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Case AS, Hochberg CH, Hager DN. The Role of Intermediate Care in Supporting Critically Ill Patients and Critical Care Infrastructure. Crit Care Clin 2024; 40:507-522. [PMID: 38796224 PMCID: PMC11175835 DOI: 10.1016/j.ccc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.
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Affiliation(s)
- Aaron S Case
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, 5th Floor, Baltimore, MD 21287, USA
| | - Chad H Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, 5th Floor, Baltimore, MD 21287, USA
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1800 Orleans Street, Zayed Tower, Suite 9121, Baltimore, MD 21287, USA.
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Peeler A, Nelson K, Agrawalla V, Badawi S, Moore R, Li D, Street L, Hager DN, Dennison Himmelfarb C, Davidson PM, Koirala B. Living with multimorbidity: A qualitative exploration of shared experiences of patients, family caregivers, and healthcare professionals in managing symptoms in the United States. J Adv Nurs 2024; 80:2525-2539. [PMID: 38197539 DOI: 10.1111/jan.15998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 11/12/2023] [Accepted: 11/19/2023] [Indexed: 01/11/2024]
Abstract
AIMS To elicit experiences of patients, family caregivers, and healthcare professionals in intermediate care units (IMCUs) in an academic medical centre in Baltimore, MD related to the challenges and intricacies of multimorbidity management to inform development of a multimorbidity symptom management toolkit. DESIGN Experience-based co-design. METHODS Between July and October 2021, patients aged 55 years and older with multimorbidity admitted to IMCUs at an academic medical centre in Baltimore, Maryland, USA were recruited and interviewed in person. Interdisciplinary healthcare professionals working in the IMCU were interviewed virtually. Participants were asked questions about their role in recognizing and treating symptoms, factors affecting the quality of life, symptom burden and trajectory over time, and strategies that have and have not worked for managing symptoms. An inductive thematic analysis approach was used for analysis. RESULTS Twenty-three interviews were conducted: 9 patients, 2 family caregivers, and 12 healthcare professionals. Patients' mean age was 67.5 (±6.5) years, over half (n = 5) were Black or Hispanic, and the average number of comorbidities was 3.67. Five major themes that affect symptom management emerged: (1) the patient-provider relationship; (2) open and honest communication; (3) accessibility of resources during hospitalization and at discharge; (4) caregiver support, training, and education; and (5) care coordination and follow-up care. CONCLUSION Patients, caregivers, and healthcare professionals often have similar goals but different priorities for multimorbidity management. It is imperative to identify shared priorities and target holistic interventions that consider patient and caregiver experiences to improve outcomes. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE AND IMPACT This paper addresses the paucity of research related to the shared experience of disease trajectory and symptom management for people living with multimorbidity. We found that patients, caregivers, and healthcare professionals often have similar goals but different care and communication priorities. Understanding differing priorities will help better design interventions to support symptom management so people with multimorbidity can have the best possible quality of life. REPORTING METHOD We have adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines in our reporting. PATIENT OR PUBLIC CONTRIBUTION This study has been designed and implemented with patient and public involvement throughout the process, including community advisory board engagement in the project proposal phase and interview guide development, and member checking in the data collection and analysis phases. The method we chose, experience-based co-design, emphasizes the importance of engaging members of a community to act as experts in their own life challenges. In the coming phases of the study, the public will be involved in developing and testing a new intervention, informed by these qualitative interviews and co-design events, to support symptom management for people with multimorbidity.
