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Moser A, Raj R, Reinikainen M, Jakob SM, Takala J. Effect of mortality prediction models on resource use benchmarking of intensive care units. J Crit Care 2024; 82:154814. [PMID: 38643569 DOI: 10.1016/j.jcrc.2024.154814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/06/2024] [Accepted: 04/15/2024] [Indexed: 04/23/2024]
Abstract
PURPOSE Intensive care requires extensive resources. The ICUs' resource use can be compared using standardized resource use ratios (SRURs). We assessed the effect of mortality prediction models on the SRURs. MATERIALS AND METHODS We compared SRURs using different mortality prediction models: the recent Finnish Intensive Care Consortium (FICC) model and the SAPS-II model (n = 68,914 admissions). We allocated the resources to severity of illness strata using deciles of predicted mortality. In each risk and year stratum, we calculated the expected resource use per survivor from our modelling approaches using length of ICU stay and Therapeutic Intervention Scoring System (TISS) points. RESULTS Resource use per survivor increased from one length of stay (LOS) day and around 50 TISS points in the first decile to 10 LOS-days and 450 TISS in the tenth decile for both risk scoring systems. The FICC model predicted mortality risk accurately whereas the SAPS-II grossly overestimated the risk of death. Despite this, SRURs were practically identical and consistent. CONCLUSIONS SRURs provide a robust tool for benchmarking resource use within and between ICUs. SRURs can be used for benchmarking even if recently calibrated risk scores for the specific population are not available.
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Affiliation(s)
- André Moser
- CTU Bern, Department of Clinical Research, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Stephan M Jakob
- University of Bern, Hochschulstrasse 4, 3012 Bern, Switzerland
| | - Jukka Takala
- University of Bern, Hochschulstrasse 4, 3012 Bern, Switzerland
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Feldman C, Joynt GM, Mentzelopoulos SD, Sprung CL, Avidan A, Richards GA. Limitations of life-sustaining therapies in South Africa. J Crit Care 2024; 82:154797. [PMID: 38554544 DOI: 10.1016/j.jcrc.2024.154797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/01/2024]
Abstract
PURPOSE Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA). MATERIALS AND METHODS This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world. RESULTS LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered. CONCLUSIONS Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, China
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Guy A Richards
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Soares M, Salluh JIF, Zampieri FG, Bozza FA, Kurtz PMP. A decade of the ORCHESTRA study: organizational characteristics, patient outcomes, performance and efficiency in critical care. CRITICAL CARE SCIENCE 2024; 36:e20240118en. [PMID: 39046062 PMCID: PMC11239203 DOI: 10.62675/2965-2774.20240118-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/22/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Marcio Soares
- Instituto D’Or de Pesquisa e EnsinoRio de JaneiroRJBrazilInstituto D’Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil.
| | - Jorge Ibrain Figueira Salluh
- Instituto D’Or de Pesquisa e EnsinoRio de JaneiroRJBrazilInstituto D’Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil.
| | - Fernando Godinho Zampieri
- Faculty of Medicine and DentistryUniversity of AlbertaEdmontonCanadaFaculty of Medicine and Dentistry, University of Alberta - Edmonton, Canada.
| | - Fernando Augusto Bozza
- Instituto D’Or de Pesquisa e EnsinoRio de JaneiroRJBrazilInstituto D’Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil.
| | - Pedro Martins Pereira Kurtz
- Instituto D’Or de Pesquisa e EnsinoRio de JaneiroRJBrazilInstituto D’Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brazil.
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Sarfati S, Ehrmann S, Vodovar D, Jung B, Aissaoui N, Darreau C, Bougouin W, Deye N, Kallel H, Kuteifan K, Luyt CE, Terzi N, Vanderlinden T, Vinsonneau C, Muller G, Guitton C. Inadequate intensive care physician supply in France: a point-prevalence prospective study. Ann Intensive Care 2024; 14:92. [PMID: 38888663 PMCID: PMC11189355 DOI: 10.1186/s13613-024-01298-y] [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: 10/04/2023] [Accepted: 04/19/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has highlighted the importance of intensive care units (ICUs) and their organization in healthcare systems. However, ICU capacity and availability are ongoing concerns beyond the pandemic, particularly due to an aging population and increasing complexity of care. This study aimed to assess the current and future shortage of ICU physicians in France, ten years after a previous evaluation. A national e-survey was conducted among French ICUs in January 2022 to collect data on ICU characteristics, medical staffing, individual physician characteristics, and education and training capacities. RESULTS Among 290 ICUs contacted, 242 responded (response rate: 83%), representing 4943 ICU beds. The survey revealed an overall of 300 full time equivalent (FTE) ICU physician vacancies in the country. Nearly two-thirds of the participating ICUs reported at least one physician vacancy and 35% relied on traveling physicians to cover shifts. The ICUs most affected by physician vacancies were the ICUs of non-university affiliated public hospitals. The retirements expected in the next five years represented around 10% of the workforce. The median number of physicians per ICU was 7.0, corresponding to a ratio of 0.36 physician (FTE) per ICU bed. In addition, 27% of ICUs were at risk of critical dysfunction or closure due to vacancies and impending retirements. CONCLUSION The findings highlight the urgent need to address the shortage of ICU physicians in France. Compared to a similar study conducted in 2012, the inadequacy between ICU physician supply and demand has increased, resulting in a higher number of vacancies. Our study suggests that, among others, increasing the number of ICM residents trained each year could be a crucial step in addressing this issue. Failure to take appropriate measures may lead to further closures of ICUs and increased risks to patients in this healthcare system.
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Affiliation(s)
- Sacha Sarfati
- Medical Intensive Care Unit, Normandie Univ, UNIROUEN, UR 3830, CHU Rouen, 76000, Rouen, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSEP F-CRIN Research Network and Centre d'études Des Pathologies Respiratoires, INSERM U1100, Tours University, Tours, France
| | - Dominique Vodovar
- Centre Antipoison de Paris, Hopital Fernand Widal, 75010, Paris, France
- Université Paris Cite, UFR de médecine, 75010, Paris, France
- Inserm UMR-S 1144 - Faculté de Pharmacie, 75006, Paris, France
| | - Boris Jung
- Médecine Intensive Réanimation, INSERM PhyMedExp, Université de Montpellier, CHU Montpellier, France
| | - Nadia Aissaoui
- Médecine Intensive Réanimation Hôpital Cochin, APHP, Paris, France
- Université Paris CIté, INSERM U 978, Équipe 4, AfterROSC, Paris, France
| | - Cédric Darreau
- Service de Réanimation Médico-Chirurgicale, CH Le Mans, Le Mans, France
| | - Wulfran Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France
- Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Paris, France
- AfterROSC Network, Paris, France
| | - Nicolas Deye
- Medical & Toxicological Intensive Care Unit, UMR-S 942, Inserm, Lariboisiere University Hospital, APHP, Paris, France
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital, Cayenne, French Guiana
- Tropical Biome and Immunopathology CNRS UMR-9017, Inserm U1019, Université de Guyane, Cayenne, French Guiana
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale, GHRMSA, Hôpital Emile Muller, Mulhouse, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- UMRS 1166, Sorbonne Université, GRC 30, RESPIRE, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
- Medical Intensive Care Unit, University of Rennes, Rennes, France
| | - Thierry Vanderlinden
- Médecine Intensive Réanimation, Groupement Hospitalier de L'Institut Catholique de Lille, FMMS - ETHICS EA 7446, Université Catholique de Lille, Lille, France
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Béthune, France
| | - Grégoire Muller
- CRICS_TRIGGERSep F-CRIN Research Network, Centre Hospitalier Universitaire (CHU) d'Orléans, Médecine Intensive Réanimation, Université de Tours, MR INSERM, 1327 ISCHEMIA, Université de Tours, 37000, Tours, France
| | - Christophe Guitton
- Service de Réanimation Médico-Chirurgicale, CH Le Mans, Le Mans, France.
- Faculté de Santé, Université d'Angers, Angers, France.
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Lefering R, Waydhas C. Prediction of prolonged length of stay on the intensive care unit in severely injured patients-a registry-based multivariable analysis. Front Med (Lausanne) 2024; 11:1358205. [PMID: 38903820 PMCID: PMC11188296 DOI: 10.3389/fmed.2024.1358205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/22/2024] [Indexed: 06/22/2024] Open
Abstract
Purpose Mortality is the primary outcome measure in severely injured trauma victims. However, quality indicators for survivors are rare. We aimed to develop and validate an outcome measure based on length of stay on the intensive care unit (ICU). Methods The TraumaRegister DGU of the German Trauma Society (DGU) was used to identify 108,178 surviving patients with serious injuries who required treatment on ICU (2014-2018). In a first step, need for prolonged ICU stay, defined as 8 or more days, was predicted. In a second step, length of stay was estimated in patients with a prolonged stay. Data from the same trauma registry (2019-2022, n = 72,062) were used to validate the models derived with logistic and linear regression analysis. Results The mean age was 50 years, 70% were males, and the average Injury Severity Score was 16.2 points. Average/median length of stay on ICU was 6.3/2 days, where 78% were discharged from ICU within the first 7 days. Prediction of need for a prolonged ICU stay revealed 15 predictors among which injury severity (worst Abbreviated Injury Scale severity level), need for intubation, and pre-trauma condition were the most important ones. The area under the receiver operating characteristic curve was 0.903 (95% confidence interval 0.900-0.905). Length of stay prediction in those with a prolonged ICU stay identified the need for ventilation and the number of injuries as the most important factors. Pearson's correlation of observed and predicted length of stay was 0.613. Validation results were satisfactory for both estimates. Conclusion Length of stay on ICU is a suitable outcome measure in surviving patients after severe trauma if adjusted for severity. The risk of needing prolonged ICU care could be calculated in all patients, and observed vs. predicted rates could be used in quality assessment similar to mortality prediction. Length of stay prediction in those who require a prolonged stay is feasible and allows for further benchmarking.
