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Bogdanov C, Hohenstein S, Brederlau J, Groesdonk HV, Bollmann A, Kuhlen R. A Comparison of Different Intensive Care Unit Definitions Derived from the German Administrative Data Set: A Methodological, Real-World Data Analysis from 86 Helios Hospitals. J Clin Med 2024; 13:3393. [PMID: 38929923 DOI: 10.3390/jcm13123393] [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: 04/15/2024] [Revised: 05/24/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The intensive care unit (ICU) is a scarce resource in all health care systems, necessitating a well-defined utilization. Therefore, benchmarks are essential; and yet, they are limited due to heterogenous definitions of what an ICU is. This study analyzed the case distribution, patient characteristics, and hospital course and outcomes of 6,204,093 patients in the German Helios Hospital Group according to 10 derived ICU definitions. We aimed to set a baseline for the development of a nationwide, uniform ICU definition. Methods: We analyzed ten different ICU definitions: seven derived from the German administrative data set of claims data according to the German Hospital Remuneration Act, three definitions were taken from the Helios Hospital Group's own bed classification. For each ICU definition, the size of the respective ICU population was analyzed. Due to similar patient characteristics for all ten definitions, we selected three indicator definitions to additionally test statistically against IQM. Results: We analyzed a total of 5,980,702 completed hospital cases, out of which 913,402 referred to an ICU criterion (14.7% of all cases). A key finding is the significant variability in ICU population size, depending on definitions. The most restrictive definition of only mechanical ventilation (DOV definition) resulted in 111,966 (1.9%) cases; mechanical ventilation plus typical intensive care procedure codes (IQM definition) resulted in 210,147 (3.5%) cases; defining each single bed individually as ICU or IMC (ICUᴧIMC definition) resulted in 411,681 (6.9%) cases; and defining any coded length of stay at ICU (LOSi definition) resulted in 721,293 (12.1%) cases. Further testing results for indicator definitions are reported. Conclusions: The size of the population, utilization rates, outcomes, and capacity assumptions clearly depend on the definition of ICU. Therefore, the underlying ICU definition should be stated when making any comparisons. From previous studies, we anticipated that 25-30% of all ICU patients should be mechanically ventilated, and therefore, we conclude that the ICUᴧIMC definition is the most plausible approximation. We suggest a mandatory application of a clearly defined ICU term for all hospitals nationwide for improved benchmarking and data analysis.
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Affiliation(s)
| | | | | | | | | | - Ralf Kuhlen
- Helios Health Institute, 13125 Berlin, Germany
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Porta G, Signorini F, Converso M, Cavalot G, Caramello V, Rossi C, Aprà F, Beltrame A, Boccuzzi A, Boverio R, Calci M, Castaldo E, Covella M, Cuppini P, Ghilardi GI, Mirante E, Noto P, Pierpaoli L, Parpaglia PP, Ricchiardi A, Zanetti M, Zatelli D, Nattino G, Bertolini G. The Fenice project to evaluate and improve the quality of healthcare in high-dependency care units: results after the first year. Intern Emerg Med 2024:10.1007/s11739-024-03640-5. [PMID: 38761333 DOI: 10.1007/s11739-024-03640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
High-Dependency care Units (HDUs) have been introduced worldwide as intermediate wards between Intensive Care Units (ICUs) and general wards. Performing a comparative assessment of the quality of care in HDU is challenging because there are no uniform standards and heterogeneity among centers is wide. The Fenice network promoted a prospective cohort study to assess the quality of care provided by HDUs in Italy. This work aims at describing the structural characteristics and admitted patients of Italian HDUs. All Italian HDUs affiliated to emergency departments were eligible to participate in the study. Participating centers reported detailed structural information and prospectively collected data on all admitted adult patients. Patients' data are presented overall and analyzed to evaluate the heterogeneity across the participating centers. A total of 12 HDUs participated in the study and enrolled 3670 patients. Patients were aged 68 years on average, had multiple comorbidities and were on major chronic therapies. Several admitted patients had at least one organ failure (39%). Mortality in HDU was 8.4%, raising to 16.6% in hospital. While most patients were transferred to general wards, a small proportion required ICU transfer (3.9%) and a large group was discharged directly home from the HDU (31%). The expertise of HDUs in managing complex and fragile patients is supported by both the available equipment and the characteristics of admitted patients. The limited proportion of patients transferred to ICUs supports the hypothesis of preventing of ICU admissions. The heterogeneity of HDU admissions requires further research to define meaningful patients' outcomes to be used by quality-of-care assessment programs.
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Affiliation(s)
- Giovanni Porta
- Department of Emergency Medicine, Santa Maria Delle Grazie Hospital, Pozzuoli, Naples, Italy
| | - Fabiola Signorini
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | | | - Giulia Cavalot
- High Dependency Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Valeria Caramello
- Department of Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Carlotta Rossi
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy.
| | - Franco Aprà
- High Dependency Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Angela Beltrame
- Pronto Soccorso E Medicina d'Urgenza, Ca Foncello ULSS9, Treviso, Italy
| | - Adriana Boccuzzi
- Department of Emergency Medicine, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Riccardo Boverio
- Department of Emergency Medicine, Azienda Ospedaliera SS. Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Mario Calci
- Pronto Soccorso E Medicina d'Urgenza, Azienda Sanitaria Universitaria Friuli Centrale, Presidio Ospedaliero Universitario "Santa Maria Della Misericordia" Di Udine, Udine, Italy
| | | | | | | | - Giulia Irene Ghilardi
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | | | - Paola Noto
- Department of Emergency Medicine, Azienda Ospedaliero Universitario Policlinico G. Rodolico-San Marco, Catania, Italy
| | - Lucia Pierpaoli
- Emergency Medicine, S. Maria Delle Croci Hospital, Ravenna, Italy
| | | | | | - Michele Zanetti
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | - Daniela Zatelli
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | - Giovanni Nattino
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
| | - Guido Bertolini
- Department of Medical Epidemiology, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, 24020, Ranica, Bergamo, Italy
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Abstract
Patients admitted to a medical-surgical unit infrequently require early transfer to higher level care, although how their inpatient length of stay compares to untransferred patients, or those directly admitted to intermediate care, is unknown. We sought to compare the inpatient length of stay of these groups.
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Ay E, Weigand MA, Röhrig R, Gruss M. Dying in the Intensive Care Unit (ICU): A Retrospective Descriptive Analysis of Deaths in the ICU in a Communal Tertiary Hospital in Germany. Anesthesiol Res Pract 2020; 2020:2356019. [PMID: 32190047 PMCID: PMC7068140 DOI: 10.1155/2020/2356019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Modern intensive care methods led to an increased survival of critically ill patients over the last decades. But an unreflected application of modern intensive care measures might lead to prolonged treatment for incurable diseases, and an inadaequate or too aggressive therapy can prolong the dying process of patients. In this study, we analysed end-of-life decisions regarding withholding and withdrawal of intensive care measures in a German intensive care unit (ICU) of a communal tertiary hospital. METHODS Patient datasets of all adult patients dying in an ICU or an intermediate care unit (IMC) in a tertiary communal hospital (Klinikum Hanau, Germany) between 01.01.2011 and 31.12.2012 were analysed for withholding and withdrawal of intensive care measures. RESULTS During the two-year period, 1317 adult patients died in Klinikum Hanau. Of these, 489 (37%) died either in an ICU/IMC unit. The majority of those deceased patients (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (. CONCLUSIONS About one-third of patients dying in the hospital died in ICU/IMC. At least one life-sustaining therapy was limited/withdrawn in more than 60% of those patients. Withholding of a therapy was more common than active therapy withdrawal. Ventilation and renal replacement therapy were withdrawn in less than 5% of patients, respectively.
