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Cohen O, Shnipper R, Yosef L, Stavi D, Shapira-Galitz Y, Hain M, Lahav Y, Shoffel-Havakuk H, Halperin D, Adi N. Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience. J Crit Care 2018; 47:127-132. [PMID: 29957510 DOI: 10.1016/j.jcrc.2018.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess the safety of medical-ward bedside percutaneous dilatational tracheostomy (GWB-PDT). MATERIALS AND METHODS A retrospective study of all patients who underwent elective GWB-PDT between 2009 and 2015. A joint otolaryngology-ICU team performed all GWB-PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major. RESULTS Two hundred and fifty six patients were included in the study. The mean age was 77.7 ± 11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway - two patients [0.8%], pneumothorax - two patients [0.8%], resuscitation - one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3. CONCLUSION GWB-PDT is a feasible and safe solution for tracheostomies in general-ward ventilated patients.
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Affiliation(s)
- Oded Cohen
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel.
| | - Ruth Shnipper
- Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Liron Yosef
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Dekel Stavi
- Intensive Care Unit, Kaplan Medical Center, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Shapira-Galitz
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Moshe Hain
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yonatan Lahav
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Hagit Shoffel-Havakuk
- Department of Otolaryngology, Head and Neck Surgery, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Doron Halperin
- Department of Otolaryngology, Head and Neck Surgery, Kaplan Medical Center, Rehovot, Israel; Hebrew University- Hadassah Medical School, Jerusalem, Israel
| | - Nimrod Adi
- Intensive Care Unit, Kaplan Medical Center, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Oud L, Chan YM. Predictors and variation of routine home discharge in critically ill adults with cystic fibrosis. Heart Lung 2018; 47:511-515. [PMID: 29866586 DOI: 10.1016/j.hrtlng.2018.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The short-term outcomes of patients with cystic fibrosis (CF) surviving critical illness were not examined systematically. OBJECTIVES To determine the factors associated with and variation in rates of routine home discharge among ICU-managed adult CF patients. METHODS Predictors of routine home discharge and its hospital-level variation were examined in ICU-managed adults with cystic fibrosis in Texas during 2004-2013. RESULTS Older age, rural residence, and severity of illness decreased odds of routine home discharge, while hospitalization in facilities accredited as part of the Cystic Fibrosis Foundation Care Center Network nearly doubled the odds of routine home discharge. The median (interquartile) adjusted rate of routine home discharge was 62.0% (31.5-82.5). CONCLUSIONS The identified determinants of routine home discharge can inform clinical decision-making, while the demonstrated wide variation in adjusted across-hospital rates of routine home discharge of ICU-managed adults with CF can provide benchmark data for future quality improvement efforts.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, 701 W. 5th St., Odessa, Texas, 79763, USA.
| | - Yiu Ming Chan
- Mathematics and Computer Science Department, University of Texas at the Permian Basin, 4901 East University, Odessa, Texas, 79762, USA
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Survey of Annual Staffing Workloads for Adult Critical Care Physicians Working in the United States. Ann Am Thorac Soc 2018; 13:751-3. [PMID: 27144800 DOI: 10.1513/annalsats.201508-502le] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Huang Q, Huang C, Luo Y, He F, Zhang R. Circulating lncRNA NEAT1 correlates with increased risk, elevated severity and unfavorable prognosis in sepsis patients. Am J Emerg Med 2018; 36:1659-1663. [PMID: 29936011 DOI: 10.1016/j.ajem.2018.06.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/09/2018] [Accepted: 06/04/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To investigate the correlation of circulating long non-coding RNA nuclear-enriched abundant transcript 1 (lncRNA NEAT1) expression with disease risk, severity, prognosis and inflammatory cytokine levels in sepsis patients. METHODS 152 sepsis patients and 150 health controls (HCs) were enrolled in this study. Plasma and serum samples were obtained from sepsis patients and HCs, and lncRNA NEAT1 expression in plasma was determined by quantitative polymerase chain reaction, while levels of inflammatory cytokines in serum were detected by enzyme linked immune sorbent assay. RESULTS LncRNA NEAT1 expression was remarkably higher in sepsis patients than in HCs (P < 0.001). Receiver operating characteristic (ROC) curve disclosed a good predictive value of lncRNA NEAT1 expression for sepsis risk with area under curve (AUC) of 0.730 (95% CI: 0.740-0.861). Subsequent multivariate logistic regression analysis demonstrated that lncRNA NEAT1 expression was independently associated with higher sepsis risk (P < 0.001). In sepsis patients, lncRNA NEAT1 expression was also observed to be positively correlated with Acute Physiology and Chronic Health Evaluation (APACHE) II score (P < 0.001), serum tumor necrosis factor-α (P < 0.001), interleukin (IL)-1β (P = 0.043), IL-6 (P = 0.001) and IL-8 (P = 0.038), while negatively correlated with IL-10 (P < 0.001). In addition, lncRNA NEAT1 expression was increased in non-survivors compared to survivors (P = 0.006), and ROC curve revealed a good prognostic value of lncRNA NEAT1 for non-survivor risk with AUC 0.641 (95% CI: 0.536-0.746). CONCLUSION Circulating lncRNA NEAT1 correlates with increased disease risk, elevated severity and unfavorable prognosis as well as higher expression of pro-inflammatory cytokines in sepsis patients.
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Affiliation(s)
- Qinghe Huang
- Department of Intensive Care Unit, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.
| | - Cuiyu Huang
- Department of Surgery, Yongan Municipal Hospital, Yongan, China
| | - Yan Luo
- Department of Intensive Care Unit, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Fuyun He
- Department of Intensive Care Unit, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Rongfang Zhang
- Department of Intensive Care Unit, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
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Hager DN, Tanykonda V, Noorain Z, Sahetya SK, Simpson CE, Lucena JF, Needham DM. Hospital mortality prediction for intermediate care patients: Assessing the generalizability of the Intermediate Care Unit Severity Score (IMCUSS). J Crit Care 2018; 46:94-98. [PMID: 29804039 DOI: 10.1016/j.jcrc.2018.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/04/2018] [Accepted: 05/15/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE The Intermediate Care Unit Severity Score (IMCUSS) is an easy to calculate predictor of in-hospital death, and the only such tool developed for patients in the intermediate care setting. We sought to examine its external validity. MATERIALS AND METHODS Using data from patients admitted to the intermediate care unit (IMCU) of an urban academic medical center from July to December of 2012, model discrimination and calibration for predicting in-hospital death were assessed using the area under the receiver operating characteristic (AUROC) and the Hosmer-Lemeshow goodness-of-fit chi-squared (HL GOF X2) test, respectively. The standardized mortality ratio (SMR) with 95% confidence intervals (95% CI) was also calculated. RESULTS The cohort included data from 628 unique admissions to the IMCU. Overall hospital mortality was 8.3%. The median IMCUSS was 10 (Interquartile Range: 0-16), with 229 (36%) patients having a score of zero. The AUROC for the IMCUSS was 0.72 (95% CI: 0.64-0.78), the HL GOF X2 = 30.7 (P < 0.001), and the SMR was 1.22 (95% CI: 0.91-1.60). CONCLUSIONS The IMCUSS exhibited acceptable discrimination, poor calibration, and underestimated mortality. Other centers should assess the performance of the IMCUSS before adopting its use.
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Affiliation(s)
- David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | | | - Zeba Noorain
- Bangalore Medical College and Research Institute, Bangalore, India
| | - Sarina K Sahetya
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Catherine E Simpson
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States.
| | - Juan Felipe Lucena
- Division of Intermediate Care and Hospitalists Unit, Department of Internal Medicine, Clinica Universidad de Navarra, Pamplona, Navarra, Spain.
| | - Dale M Needham
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States; Armstrong Institute for Patient Safety, John Hopkins University, Baltimore, MD, United States; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, United States; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, United States.