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Affiliation(s)
- Rolf Lefering
- Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Cologne, Germany
| | - Christian Waydhas
- Department of Trauma Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Bastos LSL, Hamacher S, Kurtz P, Ranzani OT, Zampieri FG, Soares M, Bozza FA, Salluh JIF. The Association Between Prepandemic ICU Performance and Mortality Variation in COVID-19: A Multicenter Cohort Study of 35,619 Critically Ill Patients. Chest 2024; 165:870-880. [PMID: 37838338 DOI: 10.1016/j.chest.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/20/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, ICUs remained under stress and observed elevated mortality rates and high variations of outcomes. A knowledge gap exists regarding whether an ICU performing best during nonpandemic times would still perform better when under high pressure compared with the least performing ICUs. RESEARCH QUESTION Does prepandemic ICU performance explain the risk-adjusted mortality variability for critically ill patients with COVID-19? STUDY DESIGN AND METHODS This study examined a cohort of adults with real-time polymerase chain reaction-confirmed COVID-19 admitted to 156 ICUs in 35 hospitals from February 16, 2020, through December 31, 2021, in Brazil. We evaluated crude and adjusted in-hospital mortality variability of patients with COVID-19 in the ICU during the pandemic. Association of baseline (prepandemic) ICU performance and in-hospital mortality was examined using a variable life-adjusted display (VLAD) during the pandemic and a multivariable mixed regression model adjusted by clinical characteristics, interaction of performance with the year of admission, and mechanical ventilation at admission. RESULTS Thirty-five thousand six hundred nineteen patients with confirmed COVID-19 were evaluated. The median age was 52 years, median Simplified Acute Physiology Score 3 was 42, and 18% underwent invasive mechanical ventilation. In-hospital mortality was 13% and 54% for those receiving invasive mechanical ventilation. Adjusted in-hospital mortality ranged from 3.6% to 63.2%. VLAD in the most efficient ICUs was higher than the overall median in 18% of weeks, whereas VLAD was 62% and 84% in the underachieving and least efficient groups, respectively. The least efficient baseline ICU performance group was associated independently with increased mortality (OR, 2.30; 95% CI, 1.45-3.62) after adjusting for patient characteristics, disease severity, and pandemic surge. INTERPRETATION ICUs caring for patients with COVID-19 presented substantial variation in risk-adjusted mortality. ICUs with better baseline (prepandemic) performance showed reduced mortality and less variability. Our findings suggest that achieving ICU efficiency by targeting improvement in organizational aspects of ICUs may impact outcomes, and therefore should be a part of the preparedness for future pandemics.
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Affiliation(s)
- Leonardo S L Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Hospital Copa Star, Rio de Janeiro, Brazil; Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra, CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Fernando G Zampieri
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marcio Soares
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
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Andrade HB, Rocha Ferreira da Silva I, Espinoza R, da Silva MST, Theodoro PHN, Ferreira MT, Soares J, Belay ED, Sejvar JJ, Bozza FA, Cerbino-Neto J, Japiassú AM. Profiling and Benchmarking Central Nervous System Infections in an Infectious Diseases Intensive Care Unit. J Intensive Care Med 2024; 39:59-68. [PMID: 37455413 DOI: 10.1177/08850666231188665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND There is little information comparing the performance of community acquired central nervous system infections (CNSI) treatment by intensive care units (ICUs) specialized in infectious diseases with treatment at other ICUs. Our objective was to reduce these gaps, creating bases for benchmarking and future case-mix classification. METHODS This is a retrospective observational cohort of 785 admissions with 82 cases of CNSI admitted to the ICU of an important Brazilian referral center for infectious diseases (INI) between January 2012 and January 2019. Comparisons were made to data retrospectively collected from the 303,500 intensive care admissions from the Brazilian state health care system included in the Epimed Monitor database. Clinical, epidemiologic, and performance indicators: the standardized mortality rate (SMR) and the standardized resource use rate per ICU surviving patient (SRU) were collected. RESULTS Case-mix infections profile and SMR/SRU data. SUS Mixed medical/surgical ICUs: SMR = 1.26, SRU = 1.59; SUS Neurological ICUs: SMR = 1.17, SRU = 2.23; INI ICU: SMR = 1.1, SRU = 1.1; INI ICU CNSI patients: SMR = 0.95, SRU = 1.01. CONCLUSIONS Severe patients with CNSI can be efficiently and effectively treated in an ICU specialized in infectious diseases when compared to mixed medical/surgical and neurological ICUs from the public health system. At the same time, we provided profiling and a case-mix that can help and encourage benchmarking by other institutions and other countries.
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Affiliation(s)
- Hugo Boechat Andrade
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
- Sexually Transmitted Diseases Sector, Instituto Biomédico, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | | | - Rodolfo Espinoza
- Surgical Intensive Care Unit, Hospital Copa Star, Rio de Janeiro, RJ, Brazil
- Intensive Care Unit II, Instituto Nacional do Câncer, Rio de Janeiro, RJ, Brazil
| | - Mayara Secco Torres da Silva
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Marcel Treptow Ferreira
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Jesus Soares
- Division of High-Consequence Pathology and Pathogens, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ermias D Belay
- Division of High-Consequence Pathology and Pathogens, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James J Sejvar
- Division of High-Consequence Pathology and Pathogens, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Fernando Augusto Bozza
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
- Department of Critical Care, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brazil
| | - José Cerbino-Neto
- Immunization and Health Surveillance Research Laboratory, Instituto Nacional de Infectologia Evandro Chagas (INI), Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - André Miguel Japiassú
- Intensive Care Unit, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
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Peres IT, Ferrari GF, Quintairos A, Bastos LDSL, Salluh JIF. Validation of a new data-driven SLOSR ICU efficiency measure compared to the traditional SRU. Intensive Care Med 2023; 49:1546-1548. [PMID: 37922007 DOI: 10.1007/s00134-023-07255-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 11/05/2023]
Affiliation(s)
- Igor Tona Peres
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rua Marquês de São Vicente, 225, Rio de Janeiro, Rio de Janeiro, 22451-900, Brazil.
| | - Guilherme Fonseca Ferrari
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rua Marquês de São Vicente, 225, Rio de Janeiro, Rio de Janeiro, 22451-900, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30, Rio de Janeiro, Rio de Janeiro, 22281-100, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Carrera 7 117-15, Bogotá, Colombia
| | - Leonardo Dos Santos Lourenço Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rua Marquês de São Vicente, 225, Rio de Janeiro, Rio de Janeiro, 22451-900, Brazil
| | - Jorge Ibrain Figueira Salluh
- D'Or Institute for Research and Education (IDOR), Rua Diniz Cordeiro, 30, Rio de Janeiro, Rio de Janeiro, 22281-100, Brazil
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Makris D, Tsolaki V, Robertson R, Dimopoulos G, Rello J. The future of training in intensive care medicine: A European perspective. JOURNAL OF INTENSIVE MEDICINE 2022; 3:52-61. [PMID: 36789360 PMCID: PMC9923960 DOI: 10.1016/j.jointm.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Ross Robertson
- Medical School, University of Thessaly, Larisa 41110, Greece
| | - George Dimopoulos
- Third Department of Critical Care, Medical School, National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Jordi Rello
- CRIPS Department, Vall d'Hebron Institut of Research, Barcelona 08035, Spain,Clinical Research, CHU Nîmes, Nîmes 30029, France,Medical School, Universitat Internacional de Catalunya, Campus Sant Cugat, Sant Cugat del Valles, Barcelona 08195, Spain,Corresponding author: Jordi Rello, CRIPS Department, Vall d'Hebron Institut of Research, Barcelona 08035, Spain.
