The impact of hospital and ICU organizational factors on outcome in critically ill patients: results from the Extended Prevalence of Infection in Intensive Care study. Crit Care Med. 2015;43:519-526. [PMID: 25479111 DOI: 10.1097/ccm.0000000000000754]

Association of Shift-Level Organizational Factors with Nosocomial Infection in the Neonatal Intensive Care Unit

Objective

To evaluate the association between shift-level organizational data (unit occupancy, nursing overtime ratios [OTRs], and nursing provision ratios [NPRs]) with nosocomial infection (NI) among infants born very preterm in the neonatal intensive care unit (NICU).

Study design

This was a multicenter, retrospective cohort study, including 1921 infants 230/7-326/7 weeks of gestation admitted to 3 tertiary-level NICUs in Quebec between 2014 and 2018. Patient characteristics and outcomes (NIs) were obtained from the Canadian Neonatal Network database and linked to administrative data. For each shift, unit occupancy (occupied/total beds), OTR (nursing overtime hours/total nursing hours), and NPR (number of actual/number of recommended nurses) were calculated. Mixed-effect logistic regression models were used to calculate aOR for the association of organizational factors (mean over 3 days) with the risk of NI on the following day for each infant.

Results

Rate of NI was 11.5% (220/1921). Overall, median occupancy was 88.7% [IQR 81.0-94.6], OTR 4.4% [IQR 1.5-7.6], and NPR 101.1% [IQR 85.5-125.1]. A greater 3-day mean OTR was associated with greater odds of NI (aOR 1.08, 95% CI 1.02-1.15), a greater 3-day mean NPR was associated lower odds of NI (aOR 0.96, 95% CI 0.95-0.98), and occupancy was not associated with NI (aOR, 0.99, 95% CI 0.96-1.02). These findings were consistent across multiple sensitivity analyses.

Conclusions

Nursing overtime and nursing provision are associated with the adjusted odds of NI among infants born very preterm in the NICU. Further interventional research is needed to infer causality.

Rationing of nursing care and assessment of work safety and a healthy work environment in intensive care units: A cross-sectional, correlational study

INTRODUCTION

Rationing of nursing care, whichrefers to the aspects of care not delivered by nurses in an intensive care unit (ICU), has implicationsfor patient outcomes and experiences.

OBJECTIVES

This study aimed to identify the extent to which nursing care is rationed in intensive care units, as well as asses quality of nursing care, and the level of job satisfaction and its correlation with an assessment of the climate of work safety, teamwork, and a healthy work environment.

METHODOLOGY

A cross-sectional, correlational study was conducted. The study included 226 ICU nurses. It was conducted with the use of three instruments: the Perceived Implicit Rationing of Nursing Care (PRINCA) questionnaire on the rationing of nursing care, assessment of patient care quality and job satisfaction, American Association of Critical-Care Nurses Healthy Work Environment Assessment Tool (HWEAT) and the Safe Attitudes and Behaviours Questionnaire questionnaire in the version: Teamwork and Safety Climate (BePoZa).

SETTINGS

Intensive Care Units in Warmia and Mazury Region in Poland.

MAIN OUTCOME MEASURES

Level of Nursing Care Rationing in Intensive Care Units.

RESULTS

The majority of participants were women (89.82 %) with a mean age of 42.47 years. The average score for nursing care rationing across all groups was 0.58. The mean score for the HWEAT was 2.7 and BePoZa was 3.72. The scores from the questionnaires were negatively correlated with the nursing care rationing scores, being -0.36 for the HWEAT and -0.45 for BePoZa. All correlation coefficients were statistically significant at a p-value of less than 0.05.

CONCLUSIONS

It is important to monitor work safety, teamwork climate, and standards of a healthy work environment in ICUs to minimise the risk of rationing nursing care.

IMPLICATIONS FOR CLINICAL PRACTICE

Interventions that enhance work organisation and teamwork can elevate nursing quality and job satisfaction in ICUs, while underestimating patient care tasks; thus, highlighting the need for further research on the factors influencing nursing performance.

What trauma patients need: the European dilemma

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

The role of centre and country factors on process and outcome indicators in critically ill patients with hospital-acquired bloodstream infections

PURPOSE

The primary objective of this study was to evaluate the associations between centre/country-based factors and two important process and outcome indicators in patients with hospital-acquired bloodstream infections (HABSI).

METHODS

We used data on HABSI from the prospective EUROBACT-2 study to evaluate the associations between centre/country factors on a process or an outcome indicator: adequacy of antimicrobial therapy within the first 24 h or 28-day mortality, respectively. Mixed logistical models with clustering by centre identified factors associated with both indicators.

RESULTS

Two thousand two hundred nine patients from two hundred one intensive care units (ICUs) were included in forty-seven countries. Overall, 51% (n = 1128) of patients received an adequate antimicrobial therapy and the 28-day mortality was 38% (n = 839). The availability of therapeutic drug monitoring (TDM) for aminoglycosides everyday [odds ratio (OR) 1.48, 95% confidence interval (CI) 1.03-2.14] or within a few hours (OR 1.79, 95% CI 1.34-2.38), surveillance cultures for multidrug-resistant organism carriage performed weekly (OR 1.45, 95% CI 1.09-1.93), and increasing Human Development Index (HDI) values were associated with adequate antimicrobial therapy. The presence of intermediate care beds (OR 0.63, 95% CI 0.47-0.84), TDM for aminoglycoside available everyday (OR 0.66, 95% CI 0.44-1.00) or within a few hours (OR 0.51, 95% CI 0.37-0.70), 24/7 consultation of clinical pharmacists (OR 0.67, 95% CI 0.47-0.95), percentage of vancomycin-resistant enterococci (VRE) between 10% and 25% in the ICU (OR 1.67, 95% CI 1.00-2.80), and decreasing HDI values were associated with 28-day mortality.

CONCLUSION

Centre/country factors should be targeted for future interventions to improve management strategies and outcome of HABSI in ICU patients.

Association Between In-hospital Mortality and the Institutional Factors of Intensive Care Units with a Focus on the Intensivist- to-bed Ratio: A Retrospective Cohort Study

Purpose: To elucidate the relationship between in-hospital mortality and the institutional factors of intensive care units (ICUs), with a focus on the intensivist-to-bed ratio. Methods: A retrospective cohort study was conducted using a Japanese ICU database, including adult patients admitted between April 1, 2020 and March 31, 2021. We used a multilevel logistic regression model to investigate the associations between in-hospital mortality and the following institutional factors: the intensivist-to-bed ratios on weekdays or over weekends/holidays, different work shifts, hospital-to-ICU-bed ratio, annual-ICU-admission-to-bed ratio, type of hospital, and the presence of other medical staff. Results: The study population comprised 46 503 patients admitted to 65 ICUs. The in-hospital mortality rate was 8.1%. The median numbers of ICU beds and intensivists were 12 (interquartile range [IQR] 8-14) and 4 (IQR 2-9), respectively. In-hospital mortality decreased significantly as the intensivist-to-bed ratio at 10 am on weekdays increased: the average contrast indicated a 20% (95% confidence interval [CI]: 1%-38%) reduction when the ratio increased from 0 to 0.5, and a 38% (95% CI: 9%-67%) reduction when the ratio increased from 0 to 1. The other institutional factors did not present a significant effect. Conclusions: The intensivist-to-bed ratio at 10 am on weekdays had a significant effect on in-hospital mortality. Further investigation is needed to understand the processes leading to improved outcomes.

