan, Balaji; Hubbard, Marie; Lal, Mithilesh; Ali, Imdad; Shah, Divyen; Sketchley, Suzanne; Gupta, Richa; Schofield, Joanne; Ezzat, Medhat; Mupanemunda, Richard; Gallagher, Andrew; Kronsberg, Shari
Background Neonates who are in pain or are stressed during care in the intensive care unit (ICU) are often given sedation or analgesia. We investigated the current use of sedation or analgesia in neonatal ICUs (NICUs) in European countries. Methods EUROPAIN (EUROpean Pain Audit In Neonates) was a
Full Text Available Abstract Background The incidence of fungal healthcare-associated infection (HAI has increased in a major teaching hospital in the northern part of Taiwan over the past decade, especially in the intensive care units (ICUs. The purpose of this study was to determine the factors that were responsible for the outbreak and trend in the ICU. Methods Surveillance fungal cultures were obtained from “sterile” objects, antiseptic solutions, environment of infected patients and hands of medical personnel. Risk factors for comparison included age, gender, admission service, and total length of stay in the ICU, Acute Physiology and Chronic Health Evaluation (APACHE II scores at admission to the ICU, main diagnosis on ICU admission, use of invasive devices, receipt of hemodialysis, total parenteral nutrition (TPN use, history of antibiotic therapy before HAI or during ICU stay in no HAI group, and ICU discharge status (ie, dead or alive. Univariable analysis followed by multiple logistic regression analysis was performed to identify the independent risk factors for ICU fungal HAIs and ICU mortality. Results There was a significant trend in ICU fungal HAIs from 1998 to 2009 (P Candida albicans (27.3%, Candida tropicalis (6.6%, Candida glabrata (6.6%, Candida parapsilosis (1.9%, Candida species (0.8%, and other fungi (1.9%. Candida albicans accounted for 63% of all Candida species. Yeasts were found in the environment of more heavily infected patients. The independent risk factors (P P Conclusions There was a secular trend of an increasing number of fungal HAIs in our ICU over the past decade. Patients with ICU fungal HAIs had a significantly higher mortality rate than did patients without ICU HAIs. Total parenteral nutrition was a significant risk factor for all types of ICU fungal HAIs, and its use should be monitored closely.
Ramos, Kathleen J; Downey, Lois; Nielsen, Elizabeth L; Treece, Patsy D; Shannon, Sarah E; Curtis, J Randall; Engelberg, Ruth A
Communication among doctors, nurses, and families contributes to high-quality end-of-life care, but is difficult to improve. Our objective was to identify aspects of communication appropriate for interventions to improve quality of dying in the intensive care unit (ICU). This observational study used data from a cluster-randomized trial of an interdisciplinary intervention to improve end-of-life care at 15 Seattle/Tacoma area hospitals (2003-2008). Nurses completed surveys for patients dying in the ICU. We examined associations between nurse-assessed predictors (physician-nurse communication, physician-family communication) and nurse ratings of patients' quality of dying (nurse-QODD-1). Based on 1173 nurse surveys, four of six physician-nurse communication topics were positively associated with nurse-QODD-1: family questions, family dynamics, spiritual/religious issues, and cultural issues. Discussions between nurses and physicians about nurses' concerns for patients or families were negatively associated. All physician-family communication ratings, as assessed by nurses, were positively associated with nurse-QODD-1: answering family's questions, listening to family, asking about treatments patient would want, helping family decide patient's treatment wishes, and overall communication. Path analysis suggested overall physician-family communication and helping family incorporate patient's wishes were directly associated with nurse-QODD-1. Several topics of physician-nurse communication, as rated by nurses, were associated with higher nurse-rated quality of dying, whereas one topic, nurses' concerns for patient or family, was associated with poorer ratings. Higher nurse ratings of physician-family communication were uniformly associated with higher quality of dying, highlighting the importance of this communication. Physician support of family decision making was particularly important, suggesting a potential target for interventions to improve end-of-life care.
Full Text Available In resource-constrained settings and in the context of HIV-infected patients requiring intensive care, value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines. These are often based on individual practitioners’ knowledge and experience, which may be subject to bias. We reviewed published information on legislation and practices related to intensive care unit (ICU admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV. Each of these countries has legal instruments in place to provide their citizens with health services, but they differ in their provision of ICU care for HIV-infected persons. In Brazil, some ICUs have no admission criteria, and this decision vests solely on the ‘availability, and the knowledge and the experience’ of the most experienced ICU specialist at the institution. India has few regulatory mechanisms to ensure ICU care for critically ill patients including HIV-infected persons. SA has made concerted efforts towards non-discriminatory criteria for ICU admissions and, despite the shortage of ICU beds, HIV-infected patients have relatively greater access to this level of care than in other developing countries in Africa, such as Botswana. Policymakers and clinicians should devise explicit policy frameworks to govern ICU admissions in the context of HIV status. S Afr J HIV Med 2013;14(1:15-16. DOI:10.7196/SAJHIVMED.887
Engström, Asa; Lindberg, Inger
Providing nursing care for a critically ill obstetric patient or a patient who has just become a mother after a complicated birth can be a challenging experience for critical care nurses (CCNs). These patients have special needs because of the significant alterations in their physiology and anatomy together with the need to consider such specifics as breastfeeding and mother-child bonding. The aim with this study was to describe CCNs' experience of nursing the new mother and her family after a complicated childbirth. The design of the study was qualitative. Data collection was carried out through focus group discussions with 13 CCNs in three focus groups during spring 2012. The data were subjected to qualitative content analysis. The analysis resulted in the formulation of four categories: the mother and her vital functions are prioritized; not being responsible for the child and the father; an environment unsuited to the new family and collaboration with staff in neonatal and maternity delivery wards. When nursing a mother after a complicated birth the CCNs give her and her vital signs high priority. The fathers of the children or partners of the mothers are expected to take on the responsibility of caring for the newborn child and of being the link with the neonatal ward. It is suggested that education about the needs of new families for nursing care would improve the situation and have clinical implications. Whether the intensive care unit is always the best place in which to provide care for mothers and new families is debatable. © 2013 British Association of Critical Care Nurses.
Oosterhouse, Kimberly J; Vincent, Catherine; Foreman, Marquis D; Gruss, Valerie A; Corte, Colleen; Berger, Barbara
Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium. ©2016 American Association of Critical-Care Nurses.
Mol, Margo; Kompanje, Erwin; Benoit, Dominique; Bakker, Jan; Nijkamp, Marjan; Seedat, Soraya
textabstractBackground: 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...
Su, Amanda; Lief, Lindsay; Berlin, David; Cooper, Zara; Ouyang, Daniel; Holmes, John; Maciejewski, Renee; Maciejewski, Paul K; Prigerson, Holly G
Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU. The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity. From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care. The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12). Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.
Reignier, Jean; Dumont, Romain; Katsahian, Sandrine; Martin-Lefevre, Laurent; Renard, Benoit; Fiancette, Maud; Lebert, Christine; Clementi, Eva; Bontemps, Frederic
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 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.
Watkins, Jessamy; Weatherburn, Gwyn; Bryan, Stirling
Objective: The aim of the study was to assess the effect of the introduction of PACS (Picture Archiving and Communication System) upon image availability in an Intensive Care Unit (ICU) and the consequent impact upon the behaviour of the ICU physicians, in terms of the initiation of image-based clinical actions. Design: A before and after study was used to compare the speed of image availability prior to, and following, the implementation of a hospital-wide PACS. Setting: The research was part of an economic evaluation of PACS at Hammersmith Hospital, West London. Patients and participants: All ICU patients who were X-rayed during two pre-PACS and one post-PACS data collection periods were included within the study. Measurements: The times of: the X-ray request; acquisition; availability on ICU; and of any image-based clinical action taken by the ICU physician were recorded by radiographers and ICU physicians. Results: PACS significantly reduced the time between request and image availability on ICU for routine X-rays but did not have any measurable impact upon the time clinical actions were initiated by ICU physicians. The data on non-routine images were statistically inconclusive. Conclusions: This study shows that PACS significantly improves the speed of delivery of routine images to the ICU, but it appears that the instigation of image-based clinical actions is determined by other organisational factors in ICU, such as ward rounds, rather than the availability of the image for viewing. Further work is required on non-routine X-rays to clarify the impact of PACS on physician behaviour in clinically urgent situations
Wong, Rowena Syn Yin; Ismail, Noor Azina
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.
Rowena Syn Yin Wong
Full Text Available 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.
Park, Dong Won; Moon, Jae Young; Ku, Eun Yong; Kim, Sun Jong; Koo, Young-Mo; Kim, Ock-Joo; Lee, Soon Haeng; Jo, Min-Woo; Lim, Chae-Man; Armstrong, John David; Koh, Younsuck
This research aimed to investigate the changes in ethical issues in everyday clinical practice recognized by critical care nurses during two observation periods. We conducted a retrospective analysis of data obtained by prospective questionnaire surveys of nurses in the intensive care units (ICU) of a tertiary university-affiliated hospital in Seoul, Korea. Data were collected prospectively during two different periods, February 2002-January 2003 (Period 1) and August 2011-July 2012 (Period 2). Significantly fewer cases with ethical issues were reported in Period 2 than in Period 1 (89 cases [2.1%] of 4,291 ICU admissions vs. 51 [0.5%] of 9,302 ICU admissions, respectively; P ethical issues in both Periods occurred in MICU. The major source of ethical issues in Periods 1 and 2 was behavior-related. Among behaviorrelated issues, inappropriate healthcare professional behavior was predominant in both periods and mainly involved resident physicians. Ethical issue numbers regarding end-oflife (EOL) care significantly decreased in the proportion with respect to ethical issues during Period 2 (P = 0.044). In conclusion, the decreased incidence of cases with identified ethical issues in Period 2 might be associated with ethical enhancement related with EOL and improvements in the ICU care environment of the studied hospital. However, behaviorrelated issues involving resident physicians represent a considerable proportion of ethical issues encountered by critical care nurses. A systemic approach to solve behavior-related issues of resident physicians seems to be required to enhance an ethical environment in the studied ICU.
Nelson, Judith E; Mathews, Kusum S; Weissman, David E; Brasel, Karen J; Campbell, Margaret; Curtis, J Randall; Frontera, Jennifer A; Gabriel, Michelle; Hays, Ross M; Mosenthal, Anne C; Mulkerin, Colleen; Puntillo, Kathleen A; Ray, Daniel E; Weiss, Stefanie P; Bassett, Rick; Boss, Renee D; Lustbader, Dana R
Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.
Hawkins, Carrie L
The first of its kind in the Veterans Affairs (VA) system, the Denver VA Medical Center's tele-intensive care unit (ICU) program is unique because it is entirely nurse driven. A nontraditional tele-ICU model, the program was tailored to meet the needs of rural veterans by using critical care nursing expertise in Denver, Colorado. An experienced CCRN-certified nurse manages the system 24 hours a day, 7 days a week, from Eastern Colorado Health Care System. The virtual ICU provides rapid response interventions through virtual technology. This tele-ICU technology allows for a "virtual handshake" by nursing staff at the start of the shift and a report on potential patient issues. Clinical relationships have been strengthened between all 5 VA facilities in the Rocky Mountain Region, increasing the likelihood of early consultation at the onset of clinical decline of a patient. In addition, the tele-ICU nurse is available for immediate nursing consultation and support, coordinates point-to-point virtual consultation between physicians at the rural sites and specialists in Denver, and assists in expediting critical care transfers. The primary objectives for the tele-ICU program include improving quality and access of care to critical care services in rural sites, reducing community fee basis costs and frequency of transfers, and increasing collaboration and collegiality among nursing and medical staff in all Region 19's medical centers.
Dahl, Deborah; Wojtal, Greg G; Breslow, Michael J; Holl, Randy; Huguez, Debra; Stone, David; Korpi, Gloria
Direct variable costs were determined on each hospital day for all patients with an intensive care unit (ICU) stay in four Phoenix-area hospital ICUs. Average daily direct variable cost in the four ICUs ranged from $1,436 to $1,759 and represented 69.4 percent and 45.7 percent of total hospital stay cost for medical and surgical patients, respectively. Daily ICU cost and length of stay (LOS) were higher in patients with higher ICU admission acuity of illness as measured by the APACHE risk prediction methodology; 16.2 percent of patients had an ICU stay in excess of six days, and these LOS outliers accounted for 56.7 percent of total ICU cost. While higher-acuity patients were more likely to be ICU LOS outliers, 11.1 percent of low-risk patients were outliers. The low-risk group included 69.4 percent of the ICU population and accounted for 47 percent of all LOS outliers. Low-risk LOS outliers accounted for 25.3 percent of ICU cost and incurred fivefold higher hospital stay costs and mortality rates. These data suggest that severity of illness is an important determinant of daily resource consumption and LOS, regardless of whether the patient arrives in the ICU with high acuity or develops complications that increase acuity. The finding that a substantial number of long-stay patients come into the ICU with low acuity and deteriorate after ICU admission is not widely recognized and represents an important opportunity to improve patient outcomes and lower costs. ICUs should consider adding low-risk LOS data to their quality and financial performance reports.
Background. We aimed to determine the outcome and certain predictors of outcome for acute renal failure (ARF) in the medical intensive care unit (ICU) at Tygerberg Hospital. Method. We conducted a retrospective, single-centre cohort study over 12 months comprising all patients admitted to the medical ICU with all causes ...
Wen-Ping Zeng; Han Su; Chein-Wen Chen; Shu-Meng Cheng; Li-Fang Chang; Wen-Chii Tzeng; Bing-Hsiean Tzeng
Background: Ventilator-associated pneumonia (VAP) occurs in patients requiring mechanical ventilators for more than 48 h. VAP is the most common nosocomial infection and the leading cause of complications and death in intensive care units (ICUs). Materials and Methods: Two historical comparison groups of 375 patients who used mechanical ventilators for more than 48 h in the medical ICU (MICU) from December 1, 2011 to May 31, 2012 and December 1, 2013 to May 31, 2014 were enrolled in this stud...
Full Text Available Recently, new staffing rules for neonatal nurses in intensive care units (ICU were issued in Germany, using categories of care of the British Association of Perinatal Medicine as blueprint. Neonates on intensive care require a nurse-to-patient ratio of 1:1, on intensive surveillance (high dependency care of 1:2. No requirements exist for special care, transitional care, and pediatric ICU patients. Using these rules, nursing staff requirement was calculated over a period of 31 consecutive days once a day in a combined pediatric and neonatal ICU of a metropolitan academic medical center in south-west Germany. Each day, 18.9±0.98 patients (mean±standard deviation were assessed (14.26±1.21 neonatal, 4.65±0.98 pediatric. Among neonates, 9.94±2.56 received intensive therapy, 3.77±1.85 intensive surveillance, and 0.65±0.71 special care. Average nursing staff requirement was 12.10±1.81 full time equivalents (FTE per shift. Considering additional pediatric patients in the ICU and actual nursing staff availability (8.97±0.87 FTE per shift, this ICU seems understaffed.
Asimakopoulou, E; Madianos, M
Recent progress in medicine and technology has produced a significant increase in the survival rate of critically ill patients who have been treated in Intensive Care Units (ICU). Consequently, researchers have become increasingly interested in the relationship between critical illness and psychiatric consequences. The experience of critical illness has been often associated with Major Depression (MD) and Post-Traumatic Stress Disorder (PTSD). There has been no similar study in Greece. The aim of the present study was to investigate the prevalence of MD and PTSD among patients after discharge from ICU in comparison with patients who discharge from pathological or surgical department. The study was conducted on five major hospitals "ATTIKON", "THRIASSIO", "KAT", "GNA GENNIMATAS", "KORGIALENIO - BENAKIO". A standardized instrument was used especially for this study and is based on "ΜΙΝΙ: Mini International Neuropsychiatric Interview" and DSM-IV. The data collection was carried out through personal interviews with the patients. It is a cross-sectional study and also a case-control study. The sample of the research was composed of 198 patients, from whom 102 were in ICU (ICU group) and 96 were not (non-ICU group). The results of the statistical processing have shown that there is a positive and statistically significant correlation between MD-PTSD and hospitalization in ICU, and particular hospitalization in ICU increases the likelihood of developing MD by 1.94 times and PTSD by 3.48 times, compared to treatment in another part of the hospital. Furthermore, the ICU group was found to suffer more than the control group from MD (32.4% vs 19.8%) and PTSD (35,3% vs 13,5%). The investigation of sociodemographic characteristics showed that being a woman discharged from ICU is nearly five times more likely to develop MD and nearly twelve times more likely to develop PTSD compared with men. Old age in ICU acts as a protective factor from PTSD. Regarding the clinical
Richards, Guy A.; Sprung, Charles L.; Christian, Michael D.; Camargo, Ruben; Ceraso, Daniel; Azoulay, Elie; Duguet, Alexandre; Guery, Benoit; Reinhart, Konrad; Adini, Bruria; Barlavie, Yaron; Benin-Goren, Odeda; Cohen, Robert; Klein, Motti; Leoniv, Yuval; Margalit, Gila; Rubinovitch, Bina; Sonnenblick, Moshe; Steinberg, Avraham; Weissman, Charles; Wolff, Donna; Kesecioglu, Jozef; de Jong, Menno; Moreno, Rui; An, Youzhong; Du, Bin; Joynt, Gavin M.; Colvin, John; Loo, Shi; Richards, Guy; Artigas, Antonio; Pugin, Jerome; Amundson, Dennis; Devereaux, Asha; Beigel, John; Danis, Marion; Farmer, Chris; Hick, John L.; Maki, Dennis; Masur, Henry; Rubinson, Lewis; Sandrock, Christian; Talmor, Daniel; Truog, Robert; Zimmerman, Janice; Brett, Steve; Montgomery, Hugh; Rhodes, Andrew; Sanderson, Frances; Taylor, Bruce
To provide recommendations and standard operating procedures (SOPs) for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with focus on education of all stakeholders, specifically the emergency executive control groups, ICU staff and staff co-opted to
Chen, Yong; Zhao, Wei; Liu, Hui; Song, Qing; Wang, Yan; Zhao, Jingya; Zheng, Dongyu; Han, Xuelin; Hu, Xiaohua; Grundmann, Hajo; Han, Li
In 2008, an intensive care unit (ICU) in a large Chinese hospital was moved from a 6-bed old ward to a 20-bed new ward. After the move, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in patients and environmental sites decreased significantly, but the number of ICU-acquired
Klopotowska, Joanna E.; Kuiper, Rob; van Kan, Hendrikus J.; de Pont, Anne-Cornelie; Dijkgraaf, Marcel G.; Lie-A-Huen, Loraine; Vroom, Margreeth B.; Smorenburg, Susanne M.
Patients admitted to an intensive care unit (ICU) are at high risk for prescribing errors and related adverse drug events (ADEs). An effective intervention to decrease this risk, based on studies conducted mainly in North America, is on-ward participation of a clinical pharmacist in an ICU team. As
Dziadzko, Mikhail A; Thongprayoon, Charat; Ahmed, Adil; Tiong, Ing C; Li, Man; Brown, Daniel R; Pickering, Brian W; Herasevich, Vitaly
To examine the feasibility and validity of electronic generation of quality metrics in the intensive care unit (ICU). This minimal risk observational study was performed at an academic tertiary hospital. The Critical Care Independent Multidisciplinary Program at Mayo Clinic identified and defined 11 key quality metrics. These metrics were automatically calculated using ICU DataMart, a near-real time copy of all ICU electronic medical record (EMR) data. The automatic report was compared with data from a comprehensive EMR review by a trained investigator. Data was collected for 93 randomly selected patients admitted to the ICU during April 2012 (10% of admitted adult population). This study was approved by the Mayo Clinic Institution Review Board. All types of variables needed for metric calculations were found to be available for manual and electronic abstraction, except information for availability of free beds for patient-specific time-frames. There was 100% agreement between electronic and manual data abstraction for ICU admission source, admission service, and discharge disposition. The agreement between electronic and manual data abstraction of the time of ICU admission and discharge were 99% and 89%. The time of hospital admission and discharge were similar for both the electronically and manually abstracted datasets. The specificity of the electronically-generated report was 93% and 94% for invasive and non-invasive ventilation use in the ICU. One false-positive result for each type of ventilation was present. The specificity for ICU and in-hospital mortality was 100%. Sensitivity was 100% for all metrics. Our study demonstrates excellent accuracy of electronically-generated key ICU quality metrics. This validates the feasibility of automatic metric generation.
Abelha, Fernando José; Castro, Maria Ana; Landeiro, Nuno Miguel; Neves, Aida Maria; Santos, Cristina Costa
Outcome in intensive care can be categorized as mortality related or morbidity related. Mortality is an insufficient measure of ICU outcome when measured alone and length of stay may be seen as an indirect measure of morbidity related outcome. The aim of the present study was to estimate the incidence and predictive factors for intrahospitalar outcome measured by mortality and LOS in patients admitted to a surgical ICU. In this prospective study all 185 patients, who underwent scheduled or emergency surgery admitted to a surgical ICU in a large tertiary university medical center performed during April and July 2004, were eligible to the study. The following variables were recorded: age, sex, body weight and height, core temperature (Tc), ASA physical status, emergency or scheduled surgery, magnitude of surgical procedure, anesthesia technique, amount of fluids during anesthesia, use of temperature monitoring and warming techniques, duration of the anesthesia, length of stay in ICU and in the hospital and SAPS II score. The mean length of stay in the ICU was 4.09 +/- 10.23 days. Significant risk factors for staying longer in ICU were SAPS II, ASA physical status, amount of colloids, fresh frozen plasma units and packed erythrocytes units used during surgery. Fourteen (7.60%) patients died in ICU and 29 (15.70%) died during their hospitalization. Statistically significant independent risk factors for mortality were emergency surgery, major surgery, high SAPS II scores, longer stay in ICU and in the hospital. Statistically significant protective factors against the probability of dying in the hospital were low body weight and low BMI. In conclusion, prolonged ICU stay is more frequent in more severely ill patients at admission and it is associated with higher hospital mortality. Hospital mortality is also more frequent in patients submitted to emergent and major surgery.
Full Text Available Background: Although enterococci are relatively common nosocomial pathogens in surgical intensive care units (ICUs, their significance in blood cultures from patients in the medical ICU is unclear. Materials and Methods: In this retrospective study spanning 2 years, the clinical and microbiological characteristics of enterococcal bacteremia among medical ICU patients were evaluated. Results: Of 1325 admissions, 35 with enterococcal bacteremia accounted for 14.8% of positive blood cultures. They were significantly older (P=0.03 and had various co-morbidities. Most had vascular (96.9% and urinary (85.3% catheters, and 67.7% were mechanically ventilated. In addition to blood, enterococci were isolated from vascular catheters (8.6% and other sites (20%, while no focus was identified in 77% of patients. Prior use of broad-spectrum antimicrobials was nearly universal. All isolates tested were sensitive to vancomycin and linezolid. Resistance to ampicillin and gentamicin were 44.7% and 52.6%, respectively. Compared with other medical ICU patients, patients with enterococcal bacteremia had a longer ICU stay (P<0.0001 and a trend toward higher ICU mortality (P=0.08. Conclusions: Enterococcal bacteremia is an important nosocomial infection in the medical ICU, with a predilection for older patients with multiple comorbidities. Its occurrence is associated with a significantly longer ICU stay and a trend to a higher mortality. The choice of antibiotics should be dictated by local susceptibility data.
Full Text Available Introduction. Acinetobacter calcoaceticus-baumannii complex (ACB complex is a leading opportunistic pathogen in intensive care units (ICUs. Effective control of spread requires understanding of its epidemiological relatedness. This study aims to determine the genetic relatedness and antibiotic susceptibilities of ACB complex in an ICU in Malaysia. Methodology. Pulsed field gel electrophoresis (PFGE, E-test, and disk diffusion were used for isolates characterization. Results. During the study period (December 2011 to June 2012, 1023 patients were admitted to the ICU and 44 ACB complex (blood, n=21, and blind bronchial aspirates, n=23 were recovered from 38 ICU patients. Six isolates were from non-ICU patients. Of the 44 ICU isolates, 88.6% exhibited multidrug-resistant (MDR patterns. There was high degree of resistance, with minimum inhibitory concentration90 (MIC90 of >32 μg/mL for carbapenems and ≥256 μg/mL for amikacin, ampicillin/sulbactam, and cefoperazone/sulbactam. Isolates from the main PFGE cluster were highly resistant. There was evidence of dissemination in non-ICU wards. Conclusion. High number of clonally related MDR ACB complex was found. While the ICU is a likely reservoir facilitating transmission, importation from other wards may be important contributor. Early identification of strain relatedness and implementation of infection control measures are necessary to prevent further spread.
