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Yuan Q, Yao HJ, Xi CH, Yu C, Du ZY, Chen L, Wu BW, Yang L, Wu G, Hu J. Perioperative risk factors associated with unplanned neurological intensive care unit readmission following elective supratentorial brain tumor resection. J Neurosurg 2023; 139:315-323. [PMID: 36461816 DOI: 10.3171/2022.10.jns221318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/26/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to describe the clinical and procedural risk factors associated with the unplanned neurosurgical intensive care unit (NICU) readmission of patients after elective supratentorial brain tumor resection and serves as an exploratory analysis toward the development of a risk stratification tool that may be prospectively applied to this patient population. METHODS This was a retrospective observational cohort study. The electronic medical records of patients admitted to an institutional NICU between September 2018 and November 2021 after elective supratentorial brain tumor resection were reviewed. Demographic and perioperative clinical factors were recorded. A prognostic model was derived from the data of 4892 patients recruited between September 2018 and May 2021 (development cohort). A nomogram was created to display these predictor variables and their corresponding points and risks of readmission. External validation was evaluated using a series of 1118 patients recruited between June 2021 and November 2021 (validation cohort). Finally, a decision curve analysis was performed to determine the clinical usefulness of the prognostic model. RESULTS Of the 4892 patients in the development cohort, 220 (4.5%) had an unplanned NICU readmission. Older age, lesion type, Karnofsky Performance Status (KPS) < 70 at admission, longer duration of surgery, retention of endotracheal intubation on NICU entry, and longer NICU length of stay (LOS) after surgery were independently associated with an unplanned NICU readmission. A total of 1118 patients recruited between June 2021 and November 2021 were included for external validation, and the model's discrimination remained acceptable (C-statistic = 0.744, 95% CI 0.675-0.814). The decision curve analysis for the prognostic model in the development and validation cohorts showed that at a threshold probability between 0.05 and 0.8, the prognostic model showed a positive net benefit. CONCLUSIONS A predictive model that included age, lesion type, KPS < 70 at admission, duration of surgery, retention of endotracheal intubation on NICU entry, and NICU LOS after surgery had an acceptable ability to identify elective supratentorial brain tumor resection patients at high risk for an unplanned NICU readmission. These risk factors and this prediction model may facilitate better resource allocation in the NICU and improve patient outcomes.
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Affiliation(s)
- Qiang Yuan
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai
- 4Neurosurgical Institute of Fudan University, Shanghai
- 5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Hai-Jun Yao
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Cai-Hua Xi
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chun Yu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhuo-Ying Du
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai
- 4Neurosurgical Institute of Fudan University, Shanghai
- 5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
| | - Long Chen
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Bi-Wu Wu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Yang
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Gang Wu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai
- 4Neurosurgical Institute of Fudan University, Shanghai
- 5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin Hu
- 1Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai
- 2National Center for Neurological Disorders, Shanghai
- 3Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai
- 4Neurosurgical Institute of Fudan University, Shanghai
- 5Shanghai Clinical Medical Center of Neurosurgery, Shanghai; and
- 6Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Vegh LA, Blunt AM, Wishart LR, Gane EM, Paratz JD. Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study. Aust Crit Care 2023; 36:223-231. [PMID: 35341669 DOI: 10.1016/j.aucc.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Critical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. OBJECTIVES The objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach-style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. METHODS A new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. RESULTS The service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. CONCLUSIONS Critical care outreach-style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.
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Affiliation(s)
- Leah A Vegh
- Department of Physiotherapy, Princess Alexandra Hospital, Brisbane, Australia.
| | - Alison M Blunt
- Department of Physiotherapy, Princess Alexandra Hospital, Brisbane, Australia
| | - Laurelie R Wishart
- Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia; School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Elise M Gane
- Department of Physiotherapy, Princess Alexandra Hospital, Brisbane, Australia; Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia; School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Jennifer D Paratz
- School of Allied Health Sciences, Griffith University, Brisbane, Australia
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AlZaher RA, Murabi I, Enazi J, Antar M, Kolobe E, Delafuente S, Awani M. Implementation of nursing-led follow-up service for patients newly discharged from paediatric intensive care units: quality improvement initiative. BMJ Open Qual 2023; 12:bmjoq-2022-002148. [PMID: 37001907 PMCID: PMC10069594 DOI: 10.1136/bmjoq-2022-002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundHuman resource shortages are a global challenge in the healthcare system and create barriers in providing timely follow-up visits for paediatric patients discharged recently from the intensive care unit (ICU). Relying on experienced intensive care nurses to provide follow-up services for patients post paediatric ICU (PICU) transfer has been proven a cost-effective and safe practice. This study aimed to achieve no delays in initiating follow-up visits and to assess the safety of implementing a nurse-led follow-up service.MethodsPlan–Do–Study–Act cycle was used targeting to achieve no delay in initiating follow-up visits and to maintain the safety of the patients. This cycle resulted in the implementation of a nurse-led follow-up service, which is under the provision of a paediatric rapid response team (RRT). Fifteen PICU nurses were trained in their new roles and responsibilities. Service databases were established to track and trend the frequency of visits, service safety measures and clinical deterioration.ResultsAfter the implementation of the nurse-led follow-up service, we achieved no delays in initiating the follow-up visits. 45% (n=487) of patients received a nurse-led follow-up visit service. Safety measures demonstrated 0.21% (n=1) recorded events of RRT activations during the follow-up service. RRT activation within 48 hours from service discharge was 1.2% (n=6), and readmission to PICU within 48 hours was 0.8% (n=4). No cardiopulmonary arrest event was recorded for patients under the nurse-led follow-up service during the service, postservice discharge or postreadmission to PICU.ConclusionsImplementing nursing-led service has been shown to be safe, efficient and provides patients with timely visits post-PICU discharge.
