Critical Care Facilities Research Articles

Critical care in rural hospitals in the Indian state of West Bengal (WB)

This paper tries to showcase how critical care facilities can be extended to the remote regions of the state of WB. To set the context, medical management is provided for by the state hospital with the tertiary medical colleges at the upper and of the pyramid with district hospital (DH), sub-divisional Hospital (SDH), state general hospital (SGH), in the middle tier and rural hospitals. The pre-existent set-up has not been functioning satisfactorily. Due to lack of funds and huge workload, the number of referrals from district …

Obstetric critical care services in South Africa

More than half of all global maternal deaths occur in Africa. A large percentage of these deaths are preventable, and lack of access to adequate critical care facilities is a contributing factor. There are limited published data on the clinical and management challenges presented by the critically ill obstetric patient admitted to the intensive care unit in our setting, and more data are required in order to better define the critical care needs of this group of patients.

Interfacility Transports Utilizing the 9-1-1 Emergency Medical Services System

Background. With the increasing development of regional specialty centers, emergency physicians are often confronted with patients needing definitive care unavailable at their hospital. Interfacility transports (IFTs) may be a useful option to ensure timely, definitive patient care. However, since traditional IFT can be a challenging and time-consuming process, some EMS agencies that have previously limited their service to 9-1-1 emergency responses are now performing emergency IFTs.Objective. We sought to determine the frequency and nature of transfers provided by a local fire-based 9-1-1 EMS agency that recently began to provide limited IFT for time-critical emergencies.Methods. A retrospective review of paramedic reports for all IFTs between April 2007 and March 2014 in the City of Los Angeles, California. All IFTs initiated by 9-1-1 call from an emergency department (ED) and performed by Los Angeles Fire Department paramedics were included. Reason for transfer, patient demographics, and key time metrics were captured.Results. There were 919 IFTs during the study period, out of approximately 1,160,000 total ambulance transports (0.1%). The most frequent reason for IFT request was for transport of patients with ST segment elevation MI (STEMI) to a STEMI receiving center, followed by major trauma to a trauma center, and intracranial hemorrhage to a center with neurosurgical capability. Less common reasons included vascular emergencies, acute stroke, obstetric emergencies, and transfers to pediatric critical care facilities. Median transport time was 8 minutes (IQR 6–13 minutes) and median total time for IFT was 51 minutes (IQR 39–69 minutes). All IFTs involved a potentially life-threatening condition requiring a higher level of care than was available at the referring hospital.Conclusions. Emergent ED-to-ED interfacility transport can provide access to time critical definitive care. EMS agencies that have limited the scope of their response to community 9-1-1 emergencies should have policies in place to assure timely response for emergent IFT requests.

Prognosis of neonatal tetanus in the modern management era: an observational study in 107 Vietnamese infants

Most data regarding the prognosis in neonatal tetanus originate from regions where limited resources have historically impeded management. It is not known whether recent improvements in critical care facilities in many low- and middle-income countries have affected indicators of a poor prognosis in neonatal tetanus. We aimed to determine the factors associated with worse outcomes in a Vietnamese hospital with neonatal intensive care facilities. Data were collected from 107 cases of neonatal tetanus. Clinical features on admission were analyzed against mortality and a combined endpoint of 'death or prolonged hospital stay'. Multivariable analysis showed that only younger age (odds ratio (OR) for mortality 0.69, 95% confidence interval (CI) 0.48-0.98) and lower weight (OR for mortality 0.06, 95% CI 0.01-0.54) were significantly associated with both the combined endpoint and death. A shorter period of onset (OR 0.94, 95% CI 0.88-0.99), raised white cell count (OR 1.17, 95% CI 1.02-1.35), and time between first symptom and admission (OR 3.77, 95% CI 1.14-12.51) were also indicators of mortality. Risk factors for a poor outcome in neonatal tetanus in a setting with critical care facilities include younger age, lower weight, delay in admission, and leukocytosis.

Maternal mortality and derivations from the WHO near-miss tool: An institutional experience over a decade in Southern India.

