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Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study. BMC Med Ethics 2022; 23:12. [PMID: 35172834 PMCID: PMC8851755 DOI: 10.1186/s12910-022-00752-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.
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Volume-Mortality Relationships during Hospitalization with Severe Sepsis Exist Only at Low Case Volumes. Ann Am Thorac Soc 2016; 12:1177-84. [PMID: 26086787 DOI: 10.1513/annalsats.201406-287oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Volume-outcome associations have been demonstrated in conditions with high morbidity and mortality; however, the existing literature regarding such associations in sepsis is not definitive. OBJECTIVES To test the hypothesis that annual hospital severe sepsis case volume is associated with mortality during admissions with severe sepsis in teaching and nonteaching hospitals. METHODS This work was a retrospective cohort study of administrative data from the South Carolina State Inpatient Database using multivariate logistic regression and case mix adjustment. MEASUREMENTS AND MAIN RESULTS In the calendar year 2010, 9,815 patients were admitted with severe sepsis or septic shock. Hospitals were stratified into low- (0-75 cases/yr, n = 26), intermediate- (76-300 cases/yr, n = 19), and high (>300 cases/yr, n = 12) -volume tertiles. Patients admitted to hospitals with a low annual case volume for sepsis had higher adjusted odds of dying before discharge (odds ratio, 1.56; 95% confidence interval, 1.25-1.94) compared with patients admitted to high-volume hospitals. Hospitalization at intermediate-volume hospitals was not associated with a difference in mortality (odds ratio, 0.99; 95% confidence interval, 0.90-1.09) compared with high-volume hospitals. There was no difference between the mortality rates of intermediate- and high-volume hospitals at different severity of illness quartiles. Hospital length of stay differed significantly by hospital case volume (low = 8.0, intermediate = 12.7, high = 14.9 [d]; P < 0.0001). CONCLUSIONS Hospitals with low annual sepsis case volume are associated with higher mortality rates, whereas hospitals with intermediate sepsis case volumes are associated with similar mortality rates compared with hospitals with high case volumes.
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Dayal A, Alvarez F. The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital. Hosp Pediatr 2016; 5:624-9. [PMID: 26596964 DOI: 10.1542/hpeds.2015-0140] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Standardization of evidence-based care, resource utilization, and cost efficiency are commonly used metrics to measure inpatient clinical care delivery. The aim of our project was to evaluate the effect of pediatric respiratory order sets and an asthma pathway on the efficiency and quality measures of pediatric patients treated with respiratory illnesses in an adult community hospital setting. METHODS We used a pre-post study to review pediatric patients admitted to the inpatient setting with the primary diagnoses of asthma, bronchiolitis, or pneumonia. Patients with concomitant chronic respiratory illnesses were excluded. After implementation of order sets and asthma pathway, we examined changes in respiratory medication use, hospital utilization cost, length of stay (LOS), and 30-day readmission rate. Statistical significance was measured via 2-tailed t-test and Fisher test. RESULTS After implementation of evidence-based order sets and asthma pathway, utilization of bronchodilators decreased and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011 (P < .05). Asthma LOS decreased from 1.90 days to 1.45 days (P < .05), bronchiolitis LOS decreased from 2.37 days to 2.04 days (P < .05), and pneumonia LOS decreased from 2.3 days to 2.1 days (P = .083). Readmission rates were unchanged. CONCLUSION The use of order sets and an asthma pathway was associated with a reduction in respiratory treatment use as well as hospitalization utilization costs. Statistically significant decrease in LOS was achieved within the asthma and bronchiolitis populations but not in the pneumonia population. No statistically significant effect was found on the 30-day readmission rates.
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Affiliation(s)
- Anuradha Dayal
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, District of Columbia; George Washington University School of Medicine Department of Pediatrics, Washington, District of Columbia; and Mary Washington Hospital, Department of Pediatric Hospitalist Medicine, Fredericksburg, Virginia
| | - Francisco Alvarez
- Division of Hospitalist Medicine, Children's National Medical Center, Washington, District of Columbia; George Washington University School of Medicine Department of Pediatrics, Washington, District of Columbia; and Mary Washington Hospital, Department of Pediatric Hospitalist Medicine, Fredericksburg, Virginia
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Wolfenden LL, Anderson G, Veledar E, Srinivasan A. Catheter-Associated Bloodstream Infections in 2 Long-Term Acute Care Hospitals. Infect Control Hosp Epidemiol 2015; 28:105-6. [PMID: 17301939 DOI: 10.1086/510869] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Expanded abstract
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Affiliation(s)
- Nikhil R Asher
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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Lewis CM, Hessel AC, Roberts DB, Guo YZ, Holsinger FC, Ginsberg LE, El-Naggar AK, Weber RS. Prereferral head and neck cancer treatment: compliance with national comprehensive cancer network treatment guidelines. ACTA ACUST UNITED AC 2011; 136:1205-11. [PMID: 21173369 DOI: 10.1001/archoto.2010.206] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE to evaluate the prereferral treatment of patients referred to our tertiary care center with recurrent or persistent head and neck cancer for compliance with National Comprehensive Cancer Network (NCCN) guidelines. DESIGN a prospective recruitment and retrospective chart review. PATIENTS the study included new patients identified at multidisciplinary treatment planning conference from October 1, 2008, to February 1, 2009, who had received prior treatment at an outside institution and presented to our department with recurrent or persistent disease. MAIN OUTCOME MEASURES all facets of prior care were examined, including the time from initial symptoms to diagnosis and whether their prereferral treatment was compliant with or deviated from NCCN guidelines for head and neck cancer. RESULTS a total of 566 consecutive new patients were identified, of whom 107 (18.9%) had persistent or recurrent disease. The average time from first presentation with initial symptoms to diagnosis among patients who presented with persistent disease was 23.8 weeks. Nearly half of the patients who presented with persistent or recurrent disease had either endocrine (21.5%) or cutaneous (24.2%) primary cancers, with the rest of the cases being distributed among 10 other sites. Of the patients who presented with recurrent or persistent disease, 43.0% had prereferral care that was noncompliant with NCCN guidelines. Of these patients, 58.7% had inadequate surgical management, 15.2% were treated for the wrong diagnosis, 10.9% received inadequate adjuvant therapy, 4.4% received inadequate radiotherapy, and 10.9% refused indicated recommended treatment. CONCLUSIONS significant deviation from NCCN guidelines for head and neck cancer treatment was observed in the cohort of study patients. The failure to administer adjuvant therapy when indicated by NCCN guidelines is particularly concerning. Economic and noneconomic costs, including lost wages, cost of "do-over" therapy, and potentially diminished survival, are substantial. Measures to ensure that patients receive therapy according to guidelines should be a national priority.