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Bastos LS, Wortel SA, de Keizer NF, Bakhshi-Raiez F, Salluh JI, Dongelmans DA, Zampieri FG, Burghi G, Abu-Hanna A, Hamacher S, Bozza FA, Soares M. Comparing continuous versus categorical measures to assess and benchmark intensive care unit performance. J Crit Care 2022; 70:154063. [DOI: 10.1016/j.jcrc.2022.154063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/11/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
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Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis. Crit Care Med 2022; 50:1503-1512. [PMID: 35834661 DOI: 10.1097/ccm.0000000000005624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We aim to describe incidence and outcomes of cardiopulmonary resuscitation (CPR) efforts and their outcomes in ICUs and their changes over time. DESIGN Retrospective cohort analysis. SETTING Patient data documented in the Austrian Center for Documentation and Quality Assurance in Intensive Care database. PATIENTS Adult patients (age ≥ 18 yr) admitted to Austrian ICUs between 2005 and 2019. INTERVENTIONS None. MEASUREMENTS ANDN MAIN RESULTS Information on CPR was deduced from the Therapeutic Intervention Scoring System. End points were overall occurrence rate of CPR in the ICU and CPR for unexpected cardiac arrest after the first day of ICU stay as well as survival to discharge from the ICU and the hospital. Incidence and outcomes of ICU-CPR were compared between 2005 and 2009, 2010 and 2014, and 2015 and 2019 using chi-square test. A total of 525,518 first admissions and readmissions to ICU of 494,555 individual patients were included; of these, 72,585 patients (14.7%) died in hospital. ICU-CPR was performed in 20,668 (3.9%) admissions at least once; first events occurred on the first day of ICU admission in 15,266 cases (73.9%). ICU-CPR was first performed later during ICU stay in 5,402 admissions (1.0%). The incidence of ICU-CPR decreased slightly from 4.4% between 2005 and 2009, 3.9% between 2010 and 2014, and 3.7% between 2015 and 2019 (p < 0.001). A total of 7,078 (34.5%) of 20,499 patients who received ICU-CPR survived until hospital discharge. Survival rates varied slightly over the observation period; 59,164 (12.0%) of all patients died during hospital stay without ever receiving CPR in the ICU. CONCLUSIONS The incidence of ICU-CPR is approximately 40 in 1,000 admissions overall and approximately 10 in 1,000 admissions after the day of ICU admission. Short-term survival is approximately four out of 10 patients who receive ICU-CPR.
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Fan G, Yang S, Liu H, Xu N, Chen Y, He J, Su X, Pang M, Liu B, Han L, Rong L. Machine Learning-based Prediction of Prolonged Intensive Care Unit Stay for Critical Patients with Spinal Cord Injury. Spine (Phila Pa 1976) 2022; 47:E390-E398. [PMID: 34690328 DOI: 10.1097/brs.0000000000004267] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The objective of the study was to develop machine-learning (ML) classifiers for predicting prolonged intensive care unit (ICU)-stay and prolonged hospital-stay for critical patients with spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA Critical patients with SCI in ICU need more attention. SCI patients with prolonged stay in ICU usually occupy vast medical resources and hinder the rehabilitation deployment. METHODS A total of 1599 critical patients with SCI were included in the study and labeled with prolonged stay or normal stay. All data were extracted from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care III-IV Database. The extracted data were randomly divided into training, validation and testing (6:2:2) subdatasets. A total of 91 initial ML classifiers were developed, and the top three initial classifiers with the best performance were further stacked into an ensemble classifier with logistic regressor. The area under the curve (AUC) was the main indicator to assess the prediction performance of all classifiers. The primary predicting outcome was prolonged ICU-stay, while the secondary predicting outcome was prolonged hospital-stay. RESULTS In predicting prolonged ICU-stay, the AUC of the ensemble classifier was 0.864 ± 0.021 in the three-time five-fold cross-validation and 0.802 in the independent testing. In predicting prolonged hospital-stay, the AUC of the ensemble classifier was 0.815 ± 0.037 in the three-time five-fold cross-validation and 0.799 in the independent testing. Decision curve analysis showed the merits of the ensemble classifiers, as the curves of the top three initial classifiers varied a lot in either predicting prolonged ICU-stay or discriminating prolonged hospital-stay. CONCLUSION The ensemble classifiers successfully predict the prolonged ICU-stay and the prolonged hospital-stay, which showed a high potential of assisting physicians in managing SCI patients in ICU and make full use of medical resources.Level of Evidence: 3.
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Affiliation(s)
- Guoxin Fan
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yatsen University, Guangzhou, China
- Intelligent and Digital Surgery Innovation Center, Southern University of Science and Technology Hospital, Shenzhen, Guangdong, China
| | - Sheng Yang
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huaqing Liu
- Artificial Intelligence Innovation Center, Research Institute of Tsinghua, Pearl River Delta, Guangzhou, China
| | - Ningze Xu
- Tongji University School of Medicine, Shanghai, P. R. China
| | - Yuyong Chen
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yatsen University, Guangzhou, China
- Intelligent and Digital Surgery Innovation Center, Southern University of Science and Technology Hospital, Shenzhen, Guangdong, China
| | - Jie He
- Intelligent and Digital Surgery Innovation Center, Southern University of Science and Technology Hospital, Shenzhen, Guangdong, China
| | - Xiuyun Su
- Intelligent and Digital Surgery Innovation Center, Southern University of Science and Technology Hospital, Shenzhen, Guangdong, China
| | - Mao Pang
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yatsen University, Guangzhou, China
| | - Bin Liu
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yatsen University, Guangzhou, China
| | - Lanqing Han
- Artificial Intelligence Innovation Center, Research Institute of Tsinghua, Pearl River Delta, Guangzhou, China
| | - Limin Rong
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yatsen University, Guangzhou, China
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Variation in severity-adjusted resource use and outcome in intensive care units. Intensive Care Med 2022; 48:67-77. [PMID: 34661693 PMCID: PMC8724095 DOI: 10.1007/s00134-021-06546-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/25/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE Intensive care patients have increased risk of death and their care is expensive. We investigated whether risk-adjusted mortality and resources used to achieve survivors change over time and if their variation is associated with variables related to intensive care unit (ICU) organization and structure. METHODS Data of 207,131 patients treated in 2008-2017 in 21 ICUs in Finland, Estonia and Switzerland were extracted from a benchmarking database. Resource use was measured using ICU length of stay, daily Therapeutic Intervention Scoring System Scores (TISS) and purchasing power parity-adjusted direct costs (2015-2017; 17 ICUs). The ratio of observed to severity-adjusted expected resource use (standardized resource use ratio; SRUR) was calculated. The number of expected survivors and the ratio of observed to expected mortality (standardized mortality ratio; SMR) was based on a mortality prediction model covering 2015-2017. Fourteen a priori variables reflecting structure and organization were used as explanatory variables for SRURs in multivariable models. RESULTS SMR decreased over time, whereas SRUR remained unchanged, except for decreased TISS-based SRUR. Direct costs of one ICU day, TISS score and ICU admission varied between ICUs 2.5-5-fold. Differences between individual ICUs in both SRUR and SMR were up to > 3-fold, and their evolution was highly variable, without clear association between SRUR and SMR. High patient turnover was consistently associated with low SRUR but not with SMR. CONCLUSION The wide and independent variation in both SMR and SRUR suggests that they should be used together to compare the performance of different ICUs or an individual ICU over time.
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Antunes BBP, Bastos LSL, Hamacher S, Bozza FA. Using data envelopment analysis to perform benchmarking in intensive care units. PLoS One 2021; 16:e0260025. [PMID: 34793542 PMCID: PMC8601512 DOI: 10.1371/journal.pone.0260025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Studies using Data Envelopment Analysis to benchmark Intensive Care Units (ICUs) are scarce. Previous studies have focused on comparing efficiency using only performance metrics, without accounting for resources. Hence, we aimed to perform a benchmarking analysis of ICUs using data envelopment analysis. METHODS We performed a retrospective analysis on observational data of patients admitted to ICUs in Brazil (ORCHESTRA Study). The outputs in our data envelopment analysis model were the performance metrics: Standardized Mortality Ratio (SMR) and Standardized Resource Use (SRU); whereas the inputs consisted of three groups of variables that represented staffing patterns, structure, and strain, thus resulting in three models. We compared efficient and non-efficient units for each model. In addition, we compared our results to the efficiency matrix method and presented targets to each non-efficient unit. RESULTS We performed benchmarking in 93 ICUs and 129,680 patients. The median age was 64 years old, and mortality was 12%. Median SMR was 1.00 [interquartile range (IQR): 0.79-1.21] and SRU was 1.15 [IQR: 0.95-1.56]. Efficient units presented lower median physicians per bed ratio (1.44 [IQR: 1.18-1.88] vs. 1.7 [IQR: 1.36-2.00]) and nursing workload (168 hours [IQR: 168-291] vs 396 hours [IQR: 336-672]) but higher nurses per bed ratio (2.02 [1.16-2.48] vs. 1.71 [1.43-2.36]) compared to non-efficient units. Units from for-profit hospitals and specialized ICUs presented the best efficiency scores. Our results were mostly in line with the efficiency matrix method: the efficiency units in our models were mostly in the "most efficient" quadrant. CONCLUSION Data envelopment analysis provides managers the information needed to identify not only the outcomes to be achieved but what are the levels of resources needed to provide efficient care. Different perspectives can be achieved depending on the chosen variables. Its use jointly with the efficiency matrix can provide deeper understanding of ICU performance and efficiency.
