Structural models for intermediate care areas

Utility of Intermediate Care Units: A Systematic Review Study

Intermediate care units (IMCUs) have become increasingly important in the care of critical and semi-critical patients, particularly during the COVID-19 pandemic. However, there is still no clear definition of their structural characteristics, specialties, types of patients, and the benefits they provide. The aim of this work is to describe the current state of implementation and operation of IMCUs in hospitals and patient care. To achieve this goal, a systematic review was conducted in the Web of Science, Scopus and CINAHL databases, along with a hand search. The research yielded 419 documents, of which 26 were included in this review after applying inclusion and exclusion criteria. The results were highly diverse and were categorized based on the following topics: material resources, human resources, continuity of care, and patient benefits. Despite the different objectives outlined in the studies, all of them demonstrate the numerous benefits provided by an IMCU, along with the increased relevance of this type of unit in recent years. Therefore, this systematic review highlights the benefits of IMCUs in the care of critical patients, as well as the role of health workers in these units.

Does the ICU Requirement Score allow the poisoned patient to be safely managed without admission to the intensive care unit? - a validation cohort study

BACKGROUND

The Intensive care unit (ICU) Requirement Score (IRS) has been defined as identifying poisoned patients on hospital admission who do not require ICU referral, in an effort to reduce health expenses. However, this score has been poorly validated. We aimed to evaluate the IRS in a large cohort of poisoned patients.

METHODS

We performed a single-center retrospective cohort study. IRS was calculated using clinical parameters obtained on admission including age, systolic blood pressure, heart rate, Glasgow coma score, intoxication type, co-morbidities (i.e., arrhythmia, cirrhosis, and respiratory insufficiency), and the combination of the intoxication with another reason for ICU admission. We evaluated the ability of IRS < 6 determined on admission to predict the lack of need for ICU treatment, defined as the need for mechanical ventilation, vasopressors, and/or renal replacement therapy in the first 24 h post-admission and/or death during the hospital stay. This score was compared to the usual prognostic scores, i.e., SAPS II and III, SOFA score, and PSS.

RESULTS

During the 10-year study period, 2,514 poisoned patients were admitted, 1,011 excluded as requiring ICU treatment on admission, and 1,503 included. Among these patients, 232 met the endpoint whereas only 23/510 patients with IRS < 6 (4.5%) presented the endpoint and one patient died. The area under the curve of the IRS ROC curve was 0.736 (95% confidence interval (CI), 0.702-0.770). The negative predictive value of IRS < 6 was 95% (95% CI, 93-97), sensitivity 89% (95% CI, 85-93), specificity 38% (95% CI, 36-41), and positive predictive value 21% (95% CI, 18-24). IRS performance was similar to those of the other tested scores, which are however not readily available on admission.

CONCLUSION

Our data demonstrate the excellent negative predictive value of the IRS, allowing the exclusion of ICU requirements for poisoned patients with IRS < 6. IRS usefulness should be confirmed based on a prospective multicenter cohort study before extensive routine use.

Intermediate care units : Recommendations on facilities and structure

A growing number of patients with increasingly complex or specialized diseases are being treated in hospitals worldwide. The treatment requirements of some of these patients are exceeding the capacity of standard nursing units. However, the severity of these diseases or the treatment requirements for these specific clinical pictures do not always justify admission to an intensive care unit. For this reason, an increasing number of special units (intermediate care units) are being set up to offer highly specialized treatment and close monitoring, in order to fulfil an intermediate role between the standard care unit and the intensive care unit. The recommendations of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) on the personnel, capacity, equipment and structure of these units are intended to provide the framework for the setting up and operation of intermediate care units in collaboration with experts on both an evidence-based and an expert-based basis (where scientific evidence is not available). Where only minimal or indirect evidence is available, patient safety is paramount in the formulation of the recommendation.

Workload and severity of illness of patients on intensive care units with available intermediate care units: a multicenter cohort study

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.

