Combined Medical-surgical Intensive Care Unit Research Articles

Using a Systems Engineering Framework to Evaluate Proton Pump Inhibitor Prescribing in Critically Ill Patients.

Proton pump inhibitors (PPIs) are a risk factor for hospital-acquired Clostridium difficile infection (CDI). Much PPI use is inappropriate, and interventions to reduce PPI use, such as for stress ulcer prophylaxis in all critically ill patients, are essential to reduce CDI rates. This mixed-methods study in a combined medical-surgical intensive care unit at a tertiary academic medical center used a human factors engineering approach to understand barriers and facilitators to optimizing PPI prescribing in these patients. We performed chart review of patients for whom PPIs were prescribed to evaluate prescribing practices. Semistructured provider interviews were conducted to determine barriers and facilitators to reducing unnecessary PPI use. Emergent themes from provider interviews were classified according to the Systems Engineering Initiative for Patient Safety model. In our intensive care unit, 25% of PPI days were not clinically indicated. Barriers to optimizing PPI prescribing included inadequate provider education, lack of institutional guidelines for stress ulcer prophylaxis, and strong institutional culture favoring PPI use. Potential facilitators included increased pharmacy oversight, provider education, and embedded decision support in the electronic medical record. Interventions addressing barriers noted by front line providers are needed to reduce unnecessary PPI use, and future studies should assess the impact of such interventions on CDI rates.

Prophylactic Platelet Transfusions for Critically Ill Patients With Thrombocytopenia: A Single-Institution Propensity-Matched Cohort Study.

Thrombocytopenia is frequently encountered in critically ill patients, often resulting in prophylactic transfusion of platelets for the prevention of bleeding complications. However, the efficacy of this practice remains unclear. The objective of this study was to determine the relationship between prophylactic platelet transfusion and bleeding complications in critically ill patients. This is a retrospective cohort study of adults admitted to surgical, medical, or combined medical-surgical intensive care units (ICUs) at a single academic institution between January 1, 2009, and December 31, 2013. Inclusion criteria included age ≥18 years and a platelet count measured during ICU admission. Propensity-matched analyses were used to evaluate associations between prophylactic platelet transfusions and the outcomes of interest with a primary outcome of red blood cell transfusion in the ensuing 24 hours and secondary outcomes of ICU and hospital-free days and changes in sequential organ failure assessment scores. A total of 40,693 patients were included in the investigation with 3227 (7.9%) receiving a platelet transfusion and 1065 (33.0%) for which platelet transfusion was prophylactic in nature. In propensity-matched analyses, 994 patients with prophylactic platelet transfusion were matched to those without a transfusion. Patients receiving prophylactic platelets had significantly higher red blood cell transfusion rates (odds ratio 7.5 [5.9-9.5]; P < .001), fewer ICU-free days (mean [standard deviation] 20.8 [9.1] vs 22.7 [8.3] days; P = .004), fewer hospital-free days (13.0 [9.7] vs 15.8 [9.4] days; P < .001), and less improvement in sequential organ failure assessment scores (mean decrease of 0.2 [3.6] vs 1.8 [3.3]; P < .001) in the subsequent 24 hours. These findings appeared robust, persisting in multiple predefined sensitivity analyses. Prophylactic administration of platelets in the critically ill was not associated with improved clinical outcomes, though residual confounding may exist. Further investigation of platelet transfusion strategies in this population is warranted.

Focused cardiac ultrasound in the early resuscitation of severe sepsis and septic shock: a prospective pilot study.