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Affiliation(s)
- Anna Peeler
- Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, King's College London, London, England
| | - Katie Nelson
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | | | - Sarah Badawi
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Robyn Moore
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - David Li
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Lara Street
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Binu Koirala
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
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Koirala B, Badawi S, Frost S, Ferguson C, Hager DN, Street L, Perrin N, Dennison Himmelfarb C, Davidson P. Study protocol for Care cOORDInatioN And sympTom managEment (COORDINATE) programme: a feasibility study. BMJ Open 2023; 13:e072846. [PMID: 38110376 DOI: 10.1136/bmjopen-2023-072846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Sustainable approaches to support care coordination and symptom management needs of critically ill adults living with multimorbidity are needed to combat the challenges and complexity that multimorbidity presents. The study aims to test the feasibility of the Care cOORDInatioN And sympTom managEment (COORDINATE) intervention to improve health outcomes of adults living with multimorbidity. METHODS AND ANALYSIS A multicomponent nurse-driven intervention was developed using experience-based co-design and human-centred design. Inclusion criteria include (1) age 55 years and older, (2) admitted to an intermediate care unit, (3) presence of two or more chronic health conditions and (4) signed informed consent. Data collection will occur at baseline (time of recruitment predischarge) and 6 weeks and 3 months following hospital discharge. Outcome of interest from this feasibility study is to evaluate the financial, technical and logistic feasibility of a full-scale study including data collection and protocol adherence. Additionally, Cohen's d effect sizes for the change in outcomes over time will be computed to establish power calculations required for a full-scale study. The protocol was prepared in accordance with Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Institutional Review Board of Johns Hopkins Medical Institutions. Given the success of this feasibility study, the potential for the COORDINATE intervention to decrease the symptom burden and improve participant quality of life among critically ill people with multimorbidity will be tested in a full-scale study, and findings will be actively disseminated. TRIAL REGISTRATION NUMBER NCT05985044.
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Affiliation(s)
- Binu Koirala
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Sarah Badawi
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Steven Frost
- University of Wollongong, Wollongong, New South Wales, Australia
| | - Caleb Ferguson
- University of Wollongong, Wollongong, New South Wales, Australia
| | - David N Hager
- Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lara Street
- The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nancy Perrin
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Yau YC'C, Christensen M. Hong Kong general ward nurses' experiences of transitional care for patients discharged from the intensive care unit: An inductive thematic analysis. Intensive Crit Care Nurs 2023; 79:103479. [PMID: 37541065 DOI: 10.1016/j.iccn.2023.103479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/11/2023] [Accepted: 06/08/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVES The aim of this study was to explore and better understand the experiences of Hong Kong general ward nurses who care for post-intensive care patients. RESEARCH METHODOLOGY/DESIGN Inductive thematic analysis and focus groups interviews were used in this study. SETTING A purposive sample of 20 ward-based registered nurses were recruited, formed five focus groups and interviewed online using video-conferencing media. FINDINGS The ward nurses in this study described the difficulties and challenges they experienced caring for the post-intensive care patient. Issues around workload and patient allocation figured highly along with a lack of education and training. Many felt scared and helpless when caring for these patients which significantly increased their anxiety. Some were compelled to spend more time with their other patients while others were so consumed with the post-ICU patient that they often neglected their other patients. The handover from the intensive care unit nurse was filled with trepidation and concern because of the level of information being handed-over was alien and complex to them so was the medications and the level of monitoring the intensive care unit nurse expected which was not often forthcoming on the ward simply because they didn't know what they were doing. CONCLUSION The findings of this study demonstrate that these ward-nurses found themselves in a difficult situation with trying to understand of the needs of the post-intensive care patient. A lack of support, a lack of education and an increased workload made this situation hard. One possible solution is the development and evaluation of a critical care outreach team to support ward-based decision-making. Combined with formal training and education around the acutely ill and /or the deteriorating patient would be a positive step forward. IMPLICATIONS FOR CLINICAL PRACTICE The post-intensive care patient poses significant challenges to ward nurses unfamiliar with the level of care they require. Unlike intensive care unit nurses whose focus is on survival and preventing deterioration, the ward nurse's attention is meeting the activities of daily living and progressing the patient's rehabilitation. One of the major obstacle experienced was at handover and the transferring of responsibility where the information conveyed was overly complex and to the ward nurse mostly irrelevant. For this, critical nurses must improve their proficiency at handover so that information is tailored to the needs of the ward environment. One way would be the development of a intensive care unit/Ward handover tool developed collaboratively so as maximise the priorities of care and improve patient outcome.
