Intensive Care Ward Research Articles

A comparative study of epidural catheter colonization and infection in Intensive Care Unit and wards in a Tertiary Care Public Hospital.

Infection is a potentially serious complication of epidural analgesia and with an increase in its use in wards there is a necessity to demonstrate its safety. We aimed to compare the incidence of colonization of epidural catheters retained for short duration (for 48 h) postoperative analgesia in postanesthesia care unit and wards. It was a prospective observational study done in a tertiary care teaching public hospital over a period of 2 years and included 400 patients with 200 each belonged to two groups PACU and ward. We also studied epidural tip culture pattern, skin swab culture at the entry point of the catheter, their relation to each other and whether colonization is equivalent to infection. Data were analyzed using statistical software GraphPad. Overall positive tip culture was 6% (24), of them 7% (14) were from PACU and 5% (10) were from ward (P = 0.5285). Positive skin swab culture was 38% (150), of them 20% (80) were from PACU and 18% (70) were from ward (P = 0.3526). The relation between positive tip culture and positive skin swab culture in same patients is extremely significant showing a strong linear relationship (95% confidence interval = 0.1053–0.2289). The most common microorganism isolated was Staphylococcus epidermidis. No patient had signs of local or epidural infection. There is no difference in the incidence of epidural catheter tip culture and skin swab culture of patients from the general ward and PACU. Epidural analgesia can be administered safely for 48 h in general wards without added risk of infection. The presence of positive tip culture is not a predictor of epidural space infection, and colonization is not equivalent to infection; hence, routine culture is not needed. Bacterial migration from the skin along the epidural track is the most common mode of bacterial colonization; hence, strict asepsis is necessary.

Diagnosis and management of acute heart failure.

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an ‘aged’ population. As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department, intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Integrative review of nurse-led follow-up after discharge from the ICU.

To analyse and synthesise the structure, content, types of outcome variables and advantages of nurse-led follow-up of adult patients after discharge from intensive care units. Follow-up service after discharge from the intensive care unit has been suggested as a way of supporting recovery of patients. Nevertheless, varieties exist in the understanding and content of nurse-led follow-up. An integrative review of nurse-led follow-up inspired by the framework of Whittemore and Knafl. An integrative method merged with the recommendations of the PRISMA statement was used to structure the review and findings. Online databases PubMed, CINAHL, ScienceDirect and Scopus were searched from the years 2003-2014. The retrieved articles were independently assessed by two reviewers. Critical appraisal was conducted using check lists from Johanna Briggs Institute. Emerging patterns were validated by all the authors throughout the entire process of analysis. Seventeen papers were included. Three patterns of nurse-led follow-up were identified: (1) Ward visits--in the immediate time after discharge from intensive care unit, (2) Ward visits and appointment(s) to an intensive care unit follow-up clinic and (3) follow-up visit to an intensive care unit and phone call(s) after discharge. Content of short-term nurse-led follow-up (1) ranged from clinical assessment to supporting patients in articulating their subjective health concerns. Long-term nurse-led follow-up (2, 3) included appointments, phone call(s) or information on where advice could be sought. Types of outcome variables were primarily descriptive. There were strong implications for patients' satisfaction with nurse-led follow-up up to six months after discharge. Nurse-led follow-up might promote patients' health and enable use of adequate resources. The findings of this review could be used to design, and test, future interventions and their implementation.

Identification and Comparison of Barriers to Assessing and Combating Acute and Postoperative Pain in Elderly Patients in Surgical Wards of Polish Hospitals: A Multicenter Study

Inadequate pain monitoring and management in hospitalized patients poses a serious clinical problem which has been extensively covered in literature for over 25 years. The purpose of the paper was to learn about and compare the existing barriers to effective analgesia controlled by nurses on surgical wards in Polish hospitals. The study was carried out upon the approval of the study protocol by the Independent Bioethics Committee for Scientific Research of the Medical University of Gdańsk. The research project was multi-center and took a year. The study was questionnaire-based. It used the Polish version of the Nurses' Perceived Obstacles to Pain Assessment and Management Practices questionnaire. The study included a total of 1300 nurses working on surgical wards. The barriers most frequently observed by the respondents were: disorganization of the healthcare system, physicians' mistrust of pain assessment by nursing staff, difficulty contacting and communicating with physicians to discuss the results of patients' pain assessments and difficulties experienced by elderly patients with completing pain assessment scales. The barriers most frequently impeding pain therapy in elderly patients are associated with the healthcare system, and they were more frequently present on the anesthesiology and intensive care ward and in the emergency department, and occurred the least frequently on the surgical ward. Patient-related problems were more frequent on the anesthesiology and intensive care wards than in the emergency department. Doctor-related problems most frequently occurred on the gynecological ward, while nurse-related problems were more frequent on the anesthesiology and intensive care ward.

