Days In Medical Intensive Care Unit Research Articles

Admission and Discharge Sampling Underestimates Multidrug-Resistant Organism (MDRO) Acquisition in an Intensive Care Unit

Background: Identification of hospitalized patients with enteric multidrug-resistant organism (MDRO) carriage, combined with implementation of targeted infection control interventions, may help reduce MDRO transmission. However, the optimal surveillance approach has not been defined. We sought to determine whether daily serial rectal surveillance for MDROs detects more incident cases (acquisition) of MDRO colonization in medical intensive care unit (MICU) patients than admission and discharge surveillance alone. Methods: Prospective longitudinal observational single-center study from January 11, 2017, to January 11, 2018. Inclusion criteria were ≥3 consecutive MICU days and ≥2 rectal or stool swabs per MICU admission. Daily rectal or stool swabs were collected from patients and cultured for MDROs, including vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacterales (CRE), third-generation cephalosporin-resistant Enterobacterales (3GCR), and extended-spectrum β-lactamase–producing Enterobacterales (ESBL-E) (as a subset of 3GCR). MDRO detection at any time during the MICU stay was used to calculate prevalent colonization. Incident colonization (acquisition) was defined as new detection of an MDRO after at least 1 prior negative swab. We then determined the proportion of prevalent and incident cases detected by daily testing that were also detected when only first swabs (admission) and last swabs (discharge) were tested. Data were analyzed using SAS version 9.4 software. Results: In total, 939 MICU stays of 842 patients were analyzed. Patient characteristics were median age 64 years (interquartile range [IQR], 51–74), median MICU length of stay 5 days (IQR, 3–8), median number of samples per admission 3 (IQR, 2–5), and median Charlson index 4 (IQR, 2–7). Prevalent colonization with any MDRO was detected by daily swabbing in 401 stays (42.7%). Compared to daily serial swabbing, an admission- and discharge-only approach detected ≥86% of MDRO cases (ie, overall prevalent MDRO colonization). Detection of incident MDRO colonization by an admission- or discharge-only approach would have detected fewer cases than daily swabbing (Figure 1); ≥34% of total MDRO acquisitions would have been missed. Conclusions: Testing patients upon admission and discharge to an MICU may fail to detect MDRO acquisition in more than one-third of patients, thereby reducing the effectiveness of MDRO control programs that are targeted against known MDRO carriers. The poor performance of a single discharge swab may be due to intermittent or low-level MDRO shedding, inadequate sampling, or transient MDRO colonization. Additional research is needed to determine the optimal surveillance approach of enteric MDRO carriage.Funding: NoDisclosures: None

Patterns of Admission and Clinical Outcomes Among Patients Admitted to Medical Intensive Care Unit of a Teaching and Referral Hospital, Northwest Ethiopia.

BackgroundThe intensive care unit (ICU) is a health care delivery service for patients who are in critical condition with potentially recoverable diseases. Patients can benefit from more detailed observation, monitoring and advanced treatment than other wards or department. The care is advancing but in resource-limited settings, it is lagging far behind and mortality is still higher due to various reasons. Therefore, we aimed to determine the admission patterns, clinical outcomes and associated factors among patients admitted medical intensive care unit (MICU).MethodsA retrospective cross-sectional study was conducted based on a record review of logbook and charts of patients admitted from September, 2015 to April, 2019. Data were entered and analysed using SPSS version 20. Both bivariate and multivariate logistic regression analyses were used and a P-value < 0.05 was considered statistically significant.ResultsA total of 738 patients were admitted to medical intensive care unit (MICU) during September, 2015 - April, 2019. Five hundred and four patients (68%) of all intensive care unit (ICU) admissions had complete data. Out of the 504 patients, 268 (53.2%) patients were females. Cardiovascular disease 182(36.1%) was the commonest categorical admission diagnosis. The overall mortality rate was 38.7%. In the multivariate analysis, mortality was associated with need for mechanical ventilation (AOR = 5.87, 95% CI: 3.24 - 10.65) and abnormal mental status at admission (AOR = 2.8, 95% CI: 1.83-4.29). Patients who had stay less than four days in MICU were 5 times more likely to die than those who has stay longer time (AOR= 5.58, 95% CI: 3.58- 8.69).ConclusionsThe overall mortality was considerably high and cardiovascular diseases were the most common cause of admission in MICU. Need for mechanical ventilator, length of intensive care unit stay and mental status at admission were strongly associated with clinical outcome of patients admitted to medical intensive care unit.

