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Cheng H, Li J, Wei F, Yang X, Yuan S, Huang X, Zhou F, Lyu J. A risk nomogram for predicting prolonged intensive care unit stays in patients with chronic obstructive pulmonary disease. Front Med (Lausanne) 2023; 10:1177786. [PMID: 37484842 PMCID: PMC10359115 DOI: 10.3389/fmed.2023.1177786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/15/2023] [Indexed: 07/25/2023] Open
Abstract
Background Providing intensive care is increasingly expensive, and the aim of this study was to construct a risk column line graph (nomograms)for prolonged length of stay (LOS) in the intensive care unit (ICU) for patients with chronic obstructive pulmonary disease (COPD). Methods This study included 4,940 patients, and the data set was randomly divided into training (n = 3,458) and validation (n = 1,482) sets at a 7:3 ratio. First, least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimize variable selection by running a tenfold k-cyclic coordinate descent. Second, a prediction model was constructed using multifactorial logistic regression analysis. Third, the model was validated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow tests, calibration plots, and decision-curve analysis (DCA), and was further internally validated. Results This study selected 11 predictors: sepsis, renal replacement therapy, cerebrovascular disease, respiratory failure, ventilator associated pneumonia, norepinephrine, bronchodilators, invasive mechanical ventilation, electrolytes disorders, Glasgow Coma Scale score and body temperature. The models constructed using these 11 predictors indicated good predictive power, with the areas under the ROC curves being 0.826 (95%CI, 0.809-0.842) and 0.827 (95%CI, 0.802-0.853) in the training and validation sets, respectively. The Hosmer-Lemeshow test indicated a strong agreement between the predicted and observed probabilities in the training (χ2 = 8.21, p = 0.413) and validation (χ2 = 0.64, p = 0.999) sets. In addition, decision-curve analysis suggested that the model had good clinical validity. Conclusion This study has constructed and validated original and dynamic nomograms for prolonged ICU stay in patients with COPD using 11 easily collected parameters. These nomograms can provide useful guidance to medical and nursing practitioners in ICUs and help reduce the disease and economic burdens on patients.
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Affiliation(s)
- Hongtao Cheng
- School of Nursing, Jinan University, Guangzhou, China
| | - Jieyao Li
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Fangxin Wei
- School of Nursing, Jinan University, Guangzhou, China
| | - Xin Yang
- School of Nursing, Jinan University, Guangzhou, China
| | - Shiqi Yuan
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaxuan Huang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
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Barwise AK, Moriarty JP, Rosedahl JK, Soleimani J, Marquez A, Weister TJ, Gajic O, Borah BJ. Comparative costs for critically ill patients with limited English proficiency versus English proficiency. PLoS One 2023; 18:e0279126. [PMID: 37186248 PMCID: PMC10132690 DOI: 10.1371/journal.pone.0279126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 11/30/2022] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES To conduct comparative cost analysis of hospital care for critically ill patients with Limited English Proficiency (LEP) versus patients with English proficiency (controls). PATIENTS AND METHODS We conducted a historical cohort study using propensity matching at Mayo Clinic Rochester, a quaternary care academic center. We included hospitalized patients who had at least one admission to ICU during a 10-year period between 1/1/2008-12/31/2017. RESULTS Due to substantial differences in baseline characteristics of the groups, propensity matching for the covariates age, sex, race, ethnicity, APACHE 3 score, and Charlson Comorbidity score was used, and we achieved the intended balance. The final cohort included 80,404 patients, 4,246 with LEP and 76,158 controls. Patients with LEP had higher costs during hospital admission to discharge, with a mean cost difference of $3861 (95% CI $822 to $6900, p = 0.013) and also higher costs during index ICU admission to hospital discharge, with a mean cost difference of $3166 (95% CI $231 to $6101, p = 0.035). A propensity matched cohort including only those that survived showed those with LEP had significantly greater mean costs for all outcomes. Sensitivity analysis revealed that international patients with LEP had significantly greater overall hospital costs of $9,240 than patients with LEP who resided in the US (95% CI $3341 to $15,140, p = 0.002). CONCLUSION This is the first study to demonstrate significantly higher costs for patients with LEP experiencing a critical illness. The causes for this may be increased healthcare utilization secondary to communication deficiencies that impede timely decision making about care.
