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Hietbrink F, Mohseni S, Mariani D, Naess PA, Rey-Valcárcel C, Biloslavo A, Bass GA, Brundage SI, Alexandrino H, Peralta R, Leenen LPH, Gaarder T. What trauma patients need: the European dilemma. Eur J Trauma Emerg Surg 2024; 50:627-634. [PMID: 35798972 PMCID: PMC11249462 DOI: 10.1007/s00068-022-02014-w] [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: 02/25/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Diego Mariani
- Department of General Surgery, ASST Ovest Milanese, Milan, Italy
| | - Päl Aksel Naess
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | | | - Alan Biloslavo
- General Surgery Department, Cattinara University Hospital, Trieste, Italy
| | - Gary A Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA
| | - Susan I Brundage
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, USA
| | | | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
- Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic
- Hamad Injury Prevention Program, Hamad Trauma Center, Hamad General Hospital, Doha, Qatar
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tina Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
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2
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Johnson LA, Klucher B, Jensen H, Reif R, Kalkwarf KJ, Sexton K, Kimbrough MK. A closed surgical intensive care unit organization improves cardiac surgical patient outcomes. J Thorac Dis 2024; 16:1262-1269. [PMID: 38505036 PMCID: PMC10944794 DOI: 10.21037/jtd-22-1471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/19/2023] [Indexed: 03/21/2024]
Abstract
Background Intensive care unit (ICU) organization is a critical factor in optimizing patient outcomes. ICU organization can be divided into "OPEN" (O) and "CLOSED" (C) models, where the specialist or intensivist, respectively, assumes the role of primary physician. Recent studies support improved outcomes in closed ICUs, however, most of the available data is centered on ICUs generally or on subspecialty surgical patients in the setting of a subspecialized surgical intensive care unit (SICU). We examined the impact of closing a general SICU on patient outcomes following cardiac and ascending aortic surgery. Methods A retrospective cohort of patients following cardiac or ascending aortic surgery by median sternotomy was examined at a single academic medical center one year prior and one year after implementation of a closed SICU model. Patients were divided into "OPEN" (O; n=53) and "CLOSED" (C; n=73) cohorts. Results Cohorts were comparable in terms of age, race, and number of comorbid conditions. A significant difference in male gender (O: 60.4% vs. C: 76.7%, P=0.049), multiple procedure performed (O: 13.21% vs. C: 35.62%, P=0.019), and hospital readmission rates was detected (O: 39.6% vs. C: 9.6%, P=0.0003). Using a linear regression model, a closed model SICU organization decreased SICU length of stay (LOS). Using a multivariate logistic regression, being treated in a closed ICU decreased a patient's likelihood of having an ICU LOS greater than 48 hours. Conclusions Our study identified a decreased ICU LOS and hospital readmission in cardiac and ascending aortic patients in a closed general SICU despite increased procedure complexity. Further study is needed to clarify the effects on surgical complications and hospital charges.
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Affiliation(s)
- Lauren A. Johnson
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Brianna Klucher
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hanna Jensen
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca Reif
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J. Kalkwarf
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kevin Sexton
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Division of Pharmaceutical Evaluation and Policy (PEP), Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mary Katherine Kimbrough
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Ono S, Shimizu K. Analysis of the Association Between the Number of Intensivists and the Use of Cardiovascular Agonists: An Ecological Study Using Data From National Databases of Japan. Cureus 2023; 15:e48912. [PMID: 38024012 PMCID: PMC10653938 DOI: 10.7759/cureus.48912] [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] [Accepted: 11/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background Previous studies have demonstrated a correlation between management by intensivists and a decrease in hospital stay and mortality, yet the underlying reason remains unknown. Using open data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) and other databses, the present study aimed to explore the relationship between inotrope and vasoconstrictor use and the number of intensivists. Materials and methods Cardiovascular agonists listed in the 2020 NDB for which the total dose was known were included for analysis. Trends in cardiovascular agonist use over six years were then graphically assessed, and a linear regression model with the use of each target drug per prefecture as the objective variable in the 2020 data was created to analyze the impact of intensivists on drug use. Results A total of 61 drugs were classified into eight groups based on their composition, and drug use in each of the 47 prefectures was tabulated. Both the rate of use and cost showed a yearly decrease for dopamine but a yearly increase for norepinephrine. Multivariable analysis indicated that the number of intensivists was only significant for dopamine, which had a coefficient of -310 (95% CI: -548 to -72, p = 0.01) but that no such trend was evident for the other drugs. Conclusions The results demonstrated that an increasing number of intensivists in each prefecture correlated with decreasing use of dopamine, possibly explaining the improved outcomes observed in closed ICUs led by intensivists. Further research is warranted to establish causality.
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Affiliation(s)
- Shohei Ono
- Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, Saitama, JPN
| | - Keiki Shimizu
- Emergency and Critical Care Center, Tokyo Metropolitan Tama Medical Center, Tokyo, JPN
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Thacker C, Nealon K, Torres D, Leonard D, Young K, Rapp M. Fewer Levels of Dedicated Trauma Care Leads to Better Outcomes. Am Surg 2022:31348211069798. [PMID: 35098740 DOI: 10.1177/00031348211069798] [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: 11/15/2022]
Abstract
BACKGROUND Dedicated trauma intensive care units (ICUs) staffed by surgical intensivists lead to better patient outcomes. Increased length of stay (LOS) leads to worse outcomes. Little research has focused on the effect of dedicated trauma medical-surgical units or ICU/medicalsurgical systems. In 2018, our Level 1 trauma center transitioned from 3 non-dedicated levels of care (ICU/stepdown unit/medical-surgical) to 2 dedicated levels of care (ICU/medical-surgical). Our objective was to look at patient outcomes pre- and post-intervention. METHODS Retrospective analysis of trauma registry data was performed on patients (age ≥18) admitted to the trauma service at a Level 1 rural trauma center over 46-months. In the pre-intervention group, step down and medical-surgical patients were combined as "Non-ICU" for analysis. Standard statistical analysis was performed. RESULTS Analysis included 6103 patients. The group demographics were similar, except pre-intervention patients had higher ISS and fewer comorbidities. Emergency department LOS decreased from 30 versus 13.9% (P < .0001) and 15.9 versus 5.8% (P < .0001) for greater than 3 and 6 hours, respectively. Median LOS decreased for all patients (P < .0001). Mortality dropped from 9.0 versus 5.5% (P = .0009) for ICU and 1.7 versus 0.26% (P = .0013) for non-ICU patients. Overall patient mortality was level at 3.7%. Inpatient complications dropped from 9.9 versus 8.5% (P = .07). Unplanned ICU readmissions were unchanged (P = .4169). For patients with 3+ comorbidities, overall LOS dropped by 2 days (P < .0001) and home discharge increased from 42.8 versus 51% (P < .0001). CONCLUSION Implementation of 2 levels of dedicated care has decreased ED and hospital LOS for all trauma patients without increasing mortality or complications. Patients with extensive comorbidities saw the most improvements.