Point-of-care ultrasonography has been increasingly used in the care of critically ill patients; however, reports on its use during active resuscitation are limited. The aim of this study was to investigate the true impact of focused cardiac ultrasound (FCU) during the management of sepsis with early (6-h) resuscitation. A prospective pilot observational study was conducted at an academic medical center from March 2011 through July 2012. Patients undergoing resuscitation for severe sepsis or septic shock were prospectively enrolled at medical and combined medical-surgical intensive care units. Patients underwent a 10-min FCU examination when echocardiography was not part of their care plan. FCU was performed by sonographers and interpreted by cardiologists to minimize risks of inadequate image acquisition and misinterpretation. Intensivists completed surveys on their diagnostic and therapeutic plans before and after receiving FCU information. Of the 30 patients enrolled, 18 (60%) were male and the median age was 61years [interquartile range (IQR) 50-71years]. Median central venous oxygen saturation and lactate levels were 59.6% (IQR 53.1-66.2%) and 2.7mmol/L (IQR 1.2-4.1mmol/L), respectively. Clinical assessment by intensivists before FCU commonly failed to correctly estimate ventricular function; specifically, left ventricular in 12 patients [40%, 95% confidence interval (CI) 25-58%] and right ventricular function in 15 patients (50%, 95% CI 33-67%). Intensivists' therapeutic plans changed in eight cases (27%, 95% CI 14-44%) after FCU information became available. The most common changes were fluid management and imaging tests. Intensivists' confidence in their therapeutic plans improved for 11 patients (37%, 95% CI 22-55%). FCU is a valuable examination tool during early resuscitation of severe sepsis and septic shock.

Antibiotic resistance patterns in medical and surgical patients in a combined medical-surgical intensive care unit

PurposeStudies have found different rates of antimicrobial resistance among patients in medical and surgical intensive care units (ICUs). We studied whether these differences were a function of geography or differences in the patient populations, by comparing resistance rates among bacteria isolated from a combined medical/surgical ICU. Materials and MethodsWe retrospectively evaluated the results of bacterial cultures of each patient admitted to the ICU between February 2005 and September 2006. Data collection included patient demographics and culture and sensitivity results. Intensive care unit populations were compared using the Fisher exact test and the Student t test. ResultsOne hundred seventy-one medical and 94 surgical patients with positive cultures were studied. Organisms were grouped into 4 classes: Staphylococcus aureus, nonlactose fermenting gram-negative bacilli, Enterococcus species, and gram-negative enteric bacteria. In the 4 classes, no significant difference in antibiotic resistance was found between medical and surgical patients. ConclusionReported differences in resistance patterns among bacteria cultured from medical and surgical patients may be due to geographic separation of the ICUs as opposed to differences in the patient characteristics. This study suggests that ICU-specific antibiograms remain a useful tool to guide the choice of antimicrobial therapy, even in medical/surgical ICUs.

Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians.

This survey was designed to clarify the current understanding and clinical management of intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) among intensive care physicians in tertiary Chinese hospitals. A postal twenty-question questionnaire was sent to 141 physicians in different intensive care units (ICUs). A total of 108 (76.6%) questionnaires were returned. Among these, three quarters worked in combined medical-surgical ICUs and nearly 80% had primary training in internal or emergency medicine. Average ICU beds, annual admission, ICU length of stay, acute physiology and chronic health evaluation (APACHE) II score, and mortality were 18.2 beds, 764.5 cases, 8.3 d, 19.4, and 21.1%, respectively. Of the respondents, 30.6% never measured intra-abdominal pressure (IAP). Although the vast majority of the ICUs adopted the exclusively transvesicular method, the overwhelming majority (88.0%) only measured IAP when there was a clinical suspicion of IAH/ACS and only 29.3% measured either often or routinely. Moreover, 84.0% used the wrong priming saline volume while 88.0% zeroed at reference points which were not in consistence with the standard method for IAP monitoring recommended by the World Society of Abdominal Compartment Syndrome. ACS was suspected mainly when there was a distended abdomen (92%), worsening oliguria (80%), and increased ventilatory support requirement (68%). Common causes for IAH/ACS were "third-spacing from massive volume resuscitation in different settings" (88%), "intra-abdominal bleeding", and "liver failure with ascites" (52% for both). Though 60% respondents would recommend surgical decompression when the IAP exceeded 25 mmHg, accompanied by signs of organ dysfunction, nearly three quarters of respondents preferred diuresis and dialysis. A total of 68% of respondents would recommend paracentesis in the treatment for ACS. In conclusion, urgent systematic education is absolutely necessary for most intensive care physicians in China to help to establish clear diagnostic criteria and appropriate management for these common, but life-threatening, diseases.

