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Wilson ME, Rhudy LM, Ballinger BA, Tescher AN, Pickering BW, Gajic O. Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study. Intensive Care Med 2013; 39:1009-18. [DOI: 10.1007/s00134-013-2896-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 02/26/2013] [Indexed: 11/30/2022]
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Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness. Med Care 2013; 51:4-10. [PMID: 22874500 DOI: 10.1097/mlr.0b013e31826528a7] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND For patients recovering from severe acute illness, admission to a long-term acute care hospital (LTAC) is an increasingly common alternative to continued management in an intensive care unit (ICU). OBJECTIVE To examine the effectiveness of LTAC transfer in patients with chronic critical illness. RESEARCH DESIGN Retrospective cohort study in United States hospitals from 2002 to 2006. SUBJECTS Medicare beneficiaries with chronic critical illness, defined as mechanical ventilation and at least 14 days of intensive care. MEASURES Survival, costs, and hospital readmissions. We used multivariate analyses and instrumental variables to account for differences in patient characteristics, the timing of LTAC transfer, and selection bias. RESULTS A total of 234,799 patients met our definition of chronic critical illness. Of these, 48,416 (20.6%) were transferred to an LTAC. In the instrumental variable analysis, patients transferred to an LTAC experienced similar survival compared with patients who remained in an ICU [adjusted hazard ratio=0.99; 95% confidence interval (CI), 0.96 to 1.01; P=0.27). Total hospital-related costs in the 180 days after admission were lower among patients transferred to LTACs (adjusted cost difference=-$13,422; 95% CI, -26,662 to -223, P=0.046). This difference was attributable to a reduction in skilled nursing facility admissions (adjusted admission rate difference=-0.591; 95% CI, -0.728 to -0.454; P<0.001). Total Medicare payments were higher (adjusted cost difference=$15,592; 95% CI, 6343 to 24,842; P=0.001). CONCLUSIONS Patients with chronic critical illness transferred to LTACs experience similar survival compared with patients who remain in ICUs, incur fewer health care costs driven by a reduction in postacute care utilization, however, invoke higher overall Medicare payments.
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Lee H, Bae H. The Association of Nurse Staffing Levels and Patient Outcome in Intensive Care Units. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.2.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hyunjung Lee
- Department of Anesthesiology & Pain Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hongbeom Bae
- Department of Anesthesiology & Pain Medicine, Chonnam National University Hospital, Gwangju, Korea
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Sherenian M, Profit J, Schmidt B, Suh S, Xiao R, Zupancic JAF, DeMauro SB. Nurse-to-patient ratios and neonatal outcomes: a brief systematic review. Neonatology 2013; 104:179-83. [PMID: 23941740 DOI: 10.1159/000353458] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 06/04/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Higher patient-to-nurse ratios and nursing workload are associated with increased mortality in the adult intensive care unit (ICU). Most neonatal ICUs (NICUs) in the United Kingdom do not meet national staffing recommendations. The impact of staffing on outcomes in the NICU is unknown. OBJECTIVE To determine how nurse-to-patient ratios or nursing workload affects outcomes in the NICU. METHODS Two authors (M.S., S.S.) searched PubMed, Medline, and EMBASE for eligible studies. Included studies reported on both the outcomes of infants admitted to a NICU and nurse-to-patient ratios or workload, and were published between 1/1990 and 4/2010 in any language. The primary outcome was mortality before discharge, relative to nurse-to-patient ratios. Secondary outcomes were intraventricular hemorrhage, daily weight gain, days on assisted ventilation, days on oxygen and nosocomial infection. Study quality was assessed with the STROBE checklist. RESULTS Seven studies met the inclusion criteria. Three reported on the same group of patients. Only four studies reported death before discharge from the NICU relative to nurse-to-patient ratios. Three reported an association between lower nurse-to-patient ratios and higher mortality, and one reported just the opposite. Because each study used a different definition of nurse staffing, a meta-analysis could not be performed. CONCLUSIONS Nurse-to-patient ratios appear to affect outcomes of neonatal intensive care, but limitations of the existing literature prevent clear conclusions about optimal staffing strategies. Evidence-based standards for staffing could impact public policy and lead to improvements in patient safety and decreased rates of adverse outcomes. More research on this subject, including a standard and valid measure of nursing workload, is urgently needed.
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Affiliation(s)
- Michael Sherenian
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pa., USA
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Year in review in Intensive Care Medicine 2012: I. Neurology and neurointensive care, epidemiology and nephrology, biomarkers and inflammation, nutrition, experimentals. Intensive Care Med 2012; 39:232-46. [PMID: 23248038 PMCID: PMC3569582 DOI: 10.1007/s00134-012-2774-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 11/29/2012] [Indexed: 01/06/2023]
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Abstract
PURPOSE OF REVIEW Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas in which international data provide information relevant to clinical practice and resource allocation. RECENT FINDINGS International comparisons of ICU resources demonstrate that definitions of critical illness and ICU beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing. SUMMARY Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.