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Affiliation(s)
- Yim Ching 'Connie' Yau
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong; Interdisciplinary Centre for Qualitative Research, School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Martin Christensen
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong; Interdisciplinary Centre for Qualitative Research, School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong.
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Kistler EA, Klatt E, Raffa JD, West P, Fitzgerald JA, Barsamian J, Rollins S, Clements CM, Hickox Murray S, Cocchi MN, Yang J, Hayes MM. Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity. Crit Care Explor 2023; 5:e0994. [PMID: 37868027 PMCID: PMC10586855 DOI: 10.1097/cce.0000000000000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVES ICU capacity strain is associated with worsened outcomes. Intermediate care units (IMCs) comprise one potential option to offload ICUs while providing appropriate care for intermediate acuity patients, but their impact on ICU capacity has not been thoroughly characterized. The aims of this study are to describe the creation of a medical-surgical IMC and assess how the IMC affected ICU capacity. DESIGN Descriptive report with retrospective cohort review. SETTING Six hundred seventy-three-bed tertiary care academic medical center with 77 ICU beds. PATIENTS Adult inpatients who were admitted to the IMC. INTERVENTIONS An interdisciplinary working group created an IMC which was located on a general ward. The IMC was staffed by hospitalists and surgeons and supported by critical care consultants. The initial maximum census was three, but this number increased to six in response to heightened critical care demand. IMC admission criteria also expanded to include advanced noninvasive respiratory support defined as patients requiring high-flow nasal cannula, noninvasive positive pressure ventilation, or mechanical ventilation in patients with tracheostomies. MEASUREMENTS AND MAIN RESULTS The primary outcome entailed the number of ICU bed-days saved. Adverse outcomes, including ICU transfer, intubation, and death, were also recorded. From August 2021 to July 2022, 230 patients were admitted to the IMC. The most frequent IMC indications were respiratory support for medical patients and post-operative care for surgical patients. A total of 1023 ICU bed-days were made available. Most patients were discharged from the IMC to a general ward, while 8% of all patients required transfer to an ICU within 48 hours of admission. Intubation (2%) and death (1%) occurred infrequently within 48 hours of admission. Respiratory support was the indication associated with the most ICU transfers. CONCLUSIONS Despite a modest daily census, an IMC generated substantial ICU bed capacity during a time of peak critical care demand.
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Affiliation(s)
- Emmett A Kistler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Fellowship in Patient Safety and Quality, Harvard Medical School, Boston, MA
| | - Elaine Klatt
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jesse D Raffa
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA
| | - Phyllis West
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Jennifer Barsamian
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA
| | - Scott Rollins
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA
| | - Charlotte M Clements
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shelby Hickox Murray
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael N Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA
| | - Julius Yang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Sethi SM, Ahmed AS, Iqbal M, Riaz M, Mushtaq MZ, Almas A. Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan. Int J Crit Illn Inj Sci 2023; 13:97-103. [PMID: 38023573 PMCID: PMC10664031 DOI: 10.4103/ijciis.ijciis_83_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/16/2023] [Accepted: 04/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality. Methods A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses. Results Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]). Conclusions Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.