Gosling, Peter; Czyz, John; Nightingale, Peter; Manji, Mav
Comparison of urine albumin within 6 hrs of intensive care unit (ICU) admission with demography, clinical classification, outcome, inotrope/vasopressor requirement, clinical assessment of mortality risk, and Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Urine albumin-creatinine ratio (ACR) was measured on ICU admission (ACR 1) and after 4-6 hrs (ACR 2). A 17-bed general ICU in a university teaching hospital. Unselected medical (206) and surgical (225) patients recruited prospectively. None. Bedside urine ACR was measured by nurses using a Bayer DCA 2000 analyzer and expressed in mg/mmol (reference range Po2/Fio2 ratio 48 hrs after ICU admission and positively correlated with duration of mechanical ventilation and ACR 1 with ICU stay. ACR 2 predicted mortality and ACR 1 inotrope requirement independent of clinical mortality risk assessment and APACHE II and SOFA scores. Urine albumin changes rapidly within the first 6 hrs following ICU admission and predicts ICU mortality and inotrope requirement as well as or better than APACHE II and SOFA scores. Serial urine albumin measurement may provide a means of monitoring the microvascular effects of systemic inflammation.
Nolla-Salas, M; Monmany-Roca, J; Vázquez-Mata, G
The concept of continuity of care by intensivists as an element of quality control in the medical care of Intensive Care Unit (ICU) patients surviving multiple organ dysfunction syndrome has led to a rethinking of the ICU model in recent years. We discuss the rationale to design and implement a hospital-based, prospective, randomized, multicenter Intervention/Control study in order to estimate the impact of an interdisciplinary intervention during the post-ICU recovery phase on medium-term medical outcomes in ICU patients with multiple organ dysfunction.
Martin, J; Neurohr, C; Bauer, M; Weiss, M; Schleppers, A
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%.
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.
Sistematização da Assistência de Enfermagem em Unidade de Terapia Intensiva sustentada pela Teoria de Wanda Horta Sistematización de la asistencia de enfermería en una unidad de terapia intensiva basada en la Teoría de Wanda Horta Nursing care systematization at the intensive care unit (ICU based on Wanda Horta's theory
Lúcia Nazareth Amante
desarrollo calificado del cuidado de enfermería.The purpose of this study was to implement the Nursing Care Systematization - Sistematização da Assistência de Enfermagem (SAE - with Wanda Aguiar Horta's Theory of Basic Human Necessities and the North American Nursing Diagnosis Association's (NANDA Nursing Diagnosis as its references. The starting point was the evaluation of the knowledge of the nursing team about the SAE, including their participation in this process. This is a qualitative study, performed in the Intensive Care Unit in a hospital in the city of Brusque, Santa Catarina, from October, 2006 to March, 2007. It was observed that the nursing professionals know little about SAE, but they are greatly interested in learning and developing it in their daily practice. In conclusion, it was possible to execute the healthcare systematization in an easy way, with the use of simple brochures that provided all the necessary information for the qualified development of nursing care.
Kumar, Anil; Aronow, Wilbert S; Alexa, Margelusa; Gothwal, Ritu; Jesmajian, Stephen; Bhushan, Bharat; Gaba, Praveen; Catevenis, James
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.
Corcoran, Shawn P; Niven, Alexander S; Reese, Jason M
Recent events and regulatory mandates have underlined the importance of medical planning and preparedness for catastrophic events. The purpose of this review is to provide a brief summary of current commonly identified threats, an overview of mass critical care management, and a discussion of resource allocation to provide the intensive care unit (ICU) director with a practical guide to help prepare and coordinate the activities of the multidisciplinary critical care team in the event of a disaster.
Yi Lin Lee
Full Text Available Aim: Progress in medical care and technology has led to patients with more advanced illnesses being admitted to the Intensive Care Unit (ICU. The practice of approaching end-of-life (EOL care decisions and limiting care is well documented in Western literature but unknown in Singapore. We performed a retrospective cohort study to describe the practice of EOL care in patients dying in a Singapore surgical ICU (SICU. The surgical critical care population was chosen as it is unique because surgeons are frequently involved in the EOL process. Methods: All consecutive patients aged 21 and above admitted to the SICU from July 2011 to March 2012, and who passed away in the ICU or within 7 days of discharge from the ICU (to account for transferred patients out of the ICU after end-of life care decisions were made and subsequently passed away were included in the study. Results: There were 473 SICU admissions during this period, out of which 53 were included with a mean age of 67.2 ± 11.1 years. EOL discussions were held in 81.1% of patients with a median time from admission to first discussion at 1 day (IQR 0–2.75 and a median number of ICU discussion of 1 (IQR 1–2. As most patients lacked decision-making capacity (inability to retain and process information secondary to the underlying disease pathology or sedative use, a surrogate was involved: group decision in 27.9%, child in 25.6% and an unclear family nominated member in 20.9%. 28.3% of patients were managed as for full active with resuscitation, 39.6% nonescalation of care, and 32.1% for withdrawal. The main reasons for conservative management (nonescalation and withdrawal of care were certain death in 52.3%, medical futility with minimal response to maximal care (27.3%, and the presence of underlying malignancy (18.2%. There was no significant difference between race or religion among patients for active or conservative management. Conclusion: 71.7% of patients who passed away in the ICU or
Goran, Susan F
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.
Ana Paula Cezar Machado
Full Text Available Abstract Pediatric patients, especially those admitted to the neonatal intensive care unit (ICU, are highly vulnerable to medication errors. This study aimed to measure the prescription error rate in a university hospital neonatal ICU and to identify susceptible patients, types of errors, and the medicines involved. The variables related to medicines prescribed were compared to the Neofax prescription protocol. The study enrolled 150 newborns and analyzed 489 prescription order forms, with 1,491 medication items, corresponding to 46 drugs. Prescription error rate was 43.5%. Errors were found in dosage, intervals, diluents, and infusion time, distributed across 7 therapeutic classes. Errors were more frequent in preterm newborns. Diluent and dosing were the most frequent sources of errors. The therapeutic classes most involved in errors were antimicrobial agents and drugs that act on the nervous and cardiovascular systems.
Krag, M; Perner, A; Wetterslev, J
BACKGROUND: In this statistical analysis plan, we aim to provide details of the pre-defined statistical analyses of the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial. The aim of the SUP-ICU trial is to assess benefits and harms of stress ulcer prophylaxis with a proton pump......-year mortality, and a health economic analysis. Two formal interim analyses will be performed. The statistical analyses will be conducted according to the outlined pre-defined statistical analysis plan. The primary analysis will be a logistic regression analysis adjusted for stratification variables...... comparing the two intervention groups in the intention-to-treat population. In a secondary analysis, we will additionally adjust the primary outcome for potential random differences in baseline characteristics. The conclusion will be based on the intention-to-treat population. CONCLUSION: Stress ulcer...
Full Text Available Introduction: Stroke is the second most common cause of death and major cause of disability worldwide. About a quarter of stroke patients are dead within a month, about a third by 6 months, and a half by 1 year. Although the most substantial advance in stroke has been the routine management of patients in stroke care units, intensive care unit has remained the choice for stroke patients’ care in developing countries. This study explores the mortality of stroke patients in intensive care unit setting in tertiary care neurological centre in a developing country. Methods: We collected data of stroke patients admitted in our ICU from August 2009 to Aug 2010 and analyzed. Results: Total 44 (10.25% patients were admitted for acute stroke. Age ranged from 17-93 years. Low GCS (Glasgow Coma Scale, uncontrolled hypertension and aspiration pneumonia were common indications for admission in ICU. Total 23 (52.3% patients had hemorrhagic stroke and 21(47.7% patients had ischemic stroke. 13 (29.54% patients of stroke died within 7 days, 9 (69.23% patients of hemorrhagic stroke died within 6 days, and 4 patients (30.76% of ischemic stroke died within 7 days. 6 (13.63% patients left hospital against medical advice. All of these patients had ischemic stroke. Conclusions: Stroke mortality in intensive care unit remains high despite of care in tertiary neurological center in resource poor settings. Stroke care unit, which would also help dissemination of knowledge of stroke management, is an option for improved outcome in developing countries Keywords: intensive care unit; mortality; stroke; stroke care unit.
Pouwels, K B; Van Kleef, E; Vansteelandt, S; Batra, R; Edgeworth, J D; Smieszek, T; Robotham, J V
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.
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
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.
Luana Loppi Goulart
Full Text Available Severely injured patients with multiple and conflicting injuries present themselves to nursing professionals at critical care units faced with care management challenges. The goal of the present study is to evaluate nursing workload and verify the correlation between workload and the APACHE II severity index. It is a descriptive study, conducted in the Trauma Intensive Care Unit of a teaching hospital. We used the Nursing Activities Score and APACHE II as instruments. The sample comprised 32 patients, of which most were male, young adults, presenting polytrauma, coming from the Reference Emergency Unit, in surgical treatment, and discharged from the ICU. The average obtained on the Nursing Activities Score instrument was 72% during hospitalization periods. The data displayed moderate correlation between workload and patient severity. In other words, the higher the score, the higher the patient’s mortality risk. doi: 10.5216/ree.v16i2.22922.
Full Text Available Despite the considerable number of studies reported to date, the causative agents of pneumonia are not completely identified. We comprehensively applied modern and traditional laboratory diagnostic techniques to identify microbiota in patients who were admitted to or developed pneumonia in intensive care units (ICUs. During a three-year period, we tested the bronchoalveolar lavage (BAL of patients with ventilator-associated pneumonia, community-acquired pneumonia, non-ventilator ICU pneumonia and aspiration pneumonia, and compared the results with those from patients without pneumonia (controls. Samples were tested by amplification of 16S rDNA, 18S rDNA genes followed by cloning and sequencing and by PCR to target specific pathogens. We also included culture, amoeba co-culture, detection of antibodies to selected agents and urinary antigen tests. Based on molecular testing, we identified a wide repertoire of 160 bacterial species of which 73 have not been previously reported in pneumonia. Moreover, we found 37 putative new bacterial phylotypes with a 16S rDNA gene divergence ≥ 98% from known phylotypes. We also identified 24 fungal species of which 6 have not been previously reported in pneumonia and 7 viruses. Patients can present up to 16 different microorganisms in a single BAL (mean ± SD; 3.77 ± 2.93. Some pathogens considered to be typical for ICU pneumonia such as Pseudomonas aeruginosa and Streptococcus species can be detected as commonly in controls as in pneumonia patients which strikingly highlights the existence of a core pulmonary microbiota. Differences in the microbiota of different forms of pneumonia were documented.
Zhu, Zhecheng; Hen, Bee Hoon; Teow, Kiok Liang
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.
Krag, Mette; Perner, Anders; Møller, Morten H
PURPOSE OF REVIEW: Stress ulcer prophylaxis (SUP) is considered standard of care in the majority of critically ill patients in the ICU. In this review, we will present the current evidence for the use of SUP in ICU patients, including data on the prevalence of gastrointestinal bleeding and the ba......PURPOSE OF REVIEW: Stress ulcer prophylaxis (SUP) is considered standard of care in the majority of critically ill patients in the ICU. In this review, we will present the current evidence for the use of SUP in ICU patients, including data on the prevalence of gastrointestinal bleeding...
Wong, Rowena S Y; Ismail, Noor Azina; Tan, Cheng Cheng
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 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.
Hillis, D.J.; McDonald, I.G.; Kelly, W.J.
The first computed radiography (CR) unit in Australia was installed at St Vincent's Hospital, Melbourne, in February 1994. An initial qualitative evaluation of the attitude of the intensive care unit (ICU) physicians to the CR unit was conducted by use of a survey. The results of the survey of ICU physicians indicated that images were available faster than under the previous system and that the use of the CR system was preferred to evaluate chest tubes and line placements. While it is recognized that a further detailed radiological evaluation of the CR system is required to establish the diagnostic performance of CR compared with conventional film, some comments on the implementation of the system and ICU physician attitudes to the CR system are put forward for consideration by other hospitals examining the possible use of CR systems. 11 refs., 1 tab
McLaughlin, Anne Marie
OBJECTIVE: To prospectively assess the cost of patients in an adult intensive care unit (ICU) using bottom-up costing methodology and evaluate the usefulness of "severity of illness" scores in estimating ICU cost. METHODS AND DESIGN: A prospective study costing 64 consecutive admissions over a 2-month period in a mixed medical\\/surgical ICU. RESULTS: The median daily ICU cost (interquartile range, IQR) was 2,205 euro (1,932 euro-3,073 euro), and the median total ICU cost (IQR) was 10,916 euro (4,294 euro-24,091 euro). ICU survivors had a lower median daily ICU cost at
Navarro-Arnedo, J M
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.
Kemper, Peter F.; de Bruijne, Martine; van Dyck, C.; Wagner, Cordula
Introduction 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
Kemper, P.F.; Bruijne, M. de; Dyck, C. van; So, R.L.; Tangkau, P.; Wagner, C.
Introduction 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
Rello, Jordi; Manuel, Oriol; Eggimann, Philippe
This position paper is the second ESCMID Consensus Document on this subject and aims to provide intensivists, infectious disease specialists, and emergency physicians with a standardized approach to the management of serious travel-related infections in the intensive care unit (ICU) or the emerge...
Carlsen, Sarah; Perner, A
Fluid is the mainstay of resuscitation of patients with septic shock, but the optimal composition and volume are unknown. Our aim was to evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome...
Oostdijk, Evelien A. N.; Smits, Loek; de Smet, Anne Marie G. A.; Leverstein-van Hall, Maurine A.; Kesecioglu, Jozef; Bonten, Marc J. M.
Topical use of colistin as part of selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) has been associated with improved patient outcome in intensive care units (ICU), yet little is known about the risks of colistin resistance. We quantified effects of
Harris, Carolyn B; Krauss, Melissa J; Coopersmith, Craig M; Avidan, Michael; Nast, Patricia A; Kollef, Marin H; Dunagan, W Claiborne; Fraser, Victoria J
To increase patient safety event reporting in three intensive care units (ICUs) using a new voluntary card-based event reporting system and to compare and evaluate observed differences in reporting among healthcare workers across ICUs. Prospective, single-center, interventional study. A medical ICU (19 beds), surgical ICU (24 beds), and cardiothoracic ICU (17 beds) at a 1,371-bed urban teaching hospital. Adult patients admitted to these three study ICUs. Use of a new, internally designed, card-based reporting program to solicit voluntary anonymous reporting of medical errors and patient safety concerns. During a 14-month period, 714 patient safety events were reported using a new card-based reporting system, reflecting a significant increase in reporting compared with pre-intervention Web-based reporting (20.4 reported events/1,000 patient days pre-intervention to 41.7 reported events/1,000 patient days postintervention; rate ratio, 2.05; 95% confidence interval, 1.79-2.34). Nurses submitted the majority of reports (nurses, 67.1%; physicians, 23.1%; other reporters, 9.5%); however, physicians experienced the greatest increase in reporting among their group (physicians, 43-fold; nurses, 1.7-fold; other reporters, 4.3-fold) relative to pre-intervention rates. There were significant differences in the reporting of harm by job description: 31.1% of reports from nurses, 36.2% from other staff, and 17.0% from physicians described events that did not reach/affect the patient (p = .001); and 33.9% of reports from physicians, 27.2% from nurses, and 13.0% from other staff described events that caused harm (p = .005). Overall reported patient safety events per 1,000 patient days differed by ICU (medical ICU = 55.5, cardiothoracic ICU = 25.3, surgical ICU = 40.2; p reporting system increased reporting significantly compared with pre-intervention Web-based reporting and revealed significant differences in reporting by healthcare worker and ICU. These differences may reveal
Lew, Charles Chin Han; Yandell, Rosalie; Fraser, Robert J L; Chua, Ai Ping; Chong, Mary Foong Fong; Miller, Michelle
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.
Martyak, Michael; Kabir, Ishraq; Britt, Rebecca
Peripherally inserted central venous catheters (PICCs) are now commonly used for central access in the intensive care unit (ICU) setting; however, there is a paucity of data evaluating the complication rates associated with these lines. We performed a retrospective review of all PICCs placed in the inpatient setting at our institution during a 1-year period from January 2013 to December 2013. These were divided into two groups: those placed at the bedside in the ICU and those placed by interventional radiology in non-ICU patients. Data regarding infectious and thrombotic complications were collected and evaluated. During the study period, 1209 PICC line placements met inclusion criteria and were evaluated; 1038 were placed by interventional radiology in non-ICU patients, and 171 were placed at the bedside in ICU patients. The combined thrombotic and central line associated blood stream infection rate was 6.17 per cent in the non-ICU group and 10.53 per cent in the ICU group (P = 0.035). The thrombotic complication rate was 5.88 per cent in the non-ICU group and 7.60 per cent in the ICU group (P = 0.38), whereas the central line associated blood stream infection rate was 0.29 per cent in the non-ICU group and 2.92 per cent in the ICU group (P = 0.002). This study seems to suggest that PICC lines placed at the bedside in the ICU setting are associated with higher complication rates, in particular infectious complications, than those placed by interventional radiology in non-ICU patients. The routine placement of PICC lines in the ICU settings needs to be reevaluated given these findings.
Full Text Available Nosocomial infections in an intensive care unit (ICU are common and associated with a high mortality but there are no published data from the Oceania region. A retrospective study in Fiji’s largest ICU (2011-12 reported that 114 of a total 663 adult ICU admissions had bacteriological culture-confirmed nosocomial infection. The commonest sites of infection were respiratory and bloodstream. Gram negative bacteria were the commonest pathogens isolated, especially Klebsiella pneumoniae (extended-spectrum β-Lactamase-producing, Acinetobacter, and Pseudomonas species. Mortality for those with a known outcome was 33%. Improved surveillance and implementation of effective preventive interventions are needed.
Allyn, Jérôme; Angue, Marion; Corradi, Laure; Traversier, Nicolas; Belmonte, Olivier; Belghiti, Myriem; Allou, Nicolas
To our knowledge, there is no data on the epidemiology of patients hospitalized in intensive care unit (ICU) after a stay in Madagascar or other low-income countries. It is possible that such data may improve transfer delays and care quality for these patients. In a retrospective study, we reviewed the charts of all patients admitted to ICU of the Reunion Island Felix Guyon University Hospital from January 2011 through July 2013. We identified all patients who had stayed in Madagascar during the 6 months prior to ICU admission. Of 1842 ICU patients, 62 (3.4%) had stayed in Madagascar during the 6 months prior to ICU admission. Patients were 76% male and the median age was 60.5 (48.25-64.75) years; patients were more frequently residents of Madagascar than travellers (56.5%). In most cases, patients were not hospitalized or given antibiotics in Madagascar. The most frequent causes of hospitalization were infections including malaria (21%) and lower respiratory infection (11%). Carriage and infection with multidrug resistant (MDR) bacteria on ICU admission were frequent (37% and 9.7%, respectively). The mortality rate in ICU was 21%, and severity acute physiological Score II was 53.5 (37-68). Patients admitted to ICU after a stay to Madagascar are mainly elderly patients with chronic illnesses, and often foreign residents. The admission causes are specific of the country like malaria, or specific to the population concerned such as cardiovascular accidents that could be prevented. © International Society of Travel Medicine, 2016. All rights reserved. Published by Oxford University Press. For permissions, please e-mail: firstname.lastname@example.org.
Full Text Available Introduction. Length of stay (LOS in the intensive care unit (ICU of spontaneous intracerebral hemorrhage (sICH patients is one of the most important issues. The disease severity, psychosocial factors, and institutional factors will influence the length of ICU stay. This study is used in the Taiwan National Health Insurance Research Database (NHIRD to define the threshold of a prolonged ICU stay in sICH patients. Methods. This research collected the demographic data of sICH patients in the NHIRD from 2005 to 2009. The threshold of prolonged ICU stay was calculated using change point analysis. Results. There were 1599 sICH patients included. A prolonged ICU stay was defined as being equal to or longer than 10 days. There were 436 prolonged ICU stay cases and 1163 nonprolonged cases. Conclusion. This study showed that the threshold of a prolonged ICU stay is a good indicator of hospital utilization in ICH patients. Different hospitals have their own different care strategies that can be identified with a prolonged ICU stay. This indicator can be improved using quality control methods such as complications prevention and efficiency of ICU bed management. Patients’ stay in ICUs and in hospitals will be shorter if integrated care systems are established.
Pimintel, Denise M; Wei, Shang Heng; Odor, Alberto
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.
Goedken, Cassie Cunningham; Moeckli, Jane; Cram, Peter M; Reisinger, Heather Schacht
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.
Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines.
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
The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Prospective, before-after, mixed-methods study. Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center : Interprofessional ICU team members at participating institution. In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility 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, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. 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
Kumar, Parmeshwar; Jithesh, Vishwanathan; Gupta, Shakti Kumar
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
Full Text Available 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.
Ethier, Cheryl; Burry, Lisa; Martinez-Motta, Carlos; Tirgari, Sam; Jiang, Depeng; McDonald, Ellen; Granton, John; Cook, Deborah; Mehta, Sangeeta
Analgesics and sedatives are integral for the relief of pain and anxiety in critically ill patients. However, these agents may contribute to amnesia for intensive care unit (ICU) events; which has been associated with development of posttraumatic stress disorder. Drug administration strategies that minimize sedative use have been associated with less amnesia. The objective of this pilot study was to evaluate recall of ICU stay in patients managed with 2 sedation strategies: a sedation protocol or a combination of sedation protocol and daily sedative/analgesic interruption. A questionnaire was administered on day 3 following ICU discharge to evaluate patients' recollections of pain, anxiety, fear, and sleep, as well as memories for specific ICU procedures. Participants were ICU survivors who had been enrolled in SLEAP - a randomized pilot trial comparing two sedation strategies, at 3 university-affiliated medical/surgical ICUs. Twenty-one patients who regained orientation within 72 hours of ICU discharge completed the questionnaire. More than 50% of patients recalled experiencing pain, anxiety, and fear to a moderate or extreme extent; and 57% reported inadequate sleep while in the ICU. Of the 21 patients, 48%, 33%, and 29% had no memories of endotracheal tube suctioning, being on a "breathing machine," and being bathed, respectively. A notable percentage of patients discharged from the ICU report moderate to extreme pain, anxiety, and fear, and inability to sleep during their ICU stay; and 29% to 48% have no recall of specific ICU events. Copyright © 2011 Elsevier Inc. All rights reserved.
Frivold, Gro; Slettebø, Åshild; Heyland, Daren K; Dale, Bjørg
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.
Gershengorn, Hayley B; Kocher, Robert; Factor, Phillip
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.
Full Text Available Kuang-Ming Liao,1 Yi-Chen Chen,2 Kuo-Chen Cheng,3 Jhi-Joung Wang,2 Chung-Han Ho2,4 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan; 2Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 3Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; 4Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan Objective: The objective of this study was to investigate the trends in COPD patients admitted to the intensive care unit (ICU in Taiwan from 2003 to 2013. Patients and methods: A retrospective study was conducted to analyze the available data in the National Health Insurance Research Database compiled by the Taiwan Department of Health. We selected patients admitted to the ICU nationwide from 2003 to 2013. Patients older than 40 years with a diagnosis of COPD were enrolled. The ICU admission date was used as the index date. Baseline comorbidities existing before the index date were identified. The comorbidities of interest included diabetes, hypertension, diabetes mellitus, coronary artery disease, stroke, dyslipidemia, cancer, and end-stage renal disease. Results: The number of COPD patients in the ICU increased from 12,384 in 2003 to 13,308 in 2013 (P<0.0001. The mean age of patients and SD was 76.66±9.48 and 78.32±10.59 in 2003 and 2013, respectively. The percentage of COPD patients aged ≥70 years in the ICU decreased markedly. COPD patients per 10,000 ICU patients decreased for both males and females. The length of ICU stays, and in-hospital mortality increased from 21.58 to 23.14 days and 14.97% to 30.98% from 2003 to 2013, respectively. Conclusion: The number of COPD patients admitted to the ICU in Taiwan increased over the 11-year study period. Increased mean patient age, length of ICU stays, hospital mortality, and comorbidities were observed. The use of a nationwide population-based database allowed for a
Hagerty, Thomas A; Velázquez, Ángela; Schmidt, J Michael; Falo, Cristina
Patients' and family members' experiences of hospital care are important indicators of quality. "Black, Asian, and Hispanic patients are more at risk than White patients for decreased satisfaction with care." In addition, of any of these groups, Hispanic patients were most likely to report a lack of patient-centered care. In the intensive care setting, (ICU) previous research has indicated that the needs and satisfaction of family members of neurological ICU patients are different from those of family members of other types of ICU patients. The purpose of this study was to determine if there were any differences between English-speaking and Spanish-speaking family members of patients in a neurological ICU. This study was a single center prospective study conducted over a 10-month period from April 2013 to February 2014 in the 18-bed neuroscience ICU of a large, urban, academic medical center. The Family Satisfaction with ICU (FS-ICU) questionnaire was used; it provides an overall score and has two factors: satisfaction with care and satisfaction with decision-making. There was no statistical significance between the two groups in overall satisfaction or in satisfaction with care, however Spanish-speakers (n=22) were significantly less satisfied (p=.04) than English-speakers (n=50) with decision-making. There were three other discreet variables in which Spanish-speakers were also less satisfied: (a) management of patients' pain (OR 3.16, 95% CI [1.12, 8.9]) (b) management of patients' breathlessness (OR 3.5, 95% CI [1.23, 9.96]) as well as (c) ease of getting information (OR 3.25, 95% CI [1.09, 9.64]). Using a standardized survey it was found that Spanish-speakers were statistically less satisfied with decision-making than English-speakers. Additionally, Spanish-speakers were statistically less satisfied with management of patients' pain and breathlessness and ease of getting information. Based on these findings, increased vigilance is recommended regarding decision
Full Text Available Abstract Background Intensivists must provide enough analgesia and sedation to ensure dying patients receive good palliative care. However, if it is perceived that too much is given, they risk prosecution for committing euthanasia. The goal of this study is to develop consensus guidelines on analgesia and sedation in dying intensive care unit patients that help distinguish palliative care from euthanasia. Methods Using the Delphi technique, panelists rated levels of agreement with statements describing how analgesics and sedatives should be given to dying ICU patients and how palliative care should be distinguished from euthanasia. Participants were drawn from 3 panels: 1 Canadian Academic Adult Intensive Care Fellowship program directors and Intensive Care division chiefs (N = 9; 2 Deputy chief provincial coroners (N = 5; 3 Validation panel of Intensivists attending the Canadian Critical Care Trials Group meeting (N = 12. Results After three Delphi rounds, consensus was achieved on 16 statements encompassing the role of palliative care in the intensive care unit, the management of pain and suffering, current areas of controversy, and ways of improving palliative care in the ICU. Conclusion Consensus guidelines were developed to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.
