Insights into intensive care unit bed expansion in the United States. National and regional analyses

Preoperative Comorbidities Associated With Early Mortality in Hip Fracture Patients: A Multicenter Study

OBJECTIVE

Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality.

METHODS

This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables.

RESULTS

Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery.

CONCLUSION

Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

Certified and Advanced Degree Critical Care Nurses Improve Patient Outcomes

The need for highly skilled and knowledgeable critical care nurses continues to evolve today and will in the future. Demands in critical care medicine for nurses with advanced degrees (master's in nursing: clinical nurse specialist; or doctorate in nursing: doctorate of philosophy in nursing or doctor of nursing practice) working in intensive care units or progressive care units can help meet these challenges. Nurses with certification and advanced degrees in nursing can be employed to work in 1 or combined roles such as nurse leaders and nurse researcher or intermittently fulfill roles as bedside nurses. These nurses working in critical care units have the ability to provide expertise that extends to staff, families, as well as patients. In addition, they are positioned to conduct relevant clinical research for evidence-based best practices. Evidence-based practice promotes excellence in nursing care and cost containment. Data on numbers of critical care beds in the United States increased 17% between 2000 and 2010.

Update in Critical Care 2015

This review documents important progress made in 2015 in the field of critical care. Significant advances in 2015 included further evidence for early implementation of low tidal volume ventilation as well as new insights into the role of open lung biopsy, diaphragmatic dysfunction, and a potential mechanism for ventilator-induced fibroproliferation. New therapies, including a novel low-flow extracorporeal CO2 removal technique and mesenchymal stem cell-derived microparticles, have also been studied. Several studies examining the role of improved diagnosis and prevention of ventilator-associated pneumonia also showed relevant results. This review examines articles published in the American Journal of Respiratory and Critical Care Medicine and other major journals that have made significant advances in the field of critical care in 2015.

Synergy, Salary, and Satisfaction: Benefits of Training in Critical Care Medicine and Infectious Diseases Gleaned From a National Pilot Survey of Dually Trained Physicians

BACKGROUND

An increasing number of physicians are seeking dual training in critical care medicine (CCM) and infectious diseases (ID). Understanding experiences and perceptions of CCM-ID physicians could inform career choices and programmatic innovation.

METHODS

All physicians trained and/or certified in both CCM and ID to date in the United States were sent a Web-based questionnaire in 2015. Responses enabled a cross-sectional analysis of physician demographics and training and practice characteristics and satisfaction.

RESULTS

Of 202 CCM-ID physicians, 196 were alive and reachable. The response rate was 79%. Forty-six percent trained and 34% practice in the northeastern United States. Only 40% received dual training at the same institution. Eighty-three percent identified as either an intensivist with ID expertise (44%) or as equally an intensivist and ID physician (38%). Median salary was $265 000 (interquartile range [IQR], $215 000-$350 000). Practice settings were split between academic (45%) and community settings (42%). Two-thirds are clinicians but 62% conduct some research and 26% practice outpatient ID. Top reasons to dually specialize included clinical synergy (70%), procedural activity (50%), and less interest in pulmonology (49%). Although 38% cited less proficiency with bronchoscopy as a disadvantage, 87% seldom need pulmonary consultation in the intensive care unit. Median career satisfaction was 4 (IQR, 4-5) out of 5, and 76% would dually train again.

CONCLUSIONS

CCM-ID graduates prefer the acute care setting, predominantly CCM or a combination of CCM and ID. They find combination training and practice to be synergistic and satisfying, but most have had to seek CCM and ID training independently at separate institutions. Given these findings, avenues for combined training in CCM-ID should be considered.

Analysis of Unplanned Postoperative Admissions to the Intensive Care Unit

PURPOSE

To investigate factors associated with unplanned postoperative admissions to the intensive care unit (ICU).

METHODS

Data from the National Anesthesia Clinical Outcomes Registry (NACOR) were analyzed. We performed univariate and multivariate logistic regression to identify patient- and surgery-specific characteristics associated with unplanned postoperative ICU admission. We also recorded the prevalence of Current Procedural Terminology (CPT) and International Classification of Diseases, ninth revision ( ICD-9) billing codes and outcomes for unplanned postoperative ICU admissions.

RESULTS

Of 23 341 130 records in the database, 2 910 738 records met our inclusion criteria. A higher American Society of Anesthesiologists physical status (ASA PS) class, case duration greater than 4 hours, and advanced age were associated with a greater likelihood of unplanned ICU admission. Vascular and thoracic surgery patients were more likely to have an unplanned ICU admission. The most common CPT and ICD-9 codes involved repair of femur/hip fracture, bowel resection, and acute postoperative pain. Large community hospitals were more likely than university hospitals to have unplanned postoperative ICU admissions. Patients in the unplanned postoperative ICU admission group were more likely to have experienced intraoperative cardiac arrest, hemodynamic instability, or respiratory failure and were more likely to die in the immediate perioperative period.

CONCLUSION

Our study is the first diverse analysis of unplanned postoperative ICU admissions in the literature across multiple specialties and practice models. We found an association of advanced age, higher ASA PS class, and duration of procedure with unplanned ICU admission after surgery. Surgical specialties and procedures with the most unplanned ICU admissions could be areas for quality improvement and clinical pathways in the future.