Medical-surgical Intensive Care Unit Research Articles

A Multifaceted Intervention to Improve Compliance With Process Measures for ICU Clinician Communication With ICU Patients and Families*

Despite recommendations supporting the importance of clinician-family communication in the ICU, this communication is often rated as suboptimal in frequency and quality. We employed a multifaceted behavioral-change intervention to improve communication between families and clinicians in a statewide collaboration of ICUs. Our primary objective was to examine whether the intervention resulted in increased compliance with process measures that targeted clinician-family communication. As secondary objectives, we examined the ICU-level characteristics that might be associated with increased compliance (open vs closed, teaching vs nonteaching, and medical vs medical-surgical vs surgical) and patient-specific outcomes (mortality, length of stay). The intervention was a multifaceted quality improvement approach targeting process measures adapted from the Institute of Health Improvement and combined into two "bundles" to be completed either 24 or 72 hours after ICU admission. Significant increases were seen in full compliance for both day 1 and day 3 process measures. Day 1 compliance improved from 10.7% to 83.8% after 21 months of intervention (p<0.001). Day 3 compliance improved from 1.6% to 28.8% (p<0.001). Improvements in compliance varied across ICU type with less improvement in open, nonteaching, and mixed medical-surgical ICUs. Patient-specific outcome measures were unchanged, although there was a small increase in patients discharged from ICU to inpatient hospice (p=0.002). We found that a multifaceted intervention in a statewide ICU collaborative improved compliance with specific process measures targeting communication with family members. The effect of the intervention varied by ICU type.

Renal failure as a risk factor for venous thromboembolism in critically Ill patients: A cohort study

The relationship between kidney function and venous thromboembolism (VTE) in critically ill patients is not well studied. The main objective of this study was to evaluate this relationship in patients admitted to a medical-surgical intensive care unit (ICU). This was a retrospective study of 798 patients admitted to a tertiary-care ICU and prospectively followed for the development of clinically suspected and radiologically diagnosed deep venous thrombosis or pulmonary embolism. Patients were divided based on admission creatinine and dialysis history into five groups: normal kidney function, RIFLE classes R, I and F (combined=acute kidney injury [AKI]) and endstage renal disease (ESRD). We compared VTE prophylaxis practices and VTE incidence in these groups and evaluated renal failure as a VTE risk factor using multivariate Cox regression analysis. Of the 798 patients, 27.2% had AKI and 10.1% had ESRD. Unfractionated heparin use was similar in the five groups but enoxaparin use was less frequent in AKI (13.4%) and ESRD (3.8%) patients compared with patients with normal kidney function (39.0%). VTE occurred in 7.6% of patients with normal renal function, 7.8% AKI patients and 2.5% ESRD patients (p=0.22). The adjusted hazard ratios for VTE compared to patients with normal kidney function were 0.35 (95% confidence interval [CI], 0.08-1.47) for RIFLE class R, 1.19 (95% CI, 0.83-1.70) for RIFLE class I, 0.82 (95% CI, 0.59-1.14) for RIFLE class F and 0.71 (95% CI, 0.49-1.02, p=0.06) for ESRD. Neither AKI nor ESRD was an independent risk factors for critically ill patients.

A pilot investigation of the association of genetic polymorphisms regulating corticotrophin-releasing hormone with posttraumatic stress and depressive symptoms in medical-surgical intensive care unit survivors

PurposeTo determine if single nucleotide polymorphisms of the corticotrophin-releasing hormone binding protein (CRHBP, rs10055255) and CRH receptor type 1 (CRHR1, rs1876831) were associated with posttraumatic stress disorder (PTSD) and depressive symptoms following medical-surgical intensive care unit (ICU) hospitalization. Materials and MethodsWe extracted DNA for genotyping from saliva samples of 93 ICU patients enrolled in a prospective cohort investigation. Follow-up interviews conducted 3 and 12-months post-ICU included assessment of PTSD symptoms with the PTSD Checklist-Civilian Version and depressive symptoms with the Patient Health Questionnaire–9. ResultsHomozygosity for the CRHBP rs10055255 T allele was associated with significantly fewer post-ICU PTSD (β = −10.8, 95% confidence interval [95% CI], −17.7 to −3.9; P = .002) and depressive symptoms (β = −3.7, 95% CI, −6.7 to −0.7; P = .02). Carrying a CRHR1 rs1876831 C allele was associated with significantly more post-ICU depressive symptoms compared to T/T homozygotes (C/T heterozygtes: β = 6.9, 95% CI, 1.2-12.6; P = .02; C/C homozygotes: β = 5.8; 95% CI: 0.2-11.3; P = .04). These associations remained significant after adjustment for age, race, illness severity, and in-ICU steroid exposure. ConclusionsDespite a small sample size, our findings suggest a potential role for genetic variants of CRHBP and CRHR1 in the development of post-ICU psychiatric morbidity.