Christian, Michael D.; Joynt, Gavin M.; Hick, John L.; Colvin, John; Danis, Marion; Sprung, Charles L.; Christian, Micahel D.; Camargo, Ruben; Ceraso, Daniel; Azoulay, Elie; Duguet, Alexandre; Guery, Benoit; Reinhart, Konrad; Adini, Bruria; Barlavie, Yaron; Benin-Goren, Odeda; Cohen, Robert; Klein, Motti; Leoniv, Yuval; Margalit, Gila; Rubinovitch, Bina; Sonnenblick, Moshe; Steinberg, Avraham; Weissman, Charles; Wolff, Donna; Kesecioglu, Jozef; de Jong, Menno; Moreno, Rui; An, Youzhong; Du, Bin; Loo, Shi; Richards, Guy; Artigas, Antonio; Pugin, Jerome; Amundson, Dennis; Devereaux, Asha; Beigel, John; Farmer, Chris; Maki, Dennis; Masur, Henry; Rubinson, Lewis; Sandrock, Christian; Talmor, Daniel; Truog, Robert; Zimmerman, Janice; Brett, Steve; Montgomery, Hugh; Rhodes, Andrew; Sanderson, Frances; Taylor, Bruce
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
Awad, Aya; Bader-El-Den, Mohamed; McNicholas, James; Briggs, Jim
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
Full Text Available Delirium ditandai dengan perubahan status mental, tingkat kesadaran, serta perhatian yang akut dan fluktuatif. Keadaan ini merupakan kelainan yang serius berhubungan dengan pemanjangan lama perawatan di Intensive Care Unit (ICU, biaya yang lebih tinggi, memperlambat pemulihan fungsional, serta peningkatan morbiditas dan mortalitas. Tujuan penelitian adalah mengetahui angka kejadian delirium dan faktor risiko terjadinya delirium di ICU Rumah Sakit Dr. Hasan Sadikin (RSHS Bandung. Pengambilan sampel dilakukan selama tiga bulan (Januari–Maret 2015 di ICU RSHS Bandung. Metode penelitian ini deskriptif observasional secara kohort prospektif, menggunakan alat ukur Confusion Assessment Method-Intensive Care Unit (CAM-ICU, sebelumnya dilakukan penilaian dengan Richmond agitation-sedation scale (RASS pada pasien yang tersedasi. Hasil penelitian ini dari 105 pasien, 22 pasien dieksklusikan, dari 83 pasien didapatkan 31 pasien positif delirium, angka kejadian 37%. Faktor-faktor risiko pada pasien positif delirium terdiri atas geriatri 15 dari 31, pemakaian ventilator 12 dari 31, pemberian analgesik morfin 9 dari 31, sepsis atau infeksi 9 dari 31, kelainan jantung 8 dari 31, acute physiology and chronic health evaluation (APACHE II skor tinggi 8 dari 31, kelainan ginjal 7 dari 31 laboratorium abnormal 7 dari 31, pemberian sedasi midazolam 6 dari 31 kelainan endokrin 5 dari 31, pemberian analgesik fentanil 2 dari 31, dan strok 1 dari 31. Simpulan, angka kejadian delirium di ICU RSHS Bandung cukup tinggi sebesar 37% dengan faktor risiko terbesar adalah pasien geriatrik.
McShea, Michael; Holl, Randy; Badawi, Omar; Riker, Richard R; Silfen, Eric
As the volume of data that is electronically available promliferates, the health-care industry is identifying better ways to use this data for patient care. Ideally, these data are collected in real time, can support point-of-care clinical decisions, and, by providing instantaneous quality metrics, can create the opportunities to improve clinical practice as the patient is being cared for. The business-world technology supporting these activities is referred to as business intelligence, which offers competitive advantage, increased quality, and operational efficiencies. The health-care industry is plagued by many challenges that have made it a latecomer to business intelligence and data-mining technology, including delayed adoption of electronic medical records, poor integration between information systems, a lack of uniform technical standards, poor interoperability between complex devices, and the mandate to rigorously protect patient privacy. Efforts at developing a health care equivalent of business intelligence (which we will refer to as clinical intelligence) remains in its infancy. Until basic technology infrastructure and mature clinical applications are developed and implemented throughout the health-care system, data aggregation and interpretation cannot effectively progress. The need for this approach in health care is undisputed. As regional and national health information networks emerge, we need to develop cost-effective systems that reduce time and effort spent documenting health-care data while increasing the application of knowledge derived from that data.
Vergales, Jeffrey; Addison, Nancy; Vendittelli, Analise; Nicholson, Evelyn; Carver, D Jeannean; Stemland, Christopher; Hoke, Tracey; Gangemi, James
The goal was to develop and implement a comprehensive, primarily face-to-face handoff process that begins in the operating room and concludes at the bedside in the intensive care unit (ICU) for pediatric patients undergoing congenital heart surgery. Involving all stakeholders in the planning phase, the framework of the handoff system encompassed a combination of a formalized handoff tool, focused process steps that occurred prior to patient arrival in the ICU, and an emphasis on face-to-face communication at the conclusion of the handoff. The final process was evaluated by the use of observer checklists to examine quality metrics and timing for all patients admitted to the ICU following cardiac surgery. The process was found to improve how various providers view the efficiency of handoff, the ease of asking questions at each step, and the overall capability to improve patient care regardless of overall surgical complexity. © 2014 by the American College of Medical Quality.
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.
Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.
Kang, Doo Kyung; Won, Je Hwan; Kim, Jai Keun; Lee, Kwang Hun; Kim, Ji Hyung
To determine the efficacy and safety of bedside percutaneous drainage procedures with ultrasound guidance in critically ill patients in the intensive care unit (ICU). Sixty five percutaneous drainage procedures performed at the bedside, in 39 ICU patients, were evaluated. All of the procedures were performed with ultrasound guidance alone. The procedures consisted of percutaneous drainage of abdominal (n=35) and pleural (n=27) fluids, percutaneous cholecystostomy (n=2) and percutaneous nephrostomy (n=1). The clinical responses were classified as 'complete response', 'partial response', 'failure' or 'undetermined'. The medical records were reviewed retrospectively to evaluate the clinical response. Technical success was achieved in 64 of the 65 procedures (98.5%). The complication rate was 13.8% (9 cases). There was no immediate procedure-related death or worsening of the clinical condition of the patients. The clinical responses after drainage were 'complete response' in 39 cases (60.9%). 'partial response' in 14 (21.9%), 'failure' in 3 (4.7%), and 'undetermined' in 8 (12.5%). Bedside drainage procedures with ultrasound guidance are effective and safe to perform when patients are too critically ill to be moved from the ICU to the angiography room
Reznek, Martin A; Upatising, Benjavan; Kennedy, Samantha J; Durham, Natassia T; Forster, Richard M; Michael, Sean S
Emergency Department (ED) boarding threatens patient safety. It is unclear whether boarding differentially affects patients admitted to intensive care units (ICUs) versus non-ICU settings. We performed a 2-hospital, 18-month, cross-sectional, observational, descriptive study of adult patients admitted from the ED. We used Kaplan-Meier estimation and Cox Proportional Hazards regression to describe differences in boarding time among patients who died during hospitalization versus those who survived, controlling for covariates that could affect mortality risk or boarding exposure, and separately evaluating patients admitted to ICUs versus non-ICU settings. We extracted age, race, sex, time variables, admission unit, hospital disposition, and Elixhauser comorbidity measures and calculated boarding time for each admitted patient. Among 39,781 admissions from the EDs (21.3% to ICUs), non-ICU patients who died in-hospital had a 1.2-fold risk (95% confidence interval, 1.03-1.36; P=0.016) of having experienced longer boarding times than survivors, accounting for covariates. We did not observe a difference among patients admitted to ICUs. Among non-ICU patients, those who died during hospitalization were more likely to have had incrementally longer boarding exposure than those who survived. This difference was not observed for ICU patients. Boarding risk mitigation strategies focused on ICU patients may have accounted for this difference, but we caution against interpreting that boarding can be safe. Segmentation by patients admitted to ICU versus non-ICU settings in boarding research may be valuable in ensuring that the safety of both groups is considered in hospital flow and boarding care improvements.
Cappellini, Elena; Bambi, Stefano; Lucchini, Alberto; Milanesio, Erika
The aims of this study were to describe the current status of intensive care unit (ICU) visiting hours policies internationally and to explore the influence of ICUs' open visiting policies on patients', visitors', and staff perceptions, as well as on patients' outcomes. A review of the literature was done through MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The following keywords were searched: "visiting," "hours," "ICU," "policy," and "intensive care unit." Inclusion criteria for the review were original research paper, adult ICU, articles published in the last 10 years, English or Italian language, and available abstract. Twenty-nine original articles, mainly descriptive studies, were selected and retrieved. In international literature, there is a wide variability about open visiting policies in ICUs. The highest percentage of open ICUs is reported in Sweden (70%), whereas in Italy there is the lowest rate (1%). Visiting hours policies and number of allowed relatives are variable, from limits of short precise segments to 24 hours and usually 2 visitors. Open ICUs policy/guidelines acknowledge concerns with visitor hand washing to prevent the risk of infection transmission to patients. Patients, visitors, and staff seem to be inclined to support open ICU programs, although physicians are more inclined to the enhancement of visiting hours than nurses. The percentages of open ICUs are very different among countries. It can be due to local factors, cultural differences, and lack of legislation or hospital policy. There is a need for more studies about the impact of open ICUs programs on patients' mortality, length of stay, infections' risk, and the mental health of patients and their relatives.
Noome, Marijke; Dijkstra, Boukje M; van Leeuwen, Evert; Vloet, Lilian C M
The aim of this study was to examine the experience(s) of family with the nursing aspects of End-of-life care in the intensive care unit after a decision to end life-sustaining treatment, and to describe what nursing care was most appreciated and what was lacking. A phenomenological approach including inductive thematic analysis was used. Twenty-six family members of deceased critically ill-patients were interviewed within two months after the patient's death about their experiences with nursing aspects of end-of-life care in the intensive care unit. Most family members experienced nursing contribution to end-of-life care of the patient and themselves, especially supportive care. Families mentioned the following topics: Communication between intensive care nurses, critically ill patients and family; Nursing care for critically ill patients; Nursing care for families of critically ill patients; Pre-conditions. Families appreciated that intensive care nurses were available at any time and willing to answer questions. But care was lacking because families had for example, a sense of responsibility for obtaining information, they had problems to understand their role in the decision-making process, and were not invited by nurses to participate in the care. Most family appreciated the nursing EOLC they received, specifically the nursing care given to the patient and themselves. Some topics needed more attention, like information and support for the family. Copyright © 2016 Elsevier Ltd. All rights reserved.
Malkoc, Mehtap; Karadibak, Didem; Yldrm, Yucel
The aim of this study was to assess the effect of physiotherapy on ventilator dependency and lengths of intensive care unit (ICU) stay. Patients were divided into two groups. The control group, which received standard nursing care, was a retrospective chart review. The data of control patients who were not receiving physiotherapy were obtained…
Kemper, P.F.; de Bruijne, M.C.; van Dyck, C.; Wagner, C.
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
Kemper, P.F.; Bruijne, M. de; Dyck, C. van; Wagner, C.
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
Full Text Available Health care professionals working in Intensive Care Units (ICUs are exposed to high levels of stress-provoking stimuli. Some may unconsciously employ negative coping skill s which may contribute to burnout and negatively affect patient care. We chose to explore ways of facilitating and encouraging self-reflective practice in an effort to increase empathic traits and enhance communication. A narrative medicine series, which included six sessions that were focused on different narrative approaches, was organized for staff of an academic teaching hospital. Totally, 132 interdisciplinary ICU staff attended the sessions. They were generally open to exploring the selected approaches and discussing their reflections within the interdisciplinary environment. The narrative medicine series provided tools for health care professionals to enhance self-reflective skills utilizing a team-based learning approach. The anticipated outcomes were improved self-care, increased empathy and communication skills, enhanced team functioning, which all contribute to better patient care at the bedside.
2001). This period marks the first decade of the establishment of our ICU. The purpose of this study is to describe the pattern of admission of patients into the ICU, highlighting the variety of cases, indications for admission, outcome and causes of death, and the problems of medical and administrative management of the unit.
Storm, L; Schnegelsberg, A; Mackenhauer, J
BACKGROUND: A recent study showed higher risk of bacteremia among individuals with low socioeconomic status (SES). We hypothesized that patients with a low SES have a higher risk of intensive care unit (ICU) admission with sepsis compared to patients with higher SES. METHODS: This was a case......, yearly income, cohabitation status, and occupation. The odds ratio (OR) of being admitted with sepsis to the ICU was calculated using conditional logistic regression, adjusting for the Charlson Comorbidity Index and the remaining socioeconomic variables. RESULTS: The adjusted odds of being admitted...
“Kangaroo mother care” was first described as an alternative method of caring for low birth weight infants in resource-limited countries, where neonatal mortality and infection rates are high because of overcrowded nurseries, inadequate staffing, and lack of equipment. Intermittent skin-to-skin care (SSC), a modified version of kangaroo mother care, is now being offered in resource-rich countries to infants needing neonatal intensive care, including those who require ventilator support or are extremely premature. SSC significantly improves milk production by the mother and is associated with a longer duration of breastfeeding. Increased parent satisfaction, better sleep organization, a longer duration of quiet sleep, and decreased pain perception during procedures have also been reported in association with SSC. Despite apparent physiologic stability during SSC, it is prudent that infants in the NICU have continuous cardiovascular monitoring and that care be taken to verify correct head positioning for airway patency as well as the stability of the endotracheal tube, arterial and venous access devices, and other life support equipment.
Lisette Schoonhoven; Peter Pickkers; Mark van den Boogaard
A psycho-organic disorder such as delirium is a frequently occurring and serious disorder especially on Intensive Care units. Nowadays, more attention is paid to this problem by physicians, nurses and by researchers, but assessment of delirium in all ICU patients is still not common practice. If
Perner, A; Smith, S H; Carlsen, S
Transfusion of red blood cells (RBCs) remains controversial in patients with septic shock, but current practice is unknown. Our aim was to evaluate RBC transfusion practice in septic shock in the intensive care unit (ICU), and patient characteristics and outcome associated with RBC transfusion....
Tabanejad, Zeinab; Pazokian, Marzieh; Ebadi, Abbas
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.
Full Text Available Introduction: The patients’ families in intensive care units (ICUs experience excessive stress which may disrupt their performance in daily life. Empathy is basic to the nursing role and has been found to be associated with improved patient outcomes and greater satisfaction with care in patient and his/her family. However, few studies have investigated the nursing empathy with ICU patients. This study aimed to assess nursing empathy and its relationship with the needs, from the perspective of families of patients in ICU.Methods: In this cross-sectional study, 418 subjects were selected among families of patients admitted to ICUs in Tabriz, Iran, by convenience sampling, from May to August 2012. Data were collected through Barrett-Lennard Relationship inventory (BLRI empathy scale and Critical Care Family Needs Intervention (CCFNI inventories and were analyzed using descriptive and inferential statistical tests. Results: Findings showed that most of the nurses had high level of empathy to the patients (38.8%. There was also statistically significant relationship between nurses’ empathy and needs of patients’ families (p < 0.001. Conclusion: In this study we found that by increasing the nurse’s empathy skills, we would be able to improve providing family needs. Through empathic communication, nurses can encourage family members to participate in planning for the care of their patients. However, further studies are necessary to confirm the results.
Jones, Jennifer; Mitchell, Marion; Milligan, Eleanor
This discussion paper explores some of the complex ethical and moral issues confronting contemporary critical care nurses. In contemporary healthcare discussions, there is an increased appreciation of the complexity of ethical challenges, the multiplicity of stakeholders and that a broad range of possible and practical outcomes exist. Furthermore, many scholars also acknowledge the limitations of principle based ethical frameworks. In seeking to build critical care nurses' capacity to negotiate the complex - and often conflicting - ethical challenges, the authors have adopted a person-centred, values-based approach in this case study. Furthermore, by exploring these complex issues, this paper supports and builds upon critical care nurses' decision making capacities in the clinical area. This case study has been purposefully left open-ended with the aim of inviting the reader to consider the questions posed in a collegial, collaborative manner within the particular context in which she/he is embedded. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.
Sosnowski, Kellie; Lin, Frances; Mitchell, Marion L; White, Hayden
The aim of this review is to appraise current research which examines the impact of early rehabilitation practices on functional outcomes and quality of life in adult intensive care unit (ICU) survivors. A systematic literature search was undertaken; retrieved data was evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic. Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline and Google Scholar were searched using key search terms 'ICU acquired weakness', 'early rehabilitation' 'early mobility' and 'functional outcomes' combined with 'intensive care' and 'critical illness'. Additional literature was sourced from reference lists of relevant original publications. Five major themes related to the review objectives emerged from the analysis. These themes included: critically ill patients do not always receive physical therapy as a standard of care; ICU culture and resources determine early rehabilitation success; successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment; early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status; early exercise in the ICU is effective, safe and feasible. A limited body of research supports early rehabilitation interventions to optimise the short term outcomes and long term quality of life for ICU survivors. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are adopted and implemented. Copyright © 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
Zhang, Xiao-Chun; Huang, De-Sheng; Guan, Peng
Objectives The shortage of qualified nurses is one of the critical challenges in the field of healthcare. Among the contributing factors, job burnout has been indicated as a risk factor for the intention to leave. The purpose of this study was to provide a better understanding of the local status and reference data for coping strategies for intensive care unit (ICU)-nurse burnout among Liaoning ICU nurses. Design Observational study. Setting 17 ICUs from 10 tertiary-level hospitals in Liaoning, China. Participants 431 ICU nurses from 14 ICUs nested in 10 tertiary-level hospitals in Liaoning, China, were invited during October and November 2010. Primary measures Burnout was measured using the 22-item Chinese version of Maslach Burnout Inventory-Health Service Survey (MBI-HSS) questionnaires. Results 14 ICUs responded actively and were included; the response rate was 87.7% among the 486 invited participants from these 17 ICUs. The study population was a young population, with the median age 25 years, IQR 23–28 years and female nurses accounted for the major part (88.5%). 68 nurses (16%) were found to have a high degree of burnout, earning high emotional exhaustion and depersonalisation scores together with a low personal accomplishment score. Conclusions The present study indicated a moderate distribution of burnout among ICU nurses in Liaoning, China. An investigation into the burnout levels of this population could bring more attention to ICU caregivers. PMID:24948747
Julie L Darbyshire
Full Text Available Patients who develop intensive care unit (ICU acquired delirium stay longer in the ICU, and hospital, and are at risk of long-term mental and physical health problems. Despite guidelines for patient assessment, risk limitation, and treatment in the ICU population, delirium and associated delusions remain a relatively common occurrence on the ICU. There is considerable information in the literature describing the incidence, suspected causes of, and discussion of the benefits and side-effects of the various treatments for delirium in the ICU. But peer-reviewed patient-focused research is almost non-existent. There is therefore a very limited understanding of the reality of delusions in the intensive care unit from the patient's point of view.A secondary analysis of the original interviews conducted by the University of Oxford Health Experiences Research Group was undertaken to explore themes relating specifically to sleep and delirium.Patients describe a liminal existence on the ICU. On the threshold of consciousness their reality is uncertain and their sense of self is exposed. Lack of autonomy in an unfamiliar environment prompts patients to develop explanations and understandings for themselves with no foothold in fact.Patients on the ICU are perhaps more disoriented than they appear and early psychological intervention in the form of repeated orientation whilst in the ICU might improve the patient experience and defend against development of side-effects.
Karanika, Styliani; Paudel, Suresh; Zervou, Fainareti N; Grigoras, Christos; Zacharioudakis, Ioannis M; Mylonakis, Eleftherios
Background. Intensive care unit (ICU) patients are at higher risk for Clostridium difficile infection (CDI). 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.
Ewens, Beverley A; Hendricks, Joyce M; Sundin, Deb
The aim of this study was to explore the potential use of visual diarizing to enable intensive care unit (ICU) survivors to create their story of recovery. An ICU experience can have deleterious psychological and physical effects on survivors leading to reductions in quality of life which for some may be of significant duration. Although there has been exploration of many interventions to support recovery in this group, service provision for survivors remains inconsistent and inadequate. A qualitative interpretive biographical exploration of the ICU experience and recovery phase of ICU survivors using visual diarizing as method. This paper is a component of a larger study and presents an analyses of one participant's visual diary in detail. Data collection was twofold. The participant was supplied with visual diary materials at 2 months post-hospital discharge and depicted his story in words and pictures for a 3-month period, after which he was interviewed. The interview enabled the participant and researcher to interpret the visual diary and create a biographical account of his ICU stay and recovery journey. The analysis of one participant's visual diary yielded a wealth of information about his recovery trajectory articulated through the images he chose to symbolize his story. The participant confirmed feelings of persecution whilst in ICU and was unprepared for the physical and psychological disability which ensued following his discharge from hospital. However, his story was one of hope for the future and a determination that good would come out of his experience. He considered using the visual diary enhanced his recovery. The participant perceived that visual diarizing enhanced his recovery trajectory by enabling him to recreate his story using visual imagery in a prospective diary. Prospective visual diarizing with ICU survivors may have potential as an aid to recovery. © 2014 British Association of Critical Care Nurses.
Huang, David T; Clermont, Gilles; Sexton, J Bryan; Karlo, Crystal A; Miller, Rachel G; Weissfeld, Lisa A; Rowan, Kathy M; Angus, Derek C
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 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.
Plešinger, Filip; Klimeš, Petr; Halámek, Josef; Jurák, Pavel
Roč. 37, č. 8 (2016), s. 1313-1325 ISSN 0967-3334 R&D Projects: GA ČR GAP102/12/2034; GA MŠk(CZ) LO1212; GA MŠk ED0017/01/01 Institutional support: RVO:68081731 Keywords : ECG * critical care * arrhythmia * intensive care unit * ICU monitor * false alarm * beat detection Subject RIV: FS - Medical Facilities ; Equipment Impact factor: 2.058, year: 2016
Krefft, Maciej; Zamaro-Michalska, Aleksandra; Zabołotny, Wojciech M.; Zaworski, Wojciech; Grzanka, Antoni; Łazowski, Tomasz; Tavola, Mario; Siewiera, Jacek; Mikaszewska-Sokolewicz, Małgorzata
This paper presents a recording system optimized for long term measurement of bed headrest elevation angle in the Intensive Care Unit. The continuous monitoring of this parameter allows to find the correlation between the patient's position in bed and the risk of the Ventilator Associated Pneumonia (VAP), a very serious problem in therapy of critically ill patients. Recorder might be be an important tool to evaluate the "care bundles" - sets of preventive procedures recommended for treatment of patients in the ICU.
Tabanejad, Zeinab; Pazokian, Marzieh; Ebadi, Abbas
Background: 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. Methods: A systematic review of intervention studies between 2004 and 2013 was undertaken using standard and sensitiv...
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.
Krag, Morten Brøgger; Perner, A; Wetterslev, J
Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate...... incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care...... patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive...