Assessment of Potential Drug-Drug Interactions and its Associated Factors in Medical Intensive Care Unit of a Tertiary Care Hospital in Nepal

Drug interaction may cause an increase in the toxicity of a drug, increases the likelihood of adverse drug reactions, or cause a reduction in the efficacy of particular drug therapy, which may worsen the patient’s condition directly or indirectly. This study aims to assess the potential drug-drug interactions (pDDIs) and their associated factors in the Medical Intensive Care Unit (MICU). We carried out a descriptive retrospective study based on the hospital records of 100 MICU patients. Micromedex Interaction application, designed by Truven Health Analytics Inc., was used to screen prescribed medications. We found 219 drug interactions out of 856 drugs prescribed. The average number of drug interactions per patient was 2.19. The frequency of drugs prescribed, the number of days in MICU, and age had a positive correlation with the occurrence of pDDIs. There were 44.7% major pDDIs; pharmacodynamic being the commonest mechanism for it. Most patients in MICU were at the risk of developing pDDIs. A substantial number of interactions had a major severity. Therefore, there is a need for active surveillance for pDDIs to prevent patient harm during particular drug therapy.

Restoration of resident sleep and wellness with block scheduling.

Block scheduling during residency is an innovative model in which in-patient and ambulatory rotations are separated. We hypothesised that this format may have a positive impact on resident sleep and wellness in comparison with a traditional format. We performed a single-centre, cross-sectional, observational study of residents rotating in the medical intensive care unit (MICU). Residents were observed for 4weeks at a time: internal medicine (IM) residents were observed for 3weeks in the MICU followed by 1week in an ambulatory context, and non-IM residents were observed for 4weeks in the MICU. We monitored daily total sleep time (TST) utilising actigraphy, and wellness measures with weekly Epworth Sleepiness Scale (ESS) and Perceived Stress Scale (PSS) questionnaires. A total of 64 of 110 (58%) eligible residents participated; data for 49 of 110 (45%) were included in the final analysis. Mean±standard deviation (SD) daily TST in the entire cohort was 6.53±0.78hours. Residents slept significantly longer during the ambulatory block than during the MICU block (mean±SD TST 6.97±1.00hours and 6.43±0.78hours, respectively; p<0.0005). Sleep duration during night call was significantly shorter than during day shift (mean±SD TST 6.07±1.16hours and 6.50±0.73hours, respectively; p<0.0005). A total of 390 of 490 (80%) ESS and PSS questionnaires were completed; scores significantly declined during rotations in the MICU. Internal medicine residents showed significant improvements in TST, and in ESS and PSS scores (p<0.05) at the end of the ambulatory week. Non-IM residents, who remained in the MICU for a fourth week, continued a trend that showed a decline in perceived wellness. Despite duty hour restrictions, residents obtain inadequate sleep. As MICU days accumulate, measures of resident wellness decline. Residents in a block schedule experienced improvements in all measured parameters during the ambulatory week, whereas residents in a traditional schedule continued a downward trend. Block scheduling may have the previously unrecognised benefits of repaying sleep debt, correcting circadian misalignment and improving wellness.

Applying the New Institute for Healthcare Improvement Inpatient Waste Tool to Identify "Waste" in the Intensive Care Unit.