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Affiliation(s)
- Esma Ay
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
| | - Markus. A. Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg D-69120, Germany
| | - Rainer Röhrig
- Department of Medical Informatics, University Hospital RWTH Aachen, Aachen, Germany
| | - Marco Gruss
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
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Vantomme K, Siddiqui M, Cossette M, Lyster K. Medical surveillance unit: patient characteristics, outcome, and quality of care in Saskatchewan, Canada. BMC Res Notes 2020; 13:87. [PMID: 32085764 PMCID: PMC7035728 DOI: 10.1186/s13104-020-04951-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Intermediate care units provide a high level of care to complex patients and are becoming increasingly popular in North America. Despite the growing popularity of Intermediate care units, very little is known about them. This study explored a typical Intermediate care unit, identifying patient characteristics including demographics, comorbidities, length of stay, as well as primary and secondary diagnosis and mortality. RESULTS A total of 200 patients chart were reviewed, of which, 102 were male, and 89 patients were younger than 65 years old. Diabetes, hypertension, and chronic obstructive pulmonary disease were common among patients with a prevalence of 33.5%, 56%, and 32.5%, respectively. Alcohol use disorder, asthma, liver disease and IV drug abuse were much more common in patients younger than 65 years. The average length of stay was 5.31 days regardless of age. Almost two-thirds of the patients in the Intermediate care unit were admitted directly from the emergency room. The mortality rate among the patients studied was 9.5%. The most common admitting diagnosis was respiratory diseases such as chronic obstructive pulmonary disease or Pneumonia (38.0%), followed by cardiac disorders which were predominantly arrhythmias and congestive heart failure (27.0%).
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Affiliation(s)
- Karl Vantomme
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Muhammad Siddiqui
- Department of Research, Saskatchewan Health Authority, Regina, SK, Canada.
| | - Marlee Cossette
- Medical Surveillance Unit, Pasqua Hospital, Saskatchewan Health Authority, Regina, SK, Canada
| | - Kish Lyster
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.,Medical Surveillance Unit, Pasqua Hospital, Saskatchewan Health Authority, Regina, SK, Canada
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Labata C, Oliveras T, Berastegui E, Ruyra X, Romero B, Camara ML, Just MS, Serra J, Rueda F, Ferrer M, García-García C, Bayes-Genis A. Unidad de cuidados intermedios tras la cirugía cardiaca: impacto en la estancia media y la evolución clínica. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Hamsen U, Lefering R, Fisahn C, Schildhauer TA, Waydhas C. Workload and severity of illness of patients on intensive care units with available intermediate care units: a multicenter cohort study. Minerva Anestesiol 2018; 84:938-945. [PMID: 29469547 DOI: 10.23736/s0375-9393.18.12516-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intermediate Care Units (IMCU) are established in many hospitals to better match the requirements of patient care with respect to their personnel, equipment and other resources. This should relieve Intensive Care Unit (ICU) capacities for more severely ill patients and reduce readmissions to ICU. This study was conducted to investigate the effects of IMCU use on ICU populations. METHODS This is a retrospective analysis of the German National Registry of Intensive Care from the years 2000 to 2010. RESULTS We included 39 ICUs with high and 11 ICUs with low IMCU use. Patients in ICUs with high IMCU use were younger (mean age [high vs. low]: 60.5 vs. 64.5 years, P<0.001), while the severity of illness was higher (percentage of ventilated patients during ICU stay [high vs. low ICMU use]: 67.2% vs. 40.2%, P<0.001; patients ventilated >24 hours: 22% vs. 18%, P<0.001; mean therapeutic intervention scoring system-28 (TISS-28) score: 25.7 vs. 23.3, P<0.001). Readmission rates to ICU did not differ between ICU groups ([high vs. low]: 4.5% vs. 4.4%, P=0.25). ICUs with high IMCU use discharged 90.3% of all patients who were discharged to the IMCU or general ward between the regular workday hours of 06:00 and 14:59, while ICUs with low IMCU use discharged 83.8% of all patients discharged to the general ward in the same time period. CONCLUSIONS The use of IMCUs influences resource utilization of ICUs. Severity of illness and workload was higher in ICUs with high IMCU and more scheduled discharges occurred during the main working hours while readmission rates were similar.
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Affiliation(s)
- Uwe Hamsen
- Department of Surgery and Trauma Surgery, BG University Bergmannsheil, Bochum, Germany -
| | - Rolf Lefering
- Institut für Forschung in der Operativen Medizin (IFOM), Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Christian Fisahn
- Department of Surgery and Trauma Surgery, BG University Bergmannsheil, Bochum, Germany
| | - Thomas A Schildhauer
- Department of Surgery and Trauma Surgery, BG University Bergmannsheil, Bochum, Germany
| | - Chistian Waydhas
- Institut für Forschung in der Operativen Medizin (IFOM), Faculty of Health, Witten/Herdecke University, Witten, Germany.,Faculty of Medicine, University of Duisburg-Essen, Duisburg, Germany
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8
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Labata C, Oliveras T, Berastegui E, Ruyra X, Romero B, Camara ML, Just MS, Serra J, Rueda F, Ferrer M, García-García C, Bayes-Genis A. Intermediate Care Unit After Cardiac Surgery: Impact on Length of Stay and Outcomes. ACTA ACUST UNITED AC 2017; 71:638-642. [PMID: 29158075 DOI: 10.1016/j.rec.2017.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 10/05/2017] [Indexed: 01/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). METHODS From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650). RESULTS There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus coronary in 11.5%, and aorta in 1.8%). The ICU length of stay decreased from 4.9±11 to 2.9±6 days (mean±standard deviation; P<.001); 2 [1-4] to 1 [0-3] (median [Q1-Q3]); in-hospital length of stay decreased from 13.5±15 to 12.7±11 days (mean±standard deviation; P=.01); 9 [7-13] to 9 [7-11] (median [Q1-Q3]), in pre-IMCU-CS to post-IMCU-CS, respectively. There were no statistically significant differences in in-hospital mortality (4.9% vs 3.5%; P=.28) or 30-day readmission rate (4.3% vs 4.2%; P=.89). CONCLUSIONS After the establishment of an IMCU-CS for postoperative cardiac surgery, there was a reduction in ICU and in-hospital mean lengths of stay with no increase in in-hospital mortality or 30-day readmissions.
