The practice of critical care medicine. A national survey report. ACCP Council on Critical Care

Structure, Organization, and Delivery of Critical Care in Asian ICUs

OBJECTIVES

Despite being the epicenter of recent pandemics, little is known about critical care in Asia. Our objective was to describe the structure, organization, and delivery in Asian ICUs.

DESIGN

A web-based survey with the following domains: hospital organizational characteristics, ICU organizational characteristics, staffing, procedures and therapies available in the ICU and written protocols and policies.

SETTING

ICUs from 20 Asian countries from April 2013 to January 2014. Countries were divided into low-, middle-, and high-income based on the 2011 World Bank Classification.

SUBJECTS

ICU directors or representatives.

MEASUREMENTS AND MAIN RESULTS

Of 672 representatives, 335 (50%) responded. The average number of hospital beds was 973 (SE of the mean [SEM], 271) with 9% (SEM, 3%) being ICU beds. In the index ICUs, the average number of beds was 21 (SEM, 3), of single rooms 8 (SEM, 2), of negative-pressure rooms 3 (SEM, 1), and of board-certified intensivists 7 (SEM, 3). Most ICUs (65%) functioned as closed units. The nurse-to-patient ratio was 1:1 or 1:2 in most ICUs (84%). On multivariable analysis, single rooms were less likely in low-income countries (p = 0.01) and nonreferral hospitals (p = 0.01); negative-pressure rooms were less likely in private hospitals (p = 0.03) and low-income countries (p = 0.005); 1:1 nurse-to-patient ratio was lower in private hospitals (p = 0.005); board-certified intensivists were less common in low-income countries (p < 0.0001) and closed ICUs were less likely in private (p = 0.02) and smaller hospitals (p < 0.001).

CONCLUSIONS

This survey highlights considerable variation in critical care structure, organization, and delivery in Asia, which was related to hospital funding source and size, and country income. The lack of single and negative-pressure rooms in many Asian ICUs should be addressed before any future pandemic of severe respiratory illness.

Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury

RATIONALE

Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients.

OBJECTIVES

To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA).

METHODS

Cohort study of patients with acute lung injury (ALI).

MEASUREMENTS AND MAIN RESULTS

ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition.

CONCLUSIONS

Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.

In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units

OBJECTIVE

Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs.

DESIGN

: Cross-sectional survey.

SETTING

Canadian adult and pediatric ICUs.

PARTICIPANTS

ICU directors.

INTERVENTIONS

ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs.

MEASUREMENTS AND MAIN RESULTS

Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, <1 yr, >10 yrs); 129 (48%) had <3 months of ICU experience. Most shifts (83%) were >20 hrs long.

CONCLUSIONS

In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.

Improving the ICU: part 1

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.

Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs

OBJECTIVE

To establish a database that permits description and analysis of the evolving role, patterns of use, and costs of critical care medicine (CCM) in the United States from 1985 to 2000.

DESIGN

Retrospective study combining data from federal (Hospital Cost Report Information System, Center for Medicare and Medicaid Services, Baltimore, MD) and private (Hospital Statistics, American Hospital Association, Chicago, IL) databases to analyze U.S. hospitals, hospital and CCM beds, and occupancy. CCM costs were calculated by the Russell equation and compared with national health care and financial indexes.

SETTING

Nonfederal, acute care hospitals with CCM units in the United States.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed hospitals with CCM units and focused on hospital and CCM beds, CCM occupancy, and CCM costs. CCM costs were compared with national cost indexes. Between 1985 and 2000, the total number of U.S. hospitals decreased by 8.9% (6,032 to 5,494) and acute care hospitals offering CCM decreased by 13.7% (4,150 to 3,581). The total number of beds in hospitals with CCM units decreased by 26.4% (889,600 to 654,400). In contrast, CCM beds increased by 26.2% (69,300 to 87,400). CCM occupancy was constant at 65%. CCM bed costs per day increased by 126% (1,185 to 2,674 US dollars). Although CCM costs increased by 190.4% (19.1 billion to 55.5 billion US dollars), the proportion of national health expenditures allocated to CCM decreased by 5.4%. In 2000, CCM costs represented 13.3% of hospital costs, 4.2% of national health expenditures, and 0.56% of the gross domestic product.

