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Jung YH, Song IA, Choi CW, Oh TK. Association between NICU intensivist staffing and neonatal outcomes. Sci Rep 2025; 15:15891. [PMID: 40335720 PMCID: PMC12059175 DOI: 10.1038/s41598-025-99734-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Accepted: 04/22/2025] [Indexed: 05/09/2025] Open
Abstract
We aimed to evaluate whether neonatal intensive care unit (NICU) intensivist staffing is associated with improved survival outcomes among neonates admitted to NICUs in South Korea. This nationwide retrospective cohort study included all neonates hospitalized in NICUs between January 1, 2019, and December 31, 2021. Patients were categorized into two groups based on intensivist staffing: the intensivist group, comprising neonates admitted to hospitals with full-time NICU intensivists, and the non-intensivist group, comprising those treated in hospitals without dedicated NICU intensivist coverage. A total of 79,306 neonates were included in the final analysis; among them, 44,330 (56.1%) were admitted to NICUs with registered NICU intensivists. In multivariable logistic regression analysis, the intensivist group had a significantly lower odds of 30-day mortality (odds ratio [OR]: 0.73; 95% confidence interval [CI] 0.58-0.92; P = 0.007) compared to the non-intensivist group. Similarly, in Cox regression analysis, the intensivist group showed a lower risk of 1-year all-cause mortality (hazard ratio: 0.79; 95% CI 0.69-0.91; P = 0.001). These findings suggest that the presence of dedicated NICU intensivists is associated with improved short- and long-term survival outcomes among neonates, supporting policies to enhance specialized staffing in neonatal intensive care settings.
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Affiliation(s)
- Young Hwa Jung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro, 173, Beon-gil, Bundang-gu, Seongnam, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro, 173, Beon-gil, Bundang-gu, Seongnam, 13620, South Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
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Dickens C, Beserra A, Keller J, Corbridge S, Carlucci M. Nurse Practitioners and Physician Assistants: Building a Team and Optimizing Practice in the Medical ICU. Chest 2025; 167:1451-1457. [PMID: 39613150 PMCID: PMC12106958 DOI: 10.1016/j.chest.2024.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 11/13/2024] [Accepted: 11/16/2024] [Indexed: 12/01/2024] Open
Abstract
The integration of nurse practitioners (NPs) and physician assistants (PAs) into the medical ICU (MICU) is becoming increasingly vital due to the rising number of critically ill patients and the shortage of board-certified intensivists. Successful recruitment and utilization of NPs and PAs in the MICU setting require a unique understanding of potential variations of the scope of practice based on state law and educational backgrounds, as well as the implementation of best practices around training and leadership support. The purpose of this article was to review the best strategies for creating a MICU team with NPs and PAs. Key strategies for identifying suitable NP and PA candidates include assessing their education, certification, licensure, and clinical experience, particularly in critical care settings. It is important for organizations to have structured orientation programs, which should define roles, establish clear reporting structures, and provide competency-based training to ensure effective team integration. Simulation-based training and professional mentoring are emphasized as critical elements for developing clinical competency and promoting job satisfaction. There are variations in state laws and institutional policies that affect NP and PA practice that should be understood by the organization to manage expectations for the NP and PA job responsibilities. Effective productivity measurement methods are proposed to accurately assess the contributions of NPs and PAs in the MICU. This article provides comprehensive strategies for successfully hiring, onboarding, and integrating these professionals into MICU teams, ensuring high-quality care delivery in critical care settings.
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Affiliation(s)
- Carolyn Dickens
- University of Illinois Chicago, College of Nursing, Chicago, IL.
| | | | | | - Susan Corbridge
- University of Illinois Chicago, College of Nursing, Chicago, IL; American Association of Colleges of Nursing, Washington, DC
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Sinha SS, Geller BJ, Katz JN, Arslanian-Engoren C, Barnett CF, Bohula EA, Damluji AA, Menon V, Roswell RO, Vallabhajosyula S, Vest AR, van Diepen S, Morrow DA. Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association. J Am Coll Cardiol 2025:S0735-1097(25)00283-9. [PMID: 40249352 DOI: 10.1016/j.jacc.2025.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
Abstract
Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.
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Sinha SS, Geller BJ, Katz JN, Arslanian-Engoren C, Barnett CF, Bohula EA, Damluji AA, Menon V, Roswell RO, Vallabhajosyula S, Vest AR, van Diepen S, Morrow DA. Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association. Circulation 2025; 151:e687-e707. [PMID: 39945062 PMCID: PMC12063187 DOI: 10.1161/cir.0000000000001300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2025]
Abstract
Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.
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Yamamoto K. Medical Professionals' Treatment Decisions for Critical Patients With Ambiguous Treatment Wishes: A Cross-Sectional Study. Health Sci Rep 2025; 8:e70564. [PMID: 40083674 PMCID: PMC11903493 DOI: 10.1002/hsr2.70564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 01/22/2025] [Accepted: 02/22/2025] [Indexed: 03/16/2025] Open
Abstract
Background and Aims Many patients do not want life-prolonging treatments at critical stages of their illnesses, and are able to communicate their wishes to their families or surrogates. However, few among them have clarity on what such life-prolonging treatments mean or entail. This study clarifies differences in the perspectives of medical professionals based on levels of expertise with respect to treatment decisions for intensive care unit (ICU) patients whose wishes for end-of-life care are ambiguous. Methods The cross-sectional study included intensivists, surgeons, and ICU nurses working in 171 Japanese hospitals with ICUs. A total of 837 participants were mailed questionnaires which included questions on the current status and approaches to decision-making with end-of-life care for ICU patients. Additionally, a simulated case study was conducted to investigate the decision-making process for treating patients with uncertain survival rates. Results Responses were obtained from 489 participants from 151 hospitals. More than half of the intensivists and ICU nurses reported that family members' requests were respected when the patient had ambiguous treatment preferences. Participants considered the patients' survival probability when deciding to perform emergency surgery, with nurses having significantly higher thresholds than intensivists and surgeons (intensivists: 20.8 ± 20.6, surgeons: 26.6 ± 25.2, ICU nurses: 36.4 ± 26.4; p < 0.001). Conclusions Family preferences take precedence over patient preferences when deciding on end-of-life treatments for ICU patients. Shared decision-making should be promoted to correctly share patients' end-of-life medical wishes with surrogate decision-makers and medical practitioners.
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Terzi N, Thiery G, Bèle N, Bigé N, Brossier D, Boyer A, Couty E, Flender L, Manzon C, Mira JP, Ortuno S, Peigne V, Poncet MC, Renolleau S, Rigaud JP, Vivet B, Kuteifan K. Formal guidelines from an expert panel: intensive care unit medical staffing, organisation and working hours to improve quality of life at work in France. Ann Intensive Care 2025; 15:15. [PMID: 39833429 PMCID: PMC11753446 DOI: 10.1186/s13613-025-01432-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 01/06/2025] [Indexed: 01/22/2025] Open
Abstract
BACKGROUND Intensive care units (ICU) are characterized by high medical assistance costs and great complexity. Recommendations to determine the needs of medical staff are scarce, generating appreciable variability. The French Intensive Care Society (FICS) and the French National Council of Intensive Care Medicine (CNP MIR, Conseil National Professionel de Médecine Intensive Réanimation) have established a technical committee of experts, the purposes of which were to draft recommendations regarding staffing needs in ICUs and to propose optimal organisation of work hours, a key objective being improved workplace quality of life. RESULTS Literature analysis was conducted according to the GRADE methodology (Grade of Recommendation Assessment, Development and Evaluation). The synthesis work of the experts according to the GRADE method led to the development of 22 recommendations in 6 field. The experts issued a strong recommendation associated with a high level of evidence which is that work organization be given priority during periods of permanent care, with a maximum 16 h of consecutive work permitted. For 21 other recommendations, the level of evidence did not allow GRADE classification, and led to the formulation of expert opinions. All recommendations and expert opinions were validated (strong agreement). CONCLUSION The work in the intensive care unit and in the intermediate intensive care unit is multifaceted, both clinical and non-clinical, and must include at least the following continuity and quality for patient safety. This document provides a detailed framework to propose an optimal medical staff.
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Affiliation(s)
- Nicolas Terzi
- CHU Rennes, Intensive Care Unit, Hôpital Pontchaillou, Université de Rennes, INSERM CIC 1414, Service de Médecine Intensive - Réanimation, 2, Rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.
| | - Guillaume Thiery
- Service de Médecine Intensive Réanimation, CHU de Saint Étienne, Saint Priest en Jarez, France
- Université Jean Monnet, Research On Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Saint Etienne, France
| | - Nicolas Bèle
- Centre Hospitalier Intercommunal Fréjus Saint Raphaël, 83600, Fréjus, France
| | - Naike Bigé
- Département Interdisciplinaire d'Organisation du Parcours Patient, Gustave Roussy, Service de Médecine Intensive Réanimation, 94805, Villejuif, France
| | - David Brossier
- Pediatric Intensive Care Unit, CHU de Caen, 14000, Caen, France
- Medical School, Université de Caen Normandie, 14000, Caen, France
- ULR 2694 - METRICS : Évaluation des Technologies de Santé et des Pratiques Médicales, Université de Lille, CHU Lille, 59000, Lille, France
| | - Alexandre Boyer
- Médecine Intensive Réanimation CHU Bordeaux, 33000, Bordeaux, France
| | | | | | - Cyril Manzon
- Service de Réanimation, Médipole Lyon Villeurbanne. Service de Réanimation, 158 Rue Léon Blum, 69100, Villeurbanne, France
| | - Jean-Paul Mira
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Université Paris Cité, Paris, France
- UMR 8104, Institut Cochin, INSERM U1016, CNRS, Université Paris Cité, 22 Rue Méchain, 75014, Paris, France
| | - Sofia Ortuno
- Service de Médecine Intensive - Réanimation Cardiologique, AP-HP, Sorbonne Université, Pitié Salpêtrière, Paris, France
| | - Vincent Peigne
- Service de Réanimation, Centre Hospitalier Métropôle-Savoie, Place Biset, 73000, Chambéry, France
| | - Marie-Cécile Poncet
- Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Hôpitaux Universitaires de Paris Seine-Saint-Denis, Paris, France
| | - Sylvain Renolleau
- Réanimation et USC Médico-Chirurgicales Pédiatriques-SMUR Pédiatrique, CHU Necker-Enfants Malades, AP-HP, Paris, France
- Faculté de Médecine, Université Paris Cité, Paris, France
| | | | - Bérengère Vivet
- Service de Réanimation Polyvalente-USIP, GH de La Haute-Saône, Vesoul, France
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale GHRMSA, Hôpital Emile Muller 20 Av. du Dr Laennec, 68100, Mulhouse, France
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Yoshida T, Shimizu S, Fushimi K, Mihara T. Impact of board-certified intensive care training facilities on choice of adjunctive therapies and prognosis of severe respiratory failure: a nationwide cohort study. J Intensive Care 2024; 12:52. [PMID: 39696527 DOI: 10.1186/s40560-024-00766-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 12/04/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND Patients with severe respiratory failure have high mortality and need various interventions. However, the impact of intensivists on treatment choices, patient outcomes, and optimal intensivist staffing patterns is unknown. In this study, we aimed to evaluate treatments and clinical outcomes for patients at board-certified intensive care training facilities compared with those at non-certified facilities. METHODS This retrospective cohort study used Japan's nationwide in-patient database from 2016 to 2019 and included patients with non-operative severe respiratory failure who required mechanical ventilation for over 4 days. Treatments and in-hospital mortality were compared between board-certified intensive care facilities requiring at least one intensivist and non-certified facilities using propensity score matching. RESULTS Of the 66,905 patients in this study, 30,588 were treated at board-certified facilities, and 36,317 were not. The following differed between board-certified and non-certified facilities: propofol (35% vs. 18%), dexmedetomidine (37% vs. 19%), fentanyl (50% vs. 20%), rocuronium (8.5% vs. 2.6%), vecuronium (1.9% vs. 0.6%), noradrenaline (35% vs. 19%), arginine vasopressin (8.1% vs. 2.0%), adrenaline (2.3% vs. 1.0%), dobutamine (8.7% vs. 4.8%), phosphodiesterase inhibitors (1.0% vs. 0.3%), early enteral nutrition (29% vs. 14%), early rehabilitation (34% vs. 30%), renal replace therapy (15% vs. 6.7%), extracorporeal membrane oxygenation (1.6% vs. 0.3%), critical care unit admission (74% vs. 30%), dopamine (9.0% vs. 15%), sivelestat (4.1% vs. 7.0%), and high-dose methylprednisolone (13% vs. 15%). After 1:1 propensity score matching, the board-certified group had lower in-hospital mortality than the non-certified group (31% vs. 38%; odds ratio, 0.75; 95% confidence interval, 0.72-0.77; P < 0.001). Subgroup analyses showed greater benefits in the board-certified group for older patients, those who required vasopressors on the first day of mechanical ventilation, and those treated in critical care units. CONCLUSIONS Board-certified intensive care training facilities implemented several different adjunctive treatments for severe respiratory failure compared to non-board-certified facilities, and board-certified facilities were associated with lower in-hospital mortality. Because various factors may contribute to the outcome, the causal relationship remains uncertain. Further research is warranted to determine how best to strengthen patient outcomes in the critical care system through the certification of intensive care training facilities.