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Affiliation(s)
| | | | | | | | | | - Megan Rapp
- 21599Geisinger Medical Center, Danville, PA, USA
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Ko SJ, Cho J, Choi SM, Park YS, Lee CH, Yoo CG, Lee J, Lee SM. Impact of staffing model conversion from a mandatory critical care consultation model to a closed unit model in the medical intensive care unit. PLoS One 2021; 16:e0259092. [PMID: 34705879 PMCID: PMC8550369 DOI: 10.1371/journal.pone.0259092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The intensive care unit (ICU) staffing model affects clinical outcomes of critically ill patients. However, the benefits of a closed unit model have not been extensively compared to those of a mandatory critical care consultation model. METHODS This retrospective before-after study included patients admitted to the medical ICU. Anthropometric data, admission reason, Acute Physiology and Chronic Health Evaluation II score, Eastern Cooperative Oncology Group grade, survival status, length of stay (LOS) in the ICU, duration of mechanical ventilator care, and occurrence of ventilator-associated pneumonia (VAP) were recorded. The staffing model of the medical ICU was changed from a mandatory critical care consultation model to a closed unit model in September 2017, and indices before and after the conversion were compared. RESULTS A total of 1,526 patients were included in the analysis. The mean age was 64.5 years, and 954 (62.5%) patients were men. The mean LOS in the ICU among survivors was shorter in the closed unit model than in the mandatory critical care consultation model by multiple regression analysis (5.5 vs. 6.7 days; p = 0.005). Central venous catheter insertion (38.5% vs. 51.9%; p < 0.001) and VAP (3.5% vs. 8.6%; p < 0.001) were less frequent in the closed unit model group than in the mandatory critical care consultation model group. After adjusting for confounders, the closed unit model group had decreased ICU mortality (adjusted odds ratio 0.65; p < 0.001) and shortened LOS in the ICU compared to the mandatory critical care consultation model group. CONCLUSION The closed unit model was superior to the mandatory critical care consultation model in terms of ICU mortality and LOS among ICU survivors.
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Affiliation(s)
- Sung Jun Ko
- Department of Internal Medicine, Wonkwang University Sanbon Hospital, Gunpo, Republic of Korea
| | - Jaeyoung Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Sik Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail: (JL); (SML)
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail: (JL); (SML)
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van Klei WA, Hollmann MW, Sneyd JR. The value of anaesthesiologists in the COVID-19 pandemic: a model for our future practice? Br J Anaesth 2020; 125:652-655. [PMID: 32896431 PMCID: PMC7440078 DOI: 10.1016/j.bja.2020.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Markus W Hollmann
- Amsterdam University Medical Center, Academic Medical Center, Amsterdam, The Netherlands
| | - J Robert Sneyd
- Peninsula Medical School, University of Plymouth, Plymouth, UK
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Abe T, Komori A, Shiraishi A, Sugiyama T, Iriyama H, Kainoh T, Saitoh D. Trauma complications and in-hospital mortality: failure-to-rescue. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:223. [PMID: 32414401 PMCID: PMC7226721 DOI: 10.1186/s13054-020-02951-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/07/2020] [Indexed: 12/25/2022]
Abstract
Background Reducing medical errors and minimizing complications have become the focus of quality improvement in medicine. Failure-to-rescue (FTR) is defined as death after a surgical complication, which is an institution-level surgical safety and quality metric that is an important variable affecting mortality rates in hospitals. This study aims to examine whether complication and FTR are different across low- and high-mortality hospitals for trauma care. Methods This was a retrospective cohort study performed at trauma care hospitals registered at Japan Trauma Data Bank (JTDB) from 2004 to 2017. Trauma patients aged ≥ 15 years with injury severity score (ISS) of ≥ 3 and those who survived for > 48 h after hospital admission were included. The hospitals in JTDB were categorized into three groups by standardized mortality rate. We compared trauma complications, FTR, and in-hospital mortality by a standardized mortality rate (divided by the institute-level quartile). Results Among 184,214 patients that were enrolled, the rate of any complication was 12.7%. The overall mortality rate was 3.7%, and the mortality rate among trauma patients without complications was only 2.8% (non-precedented deaths). However, the mortality rate among trauma patients with any complications was 10.2% (FTR). Hospitals were categorized into high- (40 facilities with 44,773 patients), average- (72 facilities with 102,368 patients), and low- (39 facilities with 37,073 patients) mortality hospitals, using the hospital ranking of a standardized mortality rate. High-mortality hospitals showed lower ISS than low-mortality hospitals [10 (IQR, 9–18) vs. 11 (IQR, 9–20), P < 0.01]. Patients in high-mortality hospitals showed more complications (14.2% vs. 11.2%, P < 0.01), in-hospital mortality (5.1% vs. 2.5%, P < 0.01), FTR (13.6% vs. 7.4%, P < 0.01), and non-precedented deaths (3.6% vs. 1.9%, P < 0.01) than those in low-mortality hospitals. Conclusions Unlike reports of elective surgery, complication rates and FTR are associated with in-hospital mortality rates at the center level in trauma care.
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Affiliation(s)
- Toshikazu Abe
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan. .,Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | | | - Takehiro Sugiyama
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.,Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Takako Kainoh
- Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Daizoh Saitoh
- Department of Traumatology and Emergency Medicine, National Defense Medical College, Tokorozawa, Japan
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8
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Abstract
OBJECTIVE To identify hospital staffing models associated with failure to rescue (FTR) rates at low- and high-performing hospitals. BACKGROUND FTR is an important quality measure in surgical safety and is a metric that hospitals are seeking to improve. Specific unit-level determinants of FTR, however, remain unknown. METHODS Retrospective, observational study using data from the Michigan Quality Surgical Collaborative, which is a prospectively collected and clinically audited database in the state of Michigan. We identified 44,567 patients undergoing major general or vascular surgery from 2008 to 2012. Our main outcome measures were mortality, complications, and FTR rates. RESULTS Hospital rates of FTR across low, middle, and high tertiles were 8.9%, 16.5%, and 19.9%, respectively (P < 0.001). Low FTR hospitals tended to have a closed intensive care unit staffing model (56% vs 20%, P < 0.001) and a higher proportion of board-certified intensivists (88% vs 60%, P < 0.001) when compared to high FTR hospitals. There was also significantly more staffing of low FTR hospitals by hospitalists (85% vs 20%, P < 0.001) and residents (62% vs 40%, P < 0.01). Low FTR hospitals were noted to have more overnight coverage (75% vs 45%, P < 0.001) as well as a dedicated rapid response team (90% vs 60%, P < 0.001). CONCLUSIONS Low FTR hospitals had significantly more staffing resources than high FTR hospitals. Although hiring additional staff may be beneficial, there remain significant financial limitations for many hospitals to implement robust staffing models. Thus, our ongoing work seeks to improve rescue and implement effective staffing strategies within these constraints.