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Affiliation(s)
- Meghan Prin
- Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Hannah Wunsch
- Department of Anesthesiology, Columbia University, New York, NY, USA
- Department of Epidemiology, Columbia University, New York, NY, USA
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Pearson A, Pallas LO, Thomson D, Doucette E, Tucker D, Wiechula R, Long L, Porritt K, Jordan Z. Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments. INT J EVID-BASED HEA 2012; 4:337-84. [PMID: 21631774 DOI: 10.1111/j.1479-6988.2006.00055.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
UNLABELLED Background This systematic review set out to examine the impact, if any, of nursing workload and staffing on creating and maintaining healthy work environments. For the purposes of this review, the term 'healthy work environment' was defined as '. . . a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational performance'. This definition identifies nurse, patient and organisational outcomes as indicators of the establishment and maintenance of a healthy work environment. Objectives The review sought to determine the impact of: • Patient characteristics, nurse characteristics, system characteristics and system processes on workload, scheduling and concepts of productivity and utilisation • Workload, scheduling and concepts of productivity and utilisation on the quality of outcomes for clients, nurses and the system/organisation Search strategy The search strategy sought to find both published and unpublished studies and papers written in the English language. A three-step search strategy approach was used. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify optimal search terms followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second extensive search using all identified keywords and index terms was then undertaken. The third step consisted of a search of the reference lists of all identified reports and articles for additional studies. Selection criteria Types of studies: This review considered research papers that addressed the appropriateness and effectiveness of workload and staffing concepts in fostering a healthy work environment in healthcare. The types of papers to be considered included: meta-analysis, randomised controlled trials, quasi-randomised controlled trials, cohort studies, case-control studies, descriptive studies and correlational studies. TYPES OF PARTICIPANTS The review considered all participants involved or affected by workload and staffing concepts within the nursing workforce in a healthcare environment, including staff and patients. System and policy issues were also considered. Types of interventions: All workload and staffing strategies that impact on the work environment, patient and nurse outcomes were considered in this review. Types of outcome measures: Outcomes of interest were categorised into four groups: nursing staff outcomes, patient outcomes, organisational outcomes and system outcomes. Data collection and analysis Following assessment of methodological quality, data were extracted using data extraction tools based on the work of the Cochrane Collaboration and the Centre for Reviews and Dissemination. Statistical pooling was not possible and findings were presented in narrative form. Results Of the 2162 papers identified in the search, 171 were selected for full paper retrieval and assessed independently by two reviewers for methodological quality. A total of 40 papers were included in the review: one systematic review; one cohort study; and 38 correlational descriptive studies. Results were summarised in narrative form. The evidence suggests strong correlations between patient characteristics and work environments; and workload and staffing and the quality of outcomes for clients, nurses and the system/organisation. This gave rise to a number of recommendations for practice and for further research, such as: • A greater proportion of regulated staffing (i.e. registered nurses, enrolled nurses, practical or vocational nurses) is associated with improved outcomes related to the Functional Independence Measure score, the Short Form Health Survey (SF-36) vitality score, patient satisfaction with nursing care, patient adverse events (including atelectasis, decubitus ulcers, falls, pneumonia, postsurgical and treatment infection and urinary tract infections) • An increase in the number of registered nurse hours available is associated with improved patient outcomes in relation to falls, pneumonia, pressure ulcers, urinary tract infection, length of stay and postoperative infection rates.
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Affiliation(s)
- Alan Pearson
- The Joanna Briggs Institute, Royal Adelaide Hospital, Adelaide, South Australia, Australia; and Registered Nurses Association of Ontario, Toronto, Ontario, Canada
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Driscoll A, Currey J, George M, Davidson PM. Changes in health service delivery for cardiac patients: implications for workforce planning and patient outcomes. Aust Crit Care 2012; 26:55-7. [PMID: 23026243 DOI: 10.1016/j.aucc.2012.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 05/09/2012] [Accepted: 08/14/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Traditional dedicated coronary care units (CCU) are being decommissioned and cardiology precincts are evolving. These precincts often have cardiac and non-cardiac patients with a diverse array of acuity levels. Critical care trained cardiac nurses are frequently caring for lower acuity patients resulting in a deskilling of this experienced workforce. AIM The aim of this paper was to discuss the implications of restructuring CCUs on nursing workforce and patient outcomes. METHOD An integrated literature review was conducted. The following databases were searched for articles published between January 2000 and December 2011: Ovid Medline, CINHAL, EMBASE and Cochrane. Additional studies obtained from the articles searched and policy documents from key professional organisations and government departments were reviewed. RESULTS This review has highlighted the association between workforce, qualifications and quality of care. Studies have shown the relationship between an increase in critical care qualified nursing staff and an improvement in patient outcomes. Inadequate staffing levels were also shown to be associated with an increase in adverse events. Cardiology precincts have the potential to adversely impact on critical care trained cardiac nursing workforce and patient outcomes. CONCLUSION The implications that these new models have on the critical care cardiac nurse workforce are crucial to health care reform, quality of in-hospital care, sentinel events and patient outcomes.
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Affiliation(s)
- Andrea Driscoll
- School of Nursing, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia.
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Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL, Parrillo JE, Peterson PN, Winkelman C. Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models. Circulation 2012; 126:1408-28. [DOI: 10.1161/cir.0b013e31826890b0] [Citation(s) in RCA: 199] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Graham MM, Ghali WA, Southern DA, Traboulsi M, Knudtson ML. Outcomes of after-hours versus regular working hours primary percutaneous coronary intervention for acute myocardial infarction. BMJ Qual Saf 2012; 20:60-7. [PMID: 21228077 PMCID: PMC3022364 DOI: 10.1136/bmjqs.2010.041137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Primary percutaneous coronary intervention (PCI) is a proven therapy for acute ST-segment elevation myocardial infarction. However, outcomes associated with primary PCI may differ depending on time of day. Methods and results Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease, a clinical data-collection initiative capturing all cardiac catheterisation patients in Alberta, Canada, the authors described and compared crude and risk-adjusted survival for ST-segment elevation myocardial infarction patients undergoing primary PCI after-hours versus regular working hours. From 1 January 1999 to 31 March 2006, 1664 primary PCI procedures were performed (54.4% after-hours). Mortalities at 30 days were 3.6% for regular hours procedures and 5.0% for after-hours procedures (p=0.16). 1-year mortalities were 6.2% and 7.3% in the regular hours and after-hours groups, respectively (p=0.35). After adjusting for baseline risk factor differences, HRs for after-hours mortality were 1.26 (95% CI 0.78 to 2.02) for survival to 30 days and 1.08 (0.73 to 1.59) for survival to 1 year. A meta-analysis of our after-hours HR point estimate with other published risk estimates for after hours primary PCI outcomes yielded an RR of 1.23 (1.00 to 1.51) for shorter-term outcomes. Conclusions After-hours primary PCI was not associated with a statistically significant increase in mortality. However, a meta-analysis of this study with other published after-hours outcome studies yields an RR that leaves some questions about unexplored factors that may influence after-hours primary PCI care.