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Barnes‐Daly MA, Pun BT, Harmon LA, Byrum DG, Kumar VK, Devlin JW, Stollings JL, Puntillo KA, Engel HJ, Posa PJ, Barr J, Schweickert WD, Esbrook CL, Hargett KD, Carson SS, Aldrich JM, Ely EW, Balas MC. Improving Health Care for Critically Ill Patients Using an Evidence‐Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation. Worldviews Evid Based Nurs 2018; 15:206-216. [DOI: 10.1111/wvn.12290] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Brenda T. Pun
- Clinical Program ManagerVanderbilt University Medical Center Nashville TN USA
| | - Lori A. Harmon
- Director QualitySociety of Critical Care Medicine Mount Prospect IL USA
| | - Diane G. Byrum
- Quality Implementation ConsultantInnovative Solutions for HealthCare Education LLC Chicago IL USA
| | - Vishakha K. Kumar
- Senior Manager, ResearchSociety of Critical Care Medicine Mount Prospect IL USA
| | - John W. Devlin
- Professor of Pharmacy, School of Pharmacy, Northeastern University, and Scientific Staff, Division of Pulmonary and Critical Care MedicineTufts Medical Center Boston MA USA
| | - Joanna L. Stollings
- Medical Intensive Care Unit Clinical Pharmacy Specialist and Pharmacist ICU Recovery Center, Department of Pharmaceutical ServicesVanderbilt University Medical Center Nashville TN USA
| | - Kathleen A. Puntillo
- Professor EmeritaSchool of Nursing, University of California San Francisco San Francisco, CA USA
| | - Heidi J. Engel
- Clinical Specialist, Department of Rehabilitative ServicesUniversity of California San Francisco CA USA
| | - Patricia J. Posa
- Quality Excellence LeaderSaint Joseph Mercy Health System Ann Arbor MI USA
| | - Juliana Barr
- Associate Professor, Department of Anesthesiology, Perioperative, and Pain MedicineStanford University School of Medicine Stanford CA USA
- Staff Anesthesiologist and Intensivist at the VA, Anesthesiology ServiceVA Palo Alto Health Care System Palo Alto CA USA
| | - William D. Schweickert
- Director, Medical Critical Care Operations, Division of Pulmonary, Allergy and Critical CarePerelman School of Medicine at the University of Pennsylvania Philadelphia PA USA
| | - Cheryl L. Esbrook
- Program Coordinator of Occupational Therapy Professional DevelopmentUniversity of Chicago Medicine Chicago IL USA
| | - Ken D. Hargett
- Director, Respiratory Care ServicesHouston Methodist Hospital Houston TX USA
| | - Shannon S. Carson
- Professor of Medicine and Division Chief, Pulmonary Diseases & Critical Care MedicineUniversity of North Carolina‐Chapel Hill Chapel Hill NC USA
| | - J. Matthew Aldrich
- Medical Director, Critical Care Medicine, Associate Clinical Professor, Anesthesia and Perioperative CareUniversity of San Francisco‐California Medical Center San Francisco CA USA
| | - E. Wesley Ely
- Professor of Medicine, Department of Medicine, Pulmonary and Critical Care and Health Services Research CenterVanderbilt University School of Medicine and The Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC) Nashville TN USA
| | - Michele C. Balas
- Associate Professor, College of Nursing, Center of Excellence in Critical and Complex CareThe Ohio State University and Nurse Scientist, The Ohio State University Wexner Medical Center Columbus OH USA
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Cheng B, Li Z, Wang J, Xie G, Liu X, Xu Z, Chu L, Zhao J, Yao Y, Fang X. Comparison of the Performance Between Sepsis-1 and Sepsis-3 in ICUs in China: A Retrospective Multicenter Study. Shock 2018; 48:301-306. [PMID: 28448400 PMCID: PMC5516667 DOI: 10.1097/shk.0000000000000868] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The definition of sepsis was updated to sepsis-3 in February 2016. However, the performance of the previous and new definition of sepsis remains unclear in China. This was a retrospective multicenter study in six intensive care unit (ICUs) from five university-affiliated hospitals to compare the performance between sepsis-1 and sepsis-3 in China. From May 1, 2016 to June 1, 2016, 496 patients were enrolled consecutively. Data were extracted from the electronic clinical records. We evaluated the performance of sepsis-1 and sepsis-3 by measuring the area under the receiver operating characteristic curves (AUROC) to predict 28-day mortality rates. Of 496 enrolled patients, 186 (37.5%) were diagnosed with sepsis according to sepsis-1, while 175 (35.3%) fulfilled the criteria of sepsis-3. The AUROC of systemic inflammatory response syndrome (SIRS) is significantly smaller than that of sequential organ failure assessment (SOFA) (0.55 [95% confidence interval, 0.46–0.64] vs. 0.69 (95% confidence interval, 0.61–0.77], P = 0.008) to predict 28-day mortality rates of infected patients. Moreover, 5.9% infected patients (11 patients) were diagnosed as sepsis according to sepsis-1 but not to sepsis-3. The APACHE II, SOFA scores, and mortality rate of the 11 patients were significantly lower than of patients whose sepsis was defined by both the previous and new criteria (8.6±3.5 vs. 16.3±6.2, P = < 0.001; 1 (0–1) vs. 6 (4–8), P = <0.001; 0.0 vs. 33.1%, P = 0.019). In addition, the APACHE II, length of stay in ICU, and 28-day mortality rate of septic patients rose gradually corresponding with the raise in SOFA score (but not the SIRS score). Sepsis-3 performed better than sepsis-1 in the study samples in ICUs in China.
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Affiliation(s)
- Baoli Cheng
- *Department of Anesthesiology, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China †Trauma Research Center, The First Hospital Affiliated to the PLA General Hospital, Beijing, China
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Gershengorn HB, Chan CW, Xu Y, Sun H, Levy R, Armony M, Gong MN. The Impact of Opening a Medical Step-Down Unit on Medically Critically Ill Patient Outcomes and Throughput: A Difference-in-Differences Analysis. J Intensive Care Med 2018; 35:425-437. [PMID: 29552955 DOI: 10.1177/0885066618761810] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To understand the impact of adding a medical step-down unit (SDU) on patient outcomes and throughput in a medical intensive care unit (ICU). DESIGN Retrospective cohort study. SETTING Two academic tertiary care hospitals within the same health-care system. PATIENTS Adults admitted to the medical ICU at either the control or intervention hospital from October 2013 to March 2014 (preintervention) and October 2014 to March 2015 (postintervention). INTERVENTIONS Opening a 4-bed medical SDU at the intervention hospital on April 1, 2014. MEASUREMENTS AND MAIN RESULTS Using standard summary statistics, we compared patients across hospitals. Using a difference-in-differences approach, we quantified the association of opening an SDU and outcomes (hospital mortality, hospital and ICU length of stay [LOS], and time to transfer to the ICU) after adjustment for secular trends in patient case-mix and patient-level covariates which might impact outcome. We analyzed 500 (245 pre- and 255 postintervention) patients in the intervention hospital and 678 (323 pre- and 355 postintervention) in the control hospital. Patients at the control hospital were younger (60.5-60.6 vs 64.0-65.4 years, P < .001) with a higher severity of acute illness at the time of evaluation for ICU admission (Sequential Organ Failure Assessment score: 4.9-4.0 vs 3.9-3.9, P < .001). Using the difference-in-differences methodology, we identified no association of hospital mortality (odds ratio [95% confidence interval]: 0.81 [0.42 to 1.55], P = .52) or hospital LOS (% change [95% confidence interval]: -8.7% [-28.6% to 11.2%], P = .39) with admission to the intervention hospital after SDU opening. The ICU LOS overall was not associated with admission to the intervention hospital in the postintervention period (-23.7% [-47.9% to 0.5%], P = .06); ICU LOS among survivors was significantly reduced (-27.5% [-50.5% to -4.6%], P = .019). Time to transfer to ICU was also significantly reduced (-26.7% [-44.7% to -8.8%], P = .004). CONCLUSIONS Opening our medical SDU improved medical ICU throughput but did not affect more patient-centered outcomes of hospital mortality and LOS.
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Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, University of Miami and Jackson Memorial Hospitals, Miami, FL, USA.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Carri W Chan
- Division of Decision, Risk, and Operations, Columbia Business School, New York, NY, USA
| | - Yunchao Xu
- Department of Information, Operations, and Management Sciences, New York University Stern School of Business, New York, NY, USA
| | - Hanxi Sun
- Department of Statistics, Purdue University, West Lafayette, IN, USA
| | - Ronni Levy
- Division of Critical Care, New York Presbyterian Queens, Queens, NY, USA
| | - Mor Armony
- Department of Information, Operations, and Management Sciences, New York University Stern School of Business, New York, NY, USA
| | - Michelle N Gong
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
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Rood P, Huisman-de Waal G, Vermeulen H, Schoonhoven L, Pickkers P, van den Boogaard M. Effect of organisational factors on the variation in incidence of delirium in intensive care unit patients: A systematic review and meta-regression analysis. Aust Crit Care 2018; 31:180-187. [PMID: 29545081 DOI: 10.1016/j.aucc.2018.02.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 01/05/2018] [Accepted: 02/01/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Delirium occurs frequently in intensive care unit (ICU) patients and is associated with numerous deleterious outcomes. There is a large variation in reported delirium occurrence rates, ranging from 4% to 89%. Apart from patient and treatment-related factors, organisational factors could influence delirium incidence, but this is currently unknown. OBJECTIVE To systematically review delirium incidence and determine whether or not organisational factors may contribute to the observed delirium incidence in adult ICU patients. METHODS Systematic review of prospective cohort studies reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Included articles were independently assessed by two researchers. Quality of the articles was determined using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Subsequently, apart from patient characteristics, a meta-regression analysis was performed on available organisational factors, including hospital type, screening method and screening frequency. DATA SOURCES PubMed, Embase, CINAHL, and Cochrane Library databases were searched from inception to 27 January 2017, without language limitation. RESULTS A total of 9357 articles were found, of which 19 articles met the inclusion criteria and were considered as true delirium incidence studies. The articles were of good methodological quality (median [interquartile range] 32/38 [30-35] points), published between 2005 and 2016, originated from 17 countries. A total of 9867 ICU patients were included. The incidence rate of delirium varied between 4% and 55%, with a mean ± standard deviation of 29 ± 14%. Data relating to three organisational factors were included in the studies, but they were not significantly associated with the reported delirium incidence: hospital type (p 0.48), assessment methods (p 0.41), and screening frequency (p 0.28). CONCLUSIONS The mean incidence of delirium in the ICU was 29%. The organisational factors found including methods of delirium assessment, screening frequency, and hospital type were not related to the reported ICU delirium incidence.
