Objektive Verlegungskriterien und proaktives Verlegungs­management zur Steuerung von intensivmedizinischen Kapazitäten

Japan has the highest proportion of older adults worldwide but has fewer critical care beds than most high-income countries. Although the COVID-19 infection rate in Japan is low compared with Europe and the United States, by the end of 2020, several infected people died in ambulances because they could not find hospitals to accept them. Our study aimed to examine the Japanese healthcare system's capacity to accommodate critically ill COVID-19 patients during the pandemic. We created a model to estimate bed and staff capacity at 3 levels of pandemic response (conventional, contingency, and crisis), as defined by the US National Academy of Medicine, and the function of Japan's healthcare system at each level. We then compared our estimates of the number of COVID-19 patients requiring intensive care at peak times with the national health system capacity using expert panel data. Our findings suggest that Japan's healthcare system currently can accommodate only a limited number of critically ill COVID-19 patients. It could accommodate the surge of pandemic demands by converting nonintensive care unit beds to critical care beds and using nonintensive care unit staff for critical care. However, bed and staff capacity should not be expanded uniformly, so that the limited number of physicians and nurses are allocated efficiently and so staffing does not become the bottleneck of the expansion. Training and deploying physicians and nurses to provide immediate intensive care is essential. The key is to introduce and implement the concept and mechanism of tiered staffing in the Japanese healthcare system. More importantly, most intensive care facilities in Japanese hospitals are small-scaled and thinly distributed in each region. The government needs to introduce an efficient system for smooth dispatching of medical personnel among hospitals regardless of their founding institutions.

Children have not been severely affected by SARS-CoV-2-related illness but are vulnerable to the economic and social deprivation arising from the pandemic. This document describes unique risks and burdens for children and their care givers during the COVID-19 pandemic.

171 Rationing Critical Care Access From Emergency Department: Electronic Classification System for Critical Care Admission

Systematic Intensive Respiratory Care

End of life care (EOLC) in the intensive care unit (ICU) is becoming increasingly common. As a result, intensive care unit (ICU) nurses are required to make a switch from a curative mode of care, to one which promotes a peaceful death. In this transition, nurses are often ill prepared and therefore, further research is needed to adequately prepare nurses to provide this specialised care. The aims of this study were to assess the quality of dying and death in Australian ICUs according to intensive care nurses; to identify areas for improvement in current EOLC nursing practice; to identify Australian intensive care nurses' level of EOLC education to evaluate the possible need for further education; and to describe Palliative Care and Social Work involvement in EOLC. An ICU version of the Quality of Death and Dying (QODD) questionnaire was used in this study. Participants were accessed through the Australian College of Critical Care Nurses (ACCCN). There were 220 participants in this study. The findings of this study indicated that education, experience, patients' conscious state at the time of death, and having someone present at the time of death affected the quality of dying and death in Australian ICUs. Participants also expressed their views that education alone is insufficient in preparing nurses to deal with dying and death; and that learning through experience is also important. This study also found that palliative care services were underutilised. These results strengthen what is already known about this topic and suggests ways in which the quality of EOLC may be improved in future practice.

Who Should Supervise Respiratory Intensive Care Units?

To determine the number of children from a defined population who use intensive care facilities, to analyse bed occupancy data for those children, and to estimate the number of intensive care beds required to satisfy this demand throughout the year. Examination of admission data books from intensive care units within the four Birmingham health authorities and the neighbouring health authorities. Two hundred and ninety seven children resident within the four Birmingham health authorities used intensive care facilities in a calendar year. One hundred and forty one (47%) of these were admitted for specialist paediatric services. Of the remaining 156, 106 (68%) were cared for in adult intensive care units, 46 (29%) in a paediatric intensive care unit and four (3%) in a special care baby unit. Use of intensive care varied from none to 11 patients each day, and was lowest in the summer and highest during the winter months. During periods of peak demand, one in 19,000 (5.3/100,000) children were using intensive care facilities. These data provide a population based minimum need for paediatric intensive care beds. They are higher than previous estimates and do not include provision for children from outside Birmingham, or for those denied intensive care due to bed shortages. These factors and the marked seasonal variation in demand need to be considered when planning intensive care services for children if bed shortages are to be avoided.

Critical care and the global burden of critical illness in adults

Invited Commentary

In One Ear and Out the Other: Communication Barriers as a Risk Factor for Critical Incidents

Identifying Patients with High Risk of High Cost

BackgroundThe medical teams in intensive care units (ICUs) spend increasing amounts of time at computer systems for data processing, input, and interpretation purposes. As each patient creates about 1000 data points per hour, the available information is abundant, making the interpretation difficult and time-consuming. This data flood leads to a decrease in time for evidence-based, patient-centered care. Information systems, such as patient data management systems (PDMSs), are increasingly used at ICUs. However, they often create new challenges arising from the increasing documentation burden.ObjectiveNew concepts, such as artificial intelligence (AI)–based assistant systems, are hence introduced to the workflow to cope with these challenges. However, there is a lack of standardized, published metrics in order to compare the various data input and management systems in the ICU setting. The objective of this study is to compare established documentation and retrieval processes with newer methods, such as PDMSs and voice information and documentation systems (VIDSs).MethodsIn this crossover study, we compare traditional, paper-based documentation systems with PDMSs and newer AI-based VIDSs in terms of performance (required time), accuracy, mental workload, and user experience in an intensive care setting. Performance is assessed on a set of 6 standardized, typical ICU tasks, ranging from documentation to medical interpretation.ResultsA total of 60 ICU-experienced medical professionals participated in the study. The VIDS showed a statistically significant advantage compared to the other 2 systems. The tasks were completed significantly faster with the VIDS than with the PDMS (1-tailed t59=12.48; Cohen d=1.61; P<.001) or paper documentation (t59=20.41; Cohen d=2.63; P<.001). Significantly fewer errors were made with VIDS than with the PDMS (t59=3.45; Cohen d=0.45; P=.03) and paper-based documentation (t59=11.2; Cohen d=1.45; P<.001). The analysis of the mental workload of VIDS and PDMS showed no statistically significant difference (P=.06). However, the analysis of subjective user perception showed a statistically significant perceived benefit of the VIDS compared to the PDMS (P<.001) and paper documentation (P<.001).ConclusionsThe results of this study show that the VIDS reduced error rate, documentation time, and mental workload regarding the set of 6 standardized typical ICU tasks. In conclusion, this indicates that AI-based systems such as the VIDS tested in this study have the potential to reduce this workload and improve evidence-based and safe patient care.