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9
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Plate JDJ, Peelen LM, Leenen LPH, Hietbrink F. Optimizing critical care of the trauma patient at the intermediate care unit: a cost-efficient approach. Trauma Surg Acute Care Open 2018; 3:e000228. [PMID: 30402563 PMCID: PMC6203138 DOI: 10.1136/tsaco-2018-000228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 02/03/2023] Open
Abstract
Background The aim of this study was to describe the case load, safety, and cost savings of critical care of the trauma patient provided at the surgical intermediate care unit (IMCU). Methods This cohort study included all trauma admissions between January 1, 2011 and January 7, 2015 at the general intensive care unit (ICU), stand-alone neuro(surgical) IMCU, and stand-alone (trauma) surgical IMCU. Trauma mechanism, Abbreviated Injury Scale score and Injury Severity Score (ISS), vital signs, laboratory parameters, admission duration, intubation duration, ICU transfer, and in-hospital mortality were prospectively collected. Hypothetical cost savings were calculated using the fixed cost price per IMCU (US$1500) and ICU (US$2500) admission day. Results A total of 1320 admissions were included, 675 (51.1%) at the IMCU and 645 (48.9%) at the ICU. Patients admitted at the IMCU had a median ISS of 17 (11, 22). Their median duration of admission was 32.8 hours (18.8, 62.5). At the IMCU, one patient died due to aneurogenic shock. A subsequent ICU transfer was required in 38 (5.6%) IMCU admissions. Of these transfers, four patients died due to neurological deterioration. At the ICU, the median ISS was 22 (14, 30). Nearly all (n=620, 96.3%) ICU trauma patients required mechanical ventilation. Expected total cost savings due to the presence of the IMCU were US$1 772 785. Discussion A substantial amount of trauma patients in need of critical care can safely be admitted at the IMCU, without the need for further mechanical ventilation. Thereby, the IMCU could fulfill an essential cost-saving role in the management of severely injured trauma patients. Level of evidence Level IV.
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Affiliation(s)
- Joost D J Plate
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda M Peelen
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands.,Departments of Anesthesiology and Intensive Care Medicine, Utrecht University, Utrecht, The Netherlands
| | - Luke P H Leenen
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Falco Hietbrink
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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10
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Plate JDJ, Peelen LM, Leenen LPH, Houwert RM, Hietbrink F. Joint management format at the mixed-surgical intermediate care unit: an interrupted time series analysis. Trauma Surg Acute Care Open 2018; 3:e000177. [PMID: 30402555 PMCID: PMC6203139 DOI: 10.1136/tsaco-2018-000177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/15/2018] [Indexed: 11/06/2022] Open
Abstract
Background The management format of the mixed-surgical intermediate care unit (IMCU) affects its performance. A format of combined supervision of surgeons with additional critical care certifications and admitting specialists, named the “joint format”, may herein be a promising new model of specialized critical care. This study aims to assess the performance of the joint management format. Methods This observational cohort study compared three IMCU management formats at the stand-alone, mixed-surgical IMCU of a tertiary referral hospital using interrupted time series analyses. All admissions from 2001 until 2015 were included. Predetermined criteria for performance (utilization, efficiency, and safety) were applied to three different management format periods: open (2001–2006), closed (2006–2011), and joint (2011–2015) formats. Results A total of 8894 admissions were analyzed. In terms of case load (utilization), there was an overall increase in the number of surgical patients (0.25%/year) (p<0.001), age (0.38/year) (p<0.001), and readmissions from the ward (0.16%/year) (p<0.001) and from the intensive care unit (ICU) (0.17%/year) (p=0.014). In terms of efficiency, the admission duration decreased (1.58 hours/year) (p<0.001). Transfer to the ICU within 24 hours, readmission within 24 hours from the ward, and unplanned mortality (eg, safety) did not change over time. Discussion At a time of increasingly complex case load, the joint format at the mixed-surgical IMCU is an efficient and safe management format in which the admitting specialist continues to provide specialized care. Specialty-specific supervision at IMCUs is a safe option which should be considered in healthcare policy decisions. Level of evidence Level IV.
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Affiliation(s)
- Joost D J Plate
- Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M Peelen
- Departments of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Luke P H Leenen
- Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Marijn Houwert
- Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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11
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Gotlib Conn L, Nathens AB, Perrier L, Haas B, Watamaniuk A, Daniel Pereira D, Zwaiman A, da Luz LT. What is the quality of reporting on guideline, protocol or algorithm implementation in adult trauma centres? Protocol for a systematic review. BMJ Open 2018; 8:e021750. [PMID: 29743331 PMCID: PMC5942428 DOI: 10.1136/bmjopen-2018-021750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/05/2018] [Accepted: 04/05/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). METHODS AND ANALYSIS We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate. ETHICS AND DISSEMINATION Results will be disseminated through scientific publication and conferences. PROSPERO REGISTRATION NUMBER CRD42018084273.