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Affiliation(s)
- Ruqiah Ali AlZaher
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Iris Murabi
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jaber Enazi
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pediatric department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohannad Antar
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- Pediatric department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Efraim Kolobe
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Mona Awani
- Nursing Services, MNG-HA, Riyadh, Saudi Arabia
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Daoust D, Dodin P, Sy E, Lau V, Roumeliotis N. Prevalence and Readmission Rates of Discharge Directly Home From the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:62-71. [PMID: 36594800 DOI: 10.1097/pcc.0000000000003114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Critically ill patients are increasingly being discharged directly home from PICU as opposed to discharged home, via the ward. The objective was to assess the prevalence, safety, and satisfaction of discharge directly home from PICUs. DATA SOURCES We searched PubMed, Medline, EMBASE, PsycINFO, and CINAHL for studies published between January 1991 and June 2021. STUDY SELECTION We included observational or randomized studies, of children up to 18 years old, that reported on the prevalence, safety, or satisfaction of discharge directly home from the PICU, compared with the ward. Safety outcomes included readmission, unplanned visits to hospital, and any adverse events. We excluded case series, reviews, and studies discharging patients to other facilities. DATA EXTRACTION Two independent reviewers evaluated 88 full-text articles; five studies met eligibility (362,868 patients). Only one study had discharge directly home as a primary outcome. DATA SYNTHESIS Prevalence of discharge directly to home from the PICU ranged from less than 1% to 23% (random effects proportion 7.7 [95% CI, 1.3-18.6]). Readmissions to the PICU (only safety outcome) were significantly lower in the discharge directly home group compared with the ward group, in two of three studies (p < 0.0001). No studies reported on patient or family satisfaction. CONCLUSIONS The prevalence of discharge directly home from the PICU ranges from 1% to 23%. PICU readmission rates do not appear to increase after discharge directly home. Caution is needed in the interpretation of the results, given the significant heterogeneity of the included studies. Further high-quality studies are needed to evaluate the safety of discharge directly home from the PICU and support families in this transition.
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Affiliation(s)
- Daphne Daoust
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Philippe Dodin
- Medical Librarian, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, QC, Canada
| | - Eric Sy
- Department of Medicine, College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Vincent Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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Schorr CA, Seckel MA, Papathanassoglou E, Kleinpell R. Nursing Implications of the Updated 2021 Surviving Sepsis Campaign Guidelines. Am J Crit Care 2022; 31:329-336. [PMID: 35773196 DOI: 10.4037/ajcc2022324] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Sepsis is a life-threatening illness that affects millions of people worldwide. Early recognition and timely treatment are essential for decreasing mortality from sepsis. The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, the fifth iteration of the guidelines, was released in October 2021 and includes 93 recommendations for the management of sepsis. The evidence-based guidelines include recommendations and rationales for screening and early treatment, initial resuscitation, mean arterial pressure targets, admission to intensive care, management of infection, hemodynamic monitoring, ventilation, and additional therapies. A new section addresses long-term outcomes and goals of care. This article presents several recommendations, changes, and updates in the 2021 guidelines and highlights the important contributions nurses have in delivering timely and evidence-based care to patients with sepsis. Recommendations may be for or against an intervention, according to the evidence. Although many recommendations are unchanged, several new recommendations directly affect nursing care and may require specialized training (eg, venovenous extracorporeal membrane oxygenation). The newest section, long-term outcomes and goals of care, is aimed at using available resources to provide care that is aligned with the patient and the patient's family through goals-of-care discussions and shared decision-making. Interventions aimed at improving recovery across the continuum of care should include attention to long-term outcomes. Nurses are essential in identifying patients with sepsis, administering and assessing response to treatment, supporting the patient and family, and limiting sequelae from sepsis. This article highlights the 2021 recommendations that influence nursing care for patients with sepsis.