Investigation on ICU nursing factors caused nosocomial infection and counter measures

Objective To explore the ICU nursing factors caused nosocomial infection situation and nursing countermeasures. Methods From January 2007 to March 2011,107 cases happened nosocomial infection during hospitalization, the clinical data was reviewed and analyzed. Another 1047 ICU patients were selected in hospital, randomly divided into two groups. Conventional care was treated in control group. Nursing care summarized in front of the nursing countermeasures was treated in the observation group. Happening situation nosocomial infection and satisfaction of nursing of patients were compared. Results Before March 2011, nosocomial infection caused by nursing factos in the ICU patients aged> 60 years old was majority, and aged< 35 years old was significantly smaller proportion. The foundation of infection were main multiple wounds and cerebrovascular disease. Infection site were mainly respiratory tract, followed by urinary tract. 8 patients(1.26%)in the observation group happened nosocomial infection, which was obviously lower than that of the control group(8.74%).613 patients(96.54%)of the observed group were satisfied with nursing, which was much higher than that of control group(84.47%). There was statistically significant difference(P<0.05). Conclusion To the ICU patients, comprehensive and directive nursing for patients is benefit to recovery and the relationship between the harmonious, could be used as a conventional care in ICU way clinical campaign. Key words: Intensive care ward; Nosocomial infection; Nursing

The Factors Influencing Relapse in Patients Presenting to the Emergency Department with COPD Exacerbation

SUMMARYObjectivesChronic Obstructive Pulmonary Disease (COPD) is associated with high mortality and morbidity and is projected to be the third most common cause of death worldwide by 2020. For a variety of reasons, there is a drive to manage a greater number of individuals as outpatients. Preventing readmissions can reduce associated morbidity and subsequent healthcare costs.MethodsThe aim of the present study was to determine the factors affecting the relapse of COPD exacerbated patients in the emergency department (ED). This study combines data from two prospective cohort studies. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of acute exacerbation. All the information relevant to the study was collected during the patient's visit to the ED. Relapse was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks.ResultsThe cohort consists of 196 patients. Relapse rate in this study was 27%. Mean respiratory rate, exacerbations in previous year, home nebulizator therapy, home oxygen therapy, admission to intensive care or hospital ward due to COPD exacerbation, previous intubation and abnormal chest x-ray were associated with increased re-visit in univariate analysis. However, after multivariate analysis, exacerbations in previous year (OR: 1.08, 95%CI: 1.01–1.15) and abnormal chest X-ray (OR: 2.5, 95%CI: 1.10–6.11) were still significant.ConclusionsIn conclusion, the number of ED visits previous year and abnormal chest x-ray can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit.

Pressure ulcer and patient characteristics – A point prevalence study in a tertiary hospital of India based on the European Pressure Ulcer Advisory Panel minimum data set

BackgroundPressure ulcers is a frequent problem in hospitalized patients. Several prevalence studies have been conducted across the globe. Little information is available regarding prevalence of pressure ulcers in India. PurposeThe aim was to identify the prevalence of pressure ulcers in one of the tertiary hospital in northern India and the factors associated with its development. DesignA cross sectional point prevalence study. InstrumentsEuropean Pressure Ulcer Advisory Panel (EPUAP) data collection form. MethodsEthics approval was obtained prior to start of the study. Total of 358 patients were enrolled in the study. All patients above 18 years of age admitted in intensive care units and wards were included in the study. Patients admitted in emergency, day care, coronary care unit were excluded because of their short duration of hospital stay (varies from 24 to 72 h usually). All patients admitted before midnight on the predetermined day were included. The Braden scale was used to identify the risk of developing pressure ulcers. European Pressure ulcer advisory panel (EPUAP) minimum data set was used to collect prevalence data. ResultsThe overall prevalence rate was 7.8%.The sacrum and heel were more commonly affected. Grade III pressure ulcers were the most common (42.8%). ConclusionThe pressure ulcer prevalence rate in our hospital was lower than that published in international studies. Severe forms of pressure ulcers were commonly encountered This data provides background information that may help us in developing protocols for applying effective practices for prevention of pressure ulcers.

