ICU Resources Research Articles

Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness.

To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. Decision analysis using literature estimates and inpatient administrative data from Premier. Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. None. Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions' efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.

Comparative effectiveness of echinocandins versus fluconazole therapy for the treatment of adult candidaemia due to Candida parapsilosis: a retrospective observational cohort study of the Mycoses Study Group (MSG-12).

A polymorphism in the gene encoding β-1,3-glucan synthase, the target of the echinocandin class of antifungals, results in increased in vitro MICs of the echinocandins. This has resulted in controversy surrounding use of the echinocandins for treatment of Candida parapsilosis candidaemia. We aimed to compare 30 day mortality in adults with C. parapsilosis candidaemia treated with echinocandins versus fluconazole. This is a retrospective observational cohort study. We used the Premier Perspective Database to identify adult patients with C. parapsilosis candidaemia treated with only fluconazole or only an echinocandin as definitive therapy. The primary outcome was 30 day mortality. Propensity scores were derived to estimate the probability the patient would have received either an echinocandin or fluconazole. Inverse probability of treatment weighting (IPTW) was used in a weighted logistic regression to calculate odds of 30 day mortality. There were 307 unique patients with C. parapsilosis candidaemia. One hundred and twenty-six (41%) received fluconazole and 181 (59%) received an echinocandin. Age, gender, race, year of admission, need for ICU resources in the week prior to candidaemia onset, and receipt of vasopressors on the day of candidaemia onset were included in the propensity score model used to calculate inverse probability of treatment weights. Weighted logistic regression demonstrated no difference in 30 day mortality between patients receiving an echinocandin as compared with fluconazole (OR 0.82, 95% CI 0.33-2.07). Our result supports the 2016 IDSA invasive candidiasis guidelines, which no longer clearly favour treatment with fluconazole over an echinocandin for C. parapsilosis candidaemia.

Freestanding Emergency Critical Care During the Aftermath of Hurricane Sandy: Implications for Disaster Preparedness and Response.

To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy. We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated. Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively. An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).

Rationing in the intensive care unit in case of full bed occupancy: a survey among intensive care unit physicians.

BackgroundInternationally, there is no consensus on how to best deal with admission requests in cases of full ICU bed occupancy. Knowledge about the degree of dissension and insight into the reasons for this dissension is lacking. Information about the opinion of ICU physicians can be used to improve decision-making regarding allocation of ICU resources.The aim of this study was to:Assess which factors play a role in the decision-making process regarding the admission of ICU patients;Assess the adherence to a Dutch guideline pertaining to rationing of ICU resources;Investigate factors influencing the adherence to this guideline. MethodsIn March 2013, an online questionnaire was sent to all ICU physician members (n = 761, in 90 hospitals) of the Dutch Society for Intensive Care.Results166 physicians (21.8 %) working in 64 different Dutch hospitals (71.1 %) completed the questionnaire. Factors associated with a patient’s physical condition and quality of life were generally considered most important in admission decisions. Scenario-based adherence to the Dutch guideline “Admission request in case of full ICU bed occupancy” was found to be low (adherence rate 50.0 %). There were two main reasons for this poor compliance: unfamiliarity with the guideline and disagreement with the fundamental approach underlying the guideline.ConclusionsDutch ICU physicians disagree about how to deal with admission requests in cases of full ICU bed occupancy. The results of this study contribute to the discussion about the fundamental principles regarding admission of ICU patients in case of full bed occupancy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0190-5) contains supplementary material, which is available to authorized users.

Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event.

ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels ("high risk"), or if they have a low likelihood of requiring ICU support ("low risk"). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. One hundred ten American PICUs : One hundred fifty thousand records from the Virtual PICU database. None. The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions.

Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank.

IntroductionPatients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14–15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.MethodsThe National Trauma Databank (2007–2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14–15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.ResultsThe study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.ConclusionsWe found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.

A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators.

To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33]. EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.