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Affiliation(s)
- Takuo Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Yokohama, Kanazawa, 236-0027, Japan
- Department of Emergency Medicine, Jikei University School of Medicine, Minato-Ku, 105-8471, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Yokohama, Kanazawa, 236-0027, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, 22-2 Seto, Yokohama, Kanazawa, 236-0027, Japan.
- Department of Anesthesiology, Yokohama City University School of Medicine, Yokohama, 236-0004, Japan.
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Admon AJ, Kerlin MP. ICU Staffing and Organization: Everything Has Changed. Chest 2024; 166:661-662. [PMID: 39389683 DOI: 10.1016/j.chest.2024.06.3823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 06/04/2024] [Indexed: 10/12/2024] Open
Affiliation(s)
- Andrew J Admon
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI; Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Meeta Prasad Kerlin
- Department of Medicine, Palliative and Advanced Illness Research (PAIR Center), Pulmonary, Allergy and Critical Care Division, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Gershengorn HB, Garland A, Costa DK, Dzierba AL, Fowler R, Kramer AA, Liu VX, Lizano D, Scales DC, Wunsch H. ICU Staffing in the United States. Chest 2024; 166:743-753. [PMID: 38788896 PMCID: PMC11489454 DOI: 10.1016/j.chest.2024.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/11/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The last national estimates of US ICU physician staffing are 25 years old and lack information about interprofessional teams. RESEARCH QUESTION How are US adult ICUs currently staffed? STUDY DESIGN AND METHODS We conducted a cross-sectional survey (May 4, 2022-February 2, 2023) of adult ICU clinicians (targeting nurse/physician leadership) contacted using 2020 American Hospital Association (AHA) database information and, secondarily, through professional organizations. The survey included questions about interprofessional ICU staffing availability and roles at steady state (pre-COVID-19). We linked survey data to hospital data in the AHA database to create weighted national estimates by extrapolating ICU staffing data to nonrespondent hospitals based on hospital characteristics. RESULTS The cohort consisted of 596 adult ICUs (response rates: AHA contacts: 2.1%; professional organizations: unknown) with geographic diversity and size variability (median, 20 beds; interquartile range, 12-25); most cared for mixed populations (414 [69.5%]), yet medical (55 [9.2%]), surgical (70 [11.7%]), and specialty (57 [9.6%]) ICUs were well represented. A total of 554 (93.0%) had intensivists available, with intensivists covering all patients in 75.6% of these and onsite 24 h/d in one-half (53.3% weekdays; 51.8% weekends). Of all ICUs, 69.8% had physicians-in-training and 77.7% had nurse practitioners/physician assistants. For patients on mechanical ventilation, nurse to patient ratios were 1:2 in 89.6% of ICUs. Clinical pharmacists were available in 92.6%, and respiratory therapists were available in 98.8%. We estimated 85.1% (95% CI, 85.7%-84.5%) of hospitals nationally had ICUs with intensivists, 51.6% (95% CI, 50.6%-52.5%) had physicians-in-training, 72.1% (95% CI, 71.3%-72.9%) had nurse practitioners/physician assistants, 98.5% (95% CI, 98.4%-98.7%) had respiratory therapists, and 86.9% (95% CI, 86.4%-87.4%) had clinical pharmacists. For patients on mechanical ventilation, 86.4% (95% CI, 85.8%-87.0%) used 1:2 nurses/patients. INTERPRETATION We found that intensivist presence in adult US ICUs has greatly increased over 25 years. Intensivists, respiratory therapists, and clinical pharmacists are commonly available, and each nurse usually provides care for two patients on mechanical ventilation. However, team composition and workload vary.
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Affiliation(s)
- Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY.
| | - Allan Garland
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Deena K Costa
- Yale School of Nursing, West Haven, CT; Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Amy L Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY; Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY
| | - Robert Fowler
- University Health Network & Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Tory Trauma Program, Sunnybrook Hospital, Toronto, ON, Canada
| | | | - Vincent X Liu
- Division of Research, Kaiser Permanente, Oakland, CA
| | - Danny Lizano
- Physician Assistant Program, Fort Lauderdale Dr. Pallavi Patel College of Health Care Sciences Health Professions Division, Nova Southeastern University, Fort Lauderdale, FL; Florida Kendall Hospital, Miami, FL
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Hannah Wunsch
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY; Sunnybrook Research Institute, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
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Costa DK, Yakusheva O, Khadr L, Ratliff HC, Lee KA, Sjoding M, Jimenez JV, Marriott DJ. Shift-Level Team Familiarity Is Associated with Improved Outcomes in Mechanically Ventilated Adults. Am J Respir Crit Care Med 2024; 210:311-317. [PMID: 38358858 PMCID: PMC12032956 DOI: 10.1164/rccm.202310-1971oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/15/2024] [Indexed: 02/17/2024] Open
Abstract
Rationale: Organizing ICU interprofessional teams is a high priority because of workforce needs, but the role of interprofessional familiarity remains unexplored. Objectives: Determine if mechanically ventilated patients cared for by teams with greater familiarity have improved outcomes, such as lower mortality, shorter duration of mechanical ventilation (MV), and greater spontaneous breathing trial (SBT) implementation. Methods: We used electronic health records data of five ICUs in an academic medical center to map interprofessional teams and their ICU networks, measuring team familiarity as network coreness and mean team value. We used patient-level regression models to link team familiarity with patient outcomes, accounting for patient and unit factors. We also performed a split-sample analysis by using 2018 team familiarity data to predict 2019 outcomes. Measurements and Main Results: Team familiarity was measured as the average number of patients shared by each clinician with all other clinicians in the ICU (i.e., coreness) and the average number of patients shared by any two members of the team (i.e., mean team value). Among 4,485 encounters, unadjusted mortality was 12.9%, average duration of MV was 2.32 days, and SBT implementation was 89%; average team coreness was 467.2 (standard deviation [SD], 96.15), and average mean team value was 87.02 (SD, 42.42). A 1-SD increase in team coreness was significantly associated with a 4.5% greater probability of SBT implementation, 23% shorter MV duration, and 3.8% lower probability of dying; the mean team value was significantly associated with lower mortality. Split-sample results were attenuated but congruent in direction and interpretation. Conclusions: Interprofessional familiarity was associated with improved outcomes; assignment models that prioritize familiarity might be a novel solution.
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Affiliation(s)
- Deena K. Costa
- Yale School of Nursing, West Haven, Connecticut
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Lara Khadr
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | | | | | - Michael Sjoding
- Division of Pulmonary and Critical Care Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan; and
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Gershengorn HB, Costa DK, Garland A, Lizano D, Wunsch H. Interprofessional Staffing Pattern Clusters in U.S. ICUs. Crit Care Explor 2024; 6:e1138. [PMID: 39100383 PMCID: PMC11296427 DOI: 10.1097/cce.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
OBJECTIVES To identify interprofessional staffing pattern clusters used in U.S. ICUs. DESIGN Latent class analysis. SETTING AND PARTICIPANTS Adult U.S. ICUs. PATIENTS None. INTERVENTIONS None. ANALYSIS We used data from a staffing survey that queried respondents (n = 596 ICUs) on provider (intensivist and nonintensivist), nursing, respiratory therapist, and clinical pharmacist availability and roles. We used latent class analysis to identify clusters describing interprofessional staffing patterns and then compared ICU and hospital characteristics across clusters. MEASUREMENTS AND MAIN RESULTS We identified three clusters as optimal. Most ICUs (54.2%) were in cluster 1 ("higher overall staffing") characterized by a higher likelihood of good provider coverage (both intensivist [onsite 24 hr/d] and nonintensivist [orders placed by ICU team exclusively, presence of advanced practice providers, and physicians-in-training]), nursing leadership (presence of charge nurse, nurse educators, and managers), and bedside nursing support (nurses with registered nursing degrees, fewer patients per nurse, and nursing aide availability). One-third (33.7%) were in cluster 2 ("lower intensivist coverage & nursing leadership, higher bedside nursing support") and 12.1% were in cluster 3 ("higher provider coverage & nursing leadership, lower bedside nursing support"). Clinical pharmacists were more common in cluster 1 (99.4%), but present in greater than 85% of all ICUs; respiratory therapists were nearly universal. Cluster 1 ICUs were larger (median 20 beds vs. 15 and 17 in clusters 2 and 3, respectively; p < 0.001), and in larger (> 250 beds: 80.6% vs. 66.1% and 48.5%; p < 0.001), not-for-profit (75.9% vs. 69.4% and 60.3%; p < 0.001) hospitals. Telemedicine use 24 hr/d was more common in cluster 3 units (71.8% vs. 11.7% and 14.1%; p < 0.001). CONCLUSIONS More than half of U.S. ICUs had higher staffing overall. Others tended to have either higher provider presence and nursing leadership or higher bedside nursing support, but not both.
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Affiliation(s)
- Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Deena Kelly Costa
- Yale School of Nursing, West Haven, CT
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT
| | - Allan Garland
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Danny Lizano
- Physician Assistant Program, Fort Lauderdale Dr. Pallavi Patel College of Healthcare Sciences Health Professions Division, Nova Southeastern University, Fort Lauderdale, FL
- HCA Florida Kendall Hospital, Miami, FL
| | - Hannah Wunsch
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
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12
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Mohamed AR, Pena C, Kadiver S, Abdelrahman A, Mousa O, Elzanaty A, Grubb B. Outcomes of Weekday Versus Weekend Admissions for Heart Block Requiring De Novo Intracardiac Device Implantation. Cureus 2024; 16:e64141. [PMID: 39119421 PMCID: PMC11308293 DOI: 10.7759/cureus.64141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2024] [Indexed: 08/10/2024] Open
Abstract
Even with comparable healthcare structure and staffing, patients presenting on weekends often face poorer outcomes, including longer wait times in the emergency department, extended hospital stays, and delays in major procedures. This discrepancy prompts questions about whether life-saving cardiac procedures, such as permanent pacemaker (PPM) implantation for atrioventricular block, also experience similar delays and differences in outcomes. We researched over 200,000 patients from the National Inpatient Sample (NIS) database to help study whether patients admitted on the weekend truly had worse outcomes than patients admitted on the weekday. Using the International Classification of Diseases, Tenth Revision (ICD-10) using STATA software (StataCorp LLC, College Station, TX), we found that 79.6% of patients were admitted on weekdays. Among these weekday admissions, 56.2% were males, with an average age of 75.8 years. Weekend admissions included 54.4% male patients, with an average age of 76.4 years. Key variables influencing outcomes were renal failure history, non-ST elevation myocardial infarction, diabetes mellitus, and percutaneous coronary intervention. Of the total patients, 1,315 died during hospitalization, with no significant difference in mortality between weekday and weekend admissions. However, weekend admissions had a higher rate of cardiac arrest, a greater likelihood of delayed pacer implantation, and longer hospital stays. Weekend admissions were linked to delays in PPM placement, longer hospital stays, and higher hospitalization costs. Mortality rates did not increase for patients admitted on weekends. Further research is needed to explore this issue in greater depth and to identify the specific factors contributing to the discrepancy between weekend and weekday admissions, which resulted in worse outcomes for weekend patients.