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Affiliation(s)
- Carol M Lewis
- Department of Head and Neck Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1445, Houston, TX 77030, USA
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Azoulay É, Mancebo J, Brochard L. Surviving the Night in the ICU. Am J Respir Crit Care Med 2010; 182:293-4. [DOI: 10.1164/rccm.201005-0826ed] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Loertscher L, Reed DA, Bannon MP, Mueller PS. Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians. Am J Med 2010; 123:4-9. [PMID: 20102982 DOI: 10.1016/j.amjmed.2009.05.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Revised: 05/22/2009] [Accepted: 05/25/2009] [Indexed: 12/18/2022]
Abstract
The do-not-resuscitate order, introduced nearly a half century ago, continues to raise questions and controversy among health care providers and patients. In today's society, the expectation and availability of medical interventions, including at the end of life, have rendered the do-not-resuscitate order particularly relevant. The do-not-resuscitate order is the only order that requires patient consent to prevent a medical procedure from being performed; therefore, informed code status discussions between physicians and patients are especially important. Epidemiologic studies have informed our understanding of resuscitation outcomes; however, patient, provider, and institutional characteristics account for great variability in the prevalence of do-not-resuscitate orders. Specific strategies can improve the quality of code status conversations and enhance end-of-life care planning. In this article, we review the history, epidemiology, and determinants of do-not-resuscitate orders, as well as frequently encountered questions and recommended strategies for discussing this important topic with patients.
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Affiliation(s)
- Laura Loertscher
- Department of Internal Medicine, Mayo Clinic, Rochester, Minn., USA.
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Response to hypercapnic challenge is associated with successful weaning from prolonged mechanical ventilation due to brain stem lesions. Intensive Care Med 2008; 35:108-14. [PMID: 18615250 DOI: 10.1007/s00134-008-1197-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 06/17/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We propose that higher airway occlusion pressure (P0.1) responses to hypercapnic challenge (HC) indicate less severe injury. The study aim was to determine whether P0.1 responses to HC were associated with successful weaning after prolonged mechanical ventilation (PMV) in patients with brainstem lesions and to determine a reference value for clinical use. DESIGN AND SETTING Forty-two patients with brainstem lesions on PMV were recruited. Breathing parameters and P0.1 were measured before HC. Three-minute HC challenges with increasing CO(2) concentrations were initiated and P0.1, respiratory rate, minute ventilation (V (e)), tidal volume (V (t)) and end tidal CO(2) were measured. MEASUREMENTS AND RESULTS Patients were classified into high (group I) and low (group II) response groups on the basis of P0.1 responses to HC. Increases in V (e) and V (t) after HC were significantly greater in group I patients (12.22 +/- 8.22 vs. 3.08 +/- 4.84 L/min, P < 0.001 and 399.11 +/- 278.18 vs. 110.54 +/- 18.275 ml, P < 0.001). P0.1 levels were significantly higher in group I compared to group II before HC (2.69 +/- 1.81 vs. 1.28 +/- 1.04 cmH(2)O, P = 0.003). The increase in P0.1 following HC was significantly greater in group I compared to group II patients (11.05 +/- 4.06 vs. 2.90 +/- 2.53 cmH(2)O, P < 0.001). Weaning success was significantly higher in group I compared to group II patients (72.2% vs. 33.3%, P = 0.02). A P0.1 increase of >6 cmH(2)O following HC was significantly associated with successful weaning. CONCLUSIONS Assessing the P.01 response to serial increases in the level of HC may be a safe means to ascertain whether patients with brainstem lesions are ready for ventilator weaning.
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Gerber DR, Schorr C, Ahmed I, Dellinger RP, Parrillo J. Location of patients before transfer to a tertiary care intensive care unit: impact on outcome. J Crit Care 2008; 24:108-13. [PMID: 19272546 DOI: 10.1016/j.jcrc.2008.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 01/18/2008] [Accepted: 03/06/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the impact of the source of patients transferred to a tertiary care intensive care unit (ICU) (referring hospital ICU vs referring hospital emergency department [ED]) on outcomes of transferred patients. DESIGN AND SETTING We performed a retrospective review of data contained in the Project Impact database of a medical-surgical ICU at a university hospital. PATIENTS AND PARTICIPANTS A total of 503 patients transferred from local community hospitals, 283 from EDs and 220 from ICUs, were identified and included. In addition to comparing all ED transfers with all ICU transfers, comparisons between the 2 populations were made for the subgroups of patients with intracranial hemorrhage (group 1), nonhemorrhagic stroke (group 2), and all other patients (group 3). MEASUREMENTS AND RESULTS Patients were evaluated for a variety of outcome parameters, including mortality and ICU and hospital length of stay (LOS) according to their location at the referring hospital at the time of transfer: ICU (ICUtx) or ED (EDtx). Mortality was significantly lower among EDtx in all transferred patients as well as in groups 2 and 3 with no difference in mortality identified in group 1. Intensive care unit LOS was shorter for EDtx and the 3 groups, and hospital LOS was shorter among all EDtx and those in group 3. Group 3 EDtx also had lower than predicted mortality. CONCLUSIONS Transfer of patients to a tertiary care ICU from the ED of a referring hospital is associated with significantly better outcomes than transfers from referring hospital ICUs.