English

Multiple organ dysfunction syndrome (MODS) is a systemic, dysfunctional inflammatory response that requires longer admissions in acute medical care unit with high mortality rate. The present study was done prospectively to evaluate clinical profile and etiological spectrum of patients admitted in acute medical care unit categorized under multi- organ dysfunction syndrome (MODS) and to correlate outcome of MODS. 50 patients of ≥ 18 years age who were admitted in Acute Medical Care Unit, Department of Medicine, Government General Hospital, Kakinada, with more than one organ dysfunction, requiring intervention were studied during 2010-2012. In all cases provisional diagnosis was made by taking detailed history and clinical examination, and were subjected to the relevant investigations. The criteria were used to include under MODS were assessed on respiratory, renal gastrointestinal, central nervous system, Glasgow coma scale cardiovascular, hematological parameters. The outcome of MODS was correlated by application of APACHE-II score on admission day, serial SOFA score on day 1 and 3, serial serum albumin measurement on day 1 and 5. There was multiorgan involvement .Most common organ failed was renal 30 (60%), followed by CNS 27 (54%), respiratory 25 (50%), CVS 23 (46%), GIT 17 (34%), hematologic 9 (18%). Sepsis was the most common cause of MODS in 24 (48%) patients. Most common organ dysfunction as a predictor of mortality was CNS in 17 (77%) out of 22 patients expired, followed by Respiratory in 13 (59%), Renal 11 (50%), CVS 10 (45%), GIT 9 (40%), Hematologic 2 (9%). Maximum incidence of mortality was seen when ≥5 organs failed. There was significant correlation statistically in our study between APACHE II score on admission and outcome as Pearson chi-square “p”< 0.001Mean SOFA score of survivors on day 1 was 6±2 and on day 3 was 2±1. Mortality significantly decreased (3.44%) on day 3 if SOFA score was ≤7. Multi-Organ Dysfunction Syndrome (MODS) was common in younger age group with the mean age of40 years. Sepsis (48%) was the most common cause of MODS, followed by other causes. Maximum incidence of mortality (55%) was seen if the first failed organ was respiratory system and when ≥5 organs failed. Highest incidence of mortality was seen in 8 th decade (100%). APACHE II score on admission, serial SOFA scores, and serial albumin measurements can help ICU physicians in admitting patients, monitoring the clinical course, assessment of organ dysfunction, predicting mortality and for transferring patients out from ICU and thus in proper utilization of ICU resources.

A Scoping Review of Patient Discharge From Intensive Care: Opportunities and Tools to Improve Care

We conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care. We searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Data were extracted on the article type, study details for research articles, patient population, phase of care during discharge, and dimensions of health-care quality. From 8,154 unique publications we included 224 articles. Of these, 131 articles (58%) were original research, predominantly case series (23%) and cohort (16%) studies; 12% were narrative reviews; and 11% were guidelines/policies. Common themes included patient and family needs/experiences (29% of articles) and the importance of complete and accurate information (26%). Facilitators of high-quality care included provider-patient communication (30%), provider-provider communication (25%), and the use of guidelines/policies (29%). Patient and family anxiety (21%) and limited availability of ICU and ward resources (26%) were reported barriers to high-quality care. A total of 47 tools to facilitate patient discharge from the ICU were identified and focused on patient evaluation for discharge (29%), discharge planning and teaching (47%), and optimized discharge summaries (23%). Common themes, facilitators and barriers related to patient and family needs/experiences, communication, and the use of guidelines/policies to standardize patient discharge from ICU transcend the literature. Candidate tools to improve care are available; comparative evaluation is needed prior to broad implementation and could be tested through local quality-improvement programs.

Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics-those elements that provide the capability to deliver mass critical care. The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process. This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response. Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

Resource-Poor Settings: Infrastructure and Capacity Building

Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

Resource-Poor Settings: Response, Recovery, and Research: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Planning for mass critical care in resource-poor and constrained settings has been largely ignored, despite large, densely crowded populations who are prone to suffer disproportionately from natural disasters. As a result, disaster response has been suboptimal and in many instances hampered by lack of planning, education and training, information, and communication. The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of the disaster cycle (mitigation/preparedness/response/recovery). Literature searches were conducted to identify evidence to answer the key questions in these areas. Given a lack of data on which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. The five key questions were as follows: definition, capacity building and mitigation, what resources can we bring to bear to assist/surge, response, and reconstitution and recovery of host nation critical care capabilities. Addressing these led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part I, Infrastructure/Capacity in the accompanying article, and part II, Response/Recovery/Research in this article. A lack of rudimentary ICU resources and capacity to enhance services plagues resource-poor or constrained settings. Capacity building therefore entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is often needed to mount a surge response. Moreover, the disengagement of these responding groups and host country recovery require active planning. Future improvements in all phases require active research activities.

Early Bispectral Index and Sedation Requirements During Therapeutic Hypothermia Predict Neurologic Recovery Following Cardiac Arrest*

To test the hypothesis that low bispectral index scores and low sedative requirements during therapeutic hypothermia predict poor neurologic outcome. Observational study of a prospectively collected cohort. Cardiovascular ICU. One hundred sixty consecutive cardiac arrest patients treated with therapeutic hypothermia. None. Eighty-four of the 141 subjects (60%) who survived hypothermia induction were discharged from the ICU with poor neurologic outcome, defined as a cerebral performance category score of 3, 4, or 5. These subjects had lower bispectral index (p < 0.001) and sedative requirements (p < 0.001) during hypothermia compared with the 57 subjects discharged with good outcome. Early prediction of neurologic recovery was best 7 hours after ICU admission, and median bispectral index scores at that time were 31 points lower in subjects discharged with poor outcome (11 [interquartile range, 4-29] vs 42 [37-49], p < 0.001). Median sedation requirements decreased by 17% (interquartile range, -50 to 0%) 7 hours after ICU admission in subjects with poor outcome but increased by 50% (interquartile range, 0-142%) in subjects with good outcome (p < 0.001). Each 10-point decrease in bispectral index was independently associated with a 59% increase in the odds of poor outcome (95% CI, 32-76%; p < 0.001). The model including bispectral index and sedative requirement correctly reclassified 15% of subjects from good to poor outcome and 1% of subjects from poor to good outcome. The model incorrectly reclassified 1% of subjects from poor to good outcome but did not incorrectly reclassify any from good to poor outcome. Bispectral index scores and sedative requirements early in the course of therapeutic hypothermia improve the identification of patients who will not recover from brain anoxia. The ability to accurately predict nonrecovery after cardiac arrest could facilitate discussions with families, reduce patient suffering, and limit use of ICU resources in futile cases.

Increased ICU Resource Needs for an Academic Emergency General Surgery Service*

ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Retrospective database review. Academic, tertiary care, nontrauma surgical ICU. All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. None. Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

