ICU Physicians Research Articles

Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs: a multicenter qualitative study.

The purpose of this study was to describe clinicians' perceptions of interprofessional collaboration in the intensive care unit and identify factors associated with interprofessional collaboration. We performed 64 semi-structured interviews in seven hospitals with ICU nurses, physicians, respiratory therapists, nurse managers, clinical pharmacists, and dieticians. ICU clinicians perceived two distinct types of facilitators to interprofessional collaboration in critical care: cultural and structural. In the critical care setting, cultural and structural facilitators worked independently as well as in concert to create effective interprofessional collaboration. Initiatives aimed at creating and facilitating interprofessional collaboration should focus attention on cultural and structural facilitators to improve patient care and team effectiveness.

Ultrasound assessment of gastric volume in critically ill patients

To assess the feasibility and validity of ultrasonographic measurement of gastric antral cross-sectional area (usCSA) in critically ill patients to predict gastric volume and the use of computed tomography (CT) as a reference to measure gastric volume. This single-center, prospective, cross-sectional study included 55 critically ill patients who had an abdominal CT scan. usCSA measurements were performed within the hour preceding the CT scan. Gastric volumes were measured on the CT scan using semiautomatic software. The feasibility rate, performing conditions (% "good" and "poor"), internal and external validity of antral usCSA measurements, performed by an ICU physician, were assessed to predict gastric volume. Antral usCSA measurements were feasible in 95% of cases and were positively correlated with gastric volume measured by the CT scan when performed in "good" conditions (65%) (r = 0.43). There was good reproducibility of measurements (intraclass correlation coefficient of 0.97, CI 95% 0.96-0.99) and there was clinically acceptable agreement between measurements performed by radiologists and intensivists (bias -0.12 cm(2)). The receiver operating characteristic curve identified a cutoff value of 3.6 cm(2) that discriminated an "at-risk stomach" (volume >0.8 mL/kg) at a sensitivity of 76% and a specificity of 78%. Ultrasonographic measurement of antral CSA is feasible and reliable in the majority of critically ill patients. This technique could be useful to manage critically ill patients at risk of aspiration or with enteral feeding.

Model-based setting of inspiratory pressure and respiratory rate in pressure-controlled ventilation

Mechanical ventilation carries the risk of ventilator-induced-lung-injury (VILI). To minimize the risk of VILI, ventilator settings should be adapted to the individual patient properties. Mathematical models of respiratory mechanics are able to capture the individual physiological condition and can be used to derive personalized ventilator settings. This paper presents model-based calculations of inspiration pressure (pI), inspiration and expiration time (tI, tE) in pressure-controlled ventilation (PCV) and a retrospective evaluation of its results in a group of mechanically ventilated patients. Incorporating the identified first order model of respiratory mechanics in the basic equation of alveolar ventilation yielded a nonlinear relation between ventilation parameters during PCV. Given this patient-specific relation, optimized settings in terms of minimal pI and adequate tE can be obtained. We then retrospectively analyzed data from 16 ICU patients with mixed pathologies, whose ventilation had been previously optimized by ICU physicians with the goal of minimization of inspiration pressure, and compared the algorithm's ‘optimized’ settings to the settings that had been chosen by the physicians. The presented algorithm visualizes the patient-specific relations between inspiration pressure and inspiration time. The algorithm's calculated results highly correlate to the physician's ventilation settings with r = 0.975 for the inspiration pressure, and r = 0.902 for the inspiration time. The nonlinear patient-specific relations of ventilation parameters become transparent and support the determination of individualized ventilator settings according to therapeutic goals. Thus, the algorithm is feasible for a variety of ventilated ICU patients and has the potential of improving lung-protective ventilation by minimizing inspiratory pressures and by helping to avoid the build-up of clinically significant intrinsic positive end-expiratory pressure.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process.

IntroductionICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission.MethodsCOPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation.ResultsSelf-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation.ConclusionsThe information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient’s personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.