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Affiliation(s)
- Paul Rood
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Getty Huisman-de Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lisette Schoonhoven
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (Wessex), United Kingdom
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Loudet CI, Marchena MC, Maradeo MR, Fernández SL, Romero MV, Valenzuela GE, Herrera IE, Ramírez MT, Palomino SR, Teberobsky MV, Tumino LI, González AL, Reina R, Estenssoro E. Reducing pressure ulcers in patients with prolonged acute mechanical ventilation: a quasi-experimental study. Rev Bras Ter Intensiva 2018; 29:39-46. [PMID: 28444071 PMCID: PMC5385984 DOI: 10.5935/0103-507x.20170007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 12/17/2016] [Indexed: 01/09/2023] Open
Abstract
Objective: To determine the effectiveness of a quality management program in reducing the incidence and severity of pressure ulcers in critical care patients. Methods: This was a quasi-experimental, before-and-after study that was conducted in a medical-surgical intensive care unit. Consecutive patients who had received mechanical ventilation for ≥ 96 hours were included. A "Process Improvement" team designed a multifaceted interventional process that consisted of an educational session, a pressure ulcer checklist, a smartphone application for lesion monitoring and decision-making, and a "family prevention bundle". Results: Fifty-five patients were included in Pre-I group, and 69 were included in the Post-I group, and the incidence of pressure ulcers in these groups was 41 (75%) and 37 (54%), respectively. The median time for pressure ulcers to develop was 4.5 [4 - 5] days in the Pre-I group and 9 [6 - 20] days in the Post-I group after admission for each period. The incidence of advanced-grade pressure ulcers was 27 (49%) in the Pre-I group and 7 (10%) in the Post-I group, and finally, the presence of pressure ulcers at discharge was 38 (69%) and 18 (26%), respectively (p < 0.05 for all comparisons). Family participation totaled 9% in the Pre-I group and increased to 57% in the Post-I group (p < 0.05). A logistic regression model was used to analyze the predictors of advanced-grade pressure ulcers. The duration of mechanical ventilation and the presence of organ failure were positively associated with the development of pressure ulcers, while the multifaceted intervention program acted as a protective factor. Conclusion: A quality program based on both a smartphone application and family participation can reduce the incidence and severity of pressure ulcers in patients on prolonged acute mechanical ventilation.
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Affiliation(s)
- Cecilia Inés Loudet
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina.,Disciplina de Farmacologia Aplicada, Seção de Terapia Intensiva, Facultad de Ciencias Médicas, Universidad Nacional de La Plata - La Plata, Buenos Aires, Argentina
| | - María Cecilia Marchena
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - María Roxana Maradeo
- Serviço de Dermatologia, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Silvia Laura Fernández
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - María Victoria Romero
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Graciela Esther Valenzuela
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Isabel Eustaquia Herrera
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Martha Teresa Ramírez
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Silvia Rojas Palomino
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Mariana Virginia Teberobsky
- Serviço de Dermatologia, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Leandro Ismael Tumino
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Ana Laura González
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Rosa Reina
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
| | - Elisa Estenssoro
- Unidade de Terapia Intensiva, Hospital Interzonal General de Agudos "General San Martín" - La Plata, Buenos Aires, Argentina
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Hamsen U, Lefering R, Fisahn C, Schildhauer TA, Waydhas C. Workload and severity of illness of patients on intensive care units with available intermediate care units: a multicenter cohort study. Minerva Anestesiol 2018; 84:938-945. [PMID: 29469547 DOI: 10.23736/s0375-9393.18.12516-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intermediate Care Units (IMCU) are established in many hospitals to better match the requirements of patient care with respect to their personnel, equipment and other resources. This should relieve Intensive Care Unit (ICU) capacities for more severely ill patients and reduce readmissions to ICU. This study was conducted to investigate the effects of IMCU use on ICU populations. METHODS This is a retrospective analysis of the German National Registry of Intensive Care from the years 2000 to 2010. RESULTS We included 39 ICUs with high and 11 ICUs with low IMCU use. Patients in ICUs with high IMCU use were younger (mean age [high vs. low]: 60.5 vs. 64.5 years, P<0.001), while the severity of illness was higher (percentage of ventilated patients during ICU stay [high vs. low ICMU use]: 67.2% vs. 40.2%, P<0.001; patients ventilated >24 hours: 22% vs. 18%, P<0.001; mean therapeutic intervention scoring system-28 (TISS-28) score: 25.7 vs. 23.3, P<0.001). Readmission rates to ICU did not differ between ICU groups ([high vs. low]: 4.5% vs. 4.4%, P=0.25). ICUs with high IMCU use discharged 90.3% of all patients who were discharged to the IMCU or general ward between the regular workday hours of 06:00 and 14:59, while ICUs with low IMCU use discharged 83.8% of all patients discharged to the general ward in the same time period. CONCLUSIONS The use of IMCUs influences resource utilization of ICUs. Severity of illness and workload was higher in ICUs with high IMCU and more scheduled discharges occurred during the main working hours while readmission rates were similar.
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Affiliation(s)
- Uwe Hamsen
- Department of Surgery and Trauma Surgery, BG University Bergmannsheil, Bochum, Germany -
| | - Rolf Lefering
- Institut für Forschung in der Operativen Medizin (IFOM), Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Christian Fisahn
- Department of Surgery and Trauma Surgery, BG University Bergmannsheil, Bochum, Germany
| | - Thomas A Schildhauer
- Department of Surgery and Trauma Surgery, BG University Bergmannsheil, Bochum, Germany
| | - Chistian Waydhas
- Institut für Forschung in der Operativen Medizin (IFOM), Faculty of Health, Witten/Herdecke University, Witten, Germany.,Faculty of Medicine, University of Duisburg-Essen, Duisburg, Germany
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Wendlandt B, Bice T, Carson S, Chang L. Intermediate Care Units: A Survey of Organization Practices Across the United States. J Intensive Care Med 2018; 35:468-471. [PMID: 29431046 DOI: 10.1177/0885066618758627] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Intermediate care units (IMCUs) represent an alternative care setting with nurse staffing levels between those of the general ward and the intensive care unit (ICU). Despite rising prevalence, little is known about IMCU practices across US hospitals. The purpose of this study is to characterize utilization patterns and assess for variation. MATERIALS AND METHODS A 14-item survey was distributed to a random nationwide sample of pulmonary and critical care physicians between January and April 2017. RESULTS A total of 51 physicians from 24 different states completed the survey. Each response represented a unique institution, the majority of which were public (59%), academic (73%), and contained at least 1 IMCU (65%). Of the IMCUs surveyed, 58% operated as 1 mixed unit that admitted medical, cardiac, and surgical patients as opposed to having separate subspecialty units. Ninety-one percent of units admitted step-down patients from the ICU, but 39% of units accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department. Intensivists managed care in 21% of units whereas 36% had no intensivist involvement. CONCLUSION Organization practices vary considerably between IMCUs across institutions. The impact of different organization practices on patient outcomes should be assessed.
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Affiliation(s)
- Blair Wendlandt
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Thomas Bice
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Shannon Carson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Lydia Chang
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Diffusion of Evidence-based Intensive Care Unit Organizational Practices. A State-Wide Analysis. Ann Am Thorac Soc 2018; 14:254-261. [PMID: 28076685 DOI: 10.1513/annalsats.201607-579oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Several intensive care unit (ICU) organizational practices have been associated with improved patient outcomes. However, the uptake of these evidence-based practices is unknown. OBJECTIVES To assess diffusion of ICU organizational practices across the state of Pennsylvania. METHODS We conducted two web-based, cross-sectional surveys of ICU organizational practices in Pennsylvania acute care hospitals, in 2005 (chief nursing officer respondents) and 2014 (ICU nurse manager respondents). MEASUREMENTS AND MAIN RESULTS Of 223 eligible respondents, nurse managers from 136 (61%) medical, surgical, mixed medical-surgical, cardiac, and specialty ICUs in 98 hospitals completed the 2014 survey, compared with 124 of 164 (76%) chief nursing officers in the 2005 survey. In 2014, daytime physician staffing models varied widely, with 23 of 136 (17%) using closed models and 33 (24%) offering no intensivist staffing. Nighttime intensivist staffing was used in 37 (27%) ICUs, 38 (28%) used nonintensivist attending staffing, and 24 (18%) had no nighttime attending physicians. Daily multidisciplinary rounds occurred in 93 (68%) ICUs. Regular participants included clinical pharmacists in 68 of 93 (73%) ICUs, respiratory therapists in 62 (67%), and advanced practitioners in 37 (39%). Patients and family members participated in rounds in 36 (39%) ICUs. Clinical protocols or checklists for mechanically ventilated patients were available in 128 of 133 (96%) ICUs, low tidal volume ventilation for acute respiratory distress syndrome in 54 of 132 (41%) ICUs, prone positioning for severe acute respiratory distress syndrome in 37 of 134 (28%) ICUs, and family meetings in 19 of 134 (14%) ICUs. Among 61 ICUs that responded to both surveys, there was a significant increase in the proportion of ICUs using nighttime in-ICU attending physicians (23 [38%] in 2005 vs. 30 [49%] in 2014; P = 0.006). CONCLUSIONS The diffusion of evidence-based ICU organizational practices has been variable across the state of Pennsylvania. Only half of Pennsylvania ICUs have intensivists dedicated to the ICU. Variable numbers use clinical protocols for life-saving therapies, and few use structured family engagement strategies. In contrast, the diffusion of non-evidence-based practices, including overnight ICU attending physician staffing, is increasing. Future research should focus on promoting implementation of organizational evidence to promote high-quality ICU care.
