Intensive Care Unit Unit Research Articles

Pattern and consequences of cardiologic medications management for patients with elevated troponin I upon admission into an intensive care unit not linked to type 1 acute myocardial infarction: A prospective observational cohort study

No recommendations are currently available to help the clinician with the pharmacological management of intensive care unit (ICU) patients with elevated cardiac troponin (cTn) not linked to type 1 AMI. The aim of this study was to evaluate the pattern of cardiologic medications for patients with elevated cTnI in ICU not link to type 1 AMI and their effects on in-hospital mortality. A prospective observational cohort study conducted in two ICU units. Patients with increased plasma concentration of cTnI at admission not linked to type 1 AMI were consecutively included. One hundred and ninety of the 835patients admitted (23%) had an increased plasma concentration of cTnI not related to type 1 AMI. Antiplatelet therapy (AT) and statin were prescribed in 56 (29.5%) and 50 (26.3%) of patients, respectively. Others cardiologic medications were prescribed in less than 5% of all cases and were considered as contraindicated in more than 50% of cases. Antiplatelet therapy was the only cardiologic treatment associated with reduction of in-hospital mortality following uni- and multivariate analysis. The death rate was 23% and 40% in these patients treated with and without AT, respectively (aOR=0.39 [95% CI: 0.15-0.97]). Statin and AT were frequently prescribed to patients with a cTnI elevation not linked to type 1 AMI. This study suggests that AT in patients with an increased plasma concentration of cTnI, not related to type1 AMI in ICU, could reduce in-hospital mortality.

Variability in Integrated Cardiothoracic Training Program Curriculum

Development of curricula that appropriately progress a resident from medical school graduate to fully trained cardiothoracic surgeon is a key challenge for integrated cardiothoracic training programs. This study examined variability and perceived challenges in integrated curricula. Responses to the 2016 TSDA/TSRA survey that accompanies the annual in-training exam taken by current cardiothoracic surgery residents were analyzed. Standard statistical methods were utilized to examine trends in participant responses. General surgery experience decreased with post-graduate year, whereas cardiac operative experience increased. Rotations in a wide variety of adjunct fields were common. The majority (87%) of respondents reported had dedicated cardiothoracic intensive care unit (ICU) rotations, and surgical ICU and cardiac care unit rotations were less common (68% and 42%, respectively). The most common surgical subspecialty rotations were vascular (94%) and acute care surgery (88%), with a wide range of clinical exposure (ie, 3-44 weeks for vascular). Importantly, 52% felt competition with general surgery residents for experience and 22.5% of general surgery rotations were at hospitals without general surgery residents. Perceived challenges included optimization of rotations (78%), faculty allowing residents to perform case components (60%), faculty teaching in the operating room (29%), and improving surgical experience on general surgery rotations (19%). Significant variation exists in integrated cardiothoracic surgery curricula. Optimization of rotations, access to surgical experience, and integration with general surgery appear to be the most significant perceived challenges. These data suggest that optimization of early clinical and surgical experience within institutions could improve trainee preparedness for senior cardiothoracic surgery training.

Efficacy of High-Flow Nasal Cannula Therapy in Intensive Care Units.

