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Zammert M, Carpenter AJ, Zwischenberger JB, Sade RM. Surgeon or Intensivist: Who Should Be in Charge of Postoperative Intensive Care? Ann Thorac Surg 2023; 116:679-683. [PMID: 37356518 DOI: 10.1016/j.athoracsur.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Martin Zammert
- Division of Surgical Critical Care, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Andrea J Carpenter
- Department of Cardiothoracic Surgery, Joe R. And Teresa Lozano Long School of Medicine, San Antonio, Texas
| | | | - Robert M Sade
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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2
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Kopanczyk R, Long MT, Satyapriya SV, Bhatt AM, Lyaker M. Developing Cardiothoracic Surgical Critical Care Intensivists: A Case for Distinct Training. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1865. [PMID: 36557067 PMCID: PMC9784574 DOI: 10.3390/medicina58121865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
Cardiothoracic surgical critical care medicine is practiced by a diverse group of physicians including surgeons, anesthesiologists, pulmonologists, and cardiologists. With a wide array of specialties involved, the training of cardiothoracic surgical intensivists lacks standardization, creating significant variation in practice. Additionally, it results in siloed physicians who are less likely to collaborate and advocate for the cardiothoracic surgical critical care subspeciality. Moreover, the current model creates credentialing dilemmas, as experienced by some cardiothoracic surgeons. Through the lens of critical care anesthesiologists, this article addresses the shortcomings of the contemporary cardiothoracic surgical intensivist training standards. First, we describe the present state of practice, summarize past initiatives concerning specific training, outline why standardized education is needed, provide goals of such training standardization, and offer a list of desirable competencies that a trainee should develop to become a successful cardiothoracic surgical intensivist.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Sree V. Satyapriya
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Michael Lyaker
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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3
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Kopanczyk R, Kumar N, Bhatt AM. A Brief History of Cardiothoracic Surgical Critical Care Medicine in the United States. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121856. [PMID: 36557057 PMCID: PMC9788562 DOI: 10.3390/medicina58121856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/14/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Cardiothoracic surgical intensive care has developed in response to advances in cardiothoracic surgery. The invention of the cardiopulmonary bypass machine facilitated a motionless and bloodless surgical field and made operations of increasing complexity feasible. By the mid-1950s, the first successful procedures utilizing cardiopulmonary bypass took place. This was soon followed by the establishment of postoperative recovery units, the precursors to current cardiothoracic surgical intensive care units. These developments fostered the emergence of a new medical specialty: the discipline of critical care medicine. Together, surgeons and intensivists transformed the landscape of acute, in-hospital care. It is important to celebrate these achievements by remembering the individuals responsible for their conception. This article describes the early days of cardiothoracic surgery and cardiothoracic intensive care medicine.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Correspondence:
| | - Nicolas Kumar
- Department of Anesthesiology, Pain Medicine and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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4
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Sauro KM, Baker GR, Tomlinson G, Parshuram C. The role of hospital characteristics in patient safety: a protocol for a national cohort study. CMAJ Open 2021; 9:E1041-E1047. [PMID: 34815259 PMCID: PMC8612653 DOI: 10.9778/cmajo.20200266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Substantial expenditures on health care safety programs have been justified by their goal of reducing health care associated-harm (adverse events), but adverse event rates have not changed over the past 4 decades. The objective of this study is to describe hospital-level factors that are relevant to safety in Canadian hospitals and the impact of these factors on hospital adverse events. METHODS This is a protocol for a national cohort study to describe the association between hospital-level factors and adverse events. We will survey at least 90 (35%) Canadian hospitals to describe 4 safety-relevant domains, chosen based on the literature and expert consultation, namely patient safety culture, safety strategies, staffing, and volume and capacity. We will retrospectively identify hospital adverse events from a national data source. We will evaluate organization-level factors using established scales and a survey, codesigned by the study team and hospital leaders. Hospital leaders, clinical unit leaders and front-line staff will complete the surveys once a year for 3 years, with an anticipated start date of winter 2022. We will use national health administrative data to estimate the rate and type of hospital adverse events corresponding to each 1-year survey period. INTERPRETATION Analysis of data from this project will describe hospital organizational factors that are relevant to safety and help identify organizational initiatives that improve hospital patient safety. In addition to biyearly reports to the leaders of the participating hospitals, we have a multifaceted and tailored dissemination strategy that includes integrating the knowledge users into the study team to increase the likelihood that our study will lead to improved hospital patient safety.
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Affiliation(s)
- Khara M Sauro
- Department of Community Health Science and O'Brien Institute for Public Health (Sauro); Department of Oncology and Arnie Charbonneau Cancer Institute (Sauro), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Baker, Tomlinson, Parshuram), University of Toronto, Toronto, Ont.