Initial Perioperative Care of the Cardiac Surgical Patient

Recently, changes in the management of cardiac patients have allowed earlier discharge from the cardiac recovery area and reduced hospital length of stay. These changes have been drien by a need to reduce the cost of cardiac surgery and imrove efficiency. This change has been both financially sucessful and safe for patients. To allow for this success, a joint effort is required between the departments of cardiac surgery and anesthesiology involving the preoperative, intraoperative and postoperative treatment of these patients. Through recogition of suitable candidates, modifications in anesthetic techique, and appropriate postoperative management, the goal of extubation within 6 hours of admission to the cardiac recovery area can be achieved. Changes in intraoperative and early postoperative management of cardiac surgical patients are discussed. Specific recovery models are reviewed with disussion of the parallel and integrated models. Methods of preicting prolonged extubation times and intensive care unit length of stay are also discussed. Initial management of the cardiac patient in the cardiac recovery area is presented with a more in-depth review of specific complications: stroke, atril fibrillation, blood loss, left ventricular dysfunction, and pulonary dysfunction.

The effect of physician staffing model on patient outcomes in a medical progressive care unit

PURPOSE

Although evidence supports the impact of intensivist physician staffing in improving intensive care unit (ICU) outcomes, the optimal coverage for progressive care units (PCU) is unknown. We sought to determine how physician staffing models influence outcomes for intermediate care patients.

MATERIALS AND METHODS

We conducted a retrospective observational comparison of patients admitted to the medical PCU of an academic hospital during 12-month periods of high-intensity and low-intensity staffing.

RESULTS

A total of 318 PCU patients were eligible for inclusion (143 high-intensity and 175 low-intensity). We found that low-intensity patients were more often stepped up from the emergency department and floor, whereas high-intensity patients were ICU transfers (61% vs 42%, P = .001). However, Mortality Probability Model scoring was similar between the 2 groups. In adjusted analysis, there was no association between intensity of staffing and hospital mortality (odds ratio, 0.84; 95% confidence interval, 0.36-1.99; P = .69) or PCU mortality (odds ratio, 0.96; 95% confidence interval, 0.38-2.45; P = .69). There was also no difference in subsequent ICU admission rates or in PCU length of stay.

CONCLUSIONS

We found no evidence that high-intensity intensivist physician staffing improves outcomes for intermediate care patients. In a strained critical care system, our study raises questions about the role of the intensivist in the graded care options between intensive and conventional ward care.

Lights and shadows of non-invasive mechanical ventilation for chronic obstructive pulmonary disease (COPD) exacerbations

Despite the overwhelming evidence justifying the use of non-invasive ventilation (NIV) for providing ventilatory support in chronic obstructive pulmonary disease (COPD) exacerbations, recent studies demonstrated that its application in real-life settings remains suboptimal. European clinical audits have shown that 1) NIV is not invariably available, 2) its availability depends on countries and hospital sizes, and 3) numerous centers declare their inability to provide NIV to all of the eligible patients presenting throughout the year. Even with an established indication, the use of NIV in acute respiratory failure due to COPD exacerbations faces important challenges. First, the location and personnel using NIV should be carefully selected. Second, the use of NIV is not straightforward despite the availability of technologically advanced ventilators. Third, NIV therapy of critically ill patients requires a thorough knowledge of both respiratory physiology and existing ventilatory devices. Accordingly, an optimal team-training experience, the careful selection of patients, and special attention to the selection of devices are critical for optimizing NIV outcomes. Additionally, when applied, NIV should be closely monitored, and endotracheal intubation should be promptly available in the case of failure. Another topic that merits careful consideration is the use of NIV in the elderly. This patient population is particularly fragile, with several physiological and social characteristics requiring specific attention in relation to NIV. Several other novel indications should also be critically examined, including the use of NIV during fiberoptic bronchoscopy or transesophageal echocardiography, as well as in interventional cardiology and pulmonology. The present narrative review aims to provide updated information on the use of NIV in acute settings to improve the clinical outcomes of patients hospitalized for COPD exacerbations.