Motorcycle-Related Traumatic Brain Injuries: Helmet Use and Treatment Outcome.

Summary. With increasing use of motorcycle as means of transport in developing countries, traumatic brain injuries from motorcycle crashes have been increasing. The only single gadget that protects riders from traumatic brain injury is crash helmet. Objective. The objectives were to determine the treatment outcome among traumatic brain injury patients from motorcycle crashes and the rate of helmet use among them. Methods. It was a prospective, cross-sectional study of motorcycle-related traumatic brain injury patients managed in our center from 2010 to 2014. Patients were managed using our unit protocol for traumatic brain injuries. Data for the study were collected in accident and emergency, intensive care unit, wards, and outpatient clinic. The data were analyzed using Environmental Performance Index (EPI) info 7 software. Results. Ninety-six patients were studied. There were 87 males. Drivers were 65. Only one patient wore helmet. Majority of them were between 20 and 40 years. Fifty-three patients had mild head injuries. Favorable outcome among them was 84.35% while mortality was 12.5%. Severity of the injury affected the outcome significantly. Conclusion. Our study showed that the helmet use by motorcycle riders was close to zero despite the existing laws making its use compulsory in Nigeria. The outcome was related to severity of injuries.

Innovative approach using interprofessional simulation to educate surgical residents in technical and nontechnical skills in high-risk clinical scenarios.

The Accreditation Council for Graduate Medical Education core competencies stress nontechnical skills that can be difficult to evaluate and teach to surgical residents. During emergencies, surgeons work in interprofessional teams and are required to perform certain procedures. To obtain proficiency in these skills, residents must be trained. To educate surgical residents in leadership, teamwork, effective communication, and infrequently performed emergency surgical procedures with the use of interprofessional simulations. SimMan 3GS was used to simulate high-risk clinical scenarios (15-20 minutes), followed by debriefings with real-time feedback (30 minutes). A modified Oxford Non-Technical Skills scale (score range, 1-4) was used to assess surgical resident performance during the first half of the academic year (July-December 2012) and the second half of the academic year (January-June 2013). Anonymous online surveys were used to solicit participant feedback. Simulations were conducted in the operating room, intensive care unit, emergency department, ward, and simulation center. A total of 43 surgical residents (postgraduate years [PGYs] 1 and 2) participated in interdisciplinary clinical scenarios, with other health care professionals (nursing, anesthesia, critical care, medicine, respiratory therapy, and pharmacy; mean number of nonsurgical participants/session: 4, range 0-9). Thirty seven surgical residents responded to the survey. Simulation of high-risk clinical scenarios: postoperative pulmonary embolus, pneumothorax, myocardial infarction, gastrointestinal bleeding, anaphylaxis with a difficult airway, and pulseless electrical activity arrest. Evaluation of resident skills: communication, leadership, teamwork, problem solving, situation awareness, and confidence in performing emergency procedures (eg, cricothyroidotomy). A total of 31 of 35 (89%) of the residents responding found the sessions useful. Additionally, 28 of 33 (85%) reported improved confidence doing procedures and 29 of 37 (78%) reported knowing when the procedure should be applied. Oxford Non-Technical Skills evaluation demonstrated significant improvement in PGY 2 resident performance assessed during the 2 study periods: communication score increased from 3 to 3.71 (P=.01), leadership score increased from 2.77 to 3.86 (P<.001), teamwork score increased from 3.15 to 3.86 (P=.007), and procedural ability score increased from 2.23 to 3.43 (P=.03). There were no statistically significant improved scores in PGY 2 decision making or situation awareness. No improvements in skills were seen among PGY 1 participants. The PGY 2 residents improved their skills, but the PGY 1 residents did not. Participants found interprofessional simulations to be realistic and a valuable educational tool. Interprofessional simulation provides a valuable means of educating surgical residents and evaluating their skills in real-life clinical scenarios.