Bangert, K; Borch, J; Ferahli, S; Braune, S A; de Heer, G; Kluge, S
Intensive care medicine (ICM) is increasingly utilized by a growing number of critically ill patients worldwide. The reasons for this are an increasingly ageing and multimorbid population and technological improvements in ICM. Inappropriate patient admissions to the intensive care unit (ICU) can be a threat to rational resource allocation and to patient autonomy. In this study, the incidence, characteristics, and resource utilization of patients inappropriately admitted to ICUs are studied. This prospective study included all consecutive patients admitted from 01 September 2012 to 31 August 2013 to the Department of Intensive Care Medicine of a German university hospital comprised of 10 ICUs and 120 beds. Inappropriate admission was defined according to category 4B of the recommendations of the Society of Critical Care Medicine (SCCM; "futility of ICU treatment" or "ICU declined by patient") and was determined in each suspected case by structured group discussions between the study team and all involved care givers including the referring team. In all, 66 of 6452 ICU admissions (1 %) were suspected to have been inappropriate on retrospective evaluation the day after admission. In 50 patients (0.8 %), an interdisciplinary consensus was reached on the inappropriateness of the ICU admission. Of these 50 patients, 41 (82 %) had previously declined ICU treatment in principle. This information was based on the patient's presumed wish as expressed by next of kin (56 %) or in a written advanced directive (26 %). In 9 patients (18 %), ICU treatment was considered futile. In all cases, a lack of information regarding a patient's wishes or clinical prognosis was the reason for inappropriate ICU admission. In this study, patients were regularly admitted to the ICU despite their contrary wish/directive or an unfavorable clinical condition. Although this was registered in only 1 % of all admissions, optimizing preICU admission information flow with regard to
Kumar, Parmeshwar; Jithesh, V; Gupta, Shakti Kumar
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. 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. 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 was performed by Fisher's two tailed t-test. 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. 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.
Piedrafita-Susín, A B; Yoldi-Arzoz, E; Sánchez-Fernández, M; Zuazua-Ros, E; Vázquez-Calatayud, M
Adequate provision of palliative care by nursing in intensive care units is essential to facilitate a "good death" to critically ill patients. To determine the perceptions, experiences and knowledge of intensive care nurses in caring for terminal patients. A literature review was conducted on the bases of Pubmed, Cinahl and PsicINFO data using as search terms: cuidados paliativos, UCI, percepciones, experiencias, conocimientos y enfermería and their alternatives in English (palliative care, ICU, perceptions, experiences, knowledge and nursing), and combined with AND and OR Boolean. Also, 3 journals in intensive care were reviewed. Twenty seven articles for review were selected, most of them qualitative studies (n=16). After analysis of the literature it has been identified that even though nurses perceive the need to respect the dignity of the patient, to provide care aimed to comfort and to encourage the inclusion of the family in patient care, there is a lack of knowledge of the end of life care in intensive care units' nurses. This review reveals that to achieve quality care at the end of life, is necessary to encourage the training of nurses in palliative care and foster their emotional support, to conduct an effective multidisciplinary work and the inclusion of nurses in decision making. Copyright © 2014 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
Bergamasco E Paula, R; Tanita, M T; Festti, J; Queiroz Cardoso, L T; Carvalho Grion, C M
To compare readmission rates to the intensive care unit (ICU) before and after the implementation of a rapid response team (RRT), and to identify risk factors for readmission. A quasi-experimental before-after study was carried out. A University Hospital. All patients discharged from the ICU from January to December 2008 (control group) and from January 2010 to December 2012 (intervention group). Implementation of an RRT. The data included demographic parameters, diagnoses upon admission, ICU readmission, APACHE II, SOFA, and TISS 28 scores, and routine daily assessment by an RRT of patients discharged from the ICU. During the study interval, 380 patients were analyzed in the period prior to the implementation of the RRT and 1361 after implementation. There was a tendency toward decreased readmission rates one year after RRT implementation. The APACHE II score and SOFA score at ICU discharge were independent factors associated to readmission, as well as clinical referral to the ICU. The RRT intervention resulted in a sustained decrease in readmission rates one year after implementation of this service. The use of a specialized team in health institutions can be recommended for ICU survivors. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
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
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
Boesen, H C; Andersen, J H; Bendtsen, A O
. Delirium assessment was done using the confusion assessment method for the intensive care unit (CAM-ICU). RESULTS: Of four patients who were delirium free, only one had identifiable sleep on PSG. Sleep was disrupted with loss of circadian rhythm, and diminished REM sleep. In the remaining three patients...... the PSGs were atypical, meaning that no sleep signs were found, and sleep could not be quantified from the PSGs. Clinical total sleep time (ClinTST) ranged from 2.0-13.1 h in patients without delirium. Six patients with delirium all had atypical PSGs, so sleep could not be quantified. Short periods of REM......BACKGROUND: Sleep deprivation and delirium are major problems in the ICU. We aimed to assess the sleep quality by polysomnography (PSG) in relation to delirium in mechanically ventilated non-sedated ICU patients. METHODS: Interpretation of 24-h PSG and clinical sleep assessment in 14 patients...
Marque, Sophie; Cariou, Alain; Chiche, Jean-Daniel; Mallet, Vincent Olivier; Pene, Frédéric; Mira, Jean-Paul; Dhainaut, Jean-François; Claessens, Yann-Erick
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
Yoo, E J; Damaghi, N; Shakespeare, W G; Sherman, M S
Although evidence supports the impact of intensivist physician staffing in improving intensive care unit (ICU) outcomes, the optimal coverage for progressive care units (PCU) is unknown. We sought to determine how physician staffing models influence outcomes for intermediate care patients. We conducted a retrospective observational comparison of patients admitted to the medical PCU of an academic hospital during 12-month periods of high-intensity and low-intensity staffing. A total of 318 PCU patients were eligible for inclusion (143 high-intensity and 175 low-intensity). We found that low-intensity patients were more often stepped up from the emergency department and floor, whereas high-intensity patients were ICU transfers (61% vs 42%, P = .001). However, Mortality Probability Model scoring was similar between the 2 groups. In adjusted analysis, there was no association between intensity of staffing and hospital mortality (odds ratio, 0.84; 95% confidence interval, 0.36-1.99; P = .69) or PCU mortality (odds ratio, 0.96; 95% confidence interval, 0.38-2.45; P = .69). There was also no difference in subsequent ICU admission rates or in PCU length of stay. We found no evidence that high-intensity intensivist physician staffing improves outcomes for intermediate care patients. In a strained critical care system, our study raises questions about the role of the intensivist in the graded care options between intensive and conventional ward care. Copyright © 2015 Elsevier Inc. All rights reserved.
Full Text Available BACKGROUND: Delirium is one of the main causes of increased length of intensive care unit (ICU stay among patients who have undergone living donor liver transplantation (LDLT. We aimed to evaluate risk factors for delirium after LDLT as well as to investigate whether delirium impacts the length of ICU and hospital stay. METHODS: Seventy-eight patients who underwent LDLT during the period January 2010 to December 2012 at a single medical center were enrolled. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU scale was used to diagnose delirium. Preoperative, postoperative, and hematologic factors were included as potential risk factors for developing delirium. RESULTS: During the study period, delirium was diagnosed in 37 (47.4% patients after LDLT. The mean onset of symptoms occurred 7.0±5.5 days after surgery and the mean duration of symptoms was 5.0±2.6 days. The length of stay in the ICU for patients with delirium (39.8±28.1 days was significantly longer than that for patients without delirium (29.3±19.0 days (p<0.05. Risk factors associated with delirium included history of alcohol abuse [odds ratio (OR = 6.40, 95% confidence interval (CI: 1.85-22.06], preoperative hepatic encephalopathy (OR = 4.45, 95% CI: 1.36-14.51, APACHE II score ≥16 (OR = 1.73, 95% CI: 1.71-2.56, and duration of endotracheal intubation ≥5 days (OR = 1.81, 95% CI: 1.52-2.23. CONCLUSIONS: History of alcohol abuse, preoperative hepatic encephalopathy, APACHE II scores ≥16 and endotracheal intubation ≥5 days were predictive of developing delirium in the ICU following liver transplantation surgery and were associated with increased length of ICU and hospital stay.
Brown, Kyla N; Leigh, Jeanna Parsons; Kamran, Hasham; Bagshaw, Sean M; Fowler, Rob A; Dodek, Peter M; Turgeon, Alexis F; Forster, Alan J; Lamontagne, Francois; Soo, Andrea; Stelfox, Henry T
Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks. This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients. A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority. Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.
Sakaguchi, Hideya; Yamashita, Satoshi; Hirano, Teruyuki; Nakajima, Makoto; Kimura, En; Maeda, Yasushi; Uchino, Makoto
The purpose of this report was to investigate predictive factors that necessitate intensive care in myasthenic crisis (MC). We retrospectively reviewed MC patients at our institution and compared ICU and ward management groups. Higher MG-ADL scale scores, non-ocular initial symptoms, infection-triggered findings, and higher MGFA classification were observed more frequently in the ICU group. In patients with these prognostic factors, better outcomes may be obtained with early institution of intensive care. Copyright © 2012 Wiley Periodicals, Inc.
Petrinec, Amy B; Daly, Barbara J
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.
AlOtair, Hadeel; Chaudhry, Mohammed; Shaikh, Shaffi; BaHammam, Ahmed
Pulmonary embolism (PE) is an important cause of in-hospital mortality. Many patients are admitted to the intensive care unit (ICU) either due to hemodynamic instability or severe hypoxemia. Few reports have addressed the outcome of patients with PE; however, none were from ICUs in the Middle East. To describe the demographics, clinical presentation, risk factors and outcome of patients with PE admitted to the medical ICU and to identify possible factors associated with poor prognosis. Data were collected retrospectively by reviewing the records of patients admitted to the medical ICU with primary diagnosis of PE between January 2001 and June 2007. Demographic, clinical, radiological and therapeutic data were collected on admission to ICU. Fifty-six patients (43% females) with PE were admitted to the ICU during the study period. Their mean age was 40.6 + - 10.6 years. Seven patients (12.5%) had massive PE with hemodynamic instability and 15 (26.8%) had submassive PE. The remaining patients were admitted due to severe hypoxemia. Recent surgery followed by obesity were the most common risk factors (55.4 and 28.6%, respectively). Four patients with massive PE received thrombolysis because the remaining three had absolute contraindications. Fatal gastrointestinal bleeding occurred in one patient post thrombolysis. Additionally, two patients with massive PE and five with submassive PE died within 72 h of admission to the ICU, resulting in an overall mortality rate of 14%. Nonsurvivors were older and had a higher prevalence of immobility and cerebrovascular diseases compared with survivors. The mortality rate of patients with PE admitted to the ICU in our center was comparable to other published studies. Older age, immobility as well as coexistent cerebrovascular diseases were associated with a worse outcome. (author)
Liu, Qiu-Yue; Han, Fen; Pan, Li-Ping; Jia, Hong-Yan; Li, Qi; Zhang, Zong-De
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
Suzan Demir Pektas
Full Text Available Background: Intensive Care Units (ICUs are places where critically ill patients are managed. Aim: We aimed to investigate skin disorders that developed in critically ill surgical patients during their stay in the ICU. Methods: The prevalence of dermatological disorders and factors affecting their clinical features was prospectively analyzed in surgical ICU patients. We recorded age, sex, type of ICU, comorbidities, skin disorders, time to consultation, duration of ICU stay, and mortality rate. Results: Our study included 605 patients (mean age of 60.1 ± 20.2 years; 56.4% males. Seventy-three (12.1% patients were consulted with the Dermatology Department, among which 28.8% had infectious dermatological lesions, 26% dermatoses, and 45.2% drug reactions. The most common infectious dermatological disorder was wound infection (55.6%, the most common drug reaction was maculopapular drug eruption (75.8%, and the most common dermatosis was frictional blisters (47.4%. Multiple comorbidities, hypertension, diabetes mellitus, coronary artery disease, Parkinson disease, and stroke increased dermatological disorders (P < 0.05. The consulted patients had a median ICU stay of 7 days (range 2–53 days; consultation was significantly more common when it exceeded 10 days (74% vs. 26%, P < 0.05. The consulted patients died more commonly (P < 0.05. Infectious dermatological disorders and dermatoses were more common in patients older and younger than 50 years, respectively (P < 0.05. Dermatoses were more common among women (P < 0.05. The median time to consultation was 6 (2–30 days; it was longest for dermatological infections and shortest for dermatoses (P < 0.05. Infectious dermatological disorders were significantly more common among the deceased patients (P < 0.05. Conclusion: Multiple factors including multiple comorbidities, duration of ICU stay, time to consultation, and mortality increase dermatological disorders among surgical ICU patients.
Schleien, Charles L
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.
Hill, Nicholas S.; Lilly, Craig M.; Angus, Derek C.; Jacobi, Judith; Rubenfeld, Gordon D.; Rothschild, Jeffrey M.; Sales, Anne E.; Scales, Damon C.; Mathers, James A. L.
ICU telemedicine uses audiovisual conferencing technology to provide critical care from a remote location. Research is needed to best define the optimal use of ICU telemedicine, but efforts are hindered by methodological challenges and the lack of an organized delivery approach. We convened an interdisciplinary working group to develop a research agenda in ICU telemedicine, addressing both methodological and knowledge gaps in the field. To best inform clinical decision-making and health policy, future research should be organized around a conceptual framework that enables consistent descriptions of both the study setting and the telemedicine intervention. The framework should include standardized methods for assessing the preimplementation ICU environment and describing the telemedicine program. This framework will facilitate comparisons across studies and improve generalizability by permitting context-specific interpretation. Research based on this framework should consider the multidisciplinary nature of ICU care and describe the specific program goals. Key topic areas to be addressed include the effect of ICU telemedicine on the structure, process, and outcome of critical care delivery. Ideally, future research should attempt to address causation instead of simply associations and elucidate the mechanism of action in order to determine exactly how ICU telemedicine achieves its effects. ICU telemedicine has significant potential to improve critical care delivery, but high-quality research is needed to best inform its use. We propose an agenda to advance the science of ICU telemedicine and generate research with the greatest potential to improve patient care. PMID:21729894
Rashid, Mahbub; Khan, Nayma; Jones, Belinda
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.
Tahseen, U.; Talib, M.T.
Nosocomial infections caused by Acinetobacter species (Spp.) is an emerging threat in health care setups especially intensive care units (ICU). The objective of this observational study was to determine the pattern of Acinetobacter infections and its association with length of stay in patients admitted to our medical ICU from January to August 2011. Methods: All patients above 16 years of age with stay of more than 48 hours were checked for any development of new infections not present or incubating at the time of admission. Nosocomial infections were documented in the light of clinical findings and lab results. Data was analysed using statistical software SPSS 15.0. Results: A total of 146 patients had a stay of at least 48 hours; frequency of nosocomial infection was 30.8% out of which 57.8% were Acinetobacter infections. Respiratory system was most commonly involved. Acinetobacter Spp showed high resistance (96.2%) to penicillins, cephalosporins and even extended spectrum antibiotics including carbepenems, quinolones and piperacillin plus tazobactam. Extended drug resistance was seen in 92.3% isolates; while we found high susceptibility to tigecycline (88.5%) and polymyxins (100%). Acinetobacter Spp. infected patients had mean length of stay (LOS) of 12.92 days when compared to patients with other nosocomial infections and no infection with mean LOS of 7.05 days (p=0.05) and 4.86 days (p=0.00) respectively. Conclusions: Acinetobacter Spp infections increase with longer duration of stay in ICU. Emergence of multi-drug and extended-drug resistant Acinetobacter Spp is alarming and overwhelming at this rate for already stretched out health system with its economic and health implications. (author)
Ertugrul, Bulent M; Yildirim, Ayse; Ay, Pinar; Oncu, Serkan; Cagatay, Atahan; Cakar, Nahit; Ertekin, Cemalettin; Ozsut, Halit; Eraksoy, Haluk; Calangu, Semra
To investigate the incidence, risk factors and the etiology of ventilator-associated pneumonia (VAP) in surgical emergency intensive care unit (ICU) patients. We conducted this prospective cohort study in the surgical emergency ICU of Istanbul Medical Faculty between December 1999 and May 2001. We included 100 mechanically ventilated patients in this study. We diagnosed VAP according to the current diagnostic criteria. We identified the etiology of VAP cases by both quantitative cultures of endotracheal aspiration and blood cultures. To analyze the predisposing factors for the development of VAP, we recorded the following variables: age, gender, acute physiology and chronic health evaluation (APACHE) II score, Glasgow coma scale (GCS), sequential organ failure assessment (SOFA) score, serum albumin level, duration of mechanical ventilation (MV) prior to the development of VAP, and underlying diseases. We determined the VAP incidence rate as 28%. We found the APACHE II score and the duration of MV to be statistically significant variables for the development of VAP. There were no significant differences regarding age, gender, GCS, SOFA score, albumin level, or underlying diseases for the development of VAP. The isolated bacteria among VAP cases were as follows: Staphylococcus aureus (n=12, 43%), Acinetobacter spp. (n=6, 21%), coagulase-negative Staphylococci (n=4, 15%), Pseudomonas aeruginosa (n=3, 10.7%) and Klebsiella pneumoniae (n=3, 10.7%). Ventilator-associated pneumonia is a common infection, and certain interventions might affect the incidence of VAP. The ICU clinicians should be aware of the risk factors for VAP, which could prove useful in identifying patients at high risk for VAP, and modifying patient care to minimize the risk of VAP.
Render, Marta L; Freyberg, Ron W; Hasselbeck, Rachael; Hofer, Timothy P; Sales, Anne E; Deddens, James; Levesque, Odette; Almenoff, Peter L
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.
Włodarczyk, Dorota; Pawliszewska, Anna
Working at intensive care unit (ICU) is one ot the most difticult and taxing nursing speciaites. It demans not only extensive knowledge and professional skills but also specific personality temperamental dispositions. The aim of the study was to verify if typeA behavior (TAB) is a predictor ofburnout and job satisfaction in ICU nurses and if this effect still exists after controlling for selected demographic and job characteristics. The study group consisted of 99 nurses (77 women), aged 24-58 (mean (M) = 32.33; standard deviation (SD) = 8:81) working at ICU. The following tools were used: to measure TAB - Type A Behavior Survey BWZ by Wrzesniewski; job burnout - the Oldenburg Burnout Inventory OLBI by Demerouti et al.; and job satisfaction - the Job Satisfaction Scale by Zalewska. The results of hierarchical regression analyses showed that after controlling for selected demographic and job characteristics, tendency for aggressibn was a predictor of higher exhaustion, disengagement and lower job satisfaction. Achievement striving and tendency to dominate were related to higher job satisfaction and lower exhaustion, respectively. Significant predictors of professional functioning were also: duty work system, place of living and gender. The results of the study.confirmed that all 3 content features of TAB were significant predictors of job functioning of ICU nurses. They also indicate that considering TAB in the context of individual adjustment to the environment of the job at ICU would be a valuable direction forfuture research.
Kioka, Mutsumi J; DiGiovine, Bruno; Rezik, Mohamed; Jennings, Jeffrey H
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.
Abelha, Fernando J; Santos, Cristina C; Maia, Paula C; Castro, Maria A; Barros, Henrique
In addition to mortality, Health Related Quality of Life (HRQOL) has increasingly been claimed as an important outcome variable. The aim of this study was to assess HRQOL and independence in activities of daily living (ADL) six months after discharge from an Intensive Care Unit (ICU), and to study its determinants. All post-operative adult patients admitted to a surgical ICU between October 2004 and July 2005, were eligible for the study. The following variables were recorded on admission: age, gender, American Society of Anesthesiologists physical status (ASA-PS), type and magnitude of surgical procedure, ICU and hospital length of stay (LOS), mortality and Simplified Acute Physiology Score II (SAPS II). Six months after discharge, a Short Form-36 questionnaire (SF-36) and a questionnaire to assess dependency in ADL were sent to all survivors. Descriptive statistics was used to summarize data. Patient groups were compared using non-parametric tests. A logistic regression analysis was performed to identify covariate effects of each variable on dependency in personal and instrumental ADL, and for the change-in-health question of SF-36. Out of 333 hospital survivors, 226 completed the questionnaires. Fifty-nine percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients with greater co-morbidities (ASA-PS III/IV), had lower SF-36 scores in all domains and were more frequently dependent in instrumental and personal ADL. Logistic regression showed that SAPS II was associated with changes in general level of health (OR 1.06, 95%CI, 1.01-1.11, p = 0,016). Six months after ICU discharge, 60% and 34% of patients, respectively, were dependent in at least one activity in instrumental ADL (ADLI) and personal ADL (ADLP). ASA-PS (OR 3.00, 95%CI 1.31-6.87, p = 0.009) and age (OR 2.36, 95%CI, 1.04-5.34, p = 0.04) were associated with dependency in ADLI. For ADLP, only ASA-PS (OR 4.58, 95%CI, 1
Cyrol, Katharina; Fröhlich, Martin R; Piatti, Francesca; Imhof, Lorenz
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.
Sprung, Charles L.; Cohen, Robert; Adini, Bruria; Christian, Michael D.; Camargo, Ruben; Ceraso, Daniel; Azoulay, Elie; Duguet, Alexandre; Guery, Benoit; Reinhart, Konrad; Barlavie, Yaron; Benin-Goren, Odeda; Klein, Motti; Leoniv, Yuval; Margalit, Gila; Rubinovitch, Bina; Sonnenblick, Moshe; Steinberg, Avraham; Weissman, Charles; Wolff, Donna; Kesecioglu, Jozef; de Jong, Menno; Moreno, Rui; An, Youzhong; Du, Bin; Joynt, Gavin M.; Colvin, John; Loo, Shi; Richards, Guy; Artigas, Antonio; Pugin, Jerome; Amundson, Dennis; Devereaux, Asha; Beigel, John; Danis, Marion; Farmer, Chris; Hick, John L.; Maki, Dennis; Masur, Henry; Rubinson, Lewis; Sandrock, Christian; Talmor, Daniel; Truong, Robert; Zimmerman, Janice; Brett, Steve; Montgomery, Hugh; Rhodes, Andrew; Sanderson, Frances; Taylor, Bruce; Monrgomery, Hugh
In December 2007, the European Society of Intensive Care Medicine established a Task Force to develop standard operating procedures (SOPs) for operating intensive care units (ICU) during an influenza epidemic or mass disaster. To provide direction for health care professionals in the preparation and
Vlayen, Annemie; Verelst, Sandra; Bekkering, Geertruida E; Schrooten, Ward; Hellings, Johan; Claes, Nerée
Adverse events are unintended patient injuries or complications that arise from healthcare management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the healthcare system. Medical record review seems to be a reliable method for detecting adverse events. To synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission; to determine the type and consequences (patient harm, mortality, length of ICU stay and direct medical costs) of these adverse events. MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions to intensive care units (ICUs). Databases of reports, conference proceedings, grey literature, ongoing research, relevant patient safety organizations and two journals were searched for additional studies. Reference lists of retrieved papers were searched and authors were contacted in an attempt to find any further published or unpublished work. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. Studies that were published in the English, Dutch, German, French or Spanish language were included. Two reviewers independently extracted data and assessed the methodological quality of the included studies. 28 studies in the English language and one study in French were included. Of these, two were considered duplicate publications and therefore 27 studies were reviewed. Meta-analysis of the data was not appropriate due to statistical heterogeneity between studies; therefore, results are presented in a descriptive way. Studies were categorized according to the population and the providers of care. 1) The majority of the included studies investigated unplanned intensive care admissions after
Despins, Laurel A
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.