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Affiliation(s)
- Sher Muhammad Sethi
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Amber Sabeen Ahmed
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Madiha Iqbal
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Mehmood Riaz
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Muhammad Zain Mushtaq
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
| | - Aysha Almas
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, Karachi, Pakistan
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Hager DN, Dezube R, Disney SM, Flanagan E, Huang S, Kakadiya K, Langlotz R, Lautzenheiser MB, Street L, Michalek A, Biddison LD, Desai SV, Herzke CA. Models of Intermediate Care Organization and Staffing at an Academic Medical Center: Considerations of an Inpatient Planning Committee. J Intensive Care Med 2022; 37:1288-1295. [DOI: 10.1177/08850666211062151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Rationale: Geographic co-localization of patients and provider teams (geography) may improve care efficiency and quality. Patients requiring intermediate care present a unique challenge to the geographic model. Objective: Identify the best organizational and staffing model for intermediate care at our academic medical center. Methods: A modified nominal group technique was employed to assess the benefits and limitations of an existing model of intermediate care, identify and review potential alternative models, and choose a new model. Results: In addition to the institution's current model, the benefits and limitations of six alternative organizational and staffing models were characterized. The anticipated impact of each model on nurse: provider communication, maintenance of nursing competencies, nurse satisfaction, efficient utilization of technical and human resources, triage of patients to the unit, care continuity, and the impact on trainee education are described. After considering these features, stakeholders ranked a closed provider staffing model on a unit dedicated to intermediate care highest of the six alternative models. Important outcomes to monitor following transition to a closed staffing model included patient outcomes, nursing job satisfaction and retention, provider and trainee experience, unexpected patient transfers to higher or lower levels of care, and administrative costs. Conclusions: After considering six alternative staffing models for intermediate care, stakeholders ranked a closed provider staffing model highest. Further qualitative and quantitative comparisons to determine optimal models of intermediate care are needed.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lara Street
- Johns Hopkins University, Baltimore, MD, USA
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Ramos JGR, dos Santos GMN, Bispo MCC, de Almeida Matos RC, de Carvalho GMLS, Passos RDH, Caldas JR, Gobatto ALN, da Guarda SNF, Batista PBP. Unplanned Transfers From Intermediate Care Units to Intensive Care Units: A Cohort Study. Am J Crit Care 2021; 30:397-400. [PMID: 34467384 DOI: 10.4037/ajcc2021453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This study evaluated unplanned transfers from the intermediate care unit (IMCU) to the intensive care unit (ICU) among urgent admissions. This retrospective, observational study was conducted in 2 ICUs and 1 IMCU. Three patterns of urgent admission were assessed: admissions to the ICU only, admissions to the IMCU only, and admissions to the IMCU with subsequent transfer to the ICU. Of 5296 admissions analyzed, 1396 patients (26.4%) were initially admitted to the IMCU. Of these, 172 (12.3%) were transferred from the IMCU to the ICU. Mortality was higher in patients transferred from the IMCU to the ICU than in the 3900 ICU-only patients (odds ratio, 3.22; 95% CI, 1.52-6.80). Most transfers from the IMCU to the ICU (135; 78.5%) were due to deterioration of the condition for which the patient was admitted. Patient transfers from the IMCU to the ICU were common, were associated with increased hospital mortality, and were mostly due to deterioration in the condition that was the reason for admission.
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Affiliation(s)
- Joao Gabriel Rosa Ramos
- Joao Gabriel Rosa Ramos is a physician, intensive care unit, Hospital São Rafael; a researcher, D’Or Institute of Research and Education (IDOR); and a coordinator, SAPI-ENS research team, Salvador, Brazil
| | | | | | | | | | - Rogerio da Hora Passos
- Rogerio da Hora Passos is a physician, intensive care unit, Hospital São Rafael; a researcher, IDOR; and a coordinator, SAPIENS research team
| | - Juliana Ribeiro Caldas
- Juliana Ribeiro Caldas is a physician, intensive care unit, Hospital São Rafael; a researcher, IDOR; a coordinator, SAPIENS research team; and a professor, Universidade de Salvador-UNIFACS and Escola Bahiana de Medicina e Saude Publica-EBMSP
| | - Andre Luiz Nunes Gobatto
- Andre Luiz Nunes Gobatto is a physician, intensive care unit, Hospital São Rafael; a researcher, IDOR; and a coordinator, SAPIENS research team
| | - Suzete Nascimento Farias da Guarda