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162
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Measuring the nursing workload per shift in the ICU. Intensive Care Med 2012; 38:1438-44. [DOI: 10.1007/s00134-012-2648-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 06/21/2012] [Indexed: 10/28/2022]
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Endacott R. The continuing imperative to measure workload in ICU: impact on patient safety and staff well-being. Intensive Care Med 2012; 38:1415-7. [DOI: 10.1007/s00134-012-2654-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/04/2012] [Indexed: 11/30/2022]
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Quantitative Assessment of Workload and Stressors in Clinical Radiation Oncology. Int J Radiat Oncol Biol Phys 2012; 83:e571-6. [DOI: 10.1016/j.ijrobp.2012.01.063] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 01/19/2012] [Accepted: 01/20/2012] [Indexed: 11/23/2022]
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Twins born over weekends: are they at risk for elevated infant mortality? Arch Gynecol Obstet 2012; 286:1349-55. [PMID: 22797696 DOI: 10.1007/s00404-012-2463-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To assess the impact of the day of birth on twin mortality in a population sample. METHODS We analyzed weekend versus weekday twin births from the United States national twin birth data for the periods 1989-2002. We computed adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess the association between infant mortality and weekday of birth using the Cox proportional hazards model. RESULTS The crude rates for all types of mortality were found to be significantly higher for twins born on weekends than on weekdays. After adjustment, only post-neonatal mortality risk was higher on weekends as compared to weekdays [Hazards ratio (HR)=1.19, CI: 1.04, 1.36]. Twins of white mothers were at greater risk for neonatal death (HR=1.16, CI: 1.08, 1.24) but were less likely to experience post-neonatal death (HR=0.68, CI: 0.64, 0.76) as compared to twins of black mothers. We found an interaction between maternal age and weekday of birth. Twins born on weekends to teenage mothers (age<18) had a 35% greater risk for neonatal death (HR=1.35, CI: 1.06, 1.71) while those born on weekends to older mothers did not show elevated risk for any of the mortality indices. CONCLUSION Increased risks for post-neonatal death are significantly higher amongst twins born on weekends as compared to weekdays. Further research is required to identify the detailed differences in structure and procedures that result in the disadvantage associated with weekend birth.
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Salihu HM, Ibrahimou B, August EM, Dagne G. Risk of infant mortality with weekend versus weekday births: A population-based study. J Obstet Gynaecol Res 2012; 38:973-9. [DOI: 10.1111/j.1447-0756.2011.01818.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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167
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Arnal JM, Wysocki M, Novotni D, Demory D, Lopez R, Donati S, Granier I, Corno G, Durand-Gasselin J. Safety and efficacy of a fully closed-loop control ventilation (IntelliVent-ASV®) in sedated ICU patients with acute respiratory failure: a prospective randomized crossover study. Intensive Care Med 2012; 38:781-7. [PMID: 22460854 DOI: 10.1007/s00134-012-2548-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 02/28/2012] [Indexed: 01/11/2023]
Abstract
PURPOSE IntelliVent-ASV(®) is a development of adaptive support ventilation (ASV) that automatically adjusts ventilation and oxygenation parameters. This study assessed the safety and efficacy of IntelliVent-ASV(®) in sedated intensive care unit (ICU) patients with acute respiratory failure. METHODS This prospective randomized crossover comparative study was conducted in a 12-bed ICU in a general hospital. Two periods of 2 h of ventilation in randomly applied ASV or IntelliVent-ASV(®) were compared in 50 sedated, passively ventilated patients. Tidal volume (V(T)), respiratory rate (RR), inspiratory pressure (P(INSP)), SpO(2) and E(T)CO(2) were continuously monitored and recorded breath by breath. Mean values over the 2-h period were calculated. Respiratory mechanics, plateau pressure (P(PLAT)) and blood gas exchanges were measured at the end of each period. RESULTS There was no safety issue requiring premature interruption of IntelliVent-ASV(®). Minute ventilation (MV) and V(T) decreased from 7.6 (6.5-9.5) to 6.8 (6.0-8.0) L/min (p < 0.001) and from 8.3 (7.8-9.0) to 8.1 (7.7-8.6) mL/kg PBW (p = 0.003) during IntelliVent-ASV(®) as compared to ASV. P(PLAT) and FiO(2) decreased from 24 (20-29) to 20 (19-25) cmH(2)O (p = 0.005) and from 40 (30-50) to 30 (30-39) % (p < 0.001) during IntelliVent-ASV(®) as compared to ASV. RR, P(INSP), and PEEP decreased as well during IntelliVent-ASV(®) as compared to ASV. Respiratory mechanics, pH, PaO(2) and PaO(2)/FiO(2) ratio were not different but PaCO(2) was slightly higher during IntelliVent-ASV(®) as compared to ASV. CONCLUSIONS In passive patients with acute respiratory failure, IntelliVent-ASV(®) was safe and able to ventilate patients with less pressure, volume and FiO(2) while producing the same results in terms of oxygenation.
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Affiliation(s)
- Jean-Michel Arnal
- Intensive Care Unit, Hôpital Font Pré, 1208 avenue du colonel Picot, 83100, Toulon, France.
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Abstract
PURPOSE OF REVIEW Traditionally, hospitals have coped with chronically high ICU census by building more ICU beds, but this strategy is unlikely to be tenable under future financial models. Therefore, ICUs need additional tools to manage census, inflow, and throughput. RECENT FINDINGS Higher ICU census, without compensatory surges in nursing capacity, is associated with several adverse effects on patients and providers, but its relationship to mortality is uncertain. Providers also discharge patients more aggressively during times of high census. Little's Law (L = λ W), a cornerstone of queuing theory, provides an eminently practical basis for managing ICU census and throughput. One target for improving throughput is minimizing process steps that are without value to the patient, e.g., waiting for a bed at ICU discharge. Larger gains in ICU throughput can be found in ICU quality improvement. For example, spontaneous breathing trials, daily wake-ups, and early physical/occupational therapy programmes are all likely to improve throughput by reducing ICU length of stay. The magnitude of these interventions' effects on ICU census can be startling. SUMMARY ICUs should actively manage throughput and census. Operations management tools such as Little's Law can provide practical guidance about the relationship between census, throughput, and patient demand. Standard ICU quality improvement techniques can meaningfully affect both ICU census and throughput.