Preceding the use of World Health Organization (WHO) near-miss approach in our institute for the surveillance of Severe Maternal Outcome (SMO), we pilot-tested the tool on maternal death cases that took place over the last 10 years in order to establish its feasibility and usefulness at the institutional level. This was a retrospective review of maternal deaths in Christian Medical College Vellore, India, over a decade. Cases were recorded and analyzed using the WHO near-miss tool. The International Classification of Diseases, 10(th) Revision was used to define and classify maternal mortality. There were 98,139 total births and 212 recorded maternal deaths. Direct causes of mortality constituted 46.96% of total maternal deaths, indirect causes constituted 51.40%, and unknown cases constituted 1.9%. Nonobstetrical cause (48.11%) is the single largest group. Infections (19.8%) other than puerperal sepsis remain an important group, with pulmonary tuberculosis, scrub typhus, and malaria being the leading ones. According to the WHO near-miss criteria, cardiovascular and respiratory dysfunctions are the most frequent organ dysfunctions. Incidence of coagulation dysfunction is seen highest in obstetrical hemorrhage (64%). All women who died had at least one organ dysfunction; 90.54% mothers had two- and 38.52% had four- or more organ involvement. The screening questions of the WHO near-miss tool are particularly instrumental in obtaining a comprehensive assessment of the problem beyond the International Classification of Diseases-Maternal Mortality and establish the need for laboratory-based identification of organ dysfunctions and prompt availability of critical care facilities. The process indicators, on the other hand, inquire about the basic interventions that are more or less widely practiced and therefore give no added information at the institutional level.

Safety, feasibility, and outcomes of induced hypothermia therapy following in-hospital cardiac arrest-evaluation of a large prospective registry*.

Despite a lack of randomized trials, practice guidelines recommend that mild induced hypothermia be considered for comatose survivors of in-hospital cardiac arrest. This study describes the safety, feasibility, and outcomes of mild induced hypothermia treatment following in-hospital cardiac arrest. Prospective, observational, registry-based study. Forty-six critical care facilities in eight countries in Europe and the United States reporting in the Hypothermia Network Registry and the International Cardiac Arrest Registry. A total of 663 patients with in-hospital cardiac arrest and treated with mild induced hypothermia were included between January 2004 and February 2012. None. A cerebral performance category of 1 or 2 was considered a good outcome. At hospital discharge 41% of patients had a good outcome. At median 6-month follow-up, 34% had a good outcome. Among in-hospital deaths, 52% were of cardiac causes and 44% of cerebral cause. A higher initial body temperature was associated with reduced odds of a good outcome (odds ratio, 0.79; 95% CI, 0.68-0.92). Adverse events were common; bleeding requiring transfusion (odds ratio, 0.56; 95% CI, 0.31-1.00) and sepsis (odds ratio, 0.52; 95% CI, 0.30-0.91) were associated with reduced odds for a good outcome. In this registry study of an in-hospital cardiac arrest population treated with mild induced hypothermia, we found a 41% good outcome at hospital discharge and 34% at follow-up. Infectious complications occurred in 43% of cases, and 11% of patients required a transfusion for bleeding. The majority of deaths were of cardiac origin.

A cross-sectional survey of critical care services in Sri Lanka: A lower middle-income country

PurposeTo describe the extent and variation of critical care services in Sri Lanka as a first step towards the development of a nationwide critical care unit (CCU) registry. Materials and MethodsA cross-sectional survey was conducted in all state CCUs by telephone or by visits to determine administration, infrastructure, equipment, staffing, and overall patient outcomes. ResultsThere were 99 CCUs with 2.5 CCU beds per 100000 population and 13 CCU beds per 1 000 hospital beds. The median number of beds per CCU was 5. The overall admissions were 194 per 100000 population per year. The overall bed turnover was 76.5 per unit per year, with CCU mortality being 17%.Most CCUs were headed by an anesthetist. There were a total of 790 doctors (1.6 per bed), 1 989 nurses (3.9 per bed), and 626 health care assistants (1.2 per bed). Majority (87.9%) had 1:1 nurse-to-patient ratio, although few (11.4%) nurses had received formal intensive care unit training. All CCUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (such as electronic monitoring and infusion pumps). ConclusionSri Lanka, a lower middle-income country has an extensive network of critical care facilities but with inequalities in its distribution and facilities.