We conducted a meta-analysis to compare the physiological and clinical outcomes of high-flow nasal cannula (HFNC) with standard oxygen (O2) or conventional noninvasive ventilation (NIV) in intensive care units (ICUs). We selected the full-text prospective studies comparing HFNC with standard O2 or NIV in ICU. The continuous variables were analyzed with sample size-adjusted pooled t test. The categorical variables were extracted and combined for recalculating odds ratio. We included 18 articles with 2004 patients. No difference was observed in the below outcomes comparing HFNC with standard O2: oxygen saturation (95.0% vs 93.8%, P = .27), Pao2/Fio2 (217.7 vs 161.9 mm Hg, P = .29), Paco2 (38.3 vs 39.3 mm Hg, P = .33), pH (7.416 vs 7.419, P = .90), discomfort (1.19 vs 1.44, P = .44), intubation or reintubation rate (odds ratio = 0.79, 95% confidence interval [CI]: 0.39-1.21, P = .27), and ICU stay (4.0 vs 4.5 days, P = .90). Below outcomes were modestly improved with HFNC compared to standard O2: respiratory rate (21.6 vs 24.7, P = .06) and ICU mortality (odds ratio = 0.69, 95% CI: 0.43-1.11, P = .13). Below outcomes were significantly improved with HFNC compared to standard O2: heart rate (89.1 vs 98.4, P = .03), Pao2 (104.5 vs 90.0 mm Hg, P = .04), and dyspnea (2.7 vs 4.3, P = .05). When comparing HFNC to NIV, below outcomes were significantly lower: Pao2 (106.9 vs 134.2 mm Hg, P = .02), Pao2/Fio2 (178.4 vs 220.0 mm Hg, P = .02), Paco2 (37.7 vs 39.2 mm Hg, P = .04), and ICU mortality (odds ratio = 0.39, 95% CI: 0.19-0.82, P = .01). When comparing to standard O2, the most effective outcomes from HFNC are reduced heart rate and dyspnea in both ICU and critical care unit patients. The HFNC modestly reduced intubation rate and ICU mortality. Patients with pneumonia may benefit from HFNC in reduced respiratory rate, heart rate, dyspnea, discomfort, intubation rate, ICU mortality, ICU stay, and improved Pao2. When comparing to NIV, HFNC group did not do as good in Pao2 and Pao2/Fio2 but had a slightly lower intubation rate and ICU mortality.

A comparative study of voluntarily reported medication errors among adult patients in intensive care (IC) and non- IC settings in Riyadh, Saudi Arabia

Purpose: To investigate the risk factors associated with medication errors and to compare the incidence and types of voluntarily reported medication errors among adult intensive care unit (ICU) and non-ICU patients at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Methods: The design of this study was retrospective. All voluntarily reported medication errors involving adult patients (≥ 18 years) who were admitted into King Abdulaziz Medical City during the study period (January 2012 to June 2013) were included in the study. Reported medication errors were classified as ICU or non-ICU errors. Medication errors were also classified according to the node of medication use, harm category, and type of medication errors. Results: A total of 31,399 patients admitted into the hospital were included in the study, with 1,966 (6 %) admitted into the ICU and 29,433 (94 %) admitted into the non-ICU units. Overall, the incidence of medication errors was 1.2 % (390/31,399), 1. Over half of the errors were administration-related (51 %). The incidence of medication errors was 5.5 % (108/1,966) in ICU compared with 0.96 % (282/29,433) in non-ICU units ( p < 0.001. In both settings, prescribing errors, delay in drug administration and dispensing extra dose were the most common medication errors. Higher risk for medication errors was significantly associated with admission into ICU vs. non-ICU units [OR = 5.24, 95 % CI: (4.12, 6.65); p < 0.001] and with patients’ age ≥ 60 vs. < 60 years [OR = 1.48, 95 % CI: (1.19, 1.83); p < 0.001]. Conclusion: Medication errors are common in the health facility and occur during all stages of medication use from prescribing to administration. Higher risk for medication errors is associated with admission into the ICU and with patients’ age ≥ 60. Physician, pharmacists, and nurses need to be vigilant, up-to-date, and continuously trained to reduce the incidence of medication errors. Keywords: Medication errors, Voluntary reporting, Intensive care unit, Hospital setting

Predictors for ICU Admission and Clinical Outcomes of Malignant Hematology Patients Admitted to Critical Care Units