Healthcare waste-the inappropriate use of healthcare resources that provides no benefit to patients yet contributes to cost and even harm-is a potentially significant contributor to high healthcare costs. This project aimed to apply a new locally modified Institute for Healthcare Improvement (IHI)-developed waste identification tool to measure the prevalence of and reason for the inappropriate use of intensive care unit (ICU) beds, one type of potential waste. Unnecessary days (i.e., waste) and their causes in a 16-bed "closed" medical ICU (MICU) and a 10-bed "semi-closed" transplant surgical ICU (TSICU) were identified by physicians over a 3-month period. Data on 513 patients admitted to both ICUs for a total of 1,631 patient-days demonstrated that 15% of MICU days and 25.8% of TSICU days were unnecessary. Although causes of waste in each ICU differed, delays in transfer of patients out of the ICU, end-of-life decision-making, and delays in procedures were among the commonest. Determination of waste also varied among physicians, ranging from 4.5% to 27.7% in the MICU and 0%-37.5% in the TSICU. This study found that the IHI waste tool can be effectively used to identify waste in the ICU, which is common and varies based on the ICU type and physician perceptions.

Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit

ObjectiveFemoral catheters pose a potential barrier to early rehabilitation in the intensive care unit (ICU) due to concerns, such as catheter removal, local trauma, bleeding, and infection. We prospectively evaluated the feasibility and safety of physical therapy (PT) in ICU patients with femoral catheters. Design, Setting, and PatientsWe evaluated consecutive medical ICU patients who received PT with a femoral venous, arterial, or hemodialysis catheter(s) in situ. Measurements and Main ResultsOf 1074 consecutive patients, 239 (22%) received a femoral catheter (81% venous, 29% arterial, 6% hemodialysis; some patients had >1 catheter). Of those, 101 (42%) received PT interventions, while the catheter was in situ, for a total of 253 sessions over 210 medical ICU (MICU) days. On these 210 MICU days, the highest daily activity level achieved was 49 (23%) standing or walking, 57 (27%) sitting, 25 (12%) supine cycle ergometry, and 79 (38%) in-bed exercises. During 253 PT sessions, there were no catheter-related adverse events giving a 0% event rate (95% upper confidence limit of 2.1% for venous catheters). ConclusionsPhysical therapy interventions in MICU patients with in situ femoral catheters appear to be feasible and safe. The presence of a femoral catheter should not automatically restrict ICU patients to bed rest.

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Introduction: Antipsychotics may accelerate delirium resolution. Hypothesis: Among medical intensive care unit (MICU) patients, our objectives were to: (1) describe the prevalence of delirium and use of antipsychotic medications, and (2) assess the delirium duration among patients treated with haloperidol, atypicals, combination of haloperidol and atypicals, or no antipsychotic medications. Methods: This retrospective cohort study included adult patients admitted to Johns Hopkins MICU for >= 48 hours (January-June 2011). Repeat admissions during the study period and patients receiving outpatient antipsychotics were excluded. Delirium was evaluated using twice-daily Confusion Assessment Method for the ICU (CAM-ICU) performed by trained ICU nurses. Descriptive statistics were used to analyze data. Results: Of 309 eligible patients, 279 met inclusion criteria; 169 (61%) patients, with 1434 MICU days, were CAM-ICU positive at least once. On 811 (57%) of the 1434 days, patients were CAM-ICU positive. 31% (53/169) of CAM-ICU positive patients received antipsychotics: 28 received haloperidol, 9 atypical antipsychotic, 16 both. The median time from first CAM-ICU positive to anti-psychotic drug administration was 2 day (IQR 1-5 days). The median number of days of delirium was shortest in patients who received no antipsychotic (n=116, 3 days [IQR 1-5]; 65% of MICU days); similar among patients who received haloperidol or atypicals (n=28, 5.5 [IQR 3.5-9.5] vs n=9, 6 days [IQR 4-11]; 86% vs 77%, respectively); and longer in patients who received both haloperidol and atypicals (n=16, 11.5 days [IQR 6-21]; 89%). Of the 116 CAM-ICU positive patients who received no antipsychotic medication, 53% had a prolonged QTc. Conclusions: In conclusion, most MICU patients experienced delirium that lasted for >50% of their MICU stay and most did not receive any antipsychotic. Among those receiving an antipsychotic, haloperidol was most common. The use of antipsychotic agents may have been limited by QTc prolongation.

