Inpatient Intensive Care Unit Research Articles

Rehabilitation in the intensive care unit: How amount of physical and occupational therapy affects patients' function and hospital length of stay.

Patients in the intensive care unit (ICU) often experience extended periods of immobility. Following hospital discharge, many face impaired mobility and never return to their baseline function. Although the benefits of physical and occupational rehabilitation are well established in non-ICU patients, a paucity of work describes effective practices to alleviate ICU-related declines in mobility. To assess how rehabilitation with physical and occupational therapy (PT-OT) during ICU stays affects patients' mobility, self-care, and length of hospital stay. Retrospective cohort study. Inpatient ICU. A total of 6628 adult patients who received physical rehabilitation across multiple sites (Arizona, Florida, Minnesota, and Wisconsin) of a single institution between January 2018 and December 2021. Not applicable. Descriptive statistics, linear regression models, and gradient boosting machine methods were used to determine the relationship between the amount of PT-OT received and outcomes of hospital length of stay (LOS), Activity Measure for Post-Acute Care Daily Activity and Basic Mobility scores. The 6628 patients who met inclusion criteria received an average (median) of 23 (range: 1-89) minutes of PT-OT per day. Regression analyses showed each additional 10 minutes of PT-OT per day was associated with a 1.0% (95% confidence interval [CI]: 0.41-1.66, p < .001) higher final Basic Mobility score, a 1.8% (95% CI: 1.30%-2.34%, p < .001) higher final Daily Activity score, and a 1.2-day (95% CI: -1.28 to -1.09, p < .001) lower hospital LOS. One-dimensional partial dependence plots revealed an exponential decrease in predicted LOS as minutes of PT-OT received increased. Higher rehabilitation minutes provided to patients in the ICU may reduce the LOS and improve patients' functional outcomes at discharge. The benefits of rehabilitation increased with increasing amounts of time of therapy received.

Impact of emergency department-based intensive care unit on outcomes of decompensating boarding emergency department patients.

Emergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED-ICU on decompensating boarding ED patients. This is a retrospective single-center observational study. We identified decompensated boarding ED patients necessitating critical care before departure from the ED from October 2012 to December 2021. An automated query and manual chart review extracted data. Three cohorts were defined: pre-ED-ICU implementation (Group 1), post-ED-ICU implementation with ED-ICU care (Group 2), and post-ED-ICU implementation with inpatient ICU admission without ED-ICU care (Group 3). Primary outcome was ICU length of stay (LOS). Secondary outcomes included hospital LOS, in-hospital mortality, and ICU admissions with ICU LOS<24hours. Between-groups comparisons used multiple regression analysis for continuous variables, χ2 tests and multivariable logistic regression analysis for binary variables, and follow-up contrasts for statistically significant omnibus tests. A total of 1123 visits met inclusion criteria: 225 in Group 1, 780 in Group 2, and 118 in Group 3. Mean ICU LOS was shorter for Group 2 than Group 1 or 3 (47.4vs 92.3vs 103.9hours, P<0.001). Mean hospital LOS was shorter for Group 2 than Group 1 or 3 (185.1vs 246.8vs 257.3hours, P<0.01). In-hospital mortality was similar between groups. The proportion of ICU LOS<24hours was lower for Group 2 than Group 1 or 3 (16.5vs 27.1vs 32.2%, P<0.01). For decompensating boarding ED patients, ED-ICU care was associated with decreased ICU and hospital LOS, similar mortality, and fewer short-stay ICU admissions, suggesting ED-ICU care is associated with downstream resource preservation.