CHALLENGES OF PROVIDING PALLIATIVE CARE IN A CRITICAL CARE SETTING

BackgroundAn ageing population with complex co-morbidities and rising public expectation for high quality life sustaining treatment has seen a rising demand for critical care. End of life care strategy (2008)...

Assessment of the high-risk perioperative patient

Every year, 234 million people worldwide have surgery requiring an inpatient stay. In developed countries, the rate of permanent disability or death after such procedures is between 0.4 and 0.8%. However, within this population is hidden a subgroup of high-risk patients: in the UK 12.5% of patients account for 80% of perioperative deaths. 1 The short-term postoperative mortality for this high-risk group is estimated at 6% for elective patients and close to 30% for those having urgent or emergency surgery. 1 Several perioperative interventions are available to mitigate against adverse outcomes. These include targeted exercise (‘prehabilitation’), optimization of fluid and inotrope therapy, selection of surgical and anaesthetic personnel of appropriate seniority, and appropriate use of critical care facilities. However, allocation of such resources relies on recognition of ‘at risk’ patients; several recent reports have highlighted deficiencies in this process. 2,3 All patients presenting for surgery should undergo adequate preoperative evaluation as recommended by current European guidelines. 4 In addition, the assessment of the ‘high risk’ surgical patient should quantify the risk of an adverse outcome for each individual. This should be made explicit to the patient, clearly documented and used to stratify patients to receive an appropriate level of perioperative care. 2 In instances where surgical resection presents a substantial risk of short-term mortality or severe morbidity, then judicious decision-making is required about whether to proceed to surgery at all.

Anesthetic considerations in parturients with liver transplant

Advances in the surgical technique, safer anesthetic agents, improved hemodynamic monitoring, better pre-operative optimization of cirrhotic patients and postoperative critical care facilities have led to drastic improvement in the outcomes following orthotopic liver transplantation (OLT). Reproductive dysfunction in patients with end-stage liver disease can be corrected within months of successful orthotopic liver transplantation. Consequently, there is a worldwide increase in the number of women of childbearing potential after orthotopic liver transplantation. Successful pregnancies are now increasingly being reported in these patients. These are high-risk pregnancies as increased medical and obstetric complications and adverse maternal and fetal effects of immunosuppressant medications are likely to be encountered in these patients following liver transplantation. Optimal antenatal and perioperative management in these parturients warrant a multidisciplinary approach and meticulous planning. There is little evidence available regarding anesthetic concerns in this high-risk pregnant population. This review is aimed at addressing important perioperative issues in parturients, who have undergone a successful liver transplantation.

Caring for the critically ill patient: the ethical issues

The critically ill patient poses many ethical issues in relation to the provision of critical care. The increased demand for critical care facilities has prompted health care organisations worldwide to look for suitable alternatives for delivering critical care, which has led to post-anaesthesia care units (PACU) being used as an intensive care unit overflow facility. This raises ethical issues and concerns in relation to the quality of care delivery, and the patient's right to have equitable access to critical care in terms of the following ethical principles: beneficence/non-maleficence, deontology, justice and resource allocation, autonomy, utilitarianism, paternalism. Ethical principles need to be explored individually when clinical decisions are made to provide holistic ethical care, that preserves the moral and ethical integrity of both the PACU practitioner and patient. To apply ethical principles in clinical crises requires expert knowledge and experience within critical care, which needs to be underpinned with robust protocols and validated critical care training so that PACU practitioners can act in the patient's best interests and deliver safe, ethical high quality care.

