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Nurok M, Flynn BC, Pineton de Chambrun M, Kazemian M, Geiderman J, Nunnally ME. A Review and Discussion of Full-Time Equivalency and Appropriate Compensation Models for an Adult Intensivist in the United States Across Various Base Specialties. Crit Care Explor 2024; 6:e1064. [PMID: 38533294 PMCID: PMC10965199 DOI: 10.1097/cce.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES Physicians with training in anesthesiology, emergency medicine, internal medicine, neurology, and surgery may gain board certification in critical care medicine upon completion of fellowship training. These clinicians often only spend a portion of their work effort in the ICU. Other work efforts that benefit an ICU infrastructure, but do not provide billing opportunities, include education, research, and administrative duties. For employed or contracted physicians, there is no singular definition of what constitutes an intensive care full-time equivalent (FTE). Nevertheless, hospitals often consider FTEs in assessing hiring needs, salary, and eligibility for benefits. DATA SOURCES Review of existing literature, expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Not applicable. DATA SYNTHESIS Not applicable. CONCLUSIONS Understanding how an FTE is calculated, and the fraction of an FTE to be assigned to a particular cost center, is therefore important for intensivists of different specialties, as many employment models assign salary and benefits to a base specialty department and not necessarily the ICU.
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Affiliation(s)
- Michael Nurok
- Departments of Anesthesiology, Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brigid C Flynn
- Division of Critical Care, Department of Anesthesiology, University of Kansas Health System, Kansas City, KS
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, APHP, Sorbonne Université, Paris, France
- INSERM-UMRS 1166, iCAN Institute of Cardiometabolism/Nutrition, Sorbonne Université, Paris, France
| | - Mina Kazemian
- Department of Anesthesiology, Riverside University, Riverside, CA
| | - Joel Geiderman
- Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, Neurology, Surgery and Medicine, NYU Langone Health, NYU School of Medicine, New York, NY
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Choi PS, Pines KC, Swaminathan A, Nilkant R, Mendez MA, He H, Woo YJ, Martin BJ. Diversifying cardiac intensive care unit models: Successful example of an operating surgeon-led unit. JTCVS OPEN 2023; 16:524-531. [PMID: 38204639 PMCID: PMC10775107 DOI: 10.1016/j.xjon.2023.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objective The intensivist-led cardiovascular intensive care unit model is the standard of care in cardiac surgery. This study examines whether a cardiovascular intensive care unit model that uses operating cardiac surgeons, cardiothoracic surgery residents, and advanced practice providers is associated with comparable outcomes. Methods This is a single-institution review of the first 400 cardiac surgery patients admitted to an operating surgeon-led cardiovascular intensive care unit from 2020 to 2022. Inclusion criteria are elective status and operations managed by both cardiovascular intensive care unit models (aortic operations, valve operations, coronary operations, septal myectomy). Patients from the surgeon-led cardiovascular intensive care unit were exact matched by operation type and 1:1 propensity score matched with controls from the traditional cardiovascular intensive care unit using a logistic regression model that included age, sex, preoperative mortality risk, incision type, and use of cardiopulmonary bypass and circulatory arrest. Primary outcome was total postoperative length of stay. Secondary outcomes included postoperative intensive care unit length of stay, 30-day mortality, 30-day Society of Thoracic Surgeons-defined morbidity (permanent stroke, renal failure, cardiac reoperation, prolonged intubation, deep sternal infection), packed red cell transfusions, and vasopressor use. Outcomes between the 2 groups were compared using chi-square, Fisher exact test, or 2-sample t test as appropriate. Results A total of 400 patients from the surgeon-led cardiovascular intensive care unit (mean age 61.2 ± 12.8 years, 131 female patients [33%], 346 patients [86.5%] with European System for Cardiac Operative Risk Evaluation II <2%) and their matched controls were included. The most common operations across both units were coronary artery bypass grafting (n = 318, 39.8%) and mitral valve repair or replacement (n = 238, 29.8%). Approximately half of the operations were performed via sternotomy (n = 462, 57.8%). There were 3 (0.2%) in-hospital deaths, and 47 patients (5.9%) had a 30-day complication. The total length of stay was significantly shorter for the surgeon-led cardiovascular intensive care unit patients (6.3 vs 7.0 days, P = .028), and intensive care unit length of stay trended in the same direction (2.5 vs 2.9 days, P = .16). Intensive care unit readmission rates, 30-day mortality, and 30-day morbidity were not significantly different between cardiovascular intensive care unit models. The surgeon-led cardiovascular intensive care unit was associated with fewer postoperative red blood cell transfusions in the cardiovascular intensive care unit (P = .002) and decreased vasopressor use (P = .001). Conclusions In its first 2 years, the surgeon-led cardiovascular intensive care unit demonstrated comparable outcomes to the traditional cardiovascular intensive care unit with significant improvements in total length of stay, postoperative transfusions in the cardiovascular intensive care unit, and vasopressor use. This early success exemplifies how an operating surgeon-led cardiovascular intensive care unit can provide similar outcomes to the standard-of-care model for patients undergoing elective cardiac surgery.