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Affiliation(s)
| | - Clarissa Pena
- Internal Medicine, The University of Toledo Medical Center, Toledo, USA
| | - Sohrab Kadiver
- Internal Medicine, The University of Toledo Medical Center, Toledo, USA
| | - Ahmad Abdelrahman
- Internal Medicine, The University of Toledo Medical Center, Toledo, USA
| | - Omar Mousa
- Internal Medicine, Tanta University Faculty of Medicine, Tanta, EGY
| | - Ahmad Elzanaty
- Cardiovascular Medicine, The University of Toledo Medical Center, Toledo, USA
| | - Blair Grubb
- Cardiovascular Medicine, The University of Toledo Medical Center, Toledo, USA
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13
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O'Shea AM, Reisinger HS, Panos R, Goede M, Fortis S. Association of interactions between tele-critical care and bedside with length of stay and mortality. J Telemed Telecare 2024; 30:961-968. [PMID: 35770292 DOI: 10.1177/1357633x221107993] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization. METHODS We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes. RESULTS Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay. DISCUSSION Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.
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Affiliation(s)
- Amy Mj O'Shea
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Ralph Panos
- Pulmonary, Critical Care, and Sleep Division and Cincinnati Tele-CC, Cincinnati VAMC, Cincinnati, OH, USA
- Pulmonary, Critical Care, and Sleep Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matt Goede
- VA Tele-Critical. Care West, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Surgery, Division of Acute Care Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Spyridon Fortis
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
- VA Tele-Critical. Care West, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Sarfati S, Ehrmann S, Vodovar D, Jung B, Aissaoui N, Darreau C, Bougouin W, Deye N, Kallel H, Kuteifan K, Luyt CE, Terzi N, Vanderlinden T, Vinsonneau C, Muller G, Guitton C. Inadequate intensive care physician supply in France: a point-prevalence prospective study. Ann Intensive Care 2024; 14:92. [PMID: 38888663 PMCID: PMC11189355 DOI: 10.1186/s13613-024-01298-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 04/19/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has highlighted the importance of intensive care units (ICUs) and their organization in healthcare systems. However, ICU capacity and availability are ongoing concerns beyond the pandemic, particularly due to an aging population and increasing complexity of care. This study aimed to assess the current and future shortage of ICU physicians in France, ten years after a previous evaluation. A national e-survey was conducted among French ICUs in January 2022 to collect data on ICU characteristics, medical staffing, individual physician characteristics, and education and training capacities. RESULTS Among 290 ICUs contacted, 242 responded (response rate: 83%), representing 4943 ICU beds. The survey revealed an overall of 300 full time equivalent (FTE) ICU physician vacancies in the country. Nearly two-thirds of the participating ICUs reported at least one physician vacancy and 35% relied on traveling physicians to cover shifts. The ICUs most affected by physician vacancies were the ICUs of non-university affiliated public hospitals. The retirements expected in the next five years represented around 10% of the workforce. The median number of physicians per ICU was 7.0, corresponding to a ratio of 0.36 physician (FTE) per ICU bed. In addition, 27% of ICUs were at risk of critical dysfunction or closure due to vacancies and impending retirements. CONCLUSION The findings highlight the urgent need to address the shortage of ICU physicians in France. Compared to a similar study conducted in 2012, the inadequacy between ICU physician supply and demand has increased, resulting in a higher number of vacancies. Our study suggests that, among others, increasing the number of ICM residents trained each year could be a crucial step in addressing this issue. Failure to take appropriate measures may lead to further closures of ICUs and increased risks to patients in this healthcare system.
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Affiliation(s)
- Sacha Sarfati
- Medical Intensive Care Unit, Normandie Univ, UNIROUEN, UR 3830, CHU Rouen, 76000, Rouen, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSEP F-CRIN Research Network and Centre d'études Des Pathologies Respiratoires, INSERM U1100, Tours University, Tours, France
| | - Dominique Vodovar
- Centre Antipoison de Paris, Hopital Fernand Widal, 75010, Paris, France
- Université Paris Cite, UFR de médecine, 75010, Paris, France
- Inserm UMR-S 1144 - Faculté de Pharmacie, 75006, Paris, France
| | - Boris Jung
- Médecine Intensive Réanimation, INSERM PhyMedExp, Université de Montpellier, CHU Montpellier, France
| | - Nadia Aissaoui
- Médecine Intensive Réanimation Hôpital Cochin, APHP, Paris, France
- Université Paris CIté, INSERM U 978, Équipe 4, AfterROSC, Paris, France
| | - Cédric Darreau
- Service de Réanimation Médico-Chirurgicale, CH Le Mans, Le Mans, France
| | - Wulfran Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France
- Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Paris, France
- AfterROSC Network, Paris, France
| | - Nicolas Deye
- Medical & Toxicological Intensive Care Unit, UMR-S 942, Inserm, Lariboisiere University Hospital, APHP, Paris, France
| | - Hatem Kallel
- Intensive Care Unit, Cayenne General Hospital, Cayenne, French Guiana
- Tropical Biome and Immunopathology CNRS UMR-9017, Inserm U1019, Université de Guyane, Cayenne, French Guiana
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale, GHRMSA, Hôpital Emile Muller, Mulhouse, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- UMRS 1166, Sorbonne Université, GRC 30, RESPIRE, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, University Hospital of Grenoble Alpes, Grenoble, France
- Medical Intensive Care Unit, University of Rennes, Rennes, France
| | - Thierry Vanderlinden
- Médecine Intensive Réanimation, Groupement Hospitalier de L'Institut Catholique de Lille, FMMS - ETHICS EA 7446, Université Catholique de Lille, Lille, France
| | - Christophe Vinsonneau
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Béthune, Béthune, France
| | - Grégoire Muller
- CRICS_TRIGGERSep F-CRIN Research Network, Centre Hospitalier Universitaire (CHU) d'Orléans, Médecine Intensive Réanimation, Université de Tours, MR INSERM, 1327 ISCHEMIA, Université de Tours, 37000, Tours, France
| | - Christophe Guitton
- Service de Réanimation Médico-Chirurgicale, CH Le Mans, Le Mans, France.
- Faculté de Santé, Université d'Angers, Angers, France.
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15
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Debay A, Shah P, Lodha A, Shivananda S, Redpath S, Seshia M, Dorling J, Lapointe A, Canning R, Strueby L, Beltempo M. Association of 24-Hour In-house Neonatologist Coverage with Outcomes of Extremely Preterm Infants. Am J Perinatol 2024; 41:747-755. [PMID: 35170012 DOI: 10.1055/a-1772-4637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to assess if 24-hour in-house neonatologist (NN) coverage is associated with delivery room (DR) resuscitation/stabilization and outcomes among inborn infants <29 weeks' gestational age (GA). STUDY DESIGN Survey-linked cohort study of 2,476 inborn infants of 23 to 28 weeks' gestation, admitted between 2014 and 2015 to Canadian Neonatal Network Level-3 neonatal intensive care units (NICUs) with a maternity unit. Exposures were classified using survey responses based on the most senior provider offering 24-hour in-house coverage: NN, fellow, and no NN/fellow. Primary outcome was death and/or major morbidity (bronchopulmonary dysplasia, severe neurological injury, late-onset sepsis, necrotizing enterocolitis, and retinopathy of prematurity). Multivariable logistic regression analysis was used to assess the association between exposures and outcomes and adjust for confounders. RESULTS Among the 28 participating NICUs, most senior providers ensuring 24-hour in-house coverage were NN (32%, 9/28), fellows (39%, 11/28), and no NN/fellow (29%, 8/28). No NN/fellow coverage and 24-hour fellow coverage were associated with higher odds of infants receiving DR chest compressions/epinephrine compared with 24-hour NN coverage (adjusted odds ratio [aOR] = 4.72, 95% confidence interval [CI]: 2.12-10.6 and aOR = 3.33, 95% CI: 1.44-7.70, respectively). Rates of mortality/major morbidity did not differ significantly among the three groups: NN, 63% (249/395 infants); fellow, 64% (1092/1700 infants); no NN/fellow, 70% (266/381 infants). CONCLUSION 24-hour in-house NN coverage was associated with lower rates of DR chest compressions/epinephrine. There was no difference in neonatal outcomes based on type of coverage; however, further studies are needed as ecological fallacy cannot be ruled out. KEY POINTS · Lower rates of DR cardiopulmonary resuscitation with 24h in-house NN coverage. · The type of 24h in-house coverage was not associated with mortality and/or major morbidity.. · High-volume centers more often have 24h in-house neonatal fellow coverage.
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Affiliation(s)
- Anthony Debay
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Prakesh Shah
- Departement of Pediatrics, Toronto University, Toronto, Ontario, Canada
| | - Abhay Lodha
- Departement of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sandesh Shivananda
- Departement of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie Redpath
- Departement of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Seshia
- Departement of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jon Dorling
- Departement of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anie Lapointe
- Departement of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Rody Canning
- Departement of Pediatrics, Moncton Hospital, Moncton, Alberta, Canada
| | - Lannae Strueby
- Departement of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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16
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Nurok M, Flynn BC, Pineton de Chambrun M, Kazemian M, Geiderman J, Nunnally ME. A Review and Discussion of Full-Time Equivalency and Appropriate Compensation Models for an Adult Intensivist in the United States Across Various Base Specialties. Crit Care Explor 2024; 6:e1064. [PMID: 38533294 PMCID: PMC10965199 DOI: 10.1097/cce.0000000000001064] [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] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES Physicians with training in anesthesiology, emergency medicine, internal medicine, neurology, and surgery may gain board certification in critical care medicine upon completion of fellowship training. These clinicians often only spend a portion of their work effort in the ICU. Other work efforts that benefit an ICU infrastructure, but do not provide billing opportunities, include education, research, and administrative duties. For employed or contracted physicians, there is no singular definition of what constitutes an intensive care full-time equivalent (FTE). Nevertheless, hospitals often consider FTEs in assessing hiring needs, salary, and eligibility for benefits. DATA SOURCES Review of existing literature, expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Not applicable. DATA SYNTHESIS Not applicable. CONCLUSIONS Understanding how an FTE is calculated, and the fraction of an FTE to be assigned to a particular cost center, is therefore important for intensivists of different specialties, as many employment models assign salary and benefits to a base specialty department and not necessarily the ICU.