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Affiliation(s)
- Christa A Schorr
- Christa A. Schorr is a professor of medicine, Cooper Medical School of Rowan University, and a clinical nurse scientist, Cooper University Health Care, Camden, New Jersey
| | - Maureen A Seckel
- Maureen A. Seckel is a medical critical care quality and safety clinical nurse specialist and a sepsis coordinator, ChristianaCare, Newark, Delaware
| | - Elizabeth Papathanassoglou
- Elizabeth Papathanassoglou is a professor of nursing, University of Alberta, and the scientific director, Neurosciences, Rehabilitation & Vision Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Ruth Kleinpell
- Ruth Kleinpell is the associate dean for clinical scholarship and a professor, Vanderbilt University School of Nursing, Nashville, Tennessee
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First-line Vasopressor Use in Septic Shock and Route of Administration: An Epidemiologic Study. Ann Am Thorac Soc 2022; 19:1713-1721. [PMID: 35709214 DOI: 10.1513/annalsats.202203-222oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Norepinephrine is a first-line agent for treatment of hypotension in septic shock. However, its frequency of use, and potential barriers to its use are unclear. OBJECTIVES To evaluate the frequency of use of norepinephrine in septic shock, to identify potential barriers to its use, and to evaluate trends in use of vasopressors over time. METHODS Retrospective population-based cohort study of patients with septic shock in Alberta, Canada between July 1, 2012 and December 31, 2018. The primary outcome was receipt of a first-line vasopressor other than norepinephrine ("non-norepinephrine vasopressor"). Predictors of receiving a non-norepinephrine vasopressor were assessed using a multivariable-adjusted, multilevel logistic regression model with intensive care unit (ICU) as a random effect. RESULTS Among 6343 patients with septic shock, the proportion of patients receiving non-norepinephrine vasopressors as first-line treatment decreased steadily from 11.5% in 2012 to 3.0% in 2018. Two factors most strongly associated with their receipt were having peripheral intravenous access only (adjusted odds ratio (aOR) 6.15, 95% confidence interval (CI) 4.58-8.26, p<0.001) and year of admission (aOR 0.74 per year after 2012, 95% CI 0.69-0.80, p<0.001). Other factors that had associations after adjustment included admission to a non-teaching hospital (aOR 2.19, 95% CI 1.23-3.89, p=0.007), admission to a coronary care unit (aOR 2.56, 95% CI 1.001-6.54, p=0.05), SOFA score (aOR 0.92 per unit increase, 95% CI 0.88-0.96, p<0.001) and heart rate (aOR 0.92 per 10 beat per minute increase, 95% CI 0.87-0.97, p=0.002). CONCLUSIONS In a large cohort of patients in Alberta, Canada, we found a steady decrease in use of first-line vasopressors other than norepinephrine in septic shock. The strongest factor associated with their use was the presence of only peripheral venous access, suggesting this may still be considered a barrier to administration of norepinephrine.
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Sy E, Gupta C, Shahab Z, Fortin N, Kassir S, Mailman JF, Lau VI. Long-term Safety of Directly Discharging Patients Home from the ICU Compared to Ward Transfer. J Intensive Care Med 2022; 37:1344-1352. [PMID: 35350921 DOI: 10.1177/08850666221090459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the long-term safety of directly discharging intensive care unit (ICU) survivors to their home. Methods: A retrospective observational cohort of 341 ICU survivors who were directly discharged home from the ICU ("direct discharge") or discharged home ≤72 hours after ICU transfer to the ward ("ward transfer") was conducted in Regina, Saskatchewan ICUs between September 1, 2016 and September 30, 2018. The primary outcome was 90-day hospital readmission. Secondary outcomes included 30-day, 90-day, and 365-day emergency department (ED) visits, 30-day and 365-day hospital readmissions, and 365-day mortality. All outcomes were evaluated by multivariable Cox regression after adjustment for demographic and clinical characteristics. Results: Of 341 survivors (25.5% of total ICU visits), 148 (43.4%) patients were direct discharges and 193 (56.6%) were ward transfers. The median age was 46 years (interquartile range, 34-62), 38.4% were female, and 61.8% resided in Regina. Compared to the ward transfer cohort, more patients in the direct discharge cohort had at least one 90-day hospital readmission (30.4% versus 17.1% of patients, adjusted hazard ratio 2.09, 95% confidence interval 1.28-3.40, P = .003), after adjustment. Additionally, there were more 90-day ED visits (P = .045), and 30-day (P = .049) and 365-day hospital readmissions (P = .03), after adjustment. Conclusions: In Saskatchewan, direct discharge compared to ward transfer was associated with an increase in 90-day hospital readmissions, and potentially other clinical outcomes. Further study is necessary.
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Affiliation(s)
- Eric Sy
- Department of Critical Care, 7234Saskatchewan Health Authority, Regina General Hospital, Regina, Saskatchewan, Canada.,College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Chiraag Gupta
- College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada.,Research Department, 7234Saskatchewan Health Authority, Wascana Rehabilitation Centre, Regina, Saskatchewan, Canada
| | - Zunaira Shahab
- College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada.,Department of Medicine, 7235University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Nathan Fortin
- College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Sandy Kassir
- Research Department, 7234Saskatchewan Health Authority, Wascana Rehabilitation Centre, Regina, Saskatchewan, Canada
| | - Jonathan F Mailman
- Department of Critical Care, 7234Saskatchewan Health Authority, Regina General Hospital, Regina, Saskatchewan, Canada.,College of Medicine, 12371University of Saskatchewan, Regina General Hospital, Regina, Saskatchewan, Canada.,Department of Pharmacy Services, 7234Saskatchewan Health Authority, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C Mackenzie Centre, Edmonton, Alberta, Canada
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 809] [Impact Index Per Article: 269.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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9
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1305] [Impact Index Per Article: 435.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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Abstract
OBJECTIVES To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN Multicenter cohort study. SETTING Ten adult medical-surgical Canadian ICUs. PATIENTS Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.
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Mohamed I, Hussein R. A Simulation Optimisation Approach for Managing Bed Capacity in an Intensive Care Unit. JOURNAL OF INFORMATION & KNOWLEDGE MANAGEMENT 2021. [DOI: 10.1142/s0219649221500015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Determining the optimal number of beds in a hospital unit is often a very critical task. Patients’ number of arrivals and length of stay are random variables which necessitates the treatment with the number of patients at hospital as a stochastic process, and thus adding to the complexity of the bed sizing problem. The optimal number of beds is affected by some critical parameters such as target utilisation level, admission rate and target service level. This study applies a discrete event simulation model to approximate the true relationships between different control parameters and optimal number of beds. A goal programming model is then solved to find the optimal number of beds that maintains minimal deviation from target admission and utilisation levels. Data have been collected for the calendar year 2019 and then analysed and used in the simulation model. Mathematical relationships are then embedded in a multiobjective optimisation model that finds the optimal number of beds in an Intensive Care Unit that minimises the deviations from a pre-specified service and beds utilisation levels.
