Different Types Of Intensive Care Units Research Articles

Impact of Capacity Strain on the Health Status of Patients Discharged From an Intensive Care Unit

Intensive care units (ICUs) play a vital role in hospitals and often experience capacity strain. Using data from a large teaching hospital, we empirically examine the effect of ICU capacity strain on patient discharge. We find that capacity strain has no effect on the health status of discharged patients and that capacity strain leads to a shorter length-of-stay in the ICU, but the magnitude of the effect is less than half a day in the most extreme scenarios. In post-hoc analyses, we find evidence the discharge process is expedited by starting discharges earlier in the day when capacity is strained, demonstrating that more efficient discharges can free up space without compromising patient health. In addition, we find a decrease in patient admissions during periods of capacity strain. To our knowledge, this is the first study to examine the direct relationship between ICU capacity strain and patient health at discharge, and it builds on the existing literature that has examined the effects of ICU capacity strain on proxies for patient health at discharge. We advocate that hospitals use outcome measures based on patient status at discharge to accurately assess the impact of capacity strain on quality of care. In addition, our work highlights the need for tailored research approaches and management practices for different types of ICUs, as generalizing the impact of ICU capacity strain across different settings may lead to inaccuracies.

Comparing Important and Well-documented Potential Drug-Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center.

IntroductionDrug–drug interaction (DDI) is one of the major healthcare challenges in intensive care units (ICUs). The prevalence of DDIs and interacting drug pairs may vary between different types of ICUs. This study aimed to compare the frequency and nature of important and well-documented potential DDIs (pDDIs) in three types of ICUs.Materials and methodsA prospective study was conducted in medical (M), surgical (S), and emergency (E) ICUs of a tertiary referral center for respiratory diseases. A pharmacist checked the patients’ files three days in a week for 6 months. The pDDIs were identified using the Lexi-Interact database. Interactions with a severity rating of D (modify regimen) and X (avoid combination) and with a reliability rating of good and excellent were considered important and well-documented. These pDDIs were evaluated in terms of drug combinations, mechanisms of interaction, and clinical management.ResultsOne hundred eighty-nine patients admitted to MICU, SICU, and EICU were included in the study. The percentage of patients who experienced at least one important and well-documented pDDI was 18.8% in MICU, 11.1% in SICU, and 11.8% in EICU. The most common drug pairs causing important and well-documented interactions were atracurium + hydrocortisone in MICU, meropenem + valproic acid in MICU and EICU, and aspirin + warfarin in SICU.ConclusionThe current study shows different frequency and nature of pDDIs between three types of ICUs. We recommend conducting similar studies in other settings to develop evidence-based guidance on clinically relevant pDDIs in different types of ICUs.How to cite this articleHosseinpoor Z, Farzanegan B, Baniasadi S. Comparing Important and Well-documented Potential Drug–Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center. Indian J Crit Care Med 2022;26(5):574–578.

Yoğun Bakım Ünitesi Mobilizasyon Ölçeğinin Türkçeye Uyarlama, Geçerlik ve Güvenirlik Çalışması: Metadolojik Çalışma

Objective: The aim of this study was to adapt the Intensive Care Units (ICU)-Mobility Scale which evaluates and classifies the mobilization status of ICU patients into Turkish. Material and Methods: A methodological and cross-sectional study design was used. This study was conducted in different types of ICU (Anesthesia ICU, Internal Medicine ICU, Neurology ICU, Coronary ICU, Cardiovascular Surgery ICU, and Neurosurgery ICU) of an Education and Research Hospital in İstanbul between June and August 2019 with a hundred patients receiving treatment. Data were collected using a questionnaire developed by the researchers and the ICU-Mobility Scale. For the validity of the scale, the language validity was tested. In order to determine its reliability, kappa inter-observer compliance analysis was performed. Results: Patients hospitalized in medical (65%) and surgical (35%) ICUs were involved in the study. Of the patients, 51% were female and 49% were male. The average age of the patients is 69.65±16.33 years. The language validity of the scale was ensured with World Health Organization's methods for the translation and adaptation of instruments developed in different languages. As a result of the kappa observer agreement, 0.846 (p˂0.001) was found to be high in reliability. The ICU-Mobility Scale was found to be valid and reliable in this study. Conclusion: Classification of types of mobilization is important in order to overcome barriers and standardize protocols that can be carried out. The ICU-Mobility Scale may be used to standardize and record the patients' mobility status in the ICU.