Association between ICU quality and in-hospital mortality of V-V ECMO-supported patients-the ECMO quality improvement action (EQIA) study: a national cohort study in China from 2017 to 2019

This cohort study was performed to explore the influence of intensive care unit (ICU) quality on in-hospital mortality of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO)-supported patients in China. The study involved all V-V ECMO-supported patients in 318 of 1700 tertiary hospitals from 2017 to 2019, using data from the National Clinical Improvement System and China National Critical Care Quality Control Center. ICU quality was assessed by quality control indicators and capacity parameters. Among the 2563 V-V ECMO-supported patients in 318 hospitals, a significant correlation was found between ECMO-related complications and prognosis. The reintubation rate within 48 hours after extubation and the total ICU mortality rate were independent risk factors for higher in-hospital mortality of V-V ECMO-supported patients (cutoff: 1.5% and 7.0%; 95% confidence interval: 1.05-1.48 and 1.04-1.45; odds ratios: 1.25 and 1.23; P = 0.012 and P = 0.015, respectively). Meanwhile, the V-V ECMO center volume was a protective factor (cutoff of ≥ 50 cases within the 3-year study period; 95% confidence interval: 0.57-0.83, odds ratio: 0.69, P = 0.0001). The subgroup analysis of 864 patients in 11 high-volume centers further strengthened these findings. Thus, ICU quality may play an important role in improving the prognosis of V-V ECMO-supported patients.

Bacterial Infections in Intensive Care Units: Epidemiological and Microbiological Aspects

Intensive care units constitute a critical setting for the management of infections. The patients' fragilities and spread of multidrug-resistant microorganisms lead to relevant difficulties in the patients' care. Recent epidemiological surveys documented the Gram-negative bacteria supremacy among intensive care unit (ICU) infection aetiologies, accounting for numerous multidrug-resistant isolates. Regarding this specific setting, clinical microbiology support holds a crucial role in the definition of diagnostic algorithms. Eventually, the complete patient evaluation requires integrating local epidemiological knowledge into the best practice and the standardization of antimicrobial stewardship programs. Clinical laboratories usually receive respiratory tract and blood samples from ICU patients, which express a significant predisposition to severe infections. Therefore, conventional or rapid diagnostic workflows should be modified depending on patients' urgency and preliminary colonization data. Additionally, it is essential to complete each microbiological report with rapid phenotypic minimum inhibitory concentration (MIC) values and information about resistance markers. Microbiologists also help in the eventual integration of ultimate genome analysis techniques into complicated diagnostic workflows. Herein, we want to emphasize the role of the microbiologist in the decisional process of critical patient management.

In-hospital complications of work-related musculoskeletal injuries

BACKGROUND, OBJECTIVES

Work-related musculoskeletal (MSK) injuries are a major contributor to morbidity worldwide and frequently result in hospitalisation. Hospital complications are common, costly, and largely preventable, but relevant data is required to address this. This study aimed to identify the incidence and factors associated with in-hospital complications of work-related MSK injuries.

METHODS

This study is based on work-related MSK hospital admission data from Victorian Admitted Episodes Database, 2016-2022. Complications were identified based on ICD-10-AM coding using CHADx (Classification of Hospital Acquired Diagnoses). Negative binomial and logistic regression analyses were performed to identify factors related to in-hospital complications.

RESULTS

In-hospital complications occurred in 6.3 % of work-related MSK injury admissions. In the adjusted models, ages ≥45 years, female sex, and area-level disadvantage were associated with in-hospital complications. Stay at public (vs private) hospitals, comorbidity, emergency admissions, and general anaesthesia were also associated. Complication rates were higher in hospitalised workers with direct head, neck, and trunk injuries and cumulative MSK disorders than those with direct extremities injuries and acute MSK conditions. The most common complications were cardiovascular, gastrointestinal complications and adverse drug events.

CONCLUSION

This study identified patient, injury and hospital-related characteristics associated with in-hospital complications of work-related MSK injuries for informing prevention strategies and risk estimation by hospital staff and workers' compensation schemes. The results demonstrate a sizable rate of complications given the relatively young and healthy study population.

Cardiac intensive care unit: where we are in 2023

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023.

A Data-Driven Analysis of Ward Capacity Strain Metrics That Predict Clinical Outcomes Among Survivors of Acute Respiratory Failure

Supply-demand mismatch of ward resources ("ward capacity strain") alters care and outcomes. Narrow strain definitions and heterogeneous populations limit strain literature. Evaluate the predictive utility of a large set of candidate strain variables for in-hospital mortality and discharge destination among acute respiratory failure (ARF) survivors. In a retrospective cohort of ARF survivors transferred from intensive care units (ICUs) to wards in five hospitals from 4/2017-12/2019, we applied 11 machine learning (ML) models to identify ward strain measures during the first 24 hours after transfer most predictive of outcomes. Measures spanned patient volume (census, admissions, discharges), staff workload (medications administered, off-ward transports, transfusions, isolation precautions, patients per respiratory therapist and nurse), and average patient acuity (Laboratory Acute Physiology Score version 2, ICU transfers) domains. The cohort included 5,052 visits in 43 wards. Median age was 65 years (IQR 56-73); 2,865 (57%) were male; and 2,865 (57%) were white. 770 (15%) patients died in the hospital or had hospice discharges, and 2,628 (61%) were discharged home and 964 (23%) to skilled nursing facilities (SNFs). Ward admissions, isolation precautions, and hospital admissions most consistently predicted in-hospital mortality across ML models. Patients per nurse most consistently predicted discharge to home and SNF, and medications administered predicted SNF discharge. In this hypothesis-generating analysis of candidate ward strain variables' prediction of outcomes among ARF survivors, several variables emerged as consistently predictive of key outcomes across ML models. These findings suggest targets for future inferential studies to elucidate mechanisms of ward strain's adverse effects.

Critical Care Pharmacists: A Focus on Horizons

Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.

Improving Skin Care Protocol Use in the Intensive Care Unit to Reduce Hospital-Acquired Pressure Injuries

BACKGROUND

Patients in the intensive care unit have the highest rate of hospital-acquired pressure injuries (HAPIs). In the United States, treatment of HAPIs costs an estimated $9.1 to $11.6 billion annually, with each occurrence adding an average of $10 708 to a patient's total hospital cost. In addition to their financial impact, pressure injuries negatively affect patients physically, socially, and psychologically and are associated with increased morbidity and mortality.

OBJECTIVE

An intensive care unit had 42 HAPIs during a single fiscal year, with 45% of them related to lack of adherence to the institution's established evidence-based skin care protocol. This project was conducted to increase adherence to the protocol and thus reduce the incidence of HAPIs in the unit.

METHODS

This quality improvement initiative featured an evidence-based multifaceted intervention to increase adherence to the skin care protocol. A review of medical records was used to determine general skin care protocol adherence and to measure the monthly incidence of HAPIs in the unit.

RESULTS

The number of HAPIs in the unit decreased from 33 in the preintervention period to 11 in the postintervention period, a reduction of 67%. The rate of general skin care protocol adherence improved to as high as 76% by the end of the postintervention period.

CONCLUSION

Use of an evidence-based multifaceted intervention can improve adherence to a skin care protocol in the intensive care unit, resulting in a reduced incidence of HAPIs and improved patient outcomes.

Nurse staffing levels in critical care: The impact of patient characteristics

BACKGROUND

Intensive care is one of the most resource-intensive forms of care because seriously ill patients are cared for in units with high staffing levels. Studies show that the number of registered nurses (RNs) per patient and nurse education level affects patient outcome. However, there is a lack of studies that consider how nurses/patient ratio with an advanced educational level of specialized nurses in intensive care, affect the intensive care performed in different patient populations.

AIM

To investigate if differences in patient characteristics and nurse-patient ratio have an impact on the quality of care.

STUDY DESIGN

This is a retrospective observational study with a review of all patients >15 years receiving care at two general intensive care units with different nurse/patient ratio (unit A, 1:1 nurse/patient ratio and unit B, 0.5:1 nurse/patient ratio).

RESULTS

There was no significant difference in the initial severity of illness between the units. However, younger patients, male patients and patients requiring surgery entailed a higher workload and a longer intensive care unit (ICU) stay despite a 1:1 critical care nurse/patient ratio. A small difference, but not significant, with more unplanned re-intubations occurred at unit A compared with unit B.