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Affiliation(s)
- David R Gerber
- Critical Care Medicine, Cooper University Hospital, Camden, NJ 08103, USA.
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Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Chronically Critically Ill Patients: Health-Related Quality of Life and Resource Use After a Disease Management Intervention. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.5.447] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background Chronically critically ill patients often have high costs of care and poor outcomes and thus might benefit from a disease management program.
Objectives To evaluate how adding a disease management program to the usual care system affects outcomes after discharge from the hospital (mortality, health-related quality of life, resource use) in chronically critically ill patients.
Methods In a prospective experimental design, 335 intensive care patients who received more than 3 days of mechanical ventilation at a university medical center were recruited. For 8 weeks after discharge, advanced practice nurses provided an intervention that focused on case management and interdisciplinary communication to patients in the experimental group.
Results A total of 74.0% of the patients survived and completed the study. Significant predictors of death were age (P = .001), duration of mechanical ventilation (P = .001), and history of diabetes (P = .04). The disease management program did not have a significant impact on health-related quality of life; however, a greater percentage of patients in the experimental group than in the control group had “improved” physical health-related quality of life at the end of the intervention period (P = .02). The only significant effect of the intervention was a reduction in the number of days of hospital readmission and thus a reduction in charges associated with readmission.
Conclusion The intervention was not associated with significant changes in any outcomes other than duration of readmission, but the supportive care coordination program could be provided without increasing overall charges.
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Affiliation(s)
- Sara L. Douglas
- Sara L. Douglas is an associate professor, Barbara J. Daly is a professor, Carol Genet Kelley is an assistant professor, and Elizabeth O’Toole and Hugo Montenegro are professors at Case Western Reserve University, Cleveland, Ohio
| | - Barbara J. Daly
- Sara L. Douglas is an associate professor, Barbara J. Daly is a professor, Carol Genet Kelley is an assistant professor, and Elizabeth O’Toole and Hugo Montenegro are professors at Case Western Reserve University, Cleveland, Ohio
| | - Carol Genet Kelley
- Sara L. Douglas is an associate professor, Barbara J. Daly is a professor, Carol Genet Kelley is an assistant professor, and Elizabeth O’Toole and Hugo Montenegro are professors at Case Western Reserve University, Cleveland, Ohio
| | - Elizabeth O’Toole
- Sara L. Douglas is an associate professor, Barbara J. Daly is a professor, Carol Genet Kelley is an assistant professor, and Elizabeth O’Toole and Hugo Montenegro are professors at Case Western Reserve University, Cleveland, Ohio
| | - Hugo Montenegro
- Sara L. Douglas is an associate professor, Barbara J. Daly is a professor, Carol Genet Kelley is an assistant professor, and Elizabeth O’Toole and Hugo Montenegro are professors at Case Western Reserve University, Cleveland, Ohio
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Su J, Lin CY, Chen PJ, Lin FJ, Chen SK, Kuo HT. Experience with a step-down respiratory care center at a tertiary referral medical center in Taiwan. J Crit Care 2006; 21:156-61. [PMID: 16769459 DOI: 10.1016/j.jcrc.2005.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Revised: 09/13/2005] [Accepted: 10/05/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of the study was to describe the outcome of patients after 1 year's implementation of an integrated delivery system for respiratory care mandated by the National Health Insurance Bureau in Taiwan. DESIGN A retrospective observational study was conducted in a step-down respiratory care center (RCC). PATIENTS Patients included adults receiving prolonged mechanical ventilation (> or =21 days). MEASUREMENTS AND MAIN RESULTS A total of 224 cases were available for review; 108 (48.2%) patients were successfully weaned. Those who failed weaning had a longer stay in the intensive care unit and RCC (25.1 vs 20.9 and 31.4 vs 18.6 days, P < .05), but there were no differences in the patients' ages (74.3 vs 70.4 years, P = .17) or the Simplified Acute Physiology Score II (52 vs 46.9, P = .18) before admission to the RCC. After discharge from the RCC, only 4.9% of the patients still on a ventilator were weaned within 1 year. Patients who failed weaning in the RCC had a shorter overall survival (5.2 vs 10.4 months, P < .05) and a lower 1-year survival (23.6% vs 44.6%, P < .05). CONCLUSION Patients admitted to the RCC were still critically ill. Patients who failed weaning in the RCC had had a longer intensive care unit and RCC stay and a worse outcome after leaving the RCC.
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Affiliation(s)
- Jian Su
- Chest Division, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, 104 Taiwan
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MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest 2006; 128:3937-54. [PMID: 16354866 DOI: 10.1378/chest.128.6.3937] [Citation(s) in RCA: 298] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Patients requiring prolonged mechanical ventilation (PMV) are rapidly increasing in number, as improved ICU care has resulted in many patients surviving acute respiratory failure only to then require prolonged mechanical ventilatory assistance during convalescence. This patient population has clearly different needs and resource consumption patterns than patients in acute ICUs, and specialized venues, management strategies, and reimbursement schemes for them are rapidly emerging. To address these issues in a comprehensive way, a conference on the epidemiology, care, and overall management of patients requiring PMV was held. The goal was to not only review existing practices but to also develop recommendations on a variety of assessment, management, and reimbursement issues associated with patients requiring PMV. Formal presentations were made on a variety of topics, and writing groups were formed to address three specific areas: epidemiology and outcomes, management and care settings, and reimbursement. Each group was charged with summarizing current data and practice along with formulation of recommendations. A working draft of the products of these three groups was then created and circulated among all participants. The document was reworked with input from all concerned until a final product with consensus recommendations on 12 specific issues was achieved.