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Affiliation(s)
- Israa Mohamed
- Decision Support Department, Faculty of Computers and Informatics, Zagazig University, Zagazig, Egypt
| | - Rania Hussein
- Decision Support Department, Higher Technological Institute, 10th of Ramadan, Cairo, Egypt
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12
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Ghorbanzadeh K, Ebadi A, Hosseini M, Madah SSB, Khankeh H. Challenges of the patient transition process from the intensive care unit: a qualitative study. Acute Crit Care 2021; 36:133-142. [PMID: 33508186 PMCID: PMC8182156 DOI: 10.4266/acc.2020.00626] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background The transition of patients from the intensive care unit (ICU) to the general ward is challenging. This study aimed to explain the challenges that patients face during the transition process. Methods In this qualitative research of conventional content analysis, data collection was conducted between February 2018 and July 2019 in educational hospitals. After obtaining informed consent, purposive sampling was performed with 22 nurses, intensive care physicians, anesthesiologists, and patients and their families using in-depth semi-structured interviews until data saturation. Results The content analysis yielded three main themes in the challenges patients face during the transition process from the ICU: mixed feelings regarding transition (happiness/hope, worry/uncertainty, abandonment); care break (different atmosphere, the difference between the program and the quality of care, assigning care to the patient and family, and care culture and beliefs); and search for support and information (ineffective communication, self-care capacity of patient and family, ineffective and disrupted training, and weak follow-up programs), which inflicts care shock in the patients. Conclusions The results showed that patients and their families were in a state of care shock during the ICU transition process and were sometimes disconcerted. It is necessary to design and implement care models according to the needs and challenges patients face during the transition period from ICU (patient-centered), based on the evidence available, and after considering the field of medicine and the accessibility of care in the country. The transition process can be improved and enhanced by obtaining knowledge about ICU care and related challenges as well as organizing a learning environment.
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Affiliation(s)
- Kobra Ghorbanzadeh
- Ph.D. Candidate in Nursing, Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.,Department of Nursing, Khalkhal University of Medical Sciences, Khalkhal, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Lifestyle Institute, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammadali Hosseini
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | | | - Hamidreza Khankeh
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.,Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
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13
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Improving ICU transitional care by combining quality management and nursing science – two scientific fields meet in a systematic literature review. INTERNATIONAL JOURNAL OF QUALITY AND SERVICE SCIENCES 2020. [DOI: 10.1108/ijqss-03-2020-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this literature review was to explore to what extent quality management (QM) and nursing science offer complementary perspectives to provide better quality care, by looking at QM core concepts and tools.
Design/methodology/approach
A systematic literature review was conducted. Papers published in academic journals between January 2013 and December 2019 were included. A deductive content analysis was chosen using QM core values as an analytical framework.
Findings
The results showed that QM core values, methodologies and tools were found in the reviewed articles about intensive care unit (ICU) transitional care. The results indicated that core values in QM and the core competencies within nursing science in ICU transitional care are mutually dependent upon each other and exist as a whole. ICU transitional care is, however, a complex interpersonal process, characterized by differences in organizational cultures and core values and involving multidisciplinary teams that collaborate across hospital units. The QM core value that was least observed was committed leadership.
Research limitations/implications
Combining QM and nursing science can contribute to a deeper understanding of how to improve the ICU transitional care process by bringing complementary perspectives.
Practical implications
The included articles portray how QM is applied in ICU transitional care. Implications for future research focus on enhancing the understanding of how QM and nursing science can bring complementary perspectives in order to improve ICU transitional care and how QM values, methodologies and tools can be used in ICU transitional care. Committed leadership and team collaboration in ICU transitional care are areas that call for further research.
Originality/value
The findings contribute to the body of literature by providing important insights in terms of how QM core values, methodologies and tools are present in research about ICU transitional care and how the two research subjects, namely, QM and nursing science, bring complementary perspectives.
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14
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Tanner J, Cornish J. Routine critical care step-down programmes: Systematic review and meta-analysis. Nurs Crit Care 2020; 26:118-127. [PMID: 33159400 DOI: 10.1111/nicc.12572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills. AIMS AND OBJECTIVES This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care? DESIGN Systematic review of quantitative studies and meta-analysis. METHODS Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool. RESULTS Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge. CONCLUSION This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge. RELEVANCE TO CLINICAL PRACTICE While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.
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Affiliation(s)
- John Tanner
- Clinical Response Team, Guys' & St Thomas' NHS Foundation Trust, Westminster Bridge, London, UK
| | - Jocelyn Cornish
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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15
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Prevedello D, Fiore M, Creteur J, Preiser JC. Intensive care units follow-up: a scoping review protocol. BMJ Open 2020; 10:e037725. [PMID: 33148730 PMCID: PMC7643502 DOI: 10.1136/bmjopen-2020-037725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/30/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Increasing numbers of patients are surviving critical illness, leading to growing concern about the potential impact of the long-term consequences of intensive care on patients, families and society as a whole. These long-term effects are together known as postintensive care syndrome and their presence can be evaluated at intensive care unit (ICU) follow-up consultations. However, the services provided by these consultations vary across hospitals and units, in part because there is no validated standard model to evaluate patients and their quality of life after ICU discharge. We describe a protocol for a scoping review focusing on models of ICU follow-up and the impact of such strategies on improving patient quality of life. METHODS AND ANALYSIS In this scoping review, we will search the literature systematically using electronic databases (MEDLINE - from database inception to June 15th 2020) and a grey literature search. We will involve stakeholders as recommended by the Joanna Briggs Institute approach developed by Peters et al. The research will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. ETHICS AND DISSEMINATION This study does not require ethics approval, because data will be obtained through a review of published primary studies. The results of our evaluation will be published in a peer-reviewed journal and will also be disseminated through presentations at national and international conferences.