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Abstract
PURPOSE OF REVIEW Increasing demand for critical care, with limited potential for comparable expansion of supply, may strain the abilities of ICUs to provide high-quality care in an equitable fashion. Efforts to counter the untoward consequences for the quality and ethics of critical care delivery are limited by the absence of a specific and validated metric of ICU capacity strain. RECENT FINDINGS This manuscript presents a conceptual framework for ICU capacity strain, considers what data elements may contribute to it, and suggests methods for determining the optimal metric. Next, it outlines the range of potential consequences of increased capacity strain, in terms of both the quality and ethics of care delivered. Finally, consideration is given to how untoward consequences of ICU capacity strain might be mitigated through better understanding of what makes some ICUs better able than others to withstand temporal fluctuations in the demand for their services. SUMMARY Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors; elucidate organizational characteristics that make some ICUs better able to withstand high-capacity strain without substantive degradations in quality; and enhance the transparency of critical care rationing while helping to improve its equity and efficiency, thereby promoting the ethics of this inevitable practice.
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Worni M, Østbye T, Gandhi M, Rajgor D, Shah J, Shah A, Pietrobon R, Jacobs DO, Guller U. Laparoscopic Appendectomy Outcomes on the Weekend and During the Week are no Different: A National Study of 151,774 Patients. World J Surg 2012; 36:1527-33. [PMID: 22411091 DOI: 10.1007/s00268-012-1550-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Wise KR, Akopov VA, Williams BR, Ido MS, Leeper KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med 2012; 7:183-9. [PMID: 22069304 DOI: 10.1002/jhm.972] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 07/12/2011] [Accepted: 08/15/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND A shortage of critical care specialists or intensivists, coupled with expanding United States critical care needs, mandates identification of alternate qualified physicians for intensive care unit (ICU) staffing. OBJECTIVE To compare mortality and length of stay (LOS) of medical ICU patients cared for by a hospitalist or an intensivist-led team. DESIGN Prospective observational study. SETTING Urban academic community hospital affiliated with a major regional academic university. PATIENTS Consecutive medical patients admitted to a hospitalist ICU team (n = 828) with selective intensivist consultation or an intensivist-led ICU teaching team (n = 528). MEASUREMENTS Endpoints were ICU and in-hospital mortality and LOS, adjusted for patient differences with logistic and linear regression models and propensity scores. RESULTS The odds ratio adjusted for disease severity for in-hospital mortality was 0.8 (95% confidence interval [CI]: 0.49, 1.18; P = 0.23) and ICU mortality was 0.8 (95% CI: 0.51, 1.32; P = 0.41), referent to the hospitalist team. The adjusted LOS was similar between teams (hospital LOS difference 0.9 days, P = 0.98; ICU LOS difference 0.3 days, P = 0.32). Mechanically ventilated patients with intermediate illness severity had lower hospital LOS (10.6 vs 17.8 days, P < 0.001) and ICU LOS (7.2 vs 10.6 days, P = 0.02), and a trend towards decreased in-hospital mortality (15.6% vs 27.5%, P = 0.10) in the intensivist-led group. CONCLUSIONS The adjusted mortality and LOS demonstrated no statistically significant difference between hospitalist and intensivist-led ICU models. Mechanically ventilated patients with intermediate illness severity showed improved LOS and a trend towards improved mortality when cared for by an intensivist-led ICU teaching team.
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Affiliation(s)
- Kristin R Wise
- Division of Hospital Medicine, Emory University School of Medicine, Emory University Hospital Midtown (EUHM), Atlanta, GA, USA.
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Driscoll A. Coronary care units continue to be effective at improving patient outcomes. Aust Crit Care 2012; 25:143-6. [PMID: 22366085 DOI: 10.1016/j.aucc.2011.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 11/22/2011] [Indexed: 10/28/2022] Open
Affiliation(s)
- Andrea Driscoll
- Department of Epidemiology and Preventive Medicine, Monash University, 89 Commercial rd, Melbourne, Australia.
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Empfehlungen der Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie zur personellen, infrastrukturellen und apparativen Ausstattung einer herzchirurgischen Intermediate-Care-Station. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2012. [DOI: 10.1007/s00398-011-0895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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175
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Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med 2011; 37:1575-87. [PMID: 21918847 DOI: 10.1007/s00134-011-2300-7] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 06/09/2011] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To provide guidance and recommendations for the planning or renovation of intensive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine. METHODOLOGY The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version. RESULTS The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The second part deals with recommendations with respect to the planning process, floorplan and connections, accommodation, fire safety, central services, and the necessary communication systems. CONCLUSION This document provides a detailed framework for the planning or renovation of ICUs based on a multinational consensus within the ESICM.
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176
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Tsutsumi A, Kawanami S, Horie S. Effort-reward imbalance and depression among private practice physicians. Int Arch Occup Environ Health 2011; 85:153-61. [PMID: 21655960 DOI: 10.1007/s00420-011-0656-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 05/24/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Current private practice physicians provide medical services in a harsh economic situation. The effort-reward imbalance (ERI) model puts its emphasis on an imbalance between high efforts spent and low rewards received in occupational life. ERI model includes three different reward factors from task to organizational levels. We examined whether ERI in terms of low organizational reward (poor prospective and job insecurity) could be the most relevant and strongly associated with depression among private practice physicians. METHODS This is a cross-sectional questionnaire study of 1,103 private practice physicians who were currently working in clinical settings and completed the data of exposure and outcome. The study questionnaire was mailed to all the physicians listed as members of a local branch of the Japan Medical Association (n = 3,441) between November and December 2008. Outcomes were prevalence of depression as measured by the Center for Epidemiologic Studies Depression Scale and adjusted odds ratios (OR) of depression with respect to ERI. RESULTS Fifty-seven percent of physicians were exposed to ERI, and 18% of the physicians were depressed. Logistic regression analyses revealed that ERI was significantly associated with depression (OR and 95% confidence interval = 3.57; 2.43-5.26). ERI with regard to organizational reward was most prevalent (60%) and had the strongest association with depression (5.14; 3.36-7.92). CONCLUSION Predominant prevalence of ERI in terms of organizational level low reward and strong associations between the ERI component and depression suggests that countermeasures from social perspective are crucial.