CONCLUSION

The differences in the nurse/patient ratio did not reflect a difference in the severity of illness among admitted patients but might be explained by patient characteristics with different needs.

RELEVANCE TO CLINICAL PRACTICE

Health care managers should consider not only the number of nurses but also their educational level, specific competencies and skills mix and nursing-sensitive measures to provide high-quality ICU care in settings with different patient characteristics. Nursing-sensitive patient outcomes should be considered in relation to nurse/patient ratio, as important to measure to ensure a high quality of patient care in the ICU.

Effect of ICU quality control indicators on VAP incidence rate and mortality: a retrospective study of 1267 hospitals in China

PURPOSE

To investigate the effects of ICU quality control indicators on the VAP incidence rate and mortality in China throughout 2019.

METHODS

This was a retrospective study. A total of 1267 ICUs from 30 provinces in mainland China were included. Data were collected using the National Clinical Improvement System Data that report ICU information. Ten related quality control indicators were analyzed, including 5 structural factors (patient-to-bed ratio, physician-to-bed ratio, nurse-to-bed ratio, patient-to-physician ratio, and patient-to-nurse ratio), 3 process factors (unplanned endotracheal extubation rate, reintubation rate within 48 h, and microbiology detection rate before antibiotic use), and 2 outcome factors (VAP incidence rate and mortality). The information on the most common infectious pathogens and the most commonly used antibiotics in ICU was also collected. The Poisson regression model was used to identify the impact of factors on the incidence rate and mortality of VAP.

RESULTS

The incidence rate of VAP in these hospitals in 2019 was 5.03 (2.38, 10.25) per 1000 ventilator days, and the mortality of VAP was 11.11 (0.32, 26.00) %. The most common causative pathogen was Acinetobacter baumannii (in 39.98% of hospitals), followed by Klebsiella pneumoniae (38.26%), Pseudomonas aeruginosa, and Escherichia coli. In 26.90% of hospitals, third-generation cephalosporin was the most used antibiotic, followed by carbapenem (24.22%), penicillin and beta-lactamase inhibitor combination (20.09%), cephalosporin with beta-lactamase inhibitor (17.93%). All the structural factors were significantly associated with VAP incidence rate, but not with the mortality, although the trend was inconsistent. Process factors including unplanned endotracheal extubation rate, reintubation rate in 48 h, and microbiology detection rate before antibiotic use were associated with higher VAP mortality, while unplanned endotracheal extubation rate and reintubation rate in 48 h were associated with higher VAP mortality. Furthermore, K. pneumoniae as the most common pathogen was associated with higher VAP mortality, and carbapenems as the most used antibiotics were associated with lower VAP mortality.

CONCLUSION

This study highlights the association between the ICU quality control (QC) factors and VAP incidence rate and mortality. The process factors rather than the structural factors need to be further improved for the QC of VAP in the ICU.

What are the perceptions of intensive care staff about their sedation practices when caring for a mechanically ventilated patient?: A systematic mixed-methods review

Background

Sedation is used alongside mechanical ventilation for patients in intensive care units internationally; its use is complex and multifaceted. Existing evidence shows that the ways health care professionals use sedation significantly impacts patient outcomes, including how long someone spends on a ventilator, length of stay in intensive care and recovery.

Objective

Our study aimed to systematically review and synthesize qualitative and quantitative evidence about how intensive care staff perceive sedation practices when looking after sedated and mechanically ventilated patients.

Design

We performed a systematic integrated mixed-methods literature review collecting qualitative and quantitative studies according to inclusion and exclusion criteria. Studies were included if they were published from 2009 and focused on perceptions of staff working in general adult intensive care units and caring for mechanically ventilated patients.

Settings

General adult intensive care units.

Participants

Health care professionals working in adult intensive care units.

Methods

Screening, data extraction and quality appraisal was undertaken by SV. Screening for inclusion and quality issues were reviewed by TR, TM and JS. The following databases: Embase, BNI, PubMed, Scopus, AMED, CINAHL, ASSIA, The Cochrane Library and Google Scholar. We used an assessment tool called the Mixed Methods Appraisal Tool. The studies were assessed and analysed by transforming the qualitative and quantitative data into 'text-in-context' statements. The statements were then synthesized using thematic analysis.

Results

Eighteen studies were included from ten countries, fourteen quantitative and four qualitative. Three overarching themes were identified: 'Variation in Decision Making', 'Challenges in Decision Making' and 'Thinking Outside the Box'. Existing studies revealed that there is considerable variation in most aspects of perceived sedation practice. Staff face challenges with interprofessional collaboration and sedation practice, and there are barriers to using sedation protocols and light sedation. There is also evidence that there is a need for health care professionals to develop coping strategies to help them facilitate lighter sedation.

Conclusions

A review of a decade of evidence shows that variation in decision making and challenges in decision making should be addressed to improve the care of the sedated and ventilated patient, and improve the caregiving experience for staff. Staff continue to require support with sedation practice, especially in light sedation. Research should now focus on how to help staff cope with looking after lightly sedated patients. In addition, future studies should focus on exploring sedation practices using qualitative methods as there is a dearth of qualitative evidence.

Tweetable abstract

Staff perceive a range of complex challenges that explain some of the variability in sedation practice for the ventilated patient in ICU.

End of life decisions in immunocompromised patients with acute respiratory failure

PURPOSE

To identify patient, disease and organizational factors associated with decisions to forgo life-sustaining therapies (DFLSTs) in critically ill immunocompromised patients admitted to the intensive care unit (ICU) for acute respiratory failure.

MATERIAL AND METHODS

We performed a secondary analysis of the international EFRAIM prospective study, which enrolled 1611 immunocompromised patients with acute respiratory failure admitted to 68 ICUs in 16 countries between October 2015 and June 2016. Multivariate logistic analysis was performed to identify independent predictors of DFLSTs.

RESULTS

The main causes of immunosuppression were hematological malignancies (50%) and solid tumor (38%). Patients had a median age of 63 yo (54-71). A pulmonologist was involved in the patient management in 38% of cases. DFLSTs had been implemented in 28% of the patients. The following variables were independently associated with DFLSTs: 1) patient-related: older age (OR 1.02 per one year increase, 95% confidence interval(CI) 1.01-1.03,P < 0.001), poor performance status (OR 2.79, 95% CI 1.98-3.93, P < 0.001); 2) disease-related: shock (OR 2.00, 95% CI 1.45-2.75, P < 0.001), liver failure (OR 1.59, 95% CI 1.14-2.21, P = 0.006), invasive mechanical ventilation (OR 1.79, 95% CI 1.31-2.46, P < 0.001); 3) organizational: having a pulmonologist involved in patient management (OR 1.85, 95% CI 1.36-2.52, P < 0.001), and the presence of a critical care outreach services (OR 1.63, 95% CI 1.11-2.38, P = 0.012).

CONCLUSIONS

A DFLST is made in one in four immunocompromised patient admitted to the ICU for acute respiratory failure. Involving a pulmonologist in patient's management is associated with less non beneficial care.

Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry

The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (β = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (β = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (β = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (β = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.

Expedited upskilling of intermediate care nurses to provide critical care during the COVID-19 pandemic

AIM

Describe the strategy, efficacy and preferred mechanisms of training used to rapidly upskill intermediate care nursing staff to provide critical care during the COVID-19 pandemic.

DESIGN

Descriptive study.

METHODS

The strategy used from March through December 2020 to upskill nurses in an intermediate care unit to administer critical care upon rapid conversion of the intermediate care unit to an intensive care unit for coronavirus disease 2019 is described. Training and education included paired staffing models, interdisciplinary education, skills days and self-directed learning. Nurses engaged in this upskilling process were surveyed to evaluate their confidence in new critical care competencies and educational preferences.

RESULTS

Of 38 intermediate care nurses, 35 completed training and began independent intensive care practice. Nursing confidence in critical care competencies increased steadily. Nurses demonstrated the greatest preference for peer education models, particularly those incorporating the hospital's pre-existing medical intensive care nurses.