Full Text Available Pharmacist participation in patient care team has been shown to reduce incidence of adverse drug events, and overall drug costs. However, impact of pharmacist participation in the multidisciplinary intensive care team on cost saving and cost avoidance has little been studied in Thailand.Objective: To describe the characteristics of the interventions and to determine pharmacist’s interventions led to change in cost saving and cost avoidance in intensive care unit (ICU. Methods: A Prospective, standard care-controlled study design was used to compare cost saving and cost avoidance of patients receiving care from patient care team (including a clinical pharmacist versus standard care (no pharmacist on team. All patients admitted to the medical intensive care unit 1 and 2 during the same period were included in the study. The outcome measures were overall drug cost and length of ICU stay. Interventions made by the pharmacist in the study group were documented. The analyses of acceptance and cost saving and/or cost avoidance were also performed. Results: A total of 65 patients were admitted to either ICU 1 or 2 during the 5 week- study period. The pharmacist participated in patient care and made total of 127 interventions for the ICU-1 team. Ninety-eight percent of the interventions were accepted and implemented by physicians. The difference of overall drug cost per patient between two groups was 182.01 USD (1,076.37 USD in study group and 1,258.38 USD in control group, p=0.138. The average length of ICU stay for the intervention group and the control group was not significantly different (7.16 days vs. 6.18 days, p=0.995. The 125 accepted interventions were evaluated for cost saving and cost avoidance. Pharmacist’s interventions yielded a total of 1,971.43 USD from drug cost saving and 294.62 USD from adverse drug event cost avoidance. The net cost saved and avoided from pharmacist interventions was 2,266.05 USD. Interventions involving
In the context of hospital management and operation, Intensive Care Units (ICU) are one of the most challenging in terms of time responsiveness and criticality, in which adequate resource management and signal processing play a key role in overall system performance. In this work, a context aware Intensive Care Unit is implemented and analyzed to provide scalable signal acquisition capabilities, as well as to provide tracking and access control. Wireless channel analysis is performed by means of hybrid optimized 3D Ray Launching deterministic simulation to assess potential interference impact as well as to provide required coverage/capacity thresholds for employed transceivers. Wireless system operation within the ICU scenario, considering conventional transceiver operation, is feasible in terms of quality of service for the complete scenario. Extensive measurements of overall interference levels have also been carried out, enabling subsequent adequate coverage/capacity estimations, for a set of Zigbee based nodes. Real system operation has been tested, with ad-hoc designed Zigbee wireless motes, employing lightweight communication protocols to minimize energy and bandwidth usage. An ICU information gathering application and software architecture for Visitor Access Control has been implemented, providing monitoring of the Boxes external doors and the identification of visitors via a RFID system. The results enable a solution to provide ICU access control and tracking capabilities previously not exploited, providing a step forward in the implementation of a Smart Health framework. PMID:29382148
Full Text Available In the context of hospital management and operation, Intensive Care Units (ICU are one of the most challenging in terms of time responsiveness and criticality, in which adequate resource management and signal processing play a key role in overall system performance. In this work, a context aware Intensive Care Unit is implemented and analyzed to provide scalable signal acquisition capabilities, as well as to provide tracking and access control. Wireless channel analysis is performed by means of hybrid optimized 3D Ray Launching deterministic simulation to assess potential interference impact as well as to provide required coverage/capacity thresholds for employed transceivers. Wireless system operation within the ICU scenario, considering conventional transceiver operation, is feasible in terms of quality of service for the complete scenario. Extensive measurements of overall interference levels have also been carried out, enabling subsequent adequate coverage/capacity estimations, for a set of Zigbee based nodes. Real system operation has been tested, with ad-hoc designed Zigbee wireless motes, employing lightweight communication protocols to minimize energy and bandwidth usage. An ICU information gathering application and software architecture for Visitor Access Control has been implemented, providing monitoring of the Boxes external doors and the identification of visitors via a RFID system. The results enable a solution to provide ICU access control and tracking capabilities previously not exploited, providing a step forward in the implementation of a Smart Health framework.
Lopez-Iturri, Peio; Aguirre, Erik; Trigo, Jesús Daniel; Astrain, José Javier; Azpilicueta, Leyre; Serrano, Luis; Villadangos, Jesús; Falcone, Francisco
In the context of hospital management and operation, Intensive Care Units (ICU) are one of the most challenging in terms of time responsiveness and criticality, in which adequate resource management and signal processing play a key role in overall system performance. In this work, a context aware Intensive Care Unit is implemented and analyzed to provide scalable signal acquisition capabilities, as well as to provide tracking and access control. Wireless channel analysis is performed by means of hybrid optimized 3D Ray Launching deterministic simulation to assess potential interference impact as well as to provide required coverage/capacity thresholds for employed transceivers. Wireless system operation within the ICU scenario, considering conventional transceiver operation, is feasible in terms of quality of service for the complete scenario. Extensive measurements of overall interference levels have also been carried out, enabling subsequent adequate coverage/capacity estimations, for a set of Zigbee based nodes. Real system operation has been tested, with ad-hoc designed Zigbee wireless motes, employing lightweight communication protocols to minimize energy and bandwidth usage. An ICU information gathering application and software architecture for Visitor Access Control has been implemented, providing monitoring of the Boxes external doors and the identification of visitors via a RFID system. The results enable a solution to provide ICU access control and tracking capabilities previously not exploited, providing a step forward in the implementation of a Smart Health framework.
Full Text Available The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.
Blakeman, Thomas; Rodriquez, Dario; Petro, Michael; Branson, Richard
Devices may forgo US military air worthiness and safety testing in an attempt to expedite the availability of critical assets such as mechanical ventilators with a waiver for one-time use in extenuating circumstances. We evaluated two Intensive Care Unit (ICU) level ventilators: Drager Evita XL and Puritan Bennett (PB) 840 in an altitude chamber at sea level and altitudes of 8,000 and 16,000 feet. Altitude affected delivered tidal volumes (VTs) in volume control mode (VCV) and Pressure Regulated Volume Controlled (PRVC) mode at altitude with the Evita XL but the differences were not considered clinically important with the PB 840. Sixty-seven percent of the V T s were outside the ASTM standard of ± 10% of set V T with the Evita XL at altitude. The PB 840 did not deliver V T s that were larger than the ASTM standard up to an altitude of 16,000 feet while the majority of the delivered V T s with the Därger XL were greater than the ASTM standard. This could present a patient safety issue. Caregivers must be aware of the capabilities and limitations of ICU ventilators when utilized in a hypobaric environment in order to provide safe care. Copyright © 2017 Air Medical Journal Associates. All rights reserved.
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
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.
Full Text Available Abstract Background Modern methods in intensive care medicine often enable the survival of older critically ill patients. The short-term outcomes for patients treated in intensive care units (ICUs, such as survival to hospital discharge, are well documented. However, relatively little is known about subsequent long-term outcomes. Pain, anxiety and agitation are important stress factors for many critically ill patients. There are very few studies concerned with pain, anxiety and agitation and the consequences in older critically ill patients. The overall aim of this study is to identify how an ICU stay influences an older person's experiences later in life. More specific, this study has the following objectives: (1 to explore the relationship between pain, anxiety and agitation during ICU stays and experiences of the same symptoms in later life; and (2 to explore the associations between pain, anxiety and agitation experienced during ICU stays and their effect on subsequent health-related quality of life, use of the health care system (readmissions, doctor visits, rehabilitation, medication use, living situation, and survival after discharge and at 6 and 12 months of follow-up. Methods/Design A prospective, longitudinal study will be used for this study. A total of 150 older critically ill patients in the ICU will participate (ICU group. Pain, anxiety, agitation, morbidity, mortality, use of the health care system, and health-related quality of life will be measured at 3 intervals after a baseline assessment. Baseline measurements will be taken 48 hours after ICU admission and one week thereafter. Follow-up measurements will take place 6 months and 12 months after discharge from the ICU. To be able to interpret trends in scores on outcome variables in the ICU group, a comparison group of 150 participants, matched by age and gender, recruited from the Swiss population, will be interviewed at the same intervals as the ICU group. Discussion Little
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
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.
Piquette, Dominique; Reeves, Scott; Leblanc, Vicki R
Research has suggested that interprofessional collaboration could improve patient outcomes in the intensive care unit (ICU). Maintaining optimal interprofessional interactions in a setting where unpredictable medical crises occur periodically is however challenging. Our study aimed to investigate the perceptions of ICU health care professionals regarding how acute medical crises affect their team interactions. We conducted 25 semi-structured interviews of ICU nurses, staff physicians, and respiratory therapists. All interviews were audio-taped and transcribed, and the analysis was undertaken using an inductive thematic approach. Our data indicated that the nature of interprofessional interactions changed as teams passed through three key temporal periods around medical crises. During the "pre-crisis period", interactions were based on the mutual respect of each other's expertise. During the "crisis period", hierarchical interactions were expected and a certain lack of civility was tolerated. During the "post-crisis period", divergent perceptions emerged amongst health professionals. Post-crisis team dispersion left the nurses with questions and emotions not expressed by other team members. Nurses believed that systematic interprofessional feedback sessions held immediately after a crisis could address some of their needs. Further research is needed to establish the possible benefits of strategies addressing ICU health care professionals' specific needs for interprofessional feedback after a medical crisis.
Jigeeshu V Divatia
Full Text Available Tracheal intubation (TI is a routine procedure in the intensive care unit (ICU, and is often life saving. However, life-threatening complications occur in a significant proportion of procedures, making TI perhaps one the most common but underappreciated airway emergencies in the ICU. In contrast to the controlled conditions in the operating room (OR, the unstable physiologic state of critically ill patients along with underevaluation of the airways and suboptimal response to pre-oxygenation are the major factors for the high incidence of life-threatening complications like severe hypoxaemia and cardiovascular collapse in the ICU. Studies have shown that strategies planned for TI in the OR can be adapted and extrapolated for use in the ICU. Non-invasive positive-pressure ventilation for pre-oxygenation provides adequate oxygen stores during TI for patients with precarious respiratory pathology. The intubation procedure should include not only airway management but also haemodynamic, gas exchange and neurologic care, which are often crucial in critically ill patients. Hence, there is a necessity for the implementation of an Intubation Bundle during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.
ICU admission is uncommon among obstetric patients. Nevertheless, the epidemiology of ICU utilization is considered to be a useful proxy for study of severe maternal morbidity and near-miss events. However, there is paucity of population-level studies in obstetric patients in the United States. The Texas Inpatient Public Use Data File and state-based reports were used to identify pregnancy-associated hospitalizations and those involving admission to ICU (n = 158,410) for the years 2001 - 2010. The clinical characteristics, outcomes, and the overall incidence and temporal trends of ICU admission were examined and stratified analyses of pregnancy outcomes were performed in specific categories of pregnancy-associated hospitalizations. In addition, ICU utilization among hospitalizations with maternal complications and organ dysfunction was evaluated. Chronic comorbidities (9.7%) and presence of organ dysfunction (6.2%) were uncommon among ICU admissions, with 26.5% having high severity of illness. The incidence of ICU admission was 39.0 per 1,000 pregnancy-associated hospitalizations-years. Marked variability was found in ICU admission both across pregnancy outcomes (ranging from 0.6 per 1,000 abortions-years to 85.9 per 1,000 stillbirths-years) and categories of pregnancy-associated hospitalizations (ranging from 32.1 per 1,000 delivery hospitalizations-years to 144.8 per 1,000 postpartum hospitalizations-years). The incidence of ICU admission rose 68% among pregnancy-associated hospitalizations and for all examined subgroups, except abortion. Preeclampsia/eclampsia (23.3%) and obstetric hemorrhage (6.9%) were the most common maternal complications among ICU admissions. Four hundred fourteen women (0.3%) died, while 97.6% were discharged home. This study documents the highest incidence of ICU utilization in obstetric patients in the US to date. The findings suggest low threshold for obstetric ICU admissions in the state and do not support comparative use of ICU
de Hert, Stefan G.; van der Linden, Philippe J.; Cromheecke, Stefanie; Meeus, Roel; ten Broecke, Pieter W.; de Blier, Ivo G.; Stockman, Bernard A.; Rodrigus, Inez E.
BACKGROUND: Volatile anesthetics protect the myocardium during coronary surgery. This study hypothesized that the use of a volatile agent in the anesthetic regimen would be associated with a shorter intensive care unit (ICU) and hospital length of stay (LOS), compared with a total intravenous
Özsaban, Aysel; Acaroglu, Rengin
As delirium in intensive care unit (ICU) patients is a serious problem that can result in increased mortality and morbidity, routine delirium assessment of all ICU patients is recommended. The severity, duration and outcome of the syndrome are directly related to nurses' continuous assessment of patients for signs and symptoms of delirium. However, studies indicate that very few nurses monitor for delirium as a part of their daily practices. The aim of this study was to identify current practices and perceptions of intensive care nurses regarding delirium assessment and to examine the factors that affect these practices and perceptions. A descriptive, correlational study design was used. Data were collected from five Turkish public hospitals using a structured survey questionnaire. The study sample comprised 301 nurses who agreed to participate. Data were analysed using descriptive statistics. More than half of the nurses performed delirium assessments. However, the proportion of nurses who use delirium assessment tools was quite low. Almost all of the nurses perceived delirium as a problem and serious problem for ICU patients. The patient group least monitored for delirium was that of unconscious patients. Statistically significant differences were found in the proportion of nurses who assessed delirium symptoms and whose care delivery system was patient-centred and perceived delirium as a serious problem. While a majority of ICU nurses perceived delirium as a problem and serious problem, the proportion of those who perform routine delirium assessments was less. It was found that delirium assessment practices of nurses were affected from their perceptions of delirium and the implementation of patient-centred care delivery. It is essential to develop strategies to encourage ICU nurses to perform delirium assessments through the use of delirium assessment tools. © 2015 British Association of Critical Care Nurses.
Kastrup, Marc; Seeling, Matthes; Barthel, Stefan; Bloch, Andy; le Claire, Marie; Spies, Claudia; Scheller, Matthias; Braun, Jan
There is an increasing demand for intensive care in hospitals, which can lead to capacity limitations in the intensive care unit (ICU). Due to postponement of elective surgery or delayed admission of emergency patients, outcome may be negatively influenced. To optimize the admission process to intensive care, the post-anaesthesia care unit (PACU) was staffed with intensivist coverage around the clock. The aim of this study is to demonstrate the impact of the PACU on the structure of ICU-patients and the contribution to overall hospital profit in terms of changes in the case mix index for all surgical patients. The administrative data of all surgical patients (n = 51,040) 20 months prior and 20 months after the introduction of a round-the-clock intensivist staffing of the PACU were evaluated and compared. The relative number of patients with longer length of stay (LOS) (more than seven days) in the ICU increased after the introduction of the PACU. The average monthly number of treatment days of patients staying less than 24 hours in the ICU decreased by about 50% (138.95 vs. 68.19 treatment days, P case mix index (CMI) per hospital day for all surgical patients was significantly higher after the introduction of a PACU: 0.286 (± 0.234) vs. 0.309 (± 0.272) P case mix index of the patients per hospital day, increased after the implementation of a PACU and more patients can be treated in the same time, due to a better use of resources.
Trees, Darin W; Smith, James M; Hockert, Steven
Although the benefits of early mobilization in the intensive care unit (ICU) have been well documented in recent years, the decision-making process and customization of treatment strategies for patients with ICU-acquired weakness have not been well defined in the literature. This case report will describe a patient with ICU-acquired weakness in the long-term acute care hospital (LTACH) setting and mobilization strategies that include novel devices for therapeutic exercise and gait training. A 73-year-old, active woman underwent a routine cardioversion for atrial fibrillation but developed multiple complications, including sepsis and respiratory failure. The patient spent 3 weeks of limited activity in the ICU and was transferred to our LTACH for continued medical intervention and rehabilitation. A 4-phase graded mobilization program was initiated in the LTACH ICU. Within that program, the physical therapy interventions included partial weight-bearing antigravity strength training with a mobile leg press and gait training with a hydraulic-assist platform walker. Before interventions, the patient had severe weakness (Medical Research Council [MRC] sum score of 18/60) and displayed complete dependence for all functioning. She progressed to being able to ambulate 150 ft (1 ft=0.3048 m) using a rolling walker with accompanying strength increases to an MRC sum score of 52/60. This case report describes novel mobility strategies for managing a patient with ICU-acquired weakness. The application of a graded mobilization program using a mobile leg press and a hydraulic-assist platform walker was safe and feasible, and appeared to expedite the patient's recovery process while decreasing the amount of manual lifting for the therapists.
Kosmidis, Dimitrios; Koutsouki, Sotiria; Lampiri, Klairi; Nagy, Eva Ottilia; Papaioannou, Vasilios; Pneumatikos, Ioannis; Anastassopoulos, George
Intensive care electronic registries have been instrumental in quality measurement, improvement, and assurance of intensive care. In this article, the development and pilot implementation of the Intensive Care Unit Quality Management Registry are described, with a particular focus on monitoring the quality and operational cost in an adult ICU at a northern Greek state hospital. A relational database was developed for a hospital ICU so that qualitative and financial data are recorded for further analysis needed for planning quality care improvement and enhanced efficiency. Key features of this database registry were low development cost, user friendliness, maximum data security, and interoperability in existing hospital information systems. The database included patient demographics, nursing and medical parameters, and quality and performance indicators as established in many national registries worldwide. Cost recording was based on a mixed approach: at patient level ("bottom-up" method) and at department level ("top-down" method). During the pilot phase of the database operation, regular monitoring of quality and cost data revealed several fields of quality excellence, while indicating room for improvement for others. Parallel recording and trending of multiple parameters showed that the database can be utilized for optimum ICU quality and cost management and also for further research purposes by nurses, physicians, and administrators.
Ganz, Freda DeKeyser; Ofra, Raanan; Khalaila, Rabia; Levy, Hadassa; Arad, Dana; Kolpak, Orly; Ben Nun, Maureen; Drori, Yardena; Benbenishty, Julie
The purpose of this study was to determine whether there was a change in the oral care practices of intensive care unit (ICU) nurses for ventilated patients after a national effort to increase evidence-based oral care practices. Descriptive comparison of ICU nurses in 2004-2005 and 2012. Two convenience national surveys of ICU nurses were collected in 2004-2005 (n = 218) and 2012 (n = 233). After the results of the initial survey were reported, a national effort to increase awareness of evidence-based oral care practices was conducted that included in-service presentations; publication of an evidence-based protocol in a national nursing journal; publication of the survey findings in an international nursing journal; and reports to the local press. A repeat survey was conducted 7 to 8 years later. The same survey instrument was used for both periods of data collection. This questionnaire included questions about demographic and personal characteristics and a checklist of oral care practices. Nurses rated their perceived priority level concerning oral care on a scale from 0 to 100. An evidence-based practice (EBP)[O4] score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the evidence. The EBP score, priority score, and oral care practices were compared between the two samples. A regression model was built based on those variables that were associated with the EBP score in 2012. There was a statistically significant increase in the use of EBPs as shown by the EBP score and in the perceived priority level of oral care. Increased EBPs were found in the areas of teeth brushing and oral assessment. Decreases were found in the use of non-evidence-based practices, such as the use of gauze pads, tongue depressors, lemon water, and sodium bicarbonate. No differences were found in the use of chlorhexidine, toothpaste, or the nursing documentation of oral care practices. A multiple regression model was
Dickie, H; Vedio, A; Dundas, R; Treacher, D F; Leach, R M
To determine whether the therapeutic intervention scoring system (TISS) reliably reflects the cost of the overall intensive care unit (ICU) population, subgroups of that population and individual ICU patients. Prospective analysis of individual patient costs and comparison with TISS. Adult, 12 bedded general medical and surgical ICU in a university teaching hospital. Two hundred fifty-seven consecutive patients including 52 coronary care (CCU), 99 cardiac surgery (CS) and 106 general ICU (GIC) cases admitted to the ICU during a 12-week period in 1994. A total of 916 TISS-scored patient days were analysed A variable cost (VC) that included consumables and service usage (nursing, physiotherapy, radiology and pathology staff costs) for individual patients was measured daily. Nursing costs were calculated in proportion to a daily nursing dependency score. A fixed cost (FC) was calculated for each patient to include medical, technical and clerical salary costs, capital equipment depreciation, equipment and central hospital costs. The correlation between cost and TISS was analysed using regression analysis. For the whole group (n = 257) the average daily FC was pound sterling 255 and daily VC was pound sterling 541 (SEM 10); range pound sterling 23-pound sterling 2,806. In the patient subgroups average daily cost (FC + VC) for CCU was pound sterling 476 (SEM 17.5), for CS pound sterling 766 (SEM 13.8) and for GIC pound sterling 873 (SEM 13.6). In the group as a whole, a strong correlation was demonstrated between VC and the TISS for each patient day (r = 0.87, p < 0.001) and this improved further when the total TISS score was compared with the total VC of the entire patient episode (r = 0.93, p < 0.001). This correlation was maintained in CCU, CS and GIC patient cohorts with only a small median difference between actual and predicted cost (2.2 % for GIC patients). However, in the individual patient, the range of error was up to +/- 65 % of the true variable cost. For the
Vignaud, Marie; Constantin, Jean-Michel; Ruivard, Marc; Villemeyre-Plane, Michele; Futier, Emmanuel; Bazin, Jean-Etienne; Annane, Djillali
Introduction Data on the epidemiology and management of anorexia nervosa (AN) in the intensive care unit (ICU) are scarce. The aim of this study was to evaluate the prevalence and associated morbidity and mortality of AN in French ICUs. Methods We randomly selected 30 ICUs throughout France. Thereafter, we retrospectively analyzed all patients with AN admitted to any of these 30 ICUs between May 2006 and May 2008. We considered demographic data, diagnosis at admission and complications occurr...
Onur Palabıyık; Yaşar Toptaş; Aziz Öğütlü
Objective: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care units (ICUs). It causes prolonged hospital stay and increases mortality. In this study, we aimed to investigate the rate of VAP, causative microorganisms, and their antibiotic susceptibilities in anaesthesiology and reanimation ICU (ARICU). Material and Method: This retrospective study included patients who were admitted to 12-bed ARICU between January 2013 and December 2014. The ...
Granholm, A; Lange, T; Anthon, C T
BACKGROUND: Critically ill patients are at risk of gastrointestinal bleeding, but clinically important gastrointestinal bleeding is rare. The majority of intensive care unit (ICU) patients receive stress ulcer prophylaxis (SUP), despite uncertainty concerning the balance between benefit and harm....... For approximately half of ICU patients with gastrointestinal bleeding, onset is early, ie within the first two days of the ICU stay. The aetiology of gastrointestinal bleeding and consequently the balance between benefit and harm of SUP may differ between patients with early vs late gastrointestinal bleeding...... will describe baseline characteristics and assess the time to onset of the first clinically important episode of GI bleeding accounting for survival status and allocation to SUP or placebo. In addition, we will describe differences in therapeutic and diagnostic procedures used in patients with clinically...
Renal transplantation is the treatment of choice for most patients with end stage renal disease (ESRD). This procedure provides a survival benefit compared to hemodialysis and is also cost effective. The aim of this study is to identify the types and incidence rates of complications that effect renal transplant recipients admitted to the intensive care unit (ICU) during long-term follow-up and to examine the impact of these complications on the length of hospital stay as well as mortality in a tertiary closed ICU in Saudi Arabia. We reviewed the data of all adult renal transplant recipients who were admitted to the ICU at the King Abdulaziz Medical City, Riyadh between May 1999 and October 2006. During the stay period, 80 patients had a total of 96 ICU admissions; 49% were females. The admission APACHE II score and expected mortality was 25+7 and 48+23 respectively. The hospital mortality rate was 42%. Sepsis was major indication for ICU admission and pneumonia was the main cause of sepsis. In multivariate analysis the following variables were introduced in the model: APACHE II score, age, Glasgow Coma Score and need for hemodialysis in the ICU. We found only the need for hemodialysis during the ICU as an independent risk factor for mortality (P<0.02). We found in this study that the main reason for ICU admissions among renal transplant recipients was infections. Mortality rates for this particular population are relatively high and are primarily linked to the need for dialysis. (author)
Carpenter, David L; Gregg, Sara R; Owens, Daniel S; Buchman, Timothy G; Coopersmith, Craig M
Use of nurse practitioners and physician assistants ("affiliates") is increasing significantly in the intensive care unit (ICU). Despite this, few data exist on how affiliates allocate their time in the ICU. The purpose of this study was to understand the allocation of affiliate time into patient-care and non-patient-care activity, further dividing the time devoted to patient care into billable service and equally important but nonbillable care. We conducted a quasi experimental study in seven ICUs in an academic hospital and a hybrid academic/community hospital. After a period of self-reporting, a one-time monetary incentive of $2,500 was offered to 39 affiliates in each ICU in which every affiliate documented greater than 75% of their time devoted to patient care over a 6-month period in an effort to understand how affiliates allocated their time throughout a shift. Documentation included billable time (critical care, evaluation and management, procedures) and a new category ("zero charge time"), which facilitated record keeping of other patient-care activities. At baseline, no ICUs had documentation of 75% patient-care time by all of its affiliates. In the 6 months in which reporting was tied to a group incentive, six of seven ICUs had every affiliate document greater than 75% of their time. Individual time documentation increased from 53% to 84%. Zero-charge time accounted for an average of 21% of each shift. The most common reason was rounding, which accounted for nearly half of all zero-charge time. Sign out, chart review, and teaching were the next most common zero-charge activities. Documentation of time spent on billable activities also increased from 53% of an affiliate's shift to 63%. Time documentation was similar regardless of during which shift an affiliate worked. Approximately two thirds of an affiliate's shift is spent providing billable services to patients. Greater than 20% of each shift is spent providing equally important but not reimbursable
Cuzco Cabellos, C; Guasch Pomés, N
Assess whether the use of the nursing care plans improves outcomes of nursing care to patients admitted to the intensive care unit (ICU). The study was conducted in a University Hospital of Barcelona in Spain, using a pre- and post-study design. A total of 61 patient records were analysed in the pre-intervention group. A care plan was applied to 55 patients in the post-intervention group. Specific quality indicators in a medical intensive care unit to assess the clinical practice of nursing were used. Fisher's exact test was used to compare the degree of association between quality indicators in the two groups. A total of 116 records of 121 patients were evaluated: 61 pre-intervention and 55 post-intervention. Fisher test: The filling of nursing records, p=.0003. Checking cardiorespiratory arrest equipment, p <.001. Central vascular catheter related bacteraemia (B-CVC) p=.622. Ventilator associated pneumonia (VAP) p=.1000. Elevation of the head of the bed more than 30° p=.049, and the pain management in non-sedated patients p=.082. The implementation of nursing care plans in patients admitted to the intensive care area may contribute to improvement in the outcomes of nursing care. Copyright © 2015 Elsevier España, S.L.U. y SEEIUC. All rights reserved.