Appropriateness of requests for human serum albumin at the University Hospital of Palermo, Italy: a prospective study

First, to assess the appropriateness of requests for albumin using current guidelines; second, to evaluate physicians' compliance with this protocol. Descriptive, prospective study. 'Paolo Giaccone' University Hospital in Palermo (Italy). The six departments with the highest orders for albumin. An experimental, pharmacist-driven process for daily orders of albumin was activated over a period of 1 month. Pharmacy personnel handed out order forms on six different wards. Physicians were required to select one of a number of intended uses listed on the form. Data on albumin and serum protein levels; number of vials and grams of albumin requested/day; number of vials and grams of albumin/day needed to normalize serum albumin levels; informed consent; indications and appropriateness of use. A total of 126 forms were collected. Mean serum albumin and protein levels of patients in the different wards were close to normal (2.5 and 5 g/dl, respectively). The albumin doses requested by the various wards were 2 to 7 times higher than expected. 37.3% of the requests were for appropriate indications, 40.5% were for occasionally appropriate indications and 18.2% were inappropriate. According to current guidelines, 83.3% of requests were appropriate. 45% of orders from the Intensive Care ward were for inappropriate indications. The introduction of a well-defined, flexible pharmacist-driven ordering process for albumin could reduce omissions in albumin indications and aid request assessment. It would allow pharmacists to collaborate with physicians in verifying whether requests are appropriate and whether prescriptions comply with current guidelines.

Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment.

BackgroundThe incidence of hypothermia is difficult to evaluate, and the data concerning the morbidity and mortality rates do not seem to fully represent the problem. The aim of the study was to estimate the actual prevalence of accidental hypothermia in Poland, as well as the methods of diagnosis and management procedures used in emergency rooms (ERs).MethodsA specially designed questionnaire, consisting of 14 questions, was mailed to all the 223 emergency rooms (ER) in Poland. The questions concerned the incidence, methods of diagnosis and risk factors, as well as the rewarming methods used and available measurement instruments.ResultsThe analysis involved data from 42 ERs providing emergency healthcare for the population of 5 305 000. The prevalence of accidental hypothermia may have been 5.05 cases per 100.000 residents per year. Among the 268 cases listed 25% were diagnosed with codes T68, T69 or X31, and in 75% hypothermia was neither included nor assigned a code in the final diagnosis. The most frequent cause of hypothermia was exposure to cold air alongside ethanol abuse (68%). Peripheral temperature was measured in 57%, core temperature measurement was taken in 29% of the patients. Peripheral temperature was measured most often at the axilla, while core temperature measurement was predominantly taken rectally. Mild hypothermia was diagnosed in 75.5% of the patients, moderate (32-28°C) in 16.5%, while severe hypothermia (less than 28°C) in 8% of the cases. Cardiopulmonary resuscitation was carried out in 7.5% of the patients. The treatment involved mainly warmed intravenous fluids (83.5%) and active external rewarming measures (70%). In no case was extracorporeal rewarming put to use.ConclusionsThe actual incidence of accidental hypothermia in Polish emergency departments may exceed up to four times the official data. Core temperature is taken only in one third of the patients, the treatment of hypothermic patients is rarely conducted in intensive care wards and extracorporeal rewarming techniques are not used. It may be expected that personnel education and the development of management procedures will brighten the prognosis and increase the survival rate in accidental hypothermia.

Hormone modeling in preterm neonates: establishment of pituitary and steroid hormone reference intervals.

Reports suggest significant differences in serum levels of hormones in extremely preterm compared with late preterm and full-term infants. The purpose of this study was to develop reference intervals (RIs) for 3 pituitary hormones and 5 steroid hormones in serum of preterm infants. Blood samples were collected from 248 (128 male and 120 female) preterm neonates born between 24 and 32 weeks' gestation. PARTICIPANTS were recruited from 3 neonatal intensive care wards in Melbourne, Australia. No infant in this cohort had ambiguous genitalia or other endocrine abnormalities. All infants included in the RI determination survived beyond the equivalent of term. Serum was analyzed for prolactin, FSH, and LH by automated electrochemiluminescence immunoassay (Roche Cobas 8000-e601). Liquid chromatography coupled with tandem mass spectrometry was used for analysis of 17-hydroxyprogesterone, androstenedione, cortisol, cortisone, and testosterone. The robust method was applied to define the central 95% RI, after each hormone measure was transformed using a Box-Cox transformation to correct for asymmetry. RIs were established for 8 hormones. Gender-specific intervals were developed for FSH, LH, and testosterone. Cortisone and 17- hydroxyprogesterone required division based on gestational age, with neonates born at <30 weeks' gestation demonstrating higher levels than their older counterparts. Androstenedione, cortisol, and prolactin did not require any division within this cohort for RI assignment. This report provides the first characterization of serum steroids measured by mass spectrometry in preterm neonates, with the additional characterization of 3 pituitary hormones in infants born at ≤32 weeks' gestation. Use of these data allows for correct interpretation of results for very preterm neonates and reduces the risk of incorrect diagnosis due to misinterpretation of data.