1878. Title: Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover Study

BackgroundThe impact of formalized, interdisciplinary antimicrobial stewardship program (ASP) rounds in the intensive care unit (ICU) setting has not been well described.MethodsWe performed a two-arm, cluster-randomized, crossover quality improvement study over 8 months to compare the impact of weekly ICU rounds with an ASP team vs. usual care. The primary outcome was antibiotic use (AU) in days of therapy (DOT) per 1,000 days present during and following ICU exposure. Our cohort consisted of ICU patients in 5 ICUs in Duke University Hospital. The unit of randomization was rounding team, which corresponded to half of the ICU beds in each unit. Each team was randomized to the intervention for 4 months followed by usual care for 4 months (or vice versa). The intervention involved multidisciplinary review of eligible patients to discuss antibiotic optimization. Patients not on antibiotics, followed by infectious diseases, post-transplant, on ECMO, or with a ventricular assist device were excluded from review. Intervention impact was assessed with multivariable negative binomial regression rate ratios (RR). AU was assessed over time before and after the study period to assess global and unit-level trends.ResultsWe had 4,683 ICU-exposed patients. Intervention effect was not significant for the primary outcome (table). The intervention order was not significant in the model. Eligible patients were lower in the cardiothoracic ICU (CTICU) compared with other units (table); the intervention led to a significant decrease in AU when the CTICU was removed (RR = 0.93 [0.89–0.98], P = 0.0025). Intervention impact was differential among ICUs, with the greatest effect in surgical and least in CTICU (table). nit-level AU decreased in all ICUs, driven by 4 of the 5 ICUs (table, figure).ConclusionThe effect of ASP rounds on AU was mixed for different types of ICUs. The direct effect on AU (intervention vs. control) was small because the analysis addressed the whole ICU population and thus was subject to biases from exposures after an ICU stay, ineligible patients, and lack of blinding. However, we observed an overall decline in AU during the study period, which we believe represents indirect effects of increased ASP activity and awareness. Additional ASP resources to round more than weekly may result in greater effect. Disclosures All Authors: No reported Disclosures.

Cost of intensive care services at a central hospital in South Africa.

Intensive care services are one of the largest cost drivers in a hospital. Increasing life expectancy and comorbidities have resulted in an increased need for intensive care beds. To conduct a cost analysis of intensive care services at a central hospital in the public sector in South Africa (SA). A retrospective cost analysis for the 2015/16 financial year was conducted across two intensive care units (ICUs), a trauma ICU (10 beds) and a combined ICU for neurosurgery, medicine and surgery (18 beds). A mixed-methods costing approach was used based on the availability of data. The bottom-up approach was used to calculate the cost of clinical support, pharmaceuticals, consumables and human resources. The top-down approach was used to allocate the cost of equipment and goods and services. There were 544 admissions resulting in 4 987 inpatient days during the study period. The total estimated inpatient cost across the two ICUs was ZAR114 055 104, with a cost per patient day of ZAR22 870. The combined ICU cost per patient day was 58% higher than the cost per patient day in the trauma ICU (ZAR26 954 v. ZAR17 021). The mean cost per admission was ZAR157 883 in the trauma ICU and ZAR245 087 in the combined ICU. Human resources costs were the highest ICU cost driver (55%), followed by direct patient activity costs (medical consumables, pharmaceuticals, laboratory tests, radiology and blood products), which contributed 24%. This is the first reported cost analysis of intensive care services in SA. Our cost per patient day was higher than that reported in other lower-income countries, but lower than that in high-income countries. These costs vary owing to the different types of ICUs, wide spectrum of disease presentation and availability of diagnostic and treatment options. This study provides useful data that could assist in the planning and provision of intensive care services.

Intensive care unit models: Do you want them to be open or closed? A critical review.