Implementation of a protocol for integrated management of pain, agitation, and delirium can improve clinical outcomes in the intensive care unit: A randomized clinical trial

BackgroundInappropriate diagnosis and treatment of pain, agitation, and delirium (PAD) in intensive care settings results in poor patient outcomes. We designed and used a protocol for systematic assessment and management of PAD by the nurses to improve clinical intensive care unit (ICU) outcomes. Materials and MethodsA total of 201 patients admitted to 2 mixed medical-surgical ICUs were randomly allocated to protocol and control groups. A multidisciplinary team approved the protocol. Pain was assessed by Numerical Rating Scale and Behavioural Pain Scale, agitation by Richmond Agitation Sedation Scale, and delirium by Confusion Assessment Method in ICU. The Persian version of the scales was prepared and tested for validity, reliability, and feasibility in a preliminary study. The patients in the protocol group were managed pharmacologically according to the protocol, whereas those in the control group were managed according to the ICU routine. ResultsThe median (interquartile range) for the duration of mechanical ventilation in the protocol and control groups was 19 (9.3-67.8) and 40 (0-217) hours, respectively (P = .038). The median (interquartile range) length of ICU stay was 97 (54.5-189) hours in the protocol group vs 170 (80-408) hours in the control group (P < .001). The mortality rate in the protocol group was significantly reduced from 23.8% to 12.5% (P = .046). ConclusionThe current randomized trial provided evidence for a substantial reduction in the duration of need to ventilatory support, length of ICU stay, and mortality rates in ICU-admitted patients through protocol-directed management of PAD.

Heparin Thromboprophylaxis in Medical-Surgical Critically Ill Patients

Venous thromboembolism prevention during critical illness is a widely used quality metric. The objective of this systematic review was to systematically review the efficacy and safety of heparin thromboprophylaxis in medical-surgical patients in the ICU. We searched EMBASE, MEDLINE, the Cochrane Controlled Trials Register, Clinicaltrials.gov, and personal files through May 2012. Randomized trials in adult medical-surgical ICU patients comparing any heparin (unfractionated heparin or low-molecular-weight heparin) with each other or no anticoagulant prophylaxis, evaluating deep vein thrombosis, pulmonary embolism, major bleeding, or mortality. Independently, in duplicate, we abstracted trial characteristics, outcomes, and risk of bias. Seven trials involved 7,226 patients. Any heparin thromboprophylaxis compared with placebo reduced rates of deep vein thrombosis (pooled risk ratio, 0.51 [95% CI, 0.41, 0.63]; p<0.0001; I=77%) and pulmonary embolism (risk ratio, 0.52 [95% CI, 0.28, 0.97]; p=0.04; I=0%) but not symptomatic deep vein thrombosis (risk ratio, 0.86 [95% CI, 0.59, 1.25]; p=0.43). Major bleeding (risk ratio, 0.82 [95% CI, 0.56, 1.21]; p=0.32; I=50%) and mortality (risk ratio, 0.89 [95% CI, 0.78, 1.02]; p=0.09; I=0%) rates were similar. Compared with unfractionated heparin, low-molecular-weight heparin reduced rates of pulmonary embolism (risk ratio, 0.62 [95% CI, 0.39, 1.00]; p=0.05; I=53%) and symptomatic pulmonary embolism (risk ratio, 0.58 [95% CI, 0.34, 0.97]; p=0.04) but not deep vein thrombosis (risk ratio, 0.90 [95% CI, 0.74, 1.08]; p=0.26; I=0%), symptomatic deep vein thrombosis (risk ratio, 0.87 [95% CI, 0.60, 1.25]; p=0.44; I=0%), major bleeding (risk ratio, 0.97 [95% CI, 0.75, 1.26]; p=0.83; I=0%), or mortality (risk ratio, 0.93 [95% CI, 0.82, 1.04]; p=0.20; I=31%). Trial evidence to date suggests that any type of heparin thromboprophylaxis decreases deep vein thrombosis and pulmonary embolism in medical-surgical critically ill patients, and low-molecular-weight heparin compared with bid unfractionated heparin decreases pulmonary embolism and symptomatic pulmonary embolism. Major bleeding and mortality rates do not appear to be significantly influenced by heparin thromboprophylaxis in the ICU setting. Trial methodology, indirectness, and the heterogeneity and imprecision of some results temper inferences from this literature.