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Affiliation(s)
- Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Bioethics Research Program, Mayo Clinic, Rochester, Minnesota, United States of America
| | - James P Moriarty
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jordan K Rosedahl
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Alberto Marquez
- Anesthesia Clinical Research Unit (ACRU), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Timothy J Weister
- Anesthesia Clinical Research Unit (ACRU), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Bijan J Borah
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
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Chen Y, Luo M, Cheng Y, Huang Y, He Q. A nomogram to predict prolonged stay of obesity patients with sepsis in ICU: Relevancy for predictive, personalized, preventive, and participatory healthcare strategies. Front Public Health 2022; 10:944790. [PMID: 36033731 PMCID: PMC9403617 DOI: 10.3389/fpubh.2022.944790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/18/2022] [Indexed: 01/21/2023] Open
Abstract
Objective In an era of increasingly expensive intensive care costs, it is essential to evaluate early whether the length of stay (LOS) in the intensive care unit (ICU) of obesity patients with sepsis will be prolonged. On the one hand, it can reduce costs; on the other hand, it can reduce nosocomial infection. Therefore, this study aimed to verify whether ICU prolonged LOS was significantly associated with poor prognosis poor in obesity patients with sepsis and develop a simple prediction model to personalize the risk of ICU prolonged LOS for obesity patients with sepsis. Method In total, 14,483 patients from the eICU Collaborative Research Database were randomized to the training set (3,606 patients) and validation set (1,600 patients). The potential predictors of ICU prolonged LOS among various factors were identified using logistic regression analysis. For internal and external validation, a nomogram was developed and performed. Results ICU prolonged LOS was defined as the third quartile of ICU LOS or more for all sepsis patients and demonstrated to be significantly associated with the mortality in ICU by logistic regression analysis. When entering the ICU, seven independent risk factors were identified: maximum white blood cell, minimum white blood cell, use of ventilation, Glasgow Coma Scale, minimum albumin, maximum respiratory rate, and minimum red blood cell distribution width. In the internal validation set, the area under the curve was 0.73, while in the external validation set, it was 0.78. The calibration curves showed that this model predicted probability due to actually observed probability. Furthermore, the decision curve analysis and clinical impact curve showed that the nomogram had a high clinical net benefit. Conclusion In obesity patients with sepsis, we created a novel nomogram to predict the risk of ICU prolonged LOS. This prediction model is accurate and reliable, and it can assist patients and clinicians in determining prognosis and making clinical decisions.
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Menzenbach J, Layer YC, Layer YL, Mayr A, Coburn M, Wittmann M, Hilbert T. The level of postoperative care influences mortality prediction by the POSPOM score: A retrospective cohort analysis. PLoS One 2021; 16:e0257829. [PMID: 34587207 PMCID: PMC8480745 DOI: 10.1371/journal.pone.0257829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/11/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Preoperative Score to Predict Postoperative Mortality (POSPOM) assesses the patients' individual risk for postsurgical intrahospital death based on preoperative parameters. We hypothesized that mortality predicted by the POSPOM varies depending on the level of postoperative care. METHODS All patients age over 18 years undergoing inpatient surgery or interventions involving anesthesia at a German university hospital between January 2006, and December 2017, were assessed for eligibility for this retrospective study. Endpoint was death in hospital following surgery. Adaptation of the POSPOM to the German coding system was performed as previously described. The whole cohort was divided according to the level of postoperative care (normal ward vs. intensive care unit (ICU) admission within 24 h vs. later than 24 h, respectively). RESULTS 199,258 patients were finally included. Observed intrahospital mortality was 2.0% (4,053 deaths). 9.6% of patients were transferred to ICU following surgery, and mortality of those patients was increased already at low POSPOM values of 15. 17,165 patients were admitted to ICU within 24 h, and these patients were older, had more comorbidities, or underwent more invasive surgery, reflected by a higher median POSPOM score compared to the normal-ward group (29 vs. 17, p <0.001). Mortality in that cohort was significantly increased to 8.7% (p <0.001). 2,043 patients were admitted to ICU later than 24 h following surgery (therefore denoted unscheduled admission), and the median POSPOM value of that group was 23. Observed mortality in this cohort was highest (13.5%, p <0.001 vs. ICU admission <24 h cohort). CONCLUSION Increased mortality in patients transferred to high-care wards reflects the significance of, e.g., intra- or early postoperative events for the patients' outcome. Therefore, scoring systems considering only preoperative variables such as the POSPOM reveal limitations to predict the individual benefit of postoperative ICU admission.