Malignant hyperthermia in the intensive care setting

Malignant hyperthermia (MH) is a life-threatening, inherited disorder of skeletal muscle calcium homeostasis. In susceptible individuals, exposure to trigger agents such as volatile anesthetics and depolarizing muscle relaxants, typically administered to induce or maintain general anesthesia, may lead to a hypermetabolic muscular syndrome [1]. Recently, an anesthetic conserving device (AnaConDa®; Sedana Medical AB, Geretsried, Germany) was introduced for sedation of intensive care patients using volatile anesthetics, associated with shorter wake-up and extubation time, reduced duration of mechanical ventilation and earlier hospital discharge [2]. After obtaining oral and written consent, we report the case of a 59-year-old male patient, who was hospitalized due to persistent lumbalgia. On the second day of the patient’s hospital stay, increasing dyspnea and tachypnea required admission to the ICU and tracheal intubation. Sedation was maintained by propofol and sufentanil infusion. A chest radiography revealed bilateral pulmonary infiltration, suggestive of influenza pneumonia. Moxifloxacin, piperacillin/tazobactam and oseltamivir were started immediately. After 4 days on mechanical ventilation, sedation needed to be escalated and an anesthetic conserving device for additional sevoflurane sedation was installed. Suddenly, after 5 hours of sevoflurane administration, hemodynamic instability occurred. The arterial blood pressure rapidly decreased to 78/44 mmHg, while the heart rate remained constant around 110 beats/minute. Arterial blood gas analysis revealed severe acidosis (pH, 7.17; carbon dioxide partial pressure, 70.4 mmHg; oxygen partial pressure, 104 mmHg (fraction of inspired oxygen, 50%); base excess, 9.8; lactate, 0.6 mmol/l), and a rapid increase of body temperature from 39.6 to 40.7 °C within 30 minutes was noticed. Creatine kinase and myoglobin levels were significantly increased to maximum levels of 3,455 U/l and 4,197 μg/l, respectively, due to acute rhabdomyolysis. Since MH was suspected, sevoflurane application was discontinued, and dantrolene (225 mg) was administered intravenously, resulting in gradual improvement of the hemodynamic and metabolic situation. The further course was unremarkable. The subsequent ICU stay remained uneventful and the patient was extubated on day 17 without neurological deficits. Nine months after the suspected MH event, the patient underwent muscle biopsy and in vitro contracture testing according to the guidelines of the European MH group. The patient’s MH susceptibility was thus confirmed, by significant contractures at the defined thresholds after halothane and caffeine exposure [3]. The presented case underlines that MH is an important differential diagnosis in intensive care patients with hemodynamic and metabolic breakdown if volatile anesthetics are used for sedation. Hence, every ICU physician must be aware of the symptoms of MH to rapidly initiate sufficient treatment.

Epinephrine

Valley Fox is an artist and a critical care nurse in the cardiothoracic surgical ICU at Beth Israel Medical Center in New York City. She writes, “In my paintings I'm investigating the relationship between the ancient healing arts and contemporary medical sciences. The ancient Greeks believed that Asclepius, the god of medicine, represented healing. The sick would flock to his temples and sleep; their dreams would reveal clues about their treatment. Today, in the ICU setting, nurses and physicians confront the essential realities of life and death. Pharmaceuticals are our primary language in this context. In Epinephrine and other paintings, I am celebrating the power of pharmaceuticals, which can resuscitate patients at the threshold of death. In the contemporary health care landscape, one could say that pharmaceuticals are to present-day patients what dreams were to the ancient Greeks.” Epinephrine is one of many paintings on view at Fox's solo show at MSB Gallery, located at New York University's Langone Medical Center. The show runs from November 9 through December 8, with an opening reception on November 14 (for more information, visit http://hsl.med.nyu.edu/location/msb-gallery ). Epinephrine © 2013 by Valley Fox. Contact artist: [email protected]. Art of Nursing is coordinated by Sylvia Foley, senior editor: sylvia. [email protected].

To treat or not to treat

Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.

Organisation de la ventilation artificielle dans les unités de réanimation en France

ObjectivesTo clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents. Study designDeclarative survey. MethodsBetween September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions. ResultsAmong the 62 participating ICUs, a median of 15 ventilators/ICU (range 1−50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU. ConclusionsThis first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement.