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Affiliation(s)
- Bianca B. P. Antunes
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Leonardo S. L. Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando A. Bozza
- Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil
- D’Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
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The association of the COVID-19 pandemic and short-term outcomes of non-COVID-19 critically ill patients: an observational cohort study in Brazilian ICUs. Intensive Care Med 2021; 47:1440-1449. [PMID: 34518905 PMCID: PMC8437089 DOI: 10.1007/s00134-021-06528-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/03/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE To assess whether intensive care unit (ICU) outcomes for patients not affected by coronavirus disease 2019 (COVID-19) worsened during the COVID-19 pandemic. METHODS Retrospective cohort study including prospectively collected information of patients admitted to 165 ICUs in a hospital network in Brazil between 2011 and 2020. Association between admission in 2020 and worse hospital outcomes was performed using different techniques, including assessment of changes in illness severity of admitted patients, a variable life-adjusted display of mortality during 2020, a multivariate mixed regression model with admission year as both fixed effect and random slope adjusted for SAPS 3 score, an analysis of trends in performance using standardized mortality ratio (SMR) and standardized resource use (SRU), and perturbation analysis. RESULTS A total of 644,644 admissions were considered. After excluding readmissions and patients with COVID-19, 514,219 patients were available for analysis. Non-COVID-19 patients admitted in 2020 had slightly lower age and SAPS 3 score but a higher mortality (6.4%) when compared with previous years (2019: 5.6%; 2018: 6.1%). Variable-adjusted life display (VLAD) in 2020 increased but started to decrease as the number of COVID-19 cases increased; this trend reversed as number of COVID cases reduced but recurred on the second wave. After logistic regression, being admitted in 2020 was associated with higher mortality when compared to previous years from 2016 and 2019. Individual ICUs standardized mortality ratio also increased during 2020 (higher SMR) while resource use remained constant, suggesting worsening performance. A perturbation analysis further confirmed changes in ICU outcomes for non-COVID-19 patients. CONCLUSION Hospital outcomes of non-COVID-19 critically ill patients worsened during the pandemic in 2020, possibly resulting in an increased number of deaths in critically ill non-COVID patients.
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Noritomi DT, Ranzani OT, Ferraz LJR, Dos Santos MC, Cordioli E, Albaladejo R, Serpa Neto A, Correa TD, Berwanger O, de Morais LC, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JI, Azevedo LCP, Pereira AJ. TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE): protocol for a cluster-randomised clinical trial on adult general ICUs in Brazil. BMJ Open 2021; 11:e042302. [PMID: 34155070 PMCID: PMC8217943 DOI: 10.1136/bmjopen-2020-042302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group. METHODS AND ANALYSIS A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units. ETHICS AND DISSEMINATION The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient's enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit. TRIAL REGISTRATION NUMBER NCT03920501; Pre-results.
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Affiliation(s)
- Danilo Teixeira Noritomi
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Clinical Governance, DASA, Sao Paulo, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas, Universidade de Sao Paulo Faculdade de Medicina Hospital das Clinicas, Sao Paulo, SP, Brazil
- ISGlobal, Barcelona Institute for Global Health, Barcelona, Catalunya, Spain
| | | | - Maura C Dos Santos
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ary Serpa Neto
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Thiago D Correa
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, São Paulo, Brazil
| | - Lubia Caus de Morais
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Guilherme Schettino
- Institute of Social Responsibility, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- HCor Research Institute, Sao Paulo, SP, Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Santos Biondi
- Instituto de Cardiologia do Distrito Federal, Brasília, Distrito Federal, Brazil
- Hospital Brasília, Brasília, DF, Brazil
| | - Jorge If Salluh
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil, Rio de Janeiro, Brazil
| | - Luciano Cesar Pontes Azevedo
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
- Emergency Medicine Department, University of Sao Paulo, Sao Paulo, São Paulo, Brazil
| | - Adriano Jose Pereira
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Postgraduate Program of Health Sciences, Universidade Federal de Lavras, Lavras, MG, Brazil
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Burrell AJ, Udy A, Straney L, Huckson S, Chavan S, Saethern J, Pilcher D. "The ICU efficiency plot": a novel graphical measure of ICU performance in Australia and New Zealand. CRIT CARE RESUSC 2021; 23:128-131. [PMID: 38045526 PMCID: PMC10692575 DOI: 10.51893/2021.2.ed2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aidan J.C. Burrell
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew Udy
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Lahn Straney
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Sue Huckson
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Shaila Chavan
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Jostein Saethern
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
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Henzi A, Kleger GR, Hilty MP, Wendel Garcia PD, Ziegel JF. Probabilistic analysis of COVID-19 patients' individual length of stay in Swiss intensive care units. PLoS One 2021; 16:e0247265. [PMID: 33606773 PMCID: PMC7894868 DOI: 10.1371/journal.pone.0247265] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/03/2021] [Indexed: 01/08/2023] Open
Abstract
Rationale The COVID-19 pandemic induces considerable strain on intensive care unit resources. Objectives We aim to provide early predictions of individual patients’ intensive care unit length of stay, which might improve resource allocation and patient care during the on-going pandemic. Methods We developed a new semiparametric distributional index model depending on covariates which are available within 24h after intensive care unit admission. The model was trained on a large cohort of acute respiratory distress syndrome patients out of the Minimal Dataset of the Swiss Society of Intensive Care Medicine. Then, we predict individual length of stay of patients in the RISC-19-ICU registry. Measurements The RISC-19-ICU Investigators for Switzerland collected data of 557 critically ill patients with COVID-19. Main results The model gives probabilistically and marginally calibrated predictions which are more informative than the empirical length of stay distribution of the training data. However, marginal calibration was worse after approximately 20 days in the whole cohort and in different subgroups. Long staying COVID-19 patients have shorter length of stay than regular acute respiratory distress syndrome patients. We found differences in LoS with respect to age categories and gender but not in regions of Switzerland with different stress of intensive care unit resources. Conclusion A new probabilistic model permits calibrated and informative probabilistic prediction of LoS of individual patients with COVID-19. Long staying patients could be discovered early. The model may be the basis to simulate stochastic models for bed occupation in intensive care units under different casemix scenarios.
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Affiliation(s)
- Alexander Henzi
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Gian-Reto Kleger
- Division of Intensive Care Medicine, Cantonal Hospital, St.Gallen, Switzerland
| | - Matthias P. Hilty
- The RISC-19-ICU Registry Board, University of Zurich, Zürich, Switzerland
- Institute of Intensive Care Medicine, University Hospital of Zürich, Zürich, Switzerland
| | - Pedro D. Wendel Garcia
- The RISC-19-ICU Registry Board, University of Zurich, Zürich, Switzerland
- Institute of Intensive Care Medicine, University Hospital of Zürich, Zürich, Switzerland
| | - Johanna F. Ziegel
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
- * E-mail:
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Garcia RG, Katz M, Falsarella PM, Malheiros DT, Fukumoto H, Lemos GC, Teich V, Salvalaggio PR. Percutaneous Cryoablation versus Robot-Assisted Partial Nephrectomy of Renal T1A Tumors: a Single-Center Retrospective Cost-Effectiveness Analysis. Cardiovasc Intervent Radiol 2021; 44:892-900. [PMID: 33388867 DOI: 10.1007/s00270-020-02732-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/26/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the cost-effectiveness of percutaneous cryoablation (PCA) versus robot-assisted partial nephrectomy (RPN) in patients with small renal tumors (T1a stage), considering perioperative complications. MATERIALS AND METHODS Retrospective study from November 2008 to April 2017 of 122 patients with a T1a renal mass who after being analyzed by a multidisciplinary board underwent to PCA (59 patients) or RPN (63 patients). Hospital costs in US dollars, and clinical and tumor data were compared. Non-complicated intervention was considered as an effective outcome. A hypothetical model of possible complications based on Clavien-Dindo classification (CDC) was built, grouping them into mild (CDC I and II) and severe (CDC III and IV). A decision tree model was structured from complications of published data. RESULTS Patients who underwent PCA were older (62.5 vs. 52.8 years old, p < 0.001), presented with more coronary disease and previous renal cancer (25.4% vs. 10.1%, p = 0.023 and 38% vs. 7.2%, p < 0.001, respectively). Patients treated with PCA had a higher preoperative risk (American Society of Anesthesiologists-ASA ≥ 3) than those in the RPN group (25.4% vs. 0%, p < 0.001). Average operative time was significantly lower with PCA than RPN (99.92 ± 29.05 min vs. 129.28 ± 54.85 min, p < 0.001). Average hospitalization time for PCA was 2.2 ± 2.95 days, significantly lower than RPN (mean 3.03 ± 1.49 days, p = 0.04). The average total cost of PCA was significantly lower than RPN (US$12,435 ± 6,176 vs. US$19,399 ± 6,047, p < 0.001). The incremental effectiveness was 5% higher comparing PCA with RPN, resulting a cost-saving result in favor of PCA. CONCLUSION PCA was the dominant strategy (less costly and more effective) compared to RPN, considering occurrence of perioperative complications.