Triage of Patients Consulted for ICU Admission During Times of ICU-Bed Shortage

Background

The demand for specialized medical services such as critical care often exceeds availability, thus rationing of intensive care unit (ICU) beds commonly leads to difficult triage decisions. Many factors can play a role in the decision to admit a patient to the ICU, including severity of illness and the need for specific treatments limited to these units. Although triage decisions would be based solely on patient and institutional level factors, it is likely that intensivists make different decisions when there are fewer ICU beds available. The objective of this study is to evaluate the characteristics of patients referred for ICU admission during times of limited beds availability.

Methods

A single center, prospective, observational study was conducted among consecutive patients in whom an evaluation for ICU admission was requested during times of ICU overcrowding, which comprised the months of April and May 2014.

Results

A total of 95 patients were evaluated for possible ICU admission during the study period. Their mean APACHE-II score was 16.8 (median 16, range 3 - 36). Sixty-four patients (67.4%) were accepted to ICU, 18 patients (18.9%) were triaged to SDU, and 13 patients (13.7%) were admitted to hospital wards. ICU had no beds available 24 times (39.3%) during the study period, and in 39 opportunities (63.9%) only one bed was available. Twenty-four patients (25.3%) were evaluated when there were no available beds, and eight of those patients (33%) were admitted to ICU. A total of 17 patients (17.9%) died in the hospital, and 15 (23.4%) expired in ICU.

Conclusion

ICU beds are a scarce resource for which demand periodically exceeds supply, raising concerns about mechanisms for resource allocation during times of limited beds availability. At our institution, triage decisions were not related to the number of available beds in ICU, age, or gender. A linear correlation was observed between severity of illness, expressed by APACHE-II scores, and the likelihood of being admitted to ICU. Alternative locations outside the ICU in which care for critically ill patients could be delivered should be considered during times of extreme ICU-bed shortage.

Introducing an integrated intermediate care unit improves ICU utilization: a prospective intervention study

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.

Factors influencing triage decisions in patients referred for ICU admission

Background

Few data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome.

Methods

A single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units.

Results

Seventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) had active advance directives on admission to ICU. Age, gender, and number of ICU beds available at the time of evaluation were not associated with triage decisions. Thirteen patients (18.3%) died in ICU, while the in-hospital mortality for refused patients was 12.8%.

Conclusion

Refusal of admission to ICU is common, although patients in which ICU admission is granted have higher mortality. Presence of active advance directives seems to play an important role in the triage decision process. Further efforts are needed to define which patients are most likely to benefit from ICU admission. Triage protocols or guidelines to promote efficient critical care beds use are warranted.

Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching

BACKGROUND

Hospitalized patients are complex and institutions have to face the high cost of critical care and the limited resources of the ward. Intermediate care appears as an attractive strategy to provide rational care according to patient needs. It is an interesting scenario to expand co-management and teaching.

STUDY DESIGN

Retrospective observational study.

SETTING

Intermediate care unit (ImCU) of a single academic hospital.

PATIENTS AND METHODS

456 patients admitted from April 2006 to April 2010 were included in the study. Demographics, admission physiologic parameters and in-hospital mortality were recorded. We used the Simplified Acute Physiology Score II (SAPS II) as prognostic score system. Co-management with medical and surgical teams, and the number of training residents were evaluated.

RESULTS

In-hospital mortality was 20.6%, whereas the expected mortality was 23.2% based on SAPS II score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, p < 0.001). Co-management was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (p = 0.014). The number of training residents in ImCU increased from 4.3% to 30.4% (p = 0.002)

CONCLUSIONS

An ImCU led by hospitalists showed encouraging results regarding patient survival and SAPS II is an useful tool for prognostic evaluation in this population. Intermediate care serves as an expansion of role for hospitalists; and clinicians, trainees and patients may benefit from co-management and teaching opportunities at this unique level of care.