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Affiliation(s)
- Akizumi Tsutsumi
- University of Occupational and Environmental Health, Japan, Kitakyushu City, Japan.
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177
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Juneja D, Garg N, Javeri Y, Bajaj P, Gupta C, Singh O. Impact of Admission Time on Mortality in an Indian Intensive Care Unit With Round-the-Clock Intensivist Coverage. ACTA ACUST UNITED AC 2011. [DOI: 10.1177/1944451610395584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Higher mortality in patients admitted during off hours has been attributed to inadequate staffing, but only a few studies have assessed the impact of 24-hour intensivist coverage on ICU mortality. We aimed to assess the impact of admission time on mortality for patients admitted to an ICU with 24-hour in-house intensivist coverage through a retrospective study analyzing data from all admissions to a medical ICU over 15 months. Patients were divided into 2 groups by time of ICU admission: regular hours (Monday-Saturday 9 am to 5 pm) and off hours (Monday-Saturday 5 pm to 9 am, Sunday). Patients were compared with regard to demographics, severity of illness, ICU course, and ICU outcome. Primary outcome measure was ICU mortality. Of 653 admissions, 391 (59.9%) were admitted during off hours. There was no significant difference in age, sex, severity of illness, need for organ support, and ICU stay. ICU mortality was 14.9% and 16.4% in regular and off hours, respectively ( P = .689). Relative risk of death for admission in after hours was 1.018 (95% CI, 0.952-1.088), with the odds ratio of dying being 1.119 (95% CI, 0.726-1.726). We concluded that full-time intensivist coverage ensures continuity of care. Hence, off-hour admissions may not be associated with any increased mortality.
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Affiliation(s)
- Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
| | - Nitin Garg
- Department of Critical Care Medicine, Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
| | - Yash Javeri
- Department of Critical Care Medicine, Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
| | - Praveen Bajaj
- Department of Critical Care Medicine, Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
| | - Chetan Gupta
- Department of Critical Care Medicine, Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
| | - Omender Singh
- Department of Critical Care Medicine, Max Super Speciality Hospital (MSSH), Saket, New Delhi, India
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178
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Badr L, Rizk U, Farha R. The divergent opinions of nurses, nurse managers and nurse directors: the case in Lebanon. J Nurs Manag 2011; 18:182-93. [PMID: 20465746 DOI: 10.1111/j.1365-2834.2010.01052.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The present study provides an overview of the status of the nursing profession in Lebanon and compares and contrasts the opinions of directors, nurse supervisors/managers and nurses regarding the nursing profession and the workplace. BACKGROUND There are limited publications concerning the working conditions of nurses in Lebanon, and no studies on the views of directors, supervisors/managers and nurses regarding the priorities of the nursing profession. Such data are necessary to build a sound theoretical basis on which recommendations for improving the nursing profession in Lebanon are made as well as to compare and contrast cross cultural findings. METHOD Data were collected from 45 hospitals using a mixed methods design. Qualitative data was obtained from 45 nursing directors whereas quantitative data were collected from 64 nursing supervisors and 624 nurses. RESULTS Similarities and differences in the opinions of nurses, nurse supervisors/managers and nurse directors regarding critical issues for the nursing profession are discussed and contrasted. CONCLUSIONS/IMPLICATIONS Nurses are more likely to be satisfied and committed to their profession when they feel that their opinions are being heard and that their work environment promotes professional advancement.
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Affiliation(s)
- Lina Badr
- Azusa Pacific University, Azusa, CA, USA.
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179
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Holden RJ, Scanlon MC, Patel NR, Kaushal R, Escoto KH, Brown RL, Alper SJ, Arnold JM, Shalaby TM, Murkowski K, Karsh BT. A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ Qual Saf 2011; 20:15-24. [PMID: 21228071 PMCID: PMC3058823 DOI: 10.1136/bmjqs.2008.028381] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Nursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, we conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes. METHODS To test this model, we analysed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care paediatric hospitals. RESULTS Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading=0.31) and burnout (path loading=0.45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading=0.25) and medication error likelihood (path loading=1.04). Job-level workload was not uniquely and significantly associated with any outcomes. DISCUSSION The human factors engineering model of nursing workload was supported by data from two paediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.
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Affiliation(s)
- Richard J. Holden
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
- Psychology, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Neal R. Patel
- Pediatrics, Vanderbilt University, Nashville, TN, USA
| | - Rainu Kaushal
- Pediatrics and Public Health, Weill Cornell Medical College, New York, NY, USA
| | | | - Roger L. Brown
- Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Samuel J. Alper
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Judi M. Arnold
- Pediatric Critical Care, Vanderbilt Children’s Hospital, Nashville, TN, USA
| | - Theresa M. Shalaby
- Pediatric Critical Care, Vanderbilt Children’s Hospital, Nashville, TN, USA
| | | | - Ben-Tzion Karsh
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
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180
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García-Lacalle J, Bachiller P. Dissecting hospital quality. Antecedents of clinical and perceived quality in hospitals. Int J Health Plann Manage 2010; 26:264-81. [DOI: 10.1002/hpm.1076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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181
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Atilola O, Olayiwola F. Pattern of psychiatric inpatient admission in ibadan: implications for service organisation and planning. Ann Ib Postgrad Med 2010; 8:106-10. [PMID: 25161477 PMCID: PMC4111022 DOI: 10.4314/aipm.v8i2.71821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Reports from different parts of the world has shown a
seasonal pattern in psychiatric admission. Seasonal changes in
climatic and social situations have been attributed. Such audit of
psychiatric services is not a popular research venture in Nigeria. Objectives: The study aims to describe the pattern of old psychiatric
admissions in a tertiary health facility and the socio-cultural and
environmental factors that may influence the pattern. Methods: Data on monthly admissions over a 5-year period were
extracted from the admission and discharge records kept by the
nursing services unit. The data was processed using Microsoft excel
and the pattern over the 5-year period was examined using graphical
representations. Results: There were 2140 admissions during the review period,
comprising 1138 ( 53.2%) females and 1002 males. The mean new
admission per month was 34.55 (M:16.7, F:18.96) with a standard
deviation of 7.49 for all admissions. There was a seasonal pattern in
admission. Some socio-cultural and environmental factors that may
explain the pattern were examined. Conclusion: This study suggests a seasonal pattern of psychiatric
admission in a tertiary health facility in Ibadan. Recommendations
were made on how to make use of the knowledge of the seasonal
pattern of admission to mitigate disruptions in workload that may
be occasioned by the observed pattern.