Improving the outcomes from ruptured abdominal aortic aneurysm: interdisciplinary best practice guidelines

Improving the outcomes from ruptured abdominal aortic aneurysm: interdisciplinary best practice guidelines

Obstructive sleep apnea can be safely managed in a level 2 critical care setting after laparoscopic bariatric surgery

BackgroundIn the United Kingdom, demand for intensive care beds (level 3 critical care) often outstrips supply, leading to frequent and frustrating cancellation of complex elective surgery. It has been suggested that patients with obstructive sleep apnea who undergo bariatric surgery should be admitted to a level 3 facility for routine postoperative management. We have questioned the validity of this dogma in the era of laparoscopic bariatric surgery by using a simple easily applicable algorithm. ObjectivesThe aim of this study was to investigate the clinical outcome of patients with obstructive sleep apnea (OSA) without admission to the intensive care unit after laparoscopic bariatric surgery. MethodsFor the first 24 hours after surgery, all patients were admitted to a level 2 (high-dependency) area on a general surgical ward with experience of bariatric surgery. They received supplemental oxygen, continuous pulse oximetry, and judicious analgesic administration using a combination of small boluses of IV morphine together with IV paracetamol. Perioperative continuous positive airway pressure support was not routinely given, unless patients with OSA had oxygen saturation below their recorded preoperative level on 2 consecutive readings. ResultsA total of 1623 patients underwent laparoscopic bariatric surgery over a 12-year period. Of those, 192 had OSA with a median operative body mass index of 52 kg/m2 (range 34–78 kg/m2). The incidence of respiratory complications and the median length of stay (3 nights) were identical in patients with OSA and those without OSA. Four patients self-administered perioperative continuous positive airway pressure, but none required transfer to intensive care or mechanical ventilation. There were no in-hospital deaths. ConclusionLaparoscopic bariatric surgery in patients with OSA is well tolerated and does not require the routine use of level 3 critical care facilities.

A Business Case for Feature-Oriented Requirements Engineering

Owing to strong market growth for medical devices deployed in critical-care facilities, development organizations in medical engineering must continually look for opportunities to drive engineering efficiency and cost effectiveness. Furthermore, cycle time must decrease, the alignment of clinical workflow is breaking down departmental barriers, and an increased amount of product functionality is being realized in software. To help meet such challenges, adequate requirements engineering is necessary. Toward that end, Syngo (a business unit of the Imaging and Therapy division of Siemens) introduced Feature-Oriented Requirements Engineering (FORE) and developed a business case for using it in the context of a lean engineering program. FORE integrates with other engineering disciplines such as project management, software architecture, and test management. There was an error in the biographical information for Tobias Stenzel. Stenzel's biography should have indicated that he has an MS in industrial engineering and management from the University of Technology Karlsruhe, Germany.

Regional systems of care after out-of-hospital cardiac arrest in the UK: premier league care saves lives

Regional systems of care after out-of-hospital cardiac arrest in the UK: premier league care saves lives

Respiratory Manifestations of Malaria

Respiratory distress develops in up to 25% of adults and 40% of children with severe falciparum malaria. Its diverse causes include respiratory compensation of metabolic acidosis, noncardiogenic pulmonary edema, concomitant pneumonia, and severe anemia. Patients with severe falciparum, vivax, and knowlesi malaria may develop acute lung injury (ALI) and ARDS, often several days after antimalarial drug treatment. ARDS rates, best characterized for severe Plasmodium falciparum, are 5% to 25% in adults and up to 29% in pregnant women; ARDS is rare in young children. ARDS pathophysiology centers on inflammatory-mediated increased capillary permeability or endothelial damage leading to diffuse alveolar damage that can continue after parasite clearance. The role of parasite sequestration in the pulmonary microvasculature is unclear, because sequestration occurs intensely in P falciparum, less so in P knowlesi, and has not been shown convincingly in P vivax. Because early markers of ALI/ARDS are lacking, fluid resuscitation in severe malaria should follow the old adage to "keep them dry." Bacteremia and hospital-acquired pneumonia can complicate severe malaria and may contribute to ALI/ARDS. Mechanical ventilation can save life in ALI/ARDS. Basic critical care facilities are increasingly available in tropical countries. The use of lung-protective ventilation has helped to reduce mortality from malaria-induced ALI/ARDS, but permissive hypercapnia in unconscious patients is not recommended because increased intracranial pressure and cerebral swelling may occur in cerebral malaria. The best antimalarial treatment of severe malaria is IV artesunate.