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Introduction: ICU resources may be overwhelmed by a mass casualty (MC) event. MC triage schemes to allocate scarce resources have been proposed for adults, diverting ICU care from patients with high predicted mortality. Similar schemes have not been developed for children. Methods: 150,000 patients from the Virtual PICU Systems LLC database were used. 100,000 randomly selected children admitted 2009-12 were utilized to train prediction models for mortality, duration of mechanical ventilation (DMV), and PICU length of stay (LOS). The models included only variables available on PICU admission for the prediction equations (PEs). Variables that demonstrated univariate association with the outcomes of interest were added stepwise to generate multivariate regressions. The PEs were validated and calibrated on the 50,000 additional patients via receiver operating characteristic (ROC) and Hosmer-Lemeshow (H-L) tests for dichotomous outcomes, and by determining adjusted R2 for continuous outcomes. Results: Because PICU mortality during non-MC periods < 5%, a triage scheme based only on risk of mortality would minimally impact resources. Therefore, PICU exclusion was based on either Low Risk (LR, defined as mortality < .05% + PICU LOS < 3 days + no intubation) and therefore no need for ICU; or because of High Risk (HR, unlikely to benefit from, or disproportionate use of, ICU care), defined as high mortality, or prolonged DMV or LOS. The remainder comprised the Optimal Treatment (OT) group who would receive critical care. The equation predicting LR had area under the ROC (AROC) .70; H-L < .01. The equations predicting HR possessed the following characteristics: mortality: AROC > .85, H-L > .05; DMV: R2 > .10, LOS: R2 > .11 The scheme was designed so that the thresholds for assigning children to the LR, HR, and OT groups could be adjusted to change the size of the OT group and hence match evolving resource availability. For example, if probability of belonging to the LR group was adjusted to > .60, and HR was defined by predicted mortality > .70 and DMV/LOS > 90th percentile, the proportion assigned to OT and thus admitted to PICU = 30%. If probability of belonging to LR was > .50; and HR was defined by predicted mortality > .50 and DMV/LOS > 80th percentile, the proportion assigned to OT and admitted to PICU = 23%. Conclusions: We have demonstrated a pediatric triage model based on multistep triage decisions that is adaptable over a wide spectrum of MC scenarios.

Compliance with VAP bundle implementation and its effectiveness on surgical and medical sub-population in adult ICU

IntroductionDespite broad implementation of a bundled strategy aimed at preventing ventilator-associated adverse events in many hospitals, the ability of the bundle to prevent VAP has not been definitively established with high-quality studies. Aim of the workTo implement VAP bundle as a performance improvement project in adult ICU and follow up the compliance rate over the 12month study period as well as the effectiveness on surgical and medical subgroups. Patients and methodVAP Bundle Program was implemented in adult ICU, data were collected and analyzed for ventilated-associated pneumonia (VAP), and compared before and after intervention. Our bundle components were head of bed elevation greater than 30°, daily sedation break, assessment for extubation, peptic ulcer prophylaxis and deep vein thrombosis prophylaxis. ResultsThe results clearly show the difference between pre and post-intervention period and lower VAP rate after application of VAP bundle. The total VAP bundle compliance rate steadily increased during the period of implementation. We documented a significant reduction of mean ICU LOS (from 15.4±5.2 to 10.8±4.9days) and duration of mechanical ventilation (from 12.8±4.9 to 8.5±4.3days) for patients with VAP bundle compliance at the end of the study. There was a significant improvement in the outcome of surgical patients who were studied after VAP bundle initiation reflecting a decreased mortality rate. ConclusionOur study highlights that adherence with the VAP-bundle approach in our ICU decreases the incidence of VAP, more rapid ventilator weaning, fewer ICU days, and shorter hospitalizations and it has also a great impact on patient outcomes. Our study looked into surgical sub-population as getting more benefit by initiation of the VAP bundle in reducing the length of stay. Thus it results in a decrease in the burden of the health care costs and the ICU resources.

Causes and consequences of disproportionate care in intensive care medicine

Increased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU. Disproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society. Disproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resources and disproportionate care in the ICU should have high priority for ICU managers but also for every healthcare provider taking care of patients at the bedside.

Characteristics of patients admitted to the intensive care unit following self-poisoning and their impact on resource utilisation