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Affiliation(s)
- Olayinka Atilola
- Senior Registrar, Dept of Psychiatry, University College Hospital Ibadan, Nigeria
| | - Funmilayo Olayiwola
- Nursing Officer, Nursing Services Division, University College Hospital Ibadan, Nigeria
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182
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Thaler T, Tempelmann V, Maggiorini M, Rudiger A. The frequency of electrocardiographic errors due to electrode cable switches: a before and after study. J Electrocardiol 2010; 43:676-81. [DOI: 10.1016/j.jelectrocard.2010.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Indexed: 11/16/2022]
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183
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Giakoumidakis K, Baltopoulos GI, Charitos C, Patelarou E, Fotos NV, Brokalaki-Pananoudaki H. Risk factors for increased in-hospital mortality: a cohort study among cardiac surgery patients. Eur J Cardiovasc Nurs 2010; 11:23-33. [DOI: 10.1016/j.ejcnurse.2010.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Christos Charitos
- Cardiothoracic Surgeon, Director of the 2nd Cardiothoracic Department, “Evangelismos” General Hospital of Athens, Greece
| | | | - Nikolaos V Fotos
- Faculty of Nursing, National & Kapodistrian University of Athens, Greece
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184
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Abstract
Numerous studies have identified a relationship between staffing levels and nurse-sensitive outcomes for medical and surgical patients, but little has been published on the impact of nurse-sensitive outcomes for the childbearing family and even less that examines the relationship of intrapartum staffing on adverse perinatal outcomes. Using a derivation of Donabedian's classic structure, process, and outcomes framework, a model is proposed, which would allow obstetrical primary care providers and administrators alike the opportunity to examine the influence of nurse staffing on adverse obstetrical events, including unanticipated cesarean birth in low-risk women or newborn intensive care unit admissions. It is recognized that hospitals carry a significant burden in the prevention of adverse outcomes that range from nurse staffing levels to the internal process and infrastructure of the hospital setting. Patient outcomes are a direct result not only of the patient's health status and characteristics (eg, socioeconomic position and ethnicity), but also of interactions with the healthcare delivery system. As such, the opportunity to examine hospital characteristics (structure and processes) that may be detrimental to safe patient outcomes is of paramount importance in providing optimal outcomes for childbearing women and their families.
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185
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Yaghoubian A, Virgilio CD, Destro L, Kaji AH, Putnam B, Neville AL. Optimal Deployment of Trauma Personnel in the 80-Hour Work Week Era Based on Peak Times of Trauma Patient Arrival. Am Surg 2010. [DOI: 10.1177/000313481007601002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the 80-hour work week era, optimal distribution of the residency workforce is critical. Little data exist as to whether current hours of hospital staffing parallel trends in trauma activity. The purpose of this study was to determine peak periods of trauma volume, severity, need for operative intervention, and mortality and determine if there are differences in mortality based on time period of arrival. We performed a retrospective analysis of the 17,167 patients admitted to our academic Level I trauma center between 2000 and 2007. Each admission was plotted against time of arrival and trends noted. A significant increase in activity occurred between 1700 and 0100 hours. Compared with other shifts, this shift had a disproportionately higher number of patients with penetrating injuries, need for operative intervention, Injury Severity Score (ISS) greater than 15, and death ( P < 0.0001). After adjusting for ISS and penetrating trauma, arrival time was not predictive of mortality (OR 0.97, CI 0.87-1.08, P = 0.6). In conclusion, a peak in trauma activity occurs during an evening shift between 1700 and 0100 hours. In an era of optimizing resident training within the constraints of an 80-hour work week, strong consideration should be made for deploying personnel to match these findings.
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Affiliation(s)
| | | | | | - Amy H. Kaji
- Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
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186
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Graf J, Reinhold A, Brunkhorst FM, Ragaller M, Reinhart K, Loeffler M, Engel C. Variability of structures in German intensive care units – a representative, nationwide analysis. Wien Klin Wochenschr 2010; 122:572-8. [DOI: 10.1007/s00508-010-1452-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 07/28/2010] [Indexed: 10/19/2022]
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187
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Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med 2010; 38:S83-9. [PMID: 20502179 DOI: 10.1097/ccm.0b013e3181dd8364] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in diagnostic tests, technological interventions, and pharmacotherapy have resulted in spectacular results for many intensive care unit (ICU) patients who, in earlier generations, would have succumbed to their critical illness. At the same time, the complexity and intensity of care required for ICU patients is also associated with greater risks for harm resulting from care. As in other inpatient areas, medications are the most common type of therapy in ICUs and are also associated with the most frequent type of ICU adverse events. Critically ill patients are at high risk for adverse drug events for many reasons, including the complexity of their disease that creates challenges in drug dosing, their vulnerability to rapid changes in pharmacotherapy, the intensive care environment providing ample distractions and opportunity for error, the administration of complex drug regimens, the numerous high-alert medications that they receive, and the mode of drug administration. The clinical outcomes of adverse drug events can result in end-organ damage and even death. The costs of an adverse drug event can be substantial to healthcare systems with an additional $6,000-$9,000 for each event. The multiprofessional patient care team is one approach to promoting patient safety in the ICU.