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Affiliation(s)
- Michael Nurok
- Departments of Anesthesiology, Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brigid C Flynn
- Division of Critical Care, Department of Anesthesiology, University of Kansas Health System, Kansas City, KS
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, APHP, Sorbonne Université, Paris, France
- INSERM-UMRS 1166, iCAN Institute of Cardiometabolism/Nutrition, Sorbonne Université, Paris, France
| | - Mina Kazemian
- Department of Anesthesiology, Riverside University, Riverside, CA
| | - Joel Geiderman
- Ruth and Harry Roman Emergency Department, Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mark E Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, Neurology, Surgery and Medicine, NYU Langone Health, NYU School of Medicine, New York, NY
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Padte S, Samala Venkata V, Mehta P, Tawfeeq S, Kashyap R, Surani S. 21st century critical care medicine: An overview. World J Crit Care Med 2024; 13:90176. [PMID: 38633477 PMCID: PMC11019625 DOI: 10.5492/wjccm.v13.i1.90176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/24/2024] [Indexed: 03/05/2024] Open
Abstract
Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units (ICUs). This abstract provides a concise summary of the latest developments in critical care, highlighting key areas of innovation. Recent advancements in critical care include Precision Medicine: Tailoring treatments based on individual patient characteristics, genomics, and biomarkers to enhance the effectiveness of therapies. The objective is to describe the recent advancements in Critical Care Medicine. Telemedicine: The integration of telehealth technologies for remote patient monitoring and consultation, facilitating timely interventions. Artificial intelligence (AI): AI-driven tools for early disease detection, predictive analytics, and treatment optimization, enhancing clinical decision-making. Organ Support: Advanced life support systems, such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support. Infection Control: Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections. Ventilation Strategies: Precision ventilation modes and lung-protective strategies to minimize ventilator-induced lung injury. Sepsis Management: Early recognition and aggressive management of sepsis with tailored interventions. Patient-Centered Care: A shift towards patient-centered care focusing on psychological and emotional well-being in addition to medical needs. We conducted a thorough literature search on PubMed, EMBASE, and Scopus using our tailored strategy, incorporating keywords such as critical care, telemedicine, and sepsis management. A total of 125 articles meeting our criteria were included for qualitative synthesis. To ensure reliability, we focused only on articles published in the English language within the last two decades, excluding animal studies, in vitro/molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. These advancements reflect a dynamic landscape in critical care medicine, where technology, research, and patient-centered approaches converge to improve the quality of care and save lives in ICUs. The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.
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Affiliation(s)
- Smitesh Padte
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
| | | | - Priyal Mehta
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
| | - Sawsan Tawfeeq
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
| | - Rahul Kashyap
- Department of Research, Global Remote Research Scholars Program, St. Paul, MN 55104, United States
- Department of Research, WellSpan Health, York, PA 17403, United States
- Department of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim Surani
- Department of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
- Department of Medicine & Pharmacology, Texas A&M University, College Station, TX 77843, United States
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18
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Unoki Y, Ono S, Sasabuchi Y, Hashimoto Y, Yasunaga H, Yokota I. Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis. BMC Health Serv Res 2024; 24:242. [PMID: 38402190 PMCID: PMC10893682 DOI: 10.1186/s12913-024-10763-0] [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: 07/18/2023] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS). METHODS Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission. RESULTS A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results. CONCLUSIONS The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.
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Affiliation(s)
- Yoko Unoki
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, N15W7, Kita-ku, Sapporo, Hokkaido, 0608638, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Yusuke Sasabuchi
- Department of Real-world Evidence, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Yohei Hashimoto
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, N15W7, Kita-ku, Sapporo, Hokkaido, 0608638, Japan.
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19
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Chicote-Álvarez E, Mainar-Gil I, Íñiguez-de Diego A, Gómez-Camino S, Corta-Iriarte L, Martínez-Camarero L, Monfort-Lázaro E, Ruiz de la Cuesta-López M, Vilella-Llop LÁ, Calvo-Martínez A. [Effect on the time of admission to the Intensive Care Unit of the start-up of an Critical Care Outreach Team]. J Healthc Qual Res 2024; 39:50-54. [PMID: 37891094 DOI: 10.1016/j.jhqr.2023.09.008] [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: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION The implementation of the Critical Care Outreach Teams can influence the time of admission of patients to the Intensive Care Unit (ICU). MATERIAL AND METHODS Retrospective, descriptive, quasi-experimental "before-after" cohort study. All patients admitted to the unit urgently from Monday to Friday for two periods (between February 1, 2022 and June 30 and between February 1, 2023 and June 30, 2023) are included. The patients were divided into regular shift admissions (08-15h) and on-call (15-08h). The secondary objective was to assess whether there were differences in mortality between the two periods. RESULTS During the first period of the study, 239 patients were admitted. 29.29% entered the ordinary shift and 70.71% on duty shift. During the second period, 211 patients were included with 43.13% of admissions in the ordinary shift. The comparison between the two periods observed a significant increase in the percentage of admissions in the morning hours in the second period (P=.0031). Mortality in the first period was 13.80% and in the second period 9.95%. The comparison between the two periods did not reveal significant differences. CONCLUSIONS The start-up of the Critical Care Outreach Teams is associated with an increase in the proportion of ICU admissions in the morning period without any observed changes in mortality.
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Affiliation(s)
- E Chicote-Álvarez
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España.
| | - I Mainar-Gil
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | - A Íñiguez-de Diego
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | - S Gómez-Camino
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | - L Corta-Iriarte
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | - L Martínez-Camarero
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | - E Monfort-Lázaro
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | | | - L Á Vilella-Llop
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
| | - A Calvo-Martínez
- Servicio de Medicina Intensiva, Hospital San Pedro, Logroño, La Rioja, España
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20
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Ikumi S, Shiga T, Ueda T, Takaya E, Iwasaki Y, Kaiho Y, Tarasawa K, Fushimi K, Ito Y, Fujimori K, Yamauchi M. Intensive care unit mortality and cost-effectiveness associated with intensivist staffing: a Japanese nationwide observational study. J Intensive Care 2023; 11:60. [PMID: 38049894 PMCID: PMC10694900 DOI: 10.1186/s40560-023-00708-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/21/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Japan has four types of intensive care units (ICUs) that are divided into two categories according to the management fee charged per day: ICU management fees 1 and 2 (ICU1/2) (equivalent to high-intensity staffing) and 3 and 4 (ICU3/4) (equivalent to low-intensity staffing). Although ICU1/2 charges a higher rate than ICU3/4, no cost-effectiveness analysis has been performed for ICU1/2. This study evaluated the clinical outcomes and cost-effectiveness of ICU1/2 compared with those of ICU3/4. METHODS This retrospective observational study used a nationwide Japanese administrative database to identify patients admitted to ICUs between April 2020 and March 2021 and divided them into the ICU1/2 and ICU3/4 groups. The ICU mortality rates and in-hospital mortality rates were determined, and the incremental cost-effectiveness ratio (ICER) (Japanese Yen (JPY)/QALY), defined as the difference between quality-adjusted life year (QALY) and medical costs, was compared between ICU1/2 and ICU3/4. Data analysis was performed using the Chi-squared test; an ICER of < 5 million JPY/QALY was considered cost-effective. RESULTS The ICU1/2 group (n = 71,412; 60.7%) had lower ICU mortality rates (ICU 1/2: 2.6% vs. ICU 3/4: 4.3%, p < 0.001) and lower in-hospital mortality rates (ICU 1/2: 6.1% vs. ICU 3/4: 8.9%, p < 0.001) than the ICU3/4 group (n = 46,330; 39.3%). The average cost per patient of ICU1/2 and ICU3/4 was 2,249,270 ± 1,955,953 JPY and 1,682,546 ± 1,588,928 JPY, respectively, with a difference of 566,724. The ICER was 718,659 JPY/QALY, which was below the cost-effectiveness threshold. CONCLUSIONS ICU1/2 is associated with lower ICU patient mortality than ICU3/4. Treatments under ICU1/2 are more cost-effective than those under ICU3/4, with an ICER of < 5 million JPY/QALY.
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Affiliation(s)
- Saori Ikumi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- AI Lab, Tohoku University Hospital, Sendai, Japan
| | - Takuya Shiga
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
- Experience Design and Alliance Section, Tohoku University Hospital, Sendai, Japan.
- Department of Biodesign, Center for Research, Education, and Innovation, Tohoku University Hospital, Sendai, Japan.
- Department of Intensive Care Unit, Tohoku University Hospital, Sendai, Japan.
| | - Takuya Ueda
- AI Lab, Tohoku University Hospital, Sendai, Japan
- Department of Clinical Imaging, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Eichi Takaya
- AI Lab, Tohoku University Hospital, Sendai, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Kaiho
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Yukiko Ito
- College of Policy Studies, Tsuda University, Tokyo, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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21
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Blank J, Shiroff AM, Kaplan LJ. Surgical Emergencies in Patients with Significant Comorbid Diseases. Surg Clin North Am 2023; 103:1231-1251. [PMID: 37838465 DOI: 10.1016/j.suc.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.
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Affiliation(s)
- Jacqueline Blank
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA
| | - Adam M Shiroff
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 North 39th Street, MOB 1, Suite 120, Philadelphia, PA 19104, USA; Surgical Services, Section of Surgical Critical Care and Emergency General Surgery, Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
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22
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Choi AY, Park E. The impact of pediatric intensivists on the management of pediatric diabetic ketoacidosis in pediatric intensive care units. BMC Pediatr 2023; 23:562. [PMID: 37957591 PMCID: PMC10644449 DOI: 10.1186/s12887-023-04398-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION The impact of pediatric intensivists on managing pediatric patients with diabetic ketoacidosis (DKA) remains unknown. This study aimed to evaluate the impact of pediatric intensivists on outcomes in pediatric intensive care units (PICUs). METHODS This was a two-institution retrospective study of patients with DKA admitted to the PICU between 2012 and 2023. Pediatric patients (< 19 years of age) were included if they met the moderate to severe DKA criteria on PICU admission. The patients were subsequently divided into two groups based on the presence or absence of a pediatric intensivist. The primary outcome was the PICU length of stay (LOS). Secondary outcomes were adverse events during DKA treatment, hospital LOS, and mortality. RESULTS Fifty-two patients admitted to the PICU with a median age of 13.00 years (range, 0-18 years) were included; 32 (61.54%) were female. Patients managed by pediatric intensivists had significantly shorter PICU LOS (2.52 vs. 3.69 days, p < 0.05). Also, adverse events during DKA treatment were significantly decreased in the high-intensity group compared to the low-intensity group (12.50% vs. 50.00%, p < 0.05). CONCLUSIONS High-intensity ICU staffing was associated with shorter PICU LOS and lower adverse events in pediatric patients with DKA. Our results suggest that dedicated pediatric intensivists can improve outcomes of critically ill pediatric patients with DKA.
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Affiliation(s)
- Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Esther Park
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Republic of Korea.
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea.
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23
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Maratta C, Hutchison K, Nicoll J, Bagshaw SM, Granton J, Kirpalani H, Stelfox HT, Ferguson N, Cook D, Parshuram CS, Moore GP. Overnight staffing in Canadian neonatal and pediatric intensive care units. Front Pediatr 2023; 11:1271730. [PMID: 38027260 PMCID: PMC10646373 DOI: 10.3389/fped.2023.1271730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Aim Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. Methods A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. Results We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Conclusion Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.