Self-poisoning accounts for up to 10 % of hospital admissions, some of whom require admission to ICU. Few studies have looked at the epidemiology of these patients in an Irish setting. To quantify the proportion of ICU admissions attributable to self-poisoning, to examine the characteristics and outcome of these patients, and to assess their ICU resource utilisation. Retrospective review of ICU admissions from 2006 to 2010. Data were collected on patient age, sex, admission diagnosis, substances involved, APACHE II score, length of stay, organ support, and outcome. There were 80 admissions to ICU following self-poisoning accounting for 3.8 % of ICU admissions and 13 % of all hospital admissions for self-poisoning. M:F ratio was 0.9:1. Mean age 35 (range 16-75), APACHE II score 14 (2-36). Commonest substances involved were benzodiazepines, opioids, tricycle antidepressants. Median ICU stay was 2 days (IQR 0.96-4.5). 84 % of patients were ventilated, 27.5 % required inotropic support, 14 % renal replacement therapy. When opioids were involved requirement for inotropes and CRRT were higher. ICU mortality was 6.3 %. These patients consumed 280 bed days. Self-poisoning accounted for 3.8 % of ICU admissions. Patients tend to require a short period of ventilation, with a minority requiring additional organ support. The cost of ICU care is calculated based on previously published methodology to be <euro>7,717 per patient. Extrapolated nationally the annual cost for ICU care for self-poisoning is estimated to be in the order of <euro>5 m.

The role of frailty in outcomes from critical illness

Frailty is a multidimensional syndrome characterized by loss of physiologic reserves that gives rise to vulnerability to adverse events. Frailty has been described in older patients undergoing geriatric assessment and in noncardiac and cardiac surgical settings, in which it closely correlates with heightened risk for major morbidity including functional decline, postoperative complications, institutionalization, and short-term and long-term mortality. Critically ill patients may represent a population with similar vulnerabilities to older frail patients. Prior data have described the association with less favorable outcomes and poor premorbid functional status (i.e., activities of daily living, cognitive impairment, body mass index), used perhaps as a surrogate for frailty. Preliminary epidemiologic data suggest the prevalence of frailty (and intermediate frail states) among critically ill patients is high and likely to increase with the greater demand placed on ICU resources associated with population demographic transition. The concept of frailty, as a marker of biologic age and physiologic reserve, may have direct relevance to critical care, and clearly identifies a population at greater risk of adverse events, morbidity, and mortality. Its recognition in critical care settings may enable improved prognostication and shared decision-making and identify vulnerable subgroups with specific needs who might benefit from targeted follow-up.

Estimating severity of burn in children: Pediatric Risk of Mortality (PRISM) score versus Abbreviated Burn Severity Index (ABSI)

ObjectiveThe purpose of our study is to validate the Pediatric Risk of Mortality (PRISM) score and compare the accuracy of PRISM predicted outcomes to the Abbreviated Burn Severity Index (ABSI). We hypothesized that the PRISM score is more accurate in predicting mortality and hospital length of stay than the ABSI in children with severe burns. MethodsAll children <18 years of age admitted to a regional pediatric burn center between January 1, 2008 and July 1, 2010 were reviewed. Those with a Total Body Surface Area (TBSA) burn ≥20% who were admitted within 7 days of injury were selected for our study. Measured parameters included: demographics, burn characteristics, PRISM and ABSI scores at admission, and outcomes (mortality, hospital length of stay (LOS), ventilator days and cause of death). ResultsA total of 83 patients met criteria and had complete data sets. The mean age (±SEM) was 8.0±0.6 years, mean % TBSA burn 49.9±2.1%, 62.7% were male, and 45.8% had inhalation injury. Hospital LOS was 74.4±7.9 days, with 31.5±4.9 ventilator days. Mean PRISM score ranged from 14.2 to 16.0, with ABSI scores 7.9 to 8.5. Actual overall mortality was 18.1% compared to a PRISM predicted mortality of 19.8±2.5% (p<0.001, r=0.570). ABSI predicted mortality varied from 10 to 20% for a score of 7.9 to 30–50% for a score of 8.5. Logistic regression showed that both PRISM (p<0.001) and ABSI (p<0.001) mortality predictions accurately estimated actual mortality, which remained true in a combined model. ABSI was predictive of hospital LOS (p<0.001) and ventilator days (p<0.001) while PRISM was not (p=0.326 and p=0.863). ConclusionsBoth PRISM and ABSI scores are predictive of mortality in severely burned children. Only ABSI correlates with hospital length of stay and ventilator days, and thus may also be more useful in predicting ICU resource utilization.