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Affiliation(s)
- Danielle Prevedello
- Department of Intensive Care Medicine, Erasme University Hospital, Brussels, Belgium
| | - Marco Fiore
- Department of Intensive Care Medicine, Erasme University Hospital, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Medicine, Erasme University Hospital, Brussels, Belgium
| | - J C Preiser
- Department of Intensive Care Medicine, Erasme University Hospital, Brussels, Belgium
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16
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Österlind J, Gerhardsson J, Myrberg T. Critical care transition programs on readmission or death: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2020; 64:870-883. [PMID: 32232833 DOI: 10.1111/aas.13591] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Deterioration after ICU discharge may lead to readmission or even death. Interventions (eg, critical care transition programs) have been developed to improve the clinical handover between the ICU and the ward. We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) according to Cochrane Handbook and Grading of recommendations, assessment, development and evaluations (GRADE) methodology to assess the impact of these interventions on readmission and death (PROSPERO, no CRD42019121746). METHODS We searched PubMed/MEDLINE, CINAHL, AMED, PsycINFO, and the Cochrane Central Register for Controlled Trials from inception until January 2019. We included historically controlled studies that evaluated critical care transition programs in adults discharged from the ICU. Readmission and in-hospital mortality were the primary outcomes. Risk of bias, publications bias, and the quality of evidence were assessed with the ROBINS-Itool, funnel plot and GRADE, respectively. RESULTS Fifteen observational studies were included (11 in meta-analysis). All studies had at least serious risk of bias. ICU discharge within a critical care transition program modestly reduced the risk of readmission (RR 0.78; 95% CI: 0.64-0.96; TSA-adjusted 95% CI: 0.59-1.03) but not in-hospital mortality (RR 0.82; 95% CI: 0.64-1.06; TSA-adjusted 95% CI: 0.49-1.37). There was substantial heterogeneity among studies. TSA indicated lack of firm evidence. The GRADE quality of evidence on outcomes was very low. CONCLUSIONS We found no clear benefit in terms of reducing risk of readmission or death after ICU discharge, however, with overall very low certainty of evidence.
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Affiliation(s)
- Jonas Österlind
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umea University Umeå Sweden
| | - Jakob Gerhardsson
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umea University Umeå Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Sunderby Research Unit Umea University Umeå Sweden
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Hervé MEW, Zucatti PB, Lima MADDS. Transition of care at discharge from the Intensive Care Unit: a scoping review. Rev Lat Am Enfermagem 2020; 28:e3325. [PMID: 32696919 PMCID: PMC7365613 DOI: 10.1590/1518-8345.4008.3325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 04/07/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE to map the available evidence on the components of the transition of care, practices, strategies, and tools used in the discharge from the Intensive Care Unit (ICU) to the Inpatient Unit (IU) and its impact on the outcomes of adult patients. METHOD a scoping review using search strategies in six relevant health databases. RESULTS 37 articles were included, in which 30 practices, strategies or tools were identified for organizing and executing the transfer process, with positive or negative impacts, related to factors intrinsic to the Intensive Care Unit and the Inpatient Unit and cross-sectional factors regarding the staff. The analysis of hospital readmission and mortality outcomes was prevalent in the included studies, in which trends and potential protective actions for a successful care transition are found; however, they still lack more robust evidence and consensus in the literature. CONCLUSION transition of care components and practices were identified, in addition to factors intrinsic to the patient, associated with worse outcomes after discharge from the Intensive Care Unit. Discharges at night or on weekends were associated with increased rates of readmission and mortality; however, the association of other practices with the patient's outcome is still inconclusive.
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18
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Improving transitions in care from intensive care units: Development and pilot testing of an electronic communication tool for healthcare providers. J Crit Care 2020; 56:265-272. [DOI: 10.1016/j.jcrc.2020.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/08/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
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19
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Jackson Chornenki N, Liaw P, Bagshaw S, Burns K, Dodek P, English S, Fan E, Ferrari N, Fowler R, Fox-Robichaud A, Garland A, Green R, Hebert P, Kho M, Martin C, Maslove D, McDonald E, Menon K, Murthy S, Muscedere J, Scales D, Stelfox HT, Wang HT, Weiss M. Data initiatives supporting critical care research and quality improvement in Canada: an environmental scan and narrative review. Can J Anaesth 2020; 67:475-484. [PMID: 31970619 DOI: 10.1007/s12630-020-01571-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Collection and analysis of health data are crucial to achieving high-quality clinical care, research, and quality improvement. This review explores existing hospital, regional, provincial and national data platforms in Canada to identify gaps and barriers, and recommend improvements for data science. SOURCE The Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group undertook an environmental survey using list-identified names and keywords in PubMed and the grey literature, from the Canadian context. Findings were grouped into sections, corresponding to geography, purpose, and patient sub-group initiatives, using a narrative qualitative approach. Emerging themes, impressions, and recommendations towards improving data initiatives were generated. PRINCIPAL FINDINGS In Canada, the Canadian Institute for Health Information Discharge Abstract Database contains high-level clinical data on every adult and child discharged from acute care facilities; however, it does not contain data from Quebec, critical care-specific severity of illness risk-adjustment scores, physiologic data, or data pertaining to medication use. Provincially mandated critical care platforms in four provinces contain more granular data, and can be used to risk adjust and link to within-province data sets; however, no inter-provincial collaborative mechanism exists. There is very limited infrastructure to collect and link biological samples from critically ill patients nationally. Comprehensive international clinical data sets may inform future Canadian initiatives. CONCLUSION Clinical and biological data collection among critically ill patients in Canada is not sufficiently coordinated, and lags behind other jurisdictions. An integrated and inclusive critical care data platform is a key clinical and scientific priority in Canada.