Variation in the Rates of Do Not Resuscitate Orders After Major Trauma and the Impact of Intensive Care Unit Environment

There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use. Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or >/=55. Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0-3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) of a DNR order in the young. DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.

Nosocomial bloodstream infections in ICU and non-ICU patients

Nosocomial bloodstream infections (BSI) create a serious health problem in hospitals all over the world. The objectives of our study were to explore putative disease markers and potential risk factors with nosocomial BSI in patients in intensive care units (ICU) and non-ICU patients and to determine risk factors associated with increased 28-day mortality rate in patients with nosocomial BSI acquired in combined medical-surgical ICU. However, the major purposes of this report were to identify epidemiologic differences between nosocomial BSI acquired in ICU and non-ICU, as well as analyses outcomes for patients with nosocomial BSI acquired in ICU. A 1-year prospective cohort study was performed to determine the incidence of nosocomial BSI in hospitalized patients. Patient characteristics, risk factors related to health care, and source of infection of patients with BSI acquired in non-ICU were compared with those patient with BSI acquired in ICU. Also, nested case-control study of patients to nosocomial BSI acquired in ICU was performed to evaluate outcome. Patients were identified by active surveillance and positive blood culture during the study period. The incidence of nosocomial BSI was 2.2 per 1000 admission in non-ICU patients and 17.4 per 1000 admission in ICU patients. The 28-day crude mortality rate was 69% in ICU patients. A multivariate model showed that nasogastric tube (RR, 25.1; 95% CI: 3.845-163.85; P=.001), mechanical ventilation (RR, 13.04; 95% CI: 1.974-96.136; P=.008), and H2 blockers (RR, 12.16; 95% CI: 1.748-84.623; P=.012) were more prevalent among patients with BSI acquired in ICU, and aggressive procedures (RR, 8.65; 95% CI: 1.70-44.00; P=.009) were more prevalent among patients with BSI acquired in non-ICU patients. Risk factors independently associated with increased 28-day mortality rate in ICU patients were mechanical ventilation (OR, 8.63; 95% CI: 1.5-49.8; P=.016) and SAPS II >40 (OR, 6.0; 95% CI: 1.0-35.7; P=.049). The most common isolated nosocomial BSI pathogens (in both groups of patients) were coagulase-negative staphylococci (21%), Staphylococcus aureus (14%), and Klebsiella species (13%). Klebsiella species was the only organism independently influencing the poor outcome of nosocomial BSI in ICU patients (OR, 4.3; 95% CI: 1.2-15.3; P=.022). Our results show epidemiologic differences between non-ICU and ICU BSI. Also, this study suggests that severity of underlying host conditions, mechanical ventilation, and microbial agents (Klebsiella species) affect the outcome of NBI in patients in ICU.

Bedside percutaneous tracheostomy experience with 72 critically ill patients.

Tracheostomy is necessary in intensive care unit (ICU) patients requiring prolonged mechanical ventilation. As an alternative to the standard surgical method, percutaneous techniques are available. Seventy-two patients were electively selected for percutaneous tracheostomy (PCT) in a nine-bed combined medical-surgical intensive care unit. PCT was performed at bedside with the Portex Percutaneous Tracheostomy Kit that uses the Griggs technique. The procedure time and early complications were recorded. The procedure was successful in all patients. The average duration of placement was 7.4 min. There were no tracheostomy-related deaths. Major bleeding occurred in three patients and required surgical intervention. In one patient, minor bleeding occurred at the stoma site that resolved with applied pressure. Wound infections were treated with local antiseptics in two patients. These findings suggest that PCT is a simple, quick and safe procedure.