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Affiliation(s)
- Rodrigo Gobbo Garcia
- Center of Interventional Medicine, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 4º andar - Bloco B, São Paulo, SP, 05652-900, Brazil
| | - Marcelo Katz
- Department of Cardiology, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 4o andar - Bloco A1, São Paulo, SP, 05652-900, Brazil
| | - Priscila Mina Falsarella
- Center of Interventional Medicine, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 4º andar - Bloco B, São Paulo, SP, 05652-900, Brazil.
| | - Daniel Tavares Malheiros
- Value Management Office, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 8º andar- bloco D, São Paulo, SP, 05652-900, Brazil
| | - Helena Fukumoto
- Financial Division, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 3º andar - Bloco E, São Paulo, SP, 05652-900, Brazil
| | - Gustavo Caserta Lemos
- Urology Department, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 4 andar - Bloco E, São Paulo, SP, 05652-900, Brazil
| | - Vanessa Teich
- Healthy Economics Division, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 8 andar - Bloco D, São Paulo, SP, 05652-900, Brazil
| | - Paolo Rogério Salvalaggio
- Abdominal Surgery Division & Albert, Einstein Medical School, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627- 1oSS - Bloco A, São Paulo, SP, 05652-900, Brazil
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Wortel SA, de Keizer NF, Abu-Hanna A, Dongelmans DA, Bakhshi-Raiez F. Number of intensivists per bed is associated with efficiency of Dutch intensive care units. J Crit Care 2020; 62:223-229. [PMID: 33434863 DOI: 10.1016/j.jcrc.2020.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/06/2020] [Accepted: 12/12/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To measure efficiency in Intensive Care Units (ICUs) and to determine which organizational factors are associated with ICU efficiency, taking confounding factors into account. MATERIALS AND METHODS We used data of all consecutive admissions to Dutch ICUs between January 1, 2016 and January 1, 2019 and recorded ICU organizational factors. We calculated efficiency for each ICU by averaging the Standardized Mortality Ratio (SMR) and Standardized Resource Use (SRU) and examined the relationship between various organizational factors and ICU efficiency. We thereby compared the results of linear regression models before and after covariate adjustment using propensity scores. RESULTS We included 164,399 admissions from 83 ICUs. ICU efficiency ranged from 0.51-1.42 (average 0.99, 0.15 SD). The unadjusted model as well as the propensity score adjusted model showed a significant association between the ratio of employed intensivists per ICU bed and ICU efficiency. Other organizational factors had no statistically significant association with ICU efficiency after adjustment. CONCLUSIONS We found marked variability in efficiency in Dutch ICUs. After applying covariate adjustment using propensity scores, we identified one organizational factor, ratio intensivists per bed, having an association with ICU efficiency.
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Affiliation(s)
- Safira A Wortel
- Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; National Intensive Care Evaluation (NICE) Foundation, Department of Medical Informatics, Amsterdam UMC, Amsterdam, the Netherlands.
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; National Intensive Care Evaluation (NICE) Foundation, Department of Medical Informatics, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Dave A Dongelmans
- National Intensive Care Evaluation (NICE) Foundation, Department of Medical Informatics, Amsterdam UMC, Amsterdam, the Netherlands; Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Ferishta Bakhshi-Raiez
- Department of Medical Informatics, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; National Intensive Care Evaluation (NICE) Foundation, Department of Medical Informatics, Amsterdam UMC, Amsterdam, the Netherlands
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Reddy DRS, Botz GH. Triage and Prognostication of Cancer Patients Admitted to the Intensive Care Unit. Crit Care Clin 2020; 37:1-18. [PMID: 33190763 DOI: 10.1016/j.ccc.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cancer remains a leading cause of morbidity and mortality. Advances in cancer screening, early detection, targeted therapies, and supportive care have led to improvements in outcomes and quality of life. The rapid increase in novel cancer therapies can cause life-threatening adverse events. The need for intensive care unit (ICU) care is projected to increase. Until 2 decades ago, cancer diagnosis often precluded ICU admission. Recently, substantial cancer survival has been achieved; therefore, ICU denial is not recommended. ICU resources are limited and expensive; hence, appropriate utilization is needed. This review focuses on triage and prognosis in critically ill cancer patients requiring ICU admission.
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Affiliation(s)
- Dereddi Raja Shekar Reddy
- Department of Critical Care and Respiratory Care, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 112, Houston, TX 77030, USA
| | - Gregory H Botz
- Department of Critical Care and Respiratory Care, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 112, Houston, TX 77030, USA.
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Severity-Adjusted ICU Mortality Only Tells Half the Truth—The Impact of Treatment Limitation in a Nationwide Database. Crit Care Med 2020; 48:e1242-e1250. [DOI: 10.1097/ccm.0000000000004658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bastos LSL, Hamacher S, Zampieri FG, Cavalcanti AB, Salluh JIF, Bozza FA. Structure and process associated with the efficiency of intensive care units in low-resource settings: An analysis of the CHECKLIST-ICU trial database. J Crit Care 2020; 59:118-123. [PMID: 32610246 DOI: 10.1016/j.jcrc.2020.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Characteristics of structure and process impact ICU performance and the outcomes of critically ill patients. We sought to identify organizational characteristics associated with efficient ICUs in low-resource settings. MATERIALS AND METHODS This is a secondary analysis of a multicenter cluster-randomized clinical trial in Brazil (CHECKLIST-ICU). Efficient units were defined by standardized mortality ratio (SMR) and standardized resource use (SRU) lower than the overall medians and non-efficient otherwise. We used a regularized logistic regression model to evaluate associations between organizational factors and efficiency. RESULTS From 118 ICUs (13,635 patients), 47 units were considered efficient and 71 non-efficient. Efficient units presented lower incidence rates (median[IQR]) of central line-associated bloodstream infections (4.95[0.00-22.0] vs 6.29[0.00-25.6], p = .04), utilization rates of mechanical ventilation (0.41[0.07-0.73] vs 0.58[0.19-0.82], p < .001), central venous catheter (0.67[0.15-0.98] vs 0.78[0.33-0.98], p = .04), and indwelling urinary catheter (0.62[0.22-0.95] vs 0.76[0.32-0.98], p < .01) than non-efficient units. The reported active surveillance of ventilator-associated pneumonia (OR = 1.72; 95%CI, 1.16-2.57) and utilization of central venous catheters (OR = 1.94; 95%CI, 1.32-2.94) were associated with efficient ICUs. CONCLUSIONS In low-resource settings, active surveillance of nosocomial infections and the utilization of invasive devices were associated with efficiency, supporting the management and evaluation of performance indicators as a starting point for improvement in ICU.
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Affiliation(s)
- Leonardo S L Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil
| | - Fernando G Zampieri
- Research Institute, Hospital do Coração (HCor), São Paulo, Brazil; D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil
| | - Alexandre B Cavalcanti
- Research Institute, Hospital do Coração (HCor), São Paulo, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education (IDOR), Rio de Janeiro, RJ, Brazil; Brazilian Research in Intensive Care Network (BRICNet), Brazil; Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, RJ, Brazil.
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Abstract
OBJECTIVES Although one third or more of critically ill patients in the United States are obese, obesity is not incorporated as a contributing factor in any of the commonly used severity of illness scores. We hypothesize that selected severity of illness scores would perform differently if body mass index categorization was incorporated and that the performance of these score models would improve after consideration of body mass index as an additional model feature. DESIGN Retrospective cohort analysis from a multicenter ICU database which contains deidentified data for more than 200,000 ICU admissions from 208 distinct ICUs across the United States between 2014 and 2015. SETTING First ICU admission of patients with documented height and weight. PATIENTS One-hundred eight-thousand four-hundred two patients from 189 different ICUs across United States were included in the analyses, of whom 4,661 (4%) were classified as underweight, 32,134 (30%) as normal weight, 32,278 (30%) as overweight, 30,259 (28%) as obese, and 9,070 (8%) as morbidly obese. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS To assess the effect of adding body mass index as a risk adjustment element to the Acute Physiology and Chronic Health Evaluation IV and Oxford Acute Severity of Illness scoring systems, we examined the impact of this addition on both discrimination and calibration. We performed three assessments based upon 1) the original scoring systems, 2) a recalibrated version of the systems, and 3) a recalibrated version incorporating body mass index as a covariate. We also performed a subgroup analysis in groups defined using World Health Organization guidelines for obesity. Incorporating body mass index into the models provided a minor improvement in both discrimination and calibration. In a subgroup analysis, model discrimination was higher in groups with higher body mass index, but calibration worsened. CONCLUSIONS The performance of ICU prognostic models utilizing body mass index category as a scoring element was inconsistent across body mass index categories. Overall, adding body mass index as a risk adjustment variable led only to a minor improvement in scoring system performance.
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Taniguchi LU, Azevedo LCPD, Bozza FA, Cavalcanti AB, Ferreira EM, Carrara FSA, Sousa JL, Salomão R, Machado FR. Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions. Rev Bras Ter Intensiva 2019; 31:193-201. [PMID: 31166559 PMCID: PMC6649213 DOI: 10.5935/0103-507x.20190033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/04/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To characterize resource availability from a nationally representative random sample of intensive care units in Brazil. METHODS A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit. RESULTS A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%). CONCLUSION Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.