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Affiliation(s)
- Carlos Labata
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Teresa Oliveras
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Elisabet Berastegui
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Xavier Ruyra
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Bernat Romero
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maria-Luisa Camara
- Servicio de Cirugía Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maria-Soledad Just
- Servicio de Medicina Intensiva, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Jordi Serra
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ferran Rueda
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Marc Ferrer
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Cosme García-García
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Antoni Bayes-Genis
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Instituto de Investigación en Ciencias de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
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Utilisation of Intermediate Care Units: A Systematic Review. Crit Care Res Pract 2017; 2017:8038460. [PMID: 28775898 PMCID: PMC5523340 DOI: 10.1155/2017/8038460] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 05/22/2017] [Indexed: 02/03/2023] Open
Abstract
Background. The diversity in formats of Intermediate Care Units (IMCUs) makes it difficult to compare data from different settings. The purpose of this article was to describe and quantify these different formations and utilisation. Methods. We performed a systematic review extracting geographic location, nomenclature used, admitting specialties, open (admitting specialist in charge) or closed (intensivist/generalist in charge) management format, location in hospital, number of beds, nursing workload, medical staff to patient ratios, and modalities—possibilities and limitations—implemented. Results. Nomenclature used was High Dependency Unit (56.8%) or Intermediate Care Unit (24.3%), with the latter one increasingly being used recently. The median number of beds was 6 (IQR 4–10). Location (p < 0.001) and admitting specialties (p = 0.03) were related to the management format. IMCUs integrated or adjacent to Intensive Care Units were more often capable of using single vasoactive medication (p = 0.025). The mean nurse to patient ratio was 1 to 2.5. Conclusions. IMCUs often have a specific task in a hospital, which is reflected in location, format, and utilisation. The management format depends on location and admitting specialist while incorporated supportive treatment modules reflect its function. Common IMCU denominators are continuous monitoring and respiratory support, without mechanical ventilation and multiple vasoactive medications.
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Simpson CE, Sahetya SK, Bradsher RW, Scholten EL, Bain W, Siddique SM, Hager DN. Outcomes of Emergency Medical Patients Admitted to an Intermediate Care Unit With Detailed Admission Guidelines. Am J Crit Care 2017; 26:e1-e10. [PMID: 27965236 DOI: 10.4037/ajcc2017253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND An important, but not well characterized, population receiving intermediate care is that of medical patients admitted directly from the emergency department. OBJECTIVE To characterize emergency medical patients and their outcomes when admitted to an intermediate care unit with clearly defined admission guidelines. METHODS Demographic data, admitting diagnoses, illness severity, comorbid conditions, lengths of stay, and hospital mortality were characterized for all emergency medical patients admitted directly to an intermediate care unit from July through December 2012. RESULTS A total of 317 unique patients were admitted (mean age, 54 [SD, 16] years). Most patients were admitted with respiratory (26.5%) or cardiac (17.0%) syndromes. The mean (SD) Acute Physiology and Chronic Health Evaluation score version II, Simplified Acute Physiology Score version II, and Charlson Comorbidity Index were 15.6 (6.5), 20.7 (11.8), and 2.7 (2.3), respectively. Severity of illness and length of stay were significantly different for patients who required intensive care within 24 hours of admission (n = 16) or later (n = 25), patients who continued with inter mediate care for more than 24 hours (n = 247), and patients who were downgraded or discharged in less than 24 hours (n = 29). Overall hospital mortality was 4.4% (14 deaths). CONCLUSIONS Emergency medical patients with moderate severity of illness and comorbidity can be admitted to an intermediate level of care with relatively infrequent transfer to intensive care and relatively low mortality.
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Affiliation(s)
- Catherine E Simpson
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Sarina K Sahetya
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Robert W Bradsher
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Eric L Scholten
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - William Bain
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - Shazia M Siddique
- Catherine E. Simpson and Sarina K. Sahetya are fellows, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland. Robert W. Bradsher III is an instructor, Division of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee. Eric L. Scholten is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Diego, California. William Bain is a fellow, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania. Shazia M. Siddique is a fellow, Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University
| | - David N Hager
- David N. Hager is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University. David N. Hager, MD, PhD, Johns Hopkins University, Sheikh Zayed Tower, Ste 9121, 1800 Orleans St, Baltimore, MD 21287 (e-mail: )
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Armstrong E, de Waard MC, de Grooth HJS, Heymans MW, Reis Miranda D, Girbes ARJ, Spijkstra JJ. Using Nursing Activities Score to Assess Nursing Workload on a Medium Care Unit. Anesth Analg 2016; 121:1274-80. [PMID: 26484461 DOI: 10.1213/ane.0000000000000968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The medium care unit (MCU) or "stepdown" unit is an increasingly important, but understudied care environment. With an aging population and more patients with complex multiple diseases, many patients often require a higher level of inpatient care even when full intensive care is not indicated. However, the nurse-to-patient ratio required on a MCU is neither well defined nor clear whether this ratio should be adjusted per shift. The Nursing Activities Score (NAS) is an effective instrument for measuring nursing workload in the intensive care unit (ICU) but has not been used in an MCU. The aim of this study was to measure the nursing workload per 8-hour shift on an MCU using the NAS and compare it with the NAS from an ICU in the same hospital. We also compared the NAS between groups of patients with different admission sources. METHODS The NAS was prospectively measured per patient per shift for 2 months in a 9-bed tertiary referral university hospital MCU and during a similar period in an ICU in the same hospital. RESULTS The mean NAS per patient did not differ between day (7:30 AM to 4:00 PM) and evening (3:00 PM to 11:30 PM) shifts, but the NAS was significantly lower during the night shift (11:00 PM to 8:00 AM) than during the day (P < 0.0001) and evening (P < 0.0001) shifts. The mean NASs in the ICU for day and night shifts were significantly lower than the scores in the MCU (P = 0.0056 and P < 0.0001, respectively), but NAS during the evening shift did not differ between the ICU and the MCU. The mean NAS for patients admitted to the MCU from the accident and emergency department was significantly higher than for those admitted from the ICU (P = 0.002), recovery (P = 0.002), and general ward (P < 0.0001). Patients on the MCU had a NAS comparable with that of ICU patients. CONCLUSIONS In our university hospital, NAS was higher during the day and evening hours and lower at night. We also found that patients from accident and emergency had a higher NAS than those admitted to the MCU from other locations. NAS in the MCU was not lower than the NAS in the ICU. Because of its ability to discriminate between day and evening workloads and between patients from different sources, the NAS may assist MCU managers in assessing staffing needs.
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Affiliation(s)
- Elizabeth Armstrong
- From the *Department of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands; †Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands; and ‡Department of Intensive Care, University Hospital Groningen, Groningen, The Netherlands
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Vester-Andersen M, Waldau T, Wetterslev J, Møller MH, Rosenberg J, Jørgensen LN, Jakobsen JC, Møller AM, Gillesberg IE, Jakobsen HL, Hansen EG, Poulsen LM, Skovdal J, Søgaard EK, Bestle M, Vilandt J, Rosenberg I, Itenov TS, Pedersen J, Madsen MR, Maschmann C, Rasmussen M, Jessen C, Bugge L. Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial). Br J Surg 2015; 102:619-29. [DOI: 10.1002/bjs.9749] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/06/2014] [Accepted: 11/14/2014] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Emergency abdominal surgery carries a considerable risk of death and postoperative complications. Early detection and timely management of complications may reduce mortality. The aim was to evaluate the effect and feasibility of intermediate care compared with standard ward care in patients who had emergency abdominal surgery.
Methods
This was a randomized clinical trial carried out in seven Danish hospitals. Eligible for inclusion were patients with an Acute Physiology And Chronic Health Evaluation (APACHE) II score of at least 10 who were ready to be transferred to the surgical ward within 24 h of emergency abdominal surgery. Participants were randomized to either intermediate care or standard surgical ward care after surgery. The primary outcome was 30-day mortality.