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Blecha S, Dodoo-Schittko F, Brandstetter S, Brandl M, Dittmar M, Graf BM, Karagiannidis C, Apfelbacher C, Bein T. Quality of inter-hospital transportation in 431 transport survivor patients suffering from acute respiratory distress syndrome referred to specialist centers. Ann Intensive Care 2018; 8:5. [PMID: 29335831 PMCID: PMC5768581 DOI: 10.1186/s13613-018-0357-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/10/2018] [Indexed: 12/31/2022] Open
Abstract
Background The acute respiratory distress syndrome (ARDS) is a life-threatening condition. In special situations, these critically ill patients must be transferred to specialized centers for escalating treatment. The aim of this study was to evaluate the quality of inter-hospital transport (IHT) of ARDS patients. Methods We evaluated medical and organizational aspects of structural and procedural quality relating to IHT of patients with ARDS in a prospective nationwide ARDS study. The qualification of emergency staff, the organizational aspects and the occurrence of critical events during transport were analyzed. Results Out of 1234 ARDS patients, 431 (34.9%) were transported, and 52 of these (12.1%) treated with extracorporeal membrane oxygenation. 63.1% of transferred patients were male, median age was 54 years, and 26.8% of patients were obese. All patients were mechanically ventilated during IHT. Pressure-controlled ventilation was the preferred mode (92.1%). Median duration to organize the IHT was 165 min. Median distance for IHT was 58 km, and median duration of IHT 60 min. Forty-two patient-related and 8 technology-related critical events (11.6%, 50 of 431 patients) were observed. When a critical event occurred, the PaO2/FiO2 ratio before transport was significant lower (68 vs. 80 mmHg, p = 0.017). 69.8% of physicians and 86.7% of paramedics confirmed all transfer qualifications according to requirements of the German faculty guidelines (DIVI). Conclusions The transport of critically ill patients is associated with potential risks. In our study the rate of patient- and technology-related critical events was relatively low. A severe ARDS with a PaO2/FiO2 ratio < 70 mmHg seems to be a risk factor for the appearance of critical events during IHT. The majority of transport staff was well qualified. Time span for organization of IHT was relatively short. ECMO is an option to transport patients with a severe ARDS safely to specialized centers. Trial registration NCT02637011 (ClinicalTrials.gov, Registered 15 December 2015, retrospectively registered)
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Affiliation(s)
- Sebastian Blecha
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Susanne Brandstetter
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Michael Dittmar
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Bernhard M Graf
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Thomas Bein
- Department of Anaesthesiology, University Medical Centre Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Crow SS, Ballinger BA, Rivera M, Tsibadze D, Gakhokidze N, Zavrashvili N, Ritter MJ, Arteaga GM. A "Fundamentals" Train-the-Trainer Approach to Building Pediatric Critical Care Expertise in the Developing World. Front Pediatr 2018; 6:95. [PMID: 29780789 PMCID: PMC5945996 DOI: 10.3389/fped.2018.00095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/26/2018] [Indexed: 01/09/2023] Open
Abstract
Pediatric Fundamental Critical Care Support (PFCCS) is an educational tool for training non-intensivists, nurses, and critical care practitioners in diverse health-care settings to deal with the acute deterioration of pediatric patients. Our objective was to evaluate the PFCCS course as a tool for developing a uniform, reproducible, and sustainable model for educating local health-care workers in the optimal management of critically ill children in the Republic of Georgia. Over a period of 18 months and four visits to the country, we worked with Georgian pediatric critical care leadership to complete the following tasks: (1) survey health-care needs within the Republic of Georgia, (2) present representative PFCCS lectures and simulation scenarios to evaluate interest and obtain "buy-in" from key stakeholders throughout the Georgian educational infrastructure, and (3) identify PFCCS instructor candidates. Georgian PFCCS instructor training included the following steps: (1) US PFCCS consultant and content experts presented PFCCS course to Georgian instructor candidates. (2) Simulation learning principles were taught and basic equipment was acquired. (3) Instructor candidates presented PFCCS to Georgian learners, mentored by PFCCS course consultants. Objective evaluation and debriefing with instructor candidates concluded each visit. Between training visits Georgian instructors translated PFCCS slides to the Georgian language. Six candidates were identified and completed PFCCS instructor training. These Georgian instructors independently presented the PFCCS course to 15 Georgian medical students. Student test scores improved significantly from pretest results (n = 14) (pretest: 38.7 ± 7 vs. posttest 62.7 ± 6, p < 0.05). A Likert-type scale of 1 to 5 (1 = not useful or effective, 5 = extremely useful or effective) was used to evaluate each student's perception regarding (1) relevance of course content to clinical work students rated as median (IQR): (a) relevance of PFCCS content to clinical work, 5 (4-5); (b) effectiveness of lecture delivery, 4 (3-4); and (c) value of skill stations for clinical practice, 5 (4-5). Additionally, the mean (±SD) responses were 4.6 (±0.5), 3.7 (±0.6), and 4.5 (±0.6), respectively. Training local PFCCS instructors within an international environment is an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care. Future collaborations will evaluate the clinical impact of PFCCS throughout the Georgian health-care system.
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Affiliation(s)
- Sheri S Crow
- Pediatric Critical Care, Mayo Clinic, Rochester, NY, United States
| | - Beth A Ballinger
- Department of Surgery, Division of Trauma, Acute Care General Surgery and Surgical Critical Care, Mayo Clinic, Rochester, NY, United States
| | - Mariela Rivera
- Department of Surgery, Division of Trauma, Acute Care General Surgery and Surgical Critical Care, Mayo Clinic, Rochester, NY, United States
| | - David Tsibadze
- Head of Maternal and Child Health Department, EVEX Medical Corporation, Tbilisi, Georgia
| | | | | | - Matthew J Ritter
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, NY, United States
| | - Grace M Arteaga
- Pediatric Critical Care, Mayo Clinic, Rochester, NY, United States
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Abstract
In 2015, The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint care consensus document intended to develop standards for designations of levels of maternal care that are complimentary to, but distinct from, neonatal levels of care. Level III and Level IV centers must be prepared to provide obstetric intensive care services. Developing a critical care obstetric program is a resource-intensive process that requires a carefully planned strategic effort essential for successful program implementation and sustainability. In this article, a framework utilizing key components of program development is discussed including environment, scope, model, education and training, maternal transport, and unique aspects of care for women who become critically ill during pregnancy or the postpartum period.
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Labata C, Oliveras T, Berastegui E, Ruyra X, Romero B, Camara ML, Just MS, Serra J, Rueda F, Ferrer M, García-García C, Bayes-Genis A. Intermediate Care Unit After Cardiac Surgery: Impact on Length of Stay and Outcomes. ACTA ACUST UNITED AC 2017; 71:638-642. [PMID: 29158075 DOI: 10.1016/j.rec.2017.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 10/05/2017] [Indexed: 01/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). METHODS From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650). RESULTS There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus coronary in 11.5%, and aorta in 1.8%). The ICU length of stay decreased from 4.9±11 to 2.9±6 days (mean±standard deviation; P<.001); 2 [1-4] to 1 [0-3] (median [Q1-Q3]); in-hospital length of stay decreased from 13.5±15 to 12.7±11 days (mean±standard deviation; P=.01); 9 [7-13] to 9 [7-11] (median [Q1-Q3]), in pre-IMCU-CS to post-IMCU-CS, respectively. There were no statistically significant differences in in-hospital mortality (4.9% vs 3.5%; P=.28) or 30-day readmission rate (4.3% vs 4.2%; P=.89). CONCLUSIONS After the establishment of an IMCU-CS for postoperative cardiac surgery, there was a reduction in ICU and in-hospital mean lengths of stay with no increase in in-hospital mortality or 30-day readmissions.
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Affiliation(s)
- Carlos Labata
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Teresa Oliveras
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Elisabet Berastegui
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Xavier Ruyra
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Bernat Romero
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maria-Luisa Camara
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maria-Soledad Just
- Servicio de Medicina Intensiva, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Jordi Serra
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ferran Rueda
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Marc Ferrer
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Cosme García-García
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Antoni Bayes-Genis
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Instituto de Investigación en Ciencias de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
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Oud L. Critical illness among adults with cystic fibrosis in Texas, 2004-2013: Patterns of ICU utilization, characteristics, and outcomes. PLoS One 2017; 12:e0186770. [PMID: 29065161 PMCID: PMC5655478 DOI: 10.1371/journal.pone.0186770] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/07/2017] [Indexed: 02/07/2023] Open
Abstract
Objective Available reports on critically ill adults with cystic fibrosis (CF) suggest improving short-term outcomes. However, there is marked heterogeneity in reported findings, with studies mostly based on single-centered data, limiting generalizability. We sought to examine population-level patterns of demand for critical care resources, and the characteristics, resource utilization, and outcomes of ICU-managed adults with CF. Methods We used the Texas Inpatient Public Use Data File to identify ICU admissions with CF aged ≥18 years in Texas between 2004–2013. We examined ICU utilization at population level (using CF Foundation annual reports) and, among ICU admissions, socio-demographic characteristics, burden of comorbidities, organ failure, life-support utilization and hospital disposition. Linear regression and multilevel logistic regression were used to examine temporal trends and predictors of short-term mortality (hospital death and discharge to hospice), respectively. Results Of 9,579 hospitalizations of adults with CF, 1,249 (13%) were admitted to ICU. The incidence of ICU admission among adults with CF in Texas increased between 2004–2005 and 2012–2013 from 16.7 to 19.2 per 100 person-years (p = 0.0181), with ICU admissions aged ≥30 years accounting for 80.3% of the change. Among ICU admissions the following changes were noted between 2004–2005 and 2012–2013: any organ failure 30.2% vs. 56.3% (p = 0.0004), mechanical ventilation 11.5% vs. 19.2% (p = 0.0216), and hemodialysis 1.0% vs. 8.1% (p = 0.0007). Short-term mortality for the whole cohort and for those with mechanical ventilation was 11.4% and 41.8%, respectively, with corresponding home discharge among survivors 84% and 62.1%, respectively. Key predictors (adjusted odds ratios [aOR (95% CI)]) of short-term mortality included age ≥45 years (2.051 [1.231–3.415]), female gender (1.907 [1.237–2.941]), and mechanical ventilation (7.982 [5.001–12.739]). Conclusions Adults with CF had high and rising population-level burden of critical illness. Although ICU admissions were increasingly older and sicker, the majority survived hospitalization, with most discharged home, supporting short-term benefits of critical care in the present cohort.