CONCLUSIONS

CCM is increasingly used and prominent in a shrinking U.S. hospital system. CCM occupancy is lower than expected. Despite its increasing use and cost, CCM is using proportionally less of national health expenses and the gross domestic product than previously estimated.

Accuracy of 30-minute indirect calorimetry studies in predicting 24-hour energy expenditure in mechanically ventilated, critically ill patients

BACKGROUND

There is no consensus regarding the optimal duration of measurement or time of day to perform indirect calorimetry (IC). Energy expenditure (EE) varies at different times of day and with different activity levels. We sought to assess the variability of EE in mechanically ventilated patients over a 24-hour period and the accuracy of 30-minute IC studies in predicting the 24-hour energy expenditure (EE24).

METHODS

The study was a prospective comparison between the resting EE obtained by 30-minute measurement of IC and EE values obtained from 24-hour measurements. Tests were performed in the Medical Intensive Care Unit (MICU) of a tertiary care, university hospital. Oxygen consumption (VO2) and carbon dioxide production (VCO2) were measured for 24 hours in eight ventilated patients. Measurements were made every 3 minutes and used to calculate 30-minute and 24-hour oxygen consumption values. EE24 was calculated using the modified Weir equation. Each 30-minute interval was compared with the value obtained from the 24-hour measurement.

RESULTS

Three hundred forty-one of 384 30-minute intervals remained for analysis. Average EE24 measured was 1490 +/- 486 kcal/d. Average EE24 predicted by extrapolation from 30-minute studies was 1501 +/- 503 kcal/d, with a mean difference of 0 +/- 209 kcal/d from the measured 24-hour values (range: -1068 to +585 kcal/d). Thirty-minute studies were within 20% of 24-hour measurements for 89% of intervals. The difference between 24-hour and 30-minute studies correlated with changes in minute ventilation (VE), heart rate, systolic blood pressure, and breath rate from their 24-hour means (p < .001). The mean error of EE estimate was greatest between 3 and 11 PM (p < .001).

CONCLUSIONS

We conclude the following: (1) EE in MICU patients is variable; (2) 30-minute IC studies predict measured EE24 acceptably well for clinical purposes; and (3) accuracy is maximized if a 30-minute study is performed between 11 PM and 3 PM, and when Ve, heart rate, systolic blood pressure, and breath rate are near the day's average.

Diagnosis and therapy of acute respiratory distress syndrome in adults: an international survey

In an attempt to identify the range of opinions influencing the diagnosis and therapy of patients with the adult respiratory distress syndrome (ARDS), a postal survey was mailed to 3,164 physician members of the American Thoracic Society Critical Care Assembly. The questionnaire asked opinions regarding the factors important in the diagnosis of ARDS and its treatment. Thirty-one percent of physicians surveyed responded within 4 weeks, the vast majority of which were board certified or eligible in Internal Medicine, Pulmonary Disease, and/or Critical Care Medicine. A known predisposing cause, measure of oxygenation efficiency, and a chest radiograph depicting pulmonary edema were reported to be the most important criteria for a clinical and research diagnosis of ARDS. Lung compliance and bronchoalveolar lavage neutrophil or protein content were reportedly less important. The initial treatment of patients with ARDS was reported to be most commonly accomplished using volume-cycled ventilation in the assist/control mode. Nearly half the responders reported using lower tidal volumes (5 to 9 mL/kg) than the traditionally recommended 10 to 15 mL/kg. Most respondents indicated they have intentionally allowed CO2 retention. On average, oxygen toxicity was thought to begin at an FIO2 between 0.5 and 0.6. It was reported that modest levels of positive end-expiratory pressure (PEEP) were used in incremental fashion as FiO2 requirements increased. Perceived indications for insertion of pulmonary artery catheters and compensation of the effects of PEEP on the pulmonary artery occlusion pressure varied widely among the responders. We conclude that reported practice patterns regarding the care of ARDS patients vary widely even within a relatively homogenous group of critical care practitioners.