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Abstract
OBJECTIVE To complete an objective analysis of the activities that occur during the course of daily rounds in a high acuity academic tertiary care pediatric intensive care unit (PICU). DESIGN Prospective observational work sampling design. SETTING Tertiary care academic Children's Hospital Pediatric Intensive Care Unit. SUBJECTS Multidisciplinary PICU teams. INTERVENTIONS None. METHODS Intensive care unit rounds were observed as part of an initiative to improve efficiency over a 2-month period. The number of observations required was determined by Neibel's work sampling method. Rounds were broken into various constituent events and then later classified as "value-added/essential," "value-added/nonessential," and "nonessential" based on whether the observed event was essential to the core mission of PICU rounds. RESULTS The mean time spent per patient for all observed teams was 17.9 min (SD 1.3 min). Teams spent 64% of their time doing value-added/essential tasks (11.2 min, SD 2.2 min) and 13% of their time doing value-added/nonessential tasks (2.4 min, SD 0.9 min). Teams spent 23% of their time on non-value-added activities (4.1 min, SD 2.3 min). The top three non-value-added activities conducted during rounds were travel, waiting, and interruptions regarding care of other patients. Given the consistency of time spent on value-added activities among attendings, these non-value-added activities might explain the significant variability observed among attendings in total time spent rounding. CONCLUSIONS This was an observational study to characterize the activities that occur during the course of a routine PICU work rounds. Although there was significant consistency in the time spent per patient in value-added activities, there was significant disparity in time spent on nonessential activities, such as travel and waiting. A dedicated attempt to reduce time spent on nonessential activities can substantially reduce rounding times and improve the efficiency and value of rounds.
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Evans S, Darvall J, Gorelik A, Bellomo R. Influence of ward round order on critically ill patient outcomes. J Crit Care 2018; 45:110-113. [PMID: 29428606 DOI: 10.1016/j.jcrc.2018.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/01/2018] [Accepted: 02/02/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To examine the effect of order in which patients are seen on an Intensive Care Unit (ICU) ward round on ICU length of stay (LOS), mortality and duration of mechanical ventilation. MATERIALS AND METHODS Retrospective observational study in a tertiary metropolitan ICU over a 12month period. All patients who occupied the first and last three bed spaces of the ICU ward round, without having moved bed spaces during admission, were included. Separate analyses were performed for the absolute first and last patients. RESULTS 681 patients were included. There was no difference in the primary outcome, ICU LOS [median (IQR) 50 (23-102) hours for the first three patients seen vs. 51 (25-110) hours for the last three patients, p=0.594]. No differences were found in any secondary outcomes (hospital LOS, ICU mortality or duration of mechanical ventilation). CONCLUSIONS The order in which patients were seen on an ICU ward did not affect ICU LOS nor related outcomes.
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Affiliation(s)
- Steve Evans
- Intensive Care Unit, Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, Australia.
| | - Jai Darvall
- Intensive Care Unit, Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, Australia; Melbourne Medical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia.
| | - Alexandra Gorelik
- Melbourne EpiCentre, Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Grattan St, Parkville, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Abstract
OBJECTIVES To evaluate for any association between time of admission to the PICU and mortality. DESIGN Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014. SETTING One hundred and twenty-nine PICUs in the United States. PATIENTS Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons. CONCLUSIONS Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.
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Azevedo LCP, de Souza IA, Zygun DA, Stelfox HT, Bagshaw SM. Association Between Nighttime Discharge from the Intensive Care Unit and Hospital Mortality: A Multi-Center Retrospective Cohort Study. BMC Health Serv Res 2015; 15:378. [PMID: 26369933 PMCID: PMC4570509 DOI: 10.1186/s12913-015-1044-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 09/06/2015] [Indexed: 11/23/2022] Open
Abstract
Background We aimed to determine the impact of nighttime discharge from the intensive care unit (ICU) to the ward on hospital mortality and readmission rates in consecutive critically ill patients admitted to five Canadian ICUs. We hypothesized that hospital mortality and readmission rates would be higher for patients discharged after hours compared with discharge during the day. Methods A multi-center retrospective cohort study was carried out at five hospitals in Edmonton, Canada, between July 2002 and December 2009. Nighttime discharge was defined as discharge from the ICU occurring between 07:00 pm and 07:59 am. Logistic regression analysis was used to explore the associations between nighttime discharge and outcomes. Results Of 19,622 patients discharged alive from the ICU, 3,505 (17.9 %) discharges occurred during nighttime. Nighttime discharge occurred more commonly among medical than surgical patients (19.9 % vs. 13.8 %, P < 0.001) and among those with more comorbid conditions, compared with daytime discharged patients. Crude hospital mortality (11.8 % versus 8.8 %, P < 0.001) was greater for nighttime discharged as compared to daytime discharged patients. In a multivariable analysis, after adjustment for comorbidities, diagnosis and source of admission, nighttime discharge remains associated with higher mortality (odds ratio [OR] 1.29; 95 % CI, 1.14 to 1.46, P < 0.001). This finding was robust in two sensitivity analyses examining discharges occurring between 00:00 am and 04:59 am (OR 1.28; 1.12–1.47; P < 0.001) and for those who died within 48 h of ICU discharge without readmission (OR 1.24; 1.07–1.42, P = 0.002). There was no difference in ICU readmission for nighttime compared with daytime discharges (7.4 % vs. 6.9 %, p = 0.26). However, rates were higher for nighttime discharges in community compared with tertiary hospitals (7.7 % vs. 5.7 %, P = 0.023). Conclusions In a large integrated health region, 1 in 5 ICU patients are discharged at nighttime, a factor with increasing occurrence during our study and shown to be independently associated with higher hospital mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1044-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luciano C P Azevedo
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada. .,Department of Critical Care Medicine, Alberta Health Services, Edmonton Zone, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada. .,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil. .,Emergency Medicine Department ICU, University of São Paulo, São Paulo, Brazil.