Outcome and quality of life of elderly critically ill patients: an Italian prospective observational study

The demand of critical care admissions to intensive care unit (ICU) is projected to rise in the next decade. The aim of this study was to evaluate short and long-term mortality and quality of life (QoL) of elderly patients (80 years and older) admitted to two ICUs for medical conditions, abdominal surgery (planned and unplanned) and orthopedic surgery for hip fractures, over a 6-year period. Three months and one year after ICU discharge, patients or family members were contacted by telephone to obtain follow-up information using the EuroQoL questionnaire. The data were compared with an age-matched of the Italian population. Two hundred eighty-eight patients were included in the study. ICU mortality of medical (14.8%) and unplanned surgical patients (26.4%) was higher than that of planned surgical (5.0%) and orthopedic patients (2.5%), as was hospital mortality (27.7% vs. 50.0% vs. 5.0% vs. 14.3%). Three months and 12 months mortality rates after ICU discharge were 40.7% and 61.1% in medical patients, 70.5% and 76.4% in unplanned surgical patients, 20.0% and 30.0% in planned surgical patients, 36.2% and 46.2% in orthopedic patients. QoL measures revealed that, one year after ICU discharge, medical and orthopedic patients had significantly more severe problems vis-à-vis mobility, self-care and activity than abdominal surgical patients and control population. Type of admission was the independent risk factor associated with ICU and long-term mortality, whereas age 90 year and older was associated with long-term mortality. Orthopedic surgery for hip fractures seems to influence QoL similar to medical diseases.

Postoperative care after pulmonary resection: postanesthesia care unit versus intensive care unit

PURPOSE OF REVIEW

In an effort to maximize resource utilization and contain costs, immediate postoperative care after noncardiac thoracic surgery is often done in either the postanesthesia care unit or dedicated step down units, leaving the ICU for complex surgical cases, overtly high-risk patients, or the treatment of severe postoperative complications. This review analyzes the current modalities affecting length of stay and costs, mainly by allocating patients after elective lung resection to different postoperative areas according to their needs.

RECENT FINDINGS

Several surgical models have been published in recent years with the goal of optimizing perioperative patient care and subsequently decreasing hospital costs and length of stay. The main focus has been on elective lung resection for lung cancer. Preoperative evaluation, changes in surgical and anesthetic techniques as well as careful planning on where to recover these patients seem to make a clinical and financial impact.

SUMMARY

The development of models to help predict elective ICU admission should facilitate optimal care, cutting costs and shortening length of stay after lung resection.

Predictors of Adverse Events in Patients After Discharge From the Intensive Care Unit

Background Patients discharged from the intensive care unit may be at risk of adverse events because of complex care needs.

Objective To identify the types, frequency, and predictors of adverse events that occur in the 72 hours after discharge from an intensive care unit when no evidence of adverse events was apparent before discharge.

Methods A predictive cohort study of 300 patients from an adult intensive care unit was undertaken. An internationally accepted protocol for chart audit was used. Frequency of adverse events was calculated, and logistic regression was used to determine independent predictors of adverse events.

Results A total of 147 adverse events, 17 (11.6%) of which were defined as major, were incurred by 92 patients (30.7%). The 3 most common adverse events, hospital-incurred infection or sepsis (n = 32, 21.8%), hospital-incurred accident or injury (n = 17, 11.6%), and other complication such as deep vein thrombosis, pulmonary edema, or myocardial infarction (n = 17, 11.6%) accounted for 44.9% (n = 66) of all adverse events. Two predictors, respiratory rate less than 10/min or greater than or equal to 25/min and pulse rate exceeding 110/min, were significant independent predictors; requiring a high level of nursing care at the time of discharge was a significant predictor in univariate analysis but not in multivariate analysis.

Conclusion Taking, recording, and reporting vital signs are important. Nursing care requirements of patients at discharge from the intensive care unit may be worthy of further investigation in studies of patients after discharge.

Changes in intensive care unit performance measures associated with opening a dedicated thoracic surgical progressive care unit

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.

Short- and long-term outcomes of older patients in intermediate care units

OBJECTIVE

To evaluate short- and long-term outcomes of elderly patients (>or=65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors.

DESIGN AND SETTING

Prospective observational study in the IMCU of a university teaching hospital.