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Affiliation(s)
- Perry S. Choi
- Department of Cardiac Surgery, Stanford University, Palo Alto, Calif
- Department of Cardiac Surgery, Stanford Health Care, Palo Alto, Calif
| | | | | | - Riya Nilkant
- Department of Cardiac Surgery, Stanford University, Palo Alto, Calif
| | - Michael A. Mendez
- Department of Cardiac Surgery, Stanford Health Care, Palo Alto, Calif
| | - Hao He
- Department of Cardiac Surgery, Stanford University, Palo Alto, Calif
| | - Y. Joseph Woo
- Department of Cardiac Surgery, Stanford University, Palo Alto, Calif
- Department of Cardiac Surgery, Stanford Health Care, Palo Alto, Calif
| | - Billie-Jean Martin
- Department of Cardiac Surgery, Stanford University, Palo Alto, Calif
- Department of Cardiac Surgery, Stanford Health Care, Palo Alto, Calif
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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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Flynn BC. Anesthesiology Critical Care: Current State and Future Directions. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00248-3. [PMID: 37164803 DOI: 10.1053/j.jvca.2023.04.013] [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: 02/10/2023] [Revised: 03/28/2023] [Accepted: 04/07/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Brigid C Flynn
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS.
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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [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: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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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
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, 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
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, 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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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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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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Udeh C, Perez-Protto S, Canfield CM, Sreedharan R, Factora F, Hata JS. Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality. Telemed J E Health 2022; 28:1395-1403. [PMID: 35294855 DOI: 10.1089/tmj.2021.0465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.
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Affiliation(s)
- Chiedozie Udeh
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Silvia Perez-Protto
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Christina M Canfield
- Cleveland Clinic Foundation, Division of Medical Operations, Cleveland, Ohio, USA
| | - Roshni Sreedharan
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Faith Factora
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - J Steven Hata
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
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Arora RC, Lee E, Kent DE, Asif M, Lamarche Y, Hassan A, Legare JF, Hiebert B. Characterizing Physician-Staffing Models in the Care of Postoperative Cardiac Surgical Patients in Canada. CJC Open 2021; 3:1365-1371. [PMID: 34901805 PMCID: PMC8640619 DOI: 10.1016/j.cjco.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background Current intensive care unit physician-staffing (IPS) models for postoperative cardiac surgery have not been previously investigated in Canada. The purpose of this study was to determine current IPS models at 2 time points and describe the evolution of Canadian cardiac surgery IPS models. Methods A survey of 32 Canadian cardiovascular intensive care units (CVICUs) was undertaken in 2012 and 2017 to determine IPS models of care during “daytime” and “after-hours” in each unit. Data were collected regarding surgical volume, base specialties, and style of IPS management (“open”; “semi-open”; “closed”). In addition, we collected the overnight experience level of the bedside healthcare provider for in-house intensive care units. Results Survey responses were received from 27 of 32 CVICUs (87%). As of 2017, the style of 1 (4%) was open, 7 (26%) were semi-open, and 19 (70%) were closed in their unit IPS strategy. Base specialties of CVICU physicians varied. A medical doctor provided after-hours coverage in 81% of CVICUs. Senior residents (37%) or critical care certified attending staff (25%) typically provided after-hours coverage for in-house CVICUs. Linked Canadian Institute for Health Information data did not indicate a difference among CVICU models in mortality or rehospitalization for coronary artery bypass graft or valve procedures. Conclusions Considerable heterogeneity is demonstrated in CVICU staffing patterns. No consensus was identified regarding the appropriate level of training for “after-hours” coverage. In-house overnight physician staffing in CVICUs varies widely. Finally, semi-open and closed style models did not demonstrate differences compared to Canadian Institute for Health Information data. Variability among CVICUs does exist; however, benefits of one model over another have not been identified.