A survey of the attitudes and perceptions of multidisciplinary team members towards family presence at bedside rounds in the intensive care unit

To describe the attitudes and perceptions of intensive care unit (ICU) staff [critical care physicians and fellows (MDs), registered nurses (RNs), allied health discipline (HD) and managers] towards family presence at bedside rounds. We developed, tested and administered a questionnaire to the multidisciplinary staff. 24-Bed medical surgical ICU. 160/221 (72.4%) individuals responded, including 12 MDs, 95 RNs, 48 HD personnel, 4 managers and 1 unspecified. While most MDs strongly agreed and HD and management groups somewhat agreed, most RNs strongly disagreed with providing family members the option to attend rounds. Over 50% of respondents either strongly or somewhat agreed that the presence of family members prolongs rounds, reduces the medical education provided to the team and constrains delivery of negative medical information. Compared to MDs, RNs expressed greater reservation to family presence at rounds. Among RNs, more experienced RNs, expressed greater reservation with family presence during rounds. We found significant differences among the attitudes of health care providers towards family presence at bedside rounds with RNs, especially more experienced RNs, expressing the greatest reservation. Qualitative research is required to explore perceived and actual barriers to family member presence at rounds.

Cigarette smoking and risk of pressure ulcer in adult intensive care unit patients.

The objective of this study was to assess relationship between smoking, some other risk factors and ulcers development in intensive care unit. This prospective cohort study was performed in two university-affiliated hospitals. The sample consisted of adult male patients who were admitted to medical-surgical intensive care units. All eligible patients were grouped according to their cigarette smoking status as smoker and non-smoker. The final sample included 160 smokers and 192 non-smokers. Pressure ulcer occurred in 62 smoker patients and 28 of non-smoker who showed significant difference. Also number of pack-year of cigarettes smoking showed significant association with ulcer development. Ulcer stage was significantly different between the two groups. Besides of smoking, age, length of stay, faecal incontinency, diabetes mellitus, anaemia and trauma were significantly associated with pressure ulcers. Our study showed significant association between smoking and development of pressure ulcers.

Efficacy of Topical Atorvastatin for the Treatment of Pressure Ulcers: A Randomized Clinical Trial

To evaluate the effects of topical atorvastatin on the healing process of pressure ulcers in critically ill patients. Randomized, double-blind, placebo-controlled clinical trial. Medical-surgical intensive care unit of a university-affiliated teaching hospital in Tehran, Iran. One hundred four patients with stage I or II pressure ulcers, graded according to the 2-digit Stirling Pressure Sore Severity Scale. Patients were randomized to receive topical atorvastatin 1% ointment (51 patients [atorvastatin group]) or placebo ointment (53 patients [control group]) applied once/day to pressure ulcers for 14 days in addition to standard care for pressure ulcers. The efficacy of each treatment was assessed on days 7 and 14. Efficacy was determined based on the degree of healing of the existing pressure ulcer by using the 2-digit Stirling scale. The baseline stage of the pressure ulcers did not differ significantly between the control and atorvastatin groups. However, the mean ± SD stage of pressure ulcers significantly decreased in the atorvastatin group compared with the control group on day 7 (0.97 ± 0.76 vs 1.74 ± 0.75, p<0.01) and day 14 (0.42 ± 0.67 vs 1.71 ± 0.78, p<0.01) of treatment. In addition, the mean ± SD surface areas of ulcers in the atorvastatin group were significantly declined compared with the control group after 7 days (5.55 ± 4.55 vs 9.41 ± 5.03 cm², p<0.01) and 14 days (3.72 ± 4.45 vs 10.41 ± 6.41 cm², p<0.01) of treatment. Topical application of atorvastatin ointment 1% for 14 days in addition to standard care significantly accelerated the healing of stage I or II pressure ulcers in critically ill patients.