| | - G Ross Baker
- Department of Community Health Science and O'Brien Institute for Public Health (Sauro); Department of Oncology and Arnie Charbonneau Cancer Institute (Sauro), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Baker, Tomlinson, Parshuram), University of Toronto, Toronto, Ont
| | - George Tomlinson
- Department of Community Health Science and O'Brien Institute for Public Health (Sauro); Department of Oncology and Arnie Charbonneau Cancer Institute (Sauro), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Baker, Tomlinson, Parshuram), University of Toronto, Toronto, Ont
| | - Christopher Parshuram
- Department of Community Health Science and O'Brien Institute for Public Health (Sauro); Department of Oncology and Arnie Charbonneau Cancer Institute (Sauro), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Institute of Health Policy, Management and Evaluation (Baker, Tomlinson, Parshuram), University of Toronto, Toronto, Ont
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5
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Vahedian-Azimi A, Rahimibashar F, Ashtari S, Guest PC, Sahebkar A. Comparison of the clinical features in open and closed format intensive care units: A systematic review and meta-analysis. Anaesth Crit Care Pain Med 2021; 40:100950. [PMID: 34555538 DOI: 10.1016/j.accpm.2021.100950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/29/2021] [Accepted: 06/06/2021] [Indexed: 01/09/2023]
Abstract
IMPORTANCE The difference in clinical outcomes between closed and open designs of intensive care units (ICUs) is still an open question. OBJECTIVE We conducted a systematic review and meta-analysis to compare total mortality, hospital and ICU length of stay (LOS) and mortality as primary outcomes, and severity of illness based on physiological variables, organ failure assessment, age, duration of mechanical ventilation and ventilator-associated pneumonia frequency as secondary outcomes in closed and open ICUs. EVIDENCE REVIEW Medline, PubMed, Scopus, Web of Science, Cochrane database, Iran-doc and Elm-net according to the MeSH terms were searched from 1988 to October 2019. The standardised mean difference (SMD), relative risk (RR) with 95% confidence interval (CI) were applied to display summary statistics of primary and secondary outcomes. FINDINGS A total of 90 studies with 444,042 participants were analysed. ICU mortality (RR: 1.16, CI: 1.07-1.27, p < 0.001), hospital mortality (RR: 1.12, CI: 1.03-1.22, p = 0.010) and ICU LOS (SMD: 0.43, CI: 0.01-0.85, p = 0.040) were significantly higher in open ICUs. Total mortality (RR: 0.91, CI: 0.77-1.08, p = 0.28) and hospital LOS (SMD: 1.14, CI: 1.31-3.59, p = 0.36) showed no significant difference between the two types of ICU. The secondary outcome measures were also comparable between the two ICU formats (p > 0.05). CONCLUSIONS AND RELEVANCE The results demonstrated superiority of closed versus open ICUs in hospital and ICU mortality rates and ICU LOS, with no difference in total mortality, hospital LOS or severity of illness parameters. The superiority of the closed ICU format may be a result of the intensivist-led patient care and should therefore be implemented by clinicians to decrease ICU mortality rates and LOS for critically ill patients.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma Research Centre, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Farshid Rahimibashar
- Anaesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sara Ashtari
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Paul C Guest
- Department of Biochemistry and Tissue Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; School of Medicine, The University of Western Australia, Perth, Australia; School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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6
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Park J, Oh AR, Kwon JH, Kim S, Kim J, Yang K, Choi JH, Kim K, Ahn J, Sung J, Lee SH. Association between cardiologist evaluation and mortality in myocardial injury after non-cardiac surgery. Heart 2021; 108:695-702. [PMID: 34400475 DOI: 10.1136/heartjnl-2021-319511] [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: 04/11/2021] [Accepted: 07/26/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Myocardial injury after non-cardiac surgery (MINS) is strongly associated with mortality, but few studies assessed treatment strategies. This study aimed to identify whether evaluation by cardiologists could reduce mortality in MINS patients. METHODS From a single-centre retrospective cohort, we enrolled a total of 5633 adult patients diagnosed with MINS between January 2010 and June 2019. The patients were divided into two groups based on evaluation by cardiologist, which was defined as a cardiology consultation or transfer to the cardiology department. For the outcome, 30-day mortality was compared in crude and propensity-score matched populations. RESULTS Of a total of 5633 patients, 2120 (37.6%) were evaluated by cardiologists and 3513 (62.4%) were not. Mortality during the first 30 days after surgery was significantly lower in MINS patients who were evaluated by cardiologists compared with those who were not (5.8% vs 8.3%; HR, 0.64; 95% CI 0.51 to 0.80; p<0.001 for all-cause mortality and 1.6% vs 2.0; HR 0.62; 95% CI 0.40 to 0.96; p=0.03 for cardiovascular mortality). The propensity score matched analysis showed similar results (5.6% vs 8.6%; HR 0.64; 95% CI 0.50 to 0.81; p<0.001 for all-cause mortality and 1.3% vs 2.2%; HR 0.58; 95% CI 0.35 to 0.95; p=0.03 for cardiovascular mortality). CONCLUSIONS Cardiologist evaluation was associated with lower mortality in patients diagnosed with MINS. Further studies are needed to identify effective treatment strategies for MINS. TRIAL REGISTRATION NUMBER KCT0004244.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sojin Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Jidong Sung
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea .,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, South Korea
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Hayanga JWA, Likosky DS, van Diepen S, Holst K, Whitson BA, Whitman G, Arkley J, Dunning J, Arora RC. 2020 in review. J Thorac Cardiovasc Surg 2021; 162:628-632. [PMID: 34024612 DOI: 10.1016/j.jtcvs.2021.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/20/2022]
Affiliation(s)
- J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WVa.
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Sean van Diepen
- Division of Cardiology and Department of Critical Care, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kimberly Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Glenn Whitman
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Arkley
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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8
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Welch TP, Kilbaugh TJ, McCloskey JJ, Juriga LL, Abdallah AB, Fehr JJ. The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States. Anesth Analg 2021; 132:194-201. [PMID: 32665467 DOI: 10.1213/ane.0000000000005024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition. METHODS We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey. RESULTS Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again. CONCLUSIONS The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.
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Affiliation(s)
- Timothy P Welch
- From the Departments of Anesthesiology.,Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J McCloskey
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | - James J Fehr
- From the Departments of Anesthesiology.,Pediatrics, Washington University School of Medicine, St Louis, Missouri
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9
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Huard P, Kalavrouziotis D, Lipes J, Simon M, Tardif MA, Blackburn S, Langevin S, Sia YT, Mohammadi S. Does the full-time presence of an intensivist lead to better outcomes in the cardiac surgical intensive care unit? J Thorac Cardiovasc Surg 2020; 159:1363-1375.e7. [DOI: 10.1016/j.jtcvs.2019.03.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 10/26/2022]
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10
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Influence of a high-intensity staffing model in a cardiac surgery intensive care unit on postoperative clinical outcomes. J Thorac Cardiovasc Surg 2020; 159:1382-1389. [DOI: 10.1016/j.jtcvs.2019.04.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
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Kim DJ, Sohn B, Kim H, Chang HW, Lee JH, Kim JS, Lim C, Park KH. The Impact of an Attending Intensivist on the Clinical Outcomes of Patients Admitted to the Cardiac Surgical Intensive Care Unit after Coronary Artery Bypass Grafting. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:8-15. [PMID: 32090052 PMCID: PMC7006613 DOI: 10.5090/kjtcs.2020.53.1.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 10/23/2019] [Accepted: 10/28/2019] [Indexed: 12/03/2022]
Abstract
Background We aimed to investigate the associations of critical care provided in a cardiac surgical intensive care unit (CSICU) staffed by an attending intensivist with improvements in intensive care unit (ICU) quality and reductions in postoperative complications. Methods Patients who underwent elective isolated coronary artery bypass grafting (CABG) between January 2007 and December 2012 (the control group) were propensity-matched (1:1) to CABG patients between January 2013 and June 2018 (the intensivist group). Results Using propensity score matching, 302 patients were extracted from each group. The proportion of patients with at least 1 postoperative complication was significantly lower in the intensivist group than in the control group (17.2% vs. 28.5%, p=0.001). In the intensivist group, the duration of mechanical ventilation (6.4±13.7 hours vs. 13.7±49.3 hours, p=0.013) and length of ICU stay (28.7±33.9 hours vs. 41.7±90.4 hours, p=0.018) were significantly shorter than in the control group. The proportions of patients with prolonged mechanical ventilation (2.3% vs. 7.6%, p=0.006), delirium (1.3% vs. 6.3%, p=0.003) and acute kidney injury (1.3% vs. 5.3%, p=0.012) were significantly lower in the intensivist group than in the control group. Conclusion A transition from an open ICU model with trainee coverage to a closed ICU model with attending intensivist coverage can be expected to yield improvements in CSICU quality and reductions in postoperative complications.