Results
In total, 286 patients were included in the modified intention-to-treat analysis. The trial was terminated after the interim analysis owing to slow recruitment and a lower than expected mortality rate. Eleven (7·6 per cent) of 144 patients assigned to intermediate care and 12 (8·5 per cent) of 142 patients assigned to ward care died within 30 days of surgery (odds ratio 0·91, 95 per cent c.i. 0·38 to 2·16; P = 0·828). Thirty (20·8 per cent) of 144 patients assigned to intermediate care and 37 (26·1 per cent) of 142 assigned to ward care died within the total observation period (hazard ratio 0·78, 95 per cent c.i. 0·48 to 1·26; P = 0·310).
Conclusion
Postoperative intermediate care had no statistically significant effect on 30-day mortality after emergency abdominal surgery, nor any effect on secondary outcomes. The trial was stopped prematurely owing to slow recruitment and a much lower than expected mortality rate among the enrolled patients. Registration number: NCT01209663 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Vester-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - T Waldau
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - J Wetterslev
- Department of Copenhagen Trial Unit, Centre for Clinical Intervention Research, Herlev, Denmark
| | - M H Møller
- Department of Intensive Care Medicine – 4131, Rigshospitalet, University of Copenhagen, Herlev, Denmark
| | - J Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - L N Jørgensen
- Digestive Disease Centre, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - J C Jakobsen
- Department of Copenhagen Trial Unit, Centre for Clinical Intervention Research, Herlev, Denmark
| | - A M Møller
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | | | | | | | | | | | | | - M Bestle
- Hospital of North Zealand, Hillerød
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Solberg BCJ, Dirksen CD, Nieman FHM, van Merode G, Ramsay G, Roekaerts P, Poeze M. Introducing an integrated intermediate care unit improves ICU utilization: a prospective intervention study. BMC Anesthesiol 2014; 14:76. [PMID: 25276092 PMCID: PMC4177684 DOI: 10.1186/1471-2253-14-76] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 08/19/2014] [Indexed: 11/12/2022] Open
Abstract
Background Improvement of appropriate bed use and access to intensive care (ICU) beds is essential in optimizing utilization of ICU capacity. The introduction of an intermediate care unit (IMC) integrated in the ICU care may improve this utilization. Method In a before-after prospective intervention study in a university hospital mixed ICU, the impact of introducing a six-bed mixed IMC unit supervised and staffed by ICU physicians was investigated. Changes in ICU utilization (length of stay, frequency of mechanical ventilation use), nursing workload assessed byTISS-28 score, as well as inappropriate bed use, accessibility of the ICU (number of referrals), and clinical outcome indicators (readmission and mortality rates) were measured. Results During 17 months, data of 1027 ICU patients were collected. ICU utilization improved significantly with an increased appropriate use of ICU beds. However, the number of referrals, readmissions to the ICU and mortality rates did not decrease after the IMC was opened. Conclusion The IMC contributed to a more appropriate use of ICU facilities and did result in a significant increase in mean nursing workload at the ICU.
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Affiliation(s)
- Barbara C J Solberg
- Staff department of Quality and Safety, Maastricht University Medical Center, P. Debyelaan 25, Maastricht, HX 6229, The Netherlands
| | - Carmen D Dirksen
- Clinical Epidemiology & Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Fred H M Nieman
- Clinical Epidemiology & Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Godefridus van Merode
- Department of Health Organisation, Policy and Economics (BEOZ), University of Maastricht, P.O. Box 616, Maastricht, MD 6200, The Netherlands
| | - Graham Ramsay
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands ; Regent House, Mittre Way, Battle, East Sussex, UK
| | - Paul Roekaerts
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands ; Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Organizing safe transitions from intensive care. Nurs Res Pract 2014; 2014:175314. [PMID: 24782924 PMCID: PMC3982467 DOI: 10.1155/2014/175314] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/13/2014] [Accepted: 02/13/2014] [Indexed: 02/06/2023] Open
Abstract
Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team. An understanding of discharge practices is needed in order to ultimate patients' transfers from high technological intensive care units (ICU) to general wards. Aim. To describe, as experienced by intensive care and general ward staff, what strategies could be used when organizing patient's care before, during, and after transfer from intensive care. Method. Interviews of 15 participants were conducted, audio-taped, transcribed verbatim, and analyzed using qualitative content analysis. Results. The results showed that the categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and patient/families, between team members and involved units, and between patient/family and environment. Discussion/Conclusions. The findings highlight that ICU transitional care implies critical care rehabilitation. Discharge procedures need to be safe and structured and involve collaboration, encouraging support, optimal timing, early mobilization, and a multidiscipline approach.
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Vester-Andersen M, Waldau T, Wetterslev J, Møller MH, Rosenberg J, Jørgensen LN, Gillesberg I, Jakobsen HL, Hansen EG, Poulsen LM, Skovdal J, Søgaard EK, Bestle M, Vilandt J, Rosenberg I, Berthelsen RE, Pedersen J, Madsen MR, Feurstein T, Busse MJ, Andersen JDH, Maschmann C, Rasmussen M, Jessen C, Bugge L, Ørding H, Møller AM. Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial. Trials 2013; 14:37. [PMID: 23374977 PMCID: PMC3575365 DOI: 10.1186/1745-6215-14-37] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 01/25/2013] [Indexed: 01/31/2023] Open
Abstract
Background Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients. Methods and design The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power. Discussion This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care. Trial registration Clinicaltrials.gov identifier: NCT01209663
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Affiliation(s)
- Morten Vester-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Herlev Hospital, Copenhagen University, Herlev Ringvej 75, DK-2730 Herlev, Denmark.
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How can nurses facilitate patient's transitions from intensive care? Intensive Crit Care Nurs 2012; 28:224-33. [DOI: 10.1016/j.iccn.2012.01.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 12/06/2011] [Accepted: 01/03/2012] [Indexed: 11/19/2022]
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Laffey JG, Curran E, O'Gorman D, Phelan D. Impact of a new high dependency unit: An analysis of activity patterns in a HDU and its impact on ICU utilization. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.13.1.13.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Surgical intensive care unit - essential for good outcome in major abdominal surgery? Langenbecks Arch Surg 2011; 396:417-28. [PMID: 21369847 DOI: 10.1007/s00423-011-0758-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 02/16/2011] [Indexed: 02/03/2023]
Abstract
PURPOSE Surgical intensive care units (ICU) play a pivotal role in perioperative care of patients undergoing major abdominal surgery. Differences in quality of care provided by medical staff in ICUs may be linked to improved outcome. This review aims to elucidate the relationship between quality of care at various ICUs and patient outcome, with the ultimate aim of identifying key measures for achieving optimal outcome. METHODS We reviewed the literature in PubMed to identify current ICU structural and process concepts and variations before evaluating their respective impact on quality of care and outcome in major abdominal surgery. RESULTS ICU leadership, nurse and physician staffing, and provision of an intermediate care unit are important structural components that impact on patients' outcome. A "mixed ICU" model, with intensivists primarily caring for the patients in close cooperation with the primary physician, seems to be the most effective ICU model. Surgeons' involvement in intensive care is essential, and a close cooperation between surgeons and anesthesiologists is vital for good outcome. Current general process concepts include early mobilization, enteral feeding, and optimal perioperative fluid management. To decrease failure-to-rescue rates, procedure-specific intensive care processes are particularly focused on the early detection, assessment, and timely and consistent treatment of complications. CONCLUSIONS Several structures and processes in the ICU have an impact on outcome in major abdominal surgery. ICU structures and care processes connected with optimal outcome could be transmitted to other centers to improve outcome, independent of procedure volume.