Demographics and outcomes of critically ill patients transferred from other hospitals to a tertiary care academic referral center in Saudi Arabia

BackgroundThe objective of this study was to examine the outcomes of critically ill patients who were transferred from other hospitals to a tertiary care center in Saudi Arabia as a quality improvement project.MethodsThis was a retrospective study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care hospital. Patients were divided according to the source of referral into three groups: transfers from other hospitals, and direct admissions from emergency department (ED) and from hospital wards. Standardized mortality ratio (SMR) was calculated. Multivariate analysis was performed to determine the independent predictors of mortality.ResultsOf the 7,654 patients admitted to the ICU, 611 patients (8%) were transferred from other hospitals, 2,703 (35.3%) were direct admissions from ED and 4,340 (56.7%) from hospital wards. Hospital mortality for patients transferred from other hospitals was not significantly different from those who were directly admitted from ED (35% vs. 33.1%, p = 0.37) but was lower than those who were directly admitted from hospital wards (35% vs. 51.2%, p < 0.0001). SMRs did not differ significantly across the three groups.ConclusionsCritically ill patients who were transferred from other hospitals constituted 8% of all ICU admissions. Mortality of these patients was similar to patients with direct admission from the ED and lower than that of patients with direct admission from hospital wards. However, risk-adjusted mortality was not different from the other two groups.

Oral and intravenous thyroxine (T4) achieve comparable serum levels for hormonal resuscitation protocol in organ donors: a randomized double-blinded study

Thyroxine (T4) administration is advocated in the management of organ donors; however, the bioavailability of oral thyroxine is unknown in this patient population. The primary objective of this study was to compare the percentage of the study time (from study drug administration to organ procurement) that patients in the oral vs the intravenous group required inotropic support. Secondary objectives included plasma levels of T3 and T4 and number of organs donated following oral vs intravenous T4 administration. Randomized double-blinded study. Adult medical-surgical intensive care unit. Thirty-two adult solid organ donors. Patients were randomized to receive either an oral or intravenous dose of T4 (2 μg·kg⁻¹). All patients received an oral and intravenous study drug preparation, one of which was a placebo. The study was double-blinded, and randomization occurred in blocks of four and six. The number and duration of inotropic/vasopressor therapies and free serum levels of T3 and T4 were determined hourly until procurement. Following T4 administration, all patients remained on inotropic/vasopressor therapy for the same mean (SD) duration [93 (3)%] of the study period. There was a similar and gradual decrease in the number and dosages of inotropes/vasopressors required in both groups. There was no difference in T3 or T4 levels between groups. Oral bioavailability of T4 was 93% of the intravenous group at six hours and 91% overall. At six hours, the mean area under the curve for T4 was similar between the intravenous group [92.2 (33); 95% confidence interval (CI) 76 to 108.4] and the oral group [86.1 (14); 95% CI 79.4 to 92.8]. Orally administered T4 is well absorbed and achieves a bioavailability of approximately 91-93% of intravenous T4 in organ donors. Inotropic/vasopressor requirements and hemodynamic responses following oral or intravenous thyroxine administration were comparable. Oral T4 is suitable for hormonal therapy for organ donors. This trial was registered at www.clinicaltrials.gov : NCT00238030.

Catheter-related bloodstream infections: a prospective observational study of central venous and arterial catheters

Catheter-related bloodstream infections (CRBSIs) can lead to increased morbidity and length of stay (LOS) in the intensive care unit (ICU). The purpose of this study was to analyse the incidence of catheter-related bloodstream infection associated with central venous catheters (CVCs) and arterial catheters (ACs) and to identify risk factors for CRBSIs in our ICU. This was a prospective observational study in a 17-bed medical-surgical ICU of a 715-bed university hospital. Patients admitted to the ICU for ≥ 24 h between 1 September 2007 and 30 April 2008, who received a CVC or AC, were included in the study. A total of 219 patients with 258 CVCs and 336 ACs were included in the study and observed for a combined total of 3172 catheter-days. The CRBSI incidence density was 1.2 per 1000 catheter-days for CVCs and 2.1 per 1000 catheter-days for ACs. The mean LOS (p = 0.003), the number of days a catheter remained in situ (p = 0.001), and the length of pre-ICU in-hospital stay (p = 0.031) were significantly higher in the CRBSI group. Risk factor analysis was not reliable due to the low number of CRBSIs. The incidence of AC- and CVC-related CRBSIs was comparable to the incidence reported in the literature. However, the incidence for ACs was higher than for CVCs. In addition to CVCs, ACs should be considered a possible cause of catheter-related infections and both should be replaced when CRBSI is suspected.