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Affiliation(s)
- Dong Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Bongyeon Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hakju Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyoung Woo Chang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Hang Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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12
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Fletcher N, Engelman DT. Postoperative care: who should look after patients following surgery? Anaesthesia 2020; 75 Suppl 1:e5-e9. [PMID: 31903574 DOI: 10.1111/anae.14887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 11/30/2022]
Affiliation(s)
- N Fletcher
- St. George's Hospital, London, UK.,Institute of Critical Care and Anaesthesia, Cleveland Clinic London, UK
| | - D T Engelman
- Department of Surgery, University of Massachusetts-Baystate, Baystate Medical Center, Springfield, MA, USA
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13
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Hao GW, Ma GG, Liu BF, Yang XM, Zhu DM, Liu L, Zhang Y, Liu H, Zhuang YM, Luo Z, Tu GW. Evaluation of two intensive care models in relation to successful extubation after cardiac surgery. Med Intensiva 2020; 44:27-35. [PMID: 30146128 DOI: 10.1016/j.medin.2018.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare outcomes between intensivist-directed and cardiac surgeon-directed care delivery models. DESIGN This retrospective, historical-control study was performed in a cohort of adult cardiac surgical patients at Zhongshan Hospital (Fudan University, China). During the first phase (March to August 2015), cardiac surgeons were in charge of postoperative care while intensivists were in charge during the second phase (September 2015-June 2016). Both phases were compared regarding successful extubation rate, intensive care unit (ICU) length of stay (LOS), and in-hospital mortality. SETTING Tertiary Zhongshan Hospital (Fudan University, China). PATIENTS Consecutive adult patients admitted to the cardiac surgical ICU (CSICU) after heart surgery. INTERVENTIONS Phase I patients treated by cardiac surgeons, and phase II patients treated by intensivists. MAIN VARIABLES OF INTEREST Successful extubation, ICU LOS and in-hospital mortality. RESULTS A total of 1792 (phase I) and 3007 patients (phase II) were enrolled. Most variables did not differ significantly between the two phases. However, patients in phase II had a higher successful extubation rate (99.17% vs. 98.55%; p=0.043) and a shorter median duration of mechanical ventilation (MV) (18 vs. 19h; p<0.001). In relation to patients with MV duration >48h, those in phase II had a comparatively higher successful extubation rate (p=0.033), shorter ICU LOS (p=0.038) and a significant decrease in in-hospital mortality (p=0.039). CONCLUSIONS The intensivist-directed care model showed improved rates of successful extubation and shorter MV durations after cardiac surgery.
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Affiliation(s)
- G-W Hao
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - G-G Ma
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - B-F Liu
- Department of Critical Care Medicine, The First People's Hospital of Zhangjiagang, Suzhou, China
| | - X-M Yang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - D-M Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - L Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - Y Zhang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - H Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - Y-M Zhuang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China
| | - Z Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China.
| | - G-W Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, PR China.
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Arora RC, Chatterjee S, Shake JG, Hirose H, Engelman DT, Rabin J, Firstenberg M, Moosdorf RGH, Geller CM, Hiebert B, Whitman GJ. Survey of Contemporary Cardiac Surgery Intensive Care Unit Models in the United States. Ann Thorac Surg 2019; 109:702-710. [PMID: 31421102 DOI: 10.1016/j.athoracsur.2019.06.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/02/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intensive care unit (ICU) structure and intensive care physician staffing (IPS) models are thought to influence outcomes after cardiac surgery. Given limited information on staffing in the cardiothoracic ICU, The Society of Thoracic Surgeons Workforce on Critical Care undertook a survey to describe current IPS models. We hypothesized that variability would exist throughout the United States. METHODS A survey was sent to The Society of Thoracic Surgeons centers in the United States. Center case volume, ICU census, procedure profiles, and the primary specialties of consultants were queried. Definitions of IPS models were open (managed by cardiac surgeons), closed (all decisions made by dedicated intensivists 7 days a week), or semiopen (intensivist attends 5-7 days a week with surgeons cosharing management). Experience level of bedside providers and after-hours provider coverage were also assessed. RESULTS Of the 965 centers contacted, 148 (15.3%) completed surveys. Approximately 41% of reporting centers used a dedicated cardiothoracic ICU for immediate postoperative management. The most common IPS model was open (47%), followed by semiopen (41%) and closed (12%). The primary specialties of intensivists varied, with pulmonary medicine/critical care being predominant (67%). Physician assistants were the most common after-hours provider (44%). More than one-third of responding centers described having no house staff, other than bedside nurses, for nighttime coverage. CONCLUSIONS Cardiothoracic ICU models vary widely in the United States, with almost half being open, often with no in-house coverage. In-house nighttime coverage was (1) not driven by case complexity and (2) most commonly provided by a physician assistant. Clinical outcomes associated with different ISPS models require further evaluation.