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Affiliation(s)
- Christina Maratta
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Kristen Hutchison
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Jessica Nicoll
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John Granton
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Haresh Kirpalani
- Department of Paediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine and O’Brien Institute for Public Health, University of Calgary & Alberta Health Services, Calgary, AB, Canada
| | - Niall Ferguson
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Deborah Cook
- Department of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - Christopher S. Parshuram
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Gregory P. Moore
- Division of Neonatology, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Research Unit, Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
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24
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Armaignac DL, Ramamoorthy V, DuBouchet EM, Williams LM, Kushch NA, Gidel L, Badawi O. Descriptive Comparison of Two Models of Tele-Critical Care Delivery in a Large Multi-Hospital Health Care System. Telemed J E Health 2023; 29:1465-1475. [PMID: 36827094 DOI: 10.1089/tmj.2022.0415] [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] [Indexed: 02/25/2023] Open
Abstract
Introduction: The Society of Critical Care Medicine Tele-Critical Care (TCC) Committee has identified the need for rigorous comparative research of different TCC delivery models to support the development of best practices for staffing, application, and approaches to workflow. Our objective was to describe and compare outcomes between two TCC delivery models, TCC with 24/7 Bedside Intensivist (BI) compared with TCC with Private Daytime Attending Intensivist (PI) in relation to intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), cost, and complications across the spectrum of routine ICU standards of care. Methods: Observational cohort study at large health care system in 12 ICUs and included patients, ≥18, with Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores and predictions (October 2016-June 2019). Results: Of the 19,519 ICU patients, 71.7% (n = 13,993) received TCC with 24/7 BI while 28.3% (n = 5,526) received TCC with PI. ICU and Hospital mortality (4.8% vs. 3.1%, p < 0.0001; 12.6% vs. 8.1%, p < 0.001); and ICU and Hospital LOS (3.2 vs. 2.4 days, p < 0.001; 9.8 vs. 7.2 days, p < 0.001) were significantly higher among 24/7 BI compared with PI. The APACHE observed/expected ratios (odds ratio [OR]; 95% confidence interval [CI]) for ICU mortality (0.62; 0.58-0.67) vs. (0.53; 0.46-0.61) and Hospital mortality (0.95; 0.57-1.48) vs. (0.77; 0.70-0.84) were significantly different for 24/7 BI compared with PI. Multivariate mixed models that adjusted for confounders demonstrated significantly greater odds of (OR; 95% CI) ICU mortality (1.58; 1.28-1.93), Hospital mortality (1.52; 1.33-1.73), complications (1.55; 1.18-2.04), ICU LOS [3.14 vs. 2.59 (1.25; 1.19-1.51)], and Hospital LOS [9.05 vs. 7.31 (1.23; 1.21-1.25)] among 24/7 BI when compared with PI. Sensitivity analyses adjusting for ICU admission within 24 h of hospital admission, receiving active ICU treatments, nighttime admission, sepsis, and highest third acute physiology score indicated significantly higher odds for 24/7 BI compared with PI. Conclusion: Our comparison demonstrated that TCC delivery model with PI provided high-quality care with significant positive effects on outcomes. This suggests that TCC delivery models have broad-ranging applicability and benefits in routine critical care, thus necessitating progressive research in this direction.
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Affiliation(s)
- Donna Lee Armaignac
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
| | | | - Eduardo Martinez DuBouchet
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
- Wertheim School of Medicine, Florida International University, Miami, Florida, USA
| | - Lisa-Mae Williams
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
- Wertheim School of Medicine, Florida International University, Miami, Florida, USA
| | | | - Louis Gidel
- Center for Advanced Analytics, Baptist Health South Florida, Miami, Florida, USA
- Tele-Critical Care, Telehealth Center, Baptist Health South Florida, Miami, Florida, USA
| | - Omar Badawi
- School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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25
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Zammert M, Carpenter AJ, Zwischenberger JB, Sade RM. Surgeon or Intensivist: Who Should Be in Charge of Postoperative Intensive Care? Ann Thorac Surg 2023; 116:679-683. [PMID: 37356518 DOI: 10.1016/j.athoracsur.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Martin Zammert
- Division of Surgical Critical Care, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Andrea J Carpenter
- Department of Cardiothoracic Surgery, Joe R. And Teresa Lozano Long School of Medicine, San Antonio, Texas
| | | | - Robert M Sade
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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26
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Wang TY, Johnson TA, Katz MH. Intensive Care Unit Transfer Decisions-Science or Art? JAMA Intern Med 2023; 183:913-914. [PMID: 37428490 DOI: 10.1001/jamainternmed.2023.2636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Affiliation(s)
- Tracy Y Wang
- Duke Clinical Research Institute, Durham, North Carolina
- Now with the Patient Centered Outcomes Research Institute, Washington, DC
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27
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Li L, Xu Q, Cai G, Gong S, Liu D, Qiu H, Yu K, Chen D, Guan X, Yan J. Chinese critical care certified course in intensive care unit: a nationwide-based analysis. BMC MEDICAL EDUCATION 2023; 23:576. [PMID: 37582757 PMCID: PMC10428552 DOI: 10.1186/s12909-023-04534-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/24/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND A training program for intensive care unit (ICU) physicians entitled "Chinese Critical Care Certified Course" (5 C) started in China in 2009, intending to improve the quality of intensive care provision. This study aimed to explore the associations between the 5 C certification of physicians and the quality of intensive care provision in China. METHODS This nationwide analysis collected data regarding 5 C-certified physicians between 2009 and 2019. Fifteen ICU quality control indicators (three structural, four procedural, and eight outcome-based) were collected from the Chinese National Report on the Services, Quality, and Safety in Medical Care System. Provinces were stratified into three groups based on the cumulative number of 5 C certified physicians per million population. RESULTS A total of 20,985 (80.41%) physicians from 3,425 public hospitals in 30 Chinese provinces were 5 C certified. The deep vein thrombosis (DVT) prophylaxis rate in the high 5 C physician-number provinces was significantly higher than in the intermediate 5 C physician-number provinces (67.6% vs. 55.1%, p = 0.043), while ventilator-associated pneumonia (VAP) rate in the low 5 C physician-number provinces was significantly higher than in the high 5 C physician-number provinces (14.9% vs. 8.9%, p = 0.031). CONCLUSIONS The higher number of 5 C-certified physicians per million population seemed to be associated with higher DVT prophylaxis rates and lower VAP rates in China, suggesting that the 5 C program might have a beneficial impact on the quality of intensive care provision.
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Affiliation(s)
- Li Li
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013, China
| | - Qianghong Xu
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013, China
| | - Guolong Cai
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013, China
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013, China
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, No. 23, Youzheng Road, Nangang District, Harbin, Heilongjiang, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201801, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.
| | - Jing Yan
- Department of Critical Care Medicine, Zhejiang Hospital, 12 Lingyin Road, Hangzhou, 310013, China.
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28
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Oh TK, Kim S, Song IA. Intensivist coverage and critically ill COVID-19 patient outcomes: a population-based cohort study. J Intensive Care 2023; 11:19. [PMID: 37173766 PMCID: PMC10177723 DOI: 10.1186/s40560-023-00668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/10/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Trained intensivist staffing improves survival outcomes in critically ill patients at intensive care units. However, the impact on outcomes of critically ill patients with coronavirus disease 2019 has not yet been evaluated. We aimed to investigate whether trained intensivists affect outcomes among critically ill coronavirus disease 2019 patients in South Korean intensive care units. METHODS Using a nationwide registration database in South Korea, we included adult patients admitted to the intensive care unit from October 8, 2020, to December 31, 2021, with a main diagnosis of coronavirus disease 2019. Critically ill patients admitted to intensive care units that employed trained intensivists were included in the intensivist group, whereas all other critically ill patients were assigned to the non-intensivist group. RESULTS A total of 13,103 critically ill patients were included, with 2653 (20.2%) patients in the intensivist group and 10,450 (79.8%) patients in the non-intensivist group. In the covariate-adjusted multivariable logistic regression model, the intensivist group exhibited 28% lower in-hospital mortality than that of the non-intensivist group (odds ratio: 0.72; 95% confidence interval: 0.62, 0.83; P < 0.001). CONCLUSIONS Trained intensivist coverage was associated with lower in-hospital mortality among critically ill coronavirus disease 2019 patients who required intensive care unit admission in South Korea.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Saeyeon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea
- Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620, South Korea.
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
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Kahn JM, Yabes JG, Bukowski LA, Davis BS. Intensivist physician-to-patient ratios and mortality in the intensive care unit. Intensive Care Med 2023; 49:545-553. [PMID: 37133740 PMCID: PMC10155655 DOI: 10.1007/s00134-023-07066-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients. METHODS We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days. RESULTS The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14). CONCLUSIONS Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States.
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Affiliation(s)
- Jeremy M Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA.
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, 15213, USA.
| | - Jonathan G Yabes
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Leigh A Bukowski
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
| | - Billie S Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 602B Allan Magee Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15213, USA
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Flynn BC. Anesthesiology Critical Care: Current State and Future Directions. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00248-3. [PMID: 37164803 DOI: 10.1053/j.jvca.2023.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/28/2023] [Accepted: 04/07/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Brigid C Flynn
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS.
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Takemoto K, Nakamura M, Yamamoto T, Kawata H, Atagi K. The Efficacy of Acute Myocardial Infarction Intensive Care Unit Management with a Collaborative Intensivists and Cardiologists in Japan: A Retrospective Observational Study. Intern Med 2023; 62:979-985. [PMID: 35989273 PMCID: PMC10125813 DOI: 10.2169/internalmedicine.0345-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Dedicated intensive care unit (ICU) physician staffing is associated with a reduction in ICU mortality rates in general medical and surgical ICUs. However, limited data are available on the role of intensivists in ICU for cardiac disease, especially in Japan. This study investigated the association of collaborative intensivists and cardiologist care with clinical outcomes in patients with acute myocardial infarction (AMI) admitted to the ICU. Methods This study analyzed 106 patients admitted to the ICU at Nara Prefecture General Medical Center in Nara, Japan, from April 2017 to April 2019. Eligible patients were divided into either the high-intensity ICU management group (n=51) or the low-intensity ICU management group (n=55). The primary outcome of in-hospital mortality was compared in the two groups. Results The high-intensity ICU group was found to be associated with a lower mortality rate in a multivariate analysis than the low-intensity group [7.8% vs. 16.4%; odds ratio (OR): 0.07; 95% confidence interval (CI): 0.01-0.54; p=0.01]. There were no significant differences in the length of either the ICU stay or hospital stay or the hospital costs between the two groups. A subgroup analysis revealed that the in-hospital mortality rate was lower in the high-intensity ICU group than in the low-intensity ICU group among patients with Killip class IV (16.7% vs. 34.6%; OR, 0.08; 95% CI, 0.01-0.67; p=0.02). Conclusion The presence of dedicated intensivists in high-intensity ICU collaborating with cardiologists might reduce in-hospital mortality in patients with Killip class IV AMI who require critical care.
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Affiliation(s)
- Kiyoshi Takemoto
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Japan
| | - Michitaka Nakamura
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Japan
| | - Tomonori Yamamoto
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Japan
| | - Hiroyuki Kawata
- Department of Cardiovascular Medicine, Nara Prefecture General Medical Center, Japan
| | - Kazuaki Atagi
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, Japan
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Michetti CP, Evans SL, Martin ND, Ahmad S, Greene WR, Codner PA. Does Practice Match Training? Consultation Practices in Surgical Critical Care. J Surg Res 2023; 288:71-78. [PMID: 36948035 DOI: 10.1016/j.jss.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 01/16/2023] [Accepted: 02/17/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.
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Affiliation(s)
| | - Susan L Evans
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Niels D Martin
- Division of Trauma, SCC & EGS, University of Pennsylvania, Philadephia, Pennsylvania
| | - Salman Ahmad
- Department of Surgery, University of Missouri Health Care, University Hospital, Columbia, Missouri
| | - Wendy R Greene
- Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - Panna A Codner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Myers AL, Fussell JJ, Moffatt ME, Boyer D, Ross R, Dammann CEL, Degnon L, Weiss P, Sauer C, Vinci RJ. The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children. J Pediatr 2023:13365. [PMID: 36894130 DOI: 10.1016/j.jpeds.2023.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. 65 Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. 66 The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. 67 In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.