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Affiliation(s)
- Lesley Gotlib Conn
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Avery B Nathens
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- University of Toronto Libraries, Toronto, Ontario, Canada
| | - Barbara Haas
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Aaron Watamaniuk
- Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Diego Daniel Pereira
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Ashley Zwaiman
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Luis Teodoro da Luz
- Trauma, Emergency and Critical Care Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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12
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Al-Kindi SM, Naiem AA, Taqi KM, Al-Gheiti NM, Al-Toobi IS, Al-Busaidi NQ, Al-Harthy AZ, Taqi AM, Ba-Alawi SA, Al-Qadhi HA. Distribution of Trauma Care Facilities in Oman in Relation to High-Incidence Road Traffic Injury Sites: Pilot study. Sultan Qaboos Univ Med J 2018; 17:e430-e435. [PMID: 29372085 DOI: 10.18295/squmj.2017.17.04.009] [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: 03/15/2017] [Revised: 05/23/2017] [Accepted: 07/13/2017] [Indexed: 11/16/2022] Open
Abstract
Objectives Road traffic injuries (RTIs) are considered a major public health problem worldwide. In Oman, high numbers of RTIs and RTI-related deaths are frequently registered. This study aimed to evaluate the distribution of trauma care facilities in Oman with regards to their proximity to RTI-prevalent areas. Methods This descriptive pilot study analysed RTI data recorded in the national Royal Oman Police registry from January to December 2014. The distribution of trauma care facilities was analysed by calculating distances between areas of peak RTI incidence and the closest trauma centre using Google Earth and Google Maps software (Google Inc., Googleplex, Mountain View, California, USA). Results A total of 32 trauma care facilities were identified. Four facilities (12.5%) were categorised as class V trauma centres. Of the facilities in Muscat, 42.9% were ranked as class IV or V. There were no class IV or V facilities in Musandam, Al-Wusta or Al-Buraimi. General surgery, orthopaedic surgery and neurosurgery services were available in 68.8%, 59.3% and 12.5% of the centres, respectively. Emergency services were available in 75.0% of the facilities. Intensive care units were available in 11 facilities, with four located in Muscat. The mean distance between a RTI hotspot and the nearest trauma care facility was 34.7 km; however, the mean distance to the nearest class IV or V facility was 83.3 km. Conclusion The distribution and quality of trauma care facilities in Oman needs modification. It is recommended that certain centres upgrade their levels of trauma care in order to reduce RTI-associated morbidity and mortality in Oman.
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Affiliation(s)
- Sara M Al-Kindi
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Ahmed A Naiem
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Kadhim M Taqi
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Najla M Al-Gheiti
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Ikhtiyar S Al-Toobi
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Nasra Q Al-Busaidi
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Ahmed Z Al-Harthy
- General Surgery Residency Programme, Oman Medical Specialty Board, Muscat, Oman
| | - Alaa M Taqi
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Sharif A Ba-Alawi
- College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Hani A Al-Qadhi
- Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
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13
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Cnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, Nelson D, Ercole A, Stocchetti N, Citerio G, Peul WC, Maas AIR, Menon D, Steyerberg EW, Lingsma HF. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:233. [PMID: 28874206 PMCID: PMC5586023 DOI: 10.1186/s13054-017-1816-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/10/2017] [Indexed: 11/23/2022]
Abstract
Background No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI. Methods A 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. Results The survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%). Conclusions Substantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1816-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.
| | - Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David Menon
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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14
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Fanari Z, Barekatain A, Kerzner R, Hammami S, Weintraub WS, Maheshwari V. Impact of a Multidisciplinary Team Approach Including an Intensivist on the Outcomes of Critically Ill Patients in the Cardiac Care Unit. Mayo Clin Proc 2016; 91:1727-1734. [PMID: 28126152 PMCID: PMC5283841 DOI: 10.1016/j.mayocp.2016.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 07/27/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the impact of integrating a medical intensivist into a cardiac care unit (CCU) multidisciplinary team on the outcomes of CCU patients. PATIENTS AND METHODS We conducted a retrospective cohort study of 2239 CCU admissions between July 1, 2011, and July 1, 2013, which constituted patients admitted in the 12 months before and 12 months after the introduction of intensivists into the CCU multidisciplinary team. This team included a cardiologist, a medical intensivist, medical house staff, nurses, a pharmacist, a dietitian, and physical and respiratory therapists. The primary outcome was CCU mortality. Secondary outcomes included hospital mortality, CCU length of stay, hospital length of stay, and duration of mechanical ventilation. RESULTS After the implementation of a multidisciplinary team approach, there was a significant decrease in both adjusted CCU mortality (3.5% vs 5.9%; P=.01) and hospital mortality (4.4% vs 11.1%; P<.01). A similar impact was observed on adjusted mean CCU length of stay (2.5±2.0 vs 2.9±2.0 days; P<.01), adjusted mean hospital length of stay (7.0±4.5 vs 7.5±4.5 days; P<.01), and adjusted mean ventilation duration (2.0±1.0 vs 4.3±2.5 days; P<.01). CONCLUSION The implementation of a multidisciplinary team approach in which an intensivist and a cardiologist comanage the critical care of CCU patients is feasible and may result in better patient outcomes.
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Affiliation(s)
- Zaher Fanari
- Division of Cardiovascular Diseases, University of Kansas School of Medicine, Kansas City, KS; Division of Cardiology, Christiana Care Health System, Newark, DE.
| | - Armin Barekatain
- Division of Cardiology, Christiana Care Health System, Newark, DE
| | - Roger Kerzner
- Division of Cardiology, Christiana Care Health System, Newark, DE
| | - Sumaya Hammami
- Division of Cardiovascular Diseases, University of Kansas School of Medicine, Kansas City, KS
| | - William S Weintraub
- Division of Cardiology, Christiana Care Health System, Newark, DE; Value Institute, Christiana Care Health System, Newark, DE
| | - Vinay Maheshwari
- Division of Pulmonary and Critical Care, Christiana Care Health System, Newark, DE
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15
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Boyd O, Evans L. The future workforce of our Intensive Care Units - Doctor, physician assistant or no-one? J Intensive Care Soc 2016; 17:186-190. [PMID: 28979489 DOI: 10.1177/1751143716638375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Owen Boyd
- Intensive Care Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Lynn Evans
- Acute and Intensive Care Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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16
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Abstract
OBJECTIVES To provide an overview of key elements of the Affordable Care Act. To evaluate ways in which the Affordable Care Act will likely impact the practice of critical care medicine. To describe strategies that may help health systems and providers effectively adapt to changes brought about by the Affordable Care Act. DATA SOURCES AND SYNTHESIS Data sources for this concise review include search results from the PubMed and Embase databases, as well as sources relevant to public policy such as the text of the Patient Protection and Affordable Care Act and reports of the Congressional Budget Office. As all of the Affordable Care Act's provisions will not be fully implemented until 2019, we also drew upon cost, population, and utilization projections, as well as the experience of existing state-based healthcare reforms. CONCLUSIONS The Affordable Care Act represents the furthest reaching regulatory changes in the U.S. healthcare system since the 1965 Medicare and Medicaid provisions of the Social Security Act. The Affordable Care Act aims to expand health insurance coverage to millions of Americans and place an emphasis on quality and cost-effectiveness of care. From models which link pay and performance to those which center on episodic care, the Affordable Care Act outlines sweeping changes to health systems, reimbursement structures, and the delivery of critical care. Staffing models that include daily rounding by an intensivist, palliative care integration, and expansion of the role of telemedicine in areas where intensivists are inaccessible are potential strategies that may improve quality and profitability of ICU care in the post-Affordable Care Act era.