Innate immunity gene expression changes in critically ill patients with sepsis and disease-related malnutrition.

The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells).

Innovation of High-risk Infants Follow-up Surveillance System in Iran.

Background:Early childhood development is one of the most social determinants of health that must be notified in order to reducing social gap and inequity. In spite of increasingly developing intensive neonatal care wards and decreasing neonatal mortality rate, there is no follow-up surveillance system to identify high-risk infants (HRI) and their health problems for timely intervention after discharge. This study was carried out to design and pilot high-risk infant follow-ups (HRIFs) surveillance system, in Alzahra Hospital, a tertiary level center of Tabriz University of Medical Sciences (TUOMS), in 2012–2013.Methods:In this qualitative research after studying international documents, consensus about criteria of HRIs accomplished by focus group discussion. Then, Delphi agreement technique was used to finalizing assessment timetable. In the second phase, we piloted the designed surveillance system in Alzahra Hospital, a tertiary level center of TUOMS. Pilot study was implemented by follow-up team organized in designed model at the first phase of the study. Then, the findings of the pilot study were being assessed by an expert panel. If the members agreed on made decisions, they were being placed on the agenda of the national committee of development care of newborns for final approval.Results:High-risk infants follow-up surveillance system was designed in following steps: Defining of evidence-based criteria of HRIs, organizing the follow-up team, regulating the organs and neurodevelopment assessment timetable, publishing a health certificate notebook for HRIs, and designing Access database software for data collection, report and evaluation.Conclusions:We designed and piloted HRIFs surveillance system, so this system was institutionalized in Alzahra Hospital, finally. It can be prepared to apply in the whole country, after detecting the quantitative outcomes and developing the program in East Azarbijan.

Stress and Health: A Comparative Study among Nurses

This survey based descriptive research has been undertaken in Tirunelveli District, Tamil Nadu as a comparative study to identify and differentiate sources of stress and its impact on health of nurses working in four core departments namely intensive care unit, operation theatre, emergency department and ward. Sources of stress have been identified under three dimensions namely physical environment and welfare facilities related stressors, discrimination and harassment related stressors and attitude towards work related stressors. The study has sampled 360 nurses qualified with Diploma in General nursing and Midwifery and Bachelor of Science in nursing courses from 45 general types of private hospitals using a stratified sampling technique. Weighted average method has been applied to analyse sources of stress. Mean, standard deviation and coefficient of variation have been used to understand perception of nurses working in four core departments towards sources of stress. Kruskal-Wallis test has been administered to examine the relationship between sources of stress and demographic variables. Multiple regression models have been used to know relationship between sources of stress and health. The result indicated that all three dimensions of stressors have been perceived at medium level by majority of the nurses. The result also found that among three dimensions of stress or physical environment and welfare facilities related stressors has occupied the first place followed by attitude towards work related stressors and discrimination and sexual harassment related stressors. The study has given suitable suggestions to overcome the stress.

Hospital organizational climates and nurses' intent to stay: differences between units and wards.