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Gould A, Ho KM, Dobb G. Risk factors and outcomes of high-dependency patients requiring intensive care unit admission: a nested case-control study. Anaesth Intensive Care 2010; 38:855-61. [PMID: 20865869 DOI: 10.1177/0310057x1003800508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intermediate-care or high-dependency units can provide a level of care that lies between the intensive care unit (ICU) and general ward, but the patients who are most likely to benefit from such level of care remains uncertain. This nested case-control study assessed the incidence and risk factors of high-dependency patients requiring ICU admission and whether these admissions were associated with a worse outcome when compared to other emergency ICU admissions. Seventy-seven consecutive high-dependency patients requiring ICU admission (cases) were compared with 77 patients who did not require ICU admission (controls) and also 928 emergency ICU admissions from other areas. The incidence of high-dependency patients requiring ICU admission was 6.7% (95% confidence interval 5.3 to 8.2). High-dependency admissions from the ward (odds ratio 4.46, 95% confidence interval 1.55 to 12.78) or emergency department (odds ratio 4.48, 95% confidence interval 1.54 to 13.0) and a need for concurrent non-invasive ventilation, inotrope infusion and acute kidney injury (odds ratio 14.90, 95% confidence interval 3.79 to 58.3) was associated with a higher risk of ICU admission. Hospital mortality of the high-dependency patients requiring ICU admission was not significantly different from other emergency ICU admissions (odds ratio 1.08, 95% confidence interval 0.55 to 2.11). In summary, high-dependency patients requiring ICU admission were uncommon unless they had multi-organ failure and their hospital mortality was not significantly different from other emergency ICU admissions.
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Affiliation(s)
- A Gould
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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Tezval M, Dresing K, Frosch KH, Hammel D, Erichsen N, Stürmer KM. ["Surgical intermediate care unit" outcomes, facts and experiences after 5 years]. Wien Med Wochenschr 2010; 160:85-90. [PMID: 20300925 DOI: 10.1007/s10354-009-0696-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The increasing economic pressure has resulted in strategies to use efficient treatment forms. The aim of our study was to evaluate to which extent the intermediate care unit (IMC-unit) relieves the intensive care unit and the wards. We analyzed: patient population, age, gender, admission criteria and the rate of patients with intensive nursing procedures between January 1, 2005 and December 31, 2007. The level of care was calculated according to the standard patient categories. The mean age amounted to 58.9 years. Intensive care patients made up 43.6% and patients from the emergency ward 36.6% of the total IMC-allocation. After IMC care 54.3% of all IMC-patients could be taken over by wards. The confused patients amounted to 27.5% and isolated patients 4.3%. The average care intensity amounted to 4.5 hours per patient daily and the mean length of stay in hospital was 9 days. Particularly the relief of nursing intensity and the possibility of primary treatment of severely injured persons reflect the requirements of IMC.
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Affiliation(s)
- Mohammad Tezval
- Abteilung Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Universitätsmedizin Göttingen, Göttingen, Germany.
| | - Klaus Dresing
- Abteilung Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Karl Heinz Frosch
- Abteilung Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Dirk Hammel
- Abteilung Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Norbert Erichsen
- Krankenpflege-Leitung, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Klaus Michael Stürmer
- Abteilung Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Universitätsmedizin Göttingen, Göttingen, Germany
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Aburto M, Esteban C, Aguirre U, Egurrola M, Altube L, Moraza FJ, Capelastegui A. Cuidados respiratorios intermedios: un año de experiencia. Arch Bronconeumol 2009; 45:533-9. [DOI: 10.1016/j.arbres.2009.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 03/31/2009] [Accepted: 03/03/2009] [Indexed: 10/20/2022]
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APACHE III outcome prediction in patients admitted to the intensive care unit after liver transplantation: a retrospective cohort study. BMC Surg 2009; 9:11. [PMID: 19640303 PMCID: PMC2726122 DOI: 10.1186/1471-2482-9-11] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 07/29/2009] [Indexed: 12/20/2022] Open
Abstract
Background The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT Methods A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III. Results APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively. There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom). Conclusion APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution – if used at all – in recipients of liver transplantation.
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Solberg BCJ, Dirksen CD, Nieman FHM, van Merode G, Poeze M, Ramsay G. Changes in hospital costs after introducing an intermediate care unit: a comparative observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R68. [PMID: 18482443 PMCID: PMC2481456 DOI: 10.1186/cc6903] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Revised: 04/07/2008] [Accepted: 05/15/2008] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The high cost of critical care resources has resulted in strategies to reduce the costs of ruling out low-risk patients by developing intermediate care units (IMCs). The aim of this study was to compare changes in total hospital costs for intensive care patients before and after the introduction of an IMC at the University Hospital Maastricht. METHODS The design was a comparative longitudinal study. The setting was a university hospital with a mixed intensive care unit (ICU), an IMC, and general wards. Changes in total hospital costs were measured for patients who were admitted to the ICU before and after the introduction of the IMC. The comparison of interest was the opening of a six-bed mixed IMC. RESULTS The mean total hospital cost per patient increased significantly. Before the introduction of the IMC, the total hospital cost per patient was n12,961 (+/- n14,530) and afterwards it rose to n16,513 (+/- n17,718). Multiple regression analysis was used to determine to what extent patient characteristics explained these higher hospital costs using mortality, type of stay, diagnostic categories, length of ICU and ward stay, and the Therapeutic Intervention Scoring System (TISS) as predictors. More surgical patients, greater requirements of therapeutic interventions on the ICU admission day, and longer ICU stay in patients did explain the increase in hospital costs, rather than the introduction of the IMC. CONCLUSION After the introduction of the IMC, the higher mean total hospital costs for patients with a high TISS score and longer ICU stay explained the cost increase.
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Affiliation(s)
- Barbara C J Solberg
- Staff Department of Research, Care and Education, Maastricht University Hospital, P. Debyelaan 25 6229 HX Maastricht, The Netherlands
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Keegan MT, Whalen FX, Brown DR, Roy TK, Afessa B. Acute Physiology and Chronic Health Evaluation (APACHE) III outcome prediction after major vascular surgery. J Cardiothorac Vasc Anesth 2008; 22:713-8. [PMID: 18922428 DOI: 10.1053/j.jvca.2008.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system in patients admitted to the intensive care unit (ICU) after major vascular surgery. DESIGN Retrospective cohort study. SETTING A tertiary referral center. PARTICIPANTS Three thousand one hundred forty-eight patients who underwent major vascular surgery between October 1994 and March 2006. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were abstracted from an institutional APACHE III database. Standardized mortality ratios (SMRs) (with 95% confidence intervals) were calculated. The area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow C statistic were used to assess discrimination and calibration, respectively. The mean age of 3,148 patients studied was 70.5 years (+/- standard deviation 9.6). The mean Acute Physiology Score and the APACHE III score on the day of ICU admission were 31.0 (+/- 17.5) and 45.1 (+/- 18.8), respectively. The mean predicted ICU and hospital mortality rates were 3.2% (+/- 7.8%) and 5.0% (+/- 9.5%), respectively. The median (and interquartile range) ICU and hospital lengths of stay were 4.3 (3.6-5.1) and 14 days (11.9-16.8 days), respectively. The observed ICU mortality rate was 2.4% (75/3, 148 patients) and hospital mortality rate was 3.7% (116/3,148). The ICU and hospital SMRs were 0.74 (0.58-0.91) and 0.74 (0.61-0.88), respectively. The AUC of APACHE III-derived prediction of hospital mortality was 0.840 (95% confidence interval, 0.799-0.880), indicating excellent discrimination. The Hosmer-Lemeshow C statistic was 28.492, with a p value <0.01, indicating poor calibration. CONCLUSIONS The APACHE III scoring system discriminates well between survivors and nonsurvivors after major vascular surgery, but calibration of the model is poor.