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Affiliation(s)
- 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
| | - Erika Lee
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - David E Kent
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Mina Asif
- Faculty of Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Ansar Hassan
- Department of Cardiac Surgery, Saint John Regional Health Centre, Saint John, New Brunswick, Canada
| | - Jean Francois Legare
- Department of Cardiac Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Rushing AP, Strassels SA, Ricci KB, Daniel VT, Ingraham AM, Paredes AZ, Diaz A, Oslock WM, Baselice HE, Heh VK, Santry HP. In-house intensivist presence does not affect mortality in select emergency general surgery patients. J Trauma Acute Care Surg 2021; 91:719-727. [PMID: 34238856 DOI: 10.1097/ta.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to assess the relationship between availability of round-the-clock (RTC) in-house intensivists and patient outcomes in people who underwent surgery for a life-threatening emergency general surgery (LT-EGS) disease such as necrotizing soft-tissue infection, ischemic enteritis, perforated viscus, and toxic colitis. METHODS Data on hospital-level critical care structures and processes from a 2015 survey of 2,811 US hospitals were linked to patient-level data from 17 State Inpatient Databases. Patients who were admitted with a primary diagnosis code for an LT-EGS disease of interest and underwent surgery on date of admission were included in analyses. RESULTS We identified 3,620 unique LT-EGS admissions at 368 hospitals. At 66% (n = 243) of hospitals, 83.5% (n = 3,021) of patients were treated at hospitals with RTC intensivist-led care. These facilities were more likely to have in-house respiratory therapists and protocols to ensure availability of blood products or adherence to Surviving Sepsis Guidelines. When accounting for other key factors including overnight surgeon availability, perioperative staffing, and annual emergency general surgery case volume, not having a protocol to ensure adherence to Surviving Sepsis Guidelines (adjusted odds ratio, 2.10; 95% confidence interval, 1.12-3.94) was associated with increased odds of mortality. CONCLUSION Our results suggest that focused treatment of sepsis along with surgical source control, rather than RTC intensivist presence, is key feature of optimizing EGS patient outcomes. LEVEL OF EVIDENCE Therapeutic, level III.
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Affiliation(s)
- Amy P Rushing
- From the Department of Surgery-Trauma (A.P.R.), University Hospitals, Cleveland; Department of Surgery (S.A.S., A.Z.P., A.D., H.E.B., V.K.H.), Ohio State University Wexner Medical Center; Department of Surgery (K.B.R.), Johns Hopkins Medical School, Baltimore, MD; Department of Surgery (W.M.O.), University of Alabama, Birmingham, AL; Consulting Studio (H.P.S.), NBBJ Design LLC, Columbus, OH; Department of Trauma Surgery (H.P.S.), Kettering Medical Center, Kettering, OH; Center for Surgical Health Assessment, Research and Policy (S.A.S., K.B.R., A.Z.P., A.D., H.E.B., V.K.H., H.P.S.), Ohio State University, Columbus, Ohio; Department of Dermatology (V.T.D.), University of Massachusetts Medical School, Worcester MA; Department of Surgery (A.M.I.), University of Wisconsin, Madison, Wisconsin; and Ohio State University College of Medicine (W.M.O.), Columbus, Ohio
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11
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Kidd B, Flynn BC. Pro: 24/7 In-House Intensivist Coverage in the CTICU. J Cardiothorac Vasc Anesth 2021; 35:3434-3436. [PMID: 34373180 DOI: 10.1053/j.jvca.2021.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/11/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Brent Kidd
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS.