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Affiliation(s)
- Angela L Myers
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Jill J Fussell
- Professor, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR
| | - Mary E Moffatt
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Debra Boyer
- DIO/Chief Medical Education Officer, Professor of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Robert Ross
- Children's Hospital of Michigan, Professor of Pediatrics, Central Michigan University College of Medicine, Detroit, MI
| | | | | | - Pnina Weiss
- Professor of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Cary Sauer
- Professor of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Robert J Vinci
- Professor of Pediatrics, Boston University School of Medicine, Boston, MA
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Effectiveness of an intensive care telehealth programme to improve process quality (ERIC): a multicentre stepped wedge cluster randomised controlled trial. Intensive Care Med 2023; 49:191-204. [PMID: 36645446 PMCID: PMC9841931 DOI: 10.1007/s00134-022-06949-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 12/01/2022] [Indexed: 01/17/2023]
Abstract
PURPOSE Supporting the provision of intensive care medicine through telehealth potentially improves process quality. This may improve patient recovery and long-term outcomes. We investigated the effectiveness of a multifaceted telemedical programme on the adherence to German quality indicators (QIs) in a regional network of intensive care units (ICUs) in Germany. METHODS We conducted an investigator-initiated, large-scale, open-label, stepped-wedge cluster randomised controlled trial enrolling adult ICU patients with an expected ICU stay of ≥ 24 h. Twelve ICU clusters in Berlin and Brandenburg were randomly assigned to three sequence groups to transition from control (standard care) to the intervention condition (telemedicine). The quality improvement intervention consisted of daily telemedical rounds guided by eight German acute ICU care QIs and expert consultations. Co-primary effectiveness outcomes were patient-specific daily adherence (fulfilled yes/no) to QIs, assessed by a central end point adjudication committee. Analyses used mixed-effects logistic modelling adjusted for time. This study is completed and registered with ClinicalTrials.gov (NCT03671447). RESULTS Between September 4, 2018, and March 31, 2020, 1463 patients (414 treated on control, 1049 on intervention condition) were enrolled at ten clusters, resulting in 14,783 evaluated days. Two randomised clusters recruited no patients (one withdrew informed consent; one dropped out). The intervention, as implemented, significantly increased QI performance for "sedation, analgesia and delirium" (adjusted odds ratio (99.375% confidence interval [CI]) 5.328, 3.395-8.358), "ventilation" (OR 2.248, 1.198-4.217), "weaning from ventilation" (OR 9.049, 2.707-30.247), "infection management" (OR 4.397, 1.482-13.037), "enteral nutrition" (OR 1.579, 1.032-2.416), "patient and family communication" (OR 6.787, 3.976-11.589), and "early mobilisation" (OR 3.161, 2.160-4.624). No evidence for a difference in adherence to "daily multi-professional and interdisciplinary clinical visits" between both conditions was found (OR 1.606, 0.780-3.309). Temporal trends related and unrelated to the intervention were detected. 149 patients died during their index ICU stay (45 treated on control, 104 on intervention condition). CONCLUSION A telemedical quality improvement program increased adherence to seven evidence-based German performance indicators in acute ICU care. These results need further confirmation in a broader setting of regional, non-academic community hospitals and other healthcare systems.
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Oh TK, Song IA. Trained intensivist coverage and survival outcomes in critically ill patients: a nationwide cohort study in South Korea. Ann Intensive Care 2023; 13:4. [PMID: 36637567 PMCID: PMC9839899 DOI: 10.1186/s13613-023-01100-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/07/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The difference in survival outcomes between closed and open intensive care unit (ICU) designs with respect to trained intensivist coverage remains unknown. We aimed to investigate whether trained intensivist coverage is associated with mortality in critically ill patients admitted to the ICU in South Korea. METHODS This population-based cohort study used nationwide registration data from South Korea. This study enrolled all adult patients admitted to the ICU between January 1, 2016, and December 31, 2019. Patients, who were admitted ICU in a hospital that employed trained intensivists, were designated as the intensivist group. RESULTS This study included 1,147,493 critically ill patients admitted to the ICU. The intensivist and non-intensivist groups consisted of 484,004 (42.2%) and 663,489 (57.8%) patients, respectively. Mixed effect logistic regression revealed a 22% lower in-hospital mortality rate (odds ratio: 0.78. 95% confidence interval: 0.74, 0.81; P < 0.001) than that in the non-intensivist group. Mixed effect Cox regression revealed a 15% lower 1-year mortality rate (hazard ratio: 0.85. 95% confidence interval: 0.83, 0.89; P < 0.001) in the intensivist group than that in the non-intensivist group. Moreover, the in-hospital mortality was significantly lower in the intensivist group than that in the non-intensivist group, irrespective of age, Charlson comorbidity index, surgery or non-surgery associated admission, and invasive treatment during ICU stay. CONCLUSIONS A closed ICU design with trained intensivist coverage was associated with lower in-hospital and 1-year mortality rates. Our results suggest that hospitals should employ trained intensivists to improve both short-term and long-term survival outcomes of critically ill patients.
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Affiliation(s)
- Tak Kyu Oh
- grid.412480.b0000 0004 0647 3378Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620 South Korea ,grid.31501.360000 0004 0470 5905Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - In-Ae Song
- grid.412480.b0000 0004 0647 3378Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-Ro, 173, Beon-Gil, Bundang-Gu, Seongnam, 13620 South Korea ,grid.31501.360000 0004 0470 5905Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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Mortality analysis among sepsis patients in and out of intensive care units using the Japanese nationwide medical claims database: a study by the Japan Sepsis Alliance study group. J Intensive Care 2023; 11:2. [PMID: 36611188 PMCID: PMC9826578 DOI: 10.1186/s40560-023-00650-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/30/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND A substantial number of sepsis patients require specialized care, including multidisciplinary care, close monitoring, and artificial organ support in the intensive care unit (ICU). However, the efficacy of ICU management on clinical outcomes remains insufficiently researched. Therefore, we tested the hypothesis that ICU admission would increase the survival rate among sepsis patients. METHODS We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan from 2010 to 2017 with propensity score matching to adjust for baseline imbalances. Patients aged over 20 years, with a combined diagnosis of presumed serious infection and organ failure, were included in this study. The primary outcome studied was the in-hospital mortality among non-ICU and ICU patients. In addition to propensity score matching, we performed a multivariable logistic regression analysis for the primary outcome. As the treatment policy was not extracted from the database, we performed sensitivity analyses to determine mortality differences in adults (20 ≤ age ≤ 64), independent patients, patients without malignant tumors, based on the assumption that treatment intensity is likely to increase in those population. RESULTS Among 1,167,901 sepsis patients (974,289 in non-ICU and 193,612 in ICU settings), the unadjusted in-hospital mortality was 22.5% among non-ICU patients and 26.2% among ICU patients (3.7% [95% CI 3.5-3.9]). After propensity score matching, the in-hospital mortality was 29.2% among non-ICU patients and 25.8% among ICU patients ([Formula: see text] 3.4% [95% CI [Formula: see text] 3.7 to [Formula: see text] 3.1]). In-hospital mortality with a multivariable regression analysis ([Formula: see text] 5.0% [95% CI [Formula: see text] 5.2 to [Formula: see text] 4.8]) was comparable with the results of the propensity score matching analysis. In the sensitivity analyses, the mortality differences between non-ICU and ICU in adults, independent patients, and patients without malignant tumors were [Formula: see text] 2.7% [95% CI [Formula: see text] 3.3 to [Formula: see text] 2.2], [Formula: see text] 5.8% [95% CI [Formula: see text] 6.4 to [Formula: see text] 5.2], and [Formula: see text] 1.3% [95% CI [Formula: see text] 1.7 to [Formula: see text] 1.0], respectively. CONCLUSIONS Herein, using the nationwide medical claims database, we demonstrated that ICU admission was potentially associated with decreasing in-hospital mortality among sepsis patients. Further investigations are warranted to validate these results and elucidate the mechanisms favoring ICU management on clinical outcomes.
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Intensive Care Unit versus High-dependency Care Unit for COVID-19 Patients with Invasive Mechanical Ventilation. Ann Am Thorac Soc 2023; 20:102-109. [PMID: 35984418 PMCID: PMC9819267 DOI: 10.1513/annalsats.202206-475oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: High-dependency care units (HDUs), also termed "intermediate care units", "step-down units", or "respiratory HDUs", are areas in which degrees of patient care and costs are between those of the intensive care unit (ICU) and the general ward. In general, patients requiring mechanical ventilation are treated in the ICU rather than in the HDU, except for the use of HDU beds as surge capacity beds during a massive strain; however, the HDU, as well as ICU, are used as the standard care units for mechanically ventilated patients with coronavirus disease (COVID-19) in Japan. Objectives: To assess the outcomes of patients with COVID-19 with invasive mechanical ventilation treated in the HDU versus those treated in the ICU. Methods: In this retrospective cohort study, we used a multicenter inpatient database in Japan to identify mechanically ventilated patients with COVID-19 in the ICU or HDU on the start day of invasive mechanical ventilation from February 10, 2020, to November 30, 2021. The primary outcome was in-hospital mortality within 30 days from the start of the first invasive mechanical ventilation. Propensity score matching was performed to compare the outcomes of patients treated in the ICU with those treated in the HDU. Results: Of 1,985 eligible patients with COVID-19 with invasive mechanical ventilation, 1,303 (66%) were treated in the ICU, and 682 (34%) were treated in the HDU on the start day of invasive mechanical ventilation. After propensity score matching, patients treated in the ICU had significantly lower in-hospital mortality within 30 days than those treated in the HDU (18.3% vs. 24.2%; risk difference, -5.8%; 95% confidence interval, -10.9% to -0.8%). Conclusions: This multicenter observational study in Japan suggests that care for mechanically ventilated patients with COVID-19 in the ICU may significantly reduce in-hospital mortality within 30 days compared with care in the HDU. Establishing a critical care system that would allow patients with COVID-19 requiring ventilators to be treated in the ICU is desirable. Because this study was an observational study, our finding represents an association, not causation. Further studies of different critical care systems are warranted to confirm our findings.
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Variation in Bed-to-Physician Ratios During Weekday Daytime Hours in ICUs in Australia and New Zealand. Crit Care Med 2022; 50:1737-1747. [PMID: 35862614 DOI: 10.1097/ccm.0000000000005623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To determine common "bed-to-physician" ratios during weekday hours across ICUs and assess factors associated with variability in this ratio. DESIGN Retrospective cohort study. SETTING All ICUs in Australia/New Zealand that participated in a staffing survey administered in 2017-2018. PATIENTS ICU admissions from 2016 to 2018. METHODS We linked survey data with patient-level data. We defined: 1) bed-to-intensivist ratio as the number of usually available ICU beds divided by the number of onsite weekday daytime intensivists; and 2) bed-to-physician ratio as the number of available ICU beds divided by the total number of physicians (intensivists + nonintensivists, including trainees). We calculated the median and interquartile range (IQR) of bed-to-intensivist ratio and bed-to-physician ratios during weekday hours. We assessed variability in each by type of hospital and ICU and by severity of illness of patients, defined by the predicted hospital mortality. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 123 (87.2%) of Australia/New Zealand ICUs that returned staffing surveys, 114 (92.7%) had an intensivist present during weekday daytime hours, and 116 (94.3%) reported at least one nonintensivist physician. The median bed-to-intensivist ratio was 8.0 (IQR, 6.0-11.4), which decreased to a bed-to-physician ratio of 3.0 (IQR, 2.2-4.9). These ratios varied with mean severity of illness of the patients in the unit. The median bed-to-intensivist ratio was highest (13.5) for ICUs with a mean predicted mortality > 2-4%, and the median bed-to-physician ratio was highest (5.7) for ICUs with a mean predicted mortality of > 4-6%. Both ratios decreased and plateaued in ICUs with a mean predicted mortality for patients greater than 8% (median bed-to-intensivist ratio range, 6.8-8.0, and bed-to-physician ratio range of 2.4-2.7). CONCLUSIONS Weekday bed-to-physician ratios in Australia/New Zealand ICUs are lower than the bed-to-intensivist ratios and have a relatively fixed ratio of less than 3 for units taking care of patients with a higher average severity of illness. These relationships may be different in other countries or healthcare systems.