Nilsen, Marci L; Sereika, Susan M; Hoffman, Leslie A; Barnato, Amber; Donovan, Heidi; Happ, Mary Beth
The study purposes were to (a) describe interaction behaviors and factors that may effect communication and (b) explore associations between interaction behaviors and nursing care quality indicators among 38 mechanically ventilated patients (age ≥60 years) and their intensive care unit nurses (n = 24). Behaviors were measured by rating videorecorded observations from the Study of Patient-Nurse Effectiveness with Communication Strategies (SPEACS). Characteristics and quality indicators were obtained from the SPEACS dataset and medical chart abstraction. All positive behaviors occurred at least once. Significant (p quality. Copyright 2014, SLACK Incorporated.
K. V. Paromov
Full Text Available Aim. Emphasis in the study was placed on the evaluation of predictors of complications when transferring postoperative cardiac patients from the intensive care unit (ICU.Methods. 60 patients after cardiac surgery were included into this prospective observational study, with 41 of them undergoing off-pump coronary artery bypass grafting (CABG. Before the transfer from ICU, echocardiographical criteria of their systolic and diastolic dysfunction, parameters of oxygenation, hemodynamic and metabolism status, as well as postoperative complications and duration of hospitalization were evaluated. Results. Preoperatively, the patients had a moderate degree of heart failure and preserved ejection fraction. Those patients who had undergone valvular and combined procedures using cardiopulmonary bypass had higher Euroscore II values, more severe heart failure, prolonged duration of surgery, respiratory support and hospitalization in ICU and in hospital. The echocardiographical criteria of diastolic dysfunction before transfer from ICU were recorded in 14-77% patients. Despite a normal range of blood pressure, the systolic function of the left ventricle and preload (left atrial pressure, oxygenation and metabolic status, venous to arterial carbon dioxide difference (Pv-aCO2 and left ventricle performance index (Tei exceeded the normal values before transfer from ICU. The correlation analysis revealed a relationship between duration of ICU and hospital stay and the criteria of heart failure severity (left atrial pressure [rho = 0.27, 95% CI 0.02–0.48, p = 0.04] and left ventricle dysfunction (e’ [rho = 0.41, 95% CI 0.17–0.59, p<0.01] before the transfer. The increase in fluid balance during ICU stay after off-pump coronary artery bypass surgery tended to result in a complicated postoperative period (AUC = 0.73, p = 0.02 and a higher risk of atrial fibrillation.Conclusion. The impairment of the left ventricle diastolic function before transferring from
Full Text Available Background. The admission of a relative to an intensive care unit (ICU is a stressful experience for family members. There has been limited research addressing this issue in Kigali, Rwanda.Objective. To explore the needs of patient family members admitted into an ICU in Kigali, Rwanda.Methods. This study used a quantitative exploratory design focused on exploring the needs of patient family members in ICU at one hospital in Kigali, Rwanda. Family members (N=40 were recruited using the convenience sampling strategy. The Critical Care Family Needs Inventory was used to collect relevant data.Results. The participants identified various needs to be met for the family during the patientâ€™s admission in ICU. The most important was the need for assurance, followed by the need for comfort, information, proximity and lastly support. Three additional needs specific to this sample group were also identified, related to resource constraints present in the hospital where the study was carried out.Conclusion. These results offer insight for nurses and other healthcare professionals as to what the important needs are that must be considered for the patient family members in ICUs within a resource-constrained environment.
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.
Kodali, Sashikanth; Stametz, Rebecca; Clarke, Deserae; Bengier, Amanda; Sun, Haiyan; Layon, A J; Darer, Jonathan
Family-centered care provides family members with basic needs, which includes information, reassurance, and support. Though national guidelines exist, clinical adoption often lags behind in this area. The Geisinger Health System developed and implemented a program for reliable delivery of best practices related to family communication to patients and families admitted to the intensive care unit (ICU). Using a quasiexperimental study design and the 24-item Family Satisfaction in the Intensive Care Unit questionnaire (FSICU-24©) to determine family satisfaction, we measured the impact of a "family communication pathway" facilitated by tools built into the electronic health record on the family satisfaction of neurosurgical patients admitted to the ICU. There was no statistically significant difference noted in family satisfaction as determined by FSICU-24 scores, including the Care and Decision Making constructs between the pre- and post-intervention pilot population. The percentage of families reporting the occurrence of a family conference showed only minimal improvement, from 46.5% before to 52.5% following the intervention (p = 0.565). This was mirrored by low numbers of documented family conferences by providers, suggesting poor uptake despite buy-in, use of electronic checklists, and repeated attempts at education. This paper reviews the challenges to and implications for implementing national guidelines in the area of family communication in an ICU coupled with the principles of clinical reengineering.
Wang, Henry E; Yealy, Donald M
As a recommended strategy for optimally managing critical illness, regionalization of care involves matching the needs of the target population with available hospital resources. The national supply and characteristics of hospitals providing specialized critical care services is currently unknown. We seek to characterize the current distribution of specialized care centers in the United States. Using public data linked with the American Hospital Association directory and US Census, we identified US general acute hospitals providing specialized care for ST-segment elevation myocardial infarction (STEMI) (≥40 annual primary percutaneous coronary interventions reported in Medicare Hospital Compare), stroke (The Joint Commission certified stroke centers), trauma (American College of Surgeons or state-designated, adult or pediatric, level I or II), and pediatric critical care (presence of a pediatric ICU) services. We determined the characteristics and state-level distribution and density of specialized care centers (centers per state and centers per state population). Among 4,931 acute care hospitals in the United States, 1,325 (26.9%) provided one of the 4 defined specialized care services, including 574 STEMI, 763 stroke, 508 trauma, and 457 pediatric critical care centers. Approximately half of the 1,325 hospitals provided 2 or more specialized services, and one fifth provided 3 or 4 specialized services. There was variation in the number of each type of specialized care center in each state: STEMI median 7 interquartile range (IQR 2 to 14), stroke 8 (IQR 3 to 17), trauma 6 (IQR 3 to 11), pediatric specialized care 6 (IQR 3 to 11). Similarly, there was variation in the number of each type of specialized care center per population: STEMI median 1 center per 585,135 persons (IQR 418,729 to 696,143), stroke 1 center per 412,188 persons (IQR 321,604 to 572,387), trauma 1 center per 610,589 persons (IQR 406,192 to 917,588), and pediatric critical care 1 center per 665
Full Text Available Background: Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin′s Social Security Hospital (Razi Hospital through Failure Mode and Effect Analysis (FMEA. Methods: This was a qualitative-quantitative research by Focus Discussion Group (FDG performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique. Results: Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN was in respiratory care "Ventilator′s alarm malfunction (no alarm" with the score 288, and the lowest was in gastrointestinal "not washing the NG-Tube" with the score 8. Conclusions: Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care.
J. M. Juarez
Full Text Available Intensive Care Units (ICUs are hospital departments that focus on the evolution of patients. In this scenario, the temporal dimension plays an essential role in understanding the state of the patients from their temporal information. The development of methods for the acquisition, modelling, reasoning and knowledge discovery of temporal information is, therefore, useful to exploit the large amount of temporal data recorded daily in the ICU. During the past decades, some subfields of Artificial Intelligence have been devoted to the study of temporal models and techniques to solve generic problems and towards their practical applications in the medical domain. The main goal of this paper is to present our view of some aspects of practical problems of temporal reasoning in the ICU field, and to describe our practical experience in the field in the last decade. This paper provides a non-exhaustive review of some of the efforts made in the field and our particular contributions in the development of temporal reasoning methods to partially solve some of these problems. The results are a set of software tools that help physicians to better understand the patient's temporal evolution.
Full Text Available JCMSBackground and Objectives: Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. The present study was designed to determine the safety of open bedside tracheostomy (OBT as a routine intensive care units (ICU procedure without any selection criteria, considering its peri and postoperative complications.Materials & Methods: Retrospective medical chart review of all patients that underwent elective tracheostomy between June 2014 and January 2015.Results: The study group comprised 52 patients with a mean age of 40.4±15.1 years. The incidence of intra-procedure complications was 5.7% and post-procedure complications was 3.8%.Conclusions: Open bedside tracheostomy seems to be a safe and simple procedure, even when performed by a trained resident under controlled circumstances, and should be considered as an option for ICU patients.JCMS Nepal. 2015;11(1: 9-11
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
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.
Full Text Available Abstract Background Invasive fungal infection (IFI is associated with high morbidity and high mortality in hematopoietic stem cell transplantation (HSCT patientsThe purpose of this study was to assess the characteristics and outcomes of HSCT patients with IFIs who are undergoing MV at a single institution in Taiwan. Methods We performed an observational retrospective analysis of IFIs in HSCT patients undergoing mechanical ventilation (MV in an intensive care unit (ICU from the year 2000 to 2009. The characteristics of these HSCT patients and risk factors related to IFIs were evaluated. The status of discharge, length of ICU stay, date of death and cause of death were also recorded. Results There were 326 HSCT patients at the Linkou Chang-Gung Memorial Hospital (Taipei, Taiwan during the study period. Sixty of these patients (18% were transferred to the ICU and placed on mechanical ventilators. A total of 20 of these 60 patients (33% had IFIs. Multivariate analysis indicated that independent risk factors for IFI were admission to an ICU more than 40 days after HSCT, graft versus host disease (GVHD, and high dose corticosteroid (p p = 0.676. Conclusion There was a high incidence of IFIs in HSCT patients requiring MV in the ICU in our study cohort. The independent risk factors for IFI are ICU admission more than 40 days after HSCT, GVHD, and use of high-dose corticosteroid.
Wysham, Nicholas G; Mularski, Richard A; Schmidt, David M; Nord, Shirley C; Louis, Deborah L; Shuster, Elizabeth; Curtis, J Randall; Mosen, David M
Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients. We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention. Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities. Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements. Copyright © 2014 Elsevier Inc. All rights reserved.
Cho, Mi-Yeon; Min, Eun Sil; Hur, Myung-Haeng; Lee, Myeong Soo
The purpose of this study was to investigate the effects of aromatherapy on the anxiety, sleep, and blood pressure (BP) of percutaneous coronary intervention (PCI) patients in an intensive care unit (ICU). Fifty-six patients with PCI in ICU were evenly allocated to either the aromatherapy or conventional nursing care. Aromatherapy essential oils were blended with lavender, roman chamomile, and neroli with a 6 : 2 : 0.5 ratio. Participants received 10 times treatment before PCI, and the same essential oils were inhaled another 10 times after PCI. Outcome measures patients' state anxiety, sleeping quality, and BP. An aromatherapy group showed significantly low anxiety (t = 5.99, P aromatherapy effectively reduced the anxiety levels and increased the sleep quality of PCI patients admitted to the ICU. Aromatherapy may be used as an independent nursing intervention for reducing the anxiety levels and improving the sleep quality of PCI patients. PMID:23476690
Full Text Available Introduction. The TISS-28 scale, which may be used for nursing staff scheduling in ICU, does not reflect the complete scope of nursing resulting from varied cultural and organizational conditions of individual systems of health care. Aim. The objective of the study was an attempt to provide an answer to the question what scope of nursing care provided by Polish nurses in ICU does the TISS-28 scale reflect? Material and Methods. The methods of working time measurement were used in the study. For the needs of the study, 252 hours of continuous observation (day-long observation and 3.697 time-schedule measurements were carried out. Results. The total nursing time was 4125.79 min. (68.76 hours, that is, 60.15% of the total working time of Polish nurses during the period analyzed. Based on the median test, the difference was observed on the level of χ2=16945.8, P<0.001 between the nurses’ workload resulting from performance of activities qualified into the TISS-28 scale and load resulting from performance of interventions within the scopes of care not considered in this scale in Polish ICUs. Conclusions. The original version of the TISS-28 scale does not fully reflect the workload among Polish nurses employed in ICUs.
Pintado, María-Consuelo; Trascasa, María; Arenillas, Cristina; de Zárate, Yaiza Ortiz; Pardo, Ana; Blandino Ortiz, Aaron; de Pablo, Raúl
The updated Atlanta Classification of acute pancreatitis (AP) in adults defined three levels of severity according to the presence of local and/or systemic complications and presence and length of organ failure. No study focused on complications and mortality of patients with moderately severe AP admitted to intensive care unit (ICU). The main aim of this study is to describe the complications developed and outcomes of these patients and compare them to those with severe AP. Prospective, observational study. We included patients with acute moderately severe or severe AP admitted in a medical-surgical ICU during 5years. We collected demographic data, admission criteria, pancreatitis etiology, severity of illness, presence of organ failure, local and systemic complications, ICU length of stay, and mortality. Fifty-six patients were included: 12 with moderately severe AP and 44 with severe. All patients developed some kind of complications without differences on complications rate between moderately severe or severe AP. All the patients present non-infectious systemic complications, mainly acute respiratory failure and hemodynamic failure. 82.1% had an infectious complication, mainly non-pancreatic infection (66.7% on moderately severe AP vs. 79.5% on severe, p=0.0443). None of the patients with moderately severe AP died during their intensive care unit stay vs. 29.5% with severe AP (p=0.049). Moderately severe AP has a high rate of complications with similar rates to patients with severe AP admitted to ICU. However, their ICU mortality remains very low, which supports the existence of this new group of pancreatitis according to their severity. Copyright © 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Full Text Available Background: Adequate nutritional support is important for the comprehensive management of patients in intensive care units (ICUs. Aim: The study was aimed to survey prevalent enteral nutrition practices in the trauma intensive care unit, nurses′ perception, and their knowledge of enteral feeding. Study Design: The study was conducted in the ICU of a level 1 trauma center, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India. The study design used an audit. Materials and Methods: Sixty questionnaires were distributed and the results analyzed. A database was prepared and the audit was done. Results: Forty-two (70% questionnaires were filled and returned. A majority (38 of staff nurses expressed awareness of nutrition guidelines. A large number (32 of staff nurses knew about nutrition protocols of the ICU. Almost all (40 opined enteral nutrition to be the preferred route of nutrition unless contraindicated. All staff nurses were of opinion that enteral nutrition is to be started at the earliest (within 24-48 h of the ICU stay. Everyone opined that the absence of bowel sounds is an absolute contraindication to initiate enteral feeding. Passage of flatus was considered mandatory before starting enteral nutrition by 86% of the respondents. Everyone knew that the method of Ryle′s tube feeding in their ICU is intermittent boluses. Only 4 staff nurses were unaware of any method to confirm Ryle′s tube position. The backrest elevation rate was 100%. Gastric residual volumes were always checked, but the amount of the gastric residual volume for the next feed to be withheld varied. The majority said that the unused Ryle′s tube feed is to be discarded after 6 h. The most preferred (48% method to upgrade their knowledge of enteral nutrition was from the ICU protocol manual. Conclusion: Information generated from this study can be helpful in identifying nutrition practices that are lacking and may be used to review and revise enteral feeding
Magno Conceição Merces
Full Text Available Backgound and Objectives: Nursing has an important role in urinary tract infection prevention and control. Urinary catheters insertion represents the local topography with the highest rate of hospital infection. Foley catheter placement is performed solely by the nurse and requires aseptic techniques during its performance, thus preventing risks to the patients. The study aimed to evaluate the training of nurses on Foley catheter insertion and point out limits and possibilities of this practice in patients at the Intensive Care Unit (ICU of Hospital Geral do Interior da Bahia (HGIB. Methods: This was a qualitative, exploratory and descriptive study. Data collection was carried out through semi-structured interviews. After data analysis, two categories were evaluated, namely: the training of nurses on Foley catheter insertion in ICU patients and the limits and possibilities of Foley catheter insertion practice by nurses in ICU patients. Bardin analysis was used for data analysis. Results: The study shows that the nurse’s practice on Foley catheter insertion in ICU patients is based on the use of aseptic techniques for urinary tract infection prevention, theoretical and practical knowledge on Foley catheter insertion in ICU patients, knowledge on urinary tract infections and associations with catheter insertion, whereas the limits and possibilities of Foley catheter insertion practice by nurses are understood through measures to minimize the risk of hospital infection caused by long-term catheter use in the ICU. Nurses point out that the risks of hospital infection are inherent to long-term catheter use. This is an important fact, as the knowledge or its absence may constitute a limit or possibility for Foley catheter insertion practice by the nurse in ICU patients. Conclusion: Nurses must seek the systematization of knowledge, which warrants support for the team, as well as information, safety and prompt care, allowing the reduction of urinary
Lecuyer, Lucien; Chevret, Sylvie; Thiery, Guillaume; Darmon, Michael; Schlemmer, Benoît; Azoulay, Elie
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 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.
Full Text Available Background and Objectives: High prevalence of work-related musculoskeletal disorders, especially in jobs such as nursing which covers tasks like patients' repositioning, has attracted great attentions from occupational healthcare experts to necessitate the knowledge of ergonomic science. Therefore, this study was performed aiming at ergonomic relationship during work in nursing staff of Intensive Care Unit (ICU with operating room. Materials and Methods: In this descriptive-analytical study (cohort, fifty personnel of ICU staff and fifty of operating room staff were selected through a census method and were assessed using tools such as Nordic questionnaire and Rapid Entire Body Assessment (REBA standards in terms of body posture ergonomics. The obtained data were analyzed by SPSS software and Chi-Square test after collection. Results: The most complaints were from the operating room group (68% and ICU staff (60% for the lumbar musculoskeletal system. There was a significant relationship between the total REBA scores of body, legs, neck, arm, force status, load fitting with hands and static or dynamic activities in the operating room and ICU staff groups (P < 0.05. In operating room and ICU groups, most subjects obtained score 11–15 and very high-risk level. Conclusion: Nurses working at operating room and ICU ward are subjected to high-risk levels and occupational injuries which is dramatically resulted from inappropriate body posture or particular conditions of their works. As a result, taking corrective actions along with planning and identifying ways will help prohibiting the prevalence of disorders in the future.
Bui, Lan N; Pham, Vy P; Shirkey, Beverly A; Swan, Joshua T
This study compares the proportions of surgical intensive care unit (ICU) patients with delirium detected using the Confusion Assessment Method for the ICU (CAM-ICU) who received administrative documentation for delirium using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, stratified by delirium motoric subtypes. This retrospective cohort study was conducted at a surgical ICU from 06/2012 to 05/2013. Delirium was assessed twice daily and was defined as having ≥1 positive CAM-ICU rating. Delirious patients were categorized into hyperactive/mixed and hypoactive subtypes using corresponding Richmond Agitation Sedation Scales. Administrative documentation of delirium was defined as having ≥1 of 32 unique ICD-9-CM codes. Proportions were compared using Pearson's Chi-square test. Of included patients, 40 % (423/1055) were diagnosed with delirium, and 17 % (183/1055) had an ICD-9-CM code for delirium. The sensitivity and specificity of ICD-9-CM codes for delirium were 36 and 95 %. ICD-9-CM codes for delirium were available for 42 % (95 % CI 35-48 %; 105/253) of patients with hyperactive/mixed delirium and 27 % (95 % CI 20-34 %; 46/170) of patients with hypoactive delirium (relative risk = 1.5; 95 % CI 1.2-2.0; p = 0.002). ICD-9-CM codes yielded a low sensitivity for identifying patients with CAM-ICU positive delirium and were more likely to identify hyperactive/mixed delirium compared with hypoactive delirium.
Full Text Available Background: 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. Objectives: The aim of the study was to explore and describe the lived experiences of parents of premature babies in an ICU. Method: 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. Results: 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. Recommendations: 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. Conclusion: Parents with premature babies in the ICU have thoughts and emotional experiences which include hope and they affect parents’ relationships.
Steyn, Erika; Poggenpoel, Marie; Myburgh, Chris
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.
Tat, Tiberiu; Li, Huming; Constantinescu, Catalin-Sorin; Onaciu, Anca; Chira, Sergiu; Osan, Ciprian; Pasca, Sergiu; Petrushev, Bobe; Moisoiu, Vlad; Micu, Wilhelm-Thomas; Berce, Cristian; Tranca, Sebastian; Dima, Delia; Berindan-Neagoe, Ioana; Shen, Jianliang; Tomuleasa, Ciprian; Qian, Liren
Chimeric antigen receptor-modified T cells (CAR-T cells) and donor lymphocyte infusion (DLI) are important protocols in lymphocyte engineering. CAR-T cells have emerged as a new modality for cancer immunotherapy due to their potential efficacy against hematological malignancies. These genetically modified receptors contain an antigen-binding moiety, a hinge region, a transmembrane domain, and an intracellular costimulatory domain resulting in lymphocyte T cell activation subsequent to antigen binding. In present-day medicine, four generations of CAR-T cells are described depending on the intracellular signaling domain number of T cell receptors. DLI represents a form of adoptive therapy used after hematopoietic stem cell transplant for its anti-tumor and anti-infectious properties. This article covers the current status of CAR-T cells and DLI research in the intensive care unit (ICU) patient, including the efficacy, toxicity, side effects and treatment. PMID:29662667
Bidabadi, Farimah Shirani; Yazdannik, Ahmadreza; Zargham-Boroujeni, Ali
Maintaining patient's dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units. The aim of this study was to uncover the cultural factors that impeded maintaining patients' dignity in the cardiac surgery intensive care unit. The study was conducted using a critical ethnographic method proposed by Carspecken. Participants and research context: Participants included all physicians, nurses and staffs working in the study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace. Ethical Consideration: Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained. The findings of the study fell into the following main themes: "Presence: the guarantee for giving enough attention to patients' self-esteem", "Instrumental and objectified attitudes", "Adherence to the human equality principle: value-action gap", "Paternalistic conduct", "Improper language", and "Non-interactive communication". The final assertion was "Reductionism as a major barrier to the maintaining of patient's dignity". The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches. Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships.
Zhang, Yaowen; Yao, Zhiyuan; Zhan, Siyan; Yang, Zhirong; Wei, Dong; Zhang, Jing; Li, Jingyi; Kyaw, Moe H
Intensive care unit (ICU)-acquired pneumonia and ventilator-associated pneumonia (VAP) are associated with poor clinical and economic outcomes. Data regarding ICU-acquired pneumonia and VAP are not readily available from developing countries, including China. The objective of this meta-analysis was to evaluate the incidence, mortality rate, length of stay, and pathogens associated with ICU-acquired pneumonia in China. A meta-analysis and systematic review of 334 publications published between January 2007 and May 2012 and retrieved from the Chinese BioMedical database, China National Knowledge Infrastructure, VIP Chinese Science and Technique Journals database, Wanfang database, and PubMed was conducted. The incidences of ICU-acquired pneumonia and VAP were 16.2% (95% confidence interval (CI) 12.8-20.4%) and 33.7% (95% CI 31.4-36.1%), respectively; mortality rates were 37.4% (95% CI 24.6-52.2%) and 34.5% (95% CI 29.2-40.1%), respectively. The durations of stay in the ICU and hospital were 12.4 (95% CI 9.6-15.3) and 17.7 (95% CI 15.6-19.7) days and 18.0 (95% CI 16.5-19.6) and 30.5 (95% CI 26.4-34.7) days for ICU-acquired pneumonia and VAP, respectively. Pseudomonas aeruginosa (19.9%) and Acinetobacter baumannii (13.9%) were the most frequently isolated pathogens, followed by Klebsiella pneumoniae (11.9%) and Staphylococcus aureus (10.4%); 82.9% of S. aureus isolates were reported to be methicillin-resistant. ICU-acquired pneumonia/VAP remains a major cause of morbidity and mortality in patients in the ICU in China. Data on organisms causing disease in this population could help guide appropriate prevention strategies and treatment. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Haifa M. Algethamy
Full Text Available Objectives: To assess urine neutrophil gelatinase-associated lipocalin (uNGAL level as a potential predictor of acute kidney injury (AKI, and both intensive care unit (ICU and in-hospital mortality. Methods: Patients presenting to our ICU with a systolic blood pressure (SBP less than 90 mmHg or mean arterial pressure (MAP less than 65 mmHg, and no prior kidney disease were followed prospectively. Baseline data were collected on patient demographics, admission diagnosis, APACHE II and SOFA scores, SBP, MAP, serum creatinine and cystatin C, and uNGAL. Patients were monitored throughout hospitalization, including daily uNGAL, serum creatinine and cystatin C, and continuous MAP. Bivariate analysis compared those dying in the ICU and in-hospital versus survivors; with hierarchical binary logistic regression used to identify predictors of mortality. Areas under receiver-operating-characteristic curves (AUC were used to measure sensitivity and specificity at different uNGAL thresholds. Results: Among 75 patients followed, 16 died in the ICU, and another 24 prior to hospital discharge. Mortality rates were greatest in trauma and sepsis patients. The ICU survivors differed from non-survivors in almost all clinical variables; but only 2 predicted ICU mortality on multivariate analysis: day one uNGAL (p=0.01 and 24-hour APACHE II score (p=0.07. Only the APACHE II score significantly predicted in-hospital mortality (p=0.003. The AUC for day one uNGAL was greater for ICU (AUC=0.85 than in-hospital mortality (AUC=0.74. Conclusions: Day one uNGAL is a highly accurate predictor of ICU, but less so for in-hospital mortality.