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Affiliation(s)
- Rakesh C Arora
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
| | | | - Jay G Shake
- Department of Surgery, University of Mississippi, Jackson, Mississippi
| | - Hitoshi Hirose
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dan T Engelman
- Department of Surgery, Baystate Medical Center, Springfield, Massachusetts
| | - Joseph Rabin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Firstenberg
- Department of Cardiovascular Surgery, The Medical Center of Aurora, Aurora, Colorado
| | - Rainer G H Moosdorf
- Department for Cardiovascular Surgery, Phillips University, Marburg, Germany
| | - Charles M Geller
- Division of Cardiothoracic Surgery, Drexel University College of Medicine, Upland, Pennsylvania
| | - Brett Hiebert
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Glenn J Whitman
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins Medical Institute, Baltimore, Maryland
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Patel SR, Barounis DA, Milas A, Nikamal AJ, Estoos E, Anand N, Nitti K, Dodd KW. Outcomes following nighttime extubation in a high-intensity medical intensive care unit. J Crit Care 2019; 54:30-36. [PMID: 31326618 DOI: 10.1016/j.jcrc.2019.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/23/2019] [Accepted: 06/26/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Samir R Patel
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Emergency Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America; Department of Emergency Medicine, University of Illinois at Chicago, United States of America
| | - David A Barounis
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Emergency Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America; Department of Emergency Medicine, University of Illinois at Chicago, United States of America
| | - Anamaria Milas
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America.
| | - Arya J Nikamal
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America
| | - Ethan Estoos
- Department of Emergency Medicine, Advocate Christ Medical Center, United States of America
| | - Neesha Anand
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America
| | - Kara Nitti
- Department of Research, Advocate Christ Medical Center, United States of America
| | - Kenneth W Dodd
- Department of Internal Medicine, Advocate Christ Medical Center, United States of America; Department of Emergency Medicine, Advocate Christ Medical Center, United States of America; Department of Internal Medicine, University of Illinois at Chicago, United States of America; Department of Emergency Medicine, University of Illinois at Chicago, United States of America
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16
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Abstract
PURPOSE OF REVIEW Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. RECENT FINDINGS Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. SUMMARY Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence.
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van Diepen S. Commentary: More evidence for 24-7 intensivist cardiac surgical intensive care unit coverage. J Thorac Cardiovasc Surg 2019; 159:1380-1381. [PMID: 31060738 DOI: 10.1016/j.jtcvs.2019.03.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada.
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Muller Moran HR, Maguire D, Maguire D, Kowalski S, Jacobsohn E, Mackenzie S, Grocott H, Arora RC. Association of earlier extubation and postoperative delirium after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2019; 159:182-190.e7. [PMID: 31076177 DOI: 10.1016/j.jtcvs.2019.03.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Earlier extubation after cardiac surgery is reported to have benefits on length of stay and complication rates, but the influence on postoperative delirium remains unclear. We sought to determine the effect of earlier extubation on delirium after coronary artery bypass grafting. METHODS A single-center retrospective review of consecutive isolated coronary artery bypass grafting patients from January 1, 2010, to December 31, 2015, was conducted. Baseline demographic characteristics, preoperative comorbidities, intraoperative data, and postoperative data were collected. A multivariable logistic regression was performed with analysis limited to extubation within the first 24 hours postoperatively. RESULTS We identified 2561 eligible patients. Delirium occurred in 13.9% (n = 357). Duration of postoperative mechanical ventilation was associated with higher delirium rates following adjustment, particularly after 12 to 24 hours (hourly odds ratio, 1.12; 95% confidence interval, 1.05-1.19; P < .001). No association was observed during the time period from 0 to 12 hours (hourly odds ratio, 1.02; 95% confidence interval, 0.99-1.06; P = .218). Major adverse events were associated with duration of ventilation after 0 to 12 hours (hourly odds ratio, 1.08; 95% confidence interval, 1.03-1.14; P < .002) but not after 12 to 24 hours (hourly odds ratio, 1.04; 95% CI, 0.96-1.14; P = .316). The overall rate of reintubation was 2.9% (n = 73). CONCLUSIONS Our findings suggest that delirium rates increase with lengthier postoperative ventilation times. This study provides the basis for consideration of the appropriate selection of earlier extubation to minimize delirium in patients undergoing cardiac surgery.
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Affiliation(s)
- Hellmuth R Muller Moran
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Duncan Maguire
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Doug Maguire
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stephen Kowalski
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott Mackenzie
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Hilary Grocott
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.
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Masud F, Lam TYC, Fatima S. Is 24/7 In-House Intensivist Staffing Necessary in the Intensive Care Unit? Methodist Debakey Cardiovasc J 2018; 14:134-140. [PMID: 29977470 DOI: 10.14797/mdcj-14-2-134] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Over the past few decades, an increasing number of studies have shown that intensivist-staffed intensive care units (ICUs) lead to overall economic benefits and improved patient outcomes, including shorter length of stay and lower rates of complications and mortality. This body of evidence has convinced advocacy groups to adopt this staffing model as a standard of care in the ICU so that more hospitals are offering around-the-clock intensivist coverage. Even so, opponents have pointed to high ICU staffing costs and a shortage of physicians trained in critical care as barriers to implementing this model. While these arguments may hold true in low-acuity, low-volume ICUs, evidence has shown that in high-acuity, high-volume centers such as teaching hospitals and tertiary care centers, the benefits outweigh the costs. This article explores the history of intensivists and critical care, the arguments for 24/7 ICU staffing, and outcomes in various ICU settings but is not intended to be a comprehensive review of all controversies surrounding continuous ICU staffing.
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Affiliation(s)
- Faisal Masud
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | | | - Sahar Fatima
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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20
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Hosseinian L, Reich DL. Commentary: What makes a cardiac surgical intensive care unit safe after midnight? J Thorac Cardiovasc Surg 2018; 157:1543-1544. [PMID: 30448164 DOI: 10.1016/j.jtcvs.2018.09.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Leila Hosseinian
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David L Reich
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; The Mount Sinai Hospital, New York, NY.