PATIENT AND PUBLIC CONTRIBUTIONS

No patient or public contributions were made to this manuscript.

The research environment of critical care in three Asian countries: A cross-sectional questionnaire survey

Although inadequate research support for intensivists can be one major reason of the poor research productivity, no study has investigated the current research environment in critical care medicine in Asia. The objective of this study was to describe Asian academia in critical care from the research environment perspective. We conducted a cross-sectional questionnaire survey targeting all physician members of the Societies of Intensive/Critical Care Medicine in Japan, South Korea, and Singapore. We collected the characteristics of the participants and their affiliated institutions and the research environment. The outcome was the number of peer-reviewed publications. Multivariable logistic regression analyses examined the association between the outcome and the following five research environmental factors (i.e., country of the respondents, availability of secured time for research activities or research supporting staff for the hospital, practice at a university-affiliated hospital, and years of clinical practice of 10 years or longer). Four hundred ninety responded (overall response rate: 5.6%) to the survey between June 2019 and January 2020. Fifty-five percent worked for a university-affiliated hospital, while 35% worked for a community hospital. Twenty-four percent had secured time for research within their full-time work hours. The multivariable logistic model found that a secured time for the research activities [odds ratio (OR): 2.77; 95% confidence interval (CI), 1.46–5.24], practicing at a university-affiliated hospital (OR: 2.61; 95% CI, 1.19–5.74), having clinical experience of 10 years or longer (OR:11.2; 95%CI, 1.41–88.5), and working in South Korea (OR: 2.18; 95% CI, 1.09–4.34, Reference: Japan) were significantly associated with higher research productivity. Intensivists in the three countries had limited support for their research work. Dedicated time for research was positively associated with the number of research publications.

The Influence of the COVID-19 Pandemic on Intensivists' Well-Being: A Qualitative Study

BACKGROUND

The COVID-19 pandemic has strained health care systems and has resulted in widespread critical care staffing shortages, negatively impacting the quality of care delivered.

RESEARCH QUESTION

How have hospitals' emergency responses to the pandemic influenced the well-being of frontline intensivists, and do any potential strategies exist to improve their well-being and to help preserve the critical care workforce?

STUDY DESIGN AND METHODS

We conducted semistructured interviews of intensivists at clusters of tertiary and community hospitals located in six regions across the United States between August and November 2020 using the "four S" framework of acute surge planning (ie, space, staff, stuff, and system) to organize the interview guide. We then used inductive thematic analysis to identify themes describing the influence of hospitals' emergency responses on intensivists' well-being.

RESULTS

Thirty-three intensivists from seven tertiary and six community hospitals participated. Intensivists reported experiencing substantial moral distress, particularly because of restricted visitor policies and their perceived negative impacts on patients, families, and staff. Intensivists also frequently reported burnout symptoms as a result of their experiences with patient death, exhaustion over the pandemic's duration, and perceived lack of support from colleagues and hospitals. We identified several potentially modifiable factors perceived to improve morale, including the proactive provision of mental health resources, establishment of formal backup schedules for physicians, and clear actions demonstrating that clinicians are valued by their institutions.

INTERPRETATION

Restrictive visitation policies contributed to moral distress as reported by intensivists, highlighting the need to reconsider the risks and benefits of these policies. We also identified several interventions as perceived by intensivists that may help to mitigate moral distress and to improve burnout as part of efforts to preserve the critical care workforce.

The Global Open Source Severity of Illness Score (GOSSIS)

OBJECTIVES

To develop and demonstrate the feasibility of a Global Open Source Severity of Illness Score (GOSSIS)-1 for critical care patients, which generalizes across healthcare systems and countries.

DESIGN

A merger of several critical care multicenter cohorts derived from registry and electronic health record data. Data were split into training (70%) and test (30%) sets, using each set exclusively for development and evaluation, respectively. Missing data were imputed when not available.

SETTING/PATIENTS

Two large multicenter datasets from Australia and New Zealand (Australian and New Zealand Intensive Care Society Adult Patient Database [ANZICS-APD]) and the United States (eICU Collaborative Research Database [eICU-CRD]) representing 249,229 and 131,051 patients, respectively. ANZICS-APD and eICU-CRD contributed data from 162 and 204 hospitals, respectively. The cohort included all ICU admissions discharged in 2014-2015, excluding patients less than 16 years old, admissions less than 6 hours, and those with a previous ICU stay.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

GOSSIS-1 uses data collected during the ICU stay's first 24 hours, including extrema values for vital signs and laboratory results, admission diagnosis, the Glasgow Coma Scale, chronic comorbidities, and admission/demographic variables. The datasets showed significant variation in admission-related variables, case-mix, and average physiologic state. Despite this heterogeneity, test set discrimination of GOSSIS-1 was high (area under the receiver operator characteristic curve [AUROC], 0.918; 95% CI, 0.915-0.921) and calibration was excellent (standardized mortality ratio [SMR], 0.986; 95% CI, 0.966-1.005; Brier score, 0.050). Performance was held within ANZICS-APD (AUROC, 0.925; SMR, 0.982; Brier score, 0.047) and eICU-CRD (AUROC, 0.904; SMR, 0.992; Brier score, 0.055). Compared with GOSSIS-1, Acute Physiology and Chronic Health Evaluation (APACHE)-IIIj (ANZICS-APD) and APACHE-IVa (eICU-CRD), had worse discrimination with AUROCs of 0.904 and 0.869, and poorer calibration with SMRs of 0.594 and 0.770, and Brier scores of 0.059 and 0.063, respectively.

CONCLUSIONS

GOSSIS-1 is a modern, free, open-source inhospital mortality prediction algorithm for critical care patients, achieving excellent discrimination and calibration across three countries.

Critical care practices in the world: Results of the global intensive care unit need assessment survey 2020

BACKGROUND

There is variability in intensive care unit (ICU) resources and staffing worldwide. This may reflect variation in practice and outcomes across all health systems.

AIM

To improve research and quality improvement measures administrative leaders can create long-term strategies by understanding the nature of ICU practices on a global scale.

METHODS

The Global ICU Needs Assessment Research Group was formed on the basis of diversified skill sets. We aimed to survey sites regarding ICU type, availability of staffing, and adherence to critical care protocols. An international survey ‘Global ICU Needs Assessment’ was created using Google Forms, and this was distributed from February 17^th, 2020 till September 23^rd, 2020. The survey was shared with ICU providers in 34 countries. Various approaches to motivating healthcare providers were implemented in securing submissions, including use of emails, phone calls, social media applications, and WhatsApp™. By completing this survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were a total 121 adult/adult-pediatrics ICU responses from 34 countries in 76 cities. A majority of the ICUs were mixed medical-surgical [92 (76%)]. 108 (89%) were adult-only ICUs. Total 36 respondents (29.8%) were 31-40 years of age, with 79 (65%) male and 41 (35%) female participants. 89 were consultants (74%). A total of 71 (59%) respondents reported having a 24-h in-house intensivist. A total of 87 (72%) ICUs were reported to have either a 2:1 or ≥ 2:1 patient/nurse ratio. About 44% of the ICUs were open and 76% were mixed type (medical-surgical). Protocols followed regularly by the ICUs included sepsis care (82%), ventilator-associated pneumonia (79%); nutrition (76%), deep vein thrombosis prophylaxis (84%), stress ulcer prophylaxis (84%), and glycemic control (89%).

CONCLUSION

Based on the findings of this international, multi-dimensional, needs-assessment survey, there is a need for increased recruitment and staffing in critical care facilities, along with improved patient-to-nurse ratios. Future research is warranted in this field with focus on implementing appropriate health standards, protocols and resources for optimal efficiency in critical care worldwide.

Outcomes in Temporary ICUs Versus Conventional ICUs: An Observational Cohort of Mechanically Ventilated Patients With COVID-19–Induced Acute Respiratory Distress Syndrome

Throughout the COVID-19 pandemic, thousands of temporary ICUs have been established worldwide. The outcomes and management of mechanically ventilated patients in these areas remain unknown.