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Affiliation(s)
- Lavi Oud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center at the Permian Basin, Odessa, Texas, United States
- * E-mail:
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Larsen GY, Schober M, Fabio A, Wisniewski SR, Grant MJC, Shafi N, Bennett TD, Hirtz D, Bell MJ. Structure, Process, and Culture Differences of Pediatric Trauma Centers Participating in an International Comparative Effectiveness Study of Children with Severe Traumatic Brain Injury. Neurocrit Care 2017; 24:353-60. [PMID: 26627225 DOI: 10.1007/s12028-015-0218-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is an important worldwide cause of death and disability for children. The Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial is an observational, cohort study to compare the effectiveness of six aspects of TBI care. Understanding the differences between clinical sites-including their structure, clinical processes, and culture differences-will be necessary to assess differences in outcome from the study and can inform the overall community regarding differences across academic centers. METHODS We developed a survey and queried ADAPT site principal investigators with a focus on six domains: (i) hospital, (ii) pediatric intensive care unit (PICU), (iii) medical staff characteristics, (iv) quality of care, (v) medication safety, and (vi) safety culture. Summary statistics were used to describe differences between centers. RESULTS ADAPT clinical sites that enrolled a subject within the first year (32 US-based, 11 international) were studied. A wide variation in site characteristics was observed in hospital and ICU characteristics, including an almost sevenfold range in ICU size (8-55 beds) and more than fivefold range of overall ICU admissions (537-2623). Nursing staffing (predominantly 1:1 or 1:2) and the presence of pharmacists within the ICU (79 %) were less variable, and most sites "strongly agreed" or "agreed" that Neurosurgery and Critical Care teams worked well together (81.4 %). However, a minority of sites (46 %) used an explicit protocol for treatment of children with severe TBI care. CONCLUSIONS We found a variety of inter-center structure, process, and culture differences. These intrinsic differences between sites may begin to explain why interventional studies have failed to prove efficacy of experimental therapies. Understanding these differences may be an important factor in analyzing future ADAPT trial results and in determining best practices for pediatric severe TBI.
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Affiliation(s)
- Gitte Y Larsen
- Departments of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michelle Schober
- Departments of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Anthony Fabio
- Departments of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Mary Jo C Grant
- Departments of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Nadeem Shafi
- Department of Pediatrics, University of Tennessee, Memphis, TN, USA
| | - Tellen D Bennett
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | - Deborah Hirtz
- Division of Extramural Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Michael J Bell
- Department Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh, 3434 Fifth Avenue, Pittsburgh, PA, 15260, USA.
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Organizational Issues, Structure, and Processes of Care in 257 ICUs in Latin America: A Study From the Latin America Intensive Care Network. Crit Care Med 2017; 45:1325-1336. [PMID: 28437376 DOI: 10.1097/ccm.0000000000002413] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Latin America bears an important burden of critical care disease, yet the information about it is scarce. Our objective was to describe structure, organization, processes of care, and research activities in Latin-American ICUs. DESIGN Web-based survey submitted to ICU directors. SETTINGS ICUs located in nine Latin-American countries. SUBJECTS Individual ICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred fifty-seven of 498 (52%) of submitted surveys responded: 51% from Brazil, 17% Chile, 13% Argentina, 6% Ecuador, 5% Uruguay, 3% Colombia, and 5% between Mexico, Peru, and Paraguay. Seventy-nine percent of participating hospitals had less than 500 beds; most were public (59%) and academic (66%). ICUs were mainly medical-surgical (75%); number of beds was evenly distributed in the entire cohort; 77% had 24/7 intensivists; 46% had a physician-to-patient ratio between 1:4 and 7; and 69% had a nurse-to-patient ratio of 1 ≥ 2.1. The 24/7 presence of other specialists was deficient. Protocols in use averaged 9 ± 3. Brazil (vs the rest) had larger hospitals and ICUs and more quality, surveillance, and prevention committees, but fewer 24/7 intensivists and poorer nurse-to-patient ratio. Although standard monitoring, laboratory, and imaging practices were almost universal, more complex measurements and treatments and portable equipment were scarce after standard working hours, and in public hospitals. Mortality was 17.8%, without differences between countries. CONCLUSIONS This multinational study shows major concerns in the delivery of critical care across Latin America, particularly in human resources. Technology was suboptimal, especially in public hospitals. A 24/7 availability of supporting specialists and of key procedures was inadequate. Mortality was high in comparison to high-income countries.
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Kerlin MP, Adhikari NKJ, Rose L, Wilcox ME, Bellamy CJ, Costa DK, Gershengorn HB, Halpern SD, Kahn JM, Lane-Fall MB, Wallace DJ, Weiss CH, Wunsch H, Cooke CR. An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients. Am J Respir Crit Care Med 2017; 195:383-393. [PMID: 28145766 DOI: 10.1164/rccm.201611-2250st] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Studies of nighttime intensivist staffing have yielded mixed results. GOALS To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients. METHODS We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models. RESULTS Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes. CONCLUSIONS Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.
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Driscoll A, Grant MJ, Carroll D, Dalton S, Deaton C, Jones I, Lehwaldt D, McKee G, Munyombwe T, Astin F. The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. Eur J Cardiovasc Nurs 2017; 17:6-22. [DOI: 10.1177/1474515117721561] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Nurses are pivotal in the provision of high quality care in acute hospitals. However, the optimal dosing of the number of nurses caring for patients remains elusive. In light of this, an updated review of the evidence on the effect of nurse staffing levels on patient outcomes is required. Aim: To undertake a systematic review and meta-analysis examining the association between nurse staffing levels and nurse-sensitive patient outcomes in acute specialist units. Methods: Nine electronic databases were searched for English articles published between 2006 and 2017. The primary outcomes were nurse-sensitive patient outcomes. Results: Of 3429 unique articles identified, 35 met the inclusion criteria. All were cross-sectional and the majority utilised large administrative databases. Higher staffing levels were associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and a greater number of patients receiving percutaneous coronary intervention within 90 minutes. A meta-analysis involving 175,755 patients, from six studies, admitted to the intensive care unit and/or cardiac/cardiothoracic units showed that a higher nurse staffing level decreased the risk of inhospital mortality by 14% (0.86, 95% confidence interval 0.79–0.94). However, the meta-analysis also showed high heterogeneity (I2=86%). Conclusion: Nurse-to-patient ratios influence many patient outcomes, most markedly inhospital mortality. More studies need to be conducted on the association of nurse-to-patient ratios with nurse-sensitive patient outcomes to offset the paucity and weaknesses of research in this area. This would provide further evidence for recommendations of optimal nurse-to-patient ratios in acute specialist units.
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Affiliation(s)
- Andrea Driscoll
- Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University, Australia
| | - Maria J Grant
- School of Nursing, Midwifery, Social Work & Social Sciences, University of Salford, UK
| | - Diane Carroll
- Munn Center for Nursing Research, Massachusetts General Hospital, USA
| | | | - Christi Deaton
- Department of Public Health and Primary Care, University of Cambridge, UK
| | - Ian Jones
- School of Nursing and Allied Health, Liverpool John Moores University, UK
| | - Daniela Lehwaldt
- Department of Nursing and Human Sciences, Dublin City University, Ireland
| | - Gabrielle McKee
- School of Nursing & Midwifery, Trinity College Dublin, Ireland
| | | | - Felicity Astin
- Research and Development Department, University of Huddersfield and Calderdale and Huddersfield NHS Foundation Trust, UK
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Chiou H, Jopling JK, Scott JY, Ramsey M, Vranas K, Wagner TH, Milstein A. Detecting organisational innovations leading to improved ICU outcomes: a protocol for a double-blinded national positive deviance study of critical care delivery. BMJ Open 2017; 7:e015930. [PMID: 28615274 PMCID: PMC5541524 DOI: 10.1136/bmjopen-2017-015930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION There is substantial variability in intensive care unit (ICU) utilisation and quality of care. However, the factors that drive this variation are poorly understood. This study uses a novel adaptation of positive deviance approach-a methodology used in public health that assumes solutions to challenges already exist within the system to detect innovations that are likely to improve intensive care. METHODS AND ANALYSIS We used the Philips eICU Research Institute database, containing 3.3 million patient records from over 50 health systems across the USA. Acute Physiology and Chronic Health Evaluation IVa scores were used to identify the study cohort, which included ICU patients whose outcomes were felt to be most sensitive to organisational innovations. The primary outcomes included mortality and length of stay. Outcome measurements were directly standardised, and bootstrapped CIs were calculated with adjustment for false discovery rate. Using purposive sampling, we then generated a blinded list of five positive outliers and five negative comparators.Using rapid qualitative inquiry (RQI), blinded interdisciplinary site visit teams will conduct interviews and observations using a team ethnography approach. After data collection is completed, the data will be unblinded and analysed using a cross-case method to identify themes, patterns and innovations using a constant comparative grounded theory approach. This process detects the innovations in intensive care and supports an evaluation of how positive deviance and RQI methods can be adapted to healthcare. ETHICS AND DISSEMINATION The study protocol was approved by the Stanford University Institutional Review Board (reference: 39509). We plan on publishing study findings and methodological guidance in peer-reviewed academic journals, white papers and presentations at conferences.