| | - Ivens A de Souza
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada. .,Department of Critical Care Medicine, Alberta Health Services, Edmonton Zone, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada. .,Research and Education Institute, Hospital Sírio-Libanês, São Paulo, Brazil.
| | - David A Zygun
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada. .,Department of Critical Care Medicine, Alberta Health Services, Edmonton Zone, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada.
| | - Henry T Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, Institute for Public Health, University of Calgary, Calgary, Canada.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada. .,Department of Critical Care Medicine, Alberta Health Services, Edmonton Zone, 2-124E Clinical Sciences Building, 8440-122 Street, Edmonton, AB, T6G 2B7, Canada.
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Abella A, Hermosa C, Enciso V, Torrejón I, Molina R, Díaz M, Mozo T, Gordo F, Salinas I. Effect of the timing of admission upon patient prognosis in the Intensive Care Unit: On-hours versus off-hours. Med Intensiva 2015; 40:26-32. [PMID: 25682488 DOI: 10.1016/j.medin.2014.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/24/2014] [Accepted: 11/24/2014] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the repercussion of the timing of admission to the ICU upon patient prognosis. DESIGN A prospective, observational, non-interventional cohort study was carried out. SCOPE A second level hospital with 210 operational beds and a general ICU with 8 operational beds. PATIENTS OR PARTICIPANTS The study comprised all patients admitted to the ICU during 3 years (January 2010 to December 2012), excluding those subjects admitted from the operating room after scheduled surgery. The patients were divided into 2 groups according to the timing of admission (on-hours or off-hours). INTERVENTIONS Non-interventional study. VARIABLES OF INTEREST An analysis was made of demographic variables (age, sex), origin (emergency room, hospital ward, operating room), comorbidities and SAPS 3 as severity score upon admission, length of stay in the ICU and hospital ward, and ICU and hospital mortality. RESULTS A total of 504 patients were included in the on-hours group, versus 602 in the off-hours group. Multivariate analysis showed the factors independently associated to hospital mortality to be SAPS 3 (OR 1.10; 95% CI 1.08-1.12), and off-hours admission (OR 2.00; 95% CI 1.20-3.33). In a subgroup analysis of the off-hours group, the admission of patients on weekends or non-working days compared to daily night shifts was found to be independently associated to hospital mortality (OR 2.30; 95% CI 1.23-4.30). CONCLUSIONS Admission to the ICU in off-hours is independently associated to patient mortality, which is also higher in patients admitted on weekends and non-working days compared to the daily night shifts.
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Affiliation(s)
- A Abella
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - C Hermosa
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - V Enciso
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - I Torrejón
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - R Molina
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - M Díaz
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - T Mozo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - F Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España.
| | - I Salinas
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
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McCrory MC, Gower EW, Simpson SL, Nakagawa TA, Mou SS, Morris PE. Off-hours admission to pediatric intensive care and mortality. Pediatrics 2014; 134:e1345-53. [PMID: 25287463 PMCID: PMC9923532 DOI: 10.1542/peds.2014-1071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Critically ill patients are admitted to the pediatric ICU at all times, while staffing and other factors may vary by day of the week or time of day. The purpose of this study was to evaluate whether admission during off-hours is independently associated with mortality in PICUs. METHODS A retrospective cohort study of admissions of patients <18 years of age to PICUs was performed using the Virtual PICU Systems (VPS, LLC) database. "Off-hours" was defined as nighttime (7:00 pm to 6:59 am) or weekend (Saturday or Sunday any time). Mixed-effects multivariable regression was performed by using Pediatric Index of Mortality 2 (PIM2) to adjust for severity of illness. Primary outcome was death in the pediatric ICU. RESULTS Data from 234,192 admissions to 99 PICUs from January 2009 to September 2012 were included. When compared with regular weekday admissions, off-hours admissions were less likely to be elective, had a higher risk for mortality by PIM2, and had a higher observed ICU mortality (off-hours 2.7% vs weekdays 2.2%; P < .001). Multivariable regression revealed that, after adjustment for other significant factors, off-hours admission was associated with lower odds of mortality (odds ratio, 0.91; 95% confidence interval, 0.85-0.97; P = .004). Post hoc multivariable analysis revealed that admission during the morning period 6:00 am to 10:59 am was independently associated with death (odds ratio, 1.27; 95% confidence interval, 1.16-1.39; P < .0001). CONCLUSIONS Off-hours admission does not independently increase odds of death in the PICU. Admission from 6:00 am to 10:59 am is associated with increased risk for death and warrants further investigation in the PICU population.