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Affiliation(s)
| | | | | | | | - Peter Dodek
- University of British Columbia, Vancouver, BC, Canada
| | | | - Eddy Fan
- University of Toronto, Toronto, ON, Canada
| | - Nicolay Ferrari
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Robert Fowler
- University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | | | | | | | - Paul Hebert
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | | | | | | | | | | | | | - Matthew Weiss
- Centre hospitalier universitaire de Québec, Quebec City, QC, Canada
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Morgan M, Vernon T, Bradburn EH, Miller JA, Jammula S, Rogers FB. A Comprehensive Review of the Outcome for Patients Readmitted to the ICU Following Trauma and Strategies to Decrease Readmission Rates. J Intensive Care Med 2020; 35:936-942. [PMID: 31916876 DOI: 10.1177/0885066619899639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In recent years, there has been an emphasis on evaluating the outcomes of patients who have experienced an intensive care unit (ICU) readmission. This may in part be due to the Patient Protection and Affordable Care Act's Hospital Readmission Reduction Program which imposes financial sanctions on hospitals who have excessive readmission rates, informally known as bounceback rates. The financial cost associated with avoidable bounceback combined with the potentially preventable expenses can result in unnecessary financial strain. Within the hospital readmissions, there is a subset pertaining to unplanned readmission to the ICU. Although there have been studies regarding ICU bounceback, there are limited studies regarding ICU bounceback of trauma patients and even fewer proven strategies. Although many studies have concluded that respiratory complications were the most common factor influencing ICU readmissions, there is inconclusive evidence in terms of a broadly applicable strategy that would facilitate management of these patients. The purpose of this review is to highlight the outcomes of patients readmitted to the ICU and to provide an overview of possible strategies to aid in decreasing ICU readmission rates.
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Affiliation(s)
- Madison Morgan
- Trauma Services, 4399Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Tawnya Vernon
- Trauma Services, 4399Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Eric H Bradburn
- Trauma Services, 4399Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Jo Ann Miller
- Trauma Services, 4399Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Shreya Jammula
- Trauma Services, 4399Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Frederick B Rogers
- Trauma Services, 4399Penn Medicine Lancaster General Health, Lancaster, PA, USA
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A multicentre controlled pre-post trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients. Intensive Care Med 2019; 45:211-222. [PMID: 30707246 DOI: 10.1007/s00134-019-05532-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/14/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To test whether a multicomponent intervention would increase the use of low molecular weight heparin (LMWH) over unfractionated heparin (UFH) for venous thromboembolism (VTE) prophylaxis in critically ill patients and change patient outcomes and healthcare utilization. METHODS Controlled pre-post trial of 12,342 adults admitted to 11 ICUs (five intervention, six control) May 1, 2015 to April 30, 2017 with no contraindication to pharmacological prophylaxis and an ICU stay longer than 24 h. Models were developed to examine temporal changes in ICU VTE prophylaxis (primary outcome), VTE, major bleeding, heparin-induced thrombocytopenia (HIT), death and hospital costs. RESULTS The use of LMWH increased from 45.9% to 78.3% of patient days in the intervention group and from 37.9% to 53.3% in the control group, an absolute increase difference of 17.0% (32.4% vs. 15.4%, p = 0.001). Changes in the administration of UFH were inversely related to those of LMWH. There were no significant differences in the adjusted odds of VTE (ratio of odds ratios [rOR] 1.13, 95% CI 0.51-2.46) or major bleeding (rOR 1.22, 95% CI 0.97-1.54) post-implementation of the intervention (compared to pre-implementation) between the intervention group and the control group. HIT was uncommon in both groups (n = 20 patients). There were no significant changes for ICU and hospital mortality, length of stay and costs. Results were similar when stratified according to reason for ICU admission, patient weight and kidney function. CONCLUSIONS A multicomponent intervention changed practice, but not clinical and economic outcomes. The benefit of implementing LMWH for VTE prophylaxis under real-world conditions is uncertain.
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Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative. J Crit Care 2018; 50:111-117. [PMID: 30529419 DOI: 10.1016/j.jcrc.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/05/2018] [Accepted: 11/21/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients. MATERIALS AND METHODS This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach. RESULTS Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group. CONCLUSIONS The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.
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Rigaud JP, Giabicani M, Meunier-Beillard N, Ecarnot F, Beuzelin M, Marchalot A, Dargent A, Quenot JP. Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices. PLoS One 2018; 13:e0205689. [PMID: 30335804 PMCID: PMC6193659 DOI: 10.1371/journal.pone.0205689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/28/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation. MATERIALS AND METHODS Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents' practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission. RESULTS In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient's stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient's medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework. CONCLUSION This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient's individual characteristics.