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22
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Maleki M, Mousavi SM, Anjomshoa M, Shaarbafchizadeh N, Naimi Taleghani Z. Does Intradisciplinary Conflict Influence to Outcomes of Emergency Medicine Residency Program? A Mixed Methods Study. Bull Emerg Trauma 2017. [PMID: 29177177 DOI: 10.18869/acadpub.beat.5.4.475.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective To explore impact of emergency medicine residency program on patient waiting times in emergency department (ED) and determine the associated factors. Methods A two-phased sequential exploratory mixed-methods approach was used. The first phase was comprised of retrospective before-after design of ED encounters for a 3-month period, six months before and six months after the introduction of an emergency medicine residency program in an Iranian teaching hospital. The second phase included semi-structured interviews with five individuals which purposively selected to participate in qualitative design. Quantitative data were analysed descriptively and qualitative data were analysed using an iterative framework approach. Results The most patients were admitted to the hospital in night shift, both before and after the resident EMS. No statistically significant differences were found among all of the waiting times during the two time periods except for the average time interval between admission and physician start time (p<0.0001), which increased (instead of reducing), and the average time interval between physician start time and first treatment measure (p<0.0001), which decreased during the year the residents began. The interviewees revealed the intradisciplinary conflicts and interferences existing between ED and other specialist departments, are main important factor to delayed processing of patients visits. Conclusion This study has shown that intradisciplinary conflict would affect the outcomes of emergency medicine residency program and ED process. These new findings enhance the understanding of the nature of conflicts and will persuade policy makers that design a set of clinical practice guidelines to clarify the duties and responsibilities of parties involved in ED.
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Affiliation(s)
- Mohammadreza Maleki
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Seyyed Meysam Mousavi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Anjomshoa
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Shaarbafchizadeh
- Department of Health Services Management, School of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zeinab Naimi Taleghani
- Students' Scientific Research Center, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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23
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Kuo K, Shah P, Hiebert B, Love K, Menkis AH, Manji RA, Arora RC. Predictors of survival, functional survival, and hospital readmission in octogenarians after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2017; 154:1544-1553.e1. [PMID: 28673707 DOI: 10.1016/j.jtcvs.2017.05.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Kendra Kuo
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Pallav Shah
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Karin Love
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alan H Menkis
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Maleki M, Mousavi SM, Anjomshoa M, Shaarbafchizadeh N, Naimi Taleghani Z. Does Intradisciplinary Conflict Influence to Outcomes of Emergency Medicine Residency Program? A Mixed Methods Study. Bull Emerg Trauma 2017; 5:292-298. [PMID: 29177177 PMCID: PMC5694603 DOI: 10.18869/acadpub.beat.5.4.475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/08/2017] [Accepted: 09/15/2017] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To explore impact of emergency medicine residency program on patient waiting times in emergency department (ED) and determine the associated factors. METHODS A two-phased sequential exploratory mixed-methods approach was used. The first phase was comprised of retrospective before-after design of ED encounters for a 3-month period, six months before and six months after the introduction of an emergency medicine residency program in an Iranian teaching hospital. The second phase included semi-structured interviews with five individuals which purposively selected to participate in qualitative design. Quantitative data were analysed descriptively and qualitative data were analysed using an iterative framework approach. RESULTS The most patients were admitted to the hospital in night shift, both before and after the resident EMS. No statistically significant differences were found among all of the waiting times during the two time periods except for the average time interval between admission and physician start time (p<0.0001), which increased (instead of reducing), and the average time interval between physician start time and first treatment measure (p<0.0001), which decreased during the year the residents began. The interviewees revealed the intradisciplinary conflicts and interferences existing between ED and other specialist departments, are main important factor to delayed processing of patients visits. CONCLUSION This study has shown that intradisciplinary conflict would affect the outcomes of emergency medicine residency program and ED process. These new findings enhance the understanding of the nature of conflicts and will persuade policy makers that design a set of clinical practice guidelines to clarify the duties and responsibilities of parties involved in ED.
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Affiliation(s)
- Mohammadreza Maleki
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Seyyed Meysam Mousavi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Anjomshoa
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasrin Shaarbafchizadeh
- Department of Health Services Management, School of Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zeinab Naimi Taleghani
- Students’ Scientific Research Center, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.
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Kerlin MP, Adhikari NKJ, Rose L, Wilcox ME, Bellamy CJ, Costa DK, Gershengorn HB, Halpern SD, Kahn JM, Lane-Fall MB, Wallace DJ, Weiss CH, Wunsch H, Cooke CR. An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients. Am J Respir Crit Care Med 2017; 195:383-393. [PMID: 28145766 DOI: 10.1164/rccm.201611-2250st] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Studies of nighttime intensivist staffing have yielded mixed results. GOALS To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients. METHODS We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models. RESULTS Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes. CONCLUSIONS Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.
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Arora RC, Manji RA, Singal RK, Hiebert B, Menkis AH. Outcomes of octogenarians discharged from the hospital after prolonged intensive care unit length of stay after cardiac surgery. J Thorac Cardiovasc Surg 2017; 154:1668-1678.e2. [PMID: 28688711 DOI: 10.1016/j.jtcvs.2017.04.083] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 04/13/2017] [Accepted: 04/26/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Octogenarians offered complex cardiac surgery frequently experience a prolonged intensive care unit length of stay; however, minimal data exist on the outcomes of these patients. We sought to determine the rates and predictors of 1-year noninstitutionalized survival ("functional survival") and rehospitalization for octogenarian patients with prolonged intensive care unit length of stay after cardiac surgery and who were discharged from hospital. METHODS The outcomes of discharged patients aged 80 years or more who underwent cardiac surgery with prolonged intensive care unit length of stay (≥5 consecutive days) from January 1, 2000, to December 31, 2011, were examined retrospectively from linked clinical and administrative provincial databases. Regression analysis was used to determine predictors of 1-year functional survival and rehospitalization after discharge from the hospital. RESULTS A total of 80 of 683 (11.7%) discharged octogenarian patients had prolonged intensive care unit length of stay. Functional survival at 1 year was 92% and 81% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively (P < .01). Lack of outpatient physician visits within 30 days of discharge (hazard ratio, 5.18; P < .01) was a significant predictor of poor 1-year functional survival. The 1-year rehospitalization rates were 38% and 48% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively, with 41% of all rehospitalizations occurring within 30 days of initial discharge. A rural residence (hazard ratio, 1.82; P < .01) and nosocomial pneumonia during patients' operative admissions (hazard ratio, 2.74; P < .01) were associated with rehospitalization within 30 days of discharge. CONCLUSIONS Octogenarians with prolonged intensive care unit length of stay have acceptable functional survival at 1 year but have high rates of early rehospitalization. Access to health services may influence functional survival and early rehospitalizations. These data suggest that close follow-up of these vulnerable patients after hospital discharge is warranted.