Implementing a Collaborative Protocol in a Sepsis Intervention Program: Lessons Learned

The objective of this prospective cohort study was to see the effect of the implementation of a Sepsis Intervention Program on the standard processes of patient care using a collaborative approach between the Emergency Department (ED) and Medical Intensive Care Unit (MICU). This was performed in a large urban tertiary-care hospital, with no previous experience utilizing a specific intervention program as routine care for septic shock and which has services and resources commonly available in most hospitals. The study included 106 patients who presented to the ED with severe sepsis or septic shock. Eighty-seven of those patients met the inclusion criteria for complete data analysis. The ED and MICU staff underwent a 3-month training period followed by implementation of a protocol for sepsis intervention program over 6months. In the first 6months of the program's implementation, 106 patients were admitted to the ED with severe sepsis and septic shock. During this time, the ED attempted to initiate the sepsis intervention protocol in 76% of the 87 septic patients who met the inclusion criteria. This was assessed by documentation of a central venous catheter insertion for continuous SvO(2) monitoring in a patient with sepsis or septic shock. However, only 48% of the eligible patients completed the early goal-directed therapy (EGDT) protocol. Our data showed that the in-hospital mortality rate was 30.5% for the 87 septic shock patients with a mean APACHE II score of 29. This was very similar to a landmark study of EGDT (30.5% mortality with mean APACHE II of 21.5). Data collected on processes of care showed improvements in time to fluid administration, central venous access insertion, antibiotic administration, vasopressor administration, and time to MICU transfer from ED arrival in our patients enrolled in the protocol versus those who were not. Further review of our performance data showed that processes of care improved steadily the longer the protocol was in effect, although this was not statistically significant. There was no improvement in secondary outcomes, including total length of hospital stay, MICU days, and mortality. Implementation of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care. However, despite a collaborative approach, the sepsis intervention program was underutilized with only 48% of the patients completing the sepsis intervention protocol.

Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model

Objective: There are barriers to providing early physical medicine and rehabilitation (PM&R) in the intensive care unit (ICU). We present a specific model for undertaking quality improvement (QI) projects and a case study focused on QI for early PM&R in the ICU. Methods: The QI project was undertaken using a 4-step model: (1) summarizing the evidence, (2) identifying barriers, (3) establishing performance measures, and (4) ensuring patients receive the intervention. To evaluate the application and outcomes of this model, we present data collected during a 4-month QI period versus an immediately preceding 3-month control period. Results: Deep sedation was a major barrier to early PM&R that was addressed in the QI project. Compared to the control period, there was a decrease in medical ICU (MICU) days with any benzodiazepine use (73% vs 96% of days, P = .03) and narcotic use (77% vs 96%, P = .05) and improved delirium status (MICU days without delirium, 53% vs 21%, P = .003). In addition, more QI patients had physical therapy consultations (93% vs 59%, P = .004) and greater number of rehabilitation treatments with higher functional mobility (treatments involving sitting or greater mobility, 78% vs 56%, P = .03). Hospital data for the QI period demonstrated a decrease in average length of stay in the MICU (4.9 vs 7.0 days, P = .02) and hospital (14.1 vs 17.2, P = .03) compared to the prior year. Conclusion: A structured QI model can be applied to implementation of early PM&R in the ICU resulting in markedly improved delirium status, delivery of PM&R, functional mobility, and length of stay.

Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Objectives To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay. Design Seven-month prospective before/after quality improvement project. Setting Sixteen-bed medical intensive care unit (MICU) in academic hospital. Participants 57 patients mechanically ventilated 4 days or longer. Intervention A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines. Main Outcome Measures Sedation and delirium status, rehabilitation treatments, functional mobility. Results Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15mg midazolam equivalents [ P=.09] and 71 vs 24 mg morphine equivalents [ P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4–3.8) and 3.1 (0.3–5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year. Conclusions Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

Cost Savings From Reduced Catheter-Related Bloodstream Infection After Simulation-Based Education for Residents in a Medical Intensive Care Unit

Interventions to reduce preventable complications such as catheter-related bloodstream infections (CRBSI) can also decrease hospital costs. However, little is known about the cost-effectiveness of simulation-based education. The aim of this study was to estimate hospital cost savings related to a reduction in CRBSI after simulation training for residents. This was an intervention evaluation study estimating cost savings related to a simulation-based intervention in central venous catheter (CVC) insertion in the Medical Intensive Care Unit (MICU) at an urban teaching hospital. After residents completed a simulation-based mastery learning program in CVC insertion, CRBSI rates declined sharply. Case-control and regression analysis methods were used to estimate savings by comparing CRBSI rates in the year before and after the intervention. Annual savings from reduced CRBSIs were compared with the annual cost of simulation training. Approximately 9.95 CRBSIs were prevented among MICU patients with CVCs in the year after the intervention. Incremental costs attributed to each CRBSI were approximately $82,000 in 2008 dollars and 14 additional hospital days (including 12 MICU days). The annual cost of the simulation-based education was approximately $112,000. Net annual savings were thus greater than $700,000, a 7 to 1 rate of return on the simulation training intervention. A simulation-based educational intervention in CVC insertion was highly cost-effective. These results suggest that investment in simulation training can produce significant medical care cost savings.

Rehabilitation therapy and outcomes in acute respiratory failure: An observational pilot project

Purpose The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation. Materials and Methods Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted. Results Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge. Conclusions This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.

S.19.03 The cortical gene expression profile as a phenotype in genetic association

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay.Seven-month prospective before/after quality improvement project.Sixteen-bed medical intensive care unit (MICU) in academic hospital.57 patients mechanically ventilated 4 days or longer.A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.Sedation and delirium status, rehabilitation treatments, functional mobility.Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4–3.8) and 3.1 (0.3–5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

Evaluation of Clinical Practice Guidelines on Outcome of Infection in Medical Intensive Care Unit Patients

All patients in a 20-bed medical intensive care unit (ICU) were prospectively followed for a 3-month period (phase I,158 patients/1248 patient days) to collect baseline data before implementation of practice guidelines for infection management and were compared with all patients in the same unit during a 4-month period after guideline implementation (phase II, 180 patients/972 patient days). Total infections in phase I vs. phase II, respectively, were the following: lower respiratory tract infection (LRTI), 87 (55%) vs. 94 (52%); urinary tract infection (UTI), 35 (22%) vs. 41 (23%); and sepsis of undetermined etiology, 25 (16%) vs. 29 (16%). There were no significant differences in death (23% vs. 20%), cure or improvement of infection (54% vs. 57%), readmission to the unit (3.6% vs. 3.4%), hospital risk of death (mean, 29.7 vs. 30.3), predicted length of ICU stay (mean, 6.09 days vs. 5.93 days) in phases I and II, respectively. APACHE III score (mean, 64.6 vs. 59.4; P = not significant) and length of ICU stay were higher (mean, 7.9 days vs. 5.4 days; P<.001) in phase I vs. phase II. Rates for nosocomial infection in phase I vs. II (per 1000 patient medical ICU days) were the following: LRTI, 6.4 vs. 5.1; UTI, 4.0 vs. 4.1; soft tissue infection, 0.8 vs. 0; bacteremia, 0.8 vs. 2.0; and intravenous catheter infection, 0.8 vs. 1.0 (P = not significant). Costs of antibiotic acquisition were $548.0 per patient in phase I and $372.9 per patient in phase II (P <.001). Compliance with guideline recommendations was 84%. There were trends toward an increase in the susceptibility of Pseudomonas aeruginosa to ceftazidime (82% to 95% susceptible; P =.18) and imipenem (91 % to 100% susceptible; P=.17) and of Enterobacter species (P=.04) to ceftazidime. In medical ICU patients in whom guidelines for management of infections were used, antibiotic costs and bacterial resistance both decreased without adversely affecting patient outcomes. This study has important implications for the management of infections in ICU patients.