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Affiliation(s)
- Anjali P Dogra
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD
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17
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Sim J, Lee J, Lee JCJ, Heo Y, Wang H, Jung K. Risk factors for mortality of severe trauma based on 3 years' data at a single Korean institution. Ann Surg Treat Res 2015; 89:215-9. [PMID: 26448920 PMCID: PMC4595822 DOI: 10.4174/astr.2015.89.4.215] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 04/17/2015] [Accepted: 05/12/2015] [Indexed: 11/30/2022] Open
Abstract
PURPOSE This study aimed to determine the mortality rate in patients with severe trauma and the risk factors for trauma mortality based on 3 years' data in a regional trauma center in Korea. METHODS We reviewed the medical records of severe trauma patients admitted to Ajou University Hospital with an Injury Severity Score (ISS) > 15 between January 2010 and December 2012. Pearson chi-square tests and Student t-tests were conducted to examine the differences between the survived and deceased groups. To identify factors associated with mortality after severe trauma, multivariate logistic regression was performed. RESULTS There were 915 (743 survived and 172 deceased) enrolled patients with overall mortality of 18.8%. Age, blunt trauma, systolic blood pressure (SBP) at admission, Glasgow Coma Scale (GCS) at admission, head or neck Abbreviated Injury Scale (AIS) score, and ISS were significantly different between the groups. Age by point increase (odds ratio [OR], 1.016; P = 0.001), SBP ≤ 90 mmHg (OR, 2.570; P < 0.001), GCS score ≤ 8 (OR, 6.229; P < 0.001), head or neck AIS score ≥ 4 (OR, 1.912; P = 0.003), and ISS by point increase (OR, 1.042; P < 0.001) were significant risk factors. CONCLUSION In severe trauma patients, age, initial SBP, GCS score, head or neck AIS score, and ISS were associated with mortality.
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Affiliation(s)
- Joohyun Sim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jaeheon Lee
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea
| | | | - Yunjung Heo
- Department of Medical Humanities and Social Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Heejung Wang
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Kyoungwon Jung
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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18
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Timmers TK, Verhofstad MHJ, Leenen LPH. Intensive care organisation: Should there be a separate intensive care unit for critically injured patients? World J Crit Care Med 2015; 4:240-243. [PMID: 26261775 PMCID: PMC4524820 DOI: 10.5492/wjccm.v4.i3.240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 03/12/2015] [Accepted: 04/29/2015] [Indexed: 02/06/2023] Open
Abstract
In the last two decennia, the mixed population general intensive care unit (ICU) with a “closed format” setting has gained in favour compared to the specialized critical care units with an “open format” setting. However, there are still questions whether surgical patients benefit from a general mixed ICU. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requiring immediate surgical intervention and/or intensive care treatment. The role and type of the ICU has received very little attention in the literature when analyzing outcomes from critical injuries. Severely injured patients require the years of experience in complex trauma care that only a surgery/trauma ICU can provide. Should a trauma center have the capability of a separate specialized ICU for trauma patients (“closed format”) next to its standard general mixed ICU
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19
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Gomez D, Alali AS, Haas B, Xiong W, Tien H, Nathens AB. Temporal trends and differences in mortality at trauma centres across Ontario from 2005 to 2011: a retrospective cohort study. CMAJ Open 2014; 2:E176-82. [PMID: 25295237 PMCID: PMC4183166 DOI: 10.9778/cmajo.20140007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Care in a trauma centre is associated with significant reductions in mortality after severe injury. However, emerging evidence suggests that outcomes across similarly accredited trauma centres are not equivalent, even after adjusting for case-mix. The primary objective of this analysis was to evaluate secular trends in overall mortality at trauma centres. Secondarily, we explored trauma centre-specific mortality to determine the extent of variation between centres. METHODS Data on 26 421 adults (≥□18 yr) admitted to a trauma centre between 2005 and 2011 were derived from the Ontario Trauma Registry. We used generalized estimating equations to calculate in-hospital mortality over time and hierarchical models to estimate trauma-centre-specific mortality. To quantify variability between centres, we calculated median odds ratios. Adjusted odds of death were calculated for each trauma centre to identify those with higher than expected, average and lower than expected mortality. RESULTS Overall mortality at trauma centres decreased from 13.2% in 2005 to 11.2% in 2009. After adjusting for case mix, the odds of death decreased by approximately 3% a year (95% confidence interval 0%-5%). Trauma centre-specific mortality ranged from 11.4% to 13.1%. After adjusting for case mix, differences in trauma centre-specific mortality were observed (median odds ratio = 1.25), suggesting that the odds of dying could be 1.25-fold greater if the same patient was admitted to 1 randomly selected trauma centre as opposed to another. Differences were most pronounced for patients with isolated head injuries and among older patients as evidenced by higher median odds ratios and the number of outliers. INTERPRETATION We observed a significant improvement over time in the mortality of severely injured patients cared for at Ontario's trauma centres. However, considerable differences in trauma centre-specific mortality were observed. Differences were most pronounced among older injured patients and those with isolated traumatic brain injury. System-wide performance improvement initiatives should target these subgroups.
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Affiliation(s)
- David Gomez
- Department of Surgery and Division of General Surgery, University of Toronto, Toronto, Ont
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Aziz S. Alali
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont
| | - Barbara Haas
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont
| | - Wei Xiong
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Homer Tien
- Department of Surgery and Division of General Surgery, University of Toronto, Toronto, Ont
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Avery B. Nathens
- Department of Surgery and Division of General Surgery, University of Toronto, Toronto, Ont
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ont
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20
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Park CM, Chun HK, Lee DS, Jeon K, Suh GY, Jeong JC. Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit. Ann Surg Treat Res 2014; 86:319-24. [PMID: 24949324 PMCID: PMC4062451 DOI: 10.4174/astr.2014.86.6.319] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 01/29/2014] [Accepted: 02/07/2014] [Indexed: 11/30/2022] Open
Abstract
Purpose An intensivist is a key factor in the mortality of patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an intensivist on clinical outcomes of patients admitted to a surgical ICU. Methods During the study period, the surgical ICU was converted from an open ICU to an intensivist-directed ICU managed by an intensivist who was board certified in both general surgery and critical care medicine. We compared consecutive patients admitted to the surgical ICU before and after implementing the intensivist-directed care. The primary outcome was ICU mortality, and secondary outcomes were hospital mortality, 90-day mortality, length of hospital stay, ICU-free days, ventilator-free days, and ICU readmission rate. Results A total of 441 patients were included in this study: 188 before implementation of the intensivist and 253 after implementation. Clinical characteristics were not different between the two groups. ICU mortality decreased from 11.7% to 6.3% (P = 0.047) after implementation, and 90-day mortality also decreased significantly (P = 0.008). The adjusted hazard ratio of the intensivist for ICU mortality was 0.43 (95% confidence interval, 0.22-0.87; P = 0.020). ICU-free days (P = 0.013) and the hospital length of stay (P = 0.032) were significantly improved after implementing the intensivist-directed care. Before implementation period, 16.0% of patients were readmitted, compared with only 9.9% after implementation (P = 0.05). Conclusion Implementing intensivist-directed care in the surgical ICU was associated with significant improvements in ICU mortality and significant clinical outcomes.