As part of the German government's digitization initiative, the paper-based documentation that is still present in many intensive care units is to be replaced by digital patient data management systems (PDMS). In order to simplify the implementation of such systems, standards for basic functionalities that should be part of basic configurations of PDMS would be of great value. This paper describes functional requirements for PDMS in several categories. Criteria for standardized data documentation were defined by the authors and derived functional requirements were classified into two priority categories. Overall, general technical requirements, functionalities for intensive care patient care, and additional functionalities for PDMS were defined and prioritized. Using this paper as astarting point for adiscussion about basic functionalities of PDMS, it is planned to develop and obtain consensus on definitive standards with representatives from medical societies, medical informatics and PDMS manufacture.

In diesem Beitrag werden die Risikofaktoren zu Beginn des Krankhausaufenthaltes bei Patienten, die auf Intensivstationen ein Dekubitalulkus entwickelten, mit denen der Patienten verglichen, die auf Normalstationen ein Dekubitalulkus entwickelten. Im Rahmen einer prospektiven Erhebung wurde durch das Pflegepersonals von April 2003 bis April 2004 bei jedem Patienten am Tag der Aufnahme ein 29 Punkte umfassendes Risikoprofil dokumentiert. Ingesamt umfasst die Auswertung 49 904 Behandlungsfalle, von denen 5073 (10,2%) mindestens einen Tag auf einer Intensivstation verbrachten. Insgesamt entwickelten 94 Patienten wahrend eines Intensivaufenthaltes ein neues Dekubitalulkus und 186 Patienten ohne einen Aufenthalt auf einer Intensivstation. Patienten, die auf einer Intensivstation ihr Druckulkus entwickelten, unterschieden sich im Alter, der Geschlechterverteilung und der Krankenhausverweildauer nicht von den Patienten, die ihr Druckulkus ohne Intensivaufenthalt entwickelten. Der Anteil der operierten Patienten war mit 72% nur gering hoher als mit 60% bei den nicht intensivmedizinisch betreuten Patienten (p=0,046). Die mittlere Anzahl von Risikofaktoren zu Beginn des Krankenhausaufenthaltes war mit 10,0±5,7 im Vergleich zu 7,5±4,9 bei den Patienten, die ihr Druckulkus auf Normalstation entwickelten, erhoht (p=0,001). Bei den Intensivpatienten waren bereits bei Aufnahme die Risikofaktoren „stark sedierende Medikamente“, „gefasverengende Medikamente“, „Op-Dauer >60 Minuten“, „Fieber“, „Sepsis“, „Stuhl- und Urininkontinenz“, „Druckgefahrdung durch Ableitungssysteme oder Fixierung“, „Storung des Druck-, Schmerz- oder Temperaturempfindens“ haufiger als bei Patienten, die unabhangig von einem Intensivaufenthalt ein Druckulkus entwickelten. Die vorgestellten Daten zeigen, dass Patienten, die wahrend eines Aufenthalts auf einer Intensivstation ein Dekubitalulkus entwickelten, schon bei Aufnahme ins Krankenhaus ein erhohtes Risiko aufweisen.

A significant portion of intensive care unit (ICU) admissions occur through the emergency department (ED). Since there are insufficient ICU beds, critically ill patients may have to be monitored and treated in ED for an extended period. In this study, we aimed to show the importance of the emergency department intensive care unit (EDICU) and that ED applications should be taken into account in determining the number of intensive care unit (ICU) beds in hospitals by analyzing the patients hospitalized in intensive care units from the ED. In this retrospective descriptive study, patients over 18 who applied to the ED of a tertiary hospital between July 1, 2018, and July 1, 2019, and were deemed suitable for ICU admission were included. In descriptive statistics, percentages were used in categorical data, and mean, and standard deviation were used in numerical data. Chi-square test was applied for categorical variables. Since the distribution within the groups was normal in the analysis of continuous variables, one-way analysis of variance (ANOVA) was used when more than two groups were compared. The student's t-test was used when two groups were compared. Of the 2783 patients who applied to the ED and were suitable for admission to the ICU, 1341 (48.2%) were admitted to the second-level ICU, and 1442 (51.8%) were admitted to the third-level ICU. 1140 (40.96%) patients were hospitalized in the EDICU and toxicology ICU within the ED. These units played an important role in facilitating the ED operation and reducing crowding. Patients admitted to the ICU were divided into three groups based on their length of stay. Of the patients, 2312 (%83.1) were hospitalized in the first 6 hours, 337 (%12.1) in 6-12 hours, and 205 (7.36%) in more than 12 hours. It was observed that the mortality rate increased significantly when hospitalization in the ICU was delayed (P=0.014). ED admissions should be considered when determining the number of ICU beds and step levels of hospitals. In addition, the presence of EDICU in tertiary care hospitals relieves the density of the emergency department and indirectly reduces the mortality rate.