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Affiliation(s)
- Howard Chiou
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Emory University School of Medicine Medical Scientist Training Program and Department of Anthropology, Emory University, Atlanta, USA
| | - Jeffrey K Jopling
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Gordon and Betty Moore Foundation, Palo Alto, USA
| | - Jennifer Yang Scott
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Meghan Ramsey
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Kelly Vranas
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
- Oregon Health & Science University, Portland, OR, USA
| | - Todd H Wagner
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University, Stanford, California, USA
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Prevalence of healthcare-associated infections in Polish adult intensive care units: summary data from the ECDC European Point Prevalence Survey of Hospital-associated Infections and Antimicrobial Use in Poland 2012–2014. J Hosp Infect 2017; 96:145-150. [DOI: 10.1016/j.jhin.2016.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 12/28/2016] [Indexed: 12/29/2022]
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Raymondos K, Dirks T, Quintel M, Molitoris U, Ahrens J, Dieck T, Johanning K, Henzler D, Rossaint R, Putensen C, Wrigge H, Wittich R, Ragaller M, Bein T, Beiderlinden M, Sanmann M, Rabe C, Schlechtweg J, Holler M, Frutos-Vivar F, Esteban A, Hecker H, Rosseau S, von Dossow V, Spies C, Welte T, Piepenbrock S, Weber-Carstens S. Outcome of acute respiratory distress syndrome in university and non-university hospitals in Germany. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:122. [PMID: 28554331 PMCID: PMC5448143 DOI: 10.1186/s13054-017-1687-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/02/2017] [Indexed: 01/06/2023]
Abstract
Background This study investigates differences in treatment and outcome of ventilated patients with acute respiratory distress syndrome (ARDS) between university and non-university hospitals in Germany. Methods This subanalysis of a prospective, observational cohort study was performed to identify independent risk factors for mortality by examining: baseline factors, ventilator settings (e.g., driving pressure), complications, and care settings—for example, case volume of ventilated patients, size/type of intensive care unit (ICU), and type of hospital (university/non-university hospital). To control for potentially confounding factors at ARDS onset and to verify differences in mortality, ARDS patients in university vs non-university hospitals were compared using additional multivariable analysis. Results Of the 7540 patients admitted to 95 ICUs from 18 university and 62 non-university hospitals in May 2004, 1028 received mechanical ventilation and 198 developed ARDS. Although the characteristics of ARDS patients were very similar, hospital mortality was considerably lower in university compared with non-university hospitals (39.3% vs 57.5%; p = 0.012). Treatment in non-university hospitals was independently associated with increased mortality (OR (95% CI): 2.89 (1.31–6.38); p = 0.008). This was confirmed by additional independent comparisons between the two patient groups when controlling for confounding factors at ARDS onset. Higher driving pressures (OR 1.10; 1 cmH2O increments) were also independently associated with higher mortality. Compared with non-university hospitals, higher positive end-expiratory pressure (PEEP) (mean ± SD: 11.7 ± 4.7 vs 9.7 ± 3.7 cmH2O; p = 0.005) and lower driving pressures (15.1 ± 4.4 vs 17.0 ± 5.0 cmH2O; p = 0.02) were applied during therapeutic ventilation in university hospitals, and ventilation lasted twice as long (median (IQR): 16 (9–29) vs 8 (3–16) days; p < 0.001). Conclusions Mortality risk of ARDS patients was considerably higher in non-university compared with university hospitals. Differences in ventilatory care between hospitals might explain this finding and may at least partially imply regionalization of care and the export of ventilatory strategies to non-university hospitals. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1687-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Konstantinos Raymondos
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Tamme Dirks
- Department of Cardiology, KRH Klinikum Robert Koch Gehrden, Gehrden, Germany
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, Göttingen University Hospital, Göttingen, Germany
| | - Ulrich Molitoris
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jörg Ahrens
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Links der Weser, Bremen, Germany
| | - Thorben Dieck
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Kai Johanning
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Dietrich Henzler
- Department of Anaesthesiology, Herford Hospital, Herford, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Bonn University Hospital, Bonn, Germany
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Ralph Wittich
- Department of Anaesthesiology and Intensive Care Medicine, Carl Thieme Hospital, Cottbus, Germany
| | - Maximilian Ragaller
- Department of Anaesthesiology and Intensive Care Medicine, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Thomas Bein
- Department of Anaesthesiology, Regensburg University Hospital, Regensburg, Germany
| | - Martin Beiderlinden
- Department of Anaesthesiology and Intensive Care Medicine, Essen University Hospital, Essen, Germany
| | - Maxi Sanmann
- Department of Anaesthesiology, Dietrich-Bonhoeffer Hospital, Neubrandenburg, Germany
| | - Christian Rabe
- Department of Internal Medicine, Bonn University Hospital, Bonn, Germany
| | - Jörn Schlechtweg
- Department of Anaesthesiology, Klinikum Bad Salzungen, Bad Salzungen, Germany
| | - Monika Holler
- Department of Anaesthesiology and Intensive Care Medicine, Municipal Hospital Martha-Maria Halle-Dölau, Halle, Germany
| | - Fernando Frutos-Vivar
- Department of Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Andres Esteban
- Department of Intensive Care Unit, Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Hartmut Hecker
- Department of Biometry, Hannover Medical School, Hannover, Germany
| | - Simone Rosseau
- Department of Internal Medicine, Division Infectiology and Pulmonology, Charité University Hospital, Berlin, Germany
| | - Vera von Dossow
- Department of Anesthesiology and Intensive Care, Ludwig-Maximilians-Universität München, Geschwister-Scholl-Platz 1, 80539, München, Germany.
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité University Hospital, Berlin, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Siegfried Piepenbrock
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Steffen Weber-Carstens
- Department of Anaesthesiology and Intensive Care Medicine, Charité University Hospital, Berlin, Germany
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Lee A, Cheung YSL, Joynt GM, Leung CCH, Wong WT, Gomersall CD. Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Ann Intensive Care 2017; 7:46. [PMID: 28466462 PMCID: PMC5413463 DOI: 10.1186/s13613-017-0269-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 04/11/2017] [Indexed: 01/08/2023] Open
Abstract
Background Despite the central role of nurses in intensive care, a relationship between intensive care nurse workload/staffing ratios and survival has not been clearly established. We determined whether there is a threshold workload/staffing ratio above which the probability of hospital survival is reduced and then modeled the relationship between exposure to inadequate staffing at any stage of a patient’s ICU stay and risk-adjusted hospital survival. Methods Retrospective analysis of prospectively collected data from a cohort of adult patients admitted to two multi-disciplinary Intensive Care Units was performed. The nursing workload [measured using the Therapeutic Intervention Scoring System (TISS-76)] for all patients in the ICU during each day to average number of bedside nurses per shift on that day (workload/nurse) ratio, severity of illness (using Acute Physiology and Chronic Health Evaluation III) and hospital survival were analysed using net-benefit regression methodology and logistic regression. Results A total of 894 separate admissions, representing 845 patients, were analysed. Our analysis shows that there was a 95% probability that survival to hospital discharge was more likely to occur when the maximum workload-to-nurse ratio was <40 and a more than 95% chance that death was more likely to occur when the ratio was >52. Patients exposed to a high workload/nurse ratio (≥52) for ≥1 day during their ICU stay had lower risk-adjusted odds of survival to hospital discharge compared to patients never exposed to a high ratio (odds ratio 0.35, 95% CI 0.16–0.79). Conclusions Exposing critically ill patients to high workload/staffing ratios is associated with a substantial reduction in the odds of survival. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0269-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4th Floor, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | | | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4th Floor, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Czarina Chi Hung Leung
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4th Floor, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Wai-Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4th Floor, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong
| | - Charles David Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4th Floor, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong.
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Accomplishing professional jurisdiction in intensive care: An ethnographic study of three units. Soc Sci Med 2017; 181:102-111. [PMID: 28388452 DOI: 10.1016/j.socscimed.2017.03.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 03/18/2017] [Accepted: 03/22/2017] [Indexed: 11/20/2022]
Abstract
This paper reports an ethnographic study examining health professional jurisdictions within three intensive care units (ICUs) in order to draw out the social processes through which ICU clinicians organised and delivered life-saving care to critically ill patients. Data collection consisted of 240 h observation of actual practice and 27 interviews with health professionals. The research was conducted against a backdrop of international political and public pressure for national healthcare systems to deliver safe, quality and efficient healthcare. As in many Western health systems, for the English Department of Health the key to containing these challenges was a reconfiguration of responsibilities for clinicians in order to break down professional boundaries and encourage greater interprofessional working under the guise of workforce modernisation. In this paper, through the analysis of health professional interaction, we examine the properties and conditions under which professional jurisdiction was negotiated and accomplished in day-to-day ICU practice. We discuss how staff seniority influenced the nature of professional interaction and how jurisdictional boundaries were reproduced and reconfigured under conditions of routine and urgent work. Consequently, we question theorisation that treats individual professions as homogenous groups and overlooks fluctuation in the flow and intensity of work; and conclude that in ICU, urgency and seniority have a part to play in shaping jurisdictional boundaries at the level of day-to-day practice.