PARTICIPANTS

We studied 412 patients over 8 months, classified into three groups: under 65years (control group, n=158), 65-80 (n=186), and >80 (n=68).

MEASUREMENTS

At admission: APACHE II, TISS-28 first day, Charlson Index, diagnosis, and prior Barthel Index.

OUTCOME MEASURES

in-hospital mortality, length of stay, discharge destination, and 2-year mortality and readmissions. Data analysis included multivariate logistic regression and receiver operating characteristics area under the curve (ROC AUC).

RESULTS

No statistically significant differences between groups were observed in hospital mortality (14.1%), discharge to a long-term facility (2.7%), or 2-year readmissions (1.2+/-2.1). However, hospital stay was longer in patients aged 65-80years (14 vs.10 days) and 2-year mortality was higher in those 65 or over (34% vs.10.6%). In the overall series in-hospital mortality was predicted by APACHE II, first-day TISS-28, and diagnosis (ROC AUC 0.81), and 2-year mortality by Charlson Index and age (ROC AUC 0.77). In the elderly patients 2-year mortality was predicted by Charlson and Barthel indices (ROC AUC 0.70).

CONCLUSIONS

Illness severity and therapeutic intervention at admission to IMCU were predictors of short-term mortality, whereas the strongest predictor of long-term mortality was comorbidity. Our results suggest that comprehensive assessment of elderly patients at admission to IMCUs may improve outcome prediction.

Rationing critical care beds: a systematic review

OBJECTIVE

Rationing critical care beds occurs daily in the hospital setting. The objective of this systematic review was to examine the impact of rationing intensive care unit beds on the process and outcomes of care.

DATA SOURCE

We searched MEDLINE (1966-2003), CINAHL (1982-2003), Ovid Healthstar (1975-2003), EMBASE (1980-2003), Scisearch (1980-2003), the Cochrane Library, PUBMED related articles, personal files, abstract proceedings, and reference lists.

STUDY SELECTION

We included studies of seriously ill patients considered for admission to an intensive care unit bed during periods of reduced availability. We had no restriction on study design. Studies were excluded if rationing was performed using a scoring system or protocol and if cost-effectiveness was the only outcome.

DATA EXTRACTION

In duplicate and independently, we performed data abstraction and quality assessment.

DATA SYNTHESIS

We included ten observational studies. Hospital mortality rate was increased in patients refused intensive care unit admission vs. those admitted (odds ratio, 3.04; 95% confidence interval, 1.49-6.17). Factors associated with both intensive care unit bed refusal and increased mortality rate were increased age, severity of illness, and medical diagnosis. When intensive care unit beds were reduced, admitted patients were sicker, were less often admitted primarily for monitoring, and had a shorter intensive care unit length of stay, without other observed adverse effects.

CONCLUSIONS

These studies suggest that patients who are perceived not to benefit from critical care are more often refused intensive care unit admission; refusal is associated with an increased risk of hospital death. During times of decreased critical bed availability, several factors, including age, illness severity, and medical diagnosis, are used to triage patients, although their relative importance is uncertain. Critical care bed rationing requires further investigation.

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care

OBJECTIVES

To describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level.

PARTICIPANTS

A multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM).

DATA SOURCES AND SYNTHESIS

Relevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria.

CONCLUSIONS

Guidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.

Critical care without walls

Critical care medicine is a relatively young specialty that was developed in response to potentially reversible life-threatening illness and was facilitated by developments such as new drugs, support equipment, and monitoring technology. It has been largely practiced within the four walls of an intensive care unit (ICU). However, now there are increasing numbers of critically ill and at-risk patients in acute hospitals who are suffering potentially preventable, serious complications that may result in death because of a lack of appropriate systems, skills, and expertise outside of the ICU. Critical care specialists are expanding their roles beyond the four walls of their ICUs and becoming involved with strategies such as the medical emergency team, a concept designed to recognize critical illness early and to respond rapidly to resuscitate patients wherever they are in the hospital.

A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients

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.