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Affiliation(s)
- Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
- * E-mail:
| | - Mikhael Giabicani
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Nicolas Meunier-Beillard
- Service de Médecine Intensive Réanimation, Université de Bourgogne Franche Comté, CHU de Dijon, Dijon, France
- UMR 7366 CNRS, Université de Bourgogne Franche Comté, Centre Georges Chevrier, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, and University of Burgundy Franche Comté, Besançon, France
| | - Marion Beuzelin
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Antoine Marchalot
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Auguste Dargent
- Service de Médecine Intensive Réanimation, Université de Bourgogne Franche Comté, CHU de Dijon, Dijon, France
- Lipness Team, INSERM, UMR 1231, Université de Bourgogne Franche Comté, Dijon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, Université de Bourgogne Franche Comté, CHU de Dijon, Dijon, France
- Lipness Team, INSERM, UMR 1231, Université de Bourgogne Franche Comté, Dijon, France
- INSERM CIC 1432, Faculté de médecine de Dijon, Université de Bourgogne Franche Comté, Dijon, France
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Stelfox HT, Soo A, Niven DJ, Fiest KM, Wunsch H, Rowan KM, Bagshaw SM. Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study. JAMA Intern Med 2018; 178:1390-1399. [PMID: 30128550 PMCID: PMC6584269 DOI: 10.1001/jamainternmed.2018.3675] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown. OBJECTIVE To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. DESIGN, SETTING, AND PARTICIPANTS Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics. EXPOSURES Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. MAIN OUTCOMES AND MEASURES The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. RESULTS Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). CONCLUSIONS AND RELEVANCE The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesia and Interdisciplinary Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, England
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
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Martin LA, Kilpatrick JA, Al-Dulaimi R, Mone MC, Tonna JE, Barton RG, Brooke BS. Predicting ICU readmission among surgical ICU patients: Development and validation of a clinical nomogram. Surgery 2018; 165:373-380. [PMID: 30170817 DOI: 10.1016/j.surg.2018.06.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 05/21/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Unplanned intensive care unit readmission within 72 hours is an established metric of hospital care quality. However, it is unclear what factors commonly increase the risk of intensive care unit readmission in surgical patients. The objective of this study was to evaluate predictors of readmission among a diverse sample of surgical patients and develop an accurate and clinically applicable nomogram for prospective risk prediction. METHODS We retrospectively evaluated patient demographic characteristics, comorbidities, and physiologic variables collected within 48 hours before discharge from a surgical intensive care unit at an academic center between April 2010 and July 2015. Multivariable regression models were used to assess the association between risk factors and unplanned readmission back to the intensive care unit within 72 hours. Model selection was performed using lasso methods and validated using an independent data set by receiver operating characteristic area under the curve analysis. The derived nomogram was then prospectively assessed between June and August 2017 to evaluate the correlation between perceived and calculated risk for intensive care unit readmission. RESULTS Among 3,109 patients admitted to the intensive care unit by general surgery (34%), transplant (9%), trauma (43%), and vascular surgery (14%) services, there were 141 (5%) unplanned readmissions within 72 hours. Among 179 candidate predictor variables, a reduced model was derived that included age, blood urea nitrogen, serum chloride, serum glucose, atrial fibrillation, renal insufficiency, and respiratory rate. These variables were used to develop a clinical nomogram, which was validated using 617 independent admissions, and indicated moderate performance (area under the curve: 0.71). When prospectively assessed, intensive care unit providers' perception of respiratory risk was moderately correlated with calculated risk using the nomogram (ρ: 0.44; P < .001), although perception of electrolyte abnormalities, hyperglycemia, renal insufficiency, and risk for arrhythmias were not correlated with measured values. CONCLUSION Intensive care unit readmission risk for surgical patients can be predicted using a simple clinical nomogram based on 7 common demographic and physiologic variables. These data underscore the potential of risk calculators to combine multiple risk factors and enable a more accurate risk assessment beyond perception alone.
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Affiliation(s)
- Luke A Martin
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Julie A Kilpatrick
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Ragheed Al-Dulaimi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Mary C Mone
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Joseph E Tonna
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Richard G Barton
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Benjamin S Brooke
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT.
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Moreira HE, Verga F, Barbato M, Burghi G. Prognostic impact of the time of admission and discharge from the intensive care unit. Rev Bras Ter Intensiva 2018; 29:63-69. [PMID: 28444074 PMCID: PMC5385987 DOI: 10.5935/0103-507x.20170010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/01/2016] [Indexed: 11/20/2022] Open
Abstract
Objective To determine the impact of the day and time of admission and discharge from
the intensive care unit on mortality. Methods Prospective observational study that included patients admitted to the
intensive care unit of the Hospital Maciel in Montevideo
between April and November 2014. Results We analyzed 325 patients with an average age of 55 (36 - 71) years and a SAPS
II value of 43 (29 - 58) points. No differences were found in the mortality
of patients in the intensive care unit when time of admission (35% on the
weekend versus 31% on weekdays, p = ns) or the hour of entry (35% at night
versus 31% in the daytime, p = ns) were compared. The time of discharge was
associated with higher hospital mortality rates (57% for weekend discharges
versus 14% for weekday discharges, p = 0.000). The factors independently
associated with hospital mortality after discharge from the intensive care
unit were age > 50 years (OR 2.4, 95%CI, 1.1 - 5.4) and weekend discharge
(OR 7.7, 95%CI, 3.8-15.6). Conclusion This study identified the time of discharge from the intensive care unit as a
factor that was independently associated with hospital mortality.