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12
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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 JH, Kim J, Bae S, Lee T, Ahn JJ, Kang BJ. Intensivists' Direct Management without Residents May Improve the Survival Rate Compared to High-Intensity Intensivist Staffing in Academic Intensive Care Units: Retrospective and Crossover Study Design. J Korean Med Sci 2020; 35:e19. [PMID: 31950776 PMCID: PMC6970079 DOI: 10.3346/jkms.2020.35.e19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Medical staff members are concentrated in the intensive care unit (ICU), and medical residents are essentially needed to operate the ICU. However, the recent trend has been to restrict resident working hours. This restriction may lead to a shortage of ICU staff, and there is a chance that regional academic hospitals will face running ICUs without residents in the near future. METHODS We performed a retrospective observational study (intensivist crossover design) of medical patients who were transferred to two ICUs from general wards between September 2017 and February 2019 at one academic hospital. We compared the ICU outcomes according to the ICU type (ICU with resident management under high-intensity intensivist staffing vs. ICU with direct management by intensivists without residents). RESULTS Of 314 enrolled patients, 70 were primarily managed by residents, and 244 were directly managed by intensivists. The latter patients showed better ICU mortality (29.9% vs. 42.9%, P = 0.042), lower cardiopulmonary resuscitation (CPR) (10.2% vs. 21.4%, P = 0.013), lower continuous renal replacement therapy (CRRT) (24.2% vs. 40.0%, P = 0.009), and more advanced care planning decisions before death (87.3% vs. 66.7%, P = 0.013) than the former patients. The better ICU mortality (hazard ratio, 1.641; P = 0.035), lower CPR (odds ratio [OR], 2.891; P = 0.009), lower CRRT (OR, 2.602; P = 0.005), and more advanced care planning decisions before death (OR, 4.978; P = 0.007) were also associated with intensivist direct management in the multivariate cox and logistic regression analysis. CONCLUSION Intensivist direct management might be associated with better ICU outcomes than resident management under the supervision of an intensivist. Further large-scale prospective randomized trials are required to draw a definitive conclusion.
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Affiliation(s)
- Jin Hyoung Kim
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Jihye Kim
- Intensive Care Nursing Team, Ulsan University Hospital, Ulsan, Korea
| | - SooHyun Bae
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Taehoon Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jong Joon Ahn
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Byung Ju Kang
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
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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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Commentary: Time to standardize physician expertise and coverage in cardiac intensive care units? J Thorac Cardiovasc Surg 2019; 159:1390-1391. [PMID: 31202448 DOI: 10.1016/j.jtcvs.2019.04.079] [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: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 11/20/2022]
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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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Pastores SM, Kvetan V, Coopersmith CM, Farmer JC, Sessler C, Christman JW, D'Agostino R, Diaz-Gomez J, Gregg SR, Khan RA, Kapu AN, Masur H, Mehta G, Moore J, Oropello JM, Price K. Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review. Crit Care Med 2019; 47:550-557. [PMID: 30688716 DOI: 10.1097/ccm.0000000000003637] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers. DESIGN Data were synthesized from monthly expert consensus and literature review. SETTING Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force. MEASUREMENTS AND MAIN RESULTS Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals. CONCLUSIONS Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.
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Affiliation(s)
- Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Craig M Coopersmith
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
| | | | - Curtis Sessler
- Division of Pulmonary Diseases and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - John W Christman
- Division of Pulmonary, Allergy, Critical Care and Sleep, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Rhonda D'Agostino
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jose Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Sara R Gregg
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
| | - Roozehra A Khan
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - April N Kapu
- Vanderbilt University School of Nursing, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Masur
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Gargi Mehta
- Jay B. Langner Critical Care System, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY
| | - Jason Moore
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John M Oropello
- Division of Critical Care Medicine, Department of Surgery, Mount Sinai Medical Center, New York, NY
| | - Kristen Price
- Department of Critical Care Medicine, MD Anderson Cancer Center, Houston, TX
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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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Min-Jie J, Zhun-Yong G, Yan H, Yu-Jing L, Hong-Yu H, Yi-Mei L, Guo-Wei T, Jian-Feng L, Du-Ming Z, Zhe L. The 24-Hour Intensivists Staffing Model Improves the Outcome for Nighttime Admitted Patients: A Matched Historical Control Study. J Intensive Care Med 2019; 35:1439-1446. [PMID: 30744471 DOI: 10.1177/0885066619828338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION We previously showed that a "10-hour daytime on-site" and "nighttime (NT) on-call" staffing strategy was associated with higher mortality for intensive care unit (ICU) patients admitted during NT than it was for patients admitted during office hours (OH). In here, we evaluated the clinical effects of a 24-hour intensivist staffing model. METHODS We formed an intervention group of 3034 consecutive ICU patients hospitalized from January 2013 to December 2015, and a control group of 2891 patients from our previous study (2009-2011). We applied propensity score matching (PSM) for whole and subgroup analyses adjusting for confounding factors. We compared clinical outcomes of patients under the 2 staffing models using multivariate logistic regression and survival analyses. RESULTS After PSM, we balanced the clinical data between the complete cohorts and the subgroups. Comparison of ICU survivals between the intervention and control cohorts yielded no significant differences. However, the intervention was significantly associated with a higher ICU survival in the NT (5:30 pm-07:30 am) admission patients (P = .049) than in those admitted during OH (07:30 am to 5:30 pm; P = .456). Additionally, the intervention shortened the LOSHOS (P = .001) and/or LOSICU (P < .001), reduced the hospital (P = .672) and/or ICU (P = .004) expenses, and resulted in earlier mechanical ventilation extubation (P = .442) as compared to the same variables in the control group, especially for NT admissions. CONCLUSIONS The 24-hour intensivists staffing could significantly improve ICU outcomes, especially for NT-admission patients in high-acuity, high-volume ICUs with frequent NT admissions.