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Simpson CE, Sahetya SK, Bradsher RW, Scholten EL, Bain W, Siddique SM, Hager DN. Outcomes of Emergency Medical Patients Admitted to an Intermediate Care Unit With Detailed Admission Guidelines. Am J Crit Care 2017; 26:e1-e10. [PMID: 27965236 DOI: 10.4037/ajcc2017253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND An important, but not well characterized, population receiving intermediate care is that of medical patients admitted directly from the emergency department. OBJECTIVE To characterize emergency medical patients and their outcomes when admitted to an intermediate care unit with clearly defined admission guidelines. METHODS Demographic data, admitting diagnoses, illness severity, comorbid conditions, lengths of stay, and hospital mortality were characterized for all emergency medical patients admitted directly to an intermediate care unit from July through December 2012. RESULTS A total of 317 unique patients were admitted (mean age, 54 [SD, 16] years). Most patients were admitted with respiratory (26.5%) or cardiac (17.0%) syndromes. The mean (SD) Acute Physiology and Chronic Health Evaluation score version II, Simplified Acute Physiology Score version II, and Charlson Comorbidity Index were 15.6 (6.5), 20.7 (11.8), and 2.7 (2.3), respectively. Severity of illness and length of stay were significantly different for patients who required intensive care within 24 hours of admission (n = 16) or later (n = 25), patients who continued with inter mediate care for more than 24 hours (n = 247), and patients who were downgraded or discharged in less than 24 hours (n = 29). Overall hospital mortality was 4.4% (14 deaths). CONCLUSIONS Emergency medical patients with moderate severity of illness and comorbidity can be admitted to an intermediate level of care with relatively infrequent transfer to intensive care and relatively low mortality.
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Affiliation(s)
- Catherine E Simpson
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Sarina K Sahetya
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Robert W Bradsher
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Eric L Scholten
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - William Bain
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Shazia M Siddique
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - David N Hager
- David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University. David N. Hager, MD, PhD, Johns Hopkins University, Sheikh Zayed Tower, Ste 9121, 1800 Orleans St, Baltimore, MD 21287 (e-mail: )
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Prin M, Li G. Complications and in-hospital mortality in trauma patients treated in intensive care units in the United States, 2013. Inj Epidemiol 2016; 3:18. [PMID: 27747555 PMCID: PMC4974260 DOI: 10.1186/s40621-016-0084-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/02/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Traumatic injury is a leading cause of morbidity and mortality worldwide, but epidemiologic data about trauma patients who require intensive care unit (ICU) admission are scant. This study aimed to describe the annual incidence of ICU admission for adult trauma patients, including an assessment of risk factors for hospital complications and mortality in this population. METHODS This was a retrospective study of adults hospitalized at Level 1 and Level 2 trauma centers after trauma and recorded in the National Trauma Data Bank in 2013. Multiple logistic regression analyses were performed to determine predictors of hospital complications and hospital mortality for those who required ICU admission. RESULTS There were an estimated total of 1.03 million ICU admissions for trauma at Level 1 and Level 2 trauma centers in the United States in 2013, yielding an annual incidence of 3.3 per 1000 population. The annual incidence was highest in men (4.6 versus 1.9 per 100,000 for women), those aged 80 years or older (7.8 versus 3.6-4.3 per 100,000 in other age groups), and residents in the Western US Census region (3.9 versus 2.7 to 3.6 per 100,000 in other regions). The most common complications in patients admitted to the ICU were pneumonia (10.9 %), urinary tract infection (4.7 %), and acute respiratory distress syndrome (4.4 %). Hospital mortality was significantly higher for ICU patients who developed one or more complications (16.9 % versus 10.7 % for those who did not develop any complications, p < 0.001). CONCLUSIONS Admission to the ICU after traumatic injury is common, and almost a quarter of these patients experience hospital complications. Hospital complications are associated with significantly increased risk of mortality.
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Affiliation(s)
- Meghan Prin
- Department of Anesthesiology & Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 505, New York, NY 10032 USA
| | - Guohua Li
- Department of Anesthesiology & Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 505, New York, NY 10032 USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
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Raj R, Bendel S, Reinikainen M, Hoppu S, Luoto T, Ala-Kokko T, Tetri S, Laitio R, Koivisto T, Rinne J, Kivisaari R, Siironen J, Skrifvars MB. Traumatic brain injury patient volume and mortality in neurosurgical intensive care units: a Finnish nationwide study. Scand J Trauma Resusc Emerg Med 2016; 24:133. [PMID: 27821129 PMCID: PMC5100100 DOI: 10.1186/s13049-016-0320-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023] Open
Abstract
Background Differences in outcomes after traumatic brain injury (TBI) between neurosurgical centers exist, although the reasons for this are not clear. Thus, our aim was to assess the association between the annual volume of TBI patients and mortality in neurosurgical intensive care units (NICUs). Methods We collected data on all patients treated in the five Finnish university hospitals to examine all patients with TBI treated in NICUs in Finland from 2009 to 2012. We used a random effect logistic regression model to adjust for important prognostic factors to assess the independent effect of ICU volume on 6-month mortality. Subgroup analyses were performed for patients with severe TBI, moderate-to-severe TBI, and those who were undergoing mechanical ventilation or intracranial pressure monitoring. Results Altogether 2,328 TBI patients were treated during the study period in five NICUs. The annual TBI patient volume ranged from 61 to 206 patients between the NICUs. Univariate analysis, showed no association between the NICUs’ annual TBI patient volume and 6-month mortality (p = 0.063). The random effect model showed no independent association between the NICUs’ annual TBI patient volume and 6-month mortality (OR = 1.000, 95% CI = 0.996–1.004, p = 0.876). None of the pre-defined subgroup analyses indicated any association between NICU volume and patient mortality (p > 0.05 for all). Discussion and Conclusion We did not find any association between annual TBI patient volume and 6-month mortality in NICUs. These findings should be interpreted taking into account that we only included NICUs, which by international standards all treated high volumes of TBI patients, and that we were not able to study the effect of NICU volume on neurological outcome. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0320-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, FI-00029 HUS, Helsinki, Finland.
| | - Stepani Bendel
- Division of Intensive Care, Kuopio University Hospital, Puijonlaaksontie 2, PB-100, FI-70029 KYS, Kuopio, Finland
| | - Matti Reinikainen
- Division of Intensive Care, North Karelia Central Hospital, Tikkamäentie 16, 80210, Joensuu, Finland
| | - Sanna Hoppu
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tampere University Hospital, Teiskontie 35, PB-2000, FI-33521, Tampere, Finland
| | - Teemu Luoto
- Department of Neurosurgery, University of Tampere, Medical School, and Tampere University Hospital, Teiskontie 35, PB-2000, FI-33521, Tampere, Finland
| | - Tero Ala-Kokko
- Division of Intensive Care, Department of Anaesthesiology, Oulu University Hospital and Oulu University, Medical Research Center Oulu, Oulu, Finland.,Research Group of Surgery, Anaesthesia and Intensive Care, Medical Faculty, University of Oulu, PB-22 OUH, FI-90029, Oulu, Finland
| | - Sami Tetri
- Department of Neurosurgery, Oulu University Hospital, Kajaanintie 50, 90220, Oulu, Finland
| | - Ruut Laitio
- Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Timo Koivisto
- Department of Neurosurgery, Kuopio University Hospital, Puijonlaaksontie 2, PB-100, FI-70029 KYS, Kuopio, Finland
| | - Jaakko Rinne
- Department of Neurosurgery, Turku University Hospital and University of Turku, Hämeentie 11, PB-52, FI-20251, Turku, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, FI-00029 HUS, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, FI-00029 HUS, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, PB-340, FI-00029 HUS, Helsinki, Finland.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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132
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Nurse workload and inexperienced medical staff members are associated with seasonal peaks in severe adverse events in the adult medical intensive care unit: A seven-year prospective study. Int J Nurs Stud 2016; 62:60-70. [DOI: 10.1016/j.ijnurstu.2016.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 11/22/2022]
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133
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Soares M, Bozza FA, Angus DC, Japiassú AM, Viana WN, Costa R, Brauer L, Mazza BF, Corrêa TD, Nunes ALB, Lisboa T, Colombari F, Maciel AT, Azevedo LCP, Damasceno M, Fernandes HS, Cavalcanti AB, do Brasil PEAA, Kahn JM, Salluh JIF. Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study. Intensive Care Med 2016; 41:2149-60. [PMID: 26499477 DOI: 10.1007/s00134-015-4076-7] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/15/2015] [Indexed: 01/09/2023]
Abstract
PURPOSE Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs. METHODS Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients' data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score. RESULTS ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15-0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904-0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased. CONCLUSIONS In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.
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134
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Vincent JL. Evidence supports the superiority of closed ICUs for patients and families: Yes. Intensive Care Med 2016; 43:122-123. [PMID: 27586991 DOI: 10.1007/s00134-016-4466-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 07/27/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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135
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Martin-Loeches I, Wunderink RG, Nanchal R, Lefrant JY, Kapadia F, Sakr Y, Vincent JL. Determinants of time to death in hospital in critically ill patients around the world. Intensive Care Med 2016; 42:1454-60. [PMID: 27518322 DOI: 10.1007/s00134-016-4479-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/29/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE To investigate which factors influence time to death in hospital in critically ill patients worldwide, including the possible impact of gross national income (GNI). METHODS This was a pre-defined post hoc analysis of the Intensive Care Over Nations (ICON) database, which included 10,069 patients. For this sub-analysis, we included only the 2062 60-day in-hospital non-survivors (22.3 %) among the 9258 patients with available hospital mortality and length-of-stay data. We categorized these non-survivors into three groups according to the time of death after ICU admission: early (<5 days), intermediate (6-28 days) or late (>28 days). RESULTS Time to death in hospital was early in 1068 of the 2062 non-survivors (52 %), intermediate in 808 (39 %), and late in 186 (9 %). Patients who died early had higher severity scores and were more likely to require mechanical ventilation on ICU admission, whereas those who died late were more likely to be older and to have had infection on ICU admission or during the ICU stay. Multilevel analysis indicated a stepwise increase in the risk of late or intermediate deaths according to increasing GNI. Patients admitted to ICUs in countries with high or upper-middle GNI were more likely to die late than those admitted to countries with low/lower-middle GNI [odds ratio (95 % confidence interval) 4.78 (1.94-11.76), p < 0.001, and 1.64 (1.10-2.45), p = 0.02, respectively]. CONCLUSIONS Duration of hospital stay prior to death in critically ill patients is longer in older patients, surgical patients, and patients with infection. GNI is a major determinant of time to death in hospital in these patients. These observations may have important organizational and ethical implications.