Intensive care is a specialized branch of medicine dealing with the diagnosis, management, and follow up of critically ill or critically injured patients. It requires input from other branches of medicine on various issues. A critical care specialist has expertise in managing such patients round the clock. Based on his freedom to take decisions in the intensive care unit (ICU), different types of ICUs - open, closed, or semi-closed - have been defined. There is no doubt that all critical patients should be evaluated by an intensivist. Therefore, it is argued that a closed ICU model would be the ideal model. However, this may not always be feasible and other models may be more useful in resource-limited countries. In this review, we compare the different formats of ICU functioning and their suitability in different hospitals.

Intensive care unit capacity strain and adherence to prophylaxis guidelines

PurposeThe purpose of the study is to examine the relationship between different measures of capacity strain and adherence to prophylaxis guidelines in the intensive care unit (ICU). Materials and methodsWe conducted a retrospective cohort study within the Project IMPACT database. We used multivariable logistic regression to examine relationships between ICU capacity strain and appropriate usage of venous thromboembolism prophylaxis (VTEP) and stress ulcer prophylaxis (SUP). ResultsOf 776905 patient-days eligible for VTEP, appropriate therapy was provided on 68%. Strain as measured by proportion of new admissions (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.90-0.91) and census (OR, 0.97; 95% CI, 0.97-0.98) was associated with decreased odds of receiving VTEP. With increasing strain as measured by new admissions, the degradation of VTEP utilization was more severe in ICUs with closed (OR, 0.85; 95% CI, 0.83-0.88) than open (OR, 0.91; 95% CI, 0.91-0.92) staffing models (interaction P < .001). Of 185425 patient-days eligible for SUP, 48% received appropriate therapy. Administration of SUP was not significantly influenced by any measure of strain. ConclusionsRising capacity strain in the ICU reduces the odds that patients will receive appropriate VTEP but not SUP. The variability among different types of ICUs in the extent to which strain degraded VTEP use suggests opportunities for systems improvement.

Red cell distribution width improves the simplified acute physiology score for risk prediction in unselected critically ill patients

IntroductionRecently, red cell distribution width (RDW), a measure of erythrocyte size variability, has been shown to be a prognostic marker in critical illness. The aim of this study was to investigate whether adding RDW has the potential to improve the prognostic performance of the simplified acute physiology score (SAPS) to predict short- and long-term mortality in an independent, large, and unselected population of intensive care unit (ICU) patients.MethodsThis observational cohort study includes 17,922 ICU patients with available RDW measurements from different types of ICUs. We modeled the association between RDW and mortality by using multivariable logistic regression, adjusting for demographic factors, comorbidities, hematocrit, and severity of illness by using the SAPS.ResultsICU-, in-hospital-, and 1-year mortality rates in the 17,922 included patients were 7.6% (95% CI, 7.2 to 8.0), 11.2% (95% CI, 10.8 to 11.7), and 25.4% (95% CI, 24.8 to 26.1). RDW was significantly associated with in-hospital mortality (OR per 1% increase in RDW (95%CI)) (1.14 (1.08 to 1.19), P < 0.0001), ICU mortality (1.10 (1.06 to 1.15), P < 0.0001), and 1-year mortality (1.20 (95% CI, 1.14 to 1.26); P < 0.001). Adding RDW to SAPS significantly improved the AUC from 0.746 to 0.774 (P < 0.001) for in-hospital mortality and 0.793 to 0.805 (P < 0.001) for ICU mortality. Significant improvements in classification of SAPS were confirmed in reclassification analyses. Subgroups demonstrated robust results for gender, age categories, SAPS categories, anemia, hematocrit categories, and renal failure.ConclusionsRDW is a promising independent short- and long-term prognostic marker in ICU patients and significantly improves risk stratification of SAPS. Further research is needed the better to understand the pathophysiology underlying these effects.

Who is attending? End-of-life decision making in the intensive care unit.

Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.

Nosocomial infections and multidrug-resistant organisms in Germany: epidemiological data from KISS (the Hospital Infection Surveillance System).