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Affiliation(s)
- Rakesh C Arora
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Rizwan A Manji
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rohit K Singal
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan H Menkis
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
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Impact of a cardiac intensivist on mortality in patients with cardiogenic shock. Int J Cardiol 2017; 244:220-225. [PMID: 28666601 DOI: 10.1016/j.ijcard.2017.06.082] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/06/2017] [Accepted: 06/20/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study aimed to evaluate the association between high-intensity staffing by a dedicated cardiac intensivist and clinical outcomes in CS. METHODS We enrolled 2923 consecutive patients admitted to a cardiac care unit (CCU) from January 1, 2012 to December 31, 2015. In January 2013, the CCU changed from a low-intensity to high-intensity staffing unit managed by a dedicated cardiac intensivist. Patients were eligible if they required inotropes or vasopressors to maintain a systolic blood pressure>90mmHg, and had serum lactate≥2.0mmol/L. Eligible patients (n=513) were treated by low-intensity CCU (n=352) or high-intensity CCU (n=161). The primary outcome was CCU mortality. RESULTS CCU mortality occurred in 49 patients (30.6%) of the low-intensity group versus 62 patients (17.6%) of the high-intensity group (adjusted odds ratio [aOR] 0.44, 95% confidence interval [CI] 0.25-0.75, p<0.001). In-hospital mortality was not significantly different between the groups (33.1% vs 24.4%, aOR 0.75, 95% CI 0.43-1.29, p=0.29). Among 135 patients treated with extracorporeal membrane oxygenation, the high-intensity model was associated with lower CCU mortality (54.5% vs 22.5%, aOR 0.24, 95% CI 0.07-0.77, p=0.02) and in-hospital mortality (57.6% vs 29.4%, aOR 0.28, 95% CI 0.10-0.81, p=0.02). CONCLUSION High-intensity staffed CCU managed by a dedicated cardiac intensivist was associated with a significant reduction of CS-related mortality.
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Postoperative Complications and Outcomes Associated With a Transition to 24/7 Intensivist Management of Cardiac Surgery Patients. Crit Care Med 2017; 45:993-1000. [DOI: 10.1097/ccm.0000000000002434] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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30
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Na SJ, Chung CR, Jeon K, Park CM, Suh GY, Ahn JH, Carriere KC, Song YB, Choi JO, Hahn JY, Choi JH, Choi SH, On YK, Gwon HC, Jeon ES, Kim DK, Yang JH. Association Between Presence of a Cardiac Intensivist and Mortality in an Adult Cardiac Care Unit. J Am Coll Cardiol 2016; 68:2637-2648. [DOI: 10.1016/j.jacc.2016.09.947] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 09/13/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Toeg H. Providing optimal cardiovascular and thoracic critical care in the Great White North. J Thorac Cardiovasc Surg 2015; 150:463-4. [PMID: 26117489 DOI: 10.1016/j.jtcvs.2015.05.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/21/2015] [Accepted: 05/29/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Hadi Toeg
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada.
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Kumar KK, Arora RC. Cardiac critical care: Balancing educational goals with optimal patient care. J Thorac Cardiovasc Surg 2015; 150:290-1. [PMID: 26027912 DOI: 10.1016/j.jtcvs.2015.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/21/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Kanwal K Kumar
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada; Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.
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Jung P, Pereira MA, Hiebert B, Song X, Rockwood K, Tangri N, Arora RC. The impact of frailty on postoperative delirium in cardiac surgery patients. J Thorac Cardiovasc Surg 2015; 149:869-75.e1-2. [DOI: 10.1016/j.jtcvs.2014.10.118] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/03/2014] [Accepted: 10/29/2014] [Indexed: 11/16/2022]
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A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:468. [PMID: 25123092 PMCID: PMC4243831 DOI: 10.1186/s13054-014-0468-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/22/2014] [Indexed: 02/08/2023]
Abstract
Introduction Fast-track treatment in cardiac surgery has become the global standard of care. We compared the efficacy and safety of a specialised post-anaesthetic care unit (PACU) to a conventional intensive care unit (ICU) in achieving defined fast-track end points in adult patients after elective cardiac surgery. Methods In a prospective, single-blinded, randomized study, 200 adult patients undergoing elective cardiac surgery (coronary artery bypass graft (CABG), valve surgery or combined CABG and valve surgery), were selected to receive their postoperative treatment either in the ICU (n = 100), or in the PACU (n = 100). Patients who, at the time of surgery, were in cardiogenic shock, required renal dialysis, or had an additive EuroSCORE of more than 10 were excluded from the study. The primary end points were: time to extubation (ET), and length of stay in the PACU or ICU (PACU/ICU LOS respectively). Secondary end points analysed were the incidences of: surgical re-exploration, development of haemothorax, new-onset cardiac arrhythmia, low cardiac output syndrome, need for cardiopulmonary resuscitation, stroke, acute renal failure, and death. Results Median time to extubation was 90 [50; 140] min in the PACU vs. 478 [305; 643] min in the ICU group (P <0.001). Median length of stay in the PACU was 3.3 [2.7; 4.0] hours vs. 17.9 [10.3; 24.9] hours in the ICU (P <0.001). Of the adverse events examined, only the incidence of new-onset cardiac arrhythmia (25 in PACU vs. 41 in ICU, P = 0.02) was statistically different between groups. Conclusions Treatment in a specialised PACU rather than an ICU, after elective cardiac surgery leads to earlier extubation and quicker discharge to a step-down unit, without compromising patient safety. Trial registration ISRCTN71768341. Registered 11 March 2014.