Nosocomial infections in combined medical-surgical intensive care units in the United States.

To describe the epidemiology of nosocomial infections in combined medical-surgical (MS) intensive care units (ICUs) participating in the National Nosocomial Infection Surveillance (NNIS) System. Analysis of surveillance data on 498,998 patients with 1,554,070 patient-days, collected between 1992 and 1998 from 205 MS ICUs following the NNIS Intensive Care Unit protocol, representing 152 participating NNIS hospitals in the United States. Infections at three major sites represented 68% of all reported infections (nosocomial pneumonia, 31%; urinary tract infections (UTIs), 23%; and primary bloodstream infections (BSIs), 14%: 83% of episodes of nosocomial pneumonia were associated with mechanical ventilation, 97% of UTIs occurred in catheterized patients, and 87% of primary BSIs in patients with a central line. In patients with primary BSIs, coagulase-negative staphylococci (39%) were the most common pathogens reported; Staphylococcus aureus (12%) was as frequently reported as enterococci (11%). Coagulase-negative staphylococcal BSIs were increasingly reported over the 6 years, but no increase was seen in candidemia or enterococcal bacteremia. In patients with pneumonia, S. aureus (17%) was the most frequently reported isolate. Of reported isolates, 59% were gram-negative bacilli. In patients with UTIs, Escherichia coli (19%) was the most frequently reported isolate. Of reported isolates, 31% were fungi. In patients with surgical-site infections, Enterococcus (17%) was the single most frequently reported pathogen. Device-associated nosocomial infection rates for BSIs, pneumonia, and UTIs did not correlate with length of ICU stay, hospital bed size, number of beds in the ICU, or season. Combined MS ICUs in major teaching hospitals had higher device-associated infection rates compared to all other hospitals with combined medical-surgical units. Nosocomial infections in MS ICUs at the most frequent infection sites (bloodstream, urinary, and respiratory tract) almost always were associated with use of an invasive device. Device-associated infection rates were the best available comparative rates between combined MS ICUs, but the distribution of device-associated rates should be stratified by a hospital's major teaching affiliation status.

Prevalence and Severity of Neurologic Dysfunction in Critically III Patients: Influence on Need for Continued Mechanical Ventilation

The relative importance of neurologic dysfunction in critically ill mechanically ventilated patients has not been well studied. This study investigates the prevalence of neurologic dysfunction in critically ill mechanically ventilated patients and its influence on preventing the discontinuation of mechanical ventilation and patient outcome. Prospective study. University-based, tertiary care center. All eligible adult patients mechanically ventilated for more than 48 h were included. A total of 66 patients were evaluated. None. Two independent questionnaires, one completed by the critical care attending physician documenting the major clinical factors necessitating continued mechanical ventilation, and a second questionnaire, completed by a critical-care trained neurologist documenting neurologic status and objective cardiopulmonary status formed the basis for outcome measurements. Respiratory and physiologic data, the patient's clinical conditions, and outcome (mortality) were also included in the database. Pulmonary factors were the major reason for prolonged ventilation in only 51 percent of the patient evaluations. Neurologic status was the major factor necessitating continued mechanical ventilation in 32 percent of the patient evaluations and a significant contributing factor in an additional 41 percent. Of the neurologic factors, diminished level of consciousness was the major cause of continued ventilatory support. This was usually due to a systemic illness, rather than a primary central nervous system disorder. Mortality was significantly lower in patients who continued to require mechanical ventilation after 48 h because of neurologic factors as opposed to pulmonary factors (15 percent vs 72 percent, p = 0.002). There is a high prevalence of neurologic dysfunction in critically ill patients and this problem plays a significant role in preventing the discontinuation of mechanical ventilation. Altered mental status is a major factor necessitating continued mechanical ventilation in combined medical-surgical intensive care units.