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Affiliation(s)
- Leandro Utino Taniguchi
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network - São Paulo (SP), Brasil
| | - Luciano Cesar Pontes de Azevedo
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Brazilian Research in Intensive Care Network - São Paulo (SP), Brasil.,Instituto Latino Americano da Sepse - São Paulo (SP), Brasil
| | - Fernando Augusto Bozza
- Brazilian Research in Intensive Care Network - São Paulo (SP), Brasil.,Instituto Latino Americano da Sepse - São Paulo (SP), Brasil.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz - Rio de Janeiro (RJ), Brasil.,Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network - São Paulo (SP), Brasil.,Instituto Latino Americano da Sepse - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | | | | | | | - Reinaldo Salomão
- Instituto Latino Americano da Sepse - São Paulo (SP), Brasil.,Departamento de Moléstias Infecciosas, Universidade Federal de São Paulo - São Paulo (SP), Brasil
| | - Flávia Ribeiro Machado
- Brazilian Research in Intensive Care Network - São Paulo (SP), Brasil.,Instituto Latino Americano da Sepse - São Paulo (SP), Brasil.,Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo - São Paulo (SP), Brasil
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ICU mortality and variables associated with ICU survival in Poland: A nationwide database study. Eur J Anaesthesiol 2019; 35:949-954. [PMID: 30234666 DOI: 10.1097/eja.0000000000000889] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recently published international comparison data across European countries revealed high mortality rates in Polish ICUs. OBJECTIVES Estimation of the rate of ICU mortality and identification of variables associated with ICU survival in Poland. DESIGN Retrospective analyses of a database reporting ICU stays in Poland. SETTINGS AND PATIENTS The study included data from all adult patients admitted to an ICU in Poland from 1 January 2012 to 31 December 2012. MAIN OUTCOME MEASURES ICU mortality and variables associated with ICU survival. RESULTS A total of 48 282 patients were treated in 347 ICUs (mean age 63.1 ± 16.8 years, 59% men) with 20 278 deaths (42.0%). Variables associated with ICU survival were: tertiary level of hospital care [relative risk (RR) 0.86, 95% confidence interval (CI) 0.80 to 0.92, P < 0.001]; high annual patient volume in the ICU (RR 0.9995 patient year, 95% CI 0.9994 to 0.9996, P < 0.001); younger patient age (RR 1.025 year, 95% CI 1.024 to 1.026, P < 0.001); female sex (RR 0.92, 95% CI 0.88 to 0.96; P < 0.001); and lower number of comorbidities (RR 1.33, 95% CI 1.31 to 1.35, P < 0.001). CONCLUSION ICU mortality was high in Poland. Structural variables, such as the level of hospital care and annual patient volume, may be associated with ICU survival.
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Chok L, Bachli EB, Steiger P, Bettex D, Cottini SR, Keller E, Maggiorini M, Schuepbach RA. Effect of diagnosis related groups implementation on the intensive care unit of a Swiss tertiary hospital: a cohort study. BMC Health Serv Res 2018; 18:84. [PMID: 29402271 PMCID: PMC5800035 DOI: 10.1186/s12913-018-2869-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 01/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2013 the Swiss Diagnosis Related Groups ((Swiss)-DRG) was implemented in Intensive Care Units (ICU). Its impact on hospitalizations has not yet been examined. We compared the number of ICU admissions, according to clinical severity and referring institution, and screened whether implementation of Swiss-DRG affected admission policy, ICU length-of-stay (ICU-LOS) or ICU mortality. METHODS Retrospective, single centre, cohort study conducted at the University Hospital Zurich, Switzerland between January 2009 and end of September 2013. Demographic and clinical data was retrieved from a quality assurance database. RESULTS Admissions (n = 17,231) before the introduction of Swiss-DRG were used to model expected admissions after DRG, and then compared to the observed admissions. Forecasting matched observations in patients with a high clinical severity admitted from internal units and external hospitals (admitted / predicted: 709 / 703, [95% Confidence Interval (CI), 658-748] and 302 / 332, [95% CI, 269-365] respectively). In patients with low severity of disease, in-house admissions became more frequent than expected and external admission were less frequent (admitted / predicted: 1972 / 1910, [95% CI, 1898-1940] and 436 / 518, [95% CI, 482-554] respectively). Various mechanisms related to Swiss-DRG may have led to these changes. DRG could not be linked to significant changes in regard to ICU-LOS and ICU mortality. CONCLUSIONS DRG introduction had not affected ICU admissions policy, except for an increase of in-house patients with a low clinical severity of disease. DRG had neither affected ICU mortality nor ICU-LOS.
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Affiliation(s)
- Lionel Chok
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.,Department of Internal Medicine, Hospital Uster, Brunnenstrasse 42, CH-8610, Uster, Zurich, Switzerland
| | - Esther B Bachli
- Department of Internal Medicine, Hospital Uster, Brunnenstrasse 42, CH-8610, Uster, Zurich, Switzerland
| | - Peter Steiger
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Dominique Bettex
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Silvia R Cottini
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Emanuela Keller
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Marco Maggiorini
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, University Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
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Verburg IW, Holman R, Dongelmans D, de Jonge E, de Keizer NF. Is patient length of stay associated with intensive care unit characteristics? J Crit Care 2018; 43:114-121. [DOI: 10.1016/j.jcrc.2017.08.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/24/2017] [Accepted: 08/08/2017] [Indexed: 11/15/2022]
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Ho CH, Liang FW, Wang JJ, Chio CC, Kuo JR. Impact of grouping complications on mortality in traumatic brain injury: A nationwide population-based study. PLoS One 2018; 13:e0190683. [PMID: 29324771 PMCID: PMC5764255 DOI: 10.1371/journal.pone.0190683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 12/19/2017] [Indexed: 11/19/2022] Open
Abstract
Traumatic brain injury (TBI) is an important health issue with high mortality. Various complications of physiological and cognitive impairment may result in disability or death after TBI. Grouping of these complications could be treated as integrated post-TBI syndromes. To improve risk estimation, grouping TBI complications should be investigated, to better predict TBI mortality. This study aimed to estimate mortality risk based on grouping of complications among TBI patients. Taiwan's National Health Insurance Research Database was used in this study. TBI was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes: 801-804 and 850-854. The association rule data mining method was used to analyze coexisting complications after TBI. The mortality risk of post-TBI complication sets with the potential risk factors was estimated using Cox regression. A total 139,254 TBI patients were enrolled in this study. Intracerebral hemorrhage was the most common complication among TBI patients. After frequent item set mining, the most common post-TBI grouping of complications comprised pneumonia caused by acute respiratory failure (ARF) and urinary tract infection, with mortality risk 1.55 (95% C.I.: 1.51-1.60), compared with those without the selected combinations. TBI patients with the combined combinations have high mortality risk, especially those aged <20 years with septicemia, pneumonia, and ARF (HR: 4.95, 95% C.I.: 3.55-6.88). We used post-TBI complication sets to estimate mortality risk among TBI patients. According to the combinations determined by mining, especially the combination of septicemia with pneumonia and ARF, TBI patients have a 1.73-fold increased mortality risk, after controlling for potential demographic and clinical confounders. TBI patients aged<20 years with each combination of complications also have increased mortality risk. These results could provide physicians and caregivers with important information to increase their awareness about sequences of clinical syndromes among TBI patients, to prevent possible deaths among these patients.
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Affiliation(s)
- Chung-Han Ho
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Fu-Wen Liang
- National Cheng Kung University Research Center for Health Data and Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chung-Ching Chio
- Department of Neurosurgery, Chi-Mei Medical Center, Tainan, Taiwan
| | - Jinn-Rung Kuo
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Neurosurgery, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
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Abstract
OBJECTIVE We systematically reviewed models to predict adult ICU length of stay. DATA SOURCES We searched the Ovid EMBASE and MEDLINE databases for studies on the development or validation of ICU length of stay prediction models. STUDY SELECTION We identified 11 studies describing the development of 31 prediction models and three describing external validation of one of these models. DATA EXTRACTION Clinicians use ICU length of stay predictions for planning ICU capacity, identifying unexpectedly long ICU length of stay, and benchmarking ICUs. We required the model variables to have been published and for the models to be free of organizational characteristics and to produce accurate predictions, as assessed by R across patients for planning and identifying unexpectedly long ICU length of stay and across ICUs for benchmarking, with low calibration bias. We assessed the reporting quality using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies. DATA SYNTHESIS The number of admissions ranged from 253 to 178,503. Median ICU length of stay was between 2 and 6.9 days. Two studies had not published model variables and three included organizational characteristics. None of the models produced predictions with low bias. The R was 0.05-0.28 across patients and 0.01-0.64 across ICUs. The reporting scores ranged from 49 of 78 to 60 of 78 and the methodologic scores from 12 of 22 to 16 of 22. CONCLUSION No models completely satisfy our requirements for planning, identifying unexpectedly long ICU length of stay, or for benchmarking purposes. Physicians using these models to predict ICU length of stay should interpret them with reservation.