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Affiliation(s)
- Chi-Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dae-Sang Lee
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Cheol Jeong
- Department of Surgery, Hallym University Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Korea
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Abstract
PURPOSE Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma. MATERIALS AND METHODS A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS)>15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient's probability of survival. RESULTS Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001). CONCLUSION The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.
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Affiliation(s)
- Kil Dong Kim
- Department of Thoracic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Jun Wan Lee
- Division of Trauma and Surgical Critical Care, Eulji University Hospital, Daejeon, Korea
| | - Hyeung Keun Park
- Department of Health Policy and Management, School of Medicine, Jeju National University, Jeju, Korea
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Abstract
Infrastructure, processes of care and outcome measurements are the cornerstone of quality care for pediatric trauma. This review aims to evaluate current evidence on system organization and concentration of pediatric expertise in the delivery of pediatric trauma care. It discusses key quality indicators for all phases of care, from pre-hospital to post-discharge recovery. In particular, it highlights the importance of measuring quality of life and psychosocial recovery for the injured child.
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Affiliation(s)
- Amelia J Simpson
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
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23
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Bajwa SS, Kaur J, Bajwa SK, Kaur G, Singh A, Parmar SS, Kapoor V. Designing, managing and improving the operative and intensive care in polytrauma. J Emerg Trauma Shock 2012; 4:494-500. [PMID: 22090744 PMCID: PMC3214507 DOI: 10.4103/0974-2700.86642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 02/24/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND CONTEXT Polytrauma is a leading cause of mortality in the developing countries and efforts from various quarters are required to deal with this increasing menace. AIMS AND OBJECTIVES An attempt has been made by the coordinated efforts of the intensive care and trauma team of a newly established tertiary care institute in designing and improving the trauma care services to realign its functions with national policies by analyzing the profile of polytrauma victims and successfully managing them. MATERIALS AND METHODS A retrospective analysis was carried out among the 531 polytrauma admissions in the emergency department. The information pertaining to age and gender distribution, locality, time to trauma and initial resuscitation, cause of injury, type of injury, influence of alcohol, drug addiction, presenting clinical picture, Glasgow Coma score on admission and few other variables were also recorded. The indications for various operative interventions and intensive care unit (ICU) admissions were analyzed thoroughly with a concomitant improvement of our trauma care services and thereby augmenting the national policies and programs. A statistical analysis was carried out with chi-square and analysis of variance ANOVA tests, using SPSS software version 10.0 for windows. The value of P<0.05 was considered significant and P<0.0001 as highly significant. RESULTS Majority of the 531 polytrauma patients hailed from rural areas (63.65%), riding on the two wheelers (38.23%), and predominantly comprised young adult males. Fractures of long bones and head injury was the most common injury pattern (37.85%) and 51.41% of the patients presented with shock and hemorrhage. Airway management and intubation became necessary in 42.93% of the patients, whereas 52.16% of the patients were operated within the first 6 hours of admission for various indications. ICU admission was required for 45.76% of the patients because of their deteriorating clinical condition, and overall,ionotropic support was administered in 55.93% of the patients for successful resuscitation. CONCLUSIONS There is an urgent need for proper implementation ofpre-hospital and advanced trauma life support measures at grass-root level. Analyzing the profile of polytrauma victims at a national level and simultaneously improving the trauma care services at every health center are very essential to decrease the mortality and morbidity. The improvement can be augmented further by strengthening the rural health infrastructure, strict traffic rules, increasing public awareness and participation and coordination among the various public and private agencies in dealing with polytrauma.
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Affiliation(s)
- Sukhminderjit Singh Bajwa
- Department of Anaesthesiology & Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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Markandaya M, Thomas KP, Jahromi B, Koenig M, Lockwood AH, Nyquist PA, Mirski M, Geocadin R, Ziai WC. The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists. Neurocrit Care 2012; 16:72-81. [PMID: 21922343 DOI: 10.1007/s12028-011-9628-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences. METHODS An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training. RESULTS The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care. CONCLUSION Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.
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Affiliation(s)
- Manjunath Markandaya
- Divison of Neurosciences Critical Care, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Petitti D, Bennett V, Chao Hu CK. Association of changes in the use of board-certified critical care intensivists with mortality outcomes for trauma patients at a well-established level I urban trauma center. J Trauma Manag Outcomes 2012; 6:3. [PMID: 22394687 PMCID: PMC3313879 DOI: 10.1186/1752-2897-6-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 03/06/2012] [Indexed: 11/24/2022]
Abstract
Background An intensivist-directed Intensive Care Unit is a closed-model unit in which a physician formally trained in critical care plays a leadership role in patient management. In the last decade, there has been a move toward closed Intensive Care Units. The purpose of this evaluation was to assess the association of changes in the use of intensivists to a closed-model with mortality outcomes in injured patients seen in a long-established urban Level I Trauma Center. Methods This analysis used data from the Scottsdale Healthcare Osborn Medical Center trauma registry from January 1, 2002-December 31, 2008. Mortality prior to hospital discharge was compared in the pre-intensivist (intensivists were not employed and did not provide care), partial intensivist (intensivists were employed and provided care during some Intensive Care Unit shifts) and full-time intensivist (intensivists were employed and provided care in the Intensive Care Unit full time) periods. Multiple logistic regression analysis was used to estimate odds ratios for mortality adjusting for patient characteristics and injury severity for the partial intensivist and full-time intensivist periods compared with the pre-intensivist period. Results Of 18,918 patients, 365 (1.9%) died before hospital discharge. After adjustment for demographic factors and injury severity score, for all patients, odds ratios comparing the partial intensivist and full-intensivist periods with the pre-intensivist period were 0.84 (95% confidence interval 0.64-1.11) and 0.99 (95% confidence interval 0.69-1.41). In patients with an injury severity score 16-24, the adjusted OR for death was 0.20 (95% CI 0.07-0.58) comparing the partial-intensivist with the pre-intensivist period and 0.30 (95% CI 0.11-0.88) comparing the full-time intensivist period with the pre-intensivist period. For patients age 65 + years, compared with the pre-intensivist period, odds ratio were 0.51 (95% confidence interval 0.31-0.84) and 0.61 (95% confidence interval 0.32-1.16) for the partial and full-time intensivist periods respectively. Conclusions In our setting, a change to a closed Intensive Care Unit model was associated with improved mortality outcomes in patients with less severe injuries and patients age 65+ years.