Introduction:The prognosis of patients with hematologic malignancies (HM) admitted to intensive care units (ICU) is historically poor due to complications of treatment and disease progression with reported overall mortality rates of 24.3% to 84.1%. There is little known regarding predictive variables for ICU admission in adult patients with HM.Objective: Our primary objective was to audit the clinical outcomes including mortality of our HM patients admitted to any hospital ICU unit and compare their characteristics and outcomes with non-ICU hospitalized patients. A secondary objective was to identify the predictive factors for ICU admission and survival.Methods: In this single centre retrospective study, we audited 656/2141 consecutive patients with HM who were admitted to our hospital from 2009-2015 and compared the disease, patient characteristics, and clinical outcomes of HM patients who did or did not get admitted to any ICU. We excluded patients admitted for palliative care and in instances where the patient was admitted more than once, we included only the most recent admission. We enriched for patients who were admitted to the ICU over this 6-year period to improve the statistical power of comparing these two populations. The variables considered included: reason for admission, underlying diagnosis, the modified Charlson Comorbidity Index (CCI), selected laboratory parameters at admission to hospital, previous chemotherapy type, line of treatment, timing and intent, body mass index (BMI), GSCF use, age and sex. We also screened for electronic documentation of advanced directives preceding ICU or hospital admission. We compared the characteristics of ICU (n=179, 27%) and non ICU (n=477, 73%) admitted patients using the Fisher exact test and Wilcoxon rank-sum non parametric test for categorical and continuous variables, respectively. To search for the significant predictive factors for ICU admissions and mortality, univariate and multivariate logistic regression analyses were used.Results: Over the 6-year period, the admission rate to any ICU for HM patients was 9.4%. Median age of the 656 patients was 65.0 (IQR 55-74) and 57% were male with a median time from last chemotherapy and diagnosis of 1 month (IQR 0-3) and 7.8 months (IQR 2.3-44), respectively. Selected patient and disease characteristics comparing ICU and non- ICU admitted patients are in Table 1. There were no differences in median age, BMI, gender, time from last chemotherapy, reasons for admission, WBC, and line of chemotherapy. Patients admitted to any ICU were more likely to have received chemotherapy with curative intent (p=0.0323) and have myeloid cancers (p= 0.0008). They had shorter times from diagnosis, lower hemoglobin, platelet and albumin levels but higher creatinine levels, lactate dehydrogenase (LDH) and liver enzymes. ICU admitted patients had higher CCI scores and in particular history of cardio/cerebro-vascular disease. They also had lower rates of advanced directives (32% vs 49%, p=0.0001). 50% of ICU patients were mechanically ventilated and 25% received vasopressors. Median length of hospital stay was 19 days for ICU and 6 days for non-ICU patients and median ICU length of stay was 3 days (IQR 2-6 days). 34 patients (19.0%) died in ICU and but in hospital mortality was 33% (compared with 8% for non ICU). In the multivariate analysis, six covariates significantly related to ICU admission: chemotherapy intent (curative vs. palliative), history of myocardial infarction, lower platelets, creatinine and albumin levels and no advanced directives (Table 2). Median overall survival was 4.7 months vs. not yet reached for ICU and non ICU admitted patients respectively. 30-day and 6-month survivals were 67% and 47% (ICU) compared with 89%, and 77% in non-ICU admitted patients. The predictors of death in ICU admitted patients were male sex (OR 2.6, 95% CI 1-6.7, p =0.03) and mechanical ventilation (OR 6.55, 95% CI 2.6-18.5, p=0.0001).Conclusions:We validate the previously reported high rates of ICU mortality for patients with hematologic malignancies and have identified the risk factors for ICU admission. Patients without advanced directives have a high likelihood for admission to ICU and potentially represent a targetable group for interventions to avoid inappropriately aggressive care. A predictive score is in development to help identify the patients warranting closer scrutiny and goals of care discussions. [Display omitted] [Display omitted] [Display omitted] DisclosuresBuckstein:Celgene: Honoraria, Research Funding; Novartis: Honoraria.

Route of transmission of Staphylococcus aureus

Route of transmission of Staphylococcus aureus

The Diagnostic and Therapeutic Impact of Point-of-Care Ultrasonography in the Intensive Care Unit.

In light of point-of-care ultrasonography's (POCUS) recent rise in popularity, assessment of its impact on diagnosis and treatment in the intensive care unit (ICU) is of key importance. Ultrasound examinations were collected through an ultrasound reporting software in 6 multidisciplinary ICU units from 3 university hospitals in Canada and the United States. This database included a self-reporting questionnaire to assess the impact of the ultrasound findings on diagnosis and treatment. We retrieved the results of these questionnaires and analyzed them in relation to which organs were assessed during the ultrasound examination. One thousand two hundred and fifteen ultrasound studies were performed on 968 patients. Intensivists considered the image quality of cardiac ultrasound to be adequate in 94.7% compared to 99.7% for general ultrasound ( P < .001). The median duration of a cardiac examination was 10 (interquartile range [IQR] 10) minutes compared to 5 (IQR 8) minutes for a general examination ( P < .001). Overall, ultrasound findings led to a change in diagnosis in 302 studies (24.9%) and to a change in management in 534 studies (44.0%). A change in diagnosis or management was reported more frequently for cardiac ultrasound than for general ultrasound (108 [37.1%] vs 127 [16.5%], P < .001) and (170 [58.4%] vs 270 [35.1%], P < .001). Assessment of the inferior vena cava for fluid status emerged as the critical care ultrasound application associated with the greatest impact on management. Point-of-care ultrasonography has the potential to optimize care of the critically ill patients when added to the clinical armamentarium of the intensive care physician.