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Affiliation(s)
- Jan Menzenbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Yannik C Layer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Yonah L Layer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Mayr
- Institute of Medical Biometrics, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Barwise A, Wi CI, Frank R, Milekic B, Andrijasevic N, Veerabattini N, Singh S, Wilson ME, Gajic O, Juhn YJ. An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study. J Intensive Care Med 2021; 36:828-837. [PMID: 32583721 PMCID: PMC7759584 DOI: 10.1177/0885066620931020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults. OBJECTIVE We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission. METHODS We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old). RESULTS Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051). CONCLUSION Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.
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Affiliation(s)
- Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chung-Il Wi
- Precision Population Science lab and Department of Pediatric and Adolescent Medicine and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Bojana Milekic
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Nicole Andrijasevic
- Anesthesia Clinical Research Unit(ACRU), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Naresh Veerabattini
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada
| | - Sidhant Singh
- Department of Internal Medicine, Yale Waterbury Internal Medicine Residency, Waterbury, Connecticut
| | - Michael E. Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Young J. Juhn
- Precision Population Science lab and Department of Pediatric and Adolescent Medicine and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Epidemiological trends of surgical admissions to the intensive care unit in the United States. J Trauma Acute Care Surg 2020; 89:279-288. [PMID: 32384370 DOI: 10.1097/ta.0000000000002768] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Epidemiologic assessment of surgical admissions into intensive care units (ICUs) provides a framework to evaluate health care system efficiency and project future health care needs. METHODS We performed a 9-year (2008-2016), retrospective, cohort analysis of all adult admissions to 88 surgical ICUs using the prospectively and manually abstracted Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. We stratified patients into 13 surgical cohorts and modeled temporal trends in admission, mortality, surgical ICU length of stay (LOS), and change in functional status (FS) using generalized mixed-effects and Quasi-Poisson models to obtain risk-adjusted outcomes. RESULTS We evaluated 78,053 ICU admissions and observed a significant decrease in admissions after transplant and thoracic surgery, with a concomitant increase in admissions after otolaryngological and facial reconstructive procedures (all p < 0.05). While overall risk-adjusted mortality remained stable over the study period; mortality significantly declined in orthopedic, cardiac, urologic, and neurosurgical patients (all p < 0.05). Cardiac, urologic, gastrointestinal, neurosurgical, and orthopedic admissions showed significant reductions in LOS (all p < 0.05). The overall rate of FS deterioration increased per year, suggesting ICU-related disability increased over the study period. CONCLUSION Temporal analysis demonstrates a significant change in the type of surgical patients admitted to the ICU over the last decade, with decreasing mortality and LOS in selected cohorts, but an increasing rate of FS deterioration. Improvement in ICU outcomes may highlight the success of health care advancements within certain surgical cohorts, while simultaneously identifying cohorts that may benefit from future intervention. Our findings have significant implications in health care systems planning, including resource and personnel allocation, education, and surgical training. LEVEL OF EVIDENCE Economic/decision, level IV.Epidemiologic, level IV.