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Daly BJ, Douglas SL, Kelley CG, O'toole E, Montenegro H. Trial of a disease management program to reduce hospital readmissions of the chronically critically ill. Chest 2005; 128:507-17. [PMID: 16100132 DOI: 10.1378/chest.128.2.507] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. They are prone to continued morbidity and mortality after hospital discharge and are at high risk for hospital readmission. Disease management (DM) programs have been shown to be effective in improving both coordination and efficiency of care after hospital discharge for populations with single-disease diagnoses, but have not been tested with patients with multiple-disease diagnoses, such as the chronically critically ill. STUDY OBJECTIVES To test the effect of a DM program on hospital readmission patterns of chronically critically ill patients during the first 2 months after hospital discharge and to estimate the cost-effectiveness of the DM program. DESIGN Randomized, controlled trial. SETTING Academic medical center, extended care facilities, and participant homes. PARTICIPANTS Three hundred thirty-four consenting adults from one academic medical center who underwent > 3 days of mechanical ventilation and survived to hospital discharge. INTERVENTION Two hundred thirty-one patients in the experimental group received care coordination, family support, teaching, and monitoring of therapies from a team of advanced-practice nurses, a geriatrician, and a pulmonologist for 2 months post-hospital discharge. MEASUREMENTS Rehospitalization rate, time-to-first rehospitalization, duration of rehospitalization, mortality during rehospitalization, and associated costs. RESULTS Patients who received DM services had significantly fewer mean days of rehospitalization (11.4; 95% confidence interval [CI], 9.3 to 12.6) compared with the control group (16.7 days; 95% CI, 12.5 to 21.0; p = 0.03). There were no other significant differences between experimental and control groups, although all measures of rehospitalization risk for the experimental group were in a positive direction. Total cost savings associated with the intervention were approximately $481,811 for the 93 subjects who were readmitted to the hospital. CONCLUSIONS Chronic critical illness may have a natural trajectory of continued morbidity following hospital discharge that is not affected by the provision of additional care coordination services. Nevertheless, given the high cost of rehospitalization and the additional burden it imposes on patients and families, interventions that can reduce the duration of rehospitalization are cost-effective and merit continued testing.
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Affiliation(s)
- Barbara J Daly
- School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4904, USA.
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Mehall JR, Shroff S, Fassler SA, Harper SG, Nejman JH, Zebley DM. Comparing results of residents and attending surgeons to determine whether laparoscopic colectomy is safe. Am J Surg 2005; 189:738-41. [PMID: 15910729 DOI: 10.1016/j.amjsurg.2005.03.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2004] [Revised: 12/31/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study was undertaken to compare the technical success and outcomes of laparoscopic colectomy performed by resident surgeons (RS) and attending surgeons (AS). METHODS A review of 451 consecutive laparoscopic colectomies performed by 2 surgeons either with or without a general surgery resident. Data reviewed included demographics, diagnoses, operative data, and outcomes. Comparison was made between patients operated on by RS under attending surgeon supervision, and patients operated on by AS alone. RESULTS Of 451 patients, 324 were operated on by RS and 127 by AS. The mean age and preoperative diagnoses were similar between groups. Operative time was significantly longer in the RS group (155 minutes vs. 128 minutes, P < .05). Blood loss was slightly higher in RS groups but was not statistically significant (191 mL vs. 174 mL, P = .31). The incidence of conversion to an open procedure, postoperative complications, and length of stay were similar between groups. CONCLUSIONS Supervised RS can safely perform laparoscopic colectomy with results similar to AS. RS take longer to perform the procedure than AS.
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Affiliation(s)
- John R Mehall
- Department of Surgery, Abington Memorial Hospital, Abington, PA 19001, USA
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Abstract
The International Campaign to Revitalise Academic Medicine recognises that an evidence based approach is important in discussing the problems of academic medicine. A preliminary exploration of the evidence on academic medicine has led to a research agenda for examining and proposing realistic solutions
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Abstract
BACKGROUND Two large research projects funded by the National Institutes of Health, the Disease Management project and the Thrive study, which examine different phenomena in the chronically critically ill population, have combined research teams. Each study has its own project manager and maintains a separate database and budget. Operational tasks for both grants are streamlined through the collaboration and cross-training of all team members. METHODS The Disease Management project is a randomized clinical trial testing the effectiveness of a care program in improving outcomes for chronically critically ill patients and their caregivers during the first 2 months after discharge. The Thrive study is a prospective longitudinal investigation that aims to describe the weaning patterns of chronically critically ill patients as well as the patterns of illness-related variables. RESULTS To date, many participants (n = 400) have been enrolled in each study. The results of both studies will be available through future publications. CONCLUSIONS Although much information has been gleaned from gathering longitudinal data across one study population and examining two rich data sets, there are some limitations to this collaboration.
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Affiliation(s)
- Carol G Kelley
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106-4904, USA.
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Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004; 30:770-84. [PMID: 15098087 DOI: 10.1007/s00134-004-2241-5] [Citation(s) in RCA: 311] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2003] [Accepted: 02/19/2004] [Indexed: 10/26/2022]
Abstract
The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.
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Affiliation(s)
- Jean Carlet
- Réanimation Polyvalente, Fondation Hopital St Joseph, 185 rue Raymond Losserand, 75674 Paris CEDEX 14, France.