Hafeez, A.; Munir, T.; Najeeb, S.; Rehman, S.; Gilani, M.
Objective: To determine the frequency and antibiogram of pathogens in an intensive care unit (ICU). Study Design: Cross-sectional, observational study. Place and Duration of Study: Department of Microbiology, Army Medical College, National University of Science and Technology, Islamabad, from January 2013 to January 2014. Methodology: Clinical samples, received from patients admitted in ICU, were inoculated on various medias like blood agar, chocolate agar, MacConkey agar and urine samples on CLED. These were then incubated at 37 degree C for 24 hours. Isolates were identified by colony morphology, Gram reaction, catalase test, oxidase test. Species identification in case of Gram Negative Rods was done by using API 20E (BioMerieux). Antibiotic susceptibility was done by using modified KirbyBauer disc diffusion technique. Bacterial isolates were prepared and inoculated on Mueller-Hinton agar plates followed by application of various antibiotic disc (Oxoid, UK) as per manufacturer's instructions. The plates were then incubated at 37 degree C aerobically for 18 - 24 hours. Zone diameters were measured and interpreted as sensitive and resistant, according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: Out of the 367 positive cultures, 116 (31.08 percent) were Acinetobacter baumanniisusceptible to minocycline and tigecycline followed by Klebsiella pneumoniae (n=71, 16 percent) susceptible to tigecycline and meropenem. Others were Pseudomonas aeruginosa, Escherichia coli Coagulase Negative Staphylococcus, Staphylococcus aureus, Enterococcus spp., Streptococcus spp., Klebsiella oxytoca, Stenotrophomonas maltophilia, and Candida spp. Conclusion: Acinetobacter baumannii was the most frequently isolated pathogen. Most of the cultures yielding pathogens were from respiratory tract samples. Gram negative isolates were multidrug resistant but most were tigecycline and susceptible to meropenem. (author)
Varshika M. Bhana
Full Text Available Patients perceive the intensive care unit (ICU as being a stressful and anxiety-provoking environment. The physiological effects of stress and anxiety are found to be harmful and therefore should be avoided in cardiac surgery patients. The aim of the study on which this article is based was to describe cardiac surgery patients’ experiences of music as a therapeutic intervention in the ICU of a public hospital. The objectives of this article were to introduce and then expose the cardiac patients to music as part of their routine postoperative care and to explore and describe their experiences of the music intervention. The findings of the research are to be the basis for making recommendations for the inclusion of music as part of the routine postoperative care received by cardiac surgery patients in the ICU. A qualitative research methodology, using a contextual, explorative and descriptive research design, was adopted. The population of the study was cardiac surgery patients admitted to the ICU of a public hospital. An unstructured interview was conducted with each participant and content analysis and coding procedures were used to analyse the data. Four main themes were identified in the results, namely practical and operational aspects of the music sessions; participants’ experiences; discomfort due to therapeutic apparatus and the ICU environment; and the role of music and recommendations for music as a therapeutic intervention. Participants’ experiences were mainly positive. Results focused on experiences of the music and also on the participants’ experiences of the operational aspects of the therapy, as well as factors within and around the participants.
Pickworth, Thomas; Jerath, Angela; DeVine, Rita; Kherani, Nazmin; Wąsowicz, Marcin
The use of volatile-based sedation within critical care environments has been limited by difficulties of drug administration and safety concerns over environment pollution and staff exposure in an intensive care unit (ICU) with no scavenging. The aim of this study was to develop a simple scavenging system to be used with the Anesthesia Conserving Device (AnaConDa(®)) and to determine whether or not ambient concentrations of residual anesthetic are within current acceptable limits. The scavenging system consists of two Deltasorb(®) canisters attached to the ICU ventilator in series. AnaConDa is a miniature vaporizer designed to provide volatile-based sedation within an ICU. The first ten patients recruited into a larger randomized trial assessing outcomes after elective coronary graft bypass surgery were sedated within the cardiac ICU using either isoflurane or sevoflurane. Sedation was guided by the Sedation Agitation Scale, resulting in an end-tidal minimum anesthetic concentration of volatile agent ranging from 0.1-0.3. At one hour post ICU admission, infrared photometric analysis was used to assess environmental contamination at four points along the ventilator circuit and scavenging system and around the patient's head. All measurements taken within the patient's room were below 1 part per million, which satisfies criteria for occupational exposure. This study shows that volatile agents can be administered safely within critical care settings using a simple scavenging system. Our scavenging system used in conjunction with the AnaConDa device reduced the concentration of environmental contamination to a level that is acceptable to Canadian standards and standards in most Western countries and thus conforms to international safety standards. The related clinical trial was registered at www.clinicaltrials.gov (NCT01151254).
I reflected on the training I had on an extraordinary treatment for profound respiratory failure. The result of training enabled us to successfully treat a young female with the influenza A virus with extracorporeal membrane oxygenation (ECMO). I report the positive outcome that occurred, while continuing to run a busy general intensive care unit (ICU). She was the first of six patients who were all successfully treated with ECMO. Ten trained and experienced critical care nurses and two doctors attended the ECMO training course provided by the national centre in the UK. Five patients had already received ECMO therapy in the Scottish specialist unit (over the period of 8 years). As our Scottish specialist unit purchased exactly the same equipment as the national centre, it was easier for the multidisciplinary team to utilize their new-found knowledge and treat future patients with ECMO. With the predicted swine flu (H1N1) pandemic and the subsequent demand for critical care beds, funding was obtained to facilitate ECMO training. The potential need for increased provision of ECMO therapies was highlighted by recent events in Australia and New Zealand. Their most recent winter produced 68 patients requiring ECMO, whereas the previous year had manifested only three. Using our new equipment and adapted protocols from the national centre, we used these new skills to treat our first patient in October 2009. Johns' reflective practice tool was used to evaluate the care provided. Our patient was on ECMO for 9 days. She went on to make a remarkable recovery and was discharged from the ICU 1 week after ECMO was discontinued. She was discharged to the cardiothoracic high-dependency unit, where she was successfully rehabilitated. We were able to successfully treat a young lady, while providing the care for all other patients. This was a complex treatment, one that uses many resources including time and finance. Now that we have all the equipment, the necessary training and the
Sorensen, Roslyn; Iedema, Rick
The aim of this study was to understand the environment of health care, and how clinicians and managers respond in terms of performance accountability. A qualitative method was used in a tertiary metropolitan teaching intensive care unit (ICU) in Sydney, Australia, including interviews with 15 clinical managers and focus groups with 29 nurses of differing experience. The study found that a managerial focus on abstract goals, such as budgets detracted from managing the core business of clinical work. Fractures were evident within clinical units, between clinical units and between clinical and managerial domains. These fractures reinforced the status quo where seemingly unconnected patient care activities were undertaken by loosely connected individual clinicians with personalized concepts of accountability. Managers must conceptualize health services as an interconnected entity within which self-directed teams negotiate and agree objectives, collect and review performance data and define collective practice. Organically developing regimens of care within and across specialist clinical units, such as in ICUs, directly impact upon health service performance and accountability.
Taciana Guterres de Carvalho
Full Text Available Backgound and Objectives: The incidence of complications arising from the deleterious effects of immobility in the intensive care unit contributes to functional decline, increased length of hospital stay and reduced functionality. Physical therapy is able to promote recovery and preservation of functionality, which can minimize these complications - through early mobilization. To evaluate the functionality and independence of patients who underwent a early bed output in the Intensive Care Unit. Methods: A randomized controlled clinical trial was conducted with patients admitted to the Intensive Care Unit (ICU of the Santa Cruz Hospital and having a physiotherapy prescription. The patients were divided into conventional therapy group- control group and intervention group, who performed the protocol of early mobilization, promoting the bed output. The functionality was measured three times (retroactive to hospitalization, at discharge from the ICU and on hospital discharge through the instrument Functional Independence Measure (FIM. Results: Preliminary data indicates that the intervention group (n = 4 presented lower loss of functionality after discharge from the ICU, with a deficit of 19%, having recovered until the hospital discharge 97% of the prehospitalization measure. The control group (n = 5 showed higher loss in the ICU of 47.6%, and was discharged from hospital with only 72% of their basal rate. Conclusion: There was a lower loss rate and better recovery of functionality in the studied population when those were submitted to a systematized and early protocol of mobilization as well as shorter hospital stay.
Nunn, Andrew M; Hatchimonji, Justin S; Holena, Daniel N; Seamon, Mark J; Smith, Brian P; Kaplan, Lewis J; Martin, Niels D; Reilly, Patrick M; Schwab, C William; Pascual, Jose L
Surgical Intensive Care Unit (SICU) patients "boarding" in ICUs other than the designated home unit have been shown to suffer increased rates of complications. We hypothesized that ICU rounding practices are different when SICU patients are housed in home vs. boarding ICUs. SICU rounds were observed at an academic quaternary medical center. Individual patient rounding time and order seen on rounds along with patient data and demographics were recorded. Multivariable regression analysis was used for comparison between patients. Non-boarders were older, observed on a later post ICU admission day and were more likely to be mechanically ventilated. Boarded patients were often seen at the end of rounds and for less time. Not being a boarder, age, APACHE II score on admission, vasopressor use, and positive pressure ventilation all predicted increased rounding time. Surgical ICU patients boarding in non-preferred units are often seen at the end of rounds, result in a greater reliance upon telephone communication, and receive less bedside attention from ICU provider teams. Copyright © 2017 Elsevier Inc. All rights reserved.
Mª Cristina Pascual Fernández
Full Text Available When the patients are in the end-of-life, the cares would focus to favor a good death, for that reason the nursing staff must know how to integrate the death like a part of the life, being avoided that produces anxiety to them before the possibility of taking part its own fears to the death. The core of nursing staff in intensive care units is to maintain life of their patients, reason why the end-of life in them is not easy or natural.Objective: Evaluate the death anxiety levels in intensive care nursing staff.Material and method: An observational study was conducted descriptive cross hospital adult and Paediatric ICU General University Gregorio Marañón Hospital, through survey to nurses and auxiliary nurses of those units.The anxiety inventory was used to Death (Death Anxiety Inventory [DAI] for the assessment of anxiety before death. Outcomes: Paediatric ICU nurses have higher levels of anxiety that the adult ICU as well as the less experienced professionals and those declared not feel trained in the subject.Conclusions: Experience and the training are key elements that help professionals face to death, from management we must ensure that patients in stage terminal are served by professionals with this profile.
Moughrabieh, Anas; Weinert, Craig
The conflict in Syria has created the largest humanitarian emergency of the twenty-first century. The 4-year Syrian conflict has destroyed hospitals and severely reduced the capacity of intensive care units (ICUs) and on-site intensivists. The crisis has triggered attempts from abroad to support the medical care of severely injured and acutely ill civilians inside Syria, including application of telemedicine. Within the United States, tele-ICU programs have been operating for more than a decade, albeit with high start-up costs and generally long development times. With the benefit of lessons drawn from those domestic models, the Syria Tele-ICU program was launched in December 2012 to manage the care of ICU patients in parts of Syria by using inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. At the end of 2015, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The volunteer clinicians manage patients at a distance of more than 6,000 miles, separated by seven or eight time zones between North America and Syria. The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.
The conflict in Syria has created the largest humanitarian emergency of the twenty-first century. The 4-year Syrian conflict has destroyed hospitals and severely reduced the capacity of intensive care units (ICUs) and on-site intensivists. The crisis has triggered attempts from abroad to support the medical care of severely injured and acutely ill civilians inside Syria, including application of telemedicine. Within the United States, tele-ICU programs have been operating for more than a decade, albeit with high start-up costs and generally long development times. With the benefit of lessons drawn from those domestic models, the Syria Tele-ICU program was launched in December 2012 to manage the care of ICU patients in parts of Syria by using inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. At the end of 2015, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The volunteer clinicians manage patients at a distance of more than 6,000 miles, separated by seven or eight time zones between North America and Syria. The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country. PMID:26788827
Sackey, Peter V; Martling, Claes-Roland; Carlswärd, Christine; Sundin, Orjan; Radell, Peter J
To compare memories from the intensive care unit (ICU) and short- and long-term psychological morbidity in patients after sedation with intravenous midazolam or inhaled isoflurane. Prospective long-term follow-up after randomized controlled trial. General ICU at Karolinska University Hospital, Solna, Stockholm. Forty patients in need of sedation during ventilator treatment. Patients were randomized to receive isoflurane or midazolam for goal-directed sedation until extubation or for a maximum of 96 hrs. For short-term follow-up, doctors', nurses', and physiotherapists' notes from the 4 days following exposure to the study drugs were reviewed for words indicating adequate or pathologic cognitive and psychological recovery. For long-term follow-up, all 6-month survivors received questionnaires including the ICU Memory Tool (ICU-MT), Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), and Well-Being Index. Additionally, several screening questions for previous posttraumatic stress symptoms were included. In the short term follow-up, no significant differences were found between groups. In the long-term follow-up, a trend toward fewer hallucinations/delusions after isoflurane sedation than after midazolam (two of ten isoflurane patients vs. five of seven midazolam patients) was found (p = .06). None of the five solely isoflurane-sedated patients reported hallucinations/delusions from the ICU. There was no difference in groups in long-term psychological morbidity as measured with HADS and IES. Memories of negative feelings in the ICU (ICU-MT) were associated with high HADS and IES scores (Fisher's exact test, p = .02 and p = .01, respectively). Sedation of ICU patients with isoflurane may result in fewer delusional memories or hallucinations from the ICU compared with more commonly used intravenous sedation. Memories of negative feelings from the ICU were associated with symptoms of depression or anxiety or symptoms indicating posttraumatic stress
Full Text Available Abstract Background Healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA infection in intensive care unit (ICU patients prolongs ICU stay and causes high mortality. Predicting HA-MRSA infection on admission can strengthen precautions against MRSA transmission. This study aimed to clarify the risk factors for HA-MRSA infection in an ICU from data obtained within 24 hours of patient ICU admission. Methods We prospectively studied HA-MRSA infection in 474 consecutive patients admitted for more than 2 days to our medical, surgical, and trauma ICU in a tertiary referral hospital in Japan. Data obtained from patients within 24 hours of ICU admission on 11 prognostic variables possibly related to outcome were evaluated to predict infection risk in the early phase of ICU stay. Stepwise multivariate logistic regression analysis was used to identify independent risk factors for HA-MRSA infection. Results Thirty patients (6.3% had MRSA infection, and 444 patients (93.7% were infection-free. Intubation, existence of open wound, treatment with antibiotics, and steroid administration, all occurring within 24 hours of ICU admission, were detected as independent prognostic indicators. Patients with intubation or open wound comprised 96.7% of MRSA-infected patients but only 57.4% of all patients admitted. Conclusions Four prognostic variables were found to be risk factors for HA-MRSA infection in ICU: intubation, open wound, treatment with antibiotics, and steroid administration, all occurring within 24 hours of ICU admission. Preemptive infection control in patients with these risk factors might effectively decrease HA-MRSA infection.
Gungor, Sinem; Kargin, Feyza; Irmak, Ilim; Ciyiltepe, Fulya; Acartürk Tunçay, Eylem; Atagun Guney, Pinar; Aksoy, Emine; Ocakli, Birsen; Adiguzel, Nalan; Karakurt, Zuhal
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
Full Text Available Roxanne Sterniczuk,1–3 Benjamin Rusak,1,2 Kenneth Rockwood31Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, 2Department of Psychiatry, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, 3Division of Geriatric Medicine, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, CanadaAbstract: Maintaining a stable and adequate sleeping pattern is associated with good health and disease prevention. As a restorative process, sleep is important for supporting immune function and aiding the body in healing and recovery. Aging is associated with characteristic changes to sleep quantity and quality, which make it more difficult to adjust sleep–wake rhythms to changing environmental conditions. Sleep disturbance and abnormal sleep–wake cycles are commonly reported in seriously ill older patients in the intensive care unit (ICU. A combination of intrinsic and extrinsic factors appears to contribute to these disruptions. Little is known regarding the effect that sleep disturbance has on health status in the oldest of old (80+, a group, who with diminishing physiological reserve and increasing prevalence of frailty, is at a greater risk of adverse health outcomes, such as cognitive decline and mortality. Here we review how sleep is altered in the ICU, with particular attention to older patients, especially those aged ≥80 years. Further work is required to understand what impact sleep disturbance has on frailty levels and poor outcomes in older critically ill patients.Keywords: intensive care unit, sleep–wake rhythm, aging, frailty
Jensen, Hanne Irene; Ammentorp, Jette; Ørding, Helle
INTRODUCTION. Decisions regarding withholding or withdrawing therapy are common in the intensive care units. The health care professionals involved in the decision-making process do not always assess the situation identically, leading to potential conflicts. Studies have suggested that improving...... (conducted at two hospitals) with participation of primary care physicians, anaesthesiologists (both with and without ICU as their main workplace) and intensive care nurses. A total of 29 participated in the audits. The participants received beforehand three complicated cases (borrowed from other hospitals...... unit conflicts: the conflicus study. Am J Respir Crit Care Med180:853-860. (2) Halvorsen K, Forde R, Nortvedt P (2009) Value choices and considerations when limiting intensive care treatment: a qualitative study. Acta Anaesthesiol Scand 53:10-17 GRANT ACKNOWLEDGMENT. The study was supported...
Miller, David C; McSparron, Jakob I; Clardy, Peter F; Sullivan, Amy M; Hayes, Margaret M
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.
Marc A Seifman
Full Text Available Melatonin is an endogenous hormone mainly produced by the pineal gland whose dysfunction leads to abnormal sleeping patterns. Changes in melatonin have been reported in acute traumatic brain injury (TBI, however the impact of environmental conditions typical of the intensive care unit (ICU has not been assessed. The aim of this study was to compare daily melatonin production in three patient populations treated at the ICU to differentiate the role of TBI versus ICU conditions. Forty-five patients were recruited and divided into severe TBI, trauma without TBI, medical conditions without trauma and compared to healthy volunteers. Serum melatonin levels were measured at four daily intervals at 0400h, 1000h, 1600h and 2200h for 7 days post-ICU admission by commercial ELISA. The geometric mean concentrations (95% confidence intervals of melatonin in these groups showed no difference being 8.3 (6.3-11.0, 9.3 (7.0-12.3 and 8.9 (6.6-11.9 pg/mL, respectively in TBI, trauma and intensive care cohorts. All of these patient groups demonstrated decreased melatonin concentrations when compared to control patients.This study suggests that TBI as well as ICU conditions, may have a role in the dysfunction of melatonin. Monitoring and possibly substituting melatonin acutely in these settings may assist in ameliorating longterm sleep dysfunction in all of these groups, and possibly contribute to reducing secondary brain injury in severe TBI.
Full Text Available Neutrophil gelatinase-associated lipocalin (NGAL is a protein of lipocalin family highly expressed in various pathologic states and is an early biomarker of acute kidney injury in cardiac surgery. We performed an observational study to evaluate the role of NGAL in predicting postoperative intensive care stay in high-risk patients undergoing cardiac surgery. We enrolled 27 consecutive patients who underwent high-risk cardiac surgery with cardiopulmonary bypass. Urinary NGAL (uNGAL was measured before surgery, at intensive care unit (ICU arrival and 24 h later. Univariate and multivariate predictors of ICU stay were performed. uNGAL was 18.0 (8.7-28.1 ng/mL at baseline, 10.7 (4.35-36.0 ng/mL at ICU arrival and 29.6 (9.65-29.5 24 h later. The predictors of prolonged ICU stay at the multivariate analysis were body mass index (BMI, uNGAL 24 h after surgery, and aortic cross-clamp time. The predictors of high uNGAL levels 24 h after at a multivariate analysis were preoperative uNGAL and logistic European System for Cardiac Operative Risk Evaluation. At a multivariate analysis the only independent predictors of prolonged ICU stay were BMI, uNGAL 24 h after surgery and aortic cross-clamp time.
DeJournett, Leon; DeJournett, Jeremy
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. 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. 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 (artificial pancreas system for use in the ICU setting. © 2016 Diabetes Technology Society.
Yun Chen; Hui Yang
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.
Silveira, L M; Basile-Filho, A; Nicolini, E A; Dessotte, C A M; Aguiar, G C S; Stabile, A M
Sepsis is associated with morbidity and mortality, which implies high costs to the global health system. Metabolic alterations that increase glycaemia and glycaemic variability occur during sepsis. To verify mean body glucose levels and glycaemic variability in Intensive Care Unit (ICU) patients with severe sepsis or septic shock. Retrospective and exploratory study that involved collection of patients' sociodemographic and clinical data and calculation of severity scores. Glycaemia measurements helped to determine glycaemic variability through standard deviation and mean amplitude of glycaemic excursions. Analysis of 116 medical charts and 6730 glycaemia measurements revealed that the majority of patients were male and aged over 60 years. Surgical treatment was the main reason for ICU admission. High blood pressure and diabetes mellitus were the most usual comorbidities. Patients that died during the ICU stay presented the highest SOFA scores and mean glycaemia; they also experienced more hypoglycaemia events. Patients with diabetes had higher mean glycaemia, evaluated through standard deviation and mean amplitude of glycaemia excursions. Organic impairment at ICU admission may underlie glycaemic variability and lead to a less favourable outcome. High glycaemic variability in patients with diabetes indicates that monitoring of these individuals is crucial to ensure better outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.
MacLaren, Robert; Brett McQueen, R; Campbell, Jon
To compare pharmacist and prescriber perceptions of the clinical and financial outcomes of pharmacy services in the intensive care unit (ICU). ICU pharmacists were invited to participate in the survey and were asked to invite two ICU prescriber colleagues to complete questionnaires. ICUs with clinical pharmacy services. The questionnaires were designed to solicit frequency, efficiency, and perceptions about the clinical and financial impact (on a 10-point scale) of pharmacy services including patient care (eight functions), education (three functions), administration (three functions), and scholarship (four functions). Basic services were defined as fundamental, and higher-level services were categorized as desirable or optimal. Respondents were asked to suggest possible sources of funding and reimbursement for ICU pharmacy services. Eighty packets containing one 26-item pharmacy questionnaire and two 16-item prescriber questionnaires were distributed to ICU pharmacists. Forty-one pharmacists (51%) and 46 prescribers (29%) returned questionnaires. Pharmacists had worked in the ICU for 8.3 ± 6.4 years and devoted 50.3 ± 18.7% of their efforts to clinical practice. Prescribers generally rated the impact of pharmacy services more favorably than pharmacists. Fundamental services were provided more frequently and were rated more positively than desirable or optimal services across both groups. The percent efficiencies of providing services without the pharmacist ranged between 40% and 65%. Both groups indicated that salary support for the pharmacist should come from hospital departments of pharmacy or critical care or colleges of pharmacy. Prescribers were more likely to consider other sources of funding for pharmacist salaries. Both groups supported reimbursement of clinical pharmacy services. Critical care pharmacy activities were associated with perceptions of beneficial clinical and financial outcomes. Prescribers valued most services more than pharmacists
Full Text Available Abstract Background When patients are admitted to an intensive care unit (ICU their risk of getting an infection will be highly depend on the length of stay at-risk in the ICU. In addition, risk of infection is likely to vary over calendar time as a result of fluctuations in the prevalence of the pathogen on the ward. Hence risk of infection is expected to depend on two time scales (time in ICU and calendar time as well as competing events (discharge or death and their spatial location. The purpose of this paper is to develop and apply appropriate statistical models for the risk of ICU-acquired infection accounting for multiple time scales, competing risks and the spatial clustering of the data. Methods A multi-center data base from a Spanish surveillance network was used to study the occurrence of an infection due to Methicillin-resistant Staphylococcus aureus (MRSA. The analysis included 84,843 patient admissions between January 2006 and December 2011 from 81 ICUs. Stratified Cox models were used to study multiple time scales while accounting for spatial clustering of the data (patients within ICUs and for death or discharge as competing events for MRSA infection. Results Both time scales, time in ICU and calendar time, are highly associated with the MRSA hazard rate and cumulative risk. When using only one basic time scale, the interpretation and magnitude of several patient-individual risk factors differed. Risk factors concerning the severity of illness were more pronounced when using only calendar time. These differences disappeared when using both time scales simultaneously. Conclusions The time-dependent dynamics of infections is complex and should be studied with models allowing for multiple time scales. For patient individual risk-factors we recommend stratified Cox regression models for competing events with ICU time as the basic time scale and calendar time as a covariate. The inclusion of calendar time and stratification by ICU
Full Text Available Abstract Background The Intensive Care Unit (ICU is a data-rich environment where information technology (IT may enhance patient care. We surveyed ICUs in the province of Ontario, Canada, to determine the availability, implementation and variability of information systems. Methods A self-administered internet-based survey was completed by ICU directors between May and October 2006. We measured the spectrum of ICU clinical data accessible electronically, the availability of decision support tools, the availability of electronic imaging systems for radiology, the use of electronic order entry and medication administration systems, and the availability of hardware and wireless or mobile systems. We used Fisher's Exact tests to compare IT availability and Classification and Regression Trees (CART to estimate the optimal cut-point for the number of computers per ICU bed. Results We obtained responses from 50 hospitals (68.5% of institutions with level 3 ICUs, of which 21 (42% were university-affiliated. The majority electronically accessed laboratory data and imaging reports (92% and used picture archiving and communication systems (PACS (76%. Other computing functions were less prevalent (medication administration records 46%, physician or nursing notes 26%; medication order entry 22%. No association was noted between IT availability and ICU size or university affiliation. Sites used clinical information systems from15 different vendors and 8 different PACS systems were in use. Half of the respondents described the number of computers available as insufficient. Wireless networks and mobile computing systems were used in 23 ICUs (46%. Conclusion Ontario ICUs demontrate a high prevalence of the use of basic information technology systems. However, implementation of the more complex and potentially more beneficial applications is low. The wide variation in vendors utilized may impair information exchange, interoperability and uniform data collection.