To assess variables of hospitals' organizational climates and nurses' intent to stay in intensive care units and wards. Also, this study aims at studying the relationship between hospital organizational climate and nurse intention to stay. A descriptive comparative design was used to collect the data from a convenience sample of 349 nurses who were working in 7 hospitals in Jordan, with a response rate of 70%. Farley's Nursing Practice Environment Scale (NPES) was used to measure hospitals' organizational climates (Farly & Nyberg 1990). McCain's Behavioral Commitment Scale was used to measure nurses' intent to stay (McCloskey 1990). Quality of care and professionalism were the most important variables that influence hospitals' organizational climates. Nurses reported that they will stay at their jobs even if these jobs did not meet their expectations. Based on the total scores, there were no significant differences between intensive care units and wards. Intensive care units and wards were different in nurses' gender, average daily census, and model of nursing care. Nurses were also different in their perceptions about some aspects of administrative support, leadership, and professionalism. Nurses in units differed from those in wards in their decisions to retain their jobs. Hospitals' organizational climates and nurses' intent to stay were significantly correlated for the whole sample and intensive care units but not for wards. Managerial actions should be used by nursing and hospitals' administrators to enhance hospitals' organizational climates and nurses' intent to stay.These interventions include but are not limited to increasing salaries, maintaining supportive relationships between nurses and physicians, sharing nurses in policy-making and administrative decisions, creating quality assurance measures, maintaining open communication and mutual trust between nurse managers and staff, and allowing autonomy about patient care and work environments.

Cost Analysis of Immunotherapy Using Dendritic Cells for Acute Myeloid Leukemia Patients

INTRODUCTIONTreatment for acute myeloid leukemia (AML) presents a significant economic burden to patients, health care insurers and society, and is expected to remain so in the near future. There are few studies describing the costs of AML in the literature. However, the high cost of treating AML and the demographic evolution of the world population, indicate that such studies are needed to support ongoing efforts to allocate resources efficiently in health care. OBJECTIVETo describe and compare the costs of AML therapies daily used at the Antwerp University Hospital in adult patients receiving chemotherapy with/without stem cell transplantation and in patients receiving immunotherapy using dendritic cell vaccination. DESIGN AND METHODSThis monocentric study compares direct hospital medical costs of treatment for AML between 2005 and 2010, allocated and charged according to the hospital analytic accounting system. Information on use of medical resources was collected from electronic medical records. Professional and facility charges associated with inpatient and outpatient management were collected using electronic billing information. Drug costs and drug administration costs were based on list prices published by the Belgian reimbursement authority (RIZIV/INAMI). The cost analysis distinguished between group 1, patients treated with induction and consolidation therapy alone; group 2, patients treated with induction and consolidation therapy plus allogeneic hematopoietic stem cell transplantation (HSCT) and group 3, patients treated with induction and consolidation therapy plus immunotherapy using dendritic cells engineered to express the Wilms’ tumor protein (Van Tendeloo et al. Proc Natl Acad Sci USA. 2010;107(31):13824-9). RESULTS AND DISCUSSION51 adult patients who were treated for newly diagnosed AML were included. Costs on medical and nursing care at the hematology ward, pharmaceutical prescriptions, transfer episodes to the intensive care ward, laboratory tests and medical imaging were analyzed. The cost of dendritic cell vaccine preparation was € 20 450 per patient. The median cost in group 1 (15 patients) was € 32,648 (range: € 4,759 - € 140,383). Only 1 patient in group 1 went into remission after induction therapy and received consolidation therapy. All patients in group 1 died within 5 year after diagnosis, 13 patients died within 1 year and 5 died within 1 month. The median cost in group 2 (26 patients) was € 184,554 (range: € 87,932 - € 449,155). The median post-consolidation treatment cost in group 2 was € 110,430 (range: € 31,364 - € 255,948). Five-year survival in group 2 was 19%. Seventeen patients in group 2 died within 1 year after HSCT. The median cost in group 3 (10 patients) was € 88,635 (range: € 23,392 - € 215,119). The median post-consolidation treatment cost in group 3 was € 40,748 (range: € 26,907- € 156,870). Five-year survival in group 3 was 30%. Four patients in group 3 died within 1 year after vaccination. CONCLUSIONThis study comparing different post-consolidation therapies confirmes the high cost of treating AML and suggests that savings to the healthcare system could be achieved by sustaining complete remission status for longer periods. Dendritic cell vaccination is one of the new therapeutic options to attain a long remission status. DisclosuresNo relevant conflicts of interest to declare.