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Dematte D'Amico JE, Donnelly HK, Mutlu GM, Feinglass J, Jovanovic BD, Ndukwu IM. Risk assessment for inpatient survival in the long-term acute care setting after prolonged critical illness. Chest 2003; 124:1039-45. [PMID: 12970035 DOI: 10.1378/chest.124.3.1039] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE The past decade has witnessed growth in the long-term acute care (LTAC) hospital industry. There are no reliable risk assessment models that can adjust outcomes across such facilities with different criteria for admitting patients. Variation in reported outcomes makes it difficult to determine whether a patient, or group of patients, may benefit from such care. This study sought to determine the extent to which survival in the LTAC setting is associated with age, race, residual organ system failures (OSFs), or APACHE (acute physiology and chronic health evaluation) III scores at the time of admission to LTAC. DESIGN Retrospective medical record review. SETTING Four freestanding facilities of a LTAC hospital. PATIENTS A sample of 300 hospital admissions weighted to represent the study hospital population. MEASUREMENTS Inpatient survival modeled as a function of age, APACHE III score calculated within 72 h prior to LTAC admission, and residual OSFs present on admission to LTAC. RESULTS Logistic regression analysis shows age and OSF were most predictive of inpatient survival (receiver operating characteristic curve area = 0.81). APACHE III score was not predictive of survival in the multivariate model. CONCLUSIONS Survival in LTAC is primarily associated with age and OSFs, which should be used to adjust for patient populations among LTAC settings when comparing outcomes. Our model identifies a group of patients with the poorest likelihood of survival in the LTAC setting, and may be used to facilitate dialogue with patients and family in cases where continued aggressive care is least effective.
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Affiliation(s)
- Jane E Dematte D'Amico
- Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue, Tarry 14-707, Chicago, IL 60611, USA.
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Wehler M, Geise A, Hadzionerovic D, Aljukic E, Reulbach U, Hahn EG, Strauss R. Health-related quality of life of patients with multiple organ dysfunction: individual changes and comparison with normative population. Crit Care Med 2003; 31:1094-101. [PMID: 12682478 DOI: 10.1097/01.ccm.0000059642.97686.8b] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine health-related quality of life in medical intensive care patients with multiple organ dysfunction. DESIGN Prospective, observational study. SETTING A 12-bed, noncoronary, medical intensive care unit of a university hospital. PATIENTS Between June 1998 and May 1999, 318 consecutively admitted adult patients with an intensive care unit stay of >24 hrs were studied. MEASUREMENTS AND MAIN RESULTS Health-related quality of life was assessed using a generic instrument, the Medical Outcomes Study Short Form-36 Health Survey, at admission and at 6-month follow-up. Patients who developed multiple organ dysfunction (n = 170) consumed 85% of the therapeutic activity provided in the intensive care unit. Compared with age- and sex-adjusted general population controls, multiple organ dysfunction patients had a worse preadmission health-related quality of life than other intensive care unit patients, predominantly due to a higher burden of comorbid disease. In a multivariate analysis, multiple organ dysfunction was the only variable independently associated with deteriorated physical health domains at follow-up (odds ratio, 4.4; 95% confidence interval, 1.3-14.6; p =.015), but it had no impact on dimensions of mental health. Analyzing the impact of different organ system failures, respiratory failure (odds ratio, 4.1; 95% confidence interval, 1.6-10.3; p =.002) and acute renal failure (odds ratio, 3.3; 95% confidence interval, 1.0-11.5; p =.05) increased the risk of deteriorated physical health at follow-up. No impact of the various organ system failures on mental health was noted. At 6-month follow-up, 83-90% of survivors had regained their previous health-related quality of life, and 94% were living at home with their families. CONCLUSIONS This study has shown that preadmission health-related quality of life of our medical, noncoronary patients was substantially reduced compared with a matched general population. This demonstrates the need to take prehospitalization health-related quality of life into account when examining the outcomes of intensive care unit survivors. Multiple organ dysfunction was the major determinant of poor physical health at follow-up, but it had no impact on mental health domains.
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Affiliation(s)
- Markus Wehler
- Departments of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany
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21
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Keenan SP, Dodek P, Chan K, Hogg RS, Craib KJP, Anis AH, Spinelli JJ. Length of ICU stay for chronic obstructive pulmonary disease varies among large community hospitals. Intensive Care Med 2003; 29:590-5. [PMID: 12640521 DOI: 10.1007/s00134-003-1670-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2002] [Accepted: 01/15/2003] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine whether differences exist among large community hospitals in length of Intensive Care Unit (ICU) stay, hospital stay or hospital mortality for patients admitted to ICU and whose most responsible diagnosis was chronic obstructive pulmonary disease (COPD). DESIGN Retrospective cohort study. SETTING All seven large community hospitals in British Columbia, Canada. PATIENTS. All 296 patients who were admitted to ICUs and whose most responsible diagnosis was COPD during the 3 fiscal years 1994-1997. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After adjusting for age, gender, case-mix group, and co-morbidity, we found a significant difference in length of ICU stay for these patients among hospitals ( P <0.03). No differences were found in hospital mortality or length of hospital stay for the same patients among the same hospitals. CONCLUSIONS There is significant variation in length of ICU stay for patients who are admitted to ICU and whose most responsible diagnosis is COPD, among large community hospitals. These small area variations may point to opportunities to improve efficiency of care. Further prospective, detailed data collection is required to validate these observations and to identify factors responsible for any differences found.
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Affiliation(s)
- Sean P Keenan
- Centre for Health Evaluation & Outcome Sciences, St. Paul's Hospital 620B-1081 Burrard and University of British Columbia, V6Z 1Y6, Vancouver, British Columbia, Canada
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22
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Abstract
CCI patients are patients who have suffered acute illness or injury and require life support or care in an ICU setting for periods of weeks or months. These patients account for between 5% and 10% of ICU admissions, and they appear to be increasing in number. Over half of the patients are over age 65. Patients with underlying premorbid conditions who suffer complications of acute illness are at highest risk for becoming CCI. These patients have poor short-term and long-term survival, although survival may be improving for some types of CCI patients as the medical system adapts to their specific needs. Long-term survival is associated with age and premorbid condition or functional status. Survivors have significant functional limitations, but their reported quality of life is generally good. CCI patients consume a disproportionate share of ICU and hospital resources, and significant additional resources are required for continued recovery or care after discharge. Specialized units have been evolving to manage these patients at lower costs than in acute ICUs, and with similar outcomes. Further refinement of the definition of CCI is an important objective, and should pave the way to better design of outcomes studies. Efforts should continue to learn how to identify patients at high risk for CCI and poor outcome so that expensive resources can be managed effectively, and patient-provider decision making can be better informed.