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Affiliation(s)
- Ju Min-Jie
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Gu Zhun-Yong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Han Yan
- Department of General Medical Practice, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Liu Yu-Jing
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - He Hong-Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Liu Yi-Mei
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Tu Guo-Wei
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Luo Jian-Feng
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Zhu Du-Ming
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Luo Zhe
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
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Krebs ED, Hawkins RB, Mehaffey JH, Fonner CE, Speir AM, Quader MA, Rich JB, Yarboro LT, Teman NR, Ailawadi G. Is routine extubation overnight safe in cardiac surgery patients? J Thorac Cardiovasc Surg 2018; 157:1533-1542.e2. [PMID: 30578055 DOI: 10.1016/j.jtcvs.2018.08.125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 08/21/2018] [Accepted: 08/25/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Expedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database. METHODS Records from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00. RESULTS A total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality. CONCLUSIONS Extubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight.
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Affiliation(s)
- Elizabeth D Krebs
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | | | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Va
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Va
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
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Udeh C, Udeh B, Rahman N, Canfield C, Campbell J, Hata JS. Telemedicine/Virtual ICU: Where Are We and Where Are We Going? Methodist Debakey Cardiovasc J 2018; 14:126-133. [PMID: 29977469 DOI: 10.14797/mdcj-14-2-126] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.
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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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Sultan OW, Boland LL, Kinzy TG, Melamed RR, Seatter SC, Farivar RS, Kirkland LL, Mulder M. Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients. Am J Med Qual 2018; 33:576-582. [PMID: 29590756 DOI: 10.1177/1062860618766614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease ( P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.
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Tanios MA, Teres D, Park H, Beltran A, Sehgal A, Leo JD. The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes. J Intensive Care Med 2018; 35:461-467. [PMID: 29458294 DOI: 10.1177/0885066618758246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Various intensivist staffing models have been suggested, but the long-term sustainability and outcomes vary and may not be sustained. We examined the impact of implementing a high-intensity intensivist coverage model with a nighttime in-house nocturnist (non-intensivist) and its effect on intensive care unit (ICU) outcomes. METHODS We obtained historical control baseline data from 2007 to 2011 and compared the same data from 2011 to 2015. The Acute Physiological and Chronic Health Evaluation outcomes system was utilized to collect clinical, physiological, and outcome data on all adult patients in the medical ICU and to provide severity-adjusted outcome predictions. The model consists of a mandatory in-house daytime intensivist service that leads multidisciplinary rounds, and an in-house nighttime coverage is provided by nocturnist (nonintensivists) with current procedural skills in airways management, vascular access, and commitment to supervise house staff as needed. The intensivist continues to be available remotely at nighttime for house staff and consultation with the nocturnist. A backup intensivist is available for surge management. RESULTS First year yielded improved throughput (2428 patients/year to 2627 then 2724 at fifth year). Case mix stable at 53.7 versus 55.2. The ICU length of stay decreased from 4.7 days (predicted 4.25 days) to 3.8 days (4.15) in first year; second year: 3.63 days (4.29 days); third year: 3.24 days (4.37), fourth year: 3.34 days (4.45), and fifth year: 3.61 days (4.42). Intensive care unit <24 hours readmission remained at 1%; >24 hours increased from 4% to 6%. Low-risk monitoring admissions remained at an average 17% (benchmark 17.18%). Intensive care unit mortality improved with standardized mortality ration averaging at 0.84. Resident satisfaction surveys improved. CONCLUSIONS Implementing an intensivist service with nighttime nocturnist staffing in a high-intensity large teaching hospital is feasible and improved ICU outcomes in a sustained manner that persisted after the initial implementation phase. The model resulted in reduced and sustained observed-to-predicted length of ICU stay.