Cost-Effectiveness Comparison of Response Strategies to a Large-Scale Anthrax Attack on the Chicago Metropolitan Area: Impact of Timing and Surge Capacity

Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.

Mapping US Pediatric Hospitals and Subspecialty Critical Care for Public Health Preparedness and Disaster Response, 2008

The objective is to describe by geographic proximity the extent to which the US pediatric population (aged 0-17 years) has access to pediatric and other specialized critical care facilities, and to highlight regional differences in population and critical resource distribution for preparedness planning and utilization during a mass public health disaster. The analysis focused on pediatric hospitals and pediatric and general medical/surgical hospitals with specialized pediatric critical care capabilities, including pediatric intensive care units (PICU), pediatric cardiac ICUs (PCICU), level I and II trauma and pediatric trauma centers, and general and pediatric burn centers. The proximity analysis uses a geographic information system overlay function: spatial buffers or zones of a defined radius are superimposed on a dasymetric map of the pediatric population. By comparing the population living within the zones to the total population, the proportion of children with access to each type of specialized unit can be estimated. The project was conducted in three steps: preparation of the geospatial layer of the pediatric population using dasymetric mapping methods; preparation of the geospatial layer for each resource zone including the identification, verification, and location of hospital facilities with the target resources; and proximity analysis of the pediatric population within these zones. Nationally, 63.7% of the pediatric population lives within 50 miles of a pediatric hospital; 81.5% lives within 50 miles of a hospital with a PICU; 76.1% lives within 50 miles of a hospital with a PCICU; 80.2% lives within 50 miles of a level I or II trauma center; and 70.8% lives within 50 miles of a burn center. However, state-specific proportions vary from less than 10% to virtually 100%. Restricting the burn and trauma centers to pediatric units only decreases the national proportion to 26.3% for pediatric burn centers and 53.1% for pediatric trauma centers. This geospatial analysis describes the current state of pediatric critical care hospital resources and provides a visual and analytic overview of existing gaps in local pediatric hospital coverage. It also highlights the use of dasymetric mapping as a tool for public health preparedness planning.

Surgical procedures, costs and patient satisfaction

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) states that emergency patients must have prompt access to theatres, critical care facilities and appropriately-trained staff at all times. Due to the increased number of trauma cases treated by our orthopaedic teams a dedicated Day Surgery Trauma List (DSTL) was introduced. This article is a retrospective study of operations, cost implications and patient satisfaction of this list. We reviewed 49 patients operated on by the first author in six months from October 2008 to March 2009. The type of operation, place of operative decision and the time taken from the decision to actual operation was recorded. The cost was analysed with the help of the finance department. Patient satisfaction was calculated from a questionnaire. Decision to operate was taken in accident and emergency in 60% cases and 40% in fracture clinic. The average time from the decision to operation was two days. Cost-benefit to the NHS was £300 per case. 28 patients answered the questionnaire with overall patient satisfaction of 8.57 out of 10. The day surgery trauma list may be used to perform various orthopaedic trauma procedures with significant cost containment (£14 400 in six months). Benefits to patients were specified operative time, reduced waiting times and good clinical care.

What do we really know about UK paediatric dental general anaesthesia services?

Dental general anaesthesia (DGA) is only permitted within a hospital setting where critical care facilities are available. Recently, concern has been expressed about the number of hospital admissions for the dental care of children following the publication of a high profile paper which highlighted an apparent increase in children being admitted for extractions due to caries under DGA. Coincidentally new best practice standards for paediatric DGA services have been published. An evaluation of DGA services in Yorkshire and the Humber suggested that existing monitoring was inadequate and is unlikely to represent true levels of activity and that any apparent increase may reflect the method of remuneration for services. In fact, recent changes in service structure and changes to improve quality have reduced DGA activity in some areas. In addition, the evaluation revealed that many services were not meeting standards of best practice.