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The benefits of 24/7 in-house intensivist coverage for prolonged-stay cardiac surgery patients. J Thorac Cardiovasc Surg 2014; 148:290-297.e6. [DOI: 10.1016/j.jtcvs.2014.02.074] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 01/30/2014] [Accepted: 02/26/2014] [Indexed: 11/17/2022]
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Park CM, Chun HK, Lee DS, Jeon K, Suh GY, Jeong JC. Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit. Ann Surg Treat Res 2014; 86:319-24. [PMID: 24949324 PMCID: PMC4062451 DOI: 10.4174/astr.2014.86.6.319] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 01/29/2014] [Accepted: 02/07/2014] [Indexed: 11/30/2022] Open
Abstract
Purpose An intensivist is a key factor in the mortality of patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an intensivist on clinical outcomes of patients admitted to a surgical ICU. Methods During the study period, the surgical ICU was converted from an open ICU to an intensivist-directed ICU managed by an intensivist who was board certified in both general surgery and critical care medicine. We compared consecutive patients admitted to the surgical ICU before and after implementing the intensivist-directed care. The primary outcome was ICU mortality, and secondary outcomes were hospital mortality, 90-day mortality, length of hospital stay, ICU-free days, ventilator-free days, and ICU readmission rate. Results A total of 441 patients were included in this study: 188 before implementation of the intensivist and 253 after implementation. Clinical characteristics were not different between the two groups. ICU mortality decreased from 11.7% to 6.3% (P = 0.047) after implementation, and 90-day mortality also decreased significantly (P = 0.008). The adjusted hazard ratio of the intensivist for ICU mortality was 0.43 (95% confidence interval, 0.22-0.87; P = 0.020). ICU-free days (P = 0.013) and the hospital length of stay (P = 0.032) were significantly improved after implementing the intensivist-directed care. Before implementation period, 16.0% of patients were readmitted, compared with only 9.9% after implementation (P = 0.05). Conclusion Implementing intensivist-directed care in the surgical ICU was associated with significant improvements in ICU mortality and significant clinical outcomes.
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Affiliation(s)
- Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae-Sang Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Cheol Jeong
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
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The relationship between in-house attending coverage and nighttime extubation following congenital heart surgery*. Pediatr Crit Care Med 2014; 15:258-63. [PMID: 24394998 DOI: 10.1097/pcc.0000000000000068] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Many cardiac ICUs have instituted 24/7 attending physician in-house coverage, which theoretically may allow for more expeditious weaning from ventilation and extubation. We aimed to determine whether this staffing strategy impacts rates of nighttime extubation and duration of mechanical ventilation. DESIGN National data were obtained from the Virtual PICU System database for all patients admitted to the cardiac ICU following congenital heart surgery in 2011 who required postoperative mechanical ventilation. Contemporaneous data from our local institution were collected in addition to the Virtual PICU System data. The combined dataset (n = 2,429) was divided based on the type of nighttime staffing model in order to compare rates of nighttime extubation and duration of mechanical ventilation between units that used an in-house attending staffing strategy and those that employed nighttime residents, fellows, or midlevel providers only. MEASUREMENTS AND MAIN RESULTS Institutions that currently use 24/7 in-house attending coverage did not demonstrate statistically significant differences in rates of nighttime extubation or the duration of mechanical ventilation in comparison to units without in-house attendings. Younger patients cared for in non-in-house attending units were more likely to require reintubation. CONCLUSIONS Pediatric patients who have undergone congenital heart surgery can be safely and effectively extubated without the routine presence of an attending physician. The utilization of nighttime in-house attending coverage does not appear to have significant benefits on the rate of nighttime extubation and may not reduce the duration of mechanical ventilation in units that already use in-house residents, fellows, or other midlevel providers.
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Survey of in-house coverage by pediatric intensivists: characterization of 24/7 in-hospital pediatric critical care faculty coverage*. Pediatr Crit Care Med 2014; 15:97-104. [PMID: 24366511 DOI: 10.1097/pcc.0000000000000032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To characterize the current state of 24/7 in-hospital pediatric intensivist coverage in academic PICUs, including perceptions of faculty and trainees regarding the advantages and disadvantages of in-hospital coverage. DESIGN Cross-sectional observational study via web-based survey. SETTING PICUs at North American academic institutions. SUBJECTS Pediatric intensivists, pediatric critical care fellows, and pediatric residents. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,323 responses were received representing a center response rate of 74% (147 of 200). Ninety percent of respondents stated that in-hospital coverage is good for patient care, and 85% stated that in-hospital coverage provides safer care. Sixty-three percent of intensivists stated that working in in-hospital models limits academic productivity, and 65% stated that in-hospital models interfere with nonclinical responsibilities. When compared with intensivists in home coverage models, intensivists working in in-hospital models generally had more favorable perceptions of the effects of in-hospital on patient care (p < 0.0001) and faculty quality of life. Physician burnout was measured with the abbreviated Maslach Burnout Inventory. Although 57% of intensivists responded that working in in-hospital models increases burnout risk, burnout scores were not different between coverage models. Seventy-nine percent of intensivists currently working at institutions with in-hospital coverage stated that they would prefer to work in an in-hospital coverage model, compared with 31% of those working in a home coverage model (p < 0.0001). CONCLUSIONS Although concerns exist regarding the effect of 24/7 in-hospital coverage on faculty, the majority of pediatric intensivists and critical care trainees responded that in-hospital coverage by intensivists is good for patient care. The majority of intensivists also state that they would prefer to work at an institution with in-hospital coverage. Further research is needed to objectively delineate the effects of in-hospital coverage on both patients and faculty.
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Ackerman AD. A chicken in every pot-a pediatric intensivist in every unit/all the time?*. Pediatr Crit Care Med 2014; 15:170-1. [PMID: 24492184 DOI: 10.1097/pcc.0000000000000060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kogan A, Preisman S, Berkenstadt H, Segal E, Kassif Y, Sternik L, Orlov B, Shalom E, Levin S, Malachy A, Lavee J, Raanani E. Evaluation of the Impact of a Quality Improvement Program and Intensivist-Directed ICU Team on Mortality After Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:1194-200. [DOI: 10.1053/j.jvca.2013.02.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Indexed: 11/11/2022]
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Ramakrishna H, Reidy C, Riha H, Sophocles A, Lane BJ, Patel PA, Andritsos M, Ghadimi K, Augoustides JGT. The year in cardiothoracic and vascular anesthesia: selected highlights from 2012. J Cardiothorac Vasc Anesth 2013; 27:86-91. [PMID: 23312777 DOI: 10.1053/j.jvca.2012.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Indexed: 11/11/2022]
Abstract
Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.