Effects of infection control rounds on the the quality of infection management in ICU ward

Objective To understanding the implementation of ICU infection control measures and the effect of ICU infection control measures on hospital infection control,in order to take effective control measures to reduce the occurrence of hospital infection.Methods The infection control personnel inspected the implementation of ICU infection control measures 2 times per week.The results of clinical rounds were discussed and analyzed,the rectifcation measures were formulated,and the rectification results feedback.Results The rates of correct and compliance on hand hygiene were respectively 79.2％,51.6％ after rounds,and were higher than 58.5％,30.3％ before rounds,and the differences were statistically significant (x2 =10.65,50.24,respectively; P ＜ 0.05).The incidence rates of ventilator associated pneumonia (VAP),arteriovenous catheter-related bloodstream infection (CRBSI) and urethral catheter-related urinary tract infection (CAUTI)were respectively17.1％,2.4％,1.1％ after rounds,and were lower than 30.2％,4.8％,2.5％ before rounds,and the differences were statistically significant (x2 =4.08,0.42,4.06,respectively; P ＜ 0.05).The qualified rates of infection control indicators including enviroumental health management,sterile technical operation,disposable sterile items management and medical waste management were respectively 94.3％,96.2％,95.2％,91.4％ after rounds,and was significantly higher than 80.9％,72.3％,79.1％,68.6％before rounds,and the differences were statistically significant (x2 =7.42,20.71,10.88,15.74,respectively; P ＜ 0.05).The rectification rate of infection control measures problems was 95.4％ in 2012,and was significantly higher than 77.8％ in 2011.Conclusions Infection control rounds can improve subjective initiative and the bidirectional interaction in infection monitoring personnel,ICU physicians and nurses,improve the execution rate of prevention and control measures,and improve the quality of infection control. Key words: Infection control; Rounds; ICU; Infection management

The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

PurposeThis study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors’ health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies.MethodsData from 140 ECMO-treated ARDS patients admitted to three French ICUs (2008–2012) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQL, psychological and PTSD status.ResultsMain ARDS etiologies were bacterial (45 %), influenza A[H1N1] (26 %) and post-operative (17 %) pneumonias. Six months post-ICU discharge, 84 (60 %) patients were still alive. Based on multivariable logistic regression analysis, the PRESERVE (PRedicting dEath for SEvere ARDS on VV-ECMO) score (0–14 points) was constructed with eight pre-ECMO parameters, i.e. age, body mass index, immunocompromised status, prone positioning, days of mechanical ventilation, sepsis-related organ failure assessment, plateau pressure andpositive end-expiratory pressure. Six-month post-ECMO initiation cumulative probabilities of survival were 97, 79, 54 and 16 % for PRESERVE classes 0–2, 3–4, 5–6 and ≥7 (p < 0.001), respectively. HRQL evaluation in 80 % of the 6-month survivors revealed satisfactory mental health but persistent physical and emotional-related difficulties, with anxiety, depression or PTSD symptoms reported, by 34, 25 or 16 %, respectively.ConclusionsThe PRESERVE score might help ICU physicians select appropriate candidates for ECMO among severe ARDS patients. Future studies should also focus on physical and psychosocial rehabilitation that could lead to improved HRQL in this population.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-013-3037-2) contains supplementary material, which is available to authorized users.

The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over

To assess physician decisions about ICU admission for life-sustaining treatments (LSTs). Observational simulation study of physician decisions for patients aged ≥80 years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV). The physician participation rate was 100/217 (46 %); males without religious beliefs predominated, and median ICU experience was 9 years. Among participants, 85.7, 78, and 62 % felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95 % CI 0.13-0.65, p = 0.01) and cancer (OR 0.23, 95 % CI 0.10-0.52, p = 0.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95 % CI 1.04-3.97, p = 0.038) and respiratory disease (OR 0.42, 95 % CI 0.23-0.76, p = 0.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57 % of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6 %, respectively. Physician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.

Data Utilization for Medical Decision Making at the Time of Patient Admission to ICU*

Information overload in electronic medical records can impede providers' ability to identify important clinical data and may contribute to medical error. An understanding of the information requirements of ICU providers will facilitate the development of information systems that prioritize the presentation of high-value data and reduce information overload. Our objective was to determine the clinical information needs of ICU physicians, compared to the data available within an electronic medical record. Prospective observational study and retrospective chart review. Three ICUs (surgical, medical, and mixed) at an academic referral center. Newly admitted ICU patients and physicians (residents, fellows, and attending staff). The clinical information used by physicians during the initial diagnosis and treatment of admitted patients was captured using a questionnaire. Clinical information concepts were ranked according to the frequency of reported use (primary outcome) and were compared to information availability in the electronic medical record (secondary outcome). Nine hundred twenty-five of 1,277 study questionnaires (408 patients) were completed. Fifty-one clinical information concepts were identified as being useful during ICU admission. A median (interquartile range) of 11 concepts (6-16) was used by physicians per patient admission encounter with four used greater than 50% of the time. Over 25% of the clinical data available in the electronic medical record was never used, and only 33% was used greater than 50% of the time by admitting physicians. Physicians use a limited number of clinical information concepts at the time of patient admission to the ICU. The electronic medical record contains an abundance of unused data. Better electronic data management strategies are needed, including the priority display of frequently used clinical concepts within the electronic medical record, to improve the efficiency of ICU care.