Models of Intermediate Care Organization and Staffing at an Academic Medical Center: Considerations of an Inpatient Planning Committee

Rationale: Geographic co-localization of patients and provider teams (geography) may improve care efficiency and quality. Patients requiring intermediate care present a unique challenge to the geographic model. Objective: Identify the best organizational and staffing model for intermediate care at our academic medical center. Methods: A modified nominal group technique was employed to assess the benefits and limitations of an existing model of intermediate care, identify and review potential alternative models, and choose a new model. Results: In addition to the institution's current model, the benefits and limitations of six alternative organizational and staffing models were characterized. The anticipated impact of each model on nurse: provider communication, maintenance of nursing competencies, nurse satisfaction, efficient utilization of technical and human resources, triage of patients to the unit, care continuity, and the impact on trainee education are described. After considering these features, stakeholders ranked a closed provider staffing model on a unit dedicated to intermediate care highest of the six alternative models. Important outcomes to monitor following transition to a closed staffing model included patient outcomes, nursing job satisfaction and retention, provider and trainee experience, unexpected patient transfers to higher or lower levels of care, and administrative costs. Conclusions: After considering six alternative staffing models for intermediate care, stakeholders ranked a closed provider staffing model highest. Further qualitative and quantitative comparisons to determine optimal models of intermediate care are needed.

Association between hospital and ICU structural factors and patient outcomes in China: a secondary analysis of the National Clinical Improvement System Data in 2019

Background

Hospital and ICU structural factors are key factors affecting the quality of care as well as ICU patient outcomes. However, the data from China are scarce. This study was designed to investigate how differences in patient outcomes are associated with differences in hospital and ICU structure variables in China throughout 2019.

Methods

This was a multicenter observational study. Data from a total of 2820 hospitals were collected using the National Clinical Improvement System Data that reports ICU information in China. Data collection consisted of a) information on the hospital and ICU structural factors, including the hospital type, number of beds, staffing, among others, and b) ICU patient outcomes, including the mortality rate as well as the incidence of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), and catheter-associated urinary tract infections (CAUTIs). Generalized linear mixed models were used to analyse the association between hospital and ICU structural factors and patient outcomes.

Results

The median ICU patient mortality was 8.02% (3.78%, 14.35%), and the incidences of VAP, CRBSI, and CAUTI were 5.58 (1.55, 11.67) per 1000 ventilator days, 0.63 (0, 2.01) per 1000 catheter days, and 1.42 (0.37, 3.40) per 1000 catheter days, respectively. Mortality was significantly lower in public hospitals (β =  − 0.018 (− 0.031, − 0.005), p = 0.006), hospitals with an ICU-to-hospital bed percentage of more than 2% (β =  − 0.027 (− 0.034, -0.019), p < 0.001) and higher in hospitals with a bed-to-nurse ratio of more than 0.5:1 (β = 0.009 (0.001, 0.017), p = 0.027). The incidence of VAP was lower in public hospitals (β =  − 0.036 (− 0.054, − 0.018), p < 0.001). The incidence of CRBSIs was lower in public hospitals (β =  − 0.008 (− 0.014, − 0.002), p = 0.011) and higher in secondary hospitals (β = 0.005 (0.001, 0.009), p = 0.010), while the incidence of CAUTIs was higher in secondary hospitals (β = 0.010 (0.002, 0.018), p = 0.015).

Conclusion

This study highlights the association between specific ICU structural factors and patient outcomes. Modifying structural factors is a potential opportunity that could improve patient outcomes in ICUs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03892-7.

Association of care by a non-medical intensive care unit provider team with outcomes of medically critically ill patients

OBJECTIVE

To determine the association of boarding of critically ill medical patients on non-medical intensive care unit (ICU) provider teams with outcomes.

DESIGN

A retrospective cohort study.

SETTING

ICUs in a tertiary academic medical center.

PATIENTS

Patients with medical critical illness.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We compared outcomes for critically ill medical patients admitted to a non-medical specialty ICU team (April 1 - August 30, 2020) with those admitted to the medical ICU team (January 1, 2018 - March 31, 2020). The primary outcome was hospital mortality; secondary outcomes were hospital length of stay (LOS) and hospital disposition for survivors. Our cohort consisted of 1241 patients admitted to the medical ICU team and 230 admitted to non-medical ICU teams. Unadjusted hospital mortality (medical ICU, 38.8% vs non-medical ICU, 42.2%, p = 0.33) and hospital LOS (7.4 vs 7.4 days, p = 0.96) were similar between teams. Among survivors, more non-medical ICU team patients were discharged home (72.6% vs 82.0%, p = 0.024). After multivariable adjustment, we found no difference in mortality, LOS, or home discharge between teams. However, among hospital survivors, admission to a non-medical ICU team was associated with a longer LOS (regression coefficient [95% CI] for log-transformed hospital LOS: 0.23 [0.05,0.40], p = 0.022). Certain subgroups-patients aged 50-64 years (odds-ratio [95% CI]: 4.22 [1.84,9.65], p = 0.001), with ≤10 comorbidities (0-5: 2.78 (1.11,6.95], p = 0.029; 6-10: 6.61 [1.38,31.71], p = 0.018), without acute respiratory failure (1.97 [1.20,3.23], p = 0.008)-had higher mortality when admitted to non-medical ICU teams.

CONCLUSIONS

We found no association between admission to non-medical ICU team and mortality for medically critically ill patients. However, survivors experienced longer hospital LOS when admitted to non-medical ICU teams. Middle-aged patients, those with low comorbidity burden, and those without respiratory failure had higher mortality when admitted to non-medical ICU teams.

Variation in severity-adjusted resource use and outcome in intensive care units

PURPOSE

Intensive care patients have increased risk of death and their care is expensive. We investigated whether risk-adjusted mortality and resources used to achieve survivors change over time and if their variation is associated with variables related to intensive care unit (ICU) organization and structure.

METHODS

Data of 207,131 patients treated in 2008-2017 in 21 ICUs in Finland, Estonia and Switzerland were extracted from a benchmarking database. Resource use was measured using ICU length of stay, daily Therapeutic Intervention Scoring System Scores (TISS) and purchasing power parity-adjusted direct costs (2015-2017; 17 ICUs). The ratio of observed to severity-adjusted expected resource use (standardized resource use ratio; SRUR) was calculated. The number of expected survivors and the ratio of observed to expected mortality (standardized mortality ratio; SMR) was based on a mortality prediction model covering 2015-2017. Fourteen a priori variables reflecting structure and organization were used as explanatory variables for SRURs in multivariable models.

RESULTS

SMR decreased over time, whereas SRUR remained unchanged, except for decreased TISS-based SRUR. Direct costs of one ICU day, TISS score and ICU admission varied between ICUs 2.5-5-fold. Differences between individual ICUs in both SRUR and SMR were up to > 3-fold, and their evolution was highly variable, without clear association between SRUR and SMR. High patient turnover was consistently associated with low SRUR but not with SMR.

CONCLUSION

The wide and independent variation in both SMR and SRUR suggests that they should be used together to compare the performance of different ICUs or an individual ICU over time.

Survival of mechanically ventilated ward patients and association with organisational factors: a multicentre prospective study

OBJECTIVES

Determine 90-day mortality of mechanically ventilated ward patients outside the intensive care unit (ICU) and its association with organisational factors.

DESIGN

Multicentre prospective observational study of mechanically ventilated ward patients. Modified Poisson regression was used to assess association between nurse to patient ratio (NPR) and 90-day mortality, adjusted for designated medical team, Society of Critical Care Medicine (SCCM) triage priority and centre effect. NPR was divided into low (1:9.6 to 1:10), medium (1:6 to 1:8) and high (1:2.6). Sensitivity analysis was conducted for pneumonia with or without acute respiratory distress syndrome (ARDS) to assess magnitude of association.

