Intensive care utilisation after elective surgery in Australia and New Zealand: A point prevalence study

Objective

We aimed to describe the characteristics, outcomes and resource utilisation of patients being cared for in an ICU after undergoing elective surgery in Australia and New Zealand (ANZ).

Methods

This was a point prevalence study involving 51 adult ICUs in ANZ in June 2021. Patients met inclusion criteria if they were being treated in a participating ICU on he study dates. Patients were categorised according to whether they had undergone elective surgery, admitted directly from theatre or unplanned from the ward. Descriptive and comparative analysis was performed according to the source of ICU admission. Resource utilisation was measured by Length of stay, organ support and occupied bed days.

Results

712 patients met inclusion criteria, with 172 (24%) have undergone elective surgery. Of these, 136 (19%) were admitted directly to the ICU and 36 (5.1%) were an unplanned admission from the ward. Elective surgical patients occupied 15.8% of the total ICU patient bed days, of which 44.3% were following unplanned admissions. Elective surgical patients who were an unplanned admission from the ward, compared to those admitted directly from theatre, had a higher severity of illness (AP2 17 vs 13, p<0.01), require respiratory or vasopressor support (75% vs 44%, p<0.01) and hospital mortality (16.7% vs 2.2%, p < 0.01).

Conclusions

ICU resource utilisation of patients who have undergone elective surgery is substantial. Those patients admitted directly from theatre have good outcomes and low resource utilisation. Patient admitted unplanned from the ward, although fewer, were sicker, more resource intensive and had significantly worse outcomes.

[DIVI-Recommendations on the infrastruture of adult intensive care units]

This document on the Structure and Equipment for Intensive Care Units of the German Association for Intensive and Emergency Care (DIVI) aims at providing guidance and recommendations for the requirements of (infra)structure, personal, and organization of intensive care units. The recommendations are based on a systematic literature search and a formal consensus process from a group of multi-disciplinary and multiprofessional specialists from the DIVI. The recommendations comprise a 3-staged level of intensive care units, a 3-staged level of care with respect to severity of illness, the staffing requirement of physicians, nurses, physiotherapists, pharmacists, psychologists, and other specialists. Furthermore, proposals concerning the equipment and the construction of ICUs are supplied.

Acceptance and validity of the methods used to implement a competency based medical education programme in an Intensive Care Department of a teaching referral center

OBJECTIVES

1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE. 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes.

DESIGN

Prospective cohort study.

PARTICIPANTS

All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia.

INTERVENTION

CoBaTrICE implementation started in March 2016, it was based on: (1) Training the tutors in feedback techniques; (2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and (3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place.

METHODS

The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient.

RESULTS

The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity.

CONCLUSIONS

The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity.

Research productivity during residency training in Spain: Comparison among medical specialties lasting 5 years

OBJECTIVES

To compare the quantity and quality of publications during the residency training period in Cardiology, Intensive Care Medicine, Internal Medicine and Medical Oncology in Spain.

METHODS

A retrospective cohort study of residents from 4 specialties lasting 5 years (2014-2019). The number and type of publications indexed in PubMed®, the names of the journals and their bibliometric indexes (impact factor and quartiles), and author's positions were evaluated.

RESULTS

The 649 residents included in the study generated 801 publications (publication/resident ratio 1.23). Cardiology residents published significantly more (ratio 2.57) and Intensive Care Medicine residents less (ratio 0.42) than the remaining specialties (Internal Medicine, ratio 1.06; Medical Oncology, ratio 0.76; p < .001). Overall, only 44.5% of residents participated in a publication, with 27.6% participating in an original article; this latter percentage increased significantly among cardiologists (47.7%; p < .001). The predominant types of publications were original articles (47.9%) and clinical reports (36.8%). The proportion of publications in first quartile journals was higher for Cardiology residents (44.6% of total). The resident was the first or last author in only one-third of the publications. Scientific productivity was related to specialty, but not to gender or the size of the hospital in which the residency training occurred.

CONCLUSIONS

Intensive Care Medicine, Internal Medicine and Medical Oncology residents publish insufficiently, while the scientific production from Cardiology residents could be considered acceptable.

[Occupational safety in the treatment of COVID-19 patients : Relevant laws and regulations for the treating personnel]

Die intensivmedizinische Versorgung von COVID-19-Patienten stellt das eingesetzte Personal vor – bisher unbekannte – Herausforderungen. So kommen beispielsweise nun großflächig Schutzausrüstungen zum Einsatz, die ansonsten nur in ausgewählten Situationen verwendet wurden. Die Arbeit in einem solchen Umfeld ist unter dem Aspekt des Arbeitsschutzes anders zu bewerten als die sonstige Patientenversorgung. Auch in einer Pandemie bleiben die gesetzlichen Vorgaben gültig. Ziel dieser Arbeit ist es, einen Überblick über die aktuell relevanten Vorschriften und Regelungen darzulegen.