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Affiliation(s)
- Shannon S Carson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, 420 Burnett-Womack Building, CB# 7020, Chapel Hill, NC 27599, USA.
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23
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Abstract
STUDY OBJECTIVE Opinions regarding do-not-resuscitate (DNR) decisions differ between individual physicians. We attempted to determine whether the strength of DNR recommendations varies with medical specialty and experience. DESIGN Written survey. PARTICIPANTS Physicians from the pulmonary/critical-care medicine (PCCM), cardiology, internal medicine, gastroenterology, hematology/oncology, and infectious disease services as well as the Department of Medicine house staff at our tertiary-care referral center participated in the study. INTERVENTIONS Physicians were asked confidentially to quantify the strength of their opinions on discussing and recommending DNR orders for each of 20 vignettes made from the summaries of actual cases. Reasons for their opinions and demographic data also were recorded. MEASUREMENTS AND RESULTS One hundred fifteen of 155 physicians (74%) responded. PCCM physicians (mean [+/- SD] DNR score, 157 +/- 22) more strongly recommended DNR orders than cardiologists (mean DNR score, 122 +/- 32; p = 0.006), house staff (mean DNR score, 132 +/- 24; p = 0.014), and general internists (mean DNR score, 129 +/- 30; p = 0.043). PCCM physicians also trended toward recommending DNR orders for more of the 20 patients described in the vignettes compared to cardiologists (mean DNR number, 16.5 +/- 3.0 vs 11.9 +/- 5.8, respectively; p = 0.066). There were no differences between PCCM physicians and hematology/oncology, infectious disease, and gastroenterology specialists. Among the house staff, the likelihood of recommending a DNR order correlated significantly with increasing years of experience (r = 0.45; p = 0.002). The opposite trend was present in the specialty staff groups. No significant differences in opinion by gender, religion, or personal experiences were found. CONCLUSIONS The strength of DNR order recommendations varies with medicine specialty and years of training and experience. An awareness of these differences and the determination of the reasons behind them may help to target educational interventions and to ensure effective collaboration with colleagues and communication with patients.
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Affiliation(s)
- William F Kelly
- Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.
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Dennis RJ, Pérez A, Rowan K, Londoño D, Metcalfe A, Gómez C, McPherson K. [Factors associated with hospital mortality in patients admitted to the intensive care unit in Colombia]. Arch Bronconeumol 2002; 38:117-22. [PMID: 11900688 DOI: 10.1016/s0300-2896(02)75168-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To describe the demographic features, reasons for hospital admission and factors associated with hospital mortality in patients admitted to intensive care in Colombia. METHOD A cohort study of patients admitted to intensive care units (ICUs). Of 89 ICUs identified in Colombia, 20 in ten cities were invited to gather information on 200 consecutive patients admitted to each ICU. RESULTS Three thousand sixty-six patient cases were available for analysis. The mean age was 53 years and 43% were women (men vs. women, p < 0.001). The most frequent cause of admission was medical (63.9%), acute myocardial infarction patients (7.1%) comprising the largest group. Severity of disease measured as APACHE II and III was a mean 14.0 (SD 6.9) and 48.3 (SD 23.5), respectively. Multivariate analysis, independent of adjustment for severity (APACHE II or III), showed that the factors associated with hospital death were the need for mechanical ventilation, pupillary response, transfer from a medical ward, and management by the ICU team prior to admission (p < 0.01). CONCLUSION The most common reason for admission to an ICU in Colombia was myocardial infarction. Besides severity of disease, other variables related to medical care in Colombia are associated with hospital mortality, such as invasive ventilation. Although these variables may be artifacts related to disease severity, they are more likely to be related to quality of care.
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Affiliation(s)
- R J Dennis
- Unidad de Epidemiología Clínica y Bioestadística. Facultad de Medicina. Pontificia Universidad Javeriana. Bogotá. Colombia.
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Bhandari M, Guyatt GH, Swiontkowski MF. User's guide to the orthopaedic literature: how to use an article about prognosis. J Bone Joint Surg Am 2001; 83:1555-64. [PMID: 11679610 DOI: 10.2106/00004623-200110000-00017] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- M Bhandari
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
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Carson SS, Bach PB. Predicting mortality in patients suffering from prolonged critical illness: an assessment of four severity-of-illness measures. Chest 2001; 120:928-33. [PMID: 11555531 DOI: 10.1378/chest.120.3.928] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Investigators have been using severity-of-illness indexes such as APACHE II (acute physiology and chronic health evaluation score II) to describe patients with prolonged critical illness. However, little is known about the utility of these indexes for this patient population. We evaluated the ability of four severity-of-illness indexes to predict mortality rates in 182 patients with prolonged critical illness. DESIGN Retrospective inception cohort study. SETTING A single, urban, long-term, acute-care hospital in Chicago. PATIENTS One hundred eighty-two patients transferred from 37 acute-care hospital ICUs. MEASUREMENTS AND RESULTS We assessed four indexes: the acute physiology and chronic health evaluation II, the simplified acute physiology score II, the mortality prediction model II, and the logistic organ dysfunction system using variables measured on admission to the long-term acute-care hospital ICU. We found that none of these indexes distinguished well between the patients who lived and the patients who died (area under ROC [receiver operating characteristics] curve < 0.70 for all), nor did they assign correct probabilities of death to individual patients (Hosmer-Lemeshow goodness-of-fit statistics, p < 0.01 for all). CONCLUSIONS Investigators and clinicians should use caution in using severity-of-illness measures developed for acutely ill patients to describe critically ill patients admitted to long-term care units. As clinical practice and research focus more on these latter patients, development of adequately performing severity-of-illness measures appropriate to this patient population will be needed.