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Affiliation(s)
- Michael C. McCrory
- Departments of Anesthesiology, Section on Pediatric Critical Care Medicine, ,Address correspondence to Michael C. McCrory, MD, MS, Department of Anesthesiology, Section on Pediatric Critical Care Medicine, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1009. E-mail:
| | | | - Sean L. Simpson
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas A. Nakagawa
- Departments of Anesthesiology, Section on Pediatric Critical Care Medicine
| | - Steven S. Mou
- Departments of Anesthesiology, Section on Pediatric Critical Care Medicine
| | - Peter E. Morris
- Internal Medicine, Section on Pulmonary and Critical Care Medicine, and
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Kopolovic I, Simmonds K, Duggan S, Ewanchuk M, Stollery DE, Bagshaw SM. Risk factors and outcomes associated with acute kidney injury following ruptured abdominal aortic aneurysm. BMC Nephrol 2013; 14:99. [PMID: 23634748 PMCID: PMC3651711 DOI: 10.1186/1471-2369-14-99] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 04/30/2013] [Indexed: 11/16/2022] Open
Abstract
Background Current data describing the epidemiology of acute kidney injury (AKI) following repair of ruptured abdominal aortic aneurysm (rAAA) are limited and long-term outcomes are largely unknown. Our objectives were to describe the incidence rate, risk factors, clinical course and long-term outcomes of AKI following rAAA repair. Methods Retrospective population-based cohort study of all referrals undergoing emergency repair of rAAA in Northern Alberta from January 1, 2002 to December 31 2009. Demographic, clinical, physiologic and laboratory data were extracted. AKI was defined and classified according to the AKIN criteria. Results In total, 140 patients survived to receive emergent rAAA repair. Post-operative AKI occurred in 75.7% of patients (n = 106), 78.3% (n = 83) of which occurred during the initial 24 hours of ICU admission. AKIN stage 1, 2, and 3 occurred in 47 (33.6%), 36 (25.7%) and 23 (16.4%), respectively, with 19 patients receiving renal replacement therapy (RRT). Several clinical and biochemical patient factors were associated with incident AKI, including baseline estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 (odds ratio [OR] 2.94; 95% CI, 1.15-7.51, p = 0.03), need for mechanical ventilation (OR 22.7; 95% CI, 7.0-72.1, p < 0.0001) and vasoactive therapy (OR 9.9; 95% CI, 3.0-32.2, p < 0.0001) and higher mean APACHE II scores (25.7 [8.2] vs. 16.3 [4.9], p < 0.0001). AKI was associated with a higher ICU (28.3% vs. 0%; p = 0.0008) and in-hospital case-fatality rate (35.9% vs. 0%, p = 0.0001). Of 102 survivors to discharge, 65.7% (n = 67) recovered to baseline kidney function. In multivariable analysis, greater severity of AKI (OR 5.01; 95% CI, 2.34-10.7, p < 0.001) and lower baseline eGFR (OR 0.96; 95% CI, 0.93-0.99, p = 0.03) were associated with non-recovery. AKI remained independently associated with 1-year mortality after adjusting for age, sex, comorbidity, and illness severity (OR 5.21; 95% CI, 1.04-26.2, p = 0.045; AUC 0.83; H-L GoF, p = 0.26). Among survivors at 1-year, only 63.4% (n = 55) had complete kidney recovery. Conclusions Following rAAA repair, AKI is a common complication independently associated with long-term post-operative mortality. A significant proportion of AKI sufferers in this setting fail to recover to baseline kidney function.
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Affiliation(s)
- Ilana Kopolovic
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter Mackenzie Centre, 8440-112 Street, Edmonton, Alberta T6G 2B7, Canada
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Ligtenberg JJM, Bens BW, ter Maaten JC. One more idea on preventable ICU deaths ... CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:438. [PMID: 22776182 PMCID: PMC3580682 DOI: 10.1186/cc11371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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