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Affiliation(s)
| | - Federico Verga
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | | | - Gastón Burghi
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
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Bagshaw SM, Wang X, Zygun DA, Zuege D, Dodek P, Garland A, Scales DC, Berthiaume L, Faris P, Chen G, Opgenorth D, Stelfox HT. Association between strained capacity and mortality among patients admitted to intensive care: A path-analysis modeling strategy. J Crit Care 2018; 43:81-87. [DOI: 10.1016/j.jcrc.2017.08.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 01/09/2023]
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Ofoma UR, Dong Y, Gajic O, Pickering BW. A qualitative exploration of the discharge process and factors predisposing to readmissions to the intensive care unit. BMC Health Serv Res 2018; 18:6. [PMID: 29304857 PMCID: PMC5755430 DOI: 10.1186/s12913-017-2821-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 12/28/2017] [Indexed: 11/24/2022] Open
Abstract
Background Quantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions. Methods Semi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts. Results Nine factors within four broad themes were identified: (1) patient factors – severity-of-illness and undefined goals of care; (2) process factors – communication, transitions of care; (3) provider factors – discharge decision-making, provider experience and comfort level; (4) organizational factors – resource constraints, institutional policies. Conclusions Severe illness predisposes ICU patients to readmission, especially when goals of care were not adequately addressed. Communication, premature discharge, and other factors, mostly unrelated to the patient were also perceived by physicians and nurses to be associated with readmissions to intensive care. Quality improvement efforts that focus on modifying or improving aspects of non-patient factors may improve outcomes for patients at risk of ICU readmission. Electronic supplementary material The online version of this article (10.1186/s12913-017-2821-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17822, USA.
| | - Yue Dong
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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van Mol M, Nijkamp M, Markham C, Ista E. Using an intervention mapping approach to develop a discharge protocol for intensive care patients. BMC Health Serv Res 2017; 17:837. [PMID: 29258524 PMCID: PMC5737483 DOI: 10.1186/s12913-017-2782-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 12/06/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need. METHODS Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study. RESULTS Four former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice. CONCLUSION Intervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.
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Affiliation(s)
- Margo van Mol
- Department of Intensive Care Adults, Erasmus MC University Medical Center, P.O. Box 2040, Room 1005, 3000 CA Rotterdam, The Netherlands
| | - Marjan Nijkamp
- Faculty of Psychology and Educational Sciences, Open University of the Netherlands, Heerlen, The Netherlands
| | - Christine Markham
- Center for Health Promotion and Prevention Research, University of Texas Health Science Center at Houston, School of Public Health, Houston, USA
| | - Erwin Ista
- Department of Intensive Care Children, Erasmus MC University Medical Center - Sophia Children’s Hospital, Rotterdam, The Netherlands
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Enger R, Andershed B. Nurses' experience of the transfer of ICU patients to general wards: A great responsibility and a huge challenge. J Clin Nurs 2017; 27:e186-e194. [PMID: 28598014 DOI: 10.1111/jocn.13911] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2017] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES The aim of the study was to describe nurses' experiences of patients' transition from ICUs to general wards and their suggestions for improvements. BACKGROUND In the ICU, the most seriously ill patients with life-threatening conditions and multiple organ dysfunction syndromes are cared for and carefully monitored by specially trained professionals using advanced techniques for the prevention of failure of vital functions. The transfer of ICU patients to general wards means a change from a high to a lower level, including the loss of one-to-one nursing and a reduction of visible monitoring equipment and general close attention. DESIGN A qualitative descriptive design. METHODS Eight nurses from three different inpatient units in Norway, five from a university hospital and three from a local hospital were selected through a convenience sample. Interviews with open questions were conducted, and qualitative content analysis was used to explore the data. RESULTS Nurses' experiences were described in one main category: ICU patients' transition-a great responsibility and a huge challenge, and two generic categories: (i) a challenging transition for nurses, patients and relatives and (ii) dialogue and competencies as tools for improvement, with six subcategories. CONCLUSION A number of factors affected patient care, such as poor cooperation, communication, reporting, expertise and clinical gaze. It was clear that the general wards had major challenges, and a number of improvements were suggested. RELEVANCE TO CLINICAL PRACTICE This study shows that there is still a gap between the ICU and general wards and that nurses continue to struggle with this. It is therefore important that the managers responsible for the quality of care together with the professionals take seriously the criticism in the present and previous studies and work towards a safe transition for patients.
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Affiliation(s)
- Ronny Enger
- Department of Health and Care Sciences, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Birgitta Andershed
- Faculty of Health, Care and Nursing, Norwegian University of Science and Technology, Gjövik, Norway
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Rosa RG, Maccari JG, Cremonese RV, Tonietto TF, Cremonese RV, Teixeira C. The impact of critical care transition programs on outcomes after intensive care unit (ICU) discharge: can we get there from here? J Thorac Dis 2016; 8:1374-6. [PMID: 27500863 DOI: 10.21037/jtd.2016.05.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Regis Goulart Rosa
- Department of Critical Care, Hospital Moinhos de Vento, Porto Alegre, Brazil;; Department of Critical Care, Hospital Mãe de Deus, Porto Alegre, Brazil
| | | | | | | | - Rafael Viegas Cremonese
- Department of Critical Care, Hospital Moinhos de Vento, Porto Alegre, Brazil;; Department of Critical Care, Hospital Mãe de Deus, Porto Alegre, Brazil
| | - Cassiano Teixeira
- Department of Critical Care, Hospital Moinhos de Vento, Porto Alegre, Brazil
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