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Affiliation(s)
- S S Carson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC 27599, USA.
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Carmel S, Rowan K. Variation in intensive care unit outcomes: a search for the evidence on organizational factors. Curr Opin Crit Care 2001; 7:284-96. [PMID: 11571428 DOI: 10.1097/00075198-200108000-00013] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study was undertaken to determine the extent of empirical evidence on the role of organizational factors in the critical care literature and to categorize these factors. Studies evaluating organizational factors were identified through electronic and hand searching of the critical care literature. Sixty-three publications relating to 54 different studies were identified. The studies were grouped into eight main categories: staffing, teamwork, volume and pressure of work, protocols, admission to intensive care, technology, structure, and error. Studies evaluating organizational factors exist in the critical care literature, and there is evidence that the number is increasing each year. Results indicate that organizational factors may have an impact on mortality after case mix adjustment. Some areas have been investigated more thoroughly than others and are ripe for systematic review. Variation in case mix adjusted hospital mortality after intensive care is an old theme. This study has shown that emerging data will help us understand mortality differences and deliver better outcomes for patients.
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Affiliation(s)
- S Carmel
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, LondonWC1E 7HT, UK.
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Chatila W, Kreimer DT, Criner GJ. Quality of life in survivors of prolonged mechanical ventilatory support. Crit Care Med 2001; 29:737-42. [PMID: 11373458 DOI: 10.1097/00003246-200104000-00007] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the long-term quality of life (QOL) in a group of patients after prolonged mechanical ventilatory support. DESIGN Prospective cohort study. SETTING Outpatient follow-up. PATIENTS Survivors of prolonged mechanical ventilatory support who were discharged from a ventilator rehabilitation unit (VRU). INTERVENTIONS Measurement of health-related QOL using the Sickness Impact Profile (SIP). MEASUREMENTS AND MAIN RESULTS Forty-six patients were contacted approximately 2 yrs after their discharge from the VRU and asked to complete the SIP. Twenty-five patients (age, 59 +/- 17 yrs; duration of mechanical ventilatory support, 45 +/- 36 days [mean +/- sd]) agreed to participate in this study and completed the SIP questionnaire 23 +/- 18 months after their discharge from the VRU. Patients' VRU stay was 29 +/- 21 days. Two patients were discharged with nocturnal ventilatory support, and the rest were completely weaned of mechanical ventilatory support before discharge. Fifteen patients (60%) were discharged to home, eight patients (32%) were discharged to a rehabilitation facility, and two patients (8%) were discharged to a skilled-care facility. Most patients had mild dysfunction, and the global SIP score was 12 +/- 10, the physical dimension score was 12 +/- 12, and the psychosocial dimension score was 9 +/- 11 (SIP scores range from 0 to 100, with higher scores indicating worse QOL). Subgroup analysis showed that postoperative patients had lower SIP scores compared with patients with chronic respiratory diseases (global SIP, 7 +/- 6 vs. 19 +/- 8; p <.05). Moreover, the patients in the postoperative group were older, but had similar SIP scores as patients who had acute lung injury (17 +/- 15). Global SIP scores correlated with age (r = -.40; p =.046), but not with duration of mechanical ventilatory support (r = -.23) or VRU admission Acute Physiology and Chronic Health Evaluation II scores (r = -.39; p =.06). CONCLUSIONS In survivors of prolonged mechanical ventilatory support, using specific selection criteria shows that there is minimal impairment in the QOL at long-term follow-up. Although some patients continue to have moderate to severe limitations, it is the cause of respiratory failure and the underlying disease, rather than duration of ventilatory support, that have a significant impact on QOL.
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Affiliation(s)
- W Chatila
- Division of Pulmonary and Critical Care Medicine, the Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
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Abstract
The post acute health care system has evolved its infrastructure to accommodate the growing complex medical patient population, a direct result of the expanded capability in supporting critically ill patients in the ICU setting. When patients fail to wean from mechanical ventilation in the ICU, there is often less emphasis on continuing these efforts, and patients appear better served in specialized units dedicated to weaning patients from mechanical ventilation. Long-term acute care hospitals also provide an ideal environment to support patient care for other complex medical illnesses, including populations with oncologic, cardiovascular, and infectious disease. The LTAC hospital seems best adapted to this role. Its infrastructure includes significant physician support and the blending of immediate and long-term care services and provides an ideal opportunity to serve this resource-intensive group. An emphasis on the transition from acute illness to recovery serves to define the role and mission of this important entity and highlights the specialized nature of the LTAC hospital.
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Affiliation(s)
- L S Hotes
- Department of Medicine, Tufts University School of Medicine, USA
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Abstract
The development of weaning failure and need for PMV is multifactorial in origin, involving disorders of pulmonary mechanics and complications associated with critical illness. The underlying disease process is clearly important when discussing mechanisms of ventilator dependence; interventions therefore must be tailored to individual patients. Unfortunately, the main conclusion that can be drawn from the sum of the studies investigating patients on PMV to date is that an evidence-based approach to weaning is not possible and more research needs to be done. New studies need to incorporate severity-of-illness scores and an assessment of principal and comorbid conditions to allow for comparison of the findings from different centers. The best approach to a patient requiring PMV after exclusion of easily treatable conditions is not known. The literature regarding both acute and chronic cases suggests that a systematic approach to weaning involving the participation of multiple caregivers, including nurses, physicians, and respiratory, physical, and speech therapists facilitates liberation from MV. Although a gradual decrement in ventilator support would seem prudent, Scheinhorn et al have begun to identify a subpopulation of patients who can tolerate an acceleration of the weaning process. Given the known complications associated with MV, it is crucial that further research be performed to identify patients as soon as they are capable of breathing spontaneously. The literature demonstrates through multiple studies that satisfactory patient outcomes are attainable and can be achieved at LTAC facilities in a more cost-effective manner than in an ICU setting. The trend toward the concentration of patients into specialized regional weaning centers should facilitate the research process and continue to improve outcomes in this population.