Scarcity

Clinicians' perceptions of scarcity influence rationing of critical care resources, which may lead to serious adverse outcomes for patients who are denied access. We sought to better understand the phenomenon of scarcity in the critical care setting. Qualitative research methods. We used purposeful sampling to recruit ICU clinicians who were frequently involved in decisions to allocate ICU resources. Thematic analysis was performed to identify concepts related to the phenomenon of scarcity. An ICU of a university-affiliated hospital in Toronto, Canada, between October and December 2007. We conducted 22 interviews with 12 ICU physicians, 4 ICU fellows, 2 ICU nursing team leaders, and 4 ICU resource nurses. The perception of scarcity arose from a complex interaction of factors within the institution including: 1) practices of non-ICU physicians (e.g., failure to specify end-of-life treatment plans or to secure an ICU bed prior to elective high-risk surgery), 2) family demands for life support and clinicians' perception of a lack of legal support if they opposed these, and 3) inability to transfer patients to non-ICU care settings in a timely manner. Implications of scarcity included: 1) diversions of critically ill patients, 2) premature patient transfers, 3) temporary delivery of critical care in non-ICU locations (e.g., emergency department, postanesthesia care unit), and 4) interprofessional conflicts. ICU clinicians' perceptions of scarcity may lead to rationing of critical care resources. We found that nonmedical factors strongly influenced prioritization activity, both for admission and discharge. Although scarcity of ICU beds might be mitigated by process improvements such as patient flow or proactive communication, our findings highlight the importance of a fair process for inevitable limit setting at the bedside.

Implementations of the Leapfrog Group’s ICU Physician Staffing Standard May Adversely Affect the Excellence of Graduate Medical Education

Implementations of the Leapfrog Group’s ICU Physician Staffing Standard May Adversely Affect the Excellence of Graduate Medical Education

Delirium in ICU patients is associated with increased temperature variability

Delirium is an acute disturbance of consciousness and cognition. It is a common disorder in the ICU and associated with impaired long-term outcome [1,2]. Despite its frequency and impact, delirium is poorly recognized by ICU physicians and nurses using delirium screening tools [3]. A completely new approach to detect delirium is to use monitoring of physiological alterations. Temperature variability, a measure for temperature regulation, could be an interesting parameter for monitoring of ICU delirium, but this has never been investigated before. The aim of this study was to investigate whether temperature variability is affected during ICU delirium.

Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes*

To determine the prevalence and mechanism of copying among ICU physicians using an electronic medical record. Retrospective cohort study. Medical ICU of an urban, academic medical center. Two thousand sixty-eight progress notes of 135 patients generated by 62 residents and 11 attending physicians between August 1, 2009, and December 31, 2009. None. EIghty-two percent of all residents and 74% of all attending notes contained greater than or equal to 20% copied information (p = 0.001). Although residents authored more copied notes than attendings, residents copied less information between notes than attendings (55% vs. 61%, p < 0.001). Following greater than or equal to 1 day off, residents copied less often from their own prior notes compared to attendings (66% vs. 94%, p < 0.001). Of the copied information following a day off, there was no difference in the amount of information copied into notes of residents (59%) or attendings (61%, p = 0.17). In a regression model of attending notes, no patient factors were associated with copying. However, the levels of copying among attendings varied from 41% to 82% (p < 0.001). Copying among attendings and residents was common in this ICU-based cohort, with residents copying more frequently and attendings copying more information per note. The only factor that was independently associated with attending copying was the attending. Further studies should focus on further elucidating the factors influencing copying in the ICU and the effects of copying on patient outcomes.