Implementation of Clinical Decision Support Rules to Reduce Repeat Measurement of Serum Ionized Calcium, Serum Magnesium, and N-Terminal Pro-B-Type Natriuretic Peptide in Intensive Care Unit Inpatients.

We assessed the impact of clinical decision support (CDS) rules within the electronic health record for ionized calcium (iCa), serum magnesium (Mg), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in intensive care unit (ICU) inpatients at a large academic center. A repeat order for measurement of iCa or Mg placed within 24 (iCa) or 48 (Mg) h of a previously nonactionable result, or additional orders for NT-proBNP beyond 1 within a single hospitalization, triggered a CDS pop-up alert showing the prior result and offering the opportunity to cancel the order or to place the order after entering an indication for repeat testing. The number of tests performed for each of these analytes and incidence of adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia were compared between the 90-day period before CDS implementation and two 90-day periods immediately following. iCa test volumes decreased by 48%, Mg by 39%, and NT-proBNP by 28% in the 90-day period immediately following implementation and remained decreased by 54%, 49%, and 22%, respectively, during the following 90-day period (all P values <0.0002). Adverse clinical outcomes potentially associated with hypocalcemia or hypomagnesemia did not increase (all P-values >0.17). Implementation of CDS dramatically decreased repeat testing of iCa, Mg, and NT-proBNP without adversely impacting clinical outcomes in the ICU. Expansion of the rules from the ICU units to include the entire hospitalized patient population and expansion to additional analytes is expected to lead to further reductions in testing.

Platelet-to-Lymphocyte Ratio: A Novel Prognostic Factor for Prediction of 90-day Outcomes in Critically Ill Patients With Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and the novel systemic inflammation marker platelet-to-lymphocyte ratio (PLR) may be associated with clinical outcome in patients with DKA. This study aimed to investigate the utility of PLR in predicting 90-day clinical outcomes in patients with DKA. Patient data exacted from the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC II) database was analyzed. A cutoff value for PLR of 267.67 was determined using Youden index (P < 0.05) and used to categorize subjects into a high PLR group and a low PLR group. The hazard ratios (HRs) and 95% confidence intervals (CIs) for DKA were calculated across PLR. Clinical outcomes in our study were defined as intensive care unit (ICU) 90-day readmission and all-cause mortality. A total of 278 ICU admissions were enrolled and stratified by cutoff value of PLR. The incidence of readmission and mortality was 17.8% in the high PLR group, significantly higher than 7.4% in the low PLR group. In the multivariable model, after adjusting for known confounding variables including clinical parameters, comorbidities, laboratory parameters, the HRs for DKA were 2.573 (95% CI 1.239-5.345; P = 0.011), 2.648 (95% CI 1.269-5.527; P = 0.009), and 2.650 (95% CI 1.114-6.306; P = 0.028), respectively. The Kaplan-Meier survival curve showed that a high PLR level was associated with a higher risk for 90-day outcomes in patients with DKA. The authors report that higher PLR presents a higher risk for 90-day incidence of readmission and mortality in patients with DKA. It appears to be a novel independent predictor of 90-day outcomes in critically ill DKA patients in ICU units.

Random Survival Forests for Predicting the Bed Occupancy in the Intensive Care Unit.

Predicting the bed occupancy of an intensive care unit (ICU) is a daunting task. The uncertainty associated with the prognosis of critically ill patients and the random arrival of new patients can lead to capacity problems and the need for reactive measures. In this paper, we work towards a predictive model based on Random Survival Forests which can assist physicians in estimating the bed occupancy. As input data, we make use of the Sequential Organ Failure Assessment (SOFA) score collected and calculated from 4098 patients at two ICU units of Ghent University Hospital over a time period of four years. We compare the performance of our system with a baseline performance and a standard Random Forest regression approach. Our results indicate that Random Survival Forests can effectively be used to assist in the occupancy prediction problem. Furthermore, we show that a group based approach, such as Random Survival Forests, performs better compared to a setting in which the length of stay of a patient is individually assessed.