- Suzete Nascimento Farias da Guarda is a physician, intensive care unit, Hospital São Rafael; a professor, Federal University of Bahia, Department of Neurosciences and Mental Health, Salvador; a researcher, IDOR; and a coordinator, SAPIENS research team
| | - Paulo Benigno Pena Batista
- Paulo Benigno Pena Batista is a researcher, IDOR; a coordinator, SAPIENS research team, and a coordinator, medical course, UNIME Medical School
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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Molmy P, Vangrunderbeeck N, Nigeon O, Lemyze M, Thevenin D, Mallat J. Patients with limitation or withdrawal of life supporting care admitted in a medico-surgical intermediate care unit: Prevalence, description and outcome over a six-month period. PLoS One 2019; 14:e0225303. [PMID: 31756229 PMCID: PMC6874297 DOI: 10.1371/journal.pone.0225303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 10/21/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose There have been few studies on the limitation of Life Supporting Care (LSC) and Withdrawal of LSC in Intermediate Care Units (IMCUs). We report the prevalence of LSC limited patients in a medico-surgical IMCU over a six-month period, examining the description, outcomes, and patterns of LSC Limitations and Withdrawal of LSC. Methods Single center, retrospective observational study in an IMCU of a 500-bed general hospital. Results Our study of 404 patients, reported 79 (19.5%, 95%CI: [16.0–23.7]%) being admitted with LSC limitations in the IMCU. This group of LSC limited patients presented with higher chronic and acute severity scores. The most common admission diagnosis of LSC limited patients was acute respiratory failure (51%). Non-invasive ventilation (NIV) was frequently used within this population (39%). Hospital mortality for LSC limited patients was high (53%) and associated with age (OR = 1.07, 95%CI: [1.01–1.13)]), SOFA score (OR 1.29, 95%CI: [1.01–1.64]), and hypoxemic respiratory failure (OR 7.2, 95%CI: [1.27–40.9]). Withdrawal of LSC occurred in 19.5% of cases, often accompanied with terminal sedation with or without NIV removal (43.8%). Conclusions Patients with limitation of LSC are frequently admitted into IMCU. Hospital mortality rate was high and associated with age, acute organ failures, and hypoxemic respiratory failure. Life support withdrawal includes palliative sedation with or without NIV discontinuation.
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Affiliation(s)
- Perrine Molmy
- Intermediate Care Unit, Centre Hospitalier de Lens, Lens, France
- Intensive Care Unit, Centre Hospitalier de Lens, Lens, France
| | - Nicolas Vangrunderbeeck
- Intermediate Care Unit, Centre Hospitalier de Lens, Lens, France
- Respiratory & Infectious Diseases Unit, Centre Hospitalier de Lens, Lens, France
- * E-mail: (NVG); (JM)
| | - Olivier Nigeon
- Intermediate Care Unit, Centre Hospitalier de Lens, Lens, France
| | - Malcolm Lemyze
- Intensive Care Unit, Centre Hospitalier de Lens, Lens, France
| | - Didier Thevenin
- Intensive Care Unit, Centre Hospitalier de Lens, Lens, France
| | - Jihad Mallat
- Intermediate Care Unit, Centre Hospitalier de Lens, Lens, France
- Intensive Care Unit, Centre Hospitalier de Lens, Lens, France
- Department of Critical Care Medicine, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
- * E-mail: (NVG); (JM)
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11
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Brusca RM, Simpson CE, Sahetya SK, Noorain Z, Tanykonda V, Stephens RS, Needham DM, Hager DN. Performance of Critical Care Outcome Prediction Models in an Intermediate Care Unit. J Intensive Care Med 2019; 35:1529-1535. [PMID: 31635507 DOI: 10.1177/0885066619882675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intermediate care units (IMCUs) are heterogeneous in design and operation, which makes comparative effectiveness studies challenging. A generalizable outcome prediction model could improve such comparisons. However, little is known about the performance of critical care outcome prediction models in the intermediate care setting. The purpose of this study is to evaluate the performance of the Acute Physiology and Chronic Health Evaluation version II (APACHE II), Simplified Acute Physiology Score version II (SAPS II) and version 3 (SAPS 3), and Mortality Probability Model version III (MPM0III) in patients admitted to a well-characterized IMCU. MATERIALS AND METHODS In the IMCU of an academic medical center (July to December 2012), the discrimination and calibration of each outcome prediction model were evaluated using the area under the receiver-operating characteristic and Hosmer-Lemeshow goodness-of-fit test, respectively. Standardized mortality ratios (SMRs) were also calculated. RESULTS The cohort included data from 628 unique IMCU admissions with an inpatient mortality rate of 8.3%. All models exhibited good discrimination, but only the SAPS II and MPM0III were well calibrated. While the APACHE II and SAPS 3 both markedly overestimated mortality, the SMR for the SAPS II and MPM0III were 0.91 and 0.91, respectively. CONCLUSIONS The SAPS II and MPM0III exhibited good discrimination and calibration, with slight overestimation of mortality. Each model should be further evaluated in multicenter studies of patients in the intermediate care setting.