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Do Intensivist Staffing Patterns Influence Hospital Mortality Following ICU Admission? A Systematic Review and Meta-Analyses*. Crit Care Med 2013; 41:2253-74. [DOI: 10.1097/ccm.0b013e318292313a] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lunz D, Philipp A, Judemann K, Amann M, Foltan M, Schmid C, Graf B, Zausig YA. First experience with the deltastream(R) DP3 in venovenous extracorporeal membrane oxygenation and air-supported inter-hospital transport. Interact Cardiovasc Thorac Surg 2013; 17:773-7. [PMID: 23873380 DOI: 10.1093/icvts/ivt320] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Based on continuous technical innovations and recent research, extracorporeal membrane oxygenation (ECMO) has become a promising tool in the treatment of patients with acute (cardio)pulmonary failure. Nevertheless, any extracorporeal technique requires a high degree of experience and knowledge, so that a restriction to specialized centres seems to be reasonable. As a consequence of this demand, the need for inter-hospital transfer of patients with severely impaired (cardio)pulmonary function is rising. Unfortunately, most of the ECMO devices used in the clinical setting are not suitable for inter-hospital transport because of their size, weight or complexity. In this article, we describe our first experiences with the airborne transport of 6 patients on a new portable, miniaturized and lightweight extracorporeal circulation system, the Medos deltastream® DP3. METHODS Six patients suffering acute respiratory failure were taken on venovenous ECMO (DP3) out-of-centre and transferred to the University Medical Center Regensburg by helicopter. All cardiorespiratory-relevant parameters of the patients and the technical functioning of the device were continuously monitored and documented. RESULTS Implantation of the device and air-supported transport were performed without any technical complications. The patients were transported from a distance of 66-178 km, requiring a time of 40-120 min. With the help of the new deltastream® DP3 ECMO device, a prompt stabilization of the cardiopulmonary function could be achieved in all patients. One patient was under ongoing cardiopulmonary resuscitation by the time our ECMO team arrived at the peripheral hospital and died shortly after arrival in the central emergency ward. CONCLUSIONS Our experience shows that the deltastream® DP3 is an absolutely reliable and safe ECMO device that could gain growing importance in the field of airborne transportation of patients on ECMO due to its unsophisticated, miniaturized and lightweight characteristics.
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Affiliation(s)
- Dirk Lunz
- Department of Anesthesiology, University Medical Center, Regensburg, Germany
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Arenson BG, MacDonald LA, Grocott HP, Hiebert BM, Arora RC. Effect of intensive care unit environment on in-hospital delirium after cardiac surgery. J Thorac Cardiovasc Surg 2013; 146:172-8. [DOI: 10.1016/j.jtcvs.2012.12.042] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/19/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
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It is time for certification in cardiothoracic critical care. J Thorac Cardiovasc Surg 2013; 145:1446-7. [DOI: 10.1016/j.jtcvs.2013.01.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/28/2013] [Indexed: 11/19/2022]
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Shake JG, Pronovost PJ, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications. J Card Surg 2013; 28:406-13. [PMID: 23718856 DOI: 10.1111/jocs.12124] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The goal of this article is to provide an outline of the latest advances in critical care that pertain to the open heart surgery patient, pinpointing initiatives that would enable physicians and institutions to successfully implement guidelines, protocols, checklists, and initiatives that have been shown to improve patient safety.
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Affiliation(s)
- Jay G Shake
- Division of Cardiothoracic Surgery, Scott and White Memorial Hospital, Temple, Texas 76508, USA.
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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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Penny DJ, Shekerdemian LS. The American Heart Association's recent scientific statement on cardiac critical care: implications for pediatric practice. CONGENIT HEART DIS 2012; 8:3-19. [PMID: 23280102 DOI: 10.1111/chd.12028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2012] [Indexed: 10/27/2022]
Abstract
A writing group sponsored by the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the Council on Quality of Care and Outcomes Research of The American Heart Association has recently formulated a roadmap to meet the changing needs of the patient with cardiovascular disease requiring critical care. Although this roadmap has been formulated primarily to address the care needs of the adult with critical cardiovascular disease, it contains useful lessons pertinent to the care of the patient with pediatric and congenital cardiovascular disease. In this document, we have examined The Statement and applied its framework to the evolving field of pediatric cardiac critical care.
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Affiliation(s)
- Daniel J Penny
- Division of Cardiology, Texas Children's Hospital, Houston, TX 77030, USA.
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Balachandran R, Nair SG, Gopalraj SS, Vaidyanathan B, Kumar RK. Dedicated pediatric cardiac intensive care unit in a developing country: Does it improve the outcome? Ann Pediatr Cardiol 2012; 4:122-6. [PMID: 21976869 PMCID: PMC3180967 DOI: 10.4103/0974-2069.84648] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION AND AIM Focussed cardiac intensive care is known to produce better outcomes. We have evaluated the benefits of a dedicated Pediatric Cardiac Intensive Care Unit (PCICU) in the early postoperative outcomes of patients undergoing surgery for congenital heart disease. METHODS Prospectively collected data of 634 consecutive patients who underwent congenital heart surgery from September 2008 to September 2009 were analyzed. Midway through this period a dedicated PCICU was started. The patients who were treated in this new PCICU formed the study group (Group B, n = 318). The patients who were treated in a common postoperative cardiac surgery ICU formed the control group (Group A, n = 316). Early postoperative outcomes between the two groups were compared. RESULTS The two groups were comparable with respect to demographic data and intraoperative variables. The duration of mechanical ventilation in the dedicated pediatric cardiac ICU group (32.22 ± 52.02 hours) was lower when compared with the combined adult and pediatric surgery ICU group (42.92 ± 74.24 hours, P= 0.04). There was a shorter duration of ICU stay in the dedicated pediatric cardiac ICU group (2.69 ± 2.9 days vs. 3.43 ± 3.80 days, P = 0.001). The study group also showed a shorter duration of inotropic support and duration of invasive lines. The incidence of blood stream infections was also lower in the dedicated pediatric ICU group (5.03 vs. 9.18%, P = 0.04). A subgroup analysis of neonates and infants <1 year showed that the advantages of a dedicated pediatric intensive care unit were more pronounced in this group of patients. CONCLUSIONS Establishment of a dedicated pediatric cardiac intensive care unit has shown better outcomes in terms of earlier extubation, de-intensification, and discharge from the ICU. Blood stream infections were also reduced.
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Affiliation(s)
- Rakhi Balachandran
- Department of Anesthesia, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
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