Cost-effectiveness of a real-time spatiotemporal mapping surveillance system for meticillin-resistant Staphylococcus aureus prevention

OBJECTIVES

An infection surveillance system based on a hospital's digital twin [4D-Disease Outbreak Surveillance System (4D-DOSS)] is being developed in Singapore. It offers near-real-time infection surveillance and mapping capabilities. This early economic modelling study was conducted, using meticillin-resistant Staphylococcus aureus (MRSA) as the pathogen of interest, to assess the potential cost-effectiveness of 4D-DOSS.

METHODS

A Markov model that simulates the likelihood of MRSA colonization and infection was developed to evaluate the cost-effectiveness of adopting 4D-DOSS for MRSA surveillance from the hospital perspective, compared with current practice. The cycle duration was 1 day, and the model horizon was 30 days. Probabilistic sensitivity analysis was conducted, and the probability of cost-effectiveness was reported. Scenario analyses and a value of information analysis were performed.

RESULTS

In the base-case scenario, with 10-year implementation/maintenance costs of 4D-DOSS of $0, there was 68.6% chance that 4D-DOSS would be cost-effective. In a more pessimistic but plausible scenario where the effectiveness of 4D-DOSS in reducing MRSA transmission was one-quarter of the base-case scenario with 10-year implementation/maintenance costs of $1 million, there was 47.7% chance that adoption of 4D-DOSS would be cost-effective. The value of information analysis showed that uncertainty in MRSA costs made the greatest contribution to model uncertainty.

CONCLUSIONS

This early-stage modelling study revealed the circumstances for which 4D-DOSS is likely to be cost-effective at the current willingness-to-pay threshold, and identified the parameters for which further research will be worthwhile to reduce model uncertainty. Inclusion of other drug-resistant organisms will provide a more thorough assessment of the cost-effectiveness of 4D-DOSS.

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Building on a novel bootstrapping modelling technique to predict region-wide critical care capacity requirements over the next decade

We have previously described an open-source data-driven modelling technique that has been used to model critical care resource provision as well as expanded to elective surgery and even whole-hospital modelling. Here, we describe the use of this technique to model patient flow and resource use across the West Yorkshire Critical Care Network, with the advantage that recommendations can be made at an individual unit level for future resource provision, taking into account changes in population numbers and demography over the coming decade. We will be using this approach in other regions around the UK to help predict future critical care capacity requirements.

A call to incorporate systems theory and human factors into the existing investigation of harm in clinical research involving healthcare products

This is a joint statement from individual pharmacology and pharmaceutical professionals acting in their own capacity, including members of the Alliance for Clinical Research Excellence and Safety (ACRES) and the International Society of Pharmacovigilance (ISoP). By building on the extensive pharmacological and regulatory investigations that already take place, we are calling for a fuller and more robust systems-based approach to the independent investigation of clinical research when serious incidents of harm occur, starting with first-in-human clinical trials. To complement existing activities and regulations, we propose an additional approach blending evidence derived from both pharmacological and organizational science, which addresses human factors and transparency, to enhance organizational learning and continuous improvement. As happens with investigations in other sectors of society, such as the chemical and aviation sector, this systems approach should be seen as an additional way to understand how problems occur and how they might be prevented in the future. We believe that repetition of potentially preventable and adverse outcomes during clinical research, by failing to identify and act upon all systematic vulnerabilities, is a situation that needs urgent change. As we will discuss further on, approaches based on applying systems theory and human factors are much more likely to improve objectivity and transparency, leading to better system design.

Prospective randomized study of a new method of providing postoperative pain relief following femoropopliteal bypass

The extensive incision required for femoropopliteal bypass using saphenous vein causes significant postoperative pain, principally within the distribution of the cutaneous branches of the femoral nerve. This prospective randomized study investigated the efficacy of continuous postoperative femoral nerve block in reducing both pain (visual analogue pain score) and the requirement for opiate analgesia. Ten patients received a femoral nerve block by infusion of 0.5 per cent bupivacaine (5 ml/h for 48 h) via an epidural catheter together with a patient-controlled analgesia (PCA) device containing morphine; a further ten patients used a PCA device alone. The median postoperative intravenous morphine requirement was significantly reduced in patients with a nerve block at 24 h (4 versus 33 mg, P < 0.01) and at 48 h (5 versus 37 mg, P < 0.01) compared with controls. Postoperative pain was effectively abolished in the former group. The addition of a nerve block to PCA provides superior pain control after femoropopliteal bypass.

Assessing the health needs of elderly people

Under the 1990 GP contract, health visitors and district nurses attached to a GP practice on a large housing estate in Glasgow carried out a screening project to assess the health of all elderly people over 75 on the practice list. Sarah Whiteley and Olivia Brittain describe the scheme and the assessment tool they developed to provide specific information to the GPs and to the health board about the health needs of the individuals assessed and the services they required.

Evaluation of nursing education programmes--theory and practice

In this paper, the history of educational evaluation is considered through a review of the literature, in order to try and understand how current evaluation methods have developed. It is important that a historical perspective is gained, as there has been a big shift in thinking from a strongly behaviourist code of practice to a more investigative and less prescriptive approach, during the relatively short time span that evaluation has had to develop as a subject in its own right. The application of the theory to practice is also considered in terms of a working evaluation model developed through work on continuing education courses in Scotland.

Esophageal rupture in an infant secondary to esophageal placement of a Foley catheter gastrostomy tube

We report a case of esophageal rupture in a five-month-old female infant caused by a Foley catheter gastrostomy tube inadvertently placed into the esophagus at the time of tube change. The patient presented with vomiting and progressive respiratory distress and when first evaluated had a left-sided pneumothorax. The esophageal location of the Foley balloon was not initially apparent. Metrizamide radiography demonstrated the esophageal rupture. The patient recovered with drainage of the mediastinal and pleural collections. Physicians and caretakers should be alerted to the mechanical complications of Foley catheter tube gastrostomy, since these complications are mostly preventable and easily diagnosed.

Psychiatric consultation with MICU nurses: the consultation conference as a working group

A group of MICU nurses responded to a series of acute and chronic clinical and administrative stresses by establishing a consultation conference with a psychoanalyst. The evolution of the consultation conference into an ongoing working group is described. Its value as a modality to help deal with the special stresses of MICU nursing personnel is discussed. The problems of introducing a research focus into the conference are examined.