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Affiliation(s)
- Mark T Keegan
- Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN 55905, USA.
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Keegan MT, Brown DR, Thieke MP, Afessa B. Changes in intensive care unit performance measures associated with opening a dedicated thoracic surgical progressive care unit. J Cardiothorac Vasc Anesth 2008; 22:347-53. [PMID: 18503920 DOI: 10.1053/j.jvca.2007.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the effect of the introduction of a specialty-specific progressive care unit (PCU) on the intensive care unit (ICU) to which relatively low-acuity patients had previously been admitted. DESIGN Retrospective cohort study. SETTING The thoracic (noncardiac) surgical ICU of a tertiary referral institution. PATIENTS Four thousand fifty-three patients admitted to the ICU after thoracic surgery between October 1994 and December 2003. INTERVENTIONS None. MEASUREMENTS AND RESULTS The institutional Acute Physiology and Chronic Health Evaluation (APACHE) III database was searched to compare the number of admissions, severity of illness, mortality, and other aspects of care for periods before and after the introduction of the PCU. Patients in the post-PCU group were more severely ill by APACHE criteria. The ICU mortality rates for the periods before and after the introduction of the PCU were 1.14% (32/2,801 patients) and 7.27% (91/1,252 patients), respectively. The performance of the ICU appeared to be worse in the period after the opening of the PCU. The ICU- and hospital-customized standardized mortality ratio increased from 0.68 (95% confidence interval [CI], 0.47-0.96) in the pre-PCU group to 1.20 (95% CI, 0.96-1.47) in the post-PCU group and from 0.83 (95% CI, 0.66-1.03) to 1.24 (95% CI, 1.05-1.46). CONCLUSIONS The introduction of a nonintensivist-directed PCU to care for thoracic surgical patients had a significant impact on the parent ICU. Of concern is that outcome and quality measures appeared to worsen and ICU readmission rate increased.
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Affiliation(s)
- Mark T Keegan
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.
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Castillo F, López JM, Marco R, González JA, Puppo AM, Murillo F. [Care grading in Intensive Medicine: Intermediate Care Units]. Med Intensiva 2007; 31:36-45. [PMID: 17306139 DOI: 10.1016/s0210-5691(07)74768-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Intermediate Care Units are created for patients who predictably have low risk of requiring therapeutic life support measures but who require more monitoring and nursing cares than those received in the conventional hospitalization wards. Previous studies have demonstrated that Intermediate Care Units may promote hospital care grading, allowing for better classification in critical patients, improving efficacy and efficiency of the ICUs and thus decreasing costs and above all mortality in the conventional hospitalization wards. This document attempts to group the currently existing knowledge that served as a base for the consensus meeting on the application of them in the establishment of future ICUs in our hospital setting.
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Affiliation(s)
- F Castillo
- Servicio de Cuidados Críticos y Urgencias, Hospitales Universitarios Virgen del Rocío, Sevilla, España.
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The acute physiology and chronic health evaluation III outcome prediction in patients admitted to the intensive care unit after pneumonectomy. J Cardiothorac Vasc Anesth 2007; 21:832-7. [PMID: 18068061 DOI: 10.1053/j.jvca.2006.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Indexed: 01/17/2023]
Abstract
PURPOSE The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after pneumonectomy. The purpose of this study was to determine if the APACHE III predicts hospital mortality after pneumonectomy. METHODS A retrospective review of all adult patients admitted to a single thoracic surgical intensive care unit after pneumonectomy between October 1994 and December 2004. Patient demographics, ICU admission day APACHE III score, actual and predicted hospital mortality, and length of hospital and ICU stay data were collected. Data on preoperative pulmonary function tests and smoking habits were also collected. Univariate statistical methods and logistic regression were used. The performance of the APACHE III prognostic system was assessed by the Hosmer-Lemeshow statistic for calibration and area under receiver operating characteristic curve (AUC) for discrimination. RESULTS There were 417 pneumonectomies performed during the study period, of which 281 patients were admitted to the ICU. The mean age was 61.1 years, and 67.2% were men; 88.2% were smokers with a median of 40.0 (interquartile range, 18-62) pack-years of tobacco use. The mean APACHE III score on the day of ICU admission was 37.7 (+/- standard deviation 17.8), and the mean predicted hospital mortality rate was 6.4% (+/-10.4). The median (and interquartile range) lengths of ICU and hospital stay were 1.7 (0.9-3.1) and 9.0 (7.0-17.0) days, respectively. The observed ICU and hospital mortality rates were 4.6% (13/281 patients) and 8.2% (23/281), respectively. The standardized ICU and hospital mortality ratios with their 95% confidence intervals (CIs) were 1.55 (0.71-2.39) and 1.27 (0.75-1.78), respectively. There were significant differences in the mean APACHE III score (p < 0.001) and the predicted mortality rate (p < .001) between survivors and nonsurvivors. In predicting mortality, the AUC of APACHE III prediction was 0.801 (95% CI, 0.711-0.891), and the Hosmer-Lemeshow statistic was 9.898 with a p value of 0.272. Diffusion capacity of the lung for carbon monoxide (DLCO) and percentage predicted DLCO were higher in survivors, but the addition of either of these variables to a logistic regression model did not improve APACHE III mortality prediction. CONCLUSIONS In patients admitted to the ICU after pneumonectomy, the APACHE III discriminates moderately well between survivors and nonsurvivors. The calibration of the model appears to be good, although the low number of deaths limits the power of the calibration analysis. The use of APACHE III data in outcomes research involving patients who have undergone pneumonectomy is acceptable.
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Abstract
Relocation stress is a phenomenon in which physical and psychological disturbances are experienced following transfer from one environment to another [Carpenito LJ. (2000). Nursing Diagnosis. Application to Clinical Practice, 8th edn]. The purpose of this review was to identify whether a period of intermediate care minimizes the problems associated with relocation stress after discharge from the intensive care unit (ICU) and before transfer to the ward. Methods of retrieving the literature involved identifying key terms, utilizing a range of databases and applying specific criteria in order to delineate the boundaries of the search. Using electronic and manual search methods, 11 studies were selected, both primary and secondary research. Following tabulation and critiquing of the studies, the findings of the review suggest that the factors which contribute towards relocation stress are the loss of one-to-one nursing, a reduction of visible monitoring equipment, lack of continuity of care and inadequate preparation of the patient for the transfer. The evidence also indicates that in order to minimize these factors, early planning and preparation of the patient for transfer are required, incorporating strategies of gradual reduction in nursing attention and monitoring equipment and the provision of information. Although the benefits of intermediate care are established as being advanced monitoring, appropriate nurse-to-patient ratio, heightened demonstration of expert knowledge and skill, there is no sufficient evidence to indicate a period of intermediate care that can ease the transition from the ICU to the ward.