More than 800 hospitals and 586 intensive care units (ICUs) in Germany currently participate in a nationwide surveillance system for nosocomial infections (Krankenhaus-Infektions-Surveillance-System, KISS), which collects data on the frequency of nosocomial infections and pathogens and on the appearance of pathogens of special epidemiological importance. Data were collected from ICUs regarding lower respiratory tract infections, primary sepsis, and urinary tract infections and on the temporal relation of these types of infection to the use of specific medical devices (invasive ventilation, central venous catheters, and urinary catheters). On the basis of these data, device-associated infection rates (number of infection per 1000 device days) were calculated for different types of ICUs. KISS also collected data on all ICU patients colonized or infected with selected multidrug-resistant organisms (MDRO) and on all hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile-associated diarrhea (CDAD). Device-associated infection rates ranged from 0.9 to 9.6 per 1000 device-days, depending on the type of infection and the type of ICU. An extrapolation from these figures yields an estimate of 57 900 ICU-acquired infections occurring in Germany each year. The most common MDRO in ICU patients is MRSA. The frequency of MRSA has remained stable in recent years, but that of other MDROs among ICU patients is rising. Hospitalized patients are twice as likely to acquire CDAD as they are to acquire MRSA. Nosocomial infections are common in the ICU. The percentage of ICU patients with MDRO is low, but rising. Future preventive strategies must address this development.

Ventilator-Associated Pneumonia: A Review

Ventilator-associated pneumonia is the most frequent intensive care unit (ICU)-related infection in patients requiring mechanical ventilation. In contrast to other ICU-related infections, which have a low mortality rate, the mortality rate for ventilator-associated pneumonia ranges from 20% to 50%. These clinically significant infections prolong duration of mechanical ventilation and ICU length of stay, underscoring the financial burden these infections impose on the health care system. The causes of ventilator-associated pneumonia are varied and differ across different patient populations and different types of ICUs. This varied presentation underscores the need for the intensivist treating the patient with ventilator-associated pneumonia to have a clear knowledge of the ambient microbiologic flora in their ICU. Prevention of this disease process is of paramount importance and requires a multifaceted approach. Once a diagnosis of ventilator-associated pneumonia is suspected, early broad-spectrum antibiotic administration decreases morbidity and mortality and should be based on knowledge of the sensitivities of common infecting organisms in the ICU. De-escalation of therapy, once final culture results are available, is necessary to minimize development of resistant pathogens. Duration of therapy should be based on the patient's clinical response, and every effort should be made to minimize duration of therapy, thus further minimizing the risk of resistance.

Measuring Impact of Antimicrobial Resistance

To the Editor: Staphylococcus aureus and Enterococcus faecium commonly cause healthcare-associated bloodstream infections (BSI) in the intensive care unit (ICU). Antimicrobial resistance is increasing in both organisms. The impact of antimicrobial resistance on dying of BSI has been studied extensively (1,2). Many studies have concluded that BSI caused by an antimicrobial-resistant organism results in higher death rates (1,3–8). However, as discussed in a recent report by Kaye et al., outcome studies of antimicrobial drug resistance are notoriously hard to perform because of confounding variables related to coexisting conditions (9). Indeed, almost all studies have shown that infections with antimicrobial-resistant organisms occur later in hospitalization than infections with antimicrobial-susceptible organisms, which suggests that differences in death rates may be, at least in part, caused by a difference in the patients' underlying illnesses and protracted hospital course. We report 2 additional methodologic issues that can affect estimates of the impact of antimicrobial resistance: combining different organisms and combining populations from different types of ICUs. The original objective of our multicenter observational study was to quantify the clinical impact of antimicrobial resistance in S. aureus and E. faecium infections when these bacteria cause a specific type of infection: a monomicrobial, ICU-attributable, central vascular catheter–associated bloodstream infection (CVC-BSI). We studied 187 adult ICU patients with BSI caused by S. aureus and E. faecium at 3 tertiary care institutions from 1994 to 1999. The institutional review boards of each institution and the Centers for Disease Control and Prevention approved this study. Severity of illness was measured with an APACHE II score at ICU admission and on day 7 in the ICU (if applicable). The score would indicate the patient's risk of dying in the hospital before a BSI developed by using a measure validated for predicting in-hospital deaths in ICU patients (10). The study population stratified by organism is shown in the Table. Fifty-eight percent of patients had CVC-BSI with S. aureus, and 42% had CVC-BSI with E. faecium. Overall, 58% of the organisms causing CVC-BSI were resistant to oxacillin if S. aureus or to vancomycin if E. faecium. However, patients with E. faecium CVC-BSI were more likely to be infected with antimicrobial-resistant bacteria (69% versus 50%, p<0.01), and had a higher mortality rate (54% versus 34%, p<0.01) than patients with S. aureus CVC-BSI. This finding indicates that the type of organism (E. faecium versus S. aureus) confounds the association between resistance and death. In addition, the distribution of ICU type by organism varies, which suggests that patient populations infected with these 2 different organisms were different in other ways. Thus, confounding factors for the association between resistance and death may differ for E. faecium and S. aureus, and analysis of the 2 organisms should be conducted separately. This is consistent with the results of Kaye et al. who showed that the effect of resistance was higher for S. aureus (odds ratio [OR] 3.4) than for E. faecium (OR 2.5) by using separate analyses to show death rates (9). Furthermore, these researchers found different confounding factors in the adjusted analysis of S. aureus than in the adjusted analysis of E. faecium. Because of the need to conduct separate analyses, which reduced our statistical power, our study was ultimately unable to show a difference in death rates if it existed. In summary, future studies measuring the impact of antimicrobial resistance on death rates should be restricted to a specific type of infection cause by a single organism in a uniform setting using a validated system to predict mortality in that setting. As such, future studies should involve multiple study sites. Table Description of 187 adult patients with central vascular catheter-associated bloodstream infections with Staphylococcus aureus or Enterococcus faecium attributable to the intensive care unit*