Docherty, Annemarie; Lone, Nazir; Anderson, Niall; Walsh, Timothy
As the general population ages and life expectancy increases, health-care use by elderly people increases, including intensive care. Rationing and variation of access are ethically and politically challenging. We aimed to characterise the population-based incidence of intensive care unit (ICU) admissions of elderly people in Scotland; compare ICU admission and mortality between elderly and younger populations; and compare treatment intensity between these groups. We extracted complete, national 6-year cohort Scottish ICU admissions (Jan 1, 2005, to Dec 31, 2010) from the Scottish Intensive Care Society Audit Group database, which we linked to hospital Scottish Morbidity Record (SMR01) and death records. Annual incidence of ICU admissions of people aged 80 years or older was standardised for sex and socioeconomic status to the standard Scottish population (≥80 years) 2005-10. We compared mortality of elderly and younger people (Scottish Intensive Care Society, Scottish Society of Anaesthetists, Edinburgh Anaesthetics Research and Education Fund. Copyright © 2015 Elsevier Ltd. All rights reserved.
Ganz, Freda DeKeyser; Endacott, Ruth; Chaboyer, Wendy; Benbinishty, Julie; Ben Nun, Maureen; Ryan, Helen; Schoter, Amanda; Boulanger, Carole; Chamberlain, Wendy; Spooner, Amy
Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. This was a descriptive comparative study. The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). A convenience sample of 157 handovers was studied. Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool. Copyright © 2014. Published by Elsevier Ltd.
Hamze, Fernanda Luiza; de Souza, Cristiane Chaves; Chianca, Tânia Couto Machado
to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit. descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software. 529 care interventions were identified, grouped into 28 different types, of which 12 (42.8%) caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients. it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.
Fernanda Luiza Hamze
Full Text Available Objective: to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit.Method: descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software.Results: 529 care interventions were identified, grouped into 28 different types, of which 12 (42.8% caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients.Conclusion: it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.
Roberta Juliane Tono de Oliveira
Full Text Available Objective.Understand the conditions involved in the management of nursing care in emergency care units. Methodology. Qualitative research using the methodological framework of the Grounded Theory. Data collection occurred from September 2011 to June 2012 through semi-structured interviews with 20 participants of the two emergency care units in the city of Florianopolis, Brazil. Results. Hindering factors to care management are: lack of experience and knowledge of professionals in emergency services; inadequate number of professionals; work overload of emergency care units in the urgent care network; difficulty in implementing nursing care systematization, and need for team meetings. Facilitating factors are: teamwork; importance of professionals; and confidence of the nursing technicians in the presence of the nurse. Conclusion. Whereas the hindering factors in care management are related to the organizational aspects of the emergency care units in the urgency care network, the facilitating ones include specific aspects of teamwork.
Tono de Oliveira, Roberta Juliane; Vieira Hermida, Patrícia Madalena; da Silva Copelli, Fernanda Hannah; Guedes Dos Santos, José Luís; Lorenzini Erdmann, Alacoque; Regina de Andrade, Selma
Understand the conditions involved in the management of nursing care in emergency care units. Qualitative research using the methodological framework of the Grounded Theory. Data collection occurred from September 2011 to June 2012 through semi-structured interviews with 20 participants of the two emergency care units in the city of Florianopolis, Brazil. Hindering factors to care management are: lack of experience and knowledge of professionals in emergency services; inadequate number of professionals; work overload of emergency care units in the urgent care network; difficulty in implementing nursing care systematization, and need for team meetings. Facilitating factors are: teamwork; importance of professionals; and confidence of the nursing technicians in the presence of the nurse. Whereas the hindering factors in care management are related to the organizational aspects of the emergency care units in the urgency care network, the facilitating ones include specific aspects of teamwork.
Epstein, David; Unger, Jennifer B; Ornelas, Beatriz; Chang, Jennifer C; Markovitz, Barry P; Dodek, Peter M; Heyland, Daren K; Gold, Jeffrey I
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.
Hyllienmark, Petra; Gårdlund, Bengt; Persson, Jan-Olov; Ekdahl, Karl
Ventilator-associated pneumonia (VAP) is the most common intensive care unit (ICU)-acquired infection among patients requiring mechanical ventilation. A prospective surveillance programme of all patients has been implemented at the ICU, Karolinska University Hospital, Sweden since 2001. Within this programme, incidence and risk factors for ICU-acquired pneumonia and associated death over a 2-y period have been studied. Of 329 patients enrolled in the study, 221 required mechanical ventilation. 33 of 221 patients (15%) developed VAP, corresponding to a rate of 29 VAP/1000 ventilator d. Risk factors for VAP were aspiration (hazard ratio 3.79; 95% CI 1.48-9.68), recent surgery (HR 3.58; 95% CI 1.15-11.10) and trauma (HR 3.00; 95% CI 1.03-8.71). 11 patients of 33 (33%) with VAP died within 28 d compared to 46 of 288 (16%) without ICU-acquired pneumonia (odds ratio 2.73; 95% CI 0.97-7.63). We conclude that: 1) incidence of VAP was 15% and the most important risk factor was aspiration; 2) APACHE II score > or = 20 is a stronger predictor for poor outcome than VAP; 3) a minority of patients with APACHE II score > or = 20 develop VAP; and 4) continuous surveillance programmes are feasible and provide valuable data for improvement of quality of care.
Steurbaut, Kristof; Van Hoecke, Sofie; Colpaert, Kirsten; Lamont, Kristof; Taveirne, Kristof; Depuydt, Pieter; Benoit, Dominique; Decruyenaere, Johan; De Turck, Filip
The increasing complexity of procedures in the intensive care unit (ICU) requires complex software services, to reduce improper use of antibiotics and inappropriate therapies, and to offer earlier and more accurate detection of infections and antibiotic resistance. We investigated whether web-based software can facilitate the computerization of complex medical processes in the ICU. The COSARA application contains the following modules: Infection overview, Thorax, Microbiology, Antibiotic therapy overview, Admission cause with comorbidity and admission diagnosis, Infection linking and registration, and Feedback. After the implementation and test phase, the COSARA software was installed on a physician's office PC and then on the bedside PCs of the patients. Initial evaluation indicated that the services had been integrated easily into the daily clinical workflow of the medical staff. The use of a service oriented architecture with web service technology for the development of advanced decision support in the ICU offers several advantages over classical software design approaches.
Weissman, C; Mossel, P; Haimet, S; King, T C
A prototype computer-based patient data management system (PDMS) was developed for a surgery-anesthesiology intensive care unit (ICU) to reduce the time and staff needed to implement quality assurance (QA) functions. Goals of the system were to make QA functions routine and minimally intrusive to the daily operation of the ICU. PDMS collects general data (eg, admissions and discharges, lengths of stay, and bed utilization rates) and specialized data (eg, specific indicators) unique to the ICU and performs prospective monitoring for the occurrence of specific events (occurrence screening) and retrospective examinations of patient records (targeted reviews). Preliminary results suggest that PDMS facilitates the acquisition and analysis of QA data and reduces the time needed to acquire these data. Research to validate these claims and efforts to improve and expand the prototype system with a permanent production system are in progress.
Henningsen, Louise; Haase, Nicolai; Pedersen, Ulf Gøttrup
the proportion of intensive care unit (ICU) patients with shock who at the time of resuscitation fulfilled the prerequisites for using the arterial waveform-derived variables. METHODS: This was a prospective cohort study performed at six ICUs. The study included consecutive adult patients with shock (20 patients...... per ICU) who received fluid resuscitation on the first day of shock. The fulfilment or not of the prerequisites (sedation, sinus rhythm and controlled ventilation with tidal volumes > 7 ml/kg) was registered at the time of the first fluid resuscitation episode and at fluid resuscitation episodes......% CI: 46-65) were on controlled ventilation and 50% (95% CI: 39-61) received tidal volumes of more than 7 ml/kg. Only 23% (95% CI: 14-33) of the patients fulfilled all four prerequisites. CONCLUSIONS: Less than a quarter of the ICU patients with shock fulfilled all the prerequisites for the use...
Shen, Hui-Shan; Chen, Szu-Yin; Cheung, Denise Shuk Ting; Wang, Shu-Yi; Lee, Jung Jae; Lin, Chia-Chin
No study has examined the varying family experience of palliative sedation therapy (PST) for terminally ill patients in different settings. To examine and compare family concerns about PST use and its effect on the grief suffered by terminally ill patients' families in palliative care units (PCUs) or intensive care units (ICUs). A total of 154 family members of such patients were recruited in Taiwan, of whom 143 completed the study, with 81 from the PCU and 62 from the ICU. Data were collected on their concerns regarding PST during recruitment. Grief levels were assessed at three days and one month after the patient's death with the Texas Revised Inventory of Grief. Families' major concern about sedated patients in the PCU was that "there might be other ways to relieve symptoms" (90.2%), whereas families of ICU sedated patients gave the highest ratings to "feeling they still had something more to do" (93.55%), and "the patient's sleeping condition was not dignified" (93.55%). Family members recruited from the ICU tended to experience more grief than those from the PCU (P = 0.005 at Day 3 and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani
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.
Walters, Mary K; Farhat, Joseph; Bischoff, James; Foss, Mary; Evans, Cory
Rib fracture associated pain is difficult to control. There are no published studies that use ketamine as a therapeutic modality to reduce the amount of opioid to control rib fracture pain. To examine the analgesic effects of adjuvant ketamine on pain scale scores in trauma intensive care unit (ICU) rib fracture. This retrospective, case-control cohort chart review evaluated ICU adult patients with a diagnosis of ≥1 rib fracture and an Injury Severity Score >15 during 2016. Patients received standard-of-care pain management with the physician's choice analgesics with or without ketamine as a continuous, fixed, intravenous infusion at 0.1 mg/kg/h. A total of 15 ketamine treatment patients were matched with 15 control standard-of-care patients. Efficacy was measured via Numeric Pain Scale (NPS)/Behavioral Pain Scale (BPS) scores, opioid use, and ICU and hospital length of stay. Safety of ketamine was measured by changes in vital signs, adverse effects, and mortality. Average NPS/BPS, severest NPS/BPS, and opioid use were lower in the ketamine group than in controls (NPS: 4.1 vs 5.8, P rib fracture.
Bonten, M J; Weinstein, R A
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.
Full Text Available Objective: The aim of this study was to analyze the impact of process and outcome surveillance on rates of device-associated health care-associated infections (DA-HAI in an intensive care unit (ICU in Turkey over a four-year period.Material and Methods: An open label, prospective cohort, active DA-HAI surveillance study was conducted on 685 patients admitted to the ICU of a university hospital in Turkey from January 2004 to December 2007, implementing the methodology developed by the International Nosocomial Infection Control Consortium. DA-HAI rates were recorded according to Centers for Disease Control and Prevention (CDC, National Healthcare Safety Network (NHSN definitions. We analyzed the rates of DA-HAI, mechanical ventilator-associated pneumonia (VAP, central line-associated bloodstream infection (CLA-BSI, and catheter-associated urinary tract infection (CAUTI, as well as microorganism profile, extra length of stay, and hand hygiene compliance. Pooled DA-HAI rates were calculated and compared by year.Results: The DA-HAI rate per 100 patients declined as follows: for 2004, the DA-HAI rate was 58.4%; for 2005, it was 38.9%; for 2006, it was 34.8%; and for 2007, it was 10.9%. The DA-HAI rate per 1,000 bed-days also declined: for 2004, it was 42.8, and for 2007 it was 10.7. The rates decreased from 25.8 to 13.4 for VAP; from 29.9 to 25.0 for CLA-BSI; and from 9.2 to 6.2 for CAUTI cases per 1,000 device-days during the study period. Conclusion: Process and outcome surveillance of DA-HAI significantly reduced DA-HAI.
Maria Virginia Martins Faria Faddul Alves
Full Text Available Objective. To describe the experience of family members as a result of children's hospitalization at the Intensive Care Unit (ICU. Methodology. Descriptive and cross-sectional study. A structured interview was held with 20 relatives of patients hospitalized at two clinics of the Botucatu Medical School at Universidade Estadual Paulista 'Júlio de Mesquita Filho'. Information was collected between July and September 2010. Results. The main characteristics of the participating relatives were: 80% mothers of the children; 70% low education level and 70% married. Sixty percent of the children were hospitalized at the ICU for the first time. Eighty percent of the interviewees believe that the children's behavior changes inside the unit and 85% consider that visiting hours are sufficient. The predominant negative feelings are fear (50% and insecurity (20%, while the predominant positive feelings are hope (50% and the expectation of discharge (25%. The professional who most supported the relatives was the nurse (35%. Conclusion. The family members' experience as a result of the children's hospitalization at the ICU involves positive and negative aspects, which also affect the child's behavior at the unit.
Full Text Available Global Critical Care is attracting increasing attention. At several million deaths per year, the worldwide burden of critical illness is greater than generally appreciated. Low income countries (LICs have a disproportionally greater share of critical illness, and yet critical care facilities are scarce in such settings. Routines utilizing abnormal vital signs to identify critical illness and trigger medical interventions have become common in high-income countries but have not been investigated in LICs. The aim of the study was to assess whether the introduction of a vital signs directed therapy protocol improved acute care and reduced mortality in an Intensive Care Unit (ICU in Tanzania.Prospective, before-and-after interventional study in the ICU of a university hospital in Tanzania. A context-appropriate protocol that defined danger levels of severely abnormal vital signs and stipulated acute treatment responses was implemented in a four week period using sensitisation, training, job aids, supervision and feedback. Acute treatment of danger signs at admission and during care in the ICU and in-hospital mortality were compared pre and post-implementation using regression models. Danger signs from 447 patients were included: 269 pre-implementation and 178 post-implementation. Acute treatment of danger signs was higher post-implementation (at admission: 72.9% vs 23.1%, p<0.001; in ICU: 16.6% vs 2.9%, p<0.001. A danger sign was five times more likely to be treated post-implementation (Prevalence Ratio (PR 4.9 (2.9-8.3. Intravenous fluids were given in response to 35.0% of hypotensive episodes post-implementation, as compared to 4.1% pre-implementation (PR 6.4 (2.5-16.2. In patients admitted with hypotension, mortality was lower post-implementation (69.2% vs 92.3% p = 0.02 giving a numbers-needed-to-treat of 4.3. Overall in-hospital mortality rates were unchanged (49.4% vs 49.8%, p = 0.94.The introduction of a vital signs directed therapy protocol
Andrew B. Rosenzweig
Full Text Available The pronounced prevalence of delirium in geriatric patients admitted to the intensive care unit (ICU and its increased morbidity and mortality is a well-established phenomenon. The purpose of this review is to explore the potential use of dexmedetomidine in preventing or managing ICU delirium in older patients. Articles used were identified and selected through multiple search engines, including Google Scholar, PubMed, and MEDLINE. Keywords such as dexmedetomidine, delirium, geriatric, ICU delirium, delirium in elderly, and palliative were used to obtain the specific articles used for this paper and restricted to articles published in 1990 or later. Articles specifically looking at the use of dexmedetomidine as compared to a study drug and its potential for use in ICU patients, as opposed to overall reviews of dexmedetomidine, were compared. When compared to benzodiazepines for the prevention or treatment of ICU delirium in the elderly, dexmedetomidine was associated with a reduction in delirium, as well as decreased morbidity and mortality. Dexmedetomidine has also been shown to be effective in limiting risk factors associated with ICU delirium such as length and depth of sedation. As opposed to benzodiazepines or opiates, dexmedetomidine provides effective analgesia, sympatholysis, and anxiolysis without causing respiratory depression and allows a patient to more effectively interact with practitioners. The review of these nine articles indicates that these favorable attributes and overall decreased duration and incidence of delirium make dexmedetomidine a viable option in preventing or reducing ICU delirium in high-risk geriatric patients and as a palliative adjunct to help control symptoms and stressors.
Offerman, Steven R
Full Text Available Objectives: We sought to identify factors associated with need for mechanical ventilation (MV, length of intensive care unit (ICU stay, length of hospital stay, and poor outcome in injection drug users (IDUs with wound botulism (WB.Methods: This is a retrospective review of WB patients admitted between 1991-2005. IDUs were included if they had symptoms of WB and diagnostic confirmation. Primary outcome variables were the need for MV, length of ICU stay, length of hospital stay, hospital-related complications, and death.Results: Twenty-nine patients met inclusion criteria. Twenty-two (76% admitted to heroin use only and seven (24% admitted to heroin and methamphetamine use. Chief complaints on initial presentation included visual changes, 13 (45%; weakness, nine (31%; and difficulty swallowing, seven (24%. Skin wounds were documented in 22 (76%. Twenty-one (72% patients underwent mechanical ventilation (MV. Antitoxin (AT was administered to 26 (90% patients but only two received antitoxin in the emergency department (ED. The time from ED presentation to AT administration was associated with increased length of ICU stay (Regression coefficient = 2.5; 95% CI 0.45, 4.5. The time from ED presentation to wound drainage was also associated with increased length of ICU stay (Regression coefficient = 13.7; 95% CI = 2.3, 25.2. There was no relationship between time to antibiotic administration and length of ICU stay.Conclusion: MV and prolonged ICU stays are common in patients identified with WB. Early AT administration and wound drainage are recommended as these measures may decrease ICU length of stay.[West J Emerg Med. 2009;10(4:251-256.
Walid H. Nofal
Full Text Available Background: We developed a multi-dimensional score which may help in predicting those patients, undergoing bariatric surgery, who may be in need for postoperative ICU admission and which may also help in avoiding unnecessary admission to the critical care units after bariatric surgery. Methods: We collected the data of 111patients who underwent either laparoscopic gastric sleeve or bypass and studied the association between some risk factors related to obesity and their postoperative ICU admission. Those factors found to be statistically significant are included in the final score. The cutoff value of our scoring system is determined by running a Receiver Operating Curve (ROC analysis. Results: Forty patients (36% were admitted to the ICU postoperatively. Our final score includes 7 independent variables; 6 found to be significantly related to post-bariatric surgery ICU admission; these are age, gender, BMI, ASA, obstructive sleep apnea and spirometry results, and the seventh is the history of venous thrombo-embolism. According to the ROC curve analysis, we set the score value of 10 as our cut-off value for the need of postoperative ICU admission. The score median value is 9. Males’ odds to be admitted to the ICU after bariatric surgery are 11.9 times higher than females. Also, those with BMI above 50 kg m−2 have odds of 29.8 times higher than those below 50 kg m−2. Conclusions: We propose a scoring system for risk stratification, in which some of the well-known predictor risk factors are included in a simple way to help identify those high-risk patients undergoing bariatric surgery.Trial registry number: NCT02976649. Keywords: Bariatric surgery, Postoperative ICU admission, Score
Martin, Jan; Blobner, Manfred; Busch, Raymonde; Moser, Norman; Kochs, Eberhard; Luppa, Peter B
The aim of the study was to retrospectively investigate whether parameters of routine point-of-care testing (POCT) predict hospital mortality in critically ill surgical patients on admission to the intensive care unit (ICU). Arterial blood analyses of 1551 patients on admission to the adult surgical ICU of the Technical University Munich were reviewed. POCT was performed on a blood gas analyser. The association between acid-base status and mortality was evaluated. Metabolic acidosis was defined by base excess (BE) lactate >50% of BE, anion gap (AG)-acidosis by AG >16 mmol/L, hyperchloraemic acidosis by chloride >115 mmol/L. Metabolic alkalosis was defined by BE ≥3 mmol/L. Logistic regression analysis identified variables independently associated with mortality. Overall mortality was 8.8%. Mortality was greater in male patients (p=0.012). Mean age was greater in non-survivors (p55 mm Hg (mortality 23.1%). Three hundred and seventy-seven patients presented with acidosis (mortality 11.4%), thereof 163 patients with lactic acidosis (mortality 19%). Mortality for alkalosis (174 patients) was 12.1%. Mean blood glucose level for non-survivors was higher compared to survivors (plactate, glucose, age, male gender as independent predictors of mortality. Lactate and glucose on ICU admission independently predict mortality. BE and AG failed as prognostic markers. Lactic acidosis showed a high mortality rate implying that lactate levels should be obtained on ICU admission. Prevalence of hyperchloraemic acidosis was low. Metabolic alkalosis was associated with an increased mortality. Further studies on this disturbance and its attendant high mortality are warranted.
Murphy, David J; Ogbu, Ogbonna C; Coopersmith, Craig M
Improving value within critical care remains a priority because it represents a significant portion of health-care spending, faces high rates of adverse events, and inconsistently delivers evidence-based practices. ICU directors are increasingly required to understand all aspects of the value provided by their units to inform local improvement efforts and relate effectively to external parties. A clear understanding of the overall process of measuring quality and value as well as the strengths, limitations, and potential application of individual metrics is critical to supporting this charge. In this review, we provide a conceptual framework for understanding value metrics, describe an approach to developing a value measurement program, and summarize common metrics to characterize ICU value. We first summarize how ICU value can be represented as a function of outcomes and costs. We expand this equation and relate it to both the classic structure-process-outcome framework for quality assessment and the Institute of Medicine's six aims of health care. We then describe how ICU leaders can develop their own value measurement process by identifying target areas, selecting appropriate measures, acquiring the necessary data, analyzing the data, and disseminating the findings. Within this measurement process, we summarize common metrics that can be used to characterize ICU value. As health care, in general, and critical care, in particular, changes and data become more available, it is increasingly important for ICU leaders to understand how to effectively acquire, evaluate, and apply data to improve the value of care provided to patients.
Ruehsen, M M; Abdul-Wahab, A W
Injuries resulting from trauma are over-represented in Bahrain's intensive care unit beds. Using data from 1984 and 1985, this study examines the most severe etiologic agents and high-risk population groups among ICU trauma patients. Road traffic accidents were the principal cause of admission, accounting for 57% of all injury admissions. Most occurred in pedestrians suffering from severe head injury. Poisonings were the second largest category, followed by falls. In comparison with medical cases admitted to the ICU during the same 2-year period, the trauma cases included a disproportionate number of children and males in their most productive years of life, further adding to the economic burden which injuries have inflicted on this small country. The authors call for a new approach, namely passive prevention such as environmental modifications and legislation and tertiary prevention such as improvement of the country's underutilized ambulance service.
Boyko, Yuliya; Jennum, Poul; Toft, Palle
Sleep and circadian rhythm are reported to be severely abnormal in critically ill patients. Disturbed sleep can lead to the development of delirium and, as a result, can be associated with prolonged stay in the intensive care unit (ICU) and increased mortality. The standard criterion method...... aiming to improve sleep quality and circadian rhythm in the ICU. The results of these studies were inconclusive due to using the sleep assessment methods other than PSG or the absence of a reliable sleep scoring tool for the analysis of the PSG findings in this patient population. Development of a valid......, medication, as well as the critical illness itself have been reported as important sleep disturbing factors. Secretion of sleep hormone, melatonin, expressing circadian rhythmicity was found abolished or phase delayed in critically ill patients. Various interventions have been tested in several studies...
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.
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
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 DSM-5 criteria and reliable regarding inter-observer agreement in a research setting. Delirium remains under-recognized by bedside clinicians.