Association of interactions between tele-critical care and bedside with length of stay and mortality

Introduction Substantial variation exists in telemedicine critical care (Tele-CC) effectiveness, which may be explained by heterogeneity in Tele-CC implementation and utilization. Methods We studied inpatient intensive care unit (ICU) admissions within the Veterans Health Administration from January 2005 to September 2018. Tele-CC affiliation was based on a facility's Tele-CC go-live date. Tele-CC interaction was quantified as the monthly number of video activations, recorded in the eCaremanager® (Phillips) system, per patient days. Tele-CC affiliated facilities were propensity-score matched to facilities without Tele-CC by hospital volume and average modified APACHE scores. We examined the effect of Tele-CC affiliation and the quantity of video interactions between Tele-CC and bedside on hospital outcomes. Results Comparing Tele-CC affiliated and control facilities, affiliated patients were, on average, younger (66.8 years vs 67.8 years; p < 0.001) and more likely to be rural residents (11.3% vs 6.5%; p < 0.001). Stratifying the Tele-CC affiliated facilities, facilities with frequent interactions care for more rural and sicker patients relative to facilities with infrequent interactions. Adjusting for patient demographics, facilities in the top tertile of interactions and propensity score matched control facilities were assessed; patients in ICU's with Tele-CC access experienced shorter ICU-specific lengths of stay (RR = 0.39; 95% CI = [0.23, 0.65]). However, when facilities in the bottom tertile and propensity score matched control facilities were assessed, no significant differences were noted in ICU length of stay. Discussion Tele-CC interactions may occur more frequently for higher acuity patients. Increased Tele-CC interactions may improve health outcomes for the most acute and complex ICU cases.

Consenting patients for elective procedures during the pandemic: Are we consenting for risk of nosocomial COVID-19 infection.

Introduction: Nosocomial COVID-19 increases morbidity and mortality in patients undergoing surgical procedures. This study assesses the consenting process in patients admitted for surgical procedures with regard to risks of contracting nosocomial COVID-19 infection during the three lockdown periods in the United Kingdom.Methods: Retrospective review of consecutive surgical patients admitted to our tertiary referral centre for surgical procedures during the lockdown periods in the United Kingdom. Data from our hospital’s electronic theatre database cross-referenced with the online surgical operative, admission and discharge records were reviewed by three independent reviewers.Discussion: A total of 180 patients (104 males and 76 females) were studied. No patients tested positive perioperatively for COVID-19. The first lockdown had a significantly larger proportion of consultants consenting (P < 0.001). Surgeons consented patients for risk of COVID-19 infection in 34.4% of cases, COVID-19-related illness in 33.9%, inpatient Intensive Care Unit (ITU) admission secondary to COVID-19 infection and risk of death due to COVID-19 in 0.0% and risk of death secondary to inpatient COVID infection in 1.1%.Conclusion: As surgical activity continues and COVID-19 persists, surgeons should be vigilant and ensure proper documentation for consent regarding COVID-19-related complications in line with the Royal College of Surgeons of England guidelines.

Sleep and Alertness Among Interns in Intensive Care Compared to General Medicine Rotations: A Secondary Analysis of the iCOMPARE Trial.

Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015-2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am-6am (2.6 vs 1.7, P < .001) and 6am-12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (<6 hours), overall sleep duration and alertness did not significantly differ between rotations.

An Emergency Department-Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis.

Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA. This was a retrospective pre-post cohort of ED visits from 2012-2018 at a single academic medical center. Adult ED patients in DKA (pH<7.30, HCO3<18 mEq/L, anion gap>14, and glucose>250mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed. We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p<0.001, number needed to treat [NNT]=8) or general floor bed (58.0% vs. 73.3%, p<0.001, NNT=6), and more were discharged from the ED (27.1% vs. 1.4%, p<0.001, NNT=4). Rates of hypokalemia (10.1% vs. 6.0%, p=0.08) and admission to non-ICU with transfer to ICU within 24h (0.5% vs. 0%, p=0.30) did not differ. Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.

Association of an Emergency Department–Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions

Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes. To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission. This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019. Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs. The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission. A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217). Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

The Nurse-Chaplain-Family Spiritual Care Triad: A Qualitative Study.

This qualitative study utilized a phenomenological approach to better understand nurse, chaplain, and family member experiences with the delivery of spiritual services at the end of life in an inpatient intensive care unit. Triadic semistructured interviews (six with the patient's family members, six with nurses, and six with chaplains) were conducted. Family members perceived that the nurses' role was to care for the physical needs of their loved one, whereas chaplains were there to care for the emotional needs of those involved.