SETTING

7 acute public hospitals in Hong Kong.

PARTICIPANTS

All 485 mechanically ventilated patients in wards from participating hospitals between 18 January 2016 and 17 April 2016 were recruited. Three hundred patients were included after excluding patients with limitation of therapy within 24 hours of intubation.

MAIN OUTCOMES

90-day mortality, Mortality Prediction Model III Standardised mortality ratio (MPMIII₀ SMR).

RESULTS

201 patients died within 90 days after intubation (67.0%, 95% CI 61.5% to 72.1%), with MPMIII₀ SMR 1.88, 95% CI 1.63 to 2.17. Compared with high NPR, medium and low NPRs were associated with higher risk of 90-day mortality (adjusted relative risk (RR_adj) 1.84, 95% CI 1.70 to 1.99 and 1.64, 95% CI 1.47 to 1.83, respectively). For 114 patients with pneumonia with or without ARDS, low to medium NPR, too sick to benefit from ICU (SCCM priority 4b), no ICU consultation and designated medical team were associated with risk of 90-day mortality (RR_adj 1.49, 95% CI 1.40 to 1.58; RR_adj 1.60, 95% CI 1.49 to 1.72; RR_adj 1.34, 95% CI 1.27 to 1.40; RR_adj 0.85, 95% CI 0.78 to 0.93, respectively).

CONCLUSION

The 90-day mortality rates of mechanically ventilated ward patients were high. NPR was an independent predictor of survival for mechanically ventilated ward patients.

Gender-specific association of oxidative stress and immune response in septic shock mortality using NMR-based metabolomics

Background: Sepsis and septic shock are still associated with a high mortality rate. The early-stage prediction of septic shock outcomes would be helpful to clinicians for designing their treatment protocol. In addition, it would aid clinicians in patient management by understanding gender disparity in terms of clinical outcomes of septic shock by identifying whether there are sex-based differences in sepsis-associated mortality. Objective: This study aimed to test the hypothesis that gender-based metabolic heterogeneity is associated with sepsis survival and identify the biomarkers of mortality for septic shock in an Indian cohort. Method: The study was performed in an Indian population cohort diagnosed with sepsis/septic shock within 24 hours of admission. The study group was 50 patients admitted to intensive care, comprising 23 females and 27 males. Univariate and multivariate analysis were performed to identify the biomarkers for septic shock mortality and the gender-specific metabolic fingerprint in septic shock-associated mortality. Results: The energy-related metabolites, ketone bodies, choline, and NAG were found to be primarily responsible for differentiating survivors and non-survivors. The gender-based mortality stratification identified a female-specific association of the anti-inflammatory response, innate immune response, and β oxidation, and a male-specific association of the pro-inflammatory response to septic shock. Conclusion: The identified mortality biomarkers may help clinicians estimate the severity of a case, as well as predict the outcome and treatment efficacy. The study underlines that gender is one of the most significant biological factors influencing septic shock metabolomic profiles. This understanding can be utilized to identify novel gender-specific biomarkers and innovative targets relevant for gender medicine.

Automated interpretation and analysis of bronchoalveolar lavage fluid

BACKGROUND

The cytological analysis of bronchoalveolar lavage fluid (BALF) plays an essential role in the differential diagnosis of respiratory diseases. In recent years, deep learning has demonstrated excellent performance in image processing and object recognition.

OBJECTIVES

We aim to apply deep learning to the automated interpretation and analysis of BALF.

METHOD

Visual images were acquired using an automated biological microscopy platform. We propose a three-step algorithm to automatically interpret BALF cytology based on a convolutional neural network (CNN). The clinical value was evaluated at the patient level.

RESULTS

Our model successfully detected most cells in BALF specimens and achieved a sensitivity, precision, and F1 score of over 0.9 for most cell types. In two tests in the clinical context, the algorithm outperformed experienced practitioners.

CONCLUSION

The program can automatically provide the cytological background of BALF and augment clinical decision-making for clinicians.

The Influence of the COVID-19 Pandemic on ICU Organization, Care Processes, and Frontline Clinician Experiences: A Qualitative Study

BACKGROUND

The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally.

RESEARCH QUESTIONS

Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists?

STUDY DESIGN AND METHODS

Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system.

RESULTS

Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians' anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff.

INTERPRETATION

We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

Resource-rich Intensive Care Units vs. Standard Intensive Care Units on Patient Mortality: A Nationwide Inpatient Database Study

Introduction

In this present study, we aimed to assess whether care in resource-rich intensive care unit (ICU) was associated with lower ICU mortality compared with care in standard ICU.

Methods

This retrospective cohort study used administrative data that are routinely collected in Japan. Using the Japanese Diagnosis Procedure Combination inpatient database, we identified patients aged >15 years who were admitted to the ICU from April 2016 to March 2019. We defined resource-rich ICUs as ICUs with two or more intensivists as full-time employees, ≥20 m² per ICU bed, and a medical engineer in the hospital 24 hours per day; other ICUs were categorized as standard ICUs. The primary outcome was ICU mortality. A generalized estimating equation approach with ICUs as the clusters was used to compare ICU mortality between the two groups.

Results

Of the 789,630 eligible patients from 458 ICUs, 237,138 (30%) were treated in the 111 resource-rich ICUs, whereas 552,492 (70%) were treated in the 347 standard ICUs. The crude ICU mortality rate was 3.6% (8443/237,138) among patients admitted to resource-rich ICUs, while it was 4.3% (23,490/552,492) among those admitted to standard ICUs. The results of the generalized estimating equation analysis showed that patients treated in resource-rich ICUs tended to have lower ICU mortality compared to patients treated in standard ICUs (difference, -0.4%; 95% confidence interval, -0.8%-0.0%).

Conclusions

The findings of this nationwide study suggest that, compared with care in standard ICUs, care in resource-rich ICUs is associated with lower ICU mortality. This study showed the overall effect of treatment in hospitals with resource-rich ICUs including intensivist staffing and greater hospital resources. Further studies are required to assess the effects of organizational factors on mortality.

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study

BACKGROUND

We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010-2011.

METHODS

An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs.

RESULTS

On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality.

CONCLUSIONS

Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927).

HOW TO CITE THIS ARTICLE

Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093-1107.

Morbidity, mortality, and emerging drug resistance in Device-associated infections (DAIs) in intensive care patients at a 1000-bedded tertiary care teaching hospital

Background

Device-associated infections (DAIs) such as ventilator associated pneumonia (VAP), central line-associated blood stream infection (CLABSI), and catheter-related urinary tract infection (CAUTI) are principal contributors to health hazard and a major preventable threat to patient safety. Robust surveillance of DAI delineates infections, pathogens, resistograms, and facilitates antimicrobial therapy, infection-control, antimicrobial stewardship, and improvement in quality of care.

Methods

This prospective outcome surveillance study was conducted amongst 2067 ICU patients in a 1000-bedded teaching hospital. Clinical, laboratory, and environmental surveillance, as well as screening of health care professionals (HCPs) were conducted using the modified US Centers for Disease Control and Prevention-National Healthcare Safety Network definitions and methods. Morbidity, mortality, and health-care indices were analyzed and two-tier infection prevention and control was promulgated.

Results

Mean occupancy was 95.34% for 2061 patients of 7381 patients/bed/ICU days. One hundred seventeen episodes of DAI occurred in 1258 patients of 12,882 device-days with mean device utilization ratio of 1.79. Mean rate of DAI was 7.40 per 1000 device days. Multiresistant Pseudomonas aeruginosa was most commonly followed by Acinetobacter. Mean all-cause mortality in ICU was 24.85%, whereas all-cause mortality after DAI was 9.79%. Methicillin-resistant Staphylococcus aureus prevalence was 38.46% amongst health-care professionals.

Conclusion

Mean rates of VAP, CLABSI, and CAUTI were 20.69, 2.53, and 2.23 per 1000 device days comparable with Indian and global ICUs. Resolute conviction and sustained momentum in infection prevention and control is an essential step toward patient safety.