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Affiliation(s)
- Rebeccah M Brusca
- Department of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA
| | - Catherine E Simpson
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA
| | - Sarina K Sahetya
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA
| | - Zeba Noorain
- 29099Bangalore Medical College and Research Institute, Bangalore, India
| | - Varshitha Tanykonda
- Department of Medicine, 12227University of Connecticut School of Medicine, Farmington, CT, USA
| | - R Scott Stephens
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA.,Armstrong Institute for Patient Safety, 1466John Hopkins University, Baltimore, MD, USA.,Outcomes After Critical Illness and Surgery (OACIS) Group, 1466Johns Hopkins University, Baltimore, MD, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, 1466Johns Hopkins University, Baltimore, MD, USA
| | - David N Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, 1500Johns Hopkins University, Baltimore, MD, USA
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12
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Haun de Oliveira O, Pinto R, DasGupta T, Sirtartchouck L, Rashleigh L, Cross N, Srikandarajah A, Sukumaran J, Wunsch H, Cuthbertson BH. Assessment of need for lower level acuity critical care services at a tertiary acute care hospital in Canada: A prospective cohort study. J Crit Care 2019; 53:91-97. [PMID: 31202164 DOI: 10.1016/j.jcrc.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/11/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Critical care beds are commonly described in three levels (highest level 3, lowest level 1). We aimed to describe the actual level of care for patients assigned to level 2 in a tertiary hospital with inadequate level 1 bed capacity. MATERIALS AND METHODS Prospective cohort study with daily assessment of level of care. The primary outcome was the proportion of patients who could be triaged to level 1 for the entirety of their ICU stay. Secondary outcomes included the percentage of patients who could receive level 1 care on any given day. RESULTS 289 patients originally classified as level 2 were assessed for the primary, and 335 for the secondary outcomes. 14.9% could be level 1 for their entire ICU stay. 20.6%, once appropriate for level 1, remained in that level for the rest of their ICU stay. 23.6% of the assessments were suitable for level 1 on any given day. CONCLUSION In a single centre, 14.9% of level 2 patients could have been cared for in a lower acuity bed for the entirety of their ICU stay. We believe this methodology is reproducible and can help resource allocation with regard to the high demand for critical care beds.
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Affiliation(s)
- Olivia Haun de Oliveira
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada
| | - Tracey DasGupta
- Interprofessional Practice Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D404b, Toronto, ON M4N3M5, Canada
| | - Leda Sirtartchouck
- Interprofessional Practice Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D404b, Toronto, ON M4N3M5, Canada
| | - Laura Rashleigh
- Interprofessional Practice Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D404b, Toronto, ON M4N3M5, Canada
| | - Nicole Cross
- Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D503c, Toronto, ON M4N3M5, Canada
| | - Aruchana Srikandarajah
- Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D503c, Toronto, ON M4N3M5, Canada
| | - Jaya Sukumaran
- Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D408, Toronto, ON M4N3M5, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada; Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada.
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