Epidemiology, Prevalence, and Sites of Infections in Intensive Care Units

Patients in intensive care units (ICUs) have a higher risk of acquiring hospital-associated infections than those in non-critical care areas. ICUs are sites of considerable broad-spectrum antibiotic use, and antibiotic-resistant pathogens are frequent. Bloodstream infections (BSIs), pneumonias, and urinary tract infections (UTIs) are the most common hospital-acquired infections and are most often associated with the use of invasive devices. They differ in importance in different types of ICUs. Coagulase-negative staphylococcus BSIs have recently increased in frequency, and enterococci have been as frequently reported as Staphylococcus aureus as causing BSIs in increasing numbers of U.S. ICUs. Fungal urinary tract sepsis has also increased. Device-associated infection rates represent the most useful surveillance rates for comparison between units and over time, but they differ considerably between ICU types. Outbreaks are common in ICUs. Recently, gram-negative bacilli have been reported more frequently than gram-positives in this setting, especially in NICUs. Considerable crude mortality and major costs are associated with these infections, but controversy persists over the degree of mortality attributable to them.

Clinical Aspects of Bacteremia in Medical and Surgical Intensive Care Units

Background: Intensive care units(ICUs) probably represent the single largest identifiable source of infection within the hospital. Although there are several studies on ICU infections in respect to their bacteriology or mortality rate for individual types of ICU, few studies have compared ICU infections between different types of ICU. The aim of this study was to identify clinical differences in bacteremia between medical ICU(MICU) and surgical ICU(SICU) patients. Methods: 256 patients with bacteremia were retrospectively evaluated. Medical records were reviewed to obtain the clinical and bacteriologic informations. Results: 1) The mean age of the patients with bacteremia of MICU() was greater than that of all MICU patients()(p, all SICU patients: )(p>0.05). ICU stay was longer(MICU patients: day, SICU patients: day) than the mean stay of all patients( day)(p

The epidemiology of infections in intensive care units

This report identifies some of the risk factors underlying the acquisition of hospital infections in patients admitted to Intensive Care Units (ICUs). Infection rates vary in different institutes and in different types of ICUs. Patients are particularly prone to septicaemia and respiratory infections and the underlying risk factors are frequently related to poor invasive techniques or contaminated equipment used in supportive therapy. In trauma patients, wound sepsis is common and polymicrobial sepsis is a major problem. Patients in ICUs are temporarily immunocompromised and are at risk from acquiring multiply antibiotic resistant gram negative bacilli. The majority of these are of an endogenous nature and necessitate the empirical use of antibiotics. The misuse of antibiotics however often leads to the selection of difficult to treat gram negative bacilli. Antibiotic usage in ICUs should be strictly controlled and used appropriately, preferably after appropriate microbiological specimens have been collected.