Comparison of the clinical features in open and closed format intensive care units: A systematic review and meta-analysis

IMPORTANCE

The difference in clinical outcomes between closed and open designs of intensive care units (ICUs) is still an open question.

OBJECTIVE

We conducted a systematic review and meta-analysis to compare total mortality, hospital and ICU length of stay (LOS) and mortality as primary outcomes, and severity of illness based on physiological variables, organ failure assessment, age, duration of mechanical ventilation and ventilator-associated pneumonia frequency as secondary outcomes in closed and open ICUs.

EVIDENCE REVIEW

Medline, PubMed, Scopus, Web of Science, Cochrane database, Iran-doc and Elm-net according to the MeSH terms were searched from 1988 to October 2019. The standardised mean difference (SMD), relative risk (RR) with 95% confidence interval (CI) were applied to display summary statistics of primary and secondary outcomes.

FINDINGS

A total of 90 studies with 444,042 participants were analysed. ICU mortality (RR: 1.16, CI: 1.07-1.27, p < 0.001), hospital mortality (RR: 1.12, CI: 1.03-1.22, p = 0.010) and ICU LOS (SMD: 0.43, CI: 0.01-0.85, p = 0.040) were significantly higher in open ICUs. Total mortality (RR: 0.91, CI: 0.77-1.08, p = 0.28) and hospital LOS (SMD: 1.14, CI: 1.31-3.59, p = 0.36) showed no significant difference between the two types of ICU. The secondary outcome measures were also comparable between the two ICU formats (p > 0.05).

CONCLUSIONS AND RELEVANCE

The results demonstrated superiority of closed versus open ICUs in hospital and ICU mortality rates and ICU LOS, with no difference in total mortality, hospital LOS or severity of illness parameters. The superiority of the closed ICU format may be a result of the intensivist-led patient care and should therefore be implemented by clinicians to decrease ICU mortality rates and LOS for critically ill patients.

Underweight but not overweight is associated with excess mortality in septic ICU patients

Background

Higher survival has been shown for overweight septic patients compared with normal or underweight patients in the past. This study aimed at investigating the management and outcome of septic ICU patients in different body mass index (BMI) categories in a large multicenter database.

Methods

In total, 16,612 patients of the eICU collaborative research database were included. Baseline characteristics and data on organ support were documented. Multilevel logistic regression analysis was performed to fit three sequential regression models for the binary primary outcome (ICU mortality) to evaluate the impact of the BMI categories: underweight (<18.5 kg/m²), normal weight (18.5 to < 25 kg/m²), overweight (25 to < 30 kg/m²) and obesity (≥ 30 kg/m²). Data were adjusted for patient level characteristics (model 2) as well as management strategies (model 3).

Results

Management strategies were similar across BMI categories. Underweight patients evidenced higher rates of ICU mortality. This finding persisted after adjusting in model 2 (aOR 1.54, 95% CI 1.15–2.06; p = 0.004) and model 3 (aOR 1.57, 95%CI 1.16–2.12; p = 0.003). No differences were found regarding ICU mortality between normal and overweight patients (aOR 0.93, 95%CI 0.81–1.06; p = 0.29). Obese patients evidenced a lower risk of ICU mortality compared to normal weight, a finding which persisted across all models (model 2: aOR 0.83, 95%CI 0.69–0.99; p = 0.04; model 3: aOR 0.82, 95%CI 0.68–0.98; p = 0.03). The protective effect of obesity and the negative effect of underweight were significant in individuals > 65 years only.

Conclusion

In this cohort, underweight was associated with a worse outcome, whereas obese patients evidenced lower mortality. Our analysis thus supports the thesis of the obesity paradox.

Workforce and Task Sharing of Nurses in the Japanese Intensive Care Unit-Cross-Sectional Postal Survey

This study aimed to estimate the number of nurses who independently care for patients with severe respiratory failure receiving mechanical ventilation (MV) or veno-venous extracorporeal membrane oxygenation (VV-ECMO). Additionally, the study analyzed the actual role of nurses in the treatment of patients with MV and VV-ECMO. We performed a cross-sectional study using postal questionnaire surveys. The study included 725 Japanese intensive care units (ICUs). Data were analyzed using descriptive statistics. Among the 725 ICUs, we obtained 302 responses (41.7%) and analyzed 282 responses. The median number of nurses per bed was 3.25. The median proportion of nurses who independently cared for patients with MV was 60% (IQR: 42.3–77.3). The median proportion of nurses who independently cared for patients with VV-ECMO was 46.9 (35.7–63.3%) in the ICUs that had experience with VV-ECMO use. With regard to task-sharing, 33.8% of ICUs and nurses did not facilitate weaning from MV. Nurses always titrated sedative dosage in 44.5% of ICUs. Nurse staffing might be inadequate in all ICUs, especially for the management of patients with severe respiratory failure. The proportion of competent nurses to care for severe respiratory failure in ICUs should be considered when determining the workforce of nurses.

ICU-Mortality in Old and Very Old Patients Suffering From Sepsis and Septic Shock

Purpose: Old (>64 years) and very old (>79 years) intensive care patients with sepsis have a high mortality. In the very old, the value of critical care has been questioned. We aimed to compare the mortality, rates of organ support, and the length of stay in old vs. very old patients with sepsis and septic shock in intensive care.

Methods: This analysis included 9,385 patients, from the multi-center eICU Collaborative Research Database, with sepsis; 6184 were old (aged 65–79 years), and 3,201 were very old patients (aged 80 years and older). A multi-level logistic regression analysis was used to fit three sequential regression models for the binary primary outcome of ICU mortality. A sensitivity analysis in septic shock patients (n = 1054) was also conducted.

Results: In the very old patients, the median length of stay was shorter (50 ± 67 vs. 56 ± 72 h; p < 0.001), and the rate of a prolonged ICU stay was lower (>168 h; 9 vs. 12%; p < 0.001) than the old patients. The mortality from sepsis was higher in very old patients (13 vs. 11%; p = 0.005), and after multi-variable adjustment being very old was associated with higher odds for ICU mortality (aOR 1.32, 95% CI 1.09–1.59; p = 0.004). In patients with septic shock, mortality was also higher in the very old patients (38 vs. 36%; aOR 1.50, 95% CI 1.10–2.06; p = 0.01).

Conclusion: Very old ICU-patients suffer from a slightly higher ICU mortality compared with old ICU-patients. However, despite the statistically significant differences in mortality, the clinical relevance of such minor differences seems to be negligible.

Outcomes sensitive to critical care nurse staffing levels: A systematic review

OBJECTIVE

To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes.

METHODS

We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented.

RESULTS

Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured.

CONCLUSIONS

A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.

Decision support tool for hospital resource allocation during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic has placed unprecedented demands on entire health systems and driven them to their capacity, so that health care professionals have been confronted with the difficult problem of ensuring appropriate staffing and resources to a high number of critically ill patients. In light of such high-demand circumstances, we describe an open web-accessible simulation-based decision support tool for a better use of finite hospital resources. The aim is to explore risk and reward under differing assumptions with a model that diverges from most existing models which focus on epidemic curves and related demand of ward and intensive care beds in general. While maintaining intuitive use, our tool allows randomized "what-if" scenarios which are key for real-time experimentation and analysis of current decisions' down-stream effects on required but finite resources over self-selected time horizons. While the implementation is for COVID-19, the approach generalizes to other diseases and high-demand circumstances.

Survival and predictors of mortality among patients admitted to the intensive care units in southern Ethiopia: A multi-center cohort study

BACKGROUND

The burden of life-threatening conditions requiring intensive care units has grown substantially in low-income countries related to an emerging pandemic, urbanization, and hospital expansion. The rate of ICU mortality varied from region to region in Ethiopia. However, the body of evidence on ICU mortality and its predictors is uncertain. This study was designed to investigate the pattern of disease and predictors of mortality in Southern Ethiopia.