First results about recovery of walking function in patients with intensive care unit-acquired muscle weakness from the General Weakness Syndrome Therapy (GymNAST) cohort study

ObjectivesTo describe the time course of recovery of walking function and other activities of daily living in patients with intensive care unit (ICU)-acquired muscle weakness.DesignThis is a cohort study.ParticipantsWe included...

Abstract 10111: Transcatheter Aortic Valve Implantation Without Intensive Care Unit Admission is Possible in Selected "Low Risk" Patients

Introduction: Admission to the intensive care unit (ICU) after transcatheter aortic valve implantation (TAVI) is a standard of care. Hypothesis: We assessed the hypothesis that TAVI can be performed safely without ICU admission in patients considered at low risk using simple clinical, ECG and echographic criteria. Methods: In this prospective monocentric cohort study we included all consecutive patients who underwent a TAVI procedure between December 2014 and May 2015. Low risk group included patients with LVEF &gt; 40 %, transfemoral (TF) access, absence of severe pulmonary disease, stable hemodynamic state and absence of complications occurring until 2 hours after the procedure. High risk group included all other patients. Patients were admitted to the ICU or conventional cardiology unit depending on their risk evaluation. In-hospital major adverse events (VARC-2 criteria) were recorded in the two groups Results: On the 144 patients included, 67 were men (46.5 %), median age was 85 years (80-88) and median Euroscore II was 4.2 (3-6.9). The balloon expandable Edwards Sapien 3 valve was mainly used (n=118; 82%), with TF approach (n=136; 94.4% ) and general anesthesia (n=138; 95.8%). Of the 46 low risk patients (31.9%), only 1 was secondarily transferred to ICU due to non compressive pericardial effusion (minor complication) giving a negative predictive value of our triage strategy of 97.8% (CI:88.5-99.9). Conversely, of the 98 high risk patients, 40 developed major complications, mainly conductive disturbances. Positive predictive value was 40.8% (CI: 31.0-51.2). (Table 1) By univariate analysis, the main pre procedural predictive factors of complications were use of self expandable prosthesis (p&lt;0.00005) and right bundle branch block (p&lt;0.004). In conclusion, our results suggested that TAVI can be performed safely without ICU admission in selected patients. This new “minimalist” strategy may optimize efficiency and cost effectiveness of the procedure.

A pilot study of eye-tracking devices in intensive care

Eye-tracking devices have been suggested as a means of improving communication and psychosocial status among patients in the intensive care unit (ICU). This study was undertaken to explore the psychosocial impact and communication effects of eye-tracking devices in the ICU. A convenience sample of patients in the medical ICU, surgical ICU, and neurosciences critical care unit were enrolled prospectively. Patients participated in 5 guided sessions of 45 minutes each with the eye-tracking computer. After completion of the sessions, the Psychosocial Impact of Assistive Devices Scale (PIADS) was used to evaluate the device from the patient's perspective. All patients who participated in the study were able to communicate basic needs to nursing staff and family. Delirium as assessed by the Confusion Assessment Method for the Intensive Care Unit was present in 4 patients at recruitment and none after training. The device's overall psychosocial impact ranged from neutral (-0.29) to strongly positive (2.76). Compared with the absence of intervention (0 = no change), patients exposed to eye-tracking computers demonstrated a positive mean overall impact score (PIADS = 1.30; P = .004). This finding was present in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all P < .01). There is a population of patients in the ICU whose psychosocial status, delirium, and communication ability may be enhanced by eye-tracking devices. These 3 outcomes are intertwined with ICU patient outcomes and indirectly suggest that eye-tracking devices might improve outcomes. A more in-depth exploration of the population to be targeted, the device's limitations, and the benefits of eye-tracking devices in the ICU is warranted.

Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad.

Few national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with ("Abroad") or without ("Local") a recent stay abroad, and then identify the risk factors in "Abroad" patients. In this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad ("Abroad") within 6 months prior to ICU admission. Of 1,842 ICU patients, 129 (7%) "Abroad" patients were reported. In the "Abroad" group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in "Local" patients. Risk factors associated with MDR bacteria carriage at admission in "Abroad" patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and "hospitalization abroad with antibiotic treatment" [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor. The main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of "Abroad" patients should be recommended, even in case of a first negative screening.