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Affiliation(s)
- Helen Beard
- High Dependency Unit, West Suffolk Hospital NHS Trust, Hardwick Lane, Bury St Edmunds, Suffolk.
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Naeem N, Montenegro H. Beyond the intensive care unit: A review of interventions aimed at anticipating and preventing in-hospital cardiopulmonary arrest. Resuscitation 2005; 67:13-23. [PMID: 16150531 DOI: 10.1016/j.resuscitation.2005.04.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 04/12/2005] [Accepted: 04/12/2005] [Indexed: 01/01/2023]
Abstract
Despite more than four decades of experience with in-hospital cardiopulmonary arrest, outcomes have remained poor. Numerous studies have documented the physiological instability leading to clinical deterioration, which often precedes cardiopulmonary arrest. These physiological changes often go unrecognized or are acted upon inadequately. This has led to the development of interventions aimed at anticipating and/or preventing cardiopulmonary arrest. In this review, we summarize the current literature regarding outcomes from in-hospital cardiopulmonary arrest, the physiological instability leading to clinical deterioration which often precedes cardiopulmonary arrest, and the various interventions to anticipate and prevent in-hospital cardiopulmonary arrest. These interventions include the use of intermediate care units, Modified Early Warning Scores (MEWS) and Medical Emergency Teams (MET). These interventions may have the potential to decrease the cardiac arrest rate and in-hospital mortality rate associated with cardiac arrest; however, controversy remains regarding some of these interventions. The use of intermediate care units may require an organized approach to identify patients who are acutely ill and would benefit from this specialized care. There is not enough evidence currently to support the benefit of Modified Early Warning Scores to prevent in-hospital cardiopulmonary arrest. Recent studies of the Medical Emergency Team have shown a significant decrease in cardiac arrest and overall mortality rates with this intervention. The Medical Emergency Team is an intervention, which requires further studies to define its role in other aspects of hospital patient care.
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Affiliation(s)
- Nauman Naeem
- Division of Pulmonary and Critical care, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA
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Chiavone PA, Rasslan S. Influence of time elapsed from end of emergency surgery until admission to intensive care unit, on Acute Physiology and Chronic Health Evaluation II (APACHE II) prediction and patient mortality rate. SAO PAULO MED J 2005; 123:167-74. [PMID: 16389414 DOI: 10.1590/s1516-31802005000400003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Patients are often admitted to intensive care units with delay in relation to when this service was indicated. The objective was to verify whether this delay influences hospital mortality, length of stay in the unit and hospital, and APACHE II prediction. DESIGN AND SETITNG: Prospective and accuracy study, in intensive care unit of Santa Casa de São Paulo, a tertiary university hospital. METHODS We evaluated all 94 patients admitted following emergency surgery, from August 2002 to July 2003. The variables studied were APACHE II, death risk, length of stay in the unit and hospital, and hospital mortality rate. The patients were divided into two groups according to the time elapsed between end of surgery and admission to the unit: up to 12 hours and over 12 hours. RESULTS The groups were similar regarding gender, age, diagnosis, APACHE II score and hospital stay. The death risk factors were age, APACHE II and elapsed time (p < 0.02). The mortality rate for the over 12-hour group was higher (54% versus 26.1%; p = 0.018). For the over 12-hour group, observed mortality was higher than expected mortality (p = 0.015). For the up to 12-hour group, observed and expected mortality were similar (p = 0.288). CONCLUSION APACHE II foresaw the mortality rate among patients that arrived faster to the intensive core unit, while the mortality rate was higher among those patients whose admission to the intensive care unit took longer.
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Affiliation(s)
- Paulo Antonio Chiavone
- Department of Intensive Care, Hospital Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil.
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Affiliation(s)
- Wendy Chaboyer
- Wendy Chaboyer is a professor and the director of the Research Centre for Clinical Practice Innovation, Griffith University, Gold Coast, Australia. She is the past chair of the research advisory panel of the Australian College of Critical Care Nurses and a member of the editorial boards of the journals Australian Critical Care, Intensive and Critical Care Nursing, Nursing in Critical Care, and the Scandinavian Journal of Caring Sciences
| | - Heather James
- Heather James is an associate lecturer, School of Nursing, Griffith University. She is currently completing a doctoral thesis on continuity of care for intensive care unit patients
| | - Melissa Kendall
- Melissa Kendall is a research assistant in the Research Centre for Clinical Practice Innovation, Griffith University. She is also the research officer, Transitional Rehabilitation Program, Queensland Spinal Cord Injury Service, Brisbane, Australia. She is currently completing a doctoral thesis on rehabilitation psychology
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Schweizer A, Khatchatourian G, Höhn L, Spiliopoulos A, Romand J, Licker M. Opening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery. J Clin Anesth 2002; 14:486-93. [PMID: 12477582 DOI: 10.1016/s0952-8180(02)00403-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVES To assess the impact of a new postanesthesia care unit (PACU) on intensive care unit (ICU) utilization, hospital length of stay, and complications following major noncardiac surgery. DESIGN Observational study. SETTING University hospital. PATIENTS AND MEASUREMENTS From 1992 to 1999, 915 patients underwent either abdominal aortic reconstruction (n = 448) or lung resection for cancer (n = 467). Demographic, clinical, surgical, and anesthetic data, as well as perioperative complications, were abstracted from two institutional databases. INTERVENTIONS Patients were divided in two study periods, before and after the opening of a new PACU (period 1992-1995 and period 1996-1999). MAIN RESULTS Utilization of ICU decreased from 35% to 16% for vascular patients and from 57% to less than 4% for thoracic patients during the second period. Readmission to the ICU, perioperative mortality, and respiratory complications were comparable between the two periods. Patients with congestive heart failure, chronic obstructive pulmonary disease, or renal insufficiency were more likely to be admitted to the ICU than the PACU. Following vascular surgery the frequency of cardiac complications decreased from 10.6% in 1992-1995 to 5.2% in 1996-1999 (p < 0.005), as well as the need for postoperative mechanical ventilation (25% vs. 12%; P < 0.05). CONCLUSIONS Increased availability of PACU beds resulted in reduced utilization of ICU resources without compromising patient care after major noncardiac surgery.
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Affiliation(s)
- Alexandre Schweizer
- Department of Anesthesiology, Pharmacology and Surgical Intensive Care, Clinic of Cardiovascular Surgery, and Division of Thoracic Surgery, University Hospital, Geneva, Switzerland
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Loughrey JPR, Fitzpatrick G, Connolly J, Donnelly M. High dependency care: impact of lack of facilities for high-risk surgical patients. Ir J Med Sci 2002; 171:211-5. [PMID: 12647911 DOI: 10.1007/bf03170283] [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 The difference between the level of care available on general ward areas and intensive care units (ICUs) has resulted in the development of high dependency units (HDUs). AIMS This study examined the current perioperative management techniques and clinical care settings of high-risk surgical patients in a hospital without a HDU. METHODS A prospective audit of high-risk surgical patients was performed over an eight-week period. Using a pre-operative questionnaire, the anaesthetist categorised patient suitability for one of three post-operative care areas. In addition, desired and actual post-operative monitoring, pain management and organ support were indicated. RESULTS Seven (25%) of 28 patients admitted to ICU were rated HDU suitable indicating inappropriate use of resources, while 27 (75%) of 36 patients admitted to the general ward were categorised as fulfilling HDU admission criteria. A total of 21/27 (78%) and 12/27 (44%) of this latter group had alteration of idealised post-operative pain management and haemodynamic invasive monitoring plans respectively. CONCLUSIONS The absence of an intermediate care area facility in a tertiary hospital without an acute pain team impacts on the type of perioperative care provided to patients and the optimal use of resources.