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Agarwal A, Ward NS. Can We Determine Optimal Dosing of Doctors in the ICU? Crit Care Med 2022; 50:1831-1833. [PMID: 36394401 PMCID: PMC9731370 DOI: 10.1097/ccm.0000000000005687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Nicholas S Ward
- Division of Pulmonary, Critical Care, and Sleep Medicine, Warren Alpert Medical School of Brown University, Providence, RI
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Fujii Y, Hirota K, Muranishi K, Mori Y, Kambara K, Nishikawa Y, Hashiguchi M. Clinical impact of physician staffing transition in intensive care units: a retrospective observational study. BMC Anesthesiol 2022; 22:362. [PMID: 36435755 PMCID: PMC9701368 DOI: 10.1186/s12871-022-01905-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022] Open
Abstract
Background Intensivists play an essential role in improving the outcomes of critically ill patients in intensive care units (ICUs). The transition of ICU physician staffing from low-intensity ICUs (elective intensivist or no intensivist consultation) to high-intensity ICUs (mandatory intensivist consultation or a closed ICU) improves clinical outcomes. However, whether a transition from high-intensity to low-intensity ICU staffing affects ICU outcomes and quality of care remains unknown. Methods A retrospective observational study was conducted to examine the impact of high- versus low-intensity staffing models on all-cause mortality in a suburban secondary community hospital with 400 general beds and 8 ICU beds. The ICU was switched from a high-intensity staffing model (high-former period) to low-intensity staffing in July 2019 (low-mid period) and then back to high-intensity staffing in March 2020 (high-latter period). Patients admitted from the emergency department, general ward, or operating room after emergency surgery were enrolled in these three periods and compared, balancing the predicted mortality and covariates of the patients. The primary outcome was all-cause mortality analyzed using hazard ratios (HRs) from Cox proportional hazards regression. An interrupted time-series analysis (ITSA) was also conducted to evaluate the effects of events (level change) and time. Results There were 962 eligible admissions, of which 251, 213, and 498 occurred in the high-former, low-mid, and high-latter periods, respectively. In the matched group (n = 600), the all-cause mortality rate comparing the high-former period with the low-mid period showed an HR of 0.88 [95% confidence interval (CI), 0.56, 1.39; p = 0.58] and that comparing the high-latter period with the low-mid period showed an HR of 0.84 [95% CI, 0.54, 1.30; p = 0.43]. The result for comparison between the three periods was p = 0.80. ITSA showed level changes of 4.05% [95% CI, -13.1, 21.2; p = 0.63] when ICU staffing changed from the high-former to the low-mid period and 1.35% [95% CI, -13.8, 16.5; p = 0.86] when ICU staffing changed from the low-mid to the high-latter period. Conclusion There was no statistically significant difference in all-cause mortality among the three ICU staffing periods. This study suggests that low-intensity ICU staffing might not worsen clinical outcomes in the ICU in a medium-sized community hospital. Multiple factors, including the presence of an intensivist, other medical staff, and practical guidelines, influence the prognosis of critically ill patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01905-0.
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Examination of Impact of After-Hours Admissions on Hospital Resource Use, Patient Outcomes, and Costs. Crit Care Res Pract 2022; 2022:4815734. [DOI: 10.1155/2022/4815734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/23/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
Background. Nighttime and weekends in hospital and intensive care unit (ICU) contexts are thought to present a greater risk for adverse events than daytime admissions. Although some studies exist comparing admission time with patient outcomes, the results are contradictory. No studies currently exist comparing costs with the time of admission. We investigated the differences in-hospital mortality, ICU length of stay, ICU mortality, and cost between daytime and nighttime admissions. Methods. All adult patients (≥18 years of age) admitted to a large academic medical-surgical ICU between 2011 and 2015 were included. Admission cohorts were defined as daytime (8:00–16:59) or nighttime (17:00–07:59). Student’s t-tests and chi-squared tests were used to test for associations between days spent in the ICU, days on mechanical ventilation, comorbidities, diagnoses, and cohort membership. Regression analysis was used to test for associations between patient and hospitalization characteristics and in-hospital mortality and total ICU costs. Results. The majority of admissions occurred during nighttime hours (69.5%) with no difference in the overall Elixhauser comorbidity score between groups (
). Overall ICU length of stay was 7.96 days for daytime admissions compared to 7.07 days (
) for patients admitted during nighttime hours. Overall mortality was significantly higher in daytime admissions (22.5% vs 20.6,
); however, ICU mortality was not different. The average MODS was 2.9 with those admitted during the daytime having a significantly higher MODS (3.0,
). Total ICU cost was significantly higher for daytime admissions (
). Adjusted ICU mortality was similar in both groups despite an increased rate of adverse events for nighttime admissions. Daytime admissions were associated with increased cost. There was no difference in all hospital total cost or all hospital direct cost between groups. These findings are likely due to the higher severity of illness in daytime admissions. Conclusion. Daytime admissions were associated with a higher severity of illness, mortality rate, and ICU cost. To further account for the effect of staffing differences during off-hours, it may be beneficial to compare weekday and weeknight admission times with associated mortality rates.
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Agarwal A, Chen JT, Coopersmith CM, Denson JL, Dickert NW, Ferrante LE, Gershengorn HB, Gosine AD, Hayward BJ, Kaur N, Khan A, Lamberton C, Landsittel D, Lyons PG, Mikkelsen ME, Nadig NR, Pietropaoli AP, Poole BR, Viglianti EM, Sevransky JE. SWEAT ICU-An Observational Study of Physician Workload and the Association of Physician Outcomes in Academic ICUs. Crit Care Explor 2022; 4:e0774. [PMID: 36259061 PMCID: PMC9575792 DOI: 10.1097/cce.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The optimal staffing model for physicians in the ICU is unknown. Patient-to-intensivist ratios may offer a simple measure of workload and be associated with patient mortality and physician burnout. To evaluate the association of physician workload, as measured by the patient-to-intensivist ratio, with physician burnout and patient mortality. DESIGN Cross-sectional observational study. SETTING Fourteen academic centers in the United States from August 2020 to July 2021. SUBJECTS We enrolled ICU physicians and collected data on adult ICU patients under the physician's care on the single physician-selected study day for each physician. MEASUREMENTS and MAIN RESULTS The primary exposure was workload (self-reported number of patients' physician was responsible for) modeled as high (>14 patients) and low (≤14 patients). The primary outcome was burnout, measured by the Well-Being Index. The secondary outcome measure was 28-day patient mortality. We calculated odds ratio for burnout and patient outcomes using a multivariable logistic regression model and a binomial mixed effects model, respectively. We enrolled 122 physicians from 62 ICUs. The median patient-to-intensivist ratio was 12 (interquartile range, 10-14), and the overall prevalence of burnout was 26.4% (n = 32). Intensivist workload was not independently associated with burnout (adjusted odds ratio, 0.74; 95% CI, 0.24-2.23). Of 1,322 patients, 679 (52%) were discharged alive from the hospital, 257 (19%) remained hospitalized, and 347 (26%) were deceased by day 28; 28-day outcomes were unknown for 39 of patients (3%). Intensivist workload was not independently associated with 28-day patient mortality (adjusted odds ratio, 1.33; 95% CI, 0.92-1.91). CONCLUSIONS In our cohort, approximately one in four physicians experienced burnout on the study day. There was no relationship be- tween workload as measured by patient-to-intensivist ratio and burnout. Factors other than the number of patients may be important drivers of burnout among ICU physicians.
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Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Jen-Ting Chen
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Craig M Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Neal W Dickert
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Hayley B Gershengorn
- Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Adhiraj D Gosine
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Bradley J Hayward
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Navneet Kaur
- Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health and Science University, Portland, OR
| | - Courtney Lamberton
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN
| | - Patrick G Lyons
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Nandita R Nadig
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Anthony P Pietropaoli
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Brian R Poole
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Elizabeth M Viglianti
- Division Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
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Kotani Y, Na S, Phua J, Shime N, Kawasaki T, Yasuda H, Jun JH, Kawaguchi A. The research environment of critical care in three Asian countries: A cross-sectional questionnaire survey. Front Med (Lausanne) 2022; 9:975750. [PMID: 36203749 PMCID: PMC9530362 DOI: 10.3389/fmed.2022.975750] [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: 06/22/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Although inadequate research support for intensivists can be one major reason of the poor research productivity, no study has investigated the current research environment in critical care medicine in Asia. The objective of this study was to describe Asian academia in critical care from the research environment perspective. We conducted a cross-sectional questionnaire survey targeting all physician members of the Societies of Intensive/Critical Care Medicine in Japan, South Korea, and Singapore. We collected the characteristics of the participants and their affiliated institutions and the research environment. The outcome was the number of peer-reviewed publications. Multivariable logistic regression analyses examined the association between the outcome and the following five research environmental factors (i.e., country of the respondents, availability of secured time for research activities or research supporting staff for the hospital, practice at a university-affiliated hospital, and years of clinical practice of 10 years or longer). Four hundred ninety responded (overall response rate: 5.6%) to the survey between June 2019 and January 2020. Fifty-five percent worked for a university-affiliated hospital, while 35% worked for a community hospital. Twenty-four percent had secured time for research within their full-time work hours. The multivariable logistic model found that a secured time for the research activities [odds ratio (OR): 2.77; 95% confidence interval (CI), 1.46-5.24], practicing at a university-affiliated hospital (OR: 2.61; 95% CI, 1.19-5.74), having clinical experience of 10 years or longer (OR:11.2; 95%CI, 1.41-88.5), and working in South Korea (OR: 2.18; 95% CI, 1.09-4.34, Reference: Japan) were significantly associated with higher research productivity. Intensivists in the three countries had limited support for their research work. Dedicated time for research was positively associated with the number of research publications.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Sungwon Na
- Department of Anesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Jong Hun Jun
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Atsushi Kawaguchi
- School of Medicine, Department of Pediatrics, St. Marianna University, Kawasaki, Japan
- CHU Sainte Justine Research Centre, University of Montreal, CHU Sainte Justine Research Centre, Montreal, QC, Canada
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Interdisziplinäre und interprofessionelle Kommunikation im Team. Med Klin Intensivmed Notfmed 2022; 117:588-594. [DOI: 10.1007/s00063-022-00955-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
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Oh TK, Cho M, Song IA. Impact of trained intensivist coverage on survival outcomes after in-hospital cardiopulmonary resuscitation: A nationwide cohort study in South Korea. Resuscitation 2022; 178:69-77. [PMID: 35870558 DOI: 10.1016/j.resuscitation.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/09/2022] [Accepted: 07/15/2022] [Indexed: 10/17/2022]
Abstract
AIM We aimed to investigate whether trained intensivist coverage affects survival outcomes following in-hospital cardiopulmonary resuscitation (ICPR) for in-hospital cardiac arrest (IHCA). METHODS All adult patients who received ICPR for IHCA between January 1, 2016 and December 31, 2019 in South Korea were included. Patients who received ICPR in hospitals with trained intensivist coverage for ICU staffing were defined as the intensivist group, whereas other patients were considered the non-intensivist group. RESULTS In total 68,286 adult patients (36,025 [52.8%] in the intensivist group and 32,261 [47.2%] in the non-intensivist group) were included in the analysis. After propensity score (PS) matching 40,988 patients (20,494 in each group) were included. In logistic regression after PS matching, the intensivist group showed a 17% (odds ratio: 1.17; 95% confidence interval [CI]: 1.12-1.22; P < 0.001) higher live discharge rate after ICPR than the non-intensivist group. In Cox regression after PS matching, the 6-month and the 1-year mortality rates in the intensivist group after ICPR were 11% (hazard ratio [HR]: 0.89; 95% CI: 0.87-0.91; P < 0.001) and 10% (HR: 0.90; 95% CI: 0.88-0.92; P < 0.001) lower than those in the non-intensivist group, respectively. In Kaplan-Meir estimation the median survival time after ICPR in the intensivist group was 12.0 days (95% CI: 11.6-12.4) while that in the non-intensivist group was 8.0 days (95% CI: 7.7-8.3). CONCLUSIONS Trained intensivist coverage in the ICU was associated with improvements in both short and long-term survival outcomes after ICPR for IHCA.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea
| | - Mincheul Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
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Ofoma UR, Drewry AM, Maddox TM, Boyle W, Deych E, Kollef M, Girotra S, Joynt Maddox KE. Outcomes of in-hospital cardiac arrest among hospitals with and without telemedicine critical care. Resuscitation 2022; 177:7-15. [PMID: 35724851 PMCID: PMC9296566 DOI: 10.1016/j.resuscitation.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/16/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Survival rates following in-hospital cardiac arrest (IHCA) are lower during nights and weekends (off-hours), as compared to daytime on weekdays (on-hours). Telemedicine Critical Care (TCC) may provide clinical support to improve IHCA outcomes, particularly during off-hours. OBJECTIVE To evaluate the association between hospital availability of TCC and IHCA survival. METHODS We identified 44,585 adults at 280 U.S. hospitals in the Get With The Guidelines® - Resuscitation registry who suffered IHCA in an Intensive Care Unit (ICU) or hospital ward between July 2017 and December 2019. We used 2-level hierarchical multivariable logistic regression to investigate whether TCC availability was associated with better survival, overall, and during on-hours (Monday-Friday 7:00 a.m.-10:59p.m.) vs. off-hours (Monday-Friday 11:00p.m.-6:59 a.m., and Saturday-Sunday, all day, and US national holidays). RESULTS 14,373 (32.2%) participants suffered IHCA at hospitals with TCC, and 27,032 (60.6%) occurred in an ICU. There was no difference between TCC and non-TCC hospitals in acute resuscitation survival rate or survival to discharge rates for either IHCA occurring in the ICU (acute survival odds ratio [OR] 1.02, 95% CI 0.92-1.15; survival to discharge OR 0.94 [0.83-1.07]) or outside of the ICU (acute survival OR 1.03 [0.91-1.17]; survival to discharge OR 0.99 [0.86-1.12]. Timing of cardiac arrest did not modify the association between TCC availability and acute resuscitation survival (P =.37 for interaction) or survival to discharge (P =.39 for interaction). CONCLUSIONS Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.