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7
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Ghneim M, Diaz JJ. Dementia and the Critically Ill Older Adult. Crit Care Clin 2020; 37:191-203. [PMID: 33190770 DOI: 10.1016/j.ccc.2020.08.010] [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: 11/26/2022]
Abstract
Dementia is a terminal illness that leads to progressive cognitive and functional decline. As the elderly population grows, the incidence of dementia in hospitalized older adults increases and is associated with poor short-term and long-term outcomes. Delirium is associated with an accelerated cognitive decline in hospitalized patients with dementia. The first step in the management of dementia is accurate and early diagnosis. Evidence-based management guidelines in the setting of critical illness and dementia are lacking. The cornerstone of management is defining goals of care early in the course of hospitalization and using palliative care and hospice when deemed appropriate.
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Affiliation(s)
- Mira Ghneim
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, 22 South Green Street, S4D07, Baltimore, MD 21201, USA.
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, The University of Maryland Medical Center, 22 South Green Street, S4D07, Baltimore, MD 21201, USA
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Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018. Crit Care Med 2020; 47:1442-1449. [PMID: 31414993 PMCID: PMC6750122 DOI: 10.1097/ccm.0000000000003925] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. DATA SOURCES Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. STUDY SELECTION Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. DATA EXTRACTION Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. DATA SYNTHESIS Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. CONCLUSIONS Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.
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Supinski GS, Wang L, Schroder EA, Callahan LAP. Taurine administration ablates sepsis induced diaphragm weakness. Respir Physiol Neurobiol 2019; 271:103289. [PMID: 31505275 DOI: 10.1016/j.resp.2019.103289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/23/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
Abstract
Infection induced diaphragm weakness is a major contributor to death and prolonged mechanical ventilation in critically ill patients. Infection induced muscle dysfunction is associated with activation of muscle proteolytic enzymes, and taurine is known to suppress proteolysis. We therefore postulated that taurine administration may prevent infection induced diaphragm dysfunction. The purpose of this study was to test this hypothesis using a clinically relevant animal model of infection, i.e. cecal ligation puncture induced sepsis (CLP). Studies were performed on (n = 5-7 mice/group): (a) sham operated controls, (b) animals with sepsis induced by CLP, (c) sham operated animals given taurine (75 mg/kg/d, intraperitoneally), and (d) CLP animals given taurine. At intervals after surgery animals were euthanized, diaphragm force generation measured in vitro, and diaphragm calpain, caspase and proteasomal activity determined. CLP elicited a large reduction in diaphragm specific force generation at 24 h (1-150 Hz, p < 0.001) and taurine significantly attenuated CLP induced diaphragm weakness at all stimulation frequencies (p < 0.001). CLP induced significant increases in diaphragm calpain, caspase and proteasomal activity; taurine administration prevented increases in the activity of all three pathways. In additional time course experiments, diaphragm force generation remained at control levels over 72 h in CLP animals treated with daily taurine administration, while CLP animals demonstrated severe, sustained reductions in diaphragm strength (p < 0.01 for all time points). Our results indicate that taurine administration prevents infection induced diaphragm weakness and reduces activation of three major proteolytic pathways. Because this agent is has been shown to be safe, non-toxic when administered to humans, taurine may have a role in treating infection induced diaphragm weakness. Future clinical studies will be needed to assess this possibility.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Lin Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Elizabeth A Schroder
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Leigh Ann P Callahan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States.
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Alali H, Kazzaz Y, Alshehri A, Antar M, Alhamouieh O, Hasan Z, Al-Surimi K. Reducing unnecessary delays during the transfer of patients from the paediatric intensive care unit to the general ward: a quality improvement project. BMJ Open Qual 2019; 8:e000695. [PMID: 31544165 PMCID: PMC6730600 DOI: 10.1136/bmjoq-2019-000695] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/31/2019] [Accepted: 08/13/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Delaying the discharge of paediatric intensive care unit (PICU) patients is directly proportional to increased occupancy rate and cost. We aimed to study the process of transferring patients from the PICU to the general ward in order to improve the timeliness of this process while guaranteeing patient safety. Methods A multidisciplinary quality improvement (QI) team was formed to analyse the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process, and applying turnaround time (TAT)-the duration from the time of clinical transfer decision until the physical transfer of the patient-as an outcome measure, aiming for a TAT of 4 hours. Results Baseline results showed that medical transfer decisions by PICU attending physicians were taken late for most patients: only 19% of decisions were made by 08:00 by the on-call team. Average TAT of the transfer process was over 7 hours, with duration ranging from 7 to 17 hours. After implementing all suggested improvement interventions, early decision compliance improved to 59%. TAT improved gradually, starting in January 2017, until it approached our target (284-261 min≈4 hours) in February-May 2017. Conclusion PICU patient transfer process delays can be reduced by early evaluation, timely team communication and proper preparation. It is recommended that all personnel with early involvement avoid unnecessary delays by paying more attention to all process steps, starting with the clinical decision, until the physical transfer. Standardising transfer processes might lead to a decrease in the length of PICU stay, which is a desirable outcome, but this observation needs further exploration.