Risk factors for discharge on a new antipsychotic medication after admission to an intensive care unit

PurposeIncreased awareness of delirium in the intensive care unit (ICU) has led to higher use of antipsychotic medications for treatment of delirium. These medications are often not discontinued at ICU or hospital discharge, which may increase the risk of inappropriate polypharmacy. Our study sought to identify risk factors for being discharged on a new antipsychotic medication after admission to a trauma-surgical ICU or neurocritical care unit. MethodsThis was a retrospective cohort study at an academic medical center and included patients who were admitted to the trauma-surgical ICU or neurocritical care unit and received an antipsychotic medication. Those younger than 18 years, died before hospital discharge, or did not have complete documentation were excluded. ResultsA total of 341 records were included in the final analysis. Of those, 82 (24%) were discharged on a new antipsychotic and 67% of those patients had no documented indication. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.030 [95% confidence interval, 1.030-1.110]) and days treated with benzodiazepines (odds ratio, 1.101 [95% confidence interval, 1.060-1.143]) were independently associated with being discharged on a new antipsychotic medication. ConclusionsThose patients with higher Acute Physiology and Chronic Health Evaluation II scores and more benzodiazepine days are at increased odds of being discharged on a new antipsychotic.

A Conceptual Framework for Improving Critical Care Patient Flow and Bed Use.

High demand for intensive care unit (ICU) services and limited bed availability have prompted hospitals to address capacity planning challenges. Simulation modeling can examine ICU bed assignment policies, accounting for patient acuity, to reduce ICU admission delays. To provide a framework for data-driven modeling of ICU patient flow, identify key measurable outcomes, and present illustrative analysis demonstrating the impact of various bed allocation scenarios on outcomes. A description of key inputs for constructing a queuing model was outlined, and an illustrative simulation model was developed to reflect current triage protocol within the medical ICU and step-down unit (SDU) at a single tertiary-care hospital. Patient acuity, arrival rate, and unit length of stay, consisting of a "service time" and "time to transfer," were estimated from 12 months of retrospective data (n = 2,710 adult patients) for 36 ICU and 15 SDU staffed beds. Patient priority was based on acuity and whether the patient originated in the emergency department. The model simulated the following hypothetical scenarios: (1) varied ICU/SDU sizes, (2) reserved ICU beds as a triage strategy, (3) lower targets for time to transfer out of the ICU, and (4) ICU expansion by up to four beds. Outcomes included ICU admission wait times and unit occupancy. With current bed allocation, simulated wait time averaged 1.13 (SD, 1.39) hours. Reallocating all SDU beds as ICU decreased overall wait times by 7.2% to 1.06 (SD, 1.39) hours and increased bed occupancy from 80 to 84%. Reserving the last available bed for acute patients reduced wait times for acute patients from 0.84 (SD, 1.12) to 0.31 (SD, 0.30) hours, but tripled subacute patients' wait times from 1.39 (SD, 1.81) to 4.27 (SD, 5.44) hours. Setting transfer times to wards for all ICU/SDU patients to 1 hour decreased wait times for incoming ICU patients, comparable to building one to two additional ICU beds. Hospital queuing and simulation modeling with empiric data inputs can evaluate how changes in ICU bed assignment could impact unit occupancy levels and patient wait times. Trade-offs associated with dedicating resources for acute patients versus expanding capacity for all patients can be examined.

Measuring hand hygiene compliance rates in different special care settings: a comparative study of methodologies

The purpose of this study was to compare methods for assessing compliance with hand hygiene in an intensive care unit (ICU), a step-down unit (SDU), and a hematology-oncology unit. Over a 20-week period, we compared hand hygiene compliance measurements by three different methods: direct observation, electronic handwash counter for alcohol gel, and measuring the volume of product used (alcohol gel) in an ICU, an SDU, and a hematology-oncology unit of a tertiary care, private hospital. By direct observation we evaluated 1078 opportunities in the ICU, 1075 in the SDU, and 517 in the hematology-oncology unit, with compliance rates of 70.7%, 75.4%, and 73.3%, respectively. A total of 342,299, 235,914, and 248,698 hand hygiene episodes were recorded by the electronic devices in the ICU, SDU, and hematology-oncology unit, respectively. There were also 127.2 ml, 85.3 ml, and 67.6 ml of alcohol gel used per patient-day in these units. We could find no correlation between the three methods. Hand hygiene compliance was reasonably high in these units, as measured by direct observation. However, a lack of correlation with results obtained by other methodologies brings into question the validity of direct observation results, and suggests that periodic audits using other methods may be needed.