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188
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Quelle activité et quels personnels soignants dans 66 unités de réanimation du sud de la France ? ACTA ACUST UNITED AC 2010; 29:512-7. [DOI: 10.1016/j.annfar.2010.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 04/06/2010] [Indexed: 01/31/2023]
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189
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Aragon Penoyer D. Nurse staffing and patient outcomes in critical care: A concise review. Crit Care Med 2010; 38:1521-8; quiz 1529. [DOI: 10.1097/ccm.0b013e3181e47888] [Citation(s) in RCA: 169] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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190
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Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care. J Adv Nurs 2010; 66:1708-18. [PMID: 20557396 DOI: 10.1111/j.1365-2648.2010.05288.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper is a report of a study of patterns of perceptions of conscience, stress of conscience and burnout in relation to occupational belonging among Registered Nurses and nursing assistants in municipal residential care of older people. BACKGROUND Stress and burnout among healthcare personnel and experiences of ethical difficulties are associated with troubled conscience. In elder care the experience of a troubled conscience seems to be connected to occupational role, but little is known about how Registered Nurses and nursing assistants perceive their conscience, stress of conscience and burnout. METHOD Results of previous analyses of data collected in 2003, where 50 Registered Nurses and 96 nursing assistants completed the Perceptions of Conscience Questionnaire, Stress of Conscience Questionnaire and Maslach Burnout Inventory, led to a request for further analysis. In this study Partial Least Square Regression was used to detect statistical predictive patterns. RESULT Perceptions of conscience and stress of conscience explained 41.9% of the variance in occupational belonging. A statistical predictive pattern for Registered Nurses was stress of conscience in relation to falling short of expectations and demands and to perception of conscience as demanding sensitivity. A statistical predictive pattern for nursing assistants was perceptions that conscience is an authority and an asset in their work. Burnout did not contribute to the explained variance in occupational belonging. CONCLUSION Both occupational groups viewed conscience as an asset and not a burden. Registered Nurses seemed to exhibit sensitivity to expectations and demands and nursing assistants used their conscience as a source of guidance in their work. Structured group supervision with personnel from different occupations is needed so that staff can gain better understanding about their own occupational situation as well as the situation of other occupational groups.
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191
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Dorn SD, Shah ND, Berg BP, Naessens JM. Effect of weekend hospital admission on gastrointestinal hemorrhage outcomes. Dig Dis Sci 2010; 55:1658-66. [PMID: 19672711 DOI: 10.1007/s10620-009-0914-1] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 07/09/2009] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine whether outcomes for patients admitted with UGIH differ depending on weekend versus weekday admission, and whether any such differences are mediated by discrepancies in the use and timing of endoscopy. METHODS This was a cross-sectional comparison of mortality, resource use, and the utilization and timing of esophagogastroduodenoscopy (EGD) among patients admitted with upper gastrointestinal hemorrhage (UGIH) on weekends to those admitted on a weekday. Hospitals in 31 states from the Nationwide Inpatient Sample between 1998 and 2003 were included. This resulted in 75,636 patients admitted during the week and 23,339 admitted on a weekend with UGIH. Multivariable analyses were conducted to evaluate the effect of weekend admission on UGIH outcomes. RESULTS Compared to patients admitted on a weekday, for those admitted on a weekend: in-hospital mortality was higher (unadjusted mortality 3.76 vs. 3.33%; P = 0.003; adjusted HR = 1.09, 95% CI = 1.00-1.18); adjusted length of stay was 1.7% longer (P = 0.0098); and adjusted in-hospital charges were 3.3% higher (P = 0.0038). Although these patients were less likely to undergo endoscopy (adjusted OR = 0.94; P = 0.004) and waited longer for this procedure (adjusted HR = 0.87; P < 0.001), these discrepancies did not fully explain their inferior outcomes. CONCLUSIONS Weekend admission for UGIH is associated with an increased risk of death, slightly longer lengths of stay, and marginally higher in-patient charges. Discrepancies in the use and timing of endoscopy do not account for these differences.
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Affiliation(s)
- Spencer D Dorn
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
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192
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Chen KH, Lee S, Weng LC, Chen YJ. The effects of potentiality education on potentiality and job satisfaction among psychiatric nurses in Taiwan. Perspect Psychiatr Care 2010; 46:85-97. [PMID: 20377796 DOI: 10.1111/j.1744-6163.2010.00244.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE This study evaluated the effects of a potentiality education program on potentiality and job satisfaction among psychiatric nurses. DESIGN AND METHODS This quasiexperimental study recruited 59 psychiatric nurses, of whom 26 were assigned to an experimental group, based on their interest in participating in the program, and 33 to a control group. FINDINGS The results indicated that the scores for job satisfaction were significantly higher in the experimental group than in the control group. Specifically, potentiality education promoted job satisfaction but had no significant influence on potentiality. PRACTICE APPLICATION: Increasing nurses' potentiality could help them to successfully cope with their large workload and the various challenges of their job.
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Affiliation(s)
- Kang-Hua Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
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193
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Sprung CL, Zimmerman JL, Christian MD, Joynt GM, Hick JL, Taylor B, Richards GA, Sandrock C, Cohen R, Adini B. Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med 2010; 36:428-43. [PMID: 20135090 PMCID: PMC7079971 DOI: 10.1007/s00134-010-1759-y] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 01/12/2010] [Indexed: 12/01/2022]
Abstract
PURPOSE To provide recommendations and standard operating procedures for intensive care units and hospital preparedness for an influenza pandemic. METHODS Based on a literature review and expert opinion, a Delphi process was used to define the essential topics. RESULTS Key recommendations include: Hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas. Hospitals should have appropriate beds and monitors for these expansion areas. Establish a management system with control groups at facility, local, regional and/or national levels to exercise authority over resources. Establish a system of communication, coordination and collaboration between the ICU and key interface departments. A plan to access, coordinate and increase labor resources is required with a central inventory of all clinical and non-clinical staff. Delegate duties not within the usual scope of workers' practice. Ensure that adequate essential medical equipment, pharmaceuticals and supplies are available. Protect patients and staff with infection control practices and supporting occupational health policies. Maintain staff confidence with reassurance plans for legal protection and assistance. Have objective, ethical, transparent triage criteria that are applied equitably and publically disclosed. ICU triage of patients should be based on the likelihood for patients to benefit most or a 'first come, first served' basis. Develop protocols for safe performance of high-risk procedures. Train and educate staff. CONCLUSIONS Mortality, although inevitable during a severe influenza outbreak or disaster, can be reduced by adequate preparation.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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194
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Profit J, Petersen LA, McCormick MC, Escobar GJ, Coleman-Phox K, Zheng Z, Pietz K, Zupancic JA. Patient-to-nurse ratios and outcomes of moderately preterm infants. Pediatrics 2010; 125:320-6. [PMID: 20064868 PMCID: PMC3151172 DOI: 10.1542/peds.2008-3140] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Moderately preterm infants (30-34(6/7) weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants. PATIENTS AND METHODS Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of <20 or > or =20 infants. RESULTS Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR. CONCLUSIONS In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals' quality of care delivery to moderately preterm infants.