METHODS

After obtaining ethical clearance from the Institutional Review Board (IRB), a multi-center cohort study was conducted among three teaching referral hospital ICUs in Ethiopia from June 2018 to May 2020. Five hundred and seventeen Adult ICU patients were selected. Data were entered in Statistical Package for Social Sciences version 22 and STATA version 16 for analysis. Descriptive statistics were run to see the overall distribution of the variables. Chi-square test and odds ratio were determined to identify the association between independent and dependent variables. Multivariate analysis was conducted to control possible confounders and identify independent predictors of ICU mortality.

RESULTS

The mean (±SD) of the patients admitted in ICU was 34.25(±5.25). The overall ICU mortality rate was 46.8%. The study identified different independent predictors of mortality. Patients with cardiac arrest were approximately 12 times more likely to die as compared to those who didn't, AOR = 11.9(95% CI:6.1 to 23.2).

CONCLUSION

The overall mortality rate in ICU was very high as compared to other studies in Ethiopia as well as globally which entails a rigorous activity from different stakeholders.

Impact of Religiosity on Delirium Severity Among Critically Ill Shi'a Muslims: A Prospective Multi-Center Observational Study

This study assesses the impact of religiosity on delirium severity and patient outcomes among Shi'a Muslim intensive care unit (ICU) patients. We conducted a prospective observational cohort study in 21 ICUs from 6 Iranian academic medical centers. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU) tool. Eligible patients were intubated, receiving mechanical ventilation (MV) for ≥ 48 h. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. A total of 4200 patients were enrolled. Patient religiosity was categorized as more (40.6%), moderate (42.3%), or less (17.1%) based on responses to patient and surrogate questionnaires. The findings suggest that lower pre-illness religiosity may be associated with greater delirium severity, MV duration, and ICU and hospital LOS. The lower mortality in the less religiosity group may be related in part to a greater proportion of female patients, but it remains unclear whether and to what extent greater religiosity impacted treatment decisions by patients and families. Further investigation is needed to validate and clarify the mechanism of the mortality findings.

Pediatric Emergency and Critical Care Resources and Infrastructure in Resource-Limited Settings: A Multicountry Survey

OBJECTIVES

To describe the infrastructure and resources for pediatric emergency and critical care delivery in resource-limited settings worldwide.

DESIGN

Cross-sectional survey with survey items developed through literature review and revised following piloting.

SETTING

The electronic survey was disseminated internationally in November 2019 via e-mail directories of pediatric intensive care societies and networks and using social media.

PATIENTS

Healthcare providers who self-identified as working in resource-limited settings.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Results were summarized using descriptive statistics and resource availability was compared across World Bank country income groups. We received 328 responses (238 hospitals, 60 countries), predominantly in Latin America and Sub-Saharan Africa (n = 161, 67.4%). Hospitals were in low-income (28, 11.7%), middle-income (166, 69.5%), and high-income (44, 18.4%) countries. Across 174 PICU and adult ICU admitting children, there were statistically significant differences in the proportion of hospitals reporting consistent resource availability ("often" or "always") between country income groups (p < 0·05). Resources with limited availability in lower income countries included advanced ventilatory support, invasive and noninvasive monitoring, central venous access, renal replacement therapy, advanced imaging, microbiology, biochemistry, blood products, antibiotics, parenteral nutrition, and analgesic/sedative drugs. Seventy-seven ICUs (52.7%) were staffed 24/7 by a pediatric intensivist or anesthetist. The nurse-to-patient ratio was less than 1:2 in 71 ICUs (49.7%).

CONCLUSIONS

Contemporary data demonstrate significant disparity in the availability of essential and advanced human and material resources for the care of critically ill children in resource-limited settings. Minimum standards for essential pediatric emergency and critical care in resource-limited settings are needed.

Impact of Intensivist and Nursing Staff on Critically Ill Patient Mortality: A Retrospective Analysis of the Korean NHIS Cohort Data, 2011-2015

PURPOSE

Critical care medicine continues to evolve. However, critical care cases require increasing amount of medical resources. Intensive care unit (ICU) mortality significantly impacts the overall efficiency of healthcare resources within a system of limited medical resources. This study investigated the factors related to ICU mortality using long-term nationwide cohort data in South Korea.

MATERIALS AND METHODS

This retrospective cohort study used data of 14905721 patients who submitted reimbursement claims to the Korean Health Insurance Service between January 1, 2011 and December 31, 2015. A total of 1498102 patients who were admitted to all ICU types, except neonatal and long-term acute care hospitals, were enrolled.

RESULTS

Of the total 1498102 participants, 861397 (57.5%) were male and 636705 (42.5%) were female. The mean age at admission was 63.4±18.2 years; most of the subjects were aged over 60 years. During the 5-year period, in-hospital mortality rate was 12.9%. In Cox analysis, both in-hospital and 28-day mortality rates were significantly higher in male patients and those of lower socioeconomic status. As age increased and the number of nursing staff decreased, the mortality risk increased significantly by two or three times. The mortality risk was lower in patients admitted to an ICU of a tertiary university hospital and an ICU where intensivists worked.

CONCLUSION

The number of nursing staff and the presence of an intensivist in ICU were associated with the ICU mortality rate. Also, increasing the number of nursing staff and the presence of intensivist might reduce the mortality rate among ICU patients.

Sex-specific outcomes and management in critically ill septic patients

BACKGROUND

Female and male critically ill septic patients might differ with regards to risk distribution, management, and outcomes. We aimed to compare male versus female septic patients in a large collective with regards to baseline risk distribution and outcomes.

METHODS

In total, 17,146 patients were included in this analysis, 8781 (51%) male and 8365 (49%) female patients. The primary endpoint was ICU-mortality. Baseline characteristics and data on organ support were documented. Multilevel logistic regression analyses were used to assess sex-specific differences.

RESULTS

Female patients had lower SOFA scores (5 ± 5 vs. 6 ± 6; p<0.001) and creatinine (1.20±1.35 vs. 1.40±1.54; p<0.001). In the total cohort, the ICU mortality was 10% and similar between female and male (10% vs. 10%; p = 0.34) patients. The ICU remained similar between sexes after adjustment in model-1 (aOR 1.05 95% CI 0.95-1.16; p = 0.34); model-2 (aOR 0.91 95% CI 0.79-1.05; p = 0.18) and model-3 (aOR 0.93 95% CI 0.80-1.07; p = 0.29). In sensitivity analyses, no major sex-specific differences in mortality could be detected.

CONCLUSION

In this study no clinically relevant sex-specific mortality differences could be detected in critically ill septic patients. Possible subtle gender differences could play a minor role in the acute situation due to the severity of the disease in septic patients.

Number of intensivists per bed is associated with efficiency of Dutch intensive care units

PURPOSE

To measure efficiency in Intensive Care Units (ICUs) and to determine which organizational factors are associated with ICU efficiency, taking confounding factors into account.

MATERIALS AND METHODS

We used data of all consecutive admissions to Dutch ICUs between January 1, 2016 and January 1, 2019 and recorded ICU organizational factors. We calculated efficiency for each ICU by averaging the Standardized Mortality Ratio (SMR) and Standardized Resource Use (SRU) and examined the relationship between various organizational factors and ICU efficiency. We thereby compared the results of linear regression models before and after covariate adjustment using propensity scores.

RESULTS

We included 164,399 admissions from 83 ICUs. ICU efficiency ranged from 0.51-1.42 (average 0.99, 0.15 SD). The unadjusted model as well as the propensity score adjusted model showed a significant association between the ratio of employed intensivists per ICU bed and ICU efficiency. Other organizational factors had no statistically significant association with ICU efficiency after adjustment.

CONCLUSIONS

We found marked variability in efficiency in Dutch ICUs. After applying covariate adjustment using propensity scores, we identified one organizational factor, ratio intensivists per bed, having an association with ICU efficiency.