The management of Convulsive Refractory Status Epilepticus in adults in the UK: No consistency in practice and little access to continuous EEG monitoring

PurposeConvulsive Status Epilepticus (CSE) is a common neurological emergency with patients presenting with prolonged epileptic activity. Sub-optimal management is coupled with high morbidity and mortality. Continuous electroencephalogram (EEG) monitoring is considered essential by the National Institute for Health and Care Excellence (NICE) in the management of Convulsive Refractory Status Epilepticus (CRSE). The aim of this research was to determine current clinical practice in the management of CRSE amongst adults in intensive care units (ICU) in the UK and establish if the use of a standardised protocol requires re-enforcement within trusts. Methods75 randomly selected UK NHS Trusts were contacted and asked to complete a questionnaire in addition to providing their protocol for CRSE management in ICU. Results55 (73%) trusts responded. While 31 (56% of responders) had a protocol available in ICU for early stages of CSE, just 21 (38%) trusts had specific guidelines if CRSE occurred. Only 23 (42%) trusts involved neurologists at any stage of management and just 18 (33%) have access to continuous EEG monitoring. ConclusionThis study identifies significant inconsistency in the management of CSE in ICU's across the UK. A minority of ICU units have a protocol for CRSE or access to continuous EEG monitoring despite it being considered fundamental for management and supported by NICE guidance.

Outcomes of direct and indirect medical intensive care unit admissions from the emergency department of an acute care hospital: a retrospective cohort study

ObjectivesThis study aimed to determine if the risk of adverse outcomes (in-hospital and 60-day mortality, intensive care unit (ICU) and total hospital length of stay (LOS)) was greater for medical...

Hand-hygiene compliance does not predict rates of resistant infections in critically ill surgical patients.

Our institution had a major outbreak of multi-drug-resistant Acinetobacter (MDRA) in its general surgical and trauma intensive care units (ICUs) in 2011, requiring implementation of an aggressive infection-control response. We hypothesized that poor hand-hygiene compliance (HHC) may have contributed to the outbreak of MDRA. A response to the outbreak including aggressive environmental cleaning, cohorting, and increased hand hygiene compliance monitoring may have led to an increase in HHC after the outbreak and to a consequent decrease in the rates of infection by the nosocomial pathogens methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile. Hand-hygiene compliance, tracked in monthly audits by trained and anonymous observers, was abstracted from an infection control database. The incidences of nosocomial MRSA, VRE, and C. difficile were calculated from a separate prospectively collected data base for 6 mo before and 12 mo after the 2011 outbreak of MDRA in the institution's general surgical and trauma ICUs, and data collected prospectively from two unaffected ICUs (the thoracic surgical ICU and medical intensive care unit [MICU]). We created a composite endpoint of "any resistant pathogen," defined as MRSA, VRE, or C. difficile, and compared incidence rates over time, using the Wilcoxon signed rank test and Pearson product-moment correlation coefficient to measure the correlations among these rates. Rates of HHC before and after the outbreak of MDRA were consistently high in both the general surgical (median rates: 100% before and 97.6% after the outbreak, p=0.93) and trauma ICUs (median rates: 90% before and 96.75% after the outbreak, p=0.14). In none of the ICUs included in the study did the rates of HHC increase in response to the outbreak of MDRA. The incidence of "any resistant pathogen" decreased in the general surgical ICU after the outbreak (from 6.7/1,000 patient-days before the outbreak to 2.7/1,000 patient-days after the outbreak, p=0.04), but this decrease did not correlate with HHC (trauma ICU: Pearson correlation [ρ]=-0.34, p=0.28; general surgical ICU: ρ=0.52, p=0.08). The 2011 outbreak of MDRA at our institution occurred despite high rates of HHC. Notwithstanding stable rates of HHC, the rates of infection with MRSA, VRE and C. difficile decreased in the general surgical ICU after the outbreak. This suggests that infection control tactics other than HHC play a crucial role in preventing the transmission of nosocomial pathogens, especially when rates of HHC have been maximized.