Timing of palliative care referral and aggressive cancer care toward the end-of-life in pancreatic cancer: a retrospective, single-center observational study

BackgroundPancreatic cancer is noted for its late presentation at diagnosis, limited prognosis and physical and psychosocial symptom burden. This study examined associations between timing of palliative care referral (PCR) and aggressive cancer care received by pancreatic cancer patients in the last 30 days of life through a single health service.MethodA retrospective cohort analysis of end-of-life (EOL) care outcomes of patients with pancreatic cancer who died between 2012 and 2016. Key indicators of aggressive cancer care in the last 30 days of life used were: ≥1 emergency department (ED) presentations, acute inpatient/intensive care unit (ICU) admission, and chemotherapy use. We examined time from PCR to death and place of death. Early and late PCR were defined as > 90 and ≤ 90 days before death respectively.ResultsOut of the 278 eligible deaths, 187 (67.3%) were categorized as receiving a late PCR and 91 (32.7%) an early PCR. The median time between referral and death was 48 days. Compared to those receiving early PCR, those with late PCR had: 18.1% (95% CI 6.8–29.4%) more ED presentations; 12.5% (95% CI 1.7–24.8%) more acute hospital admissions; with no differences in ICU admissions. Pain and complications of cancer accounted for the majority of overall ED presentations. Of the 166 patients who received chemotherapy within 30 days of death, 23 (24.5%) had a late PCR and 12 (16.7%) an early PCR, with no association of PCR status either unadjusted or adjusted for age or gender. The majority of patients (55.8%) died at the inpatient palliative care unit.ConclusionOur findings reaffirm the benefits of early PCR for pancreatic cancer patients to avoid inappropriate care toward the EOL. We suggest that in modern cancer care, there can sometimes be a need to reconsider the use of the term ‘aggressive cancer care’ at the EOL when the care is appropriately based on an individual patient’s presenting physical and psychosocial needs. Pancreatic cancer patients warrant early PCR but the debate must thus continue as to how we best achieve and benchmark outcomes that are compatible with patient and family needs and healthcare priorities.

Cost analysis of bronchoalveolar lavage and respiratory tract biopsies in the diagnosis and management of suspected invasive fungal infection in children with cancer or who have undergone stem cell transplant.

Identification of an organism is the gold standard for the diagnosis of fungal infection; however, we have previously shown that invasive procedures infrequently lead to a change in management in children with cancer or who have undergone stem cell transplant with suspected respiratory tract invasive fungal infection (RT-IFI). There is also a paucity of data on the cost of RT-IFI in this population. We therefore compared the costs of RT-IFI diagnosed based on CT scan alone versus those who underwent a bronchoalveolar lavage (BAL) or respiratory tract biopsy (RTB). We collected cost data on patients at a single center undergoing chemotherapy or who were post-hematopoietic stem cell transplant (HSCT) and were suspected of having RT-IFI between 2007 and 2012. Cost data were included for 14 days from the day of their diagnostic CT scan or procedure. Cost data were available for 76 patients. Thirty-six patients were diagnosed with suspected RT-IFI based on CT only, and 40 patients underwent BAL or RTB. Costs related to chest X-rays (CXRs), inpatient/intensive care unit (ICU) beds, anesthesia, operating room (OR) time, and procedures were significantly higher in the BAL/RTB group versus CT scan group (all P<0.01). Costs related to CT scans were significantly higher in the CT scan group (P=0.0002). Overall costs were significantly higher for patients who underwent BAL or RTB versus CT scan only (P<0.0001). Our previous data showed that BAL and RTB infrequently led to a change in management in this population. We now demonstrate that this strategy is costly as well.