| | - Anne M Drewry
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Thomas M Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA; Healthcare Innovation Laboratory, BJC Healthcare and Washington University School of Medicine, St. Louis, MO, USA
| | - Walter Boyle
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Elena Deych
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Medicine, University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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ICU Versus High-Dependency Care Unit for Patients With Acute Myocardial Infarction: A Nationwide Propensity Score-Matched Cohort Study. Crit Care Med 2022; 50:977-985. [PMID: 35020671 DOI: 10.1097/ccm.0000000000005440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To compare the outcomes of patients with acute myocardial infarction who were treated in ICUs versus high-dependency care units (HDUs). DESIGN A nationwide, propensity score-matched, retrospective cohort study of a national administrative inpatient database in Japan from July 2010 to March 2018. SETTING Six hundred sixty-six acute-care hospitals with ICU and/or HDU beds covering about 75% of all ICU beds and 70% of all HDU beds in Japan. PATIENTS Adult patients who were hospitalized for acute myocardial infarction and admitted to the ICU or HDU on the day of hospital admission. Propensity score-matching analysis was performed to compare the inhospital mortality between patients treated in the ICU and HDU on the day of hospital admission. INTERVENTIONS ICU or HDU admission on the day of hospital admission. MEASUREMENTS AND MAIN RESULTS Of 135,142 eligible patients, 89,382 (66%) were admitted to the ICU and 45,760 (34%) were admitted to the HDU on the day of admission. After propensity score matching, there was no statistically significant difference in inhospital mortality between the ICU and HDU groups (5.0% vs 5.5%; difference, -0.5%; 95% CI, -1.0% to 0.1%). In the subgroup analyses, inhospital mortality was significantly lower in the ICU group than that in the HDU group among patients with Killip class IV (25.6% vs 28.4%; difference, -2.9%; 95% CI, -5.4% to -0.3%), patients who underwent intubation (40.0% vs 46.6%; difference, -6.6%; 95% CI, -10.6% to -2.7%), and patients who received mechanical circulatory support (21.8% vs 24.7%; difference, -2.8%; 95% CI, -5.5% to -0.2%). CONCLUSIONS Critical care in the ICU compared with that in the HDU was not associated with reduced inhospital mortality among the entire cohort of patients with acute myocardial infarction but was associated with reduced inhospital mortality among the subsets of patients with Killip class IV, intubation, or mechanical circulatory support.
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M. Patil S. Hospital-Acquired Pneumonia. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pneumonia acquired during hospitalization is called nosocomial pneumonia (NP). Nosocomial pneumonia is divided into two types. Hospital-acquired pneumonia (HAP) refers to hospital-acquired pneumonia, whereas ventilator-associated pneumonia (VAP) refers to ventilator-associated pneumonia. Most clinical literature stresses VAP’s importance and associated mortality and morbidity, whereas HAP is not given enough attention even while being the most common cause of NP. HAP, like VAP, carries a high mortality and morbidity. HAP is the commonest cause of mortality from hospital-acquired infections. HAP is a common determinant for intensive care unit (ICU) admits with respiratory failure. Recent research has identified definite risk factors responsible for HAP. If these are prevented or modified, the HAP incidence can be significantly decreased with improved clinical outcomes and lesser utilization of the health care resources. The prevention approach will need multiple strategies to address the issues. Precise epidemiological data on HAP is deficient due to limitations of the commonly used diagnostic measures. The diagnostic modalities available in HAP are less invasive than VAP. Recent infectious disease society guidelines have stressed the importance of HAP by removing healthcare-associated pneumonia as a diagnosis. Specific differences exist between HAP and VAP, which are gleaned over in this chapter.
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Jimenez JV, Olivas-Martinez A, Rios-Olais FA, Ayala-Aguillón F, Gil-López F, Leal-Villarreal MADJ, Rodríguez-Crespo JJ, Jasso-Molina JC, Enamorado-Cerna L, Dardón-Fierro FE, Martínez-Guerra BA, Román-Montes CM, Alvarado-Avila PE, Juárez-Meneses NA, Morales-Paredes LA, Chávez-Suárez A, Gutierrez-Espinoza IR, Najera-Ortíz MP, Martínez-Becerril M, Gonzalez-Lara MF, Ponce de León-Garduño A, Baltazar-Torres JÁ, Rivero-Sigarroa E, Dominguez-Cherit G, Hyzy RC, Kershenobich D, Sifuentes-Osornio J. Outcomes in Temporary ICUs Versus Conventional ICUs: An Observational Cohort of Mechanically Ventilated Patients With COVID-19-Induced Acute Respiratory Distress Syndrome. Crit Care Explor 2022; 4:e0668. [PMID: 35372841 PMCID: PMC8963854 DOI: 10.1097/cce.0000000000000668] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Throughout the COVID-19 pandemic, thousands of temporary ICUs have been established worldwide. The outcomes and management of mechanically ventilated patients in these areas remain unknown. OBJECTIVES To investigate mortality and management of mechanically ventilated patients in temporary ICUs. DESIGN SETTING AND PARTICIPANTS Observational cohort study in a single-institution academic center. We included all adult patients with severe COVID-19 hospitalized in temporary and conventional ICUs for invasive mechanical ventilation due to acute respiratory distress syndrome from March 23, 2020, to April 5, 2021. MAIN OUTCOMES AND MEASURES To determine if management in temporary ICUs increased 30-day in-hospital mortality compared with conventional ICUs. Ventilator-free days, ICU-free days (both at 28 d), hospital length of stay, and ICU readmission were also assessed. RESULTS We included 776 patients (326 conventional and 450 temporary ICUs). Thirty-day in-hospital unadjusted mortality (28.8% conventional vs 36.0% temporary, log-rank test p = 0.023) was higher in temporary ICUs. After controlling for potential confounders, hospitalization in temporary ICUs was an independent risk factor associated with mortality (hazard ratio, 1.4; CI, 1.06-1.83; p = 0.016).There were no differences in ICU-free days at 28 days (6; IQR, 0-16 vs 2; IQR, 0-15; p = 0.5) or ventilator-free days at 28 days (8; IQR, 0-16 vs 5; IQR, 0-15; p = 0.6). We observed higher reintubation (18% vs 12%; p = 0.029) and readmission (5% vs 1.6%; p = 0.004) rates in conventional ICUs despite higher use of postextubation noninvasive mechanical ventilation (13% vs 8%; p = 0.025). Use of lung-protective ventilation (87% vs 85%; p = 0.5), prone positioning (76% vs 79%; p = 0.4), neuromuscular blockade (96% vs 98%; p = 0.4), and COVID-19 pharmacologic treatment was similar. CONCLUSIONS AND RELEVANCE We observed a higher 30-day in-hospital mortality in temporary ICUs. Although both areas had high adherence to evidence-based management, hospitalization in temporary ICUs was an independent risk factor associated with mortality.
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Affiliation(s)
- Jose Victor Jimenez
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Antonio Olivas-Martinez
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Fausto Alfredo Rios-Olais
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Frida Ayala-Aguillón
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Gil-López
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Juan José Rodríguez-Crespo
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan C Jasso-Molina
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Linda Enamorado-Cerna
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Bernardo A Martínez-Guerra
- Department of Infectious Disease, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carla Marina Román-Montes
- Department of Infectious Disease, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Pedro E Alvarado-Avila
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Noé Alonso Juárez-Meneses
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis Alberto Morales-Paredes
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Adriana Chávez-Suárez
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Irving Rene Gutierrez-Espinoza
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - María Paula Najera-Ortíz
- Department of Nursing, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Marina Martínez-Becerril
- Department of Nursing, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - María Fernanda Gonzalez-Lara
- Department of Infectious Disease, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alfredo Ponce de León-Garduño
- Department of Infectious Disease, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Ángel Baltazar-Torres
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Eduardo Rivero-Sigarroa
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Guillermo Dominguez-Cherit
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Escuela de Medicina y Ciencias de la Salud TecSalud del Tecnológico de Monterrey, Monterrey, Mexico
| | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - David Kershenobich
- Escuela de Medicina y Ciencias de la Salud TecSalud del Tecnológico de Monterrey, Monterrey, Mexico
| | - José Sifuentes-Osornio
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Udeh C, Perez-Protto S, Canfield CM, Sreedharan R, Factora F, Hata JS. Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality. Telemed J E Health 2022; 28:1395-1403. [PMID: 35294855 DOI: 10.1089/tmj.2021.0465] [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: 11/12/2022] Open
Abstract
Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.
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Affiliation(s)
- Chiedozie Udeh
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Silvia Perez-Protto
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Christina M Canfield
- Cleveland Clinic Foundation, Division of Medical Operations, Cleveland, Ohio, USA
| | - Roshni Sreedharan
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - Faith Factora
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
| | - J Steven Hata
- Cleveland Clinic Foundation, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland, Ohio, USA
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