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Keegan MT, Soares M. What every intensivist should know about prognostic scoring systems and risk-adjusted mortality. Rev Bras Ter Intensiva 2017; 28:264-269. [PMID: 27737416 PMCID: PMC5051184 DOI: 10.5935/0103-507x.20160052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 05/04/2016] [Indexed: 01/15/2023] Open
Affiliation(s)
- Mark T Keegan
- Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Marcio Soares
- Departamento de Terapia Intensiva, Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, RJ, Brasil
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Salluh JIF, Soares M, Keegan MT. Understanding intensive care unit benchmarking. Intensive Care Med 2017; 43:1703-1707. [DOI: 10.1007/s00134-017-4760-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/03/2017] [Indexed: 12/26/2022]
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Halpern AB, Culakova E, Walter RB, Lyman GH. Association of Risk Factors, Mortality, and Care Costs of Adults With Acute Myeloid Leukemia With Admission to the Intensive Care Unit. JAMA Oncol 2017; 3:374-381. [PMID: 27832254 DOI: 10.1001/jamaoncol.2016.4858] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Adults with acute myeloid leukemia (AML) commonly require support in the intensive care unit (ICU), but risk factors for admission to the ICU and adverse outcomes remain poorly defined. Objective To examine risk factors, mortality, length of stay, and cost associated with admission to the ICU for patients with AML. Design, Setting, and Participants This study extracted information from the University HealthSystem Consortium database on patients 18 years or older with AML who were hospitalized for any cause between January 1, 2004, and December 31, 2012. The University HealthSystem Consortium database contains demographic, clinical, and cost variables prospectively abstracted by certified coders from discharge summaries. Outcomes were analyzed using univariate and multivariable statistical techniques. Data analysis was performed from November 15, 2013, to August 15, 2016. Main Outcomes and Measures Primary outcomes were admission to the ICU and inpatient mortality among patients requiring ICU care. Secondary outcomes included length of stay in the ICU, total hospitalization length of stay, and cost. Results Of the 43 249 patients with AML (mean [SD] age, 59.5 [16.6] years; 23 939 men and 19 310 women), 11 277 (26.1%) were admitted to the ICU. On multivariable analysis (with results reported as odds ratios [95% CIs]), independent risk factors for admission to the ICU included age younger than 80 years (1.56 [1.42-1.70]), hospitalization in the South (1.81 [1.71-1.92]), hospitalization at a low- or medium-volume hospital (1.25 [1.19-1.31]), number of comorbidities (10.64 [8.89-12.62] for 5 vs none), sepsis (4.61 [4.34-4.89]), invasive fungal infection (1.24 [1.11-1.39]), and pneumonia (1.73 [1.63-1.82]). In-hospital mortality was higher for patients requiring ICU care (4857 of 11 277 [43.1%] vs 2959 of 31 972 [9.3%]). On multivariable analysis, independent risk factors for death in patients requiring ICU care included age 60 years or older (1.16 [1.06-1.26]), nonwhite race/ethnicity (1.18 [1.07-1.30]), hospitalization on the West coast (1.19 [1.06-1.34]), number of comorbidities (18.76 [13.7-25.67] for 5 vs none), sepsis (2.94 [2.70-3.21]), invasive fungal infection (1.20 [1.02-1.42]), and pneumonia (1.13 [1.04-1.24]). Mean costs of hospitalization were higher for patients requiring ICU care ($83 354 vs $41 973) and increased with each comorbidity, from $50 543 for patients with no comorbidities to $124 820 for those with 5 or more comorbidities. Conclusions and Relevance Admission to the ICU is associated with high mortality and cost that increase proportionally with the comorbidity burden in adults with AML. Several demographic factors and medical characteristics identify patients at risk for admission to the ICU and mortality and provide an opportunity for testing primary prevention strategies.
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Affiliation(s)
- Anna B Halpern
- Hematology/Oncology Fellowship Program, Fred Hutchinson Cancer Research Center/University of Washington, Seattle
| | - Eva Culakova
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington5Division of Hematology, Department of Medicine, University of Washington, Seattle6Department of Epidemiology, University of Washington, Seattle
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington4Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington7Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
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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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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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Comparing Observed and Predicted Mortality Among ICUs Using Different Prognostic Systems. Crit Care Med 2015; 43:261-9. [DOI: 10.1097/ccm.0000000000000694] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Soares M, Angus DC, Salluh JI, Cavalcanti AB, Colombari F, Costa R, Silva E, Japiassu A, Kahn JM, Bozza FA. Outcomes and resource use in Brazilian ICUs: results from the ORCHESTRA study. Crit Care 2015. [PMCID: PMC4471045 DOI: 10.1186/cc14585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Kumpf O, Bloos F, Bause H, Brinkmann A, Deja M, Marx G, Kaltwasser A, Dubb R, Muhl E, Greim CA, Weiler N, Chop I, Jonitz G, Schaefer H, Felsenstein M, Liebeskind U, Leffmann C, Jungbluth A, Waydhas C, Pronovost P, Spies C, Braun JP. Voluntary peer review as innovative tool for quality improvement in the intensive care unit--a retrospective descriptive cohort study in German intensive care units. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2014; 12:Doc17. [PMID: 25587245 PMCID: PMC4270273 DOI: 10.3205/000202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/25/2014] [Indexed: 01/06/2023]
Abstract
Introduction: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports. Methods: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs – representing over 300 patient beds – had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. Results: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interesting Conclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.
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Affiliation(s)
- Oliver Kumpf
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Bloos
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Hanswerner Bause
- Quality Committee of the State Chamber of Physicians, Hamburg, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Heidenheim, Heidenheim, Germany
| | - Maria Deja
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, Universitätsklinikum RWTH Aachen, Aachen, Germany
| | | | - Rolf Dubb
- Kreiskliniken Reutlingen GmbH, Reutlingen, Germany
| | - Elke Muhl
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Clemens-A Greim
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Fulda, Fulda, Germany
| | - Norbert Weiler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ines Chop
- German Medical Association, Berlin, Germany
| | - Günther Jonitz
- German Medical Association, Berlin, Germany ; State Chamber of Physicians Berlin, Berlin, Germany
| | | | | | | | - Carsten Leffmann
- State Chamber of Physicians Schleswig-Holstein, Bad Segeberg, Germany
| | | | | | - Peter Pronovost
- The Johns Hopkins University School of Medicine, Departments of Anesthesiology/Critical Care Medicine and Surgery, Baltimore, Maryland, United States
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan-Peter Braun
- Department of Anaesthesiology and Intensive Care Medicine, Helios Klinikum Hildesheim, Hildesheim, Germany
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Yoo EJ, Edwards JD, Dean ML, Dudley RA. Multidisciplinary Critical Care and Intensivist Staffing: Results of a Statewide Survey and Association With Mortality. J Intensive Care Med 2014; 31:325-32. [PMID: 24825859 DOI: 10.1177/0885066614534605] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 03/05/2014] [Indexed: 12/15/2022]
Abstract
PURPOSE The role of multidisciplinary teams in improving the care of intensive care unit (ICU) patients is not well defined, and it is unknown whether the use of such teams helps to explain prior research suggesting improved mortality with intensivist staffing. We sought to investigate the association between multidisciplinary team care and survival of medical and surgical patients in nonspecialty ICUs. MATERIALS AND METHODS We conducted a community-based, retrospective cohort study of data from 60 330 patients in 181 hospitals participating in a statewide public reporting initiative, the California Hospital Assessment and Reporting Taskforce (CHART). Patient-level data were linked with ICU organizational data collected from a survey of CHART hospital ICUs between December 2010 and June 2011. Clustered logistic regression was used to evaluate the independent effect of multidisciplinary care on the in-hospital mortality of medical and surgical ICU patients. Interactions between multidisciplinary care and intensity of physician staffing were examined to explore whether team care accounted for differences in patient outcomes. RESULTS After adjustment for patient characteristics and interactions, there was no association between team care and mortality for medical patients. Among surgical patients, multidisciplinary care was associated with a survival benefit (odds ratio 0.79; 95% confidence interval (CI), 0.62-1.00; P = .05). When stratifying by intensity of physician staffing, although the lowest odds of death were observed for surgical patients cared for in ICUs with multidisciplinary teams and high-intensity staffing (odds ratio, 0.77; 95% CI, 0.55-1.09; P = .15), followed by ICUs with multidisciplinary teams and low-intensity staffing (odds ratio 0.84, 95% CI 0.65-1.09, p = 0.19), these differences were not statistically significant. CONCLUSIONS Our results suggest that multidisciplinary team care may improve outcomes for critically ill surgical patients. However, no relationship was observed between intensity of physician staffing and mortality.
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Affiliation(s)
- Erika J Yoo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Jeffrey D Edwards
- Division of Pediatric Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Mitzi L Dean
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - R Adams Dudley
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
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Daily sedative interruption versus intermittent sedation in mechanically ventilated critically ill patients: a randomized trial. Ann Intensive Care 2014; 4:14. [PMID: 24900938 PMCID: PMC4026117 DOI: 10.1186/2110-5820-4-14] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 04/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Daily sedative interruption and intermittent sedation are effective in abbreviating the time on mechanical ventilation. Whether one is superior to the other has not yet been determined. Our aim was to compare daily interruption and intermittent sedation during the mechanical ventilation period in a low nurse staffing ICU. METHODS Adult patients expected to need mechanical ventilation for more than 24 hours were randomly assigned, in a single center, either to daily interruption of continuous sedative and opioid infusion or to intermittent sedation. In both cases, our goal was to maintain a Sedation Agitation Scale (SAS) level of 3 or 4; that is patients should be calm, easily arousable or awakened with verbal stimuli or gentle shaking. Primary outcome was ventilator-free days in 28 days. Secondary outcomes were ICU and hospital mortality, incidence of delirium, nurse workload, self-extubation and psychological distress six months after ICU discharge. RESULTS A total of 60 patients were included. There were no differences in the ventilator-free days in 28 days between daily interruption and intermittent sedation (median: 24 versus 25 days, P = 0.160). There were also no differences in ICU mortality (40 versus 23.3%, P = 0.165), hospital mortality (43.3 versus 30%, P = 0.284), incidence of delirium (30 versus 40%, P = 0.472), self-extubation (3.3 versus 6.7%, P = 0.514), and psychological stress six months after ICU discharge. Also, the nurse workload was not different between groups, but it was reduced on day 5 compared to day 1 in both groups (Nurse Activity Score (NAS) in the intermittent sedation group was 54 on day 1 versus 39 on day 5, P < 0.001; NAS in daily interruption group was 53 on day 1 versus 38 on day 5, P < 0.001). Fentanyl and midazolam total dosages per patient were higher in the daily interruption group. The tidal volume was higher in the intermittent sedation group during the first five days of ICU stay. CONCLUSIONS There was no difference in the number of ventilator-free days in 28 days between both groups. Intermittent sedation was associated with lower sedative and opioid doses. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00824239.