Predictors of Short Intensive Care Unit Stay for Patients with Diabetic Ketoacidosis Using a Novel Emergency Department–Based Resuscitation and Critical Care Unit

BackgroundThe resuscitation and critical care unit is a novel emergency department–intensive care unit designed to provide early critical care to emergency department patients for ≤24 h. ObjectivesThis study sought to identify clinical variables associated with short intensive care unit (ICU) stays in patients with diabetic ketoacidosis (DKA), who commonly require ICU-level care. MethodsWe conducted a retrospective, single-center, cross-sectional study of DKA patients ≥18 years of age who presented to an academic, urban hospital emergency department over 16 months. Patient demographics and clinical variables extracted from medical records were compared between prolonged ICU stay patients of ≥24 h versus short ICU stay patients (SSPs) of <24 h. ICU care was defined as treatment in the resuscitation and critical care unit or inpatient ICU. ResultsOne hundred sixty-eight emergency department visits with a primary diagnosis of DKA were analyzed. There were 53 prolonged ICU stay patients, 58 SSPs, and 57 patients required no ICU time. SSPs had significantly higher initial serum bicarbonate (13.0 vs. 9.0 mEq/L, p = 0.01) and shorter anion gap closure time (9.8 vs. 14.4 hours, p = 0.003). Medication nonadherence was a significantly more frequent precipitant in SSPs (67.2% vs. 47.2%, p = 0.03). Initial anion gap, glucose, beta-hydroxybutyrate, and severity of illness scores were not significantly different between groups. After multivariate logistic regression adjusting for variables significant from univariate analysis, higher initial bicarbonate (p = 0.04) and medication nonadherence (p = 0.03) remained significantly associated with SSPs. ConclusionsPatients with DKA with short ICU stays have higher initial bicarbonate levels and are more likely to have medication nonadherence than patients requiring prolonged critical care. These variables may identify patients with DKA who are best treated in an emergency department–intensive care unit to potentially reduce inpatient ICU use.

The Emergency Department's Impact on Inpatient Critical Care Resources.

Critical care is an expensive and limited resource in the United States. Estimates from more than a decade ago suggest that over $100 billion a year is spent on critical care services.1 Over the past two decades, the number of patients presenting to the Emergency Department (ED) requiring critical care services has increased at a much higher rate than the growth in overall ED volume.2,3 The proportion of ED patients requiring Intensive Care Unit (ICU) admission has increased 75% over the first decade of the twenty-first century. In addition to the increase in the absolute number of patients requiring critical care admission, the ED length of stay for critically ill patients increased by 60 minutes. This resulted in a total nationwide increase in critical care provided in the ED by more than threefold. This disproportionate increase in critical care time reflects both the increase in critical care volume and the increase in ED boarding of critically ill patients. Data from 2008 reported the median boarding time for a patient waiting in the ED for an ICU bed was more than 5 hours, and 30% of patients waited more than 6 hours for an ICU bed.2,3 This article is protected by copyright. All rights reserved.

Community acquired methicillin resistant Staphylococcus aureus pneumonia presenting along with multiple subcutaneous abscesses

Community onset necrotizing pneumonia due to community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is an emerging clinical entity, especially, following a viral infection, with substantial morbidity and mortality and survivors, have long-term pulmonary complications requiring treatment. The infectious diseases society of America guidelines has recently addressed the issue of MRSA as a possible pathogen that warrants empiric antibiotic therapy for community-acquired pneumonia (CAP) in patients requiring inpatient intensive care unit treatment, recommending the use of vancomycin or linezolid, with linezolid having an advantage due to its documented suppression of panton valentine leukocidin toxin production in CA-MRSA. We report a case of a child presenting with pyothorax and multiple subcutaneous absceses over the deltoid region. The pus from the abscesses and pyothorax and the expectorated sputum showed the growth of MRSA. The case was diagnosed as CA-MRSA pneumonia and was successfully treated with vancomycin but the patient required pulmonary decortications and long-term physiotherapy. The case highlights the importance of considering CA-MRSA in the initial empirical therapy for severe CAP and the long-term morbidity associated with this otherwise fatal disease.