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Affiliation(s)
- J P R Loughrey
- Department of Anaesthesia and Intensive Care, Adelaide Meath Hospital incorporating the National Children's Hospital, Tallaght, Dublin, Ireland.
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Abstract
This review discusses the issues to be considered in establishing new or extending existing high dependency unit (HDU) services. A defined high dependency service becomes cost-effective when patient care requires more than one nurse for three patients. Professional guidelines for HDUs vary and there are no national accreditation criteria. Casemix and service delivery specifications for the HDU need to be defined and agreed upon within the institution. Establishing a new HDU service requires changes to care delivery. Many potential HDU patients are currently managed in general wards or in the intensive care unit. The service should be discussed widely and marketed within the institution, and the development of defined working relationships with the ICU and primary care teams on the wards is mandatory.
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Affiliation(s)
- R Boots
- Intensive Care Facility, Royal Brisbane Hospital, Queensland, Australia
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Junker C, Zimmerman JE, Alzola C, Draper EA, Wagner DP. A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients. Chest 2002; 121:1253-61. [PMID: 11948061 DOI: 10.1378/chest.121.4.1253] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
STUDY OBJECTIVES To describe the characteristics and outcomes of patients admitted to intermediate-care areas (ICAs) and to compare them with those of ICU patients who receive monitoring only on day 1 and are at a low risk (i.e., < 10%) for receiving subsequent active life-supporting therapy (i.e., low-risk monitor patients). DESIGN Nonrandomized, retrospective, cohort study. SETTING Thirteen US teaching hospitals and 19 nonteaching hospitals. PATIENTS A consecutive sample of 8,971 patients at 37 ICAs and 5,116 low-risk (i.e., < 10%) monitor patients at 59 ICUs in 32 US hospitals. INTERVENTIONS None. MEASUREMENTS AND RESULTS We recorded demographic and clinical characteristics, resource use, and outcomes for the ICA and ICU low-risk monitor patients. Patient data and outcomes for this study were collected concurrently or retrospectively. ICA and ICU low-risk monitor patients were similar in regard to gender, race, and frequency of comorbitities, but ICA patients were significantly (p < 0.001) older, had fewer physiologic abnormalities (mean acute physiology score, 16.7 vs 19.8, respectively), and were more frequently admitted due to nonoperative diagnoses. The mean length of stay for ICA patients was significantly longer (3.9 days) than for ICU low-risk monitor patients (2.6 days; p < 0.001). The hospital mortality rate was significantly higher for ICA patients (3.1%) compared to ICU low-risk monitor patients (2.3%; p = 0.002). CONCLUSIONS The clinical features of ICA patients are similar, but not identical to, those of less severely ill ICU monitor patients. Comparisons of hospital death rates and lengths of stay for these patients should be adjusted for characteristics that previously have been shown to influence these outcomes.
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Affiliation(s)
- Christopher Junker
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC 20037, USA.
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Wade KJ. Paediatric high dependency provision: a case for urgent review in the United Kingdom. Intensive Crit Care Nurs 2002; 18:109-17. [PMID: 12353649 DOI: 10.1016/s0964-3397(02)00020-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The issues surrounding paediatric high dependency provision require attention. The field of adult high dependency has revealed some useful studies, which promote the benefits of designated care. These relate to improved quality of care and reduced pressure on the availability of intensive care beds. This review outlines recent initiatives made in the development of paediatric intensive care units in Britain and demonstrates how practical lessons learnt in the adult critical care sector may be used to establish appropriate Level 1 care in paediatrics. Two paediatric clinical issues are reviewed that support the need for high dependency provision, these being: paediatric respiratory management and the management of sedation withdrawal. The options available to district general hospitals, specialist hospitals, as well as lead paediatric hospitals are discussed, and include quality issues, where education, training and clinical audit are integral to structural and staffing HDU considerations.
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Affiliation(s)
- Katrina J Wade
- Paediatric Intensive Care Unit at Alder Hey Children's Hospital/Liverpool, UK.
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Oliveira MF. Papel dos cuidados intermédios num serviço de insuficientes respiratórios. REVISTA PORTUGUESA DE PNEUMOLOGIA 2001. [DOI: 10.1016/s0873-2159(15)30865-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Sivagnanam T. Opportunity knocks. Anaesthesia 2001; 56:487. [PMID: 11350343 DOI: 10.1046/j.1365-2044.2001.02047-5.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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40
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Nesbit I. From gasman to hospital saviour: how far should we go? Anaesthesia 2000; 55:1234-5. [PMID: 11121968 DOI: 10.1046/j.1365-2044.2000.01798-35.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- I Nesbit
- Freeman Hospital, Newcastle upon Tyne, UK
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Abstract
High-dependency units are increasing in number and becoming an ever more important part of a hospital's facilities. The optimum staffing ratio is unknown, but the Department of Health and the Intensive Care Society recommend a level of one nurse to two patients. We recorded Therapeutic Intervention Scoring System-28 scores and Nurse Dependency Scores for all admissions to our adult, general high-dependency unit over 7 months. We found a weak correlation between the nurse dependency score and the Therapeutic Intervention Scoring System-28 score. The median Therapeutic Intervention Scoring System-28 score was 23 points (interquartile range 19-26), and the median Nurse Dependency Score was 1.0. These results are approximately two-thirds of those for European intensive care units. We conclude that a nurse-to-patient ratio of 1:2 may be insufficient for an adult general high-dependency unit, and would recommend a nurse-to-patient ratio of 2:3.
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Affiliation(s)
- M Garfield
- Critical Care Complex, Norfolk and Norwich Hospital, Norwich, UK
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42
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Fox AJ, Owen-Smith O, Spiers P. The immediate impact of opening an adult high dependency unit on intensive care unit occupancy. Anaesthesia 1999; 54:280-3. [PMID: 10364867 DOI: 10.1046/j.1365-2044.1999.00715.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We assessed the hourly occupancy of our intensive care and high dependency units over an 8-week period commencing on the day our high dependency unit opened. Using criteria established by the working group on 'Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units' published by the National Health Service Executive, we defined each patient daily as intensive care or high dependency status. Compared with hourly occupancy figures obtained before the high dependency unit opened, occupancy of the intensive care unit by high dependency patients has been shown to decrease significantly from 21.6% to 11.2%. Use of intensive care beds became more appropriate, their occupancy increasing significantly from 63.7% to 73.4%. A significant decrease in readmissions occurred, supporting the hypothesis that having high dependency beds reduces the number of patients discharged prematurely to the wards.
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Affiliation(s)
- A J Fox
- Department of Anaesthesia, Leicester General Hospital NHS Trust, UK
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