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Affiliation(s)
- Hamza Alali
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yasser Kazzaz
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Alshehri
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohannad Antar
- Department of Pediatrics, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia
| | - Ousaima Alhamouieh
- Quality and Patient Safety Department, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia
| | - Zahra Hasan
- Nursing Services, Ministry of the National Gaurd-Health Affairs, Riyadh, Saudi Arabia
| | - Khaled Al-Surimi
- Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Primary Care and Public Health, Imperial college London, London, United Kingdom
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11
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Utilisation of critical care services for surgical patients in a model three hospital. Ir J Med Sci 2019; 188:1137-1142. [PMID: 30739245 DOI: 10.1007/s11845-019-01981-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The demand for intensive care unit (ICU) beds in the surgical population has increased in recent years. This is due to increased complexity of operative interventions, development of critical care services and improved availability of technologies. The number of beds in ICUs nationwide remains limited. In model three hospitals, this is further impacted by a lack of high dependency unit (HDU) facilities and difficulty with transfer of patients to tertiary centres. AIM To assess utilisation of ICU resources amongst general surgical patients admitted for elective and emergency procedures to Mayo University Hospital. METHODS A prospective study was conducted between 31/10/2016 and 01/11/2017 on general surgical patients admitted to the intensive care unit. The ICU register and ICU database were used to collect data regarding patient demographics, admission by specialty, ICU length of stay, interventions performed, level of care, infection status and antimicrobial usage. RESULTS Eight hundred seventy-three patients were admitted to the ICU. One hundred thirty-four (15.35%) were surgical admissions, of which 55 were elective and 79 were emergency. The most common cause for emergency admission to ICU was emergency laparotomy. Mean ICU length of stay (LOS) for surgical patients was 3.6 days. Three (2.2%) surgical patients were transferred to model four hospitals. CONCLUSIONS This study demonstrates the need to protect sufficient numbers of ICU beds for delivery of emergency surgical care. It highlights the potential utility of an HDU in this setting. The introduction of such a facility would impact cost savings and increase access for those requiring definitive ICU level care.
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12
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Kim JE, Lee S, Jeong J, Lee DH, Jeong JH. Intensive care unit admission protocol controlled by intensivists can reduce transfer delays from the emergency department in critically ill patients. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918789284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Delayed transfer of patients from the emergency department to the intensive care unit is associated with adverse clinical outcomes. Critically ill patients with delayed admission to the intensive care unit had higher in-hospital mortality and increased hospital length of stay. Objectives: We investigated the effects of an intensive care unit admission protocol controlled by intensivists on the emergency department length of stay among critically ill patients. Methods: We designed the intensive care unit admission protocol to reduce the emergency department length of stay in critically ill patients. Full-time intensivists determined intensive care unit admission priorities based on the severity of illness. Data were gathered from patients who were admitted from the emergency department to the intensive care unit between 1 April 2016 and 30 November 2016. We retrospectively analyzed the clinical data and compared the emergency department length of stay between patients admitted from the emergency department to the intensive care unit before and after intervention. Results: We included 292 patients, 120 and 172 were admitted before and after application of the intensive care unit admission protocol, respectively. The demographic characteristics did not differ significantly between the groups. After intervention, the overall emergency department length of stay decreased significantly from 1045.5 (425.3–1665.3) min to 392.0 (279.3–686.8) min (p < 0.001). Intensive care unit length of stay also significantly decreased from 6.0 (4.0–11.8) days to 5.0 (3.0–10.0) days (p = 0.015). Conclusion: Our findings suggest that introduction of the intensive care unit admission protocol controlled by intensivists successfully decreased the emergency department length of stay and intensive care unit length of stay among critically ill patients at our institution.