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Affiliation(s)
- Diana Petitti
- Center for Health Information and Research, Arizona and the Division of Trauma Care Services, Scottsdale Healthcare Osborn Medical Center, Arizona State University, Phoenix, USA.
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Juneja D, Nasa P, Singh O. Physician staffing pattern in intensive care units: Have we cracked the code? World J Crit Care Med 2012. [PMID: 24701396 DOI: 10.5492/wjccm.v1.i1.10.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a "turf" war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.
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Affiliation(s)
- Deven Juneja
- Deven Juneja, Prashant Nasa, Omender Singh, Max Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110092, India
| | - Prashant Nasa
- Deven Juneja, Prashant Nasa, Omender Singh, Max Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110092, India
| | - Omender Singh
- Deven Juneja, Prashant Nasa, Omender Singh, Max Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110092, India
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Juneja D, Nasa P, Singh O. Physician staffing pattern in intensive care units: Have we cracked the code? World J Crit Care Med 2012; 1:10-4. [PMID: 24701396 PMCID: PMC3956065 DOI: 10.5492/wjccm.v1.i1.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/20/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a “turf” war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.
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Affiliation(s)
- Deven Juneja
- Deven Juneja, Prashant Nasa, Omender Singh, Max Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110092, India
| | - Prashant Nasa
- Deven Juneja, Prashant Nasa, Omender Singh, Max Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110092, India
| | - Omender Singh
- Deven Juneja, Prashant Nasa, Omender Singh, Max Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110092, India
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Glance LG, Dick AW, Osler TM, Meredith JW, Stone PW, Li Y, Mukamel DB. Relationship between Leapfrog Safe Practices Survey and outcomes in trauma. ACTA ACUST UNITED AC 2011; 146:1170-7. [PMID: 22006876 DOI: 10.1001/archsurg.2011.247] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the association between hospital self-reported compliance with the National Quality Forum patient safety practices and trauma outcomes in a nationally representative sample of level I and level II trauma centers. DESIGN Retrospective cohort study using the Nationwide Inpatient Sample. SETTING Level I and level II trauma centers. PATIENTS Trauma patients. MAIN OUTCOME MEASURES Multivariate logistic regression models were estimated to examine the association between clinical outcomes (in-hospital mortality and hospital-associated infections) and the National Quality Forum patient safety practices. We controlled for patient demographic characteristics, injury severity, mechanism of injury, comorbidities, and hospital characteristics. RESULTS The total score on the Leapfrog Safe Practices Survey was not associated with either mortality (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.79-1.06) or hospital-associated infections (1.03; 0.82-1.29). Full implementation of computerized physician order entry was not associated with reduced mortality (aOR, 1.03; 95% CI, 0.75-1.42) or with a lower risk of hospital-associated infections (0.94; 0.57-1.56). Full implementation of intensive care unit physician staffing was also not predictive of mortality (aOR, 1.13; 95% CI, 0.90-1.28) or of hospital-associated infections (1.04; 0.76-1.42). CONCLUSION In this nationally representative sample of level I and level II trauma centers, we were unable to detect evidence that hospitals reporting better compliance with the National Quality Forum patient safety practices had lower mortality or a lower incidence of hospital-associated infections.
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Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology, University of Rochester School of Medicine, Rochester, NY 14642, USA.
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Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act. Crit Care Res Pract 2011; 2011:170814. [PMID: 22110908 PMCID: PMC3206504 DOI: 10.1155/2011/170814] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 09/04/2011] [Indexed: 01/16/2023] Open
Abstract
The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.
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Duane TM, Rao IR, Aboutanos MB, Wolfe LG, Malhotra AK. Are trauma patients better off in a trauma ICU? J Emerg Trauma Shock 2011; 1:74-7. [PMID: 19561984 PMCID: PMC2700612 DOI: 10.4103/0974-2700.43183] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 08/21/2008] [Indexed: 01/15/2023] Open
Abstract
UNLABELLED There is very little data on the value of specialized intensive care unit (ICU) care in the literature. To determine if specialize ICU care for the trauma patient improved outcomes in this patient population. Level I Trauma Center Compared outcomes of trauma patients treated in a surgical trauma ICU (STICU) to those treated in non- trauma ICUs (non-STICU). Retrospective review of trauma registry data. STATISTICAL ANALYSIS Wilcoxon Rank Test, Fischer's Exact test, logistic regression. There were 1146 STICU patients compared to 1475 non-STICU. In all ISS groups there were more penetrating trauma patients in the STICU (32.54% STICU vs. 18.15% non-STICU, P<0.0001 (ISS< 15)), (21.03% STICU vs. 12.98% non-STICU, P=0.0074 (ISS between 15-25)), and (19.42% STICU vs. 11.35% non-STICU, P=0.0026 (ISS> 25)). All groups had similar lengths of stay. The blunt trauma patients were sicker in the STICU (20.8 ISS +/- 12.2 STICU vs. 19.7 ISS +/- 11.9 non-STICU, P=0.03) yet had similar outcomes to the non-STICU group. Logistic regression identified penetrating trauma and not ICU location as a predictor of mortality. Sicker STICU patients do as well as less injured non-STICU patients. Severely injured patients should be preferentially treated in a STICU where they are better equipped to care for the complex multi-trauma patient. All patients, regardless of location, do well when their management is guided by a surgical critical care team.
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Affiliation(s)
- Therese M Duane
- Department of Surgery, Division of Trauma, Critical Care and Emergency General Surgery, Virginia Commonwealth University Medical Center, VA 23298
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Watson GA, Alarcon LH. Intensivists: don't quit your day job...yet! CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:305. [PMID: 20377922 PMCID: PMC2887139 DOI: 10.1186/cc8910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gregory A Watson
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Kim MM, Barnato AE, Angus DC, Fleisher LA, Fleisher LF, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. ACTA ACUST UNITED AC 2010; 170:369-76. [PMID: 20177041 DOI: 10.1001/archinternmed.2009.521] [Citation(s) in RCA: 331] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care. METHODS We conducted a population-based retrospective cohort study of medical patients admitted to Pennsylvania acute care hospitals (N = 169) from July 1, 2004, to June 30, 2006, linking a statewide hospital organizational survey to hospital discharge data. Multivariate logistic regression was used to determine the independent relationship between daily multidisciplinary rounds and 30-day mortality. RESULTS A total of 112 hospitals and 107 324 patients were included in the final analysis. Overall 30-day mortality was 18.3%. After adjusting for patient and hospital characteristics, multidisciplinary care was associated with significant reductions in the odds of death (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76-0.93 [P = .001]). When stratifying by intensivist physician staffing, the lowest odds of death were in intensive care units (ICUs) with high-intensity physician staffing and multidisciplinary care teams (OR, 0.78; 95% CI, 0.68-0.89 [P < .001]), followed by ICUs with low-intensity physician staffing and multidisciplinary care teams (OR, 0.88; 95% CI, 0.79-0.97 [P = .01]), compared with hospitals with low-intensity physician staffing but without multidisciplinary care teams. The effects of multidisciplinary care were consistent across key subgroups including patients with sepsis, patients requiring invasive mechanical ventilation, and patients in the highest quartile of severity of illness. CONCLUSIONS Daily rounds by a multidisciplinary team are associated with lower mortality among medical ICU patients. The survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary teams in high-intensity physician-staffed ICUs.