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Affiliation(s)
- Maged A Tanios
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Daniel Teres
- Department of Public Health and Community Medicine, Tufts School of Medicine, Boston, MA, USA
| | - Hyunsoon Park
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Antonio Beltran
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Arunpal Sehgal
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - James D Leo
- MemorialCare Health System, Fountain Valley, CA, USA
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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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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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Burke CR, Chan T, Brogan TV, McMullan DM. Pediatric extracorporeal cardiopulmonary resuscitation during nights and weekends. Resuscitation 2017; 114:47-52. [PMID: 28263789 DOI: 10.1016/j.resuscitation.2017.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 02/26/2017] [Accepted: 03/01/2017] [Indexed: 11/18/2022]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) is a lifesaving rescue therapy for patients with refractory cardiac arrest. Previous studies suggest that maintaining a 24/7 in-house surgical team may reduce ECPR initiation time and improve survival in adult patients. However, an association between cardiac arrest occurring during off-hours and ECPR outcome has not been established in children. METHODS This is a single institution, retrospective review of all pediatric patients who received ECPR from December 2008 to August 2015. RESULTS During the study period, ECPR was performed 54 times in 53 patients (20 weekday, 34 night/weekend). Interval from ECPR activation to initiation of extracorporeal life support was significantly longer during night/weekends (49min night/weekend vs. 33min weekday, p<0.001) as was the interval from ECPR activation to incision for cannulation (26min night/weekend vs. 14min Weekday, p<0.001). Rate of central nervous system (CNS) injury was higher in the night/weekend group (43% night/weekend vs. 15% weekday, p=0.04), with associated 75% mortality prior to hospital discharge. Time of arrest did not impact survival to hospital discharge (44% night/weekend vs. 55% weekday, p=0.57), one-year survival (33% night/weekend vs. 44% weekday, p=0.44), or neurologic outcome (Pediatric Cerebral Performance Score at 1-year post-ECPR, 1.45 weekday vs. 1.50 night/weekend, p=0.82). CONCLUSIONS Cardiac arrest occurring at night or during weekend hours is associated with a longer ECPR initiation time and higher rates of CNS injury. However, prolonged pre-ECPR support associated with off-hours cardiac arrest does not appear to impact survival or functional outcome in pediatric patients.
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Affiliation(s)
- Christopher R Burke
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - Titus Chan
- Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Thomas V Brogan
- Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - D Michael McMullan
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, United States.
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Wall MH. Organization and Structure of the Cardiothoracic Intensive Care Unit. Oncology 2017. [DOI: 10.4018/978-1-5225-0549-5.ch027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of this chapter is to emphasize and describe the team nature of critical care medicine in the Cardiothoracic Intensive Care Unit. The chapter will review the importance of various team members and discuss various staffing models (open vs closed, high intensity vs low intensity, etc.) on patient outcomes and cost. The chapter will also examine the roles of nurse practitioners and physician assistants (NP/PAs) in critical care, and will briefly review the growing role of the tele-ICU. Most studies support the concept that a multi-disciplinary ICU team, led by an intensivist, improves patient outcomes and decreases overall cost of care. The role of the tele-ICU and 24 hour in-house intensivist staffing in improving outcomes is controversial, and more research is needed in this area. Finally, a brief discussion of billing for critical care will be discussed.
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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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Szelkowski LA, Puri NK, Singh R, Massimiano PS. Current trends in preoperative, intraoperative, and postoperative care of the adult cardiac surgery patient. Curr Probl Surg 2015; 52:531-69. [DOI: 10.1067/j.cpsurg.2014.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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