Ultra-fast-track anesthetic technique facilitates operating room extubation in patients undergoing off-pump coronary revascularization surgery

OBJECTIVE

To determine if implementation of ultra-fast-track anesthetic (UFTA) technique facilitates operating room extubation in patients undergoing off-pump coronary artery bypass graft (CABG) surgery.

DESIGN

Retrospective review.

SETTING

Referral center for cardiovascular surgery at a university hospital.

PARTICIPANTS

Thirty-seven patients undergoing off-pump CABG surgery.

INTERVENTIONS

Two groups represented UFTA (n = 10) and standard anesthetic (controls, n = 27) techniques. Anesthesia was conducted with propofol, remifentanil, vecuronium, and thoracic epidural analgesia in the UFTA group and thiopental, fentanyl, pancuronium, and isoflurane in the control group. Active temperature control was an integral part of the UFTA technique but not the standard technique. The active temperature control included intravenous fluid warmer, prewarmed skin preparation, humidified inspired gases, a circulating water warming blanket, and a forced-air warmer, along with the maintenance of the operating room temperature at 24 degrees C. The control group was managed with an intravenous fluid warmer, and the ambient temperature remained constant (20 degrees C). Patients who did not satisfy extubation criteria within 30 minutes from the end of surgery were sedated and transferred to the intensive care unit (ICU).

MEASUREMENTS AND MAIN RESULTS

All patients in the UFTA group and 2 in the control group were extubated in the operating room immediately after surgery. None of the patients required reintubation. There was no significant difference in postextubation PaO(2) and PaCO(2) between the groups. Nasopharyngeal temperature decreased from 36.7 +/- 0.4 degrees C to 36.4 +/- 0.3 degrees C in the UFTA group and from 36.6 +/- 0.5 degrees C to 35.6 +/- 0.4 degrees C in the control group (p < 0.0001). Bradycardia occurred significantly more often in the UFTA group but there was no difference in episodes of hypotension. There were no perioperative deaths. Patients who were extubated in the operating room required lower nurse-to-patient acuity ratio (1:2) in the ICU. No difference was found in ICU and hospital length of stay.

CONCLUSIONS

Implementation of UFTA technique provided adequate hemodynamic control and facilitated operating room extubation in all patients. The impact of UFTA on earlier patient discharge and actual cost savings within a fully integrated post-cardiac surgery unit requires further evaluation.

Postoperative intensive care in cardiac surgery

Postoperative intensive care in cardiac surgery is a growing area, fuelled by the increase in the number of cardiac surgical procedures performed. An increase in the number of patients has resulted in increased resource utilization. Much of the recent research in this field is concerned with the early extubation of cardiac surgical patients, reducing the length of stay in the intensive care unit and predicting which patients will have delayed extubation and a prolonged length of stay. A number of recent studies have been published advocating 'off pump' cardiac surgery as a way of reducing the physiological insult of cardiopulmonary bypass and thereby improving the postoperative course. There is still insufficient evidence that this approach reduces morbidity and intensive care unit length of stay in multi-vessel off-pump coronary artery bypass surgery. The traditional design of post-cardiac surgical intensive care units and high dependency units has also recently been challenged. More flexible integrated units improve cost control and are more suited to modern cardiac surgery.

Right patient? Right bed? A question of appropriateness

Key issues addressing appropriateness of triage decisions and the tools needed to support those decisions are identified in this article. The limitations of current approaches to appropriate utilization such as admission and continued-stay criteria, medical management models, bed control and bed management strategies, and rounding practices are discussed, and a systemic model to examine the placement of patients is proposed. Determining which patients can benefit from critical care and which can benefit from an alternative level of care is analyzed through the use of clinical decision support tools that provide both retrospective analysis of current patterns and predictive models to assist the clinician in making continued-stay decisions. Patient populations who are considered for alternative placement are defined. Those populations identified as having the potential to gain limited benefit from the level of intensity of an intensive care unit are managed in alternative sites. The role played by the advanced practice clinician in using clinical decision support tools is discussed.