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Affiliation(s)
- Michelle M Kim
- Department of Health Care Management and Economics, Wharton School of Business, University of Pennsylvania, Philadelphia, PA 19104, USA
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Ala-Kokko TI, Ohtonen P, Koskenkari J, Laurila JJ. Improved outcome after trauma care in university-level intensive care units. Acta Anaesthesiol Scand 2009; 53:1251-6. [PMID: 19681781 DOI: 10.1111/j.1399-6576.2009.02072.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Centralized trauma care has been shown to be associated with improved patient outcome. We compared the outcomes of trauma patients in relation to the size of the intensive care unit (ICU) using a large Finnish database. METHODS A national prospectively collected ICU data registry was used for analysis. All adult trauma admissions excluding isolated head trauma and burns registered from July 1999 to December 2006 were analyzed. Data from 22 ICUs were available. The non-university-affiliated units were categorized according to the number of beds and referral population as small, mid size and large. Acute physiology and chronic health evaluation (APACHE II)- and sequential organ failure assessment (SOFA)-adjusted mortalities were compared between the units. RESULTS There were 2067 trauma admissions that fulfilled the inclusion criteria; 38% were treated in the university hospitals, 26% in large non-teaching ICUs, 20% in mid size ICUs and 15% in small ICUs. The crude hospital mortality was 5.6%, being 4.7% in university ICU and 6.6% in mid size ICU. In two subgroup analyses of severely ill trauma patients with APACHE II points >25 or SOFA score >8 points, respectively, hospital mortality was significantly lower in university ICUs. CONCLUSIONS University-level hospitals were associated with better outcomes with critically ill trauma patients. These results can be used in planning future organization of trauma patient care in Finland.
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Affiliation(s)
- T I Ala-Kokko
- Departments of Anesthesiology and Surgery, Division of Intensive Care, Oulu University Hospital, Oulu, Finland.
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Ang DN, Rivara FP, Nathens A, Jurkovich GJ, Maier RV, Wang J, MacKenzie EJ. Complication rates among trauma centers. J Am Coll Surg 2009; 209:595-602. [PMID: 19854399 PMCID: PMC2768077 DOI: 10.1016/j.jamcollsurg.2009.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Revised: 08/04/2009] [Accepted: 08/07/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND The goal of this study was to examine the association between patient complications and admission to Level I trauma centers (TC) compared with nontrauma centers (NTC). STUDY DESIGN This was a retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 Level I TCs and 51 NTCs in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified, as was the presence or absence of 13 specific complications. RESULTS Patients treated in TCs were more likely to have any complication compared with patients in NTCs, with an adjusted relative risk (RR) of 1.34 (95% CI, 1.03, 1.74). For individual complications, only the urinary tract infection RR of 1.94 (95% CI, 1.07, 3.17) was significantly higher in TCs. TC patients were more likely to have 3 or more complications (RR, 1.83; 95% CI, 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500 mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TCs. CONCLUSIONS Trauma centers have a slightly higher incidence rate of complications, even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. Pulmonary artery catheter use and intubation had the most influence on overall TC complication rates. Additional study is needed to provide accurate benchmark measures of complication rates and to determine their causes.
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Affiliation(s)
- Darwin N Ang
- Department of Surgery, University of Washington, Seattle, WA
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Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers. ACTA ACUST UNITED AC 2009; 66:1327-35. [PMID: 19430235 DOI: 10.1097/ta.0b013e31819ea047] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We sought to identify patient and institutional variables predictive of a withdrawal of care order (WOCO) in trauma patients. We hypothesized that the frequency of WOCO would be higher at trauma centers. METHODS Data from the National Study on the Costs and Outcomes of Trauma were used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. chi, t tests, and multivariate analysis were used to identify variables predictive of WOCO. RESULTS Of 14,190 patients, 618 (4.4%) had WOCO, which accounted for 60.9% of patients who died in hospital. Age (p = <0.001), race (p = <0.001), comorbidity (p = <0.001), and injury mechanism were associated with WOCO (p = 0.03). WOCO patients had higher New Injury Severity Score (p = <0.001), lower Glasgow Coma Scale motor scores (p = <0.001), and higher incidence of midline shift on head computed tomography (p = 0.01). Trauma center status (odds ratio, 1.56; 95% confidence interval, 1.06-2.30) and closed intensive care units (odds ratio, 1.53; 95% confidence interval, 1.03-2.25) were also predictive of a WOCO. There was a sizable variation (0%-16%) in the percentage of patients with WOCO across centers. CONCLUSION Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed intensive care units are predictive of a WOCO, variation in the percentage of patients with WOCO across all centers speaks to the complexity of these decisions. Further investigation is needed to understand how a WOCO is applied to trauma patients.
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Abstract
OBJECTIVES To evaluate the effect of age on intensity of care provided to traumatically brain-injured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity. DESIGN Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients. SETTING AND PATIENTS A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25-84 yrs with a diagnosis of traumatic brain injury. MEASUREMENTS Injury severity was determined by the motor component of the Glasgow Coma Scale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy. MAIN RESULTS Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75-84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a do-not-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0). CONCLUSIONS There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, their consultation was associated with decreased risk of in-hospital death and death within 12 months. It is important that careproviders have an increased awareness of the potential contribution of multidisciplinary clinical decision making to patient outcomes in older traumatically brain-injured patients.
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Treggiari MM, Martin DP, Yanez ND, Caldwell E, Hudson LD, Rubenfeld GD. Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury. Am J Respir Crit Care Med 2007; 176:685-90. [PMID: 17556721 PMCID: PMC1994237 DOI: 10.1164/rccm.200701-165oc] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients. OBJECTIVES To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA). METHODS Cohort study of patients with acute lung injury (ALI). MEASUREMENTS AND MAIN RESULTS ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition. CONCLUSIONS Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Avenue, Seattle, WA 98104, USA.
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