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Affiliation(s)
- M L Nevins
- Pulmonary and Critical Care Division, Group Health Permanente, Seattle, Washington, USA
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Abstract
Hypoxemia is a prevalent problem in the chronically critically ill patient. This article reviews the pathophysiologic mechanisms of hypoxemia in this patient population, discusses how oxygenation is evaluated, and reviews methods for delivery of oxygen. Other topics directly related to oxygen use, such as oxygen toxicity, heliox use, and portable oxygen devices, are included.
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Affiliation(s)
- A C White
- Department of Medicine, Pulmonary and Critical Care Division, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.
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Abstract
It is likely that greater on-site intensivist coverage in critical care units will be observed in the future. Regionalization of critical care services will make this a financial reality because this level of expertise cannot realistically be provided to all hospitals. Perhaps units above a certain size will warrant this level of coverage and smaller community hospitals will transfer patients in need of a very high level of service, which can be provided only by intensivists on site. Community hospitals may rely on specially trained nurse practitioners or physician assistants to provide more on-site coverage during off hours. As technology advances, telemedicine will play a greater role in providing intensivist coverage to ICUs during off hours or to community hospitals in remote areas. Advanced technology and reorganization of critical care services offer opportunities for creative and nontraditional ways to deliver improved care to patients.
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Affiliation(s)
- D Lustbader
- New York University School of Medicine, Division of Pulmonary and Critical Care Medicine, North Shore University Hospital-Manhasset, USA.
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Rosenberg AL, Zimmerman JE, Alzola C, Draper EA, Knaus WA. Intensive care unit length of stay: recent changes and future challenges. Crit Care Med 2000; 28:3465-73. [PMID: 11057802 DOI: 10.1097/00003246-200010000-00016] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare case-mix adjusted intensive care unit (ICU) length of stay for critically ill patients with a variety of medical and surgical diagnoses during a 5-yr interval. DESIGN Nonrandomized cohort study. SETTING A total of 42 ICUs at 40 US hospitals during 1988-1990 and 285 ICUs at 161 US hospitals during 1993-1996. PATIENTS A total of 17,105 consecutive ICU admissions during 1988-1990 and 38,888 consecutive ICU admissions during 1993-1996. MEASUREMENTS AND MAIN RESULTS We used patient demographic and clinical characteristics to compare observed and predicted ICU length of stay and hospital mortality. Outcomes for patients studied during 1993-1996 were predicted using multivariable models that were developed and cross-validated using the 1988-1990 database. The mean observed hospital length of stay decreased by 3 days (from 14.8 days during 1988-1990 to 11.8 days during 1993-1996), but the mean observed ICU length of stay remained similar (4.70 vs. 4.53 days). After adjusting for patient and institutional differences, the mean predicted 1993-1996 ICU stay was 4.64 days. Thus, the mean-adjusted ICU stay decreased by 0.11 days during this 5-yr interval (T-statistic, 4.35; p < .001). The adjusted mean ICU length of stay was not changed for patients with 49 (75%) of the 65 ICU admission diagnoses. In contrast, the mean observed hospital length of stay was significantly shorter for 47 (72%) of the 65 admission diagnoses, and no ICU admission diagnosis was associated with a longer hospital stay. Aggregate risk-adjusted hospital mortality during 1993-1996 (12.35%) was not significantly different during 1988-1990 (12.27%, p = .54). CONCLUSIONS For patients admitted to ICUs, the pressures associated with a decrease in hospital length of stay do not seem to have influenced the duration of ICU stay. Because of the high cost of intensive care, reduction in ICU stay may become a target for future cost-cutting efforts.
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Affiliation(s)
- A L Rosenberg
- ICU Research, The Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC 20037, USA
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Affiliation(s)
- J L Vincent
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium
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35
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Scheinhorn DJ. Outcomes after acute care: analysis of 133 mechanically ventilated patients. Am J Respir Crit Care Med 1999; 160:1788-9. [PMID: 10556157 DOI: 10.1164/ajrccm.160.5.16050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ho K, Burgess KR, Braude S. Ruptured abdominal aortic aneurysm--outcome in a community teaching hospital intensive care unit. Anaesth Intensive Care 1999; 27:497-502. [PMID: 10520391 DOI: 10.1177/0310057x9902700511] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ruptured abdominal aortic aneurysm (RAAA) is a surgical emergency associated with a high mortality often requiring postoperative intensive care. Our objectives were to assess the outcome of RAAA management in a nontertiary community hospital intensive care unit (ICU) and to compare this with historical data from tertiary hospitals. We also sought to identify variables related to outcome and evaluate the potential of an organ failure score to identify patients at increased risk of death. The study was a retrospective chart review of patients with RAAA over 11 years (1986-1996 inclusive) at Manly District Hospital, a 210 bed community teaching hospital with eight intensive care beds. Forty patients were identified in the study period as having been admitted to ICU after RAAA surgery. There was an overall hospital mortality rate of 47.5% and intensive care mortality rate of 42.5% for successfully operated RAAA. Five variables were significantly different between survivors and non-survivors. These were age, total amount of blood products required, duration of operation, development of hypotension (systolic blood pressure < 90 mmHg) in ICU postoperatively, and APACHE II score at Day 1 ICU. A trend was also found between mortality rate and the number of failed systems after 48 hours intensive care stay. Mortality for a patient with zero failed systems was 38%, one failed system 42%, two 58% and three 67%. Based on these results, management of RAAA in a non-tertiary setting appears appropriate with postoperative care occurring in an ICU where there is adequate equipment and medical and nursing staff experienced in the care of complex critical illness.
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Affiliation(s)
- K Ho
- Department of Critical Care, Manly District Hospital, Manly, Sydney, New South Wales
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