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Affiliation(s)
- Ji Eun Kim
- Department of Emergency Medicine, Dong-A University Hospital, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Seul Lee
- Department of Intensive Care Medicine, Dong-A University Hospital, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University Hospital, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Dong Hyun Lee
- Department of Intensive Care Medicine, Dong-A University Hospital, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Jin-Heon Jeong
- Department of Intensive Care Medicine, Dong-A University Hospital, College of Medicine, Dong-A University, Busan, Republic of Korea
- Department of Neurology, Stroke Center, Dong-A University Hospital, College of Medicine, Dong-A University, Busan, Republic of Korea
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Fernando SM, Neilipovitz D, Sarti AJ, Rosenberg E, Ishaq R, Thornton M, Kim J. Monitoring intensive care unit performance-impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol. BMJ Open 2018; 8:e019165. [PMID: 29358441 PMCID: PMC5781100 DOI: 10.1136/bmjopen-2017-019165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Patients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance is required. Performance scorecards are used by institutions for the purposes of driving quality improvement. There is no widely accepted or standardised scorecard that has been used for overall CCM performance. We aim to improve quality of care, patient safety and patient/family experience in CCM practice through the utilisation of a standardised, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics. METHODS AND ANALYSIS This will be a mixed-methods, controlled before and after study to assess the impact of a CCM-specific quality scorecard. Scorecard metrics were developed through expert consensus and existing literature. The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation are collected daily from bedside flow sheets. Preintervention baseline data will be collected for 6 months for each participant. After this, each participant will receive their scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics following the provision of scorecard feedback to subjects. A cost analysis will also be performed, with the purpose of comparing total ICU costs prior to implementation of the scorecard with total ICU costs following implementation of the scorecard. The qualitative portion will include interviews with participants following the intervention phase. Interviews will be analysed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement. ETHICS AND DISSEMINATION This protocol has been approved by the local research ethics board. Publication of results is anticipated in 2019. If this intervention is found to improve patient- and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilisation of such a scorecard as a quality standard in CCM.
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Affiliation(s)
- Shannon M Fernando
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - David Neilipovitz
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Aimee J Sarti
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Erin Rosenberg
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Rabia Ishaq
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Mary Thornton
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
| | - John Kim
- Department of Critical Care Medicine, The Ottawa Hospital, Ottawa, Canada
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14
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Teno JM, Gozalo P, Khandelwal N, Curtis JR, Meltzer D, Engelberg R, Mor V. Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents With Advanced Dementia and Intensive Care Unit Beds. JAMA Intern Med 2016; 176:1809-1816. [PMID: 27723891 PMCID: PMC5138104 DOI: 10.1001/jamainternmed.2016.5964] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Mechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit. OBJECTIVE To describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients' demographic characteristics, function, and comorbidities. MAIN OUTCOMES AND MEASURES Mechanical ventilation. RESULTS From 2000 to 2013, a total of 635 008 hospitalizations of 380 060 eligible patients occurred (30.5% male and 69.5% female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95% CI, 1.05-1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2% vs 64.6%; P = 54). CONCLUSIONS AND RELEVANCE Among hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time without substantial improvement in survival. This increase in the use of mechanical ventilation was associated with an increase in the number of ICU beds within a hospital.
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Affiliation(s)
- Joan M Teno
- Department of Gerontology and Geriatrics, University of Washington, Seattle2Cambia Palliative Care Center of Excellence, University of Washington Medicine, Seattle
| | - Pedro Gozalo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington Medicine, Seattle5Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle
| | - David Meltzer
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Ruth Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington Medicine, Seattle5Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island7Providence Veterans Administration Hospital, Providence, Rhode Island
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