Nursing informatics and data collection from the electronic medical record: Study of characteristics, factors and occupancy impacting outcomes of critical care admissions from the Emergency Department

When collecting data from a single electronic medical record (EMR), few studies of Intensive Care Unit (ICU) patients admitted directly from an Emergency Department (ED) focus on observational methodologies examining occupancy of both the ICU and the ED, and population characteristics. This quantitative study design and analysis, with a sample size of 1433 cases using regression techniques, suggested odds of mortality were more likely with a higher ICU occupancy/census and if uninsured. There was no statistical difference based on ED occupancy/census at time of decision to admit to an ICU and no difference whether admitted on a weekend or weekday. Inpatient ICU occupancy is one of the variables that impacts waiting time and overcrowding in the ED, and, in this study, inpatient occupancy in the ICUs impacted patient outcomes. As all healthcare providers make up the interprofessional team and work within complex systems, ease of retrieval of EMR data can hasten decision support to improve quality outcomes.

Medical emergency teams at the ottawa Hospital: the first two years

Medical emergency teams (MET) merge earlier-than-conventional treatment of worrisome vital signs with a skilled resuscitation response team, and may possibly reduce cardiac arrests, postoperative complications, and hospital mortality. At the two sites of The Ottawa Hospital, MET was introduced in January 2005. We reviewed call diagnoses, interventions, and outcomes from MET activity, and examined outcomes [cardiac arrests, intensive care unit (ICU) admissions, and readmissions] from Health Records and the ICU database. We compared the first fully operational year, 2006, with pre-MET years, 2003-4. In 5,741 patient encounters, the teams (nurse, respiratory therapist, and intensivist) responded to 1,931 calls over two years, predominantly for high-risk in-patients. As well, there were 3,810 follow-up visits to these patients and to recently discharged ICU patients. In 2006, there were 40.3 calls/team/1,000 hospital admissions, with 71.2% of in-patient ICU admissions preceded by MET calls. Patient illness severity scores decreased from 4.9 +/- 2.6 (mean +/- SD) before implementing MET to 2.9 +/- 2.3 (P < 0.0001) after MET interventions. Intervention on the respiratory system was performed on 72% of patients. Admission to the ICU occurred in 27% of MET patients. Compared with the pre-MET period, we observed decreases in: cardiac arrests (from 2.53 +/- 0.8 to 1.3 +/- 0.4/1,000 admissions, P < 0.001); ICU admissions from in-patient nursing units/month (42.3 +/- 7.3 to 37.6 +/- 5.1, P = 0.05); readmissions after ICU discharge/month (13.5 +/- 5.1 to 8.8 +/- 4.5, P = 0.01); and readmissions within 48 hr of ICU discharge/month (4.4 +/- 2.4 to 2.8 +/- 1.0 ICU readmissions/month, P = 0.01). Successful implementation of MET reduces patient morbidity and ICU resource utilization.

Acute effects of sucralfate aspiration: Clinical and laboratory observations

Study Objective: To assess the complications associated with the aspiration of sucralfate. Design: Clinical (case report) and bench observations. Setting: Inpatient intensive care unit and experimental animal laboratory. Subjects: The case of a critically ill patient who aspirated sucralfate is presented. Fifteen Sprague-Dawley rats served as experimental animals to investigate the acute histologic effects of large-volume aspiration of sucralfate. Interventions: The patient underwent emergent intubation to relieve acute upper airway obstruction. All the animals were anesthetized and had tracheostomies performed. The experimental groups had acidic intratracheal injections of 2 ml/kg of a nonparticulate liquid (pH, 2.3; n = 6) or a sucralfate aspirate (1 ml/kg of a 5% sucralfate suspension of pH 3.6, followed by 1 ml/kg 0.1 of normal hydrochloric acid of pH 1.0; n = 4). Four hours after simulated aspiration, the rats were sacrificed and their lungs removed for histologic examination by light microscopy. Measurements and Main Results: Differences were noted in histopathologic injury in the experimental groups compared to the control group using a numeric scoring scale. Nonparticulate acidic liquid aspiration caused a significant increase ( p < 0.05) in inflammation. Sucralfate caused a significant increase ( p < 0.05) in lung hemorrhage. A nonsignificant trend was seen with simulated sucralfate aspiration for edema and inflammation. No long-term sequelae were attributed to the clinical aspiration episode. Conclusions: Acute complications associated with aspiration of sucralfate have been identified. In the laboratory setting, simulated aspiration of sucralfate led to acute lung injury.