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Affiliation(s)
- Ignacio Martin-Loeches
- Corporacion Sanitaria Parc Taulí, CIBER Enfermedades Respiratorias, Parc Tauli University Institute, Sabadell, Spain
| | | | - Rahul Nanchal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jean Yves Lefrant
- Service FOREVA, Division Anesthésie Réanimation Douleur Urgence, CHU Nîmes, Nîmes, France
| | - Farhad Kapadia
- Department of Critical Care, Hinduja Hospital, Mumbai, India
| | - Yasser Sakr
- Department of Intensive Care, Universitätsklinikum Jena, Jena, Germany
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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136
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Soares M, Bozza FA, Azevedo LCP, Silva UVA, Corrêa TD, Colombari F, Torelly AP, Varaschin P, Viana WN, Knibel MF, Damasceno M, Espinoza R, Ferez M, Silveira JG, Lobo SA, Moraes APP, Lima RA, de Carvalho AGR, do Brasil PEAA, Kahn JM, Angus DC, Salluh JIF. Effects of Organizational Characteristics on Outcomes and Resource Use in Patients With Cancer Admitted to Intensive Care Units. J Clin Oncol 2016; 34:3315-24. [PMID: 27432921 DOI: 10.1200/jco.2016.66.9549] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs). PATIENTS AND METHODS We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients' clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU. RESULTS Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use. CONCLUSION Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.
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Affiliation(s)
- Marcio Soares
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Fernando A Bozza
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Luciano C P Azevedo
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ulysses V A Silva
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thiago D Corrêa
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Fernando Colombari
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - André P Torelly
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Pedro Varaschin
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - William N Viana
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marcos F Knibel
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Moyzés Damasceno
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rodolfo Espinoza
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Marcus Ferez
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Juliana G Silveira
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Suzana A Lobo
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ana Paula P Moraes
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ricardo A Lima
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Alexandre G R de Carvalho
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Pedro E A A do Brasil
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeremy M Kahn
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Derek C Angus
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jorge I F Salluh
- Marcio Soares, Fernando A. Bozza, Pedro E.A.A. do Brasil, and Jorge I.F. Salluh, D'Or Institute for Research and Education; Fernando A. Bozza and Pedro E.A.A. do Brasil, Instituto Nacional de Infectologia Evandro Chagas, Instituto Oswaldo Cruz-Fiocruz; Pedro Varaschin, Hospital Pasteur; William N. Viana, Hospital Copa D'Or; Marcos F. Knibel, Hospital São Lucas Copacabana; Rodolfo Espinoza, Hospital do Câncer II-Instituto Nacional de Câncer; Juliana G. Silveira, Hospital Quinta D'Or; Ricardo A. Lima, Hospital Samaritano, Rio de Janeiro; Luciano C.P. Azevedo, Hospital Sírio-Libanês; Thiago D. Corrêa, Hospital Israelita Albert Einstein; Fernando Colombari, Hospital Alemão Oswaldo Cruz, São Paulo; Ulysses V.A. Silva, Fundação Pio XII-Hospital de Câncer de Barretos, Barretos; André P. Torelly, Complexo Hospitalar, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre; Moyzés Damasceno, Complexo Hospitalar de Niterói, Niterói; Marcus Ferez, Hospital São Francisco, Ribeirão Preto; Suzana A. Lobo, Hospital de Base de São José do Rio Preto, São José do Rio Preto; Ana Paula P. Moraes, Hospital de Câncer do Maranhão Dr Tarquinio Lopes Filho; Alexandre G.R. de Carvalho, UDI Hospital, São Luís, Brazil; Jeremy M. Kahn, University of Pittsburgh Graduate School of Public Health; and Jeremy M. Kahn and Derek C. Angus, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Abstract
Abstract
Background
The relationship between annualized case volume and mortality in patients with sepsis is not fully understood. The authors performed a dose–response meta-analysis to assess the effect of annualized case volume on mortality among patients with sepsis in the intensive care unit, emergency department, or hospital, hypothesizing that higher annualized case volume may lead to lower mortality.
Methods
The authors searched PubMed and Embase through July 2015 to identify observational studies that examined the relationship between annualized case volume and mortality in sepsis. The predefined outcome was mortality. Odds ratios with 95% CIs were pooled using a random-effects model.
Results
Ten studies involving 3,495,921 participants and 834,009 deaths were included. The pooled estimate suggested that annualized case volume was inversely associated with mortality (odds ratio, 0.76; 95% CI, 0.65 to 0.89; P = 0.001), with high heterogeneity (I2 = 96.6%). The relationship was consistent in most subgroup analyses and robust in sensitivity analysis. Dose–response analysis identified a nonlinear relationship between annualized case volume and mortality (P for nonlinearity less than 0.001).
Conclusions
This meta-analysis confirmed the study hypothesis and provided strong evidence for an inverse and a nonlinear dose–response relationship between annualized case volume and mortality in patients with sepsis. Variations in cutoff values of category for annualized case volume across studies may mainly result in the overall heterogeneity. Future studies should uncover the mechanism of volume–mortality relationship and standardize the cutoff values of category for annualized case volume in patients with sepsis.
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Research Advances in Critical Care: Targeting Patients' Physiological and Psychological Outcomes. BIOMED RESEARCH INTERNATIONAL 2015; 2015:283067. [PMID: 26587534 PMCID: PMC4637439 DOI: 10.1155/2015/283067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/14/2015] [Indexed: 11/17/2022]
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Sevransky JE, Checkley W, Herrera P, Pickering BW, Barr J, Brown SM, Chang SY, Chong D, Kaufman D, Fremont RD, Girard TD, Hoag J, Johnson SB, Kerlin MP, Liebler J, O'Brien J, O'Keefe T, Park PK, Pastores SM, Patil N, Pietropaoli AP, Putman M, Rice TW, Rotello L, Siner J, Sajid S, Murphy DJ, Martin GS. Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med 2015; 43:2076-84. [PMID: 26110488 PMCID: PMC5673100 DOI: 10.1097/ccm.0000000000001157] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized ICUs have superior patient outcomes compared with less highly protocolized ICUs. DESIGN Observational study in which participating ICUs completed a general assessment and enrolled new patients 1 day each week. PATIENTS A total of 6,179 critically ill patients. SETTING Fifty-nine ICUs in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was the number of ICU protocols; the primary outcome was hospital mortality. A total of 5,809 participants were followed prospectively, and 5,454 patients in 57 ICUs had complete outcome data. The median number of protocols per ICU was 19 (interquartile range, 15-21.5). In single-variable analyses, there were no differences in ICU and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in ICUs with a high versus low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between ICUs with high versus low numbers of protocols for lung protective ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and for spontaneous breathing trials (55% vs 51%; p = 0.27). CONCLUSIONS Clinical protocols are highly prevalent in U.S. ICUs. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality.
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Affiliation(s)
- Jonathan E Sevransky
- 1Division of Pulmonary, Allergy and Critical Care, Emory University, Atlanta, GA. 2Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD. 3Department of Anesthesia, Mayo Clinic, Rochester, MN. 4Department of Anesthesiology, Stanford University, Palo Alto, CA. 5Division of Pulmonary and Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City, UT. 6Division of Pulmonary and Critical Care, UCLA, Los Angeles, CA. 7Division of Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY. 8Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, CT. 9Division of Pulmonary and Critical Care, Meharry Medical College, Nashville, TN. 10Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research at the, Vanderbilt University School of Medicine, Nashville, TN. 11Division of Pulmonary and Critical Care, Drexel University, Philadelphia, PA. 12Department of Surgical Critical Care, University of Maryland, Baltimore, MD. 13Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Philadelphia, PA. 14Division of Pulmonary Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA. 15Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Ohio State University, Columbus, OH. 16Department of Surgery, University of Arizona, Tucson, AZ. 17Division of Acute Care Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI. 18Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY. 19Department of Surgery, Division of Thoracic Surgery, Division of Trauma, Burn & Critical Care, Brigham and Women's Hospital, Boston, MA. 20Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, NY. 21INOVA Fairfax Hospital, Falls Church, VA. 22Suburban Hospital, Bethesda, MD. 23Department of A
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Vincent JL, Rubenfeld GD. Does intermediate care improve patient outcomes or reduce costs? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:89. [PMID: 25774925 PMCID: PMC4346102 DOI: 10.1186/s13054-015-0813-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
ICUs are an essential but expensive part of all modern hospitals. With increasingly limited healthcare funding, methods to reduce expenditure without negatively influencing patient outcomes are, therefore, of interest. One possible solution has been the development of ‘intermediate care units’, which provide more intensive monitoring and patient management with higher nurse:patient ratios than the general ward but less than is offered in the ICU. However, although such units have been introduced in many hospitals, there is relatively little published, especially prospective, evidence to support the benefits of this approach on costs or patient outcomes. We review the available data and suggest that, where possible, a larger unit with combined intermediate care and intensive care beds in one location may be preferable in terms of greater flexibility and efficiency.
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