Critical care medicine growth requires dealing with our "perfect storm" of manpower shortage

Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study

OBJECTIVE

Evaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes.

METHODS

This was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3.

RESULT

The establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63-0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54-0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28-0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70-0.99, p = 0.046).

CONCLUSION

Following the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.

Initiative for Burnout of ICU Caregivers: Feasibility and Preliminary Results of a Psychological Support

Background:

Intensive care unit (ICU) caregivers are at high risk of burnout and the shortage of this highly specialized personal is a problem. The feasibility and impact of a psychological intervention were never assessed in this special context.

Methods:

A randomized controlled single-blind study in an ICU. The first intervention consisted in weekly problem-based sessions led by psychologists with small groups of caregivers using a systemic approach over 3 months. The modified intervention was lead for 9 months. The scores of Maslach Burnout Inventory and Hospital Anxiety and Depression Scale were compared between the intervention and control groups, before and after the intervention.

Results:

One-hundred and sixty six caregivers were randomized in intervention and control groups. The major finding was the way the psychologists could modify the original methodology in order to enable caregivers to attend the sessions. Burnout scores tended to decrease across the whole ICU team after the intervention period, more in the intervention group. Participation in the study was poor at 6 months after intervention.

Conclusions:

This is the first study attempting to evaluate a psychological intervention on the mental health of ICU caregivers. It shows a modified method of a psychological support with a systemic approach in the special environment of ICU. Notwithstanding the modest results related to the short length of the process and the turnover of the personal, we demonstrated that such an approach is feasible. Further studies on larger scale and of longer duration are needed to investigate the effect of such interventions on the mental health of ICU caregivers.

Lessons of War: Turning Data Into Decisions

Background

Recent conflicts in Afghanistan and Iraq produced a substantial number of critically wounded service-members. We collected biomarker and clinical information from 73 patients who sustained 116 life-threatening combat wounds, and sought to determine if the data could be used to predict the likelihood of wound failure.

Methods

From each patient, we collected clinical information, serum, wound effluent, and tissue prior to and at each surgical débridement. Inflammatory cytokines were quantified in both the serum and effluent, as were gene expression targets. The primary outcome was successful wound healing. Computer intensive methods were used to derive prognostic models that were internally validated using target shuffling and cross-validation methods. A second cohort of eighteen critically injured civilian patients was evaluated to determine if similar inflammatory responses were observed.

Findings

The best-performing models enhanced clinical observation with biomarker data from the serum and wound effluent, an indicator that systemic inflammatory conditions contribute to local wound failure. A Random Forest model containing ten variables demonstrated the highest accuracy (AUC 0.79). Decision Curve Analysis indicated that the use of this model would improve clinical outcomes and reduce unnecessary surgical procedures. Civilian trauma patients demonstrated similar inflammatory responses and an equivalent wound failure rate, indicating that the model may be generalizable to civilian settings.

Interpretation

Using advanced analytics, we successfully codified clinical and biomarker data from combat patients into a potentially generalizable decision support tool. Analysis of inflammatory data from critically ill patients with acute injury may inform decision-making to improve clinical outcomes and reduce healthcare costs.

Funding

United States Department of Defense Health Programs.

•

We analyzed biomarker and clinical data to predict the likelihood of wound failure.

•

We found that systematic inflammatory conditions contribute to local wound failure.

•

This response is comparable between combat wounded and civilian patients.

•

This response can be measured and translated into clinical decision support tools.

•

These predictive models will benefit both military and civilian health systems.