Cost–utility analysis of treating out of hospital cardiac arrests in Jerusalem

BackgroundOut-of-hospital cardiac arrest (OHCA) initiates a chain of responses including emergency medical service mobilization and medical treatment, transfer and admission first to a hospital Emergency Department (ED) and then usually to an intensive care unit and ward. Costly pre- and in-hospital care may be followed by prolonged post discharge expenditure on treatment of patients with severe neurological sequelae. We assessed the cost-effectiveness of treatment of OHCA by calculating the cost per Disability Adjusted Life Year (DALY) averted. Methods and resultsWe studied 3355 consecutive non-traumatic OHCAs (2005–2010) in Jerusalem, Israel, supplemented by hospital utilization data extracted from patient files (n=570) and post-discharge follow-up (n=196). Demographic, utilization and economic data were incorporated into a spreadsheet model to calculate the cost-utility ratio.Advanced life support was administered to 2264 of the 3355 OHCAs (67.5%) and 1048 (45.6%) patients were transferred to the ED. Of 676 (20.1%) patients who survived the ED and were admitted, there were 206 (6.1%) survivors to discharge, among them only 113 (3.4%) neurologically intact. Total cost ($39,100,000) per DALY averted (1353) was $28,864. ConclusionsThe current package of OHCA interventions in Jerusalem appears to be very cost-effective as the cost per averted DALY of $28,864 is less than the Gross Domestic Product per capita ($33,261). This paper provides a basis for studying the effects of potential interventions that can be evaluated in terms of their incremental costs per averted DALY for treatment of OHCA.

Cuidado de enfermería para la familia del paciente crítico desde la teoría de la comprensión facilitada

Introduction: The admission of a loved one into an intensive care ward is a very tense, traumatic, and disagreeable experience for the family, and is associated with a challenge to near death situations, suffering, role rupture and even ignorance. Within this context, nursing interventions, in order that the family may have a better understanding of the situation and what they should do. They should also promote the feelings of tranquility, security, comfort, and favor the adaptation, thus preventing adverse psychological results. Objective: To design a management proposal which, based on this theory, could allow giving care of quality and excellence to the families of patients in critical status. Methodology: Analysis and establishment of the facilitated sensemaking theory from the perspective of the Theoretical-Empirical-Conceptual system, and the logical frame model. Results: A nursing care plan is presented which, formulated from the facilitated sensemaking theory and the NANDA, NIC, NOC taxonomies, shows issues related to the assessment, results, and interventions in four priority evaluations of the possible more frequent situations which the family must face when a loved one is in a critical health status. Conclusion: A standardized care plan based on the facilitated sensemaking theory is a strategy to implement nursing knowledge that: 1) consolidates an integral care model which favors the visibility, continuity, efficiency, and excellence of care; 2) reduces the hostility experience by the patient’s family from the intensive care situation.

Postoperatives Röntgenbild: Immer notwendig?

Following surgical procedures in thoracic surgery a chest X-ray is routinely performed and its necessity is rarely questioned. However, there are differences in the time frame of such radiological procedures. Especially after minor procedures such as mediastinoscopy there is a wide variation from a chest X-ray immediately after surgical intervention to an image only on the following day. Also, in some hospitals patients undergo only clinical but no radiological examination. No recommendations are available in the literature. Following video-mediastinoscopy with good visualisation of all structures it appeared that a chest X-ray could be waived. 95 consecutive patients were prospectively randomised into two groups, either receiving chest X-ray four hours postoperatively or no chest X-ray. All patients were clinically examined on the evening of the day of mediastinoscopy. 48 % of the patients had a chest X-ray, 52 % did not and underwent only clinical examination. No surgical revision was necessary in either group, no difference in therapeutic consequences was noted. As a result we discontinued chest X-rays after mediastinoscopy. There are only sparse data concerning postoperative chest X-rays in thoracic surgery patients. In a study on children and young adults undergoing a Nuss procedure routine radiological examination was substituted by clinical indication resulting in a lower rate of thoracic drain placement. A chest X-ray to document the location of the metal bar prior to discharge was felt to be sufficient. In patients undergoing cardiac procedures daily routine chest X-rays on the intensive care ward were replaced by on-demand X-ray in a study without any change in length of stay, readmission or mortality. The same was found for chest X-rays following drain removal in cardiac patients: routine radiological examination seems not to be indicated. As a consequence of our own observational study on mediastinoscopy we have discontinued postoperative X-ray as the patients are examined clinically. All other patients undergoing thoracic surgery procedures who are observed in the intensive care unit receive the first chest X-ray in the morning following surgery. Only if complete expansion of the lung is warranted (pleurodesis, pneumothorax) an X-ray is performed on the day of surgery.