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Affiliation(s)
- Jochen Profit
- Houston Veterans Affairs Health Services Research and Development Center of Excellence (152), 2002 Holcombe Blvd, Houston, TX 77030, USA.
| | - Laura A. Petersen
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas,Houston Veterans Affairs Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Marie C. McCormick
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts,Division of Newborn Medicine, Harvard Medical School, Boston, Massachusetts,Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts
| | - Gabriel J. Escobar
- Perinatal Research Unit, Kaiser Permanente Medical Care Program, Oakland, California
| | - Kim Coleman-Phox
- Perinatal Research Unit, Kaiser Permanente Medical Care Program, Oakland, California
| | - Zheng Zheng
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kenneth Pietz
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas,Houston Veterans Affairs Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - John A.F. Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts,Division of Newborn Medicine, Harvard Medical School, Boston, Massachusetts
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195
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Ay D, Akkas M, Sivri B. Patient population and factors determining length of stay in adult ED of a Turkish University Medical Center. Am J Emerg Med 2010; 28:325-30. [PMID: 20223390 DOI: 10.1016/j.ajem.2008.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 12/05/2008] [Indexed: 10/19/2022] Open
Abstract
This study is designed to analyze retrospectively patients who present to adult emergency department (ED) from January 1, 2002, to February 28, 2002. Age, sex, presentation time to ED, length of stay in emergency service, consultations, the number of patients who need to be hospitalized and also the number of hospitalized patients, diagnosis categories, and discharge instructions are analyzed. It is found that patients in most admissions are at 21 to 25 years of age. At night, the number of visits is decreased. Hospitalizations could be done to only about half of patients who in fact should be hospitalized. There is a correlation between the length of stay of patients in emergency service and the number of consultations per patient. There is also a correlation between patient complexity and length of stay in emergency service. The ED overcrowding rises with increased visits and patients staying in ED who should be hospitalized.
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Affiliation(s)
- Didem Ay
- Emergency Department of Yeditepe University, Istanbul, Turkey.
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196
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197
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Al-Kandari F, Thomas D. Factors contributing to nursing task incompletion as perceived by nurses working in Kuwait general hospitals. J Clin Nurs 2009; 18:3430-40. [DOI: 10.1111/j.1365-2702.2009.02795.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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198
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On evaluating the impact of flexibility enhancing strategies on the performance of nurse schedules. Health Policy 2009; 93:188-200. [PMID: 19699004 PMCID: PMC7126851 DOI: 10.1016/j.healthpol.2009.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 07/02/2009] [Accepted: 07/06/2009] [Indexed: 11/24/2022]
Abstract
Hospitals develop nurse schedules that cover a period of 4–6 weeks and are posted several weeks in advance. Once posted, changes to the schedule require voluntary participation by the nurses, making it difficult for hospitals to respond to changes in nursing needs and availability of nurses. At the same time, nursing needs’ forecasts developed several weeks in advance are often wrong. In each hospital setting, there may exist several promising strategies to enhance scheduling flexibility and reduce the mismatch between the nursing needs and the availability of nurses. However, methodologies to evaluate such strategies, before testing them in expensive pilot implementation, do not exist. We demonstrate how such evaluations can be carried out using historical data. Furthermore, we demonstrate the use of our approach by evaluating the benefits of a strategy where nurses are divided into two cohorts and schedules are phase shifted for the two cohorts. Staggering schedules allows nursing unit managers to benefit from more frequent updating of needs’ assessments without having to change work rules. Upon applying our approach to data from a large urban hospital, we discovered that in this example staggering did not improve the performance of nurse schedules. We discuss possible reasons for this result, its implications for hospital managers, and other potential uses of our approach.
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199
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Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, Abizanda R, Svantesson M, Rubulotta F, Ricou B, Benoit D, Heyland D, Joynt G, Français A, Azeivedo-Maia P, Owczuk R, Benbenishty J, de Vita M, Valentin A, Ksomos A, Cohen S, Kompan L, Ho K, Abroug F, Kaarlola A, Gerlach H, Kyprianou T, Michalsen A, Chevret S, Schlemmer B. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 2009; 180:853-60. [PMID: 19644049 DOI: 10.1164/rccm.200810-1614oc] [Citation(s) in RCA: 338] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.
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Affiliation(s)
- Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France.
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Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare). Best Pract Res Clin Anaesthesiol 2009; 23:81-93. [PMID: 19449618 DOI: 10.1016/j.bpa.2008.08.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
New modes of mechanical ventilation with advanced closed loops are now available, and in the future these could assume a greater role in supporting critically ill patients in intensive care units (ICUs) for several reasons. Two modes of ventilation--proportional assist ventilation and neurally adjusted ventilatory assist--deliver assisted ventilation proportional to the patient's effort, improving patient-ventilator synchrony. Also, a few systems that automate the medical reasoning with advanced closed-loops, such as SmartCare and adaptive support ventilation, have the potential to improve knowledge transfer by continuously implementing automated protocols. Moreover, they may improve patient-ventilator interactions and outcomes, and provide a partial solution to the forecast clinician shortages by reducing ICU-related costs, time spent on mechanical ventilation, and staff workload. Preliminary studies are promising, and initial systems are currently being refined with increasing clinical experience. A new era of mechanical ventilation should emerge with these systems.
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