SEMICYUC Strategic Plan 2018-2022

The role of Critical Care Medicine in Spain requires continuous revision and reflection. We have values and strengths that are evidenced in our daily work and by their important effects in routine hospital activity. Other medical specialties seeking to assume activities referred to critical patient care, as well as a number of other circumstances, may have a negative impact upon our routine duties. This article reflects the impressions of an important number of members of the Planning, Organization and Management Task Force of the Spanish Society of Critical Medicine Society (Grupo de Trabajo de Planificación, Organización y Gestión; GTPOG-SEMICYUC). The actions required to upgrade our Critical Care Medicine model are presented, evolving towards a broader view such as the 'ICU without walls' or 'Expanded ICU'. The subject is addressed from three complementary standpoints: actions involving the administrative authorities; actions required on the part of our scientific Society; and initiatives to be implemented locally in each Intensive Care Unit (led by the corresponding Unit representatives) at both hospital level and involving the regional authorities.

Ultrasonographic diaphragmatic excursion is inaccurate and not better than the MRC score for predicting weaning-failure in mechanically ventilated patients. Anaesth Crit Care Pain Med. 2017;36:9-14. [PMID: 27647376 DOI: 10.1016/j.accpm.2016.05.009]

PURPOSE

To assess the ability of diaphragmatic ultrasound (US) to predict weaning failure in mechanically ventilated patients undergoing a first spontaneous breathing trial (SBT).

METHODS

During a 4-month period, 67 consecutive patients eligible for a first SBT underwent US measurements of maximal diaphragmatic excursion (MDE) by a right anterior subcostal approach. Weaning failure was defined as either the failure of SBT or the need for resumption of ventilatory support for acute respiratory failure or death within 48h following successful extubation. The accuracy of diaphragmatic ultrasound and the Medical Research Council (MRC) score when predicting weaning failure was assessed via a receiver operating curve analysis.

RESULTS

The feasibility rate for the ultrasound measurements was 63%. Mean values of MDE were significantly higher in patients who succeeded at their first weaning attempt (4.1±2.1 versus 3±1.8cm, P=0.04). Using a threshold of MDE≤2.7cm, the sensitivity and specificity of diaphragmatic ultrasound in predicting weaning failure were 59% [39-77%] and 71% [57-82%] with an AUC at 0.65 [0.51-0.78]. There was no significant difference between MDE values and MRC scores for predicting weaning failure (P=0.73).

CONCLUSION

A decrease in MDE values may be associated with an unfavourable weaning outcome. Diaphragmatic excursion measured by ultrasound is however unable by itself to predict weaning failure at the bedside of patients undergoing a first spontaneous breathing trial and does not provide any additional value compared to the MRC score.

Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine

OBJECTIVE

To explore contributing factors (CF) associated to related critical patients safety incidents.

DESIGN

SYREC study pos hoc analysis.

SETTING

A total of 79 Intensive Care Departments were involved.

PATIENTS

The study sample consisted of 1.017 patients; 591 were affected by one or more incidents.

MAIN VARIABLES

The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed.

RESULTS

A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable.

CONCLUSIONS

The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss.

Intensive care unit without walls: seeking patient safety by improving the efficiency of the system

The term "ICU without walls" refers to innovative management in Intensive Care, based on two key elements: (1) collaboration of all medical and nursing staff involved in patient care during hospitalization and (2) technological support for severity early detection protocols by identifying patients at risk of deterioration throughout the hospital, based on the assessment of vital signs and/or laboratory test values, with the clear aim of improving critical patient safety in the hospitalization process. At present, it can be affirmed that there is important work to be done in the detection of severity and early intervention in patients at risk of organ dysfunction. Such work must be adapted to the circumstances of each center and should include training in the detection of severity, multidisciplinary work in the complete patient clinical process, and the use of technological systems allowing intervention on the basis of monitored laboratory and physiological parameters, with effective and efficient use of the information generated. Not only must information be generated, but also efficient management of such information must also be achieved. It is necessary to improve our activity through innovation in management procedures that facilitate the work of the intensivist, in collaboration with other specialists, throughout the hospital environment. Innovation is furthermore required in the efficient management of the information generated in hospitals, through intelligent and directed usage of the new available technology.

A challenge within reach

The medical training model is currently immersed in a process of change. The new paradigm is intended to be more effective, more integrated within the healthcare system, and strongly oriented towards the direct application of knowledge to clinical practice. Compared with the established training system based on certification of the completion of a series or rotations and stays in certain healthcare units, the new model proposes a more structured training process based on the gradual acquisition of specific competences, in which residents must play an active role in designing their own training program. Training based on competences guarantees more transparent, updated and homogeneous learning of objective quality, and which can be homologated internationally. The tutors play a key role as the main directors of the process, and institutional commitment to their work is crucial. In this context, tutors should receive time and specific formation to allow the evaluation of training as the cornerstone of the new model. New forms of objective summative and training evaluation should be introduced to guarantee that the predefined competences and skills are effectively acquired. The free movement of specialists within Europe is very desirable and implies that training quality must be high and amenable to homologation among the different countries. The Competency Based training in Intensive Care Medicine in Europe program is our main reference for achieving this goal. Scientific societies in turn must impulse and facilitate all those initiatives destined to improve healthcare quality and therefore specialist training. They have the mission of designing strategies and processes that favor training, accreditation and advisory activities with the government authorities.