A Case report on non-invasive ventilation in the management of acute COPD exacerbation (AECOPD)

Recent years have seen the emergence of noninvasive ventilation (NIV) as an important tool for management of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Several well-conducted studies in the recent years have established its role in the initial, as well as later management of these patients. The aim of this case report is to encourage ICU physician to use NIV on selected AECOPD patients, therefore to reduce the need for endotracheal intubation, the length of hospital stay, and the risk of death. In this case report, we selected a case of AECOPD whose symptoms were getting worse in spite of adequate conventional treatment. He was given NIV for 20 hours following a standard protocol. Final result showed significant improvement in patient's symptoms, vital signs and ABG parameters ultimately patient stay time in ICU was reduced and patient was also benefited financially. From this first ever-successful application of NIV in our ICU we learned that we can use it successfully in next cases.DOI: http://dx.doi.org/10.3329/kyamcj.v2i1.13522 KYAMC Journal Vol.2(1) 2011 pp.152-155

Continuous glucose sensors for glycaemic control in the ICU: have we arrived?

Dr Blixt and colleagues show in an elegant pilot study that the continuous measurement of glucose in venous blood by microdialysis in a central venous catheter is feasible in critically ill patients. The performance of this type of continuous glucose monitoring device equals the performance of the commonly used handheld blood glucose meters. But are we, as ICU physicians and nurses, now ready to implement such continuous blood glucose sensors into the daily practice of the ICU? The only yardstick to this is "are these devices truly helping us ...in our critically ill patients".

Clinical stakeholders’ opinions on the use of selective decontamination of the digestive tract in critically ill patients in intensive care units: an international Delphi study

IntroductionSelective decontamination of the digestive tract (SDD) is a prophylactic antibiotic regimen that is not widely used in practice. We aimed to describe the opinions of key ‘stakeholders’ about the validity of the existing evidence base, likely consequences of implementation, relative importance of their opinions in influencing overall practice, likely barriers to implementation and perceptions of the requirement for further research to inform the decision about whether to embark on a further large randomised controlled trial.MethodsThis was a Delphi study informed by comprehensive framework of possible determinants of health professionals’ behaviour to study Critical Care practice in four countries. There were four key stakeholder participant groups including ICU physicians, pharmacists, clinical leads, and clinical microbiologists/ infectious disease physicians. Round one comprised participant interviews and Rounds two and three were online questionnaires using Delphi method.ResultsIn this study, 141 participants were recruited of whom 82% were retained. Participants rated themselves as knowledgeable about SDD. Antibiotic resistance was identified as the most important issue. SDD was seen as a low clinical priority but few participants reported strong opposition. There was moderate agreement that research to date has not adequately addressed concerns about antibiotic resistance and lacks generalizability. Participants indicated equipoise with regard to benefits and harms of SDD, and indicated strong support for a further randomised trial.ConclusionsClinicians have clinical equipoise about the effectiveness of SDD. Future research requires longer follow up to assess antibiotic resistance as well as greater validity/generalizability to provide definitive answers on the effectiveness of decontamination and effects on antibiotic resistance. SDD was regarded as not being a high clinical priority, which may limit future trial participation. These results have identified that further large randomised controlled trial of SDD in critical care is both warranted and appropriate.

Staffing in ICUs: Physicians and Alternative Staffing Models

The evidence regarding physician staffing of ICUs does not yet provide a consistent view of the best model to use. Most studies have significant limitations, and this subject is complicated by the fact that optimal ICU staffing may depend on ICU characteristics. The topic with the most data regarding patient outcomes is the intensity of intensivist involvement in care, particularly the value of closed- vs open-model ICUs; however, the evidence is inconsistent here as well. Even if closed-model ICUs produce better outcomes, we do not know which specific elements of that multifaceted organizational paradigm are responsible for improvement. Also, studies of around-the-clock intensivist presence have not consistently shown that it is associated with superior outcomes. Increasingly, nonphysician providers are playing innovative roles in the ICU, and care provided by teams including nurse practitioners or physician assistants appears to be safe and comparable to that provided by other staffing models. Although we do not know the best way to staff ICUs, the conditions of ICU physician coverage will continue to change under the stresses of shortages of intensivists and increasing duty hour limitations for trainees. Nonphysician providers, innovative physician staffing models, telemedicine, and other technologies will be increasingly used to cope with these realities. This evolution makes it more important than ever to study how staffing affects outcomes. Only quantitative evaluation can tell us whether one staffing model is better than another. Accordingly, we need more research from multiple sites to develop a consistent and integrated understanding of this complex topic.