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Liao JC, Ho CH, Liang FW, Wang JJ, Lin KC, Chio CC, Kuo JR. One-year mortality associations in hemodialysis patients after traumatic brain injury--an eight-year population-based study. PLoS One 2014; 9:e93956. [PMID: 24714730 PMCID: PMC3979737 DOI: 10.1371/journal.pone.0093956] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 03/10/2014] [Indexed: 11/18/2022] Open
Abstract
Purpose This study aimed to investigate the one-year mortality associations in hemodialysis patients who underwent neurosurgical intervention after traumatic brain injury (TBI) using a nationwide database in Taiwan. Materials and Methods An age- and gender-matched longitudinal cohort study of 4416 subjects, 1104 TBI patients with end-stage renal disease (ESRD) and 3312 TBI patients without ESRD, was conducted using the National Health Insurance Research Database in Taiwan between January 2000 and December 2007. The demographic characteristics, length of stay (LOS), length of ICU stay, length of ventilation (LOV), and tracheostomy were collected and analyzed. The co-morbidities of hypertension (HTN), diabetes mellitus (DM), myocardial infarction (MI), stroke, and heart failure (HF) were also evaluated. Results TBI patients with ESRD presented a shorter LOS, a longer length of ICU stay and LOV, and a higher percentage of comorbidities compared with those without ESRD. TBI patients with ESRD displayed a stable trend of one-year mortality rate, 75.82% to 76.79%, from 2000–2007. For TBI patients with ESRD, the median survival time was 0.86 months, and pre-existing stroke was a significant risk factor of mortality (HR: 1.29, 95% C.I.: 1.08–1.55). Pre-existing DM (HR: 1.35, 95% C.I.: 1.12–1.63) and MI (HR: 1.61, 95% C.I.: 1.07–2.42) effect on the mortality in ESRD patients who underwent TBI surgical intervention in the younger (age<65) and older (age≥65) population, respectively. In addition, the length of ICU stay and tracheostomy may provide important information to predict the mortality risk. Conclusions This is the first report indicating an increased risk of one-year mortality among TBI patients with a pre-existing ERSD insult. Comorbidities were more common in TBI patients with ESRD. Physicians should pay more attention to TBI patients with ESRD based on the status of age, comorbidities, length of ICU stay, and tracheostomy to improve their survival.
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Affiliation(s)
- Jen-Chieh Liao
- Department of Neurosurgery, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Fu-Wen Liang
- Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Kao-Chang Lin
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Chung-Ching Chio
- Department of Neurosurgery, Chi-Mei Medical Center, Tainan, Taiwan
| | - Jinn-Rung Kuo
- Department of Neurosurgery, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- * E-mail:
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Bion J, Rothen HU. Models for Intensive Care Training. A European Perspective. Am J Respir Crit Care Med 2014; 189:256-62. [DOI: 10.1164/rccm.201311-2058cp] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
OBJECTIVE We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. DATA SOURCES We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. STUDY SELECTION Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. DATA EXTRACTION Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. DATA SYNTHESIS From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. CONCLUSIONS Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
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Tan SS, Hakkaart-van Roijen L, van Ineveld BM, Redekop WK. Explaining length of stay variation of episodes of care in the Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:919-927. [PMID: 23086102 DOI: 10.1007/s10198-012-0436-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/01/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables. METHODS For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables. RESULTS The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm. CONCLUSIONS Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on 'general' classification variables meaningful for specific episodes of care.
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Affiliation(s)
- Siok Swan Tan
- Institute for Medical Technology Assessment, Erasmus Universiteit Rotterdam, PO Box 1738, 3000 DR, Rotterdam, The Netherlands,
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Current approach to the haemodynamic management of septic shock patients in European intensive care units: a cross-sectional, self-reported questionnaire-based survey. Eur J Anaesthesiol 2013; 28:284-90. [PMID: 21088597 DOI: 10.1097/eja.0b013e3283405062] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of this survey was to investigate clinicians' current approach to the haemodynamic management and resuscitation endpoints in septic shock. METHODS This cross-sectional, self-reported questionnaire-based survey was sent to the clinical director of selected ICUs in 16 European countries. The questionnaire consisted of two parts and 25 questions. The first part retrieved general information on the hospital and ICU, and the second part of the questionnaire collected detailed information on the approach to haemodynamic management of septic shock. RESULTS Of 481 clinicians invited to participate, 237 (49.3%) responded. Ninety-two questionnaires were excluded because of more than 20% missing responses, rendering 145 (30.1%) for statistical analysis. Administration of albumin (P = 0.007), gelatine preparations (P = 0.002), Ringer's solution (P = 0.02) and isotonic saline (P = 0.001) for fluid resuscitation varied between respondents from different countries. Further differences between respondents from different countries were observed for the choice of the first-line inotropic drug (P < 0.001), use of supplementary vasopressin (P = 0.02), supplementary fludrocortisone (P = 0.05) and measurement of cardiac output with the transpulmonary thermodilution (P = 0.001), lithium dilution (P = 0.004) and oesophageal Doppler (P = 0.005) technique. Mean arterial blood pressure (87%), central venous oxygen saturation (65%), central venous pressure (59%), systolic arterial blood pressure (48%), mixed venous oxygen saturation (42%) and cardiac index (42%) were the six haemodynamic variables most commonly claimed to be used as resuscitation endpoints. CONCLUSION The current approach to the haemodynamic management of septic shock patients in a selected cohort of European ICU clinicians is in agreement with the Surviving Sepsis Campaign guidelines with the exception of the haemodynamic goals.
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Dainty KN, Scales DC, Sinuff T, Zwarenstein M. Competition in collaborative clothing: a qualitative case study of influences on collaborative quality improvement in the ICU. BMJ Qual Saf 2013; 22:317-23. [PMID: 23417731 PMCID: PMC3607095 DOI: 10.1136/bmjqs-2012-001166] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background Multiorganisational quality improvement (QI) collaborative networks are promoted for improving quality within healthcare. Recently, several large-scale QI initiatives have been conducted in the intensive care unit (ICU) environment with successful quantitative results. However, the mechanisms through which such networks lead to QI success remain uncertain. We aim to understand ICU staff perspectives on collaborative QI based on involvement in a multiorganisational improvement network and hypothesise about theoretical constructs that might explain the effect of collaboration in such networks. Methods Qualitative study using a modified grounded theory approach. Key informant interviews were conducted with staff from 12 community hospital ICUs that participated in a cluster randomized control trial (RCT) of a QI intervention using a collaborative approach between 2006 and 2008. Data analysis followed the standard procedure for grounded theory using constant comparative methodology. Results The collaborative network was perceived to promote increased intrateam cooperation over interorganisational cooperation, but friendly competition with other ICUs appeared to be a prominent driver of behaviour change. Bedsides, clinicians reported that belonging to a collaborative network provided recognition for the high-quality patient care that they already provided. However, the existing communication structure was perceived to be ineffective for staff engagement since it was based on a hierarchical approach to knowledge transfer and project awareness. Conclusions QI collaborative networks may promote behaviour change by improving intrateam communication, fostering competition with other institutions, and increasing recognition for providing high-quality care. Other commonly held assumptions about their potential impact, for instance, increasing interorganisational legitimisation, communication and collaboration, may be less important.
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Affiliation(s)
- Katie N Dainty
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON , Canada M5B 1W8.
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Blanch L, Annane D, Antonelli M, Chiche JD, Cuñat J, Girard TD, Jiménez EJ, Quintel M, Ugarte S, Mancebo J. The future of intensive care medicine. Med Intensiva 2013; 37:91-8. [PMID: 23398846 DOI: 10.1016/j.medin.2012.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/19/2012] [Indexed: 02/04/2023]
Abstract
Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.
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Affiliation(s)
- L Blanch
- Critical Care Center, Hospital de Sabadell, Corporacio Sanitaria Universitària Parc Taulí, Sabadell, Spain.
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Guadalupe EGL, Silva E, Colombari F, Neto AS, Pardini A. Severity-adjusted resource use and outcomes of an ICU of a tertiary hospital in Sao Paulo, Brazil. Crit Care 2013; 17. [PMCID: PMC3891394 DOI: 10.1186/cc12631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- EGL Guadalupe
- Hospital Israelita Albert Einstein, Morumbi, São Paulo, SP, Brazil
| | - E Silva
- Hospital Israelita Albert Einstein, Morumbi, São Paulo, SP, Brazil
| | - F Colombari
- Hospital Israelita Albert Einstein, Morumbi, São Paulo, SP, Brazil,Hospital Alemão Oswaldo Cruz, Paraíso, São Paulo, SP, Brazil
| | - A Serpa Neto
- Hospital Israelita Albert Einstein, Morumbi, São Paulo, SP, Brazil
| | - A Pardini
- Hospital Israelita Albert Einstein, Morumbi, São Paulo, SP, Brazil
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