Accuracy of Stop-Cursor Method for Determining Systolic and Pulse Pressure Variation

Functional hemodynamic indicators (systolic pressure variation [SPV and SPV%] and pulse pressure variation [PPV%]) are sensitive and specific indicators of fluid responsiveness. It was unknown if these indicators could be accurately measured directly from the bedside monitor. Determine the accuracy of SPV, SPV%, and PPV% measurements by using a stop-cursor method compared with a digitized analog strip (gold standard). A prospective observational study using a convenience sample of 30 adult patients in a medical-surgical intensive care unit who were receiving mechanical ventilation and had no spontaneous breaths during 3 sequential ventilator breaths and had an optimized arterial catheter. The peak and nadir arterial pressure values for a ventilator cycle were simultaneously obtained by using the stop-cursor method on the bedside monitor and a hardcopy strip. The indicators were averaged over 3 breaths, and the difference between methods was calculated. Data were analyzed from 29 patients (1 patient excluded) on assist control ventilation (mean [SD] for tidal volume, 7.5 [2] mL/kg; positive end-expiratory pressure, 7 [4] cm H2O). For SPV, the mean bias was 0.4 (SD, 0.9) mm Hg (95% limits of agreement [LOA], -1.4 to 2.2 mm Hg); for SPV%, 0.3 (SD, 0.9; 95% LOA, -1.5% to 2.1%); for PPV%, 1.0 (SD, 3.3; 95% LOA, -5.5% to 7.5%). In only 1 case (PPV%) was there disagreement on fluid response characterization. Statistically significant small differences in SPV and SPV% were detected. The differences in SPV, SPV%, and PPV% were not clinically significant, suggesting that functional hemodynamic indicators can be obtained accurately with the stop-cursor method.

Do Windows or Natural Views Affect Outcomes or Costs Among Patients in ICUs?

To determine whether potential exposure to natural light via windows or to more pleasing views through windows affects outcomes or costs among critically ill patients. Retrospective cohort study. An academic hospital in Philadelphia, PA. Six thousand one hundred thirty-eight patients admitted to a 24-bed medical ICU and 6,631 patients admitted to a 24-bed surgical ICU from July 1, 2006, to June 30, 2010. Assignment to medical ICU rooms with vs. without windows and to surgical ICU rooms with natural vs. industrial views based on bed availability. In primary analyses adjusting for patient characteristics, medical ICU patients admitted to rooms with (n = 4,093) versus without (n = 2,243) windows did not differ in rates of ICU (p = 0.25) or in-hospital (p = 0.94) mortality, ICU readmissions (p = 0.37), or delirium (p = 0.56). Surgical ICU patients admitted to rooms with natural (n = 3,072) versus industrial (n = 3,588) views experienced slightly shorter ICU lengths of stay and slightly lower variable costs. Instrumental variable analyses based on initial bed assignment and exposure time did not show any differences in any outcomes in either the medical ICU or surgical ICU cohorts, and none of the differences noted in primary analyses remained statistically significant when adjusting for multiple comparisons. In a prespecified subgroup analysis among patients with ICU length of stay greater than 72 hours, MICU windows were associated with reduced ICU (p = 0.02) and hospital mortality (p = 0.04); these results did not meet criteria for significance after adjustment for multiple comparisons. ICU rooms with windows or natural views do not improve outcomes or reduce costs of in-hospital care for general populations of medical and surgical ICU patients. Future work is needed to determine whether targeting light from windows directly toward patients influences outcomes and to explore these effects in patients at high risk for adverse outcomes.

Epidemiology of hospital-acquired infections in an adult intensive care unit: results of a prospective cohort study

We aimed to describe the pattern of nosocomial infections in an adult medical-surgical intensive care unit (ICU). A 2-year prospective cohort study of nosocomial infection surveillance in a 12 - bed adult medical and surgical ICU of the Federico II University Hospital in Naples, was carried out. Data were collected between January 2009 and December 2010 using the standard surveillance protocols and nosocomial infection site definitions of the National Healthcare Safety Network's ICU surveillance component. Out of 768 patients hospitalized during this period, 434 with an ICU stay longer than 48 h were included in the study. Fifty-three patients acquired a total of 71 nosocomial infections; 55 (77,5%) ventilatorassociated pneumonia (VAP), 10 (14,1%), central-line-associated bloodstream infection (CLA-BSI) and 6 (8,4%) catheter-associated urinary tract infection (CA-UTI). The overall patient day rate was 12,9 patient days. The patient infection rate was 16,3 patients at risk. The mean VAP rate was 15,0/1.000 ventilator days, the CLA-BSI rate 2,9/1.000 central line days and the CA-UTI rate 1,2/1.000 catheter days. Of the nosocomial infections, 65 were Gram-negative, 6 Gram-positive and 5 fungal. The most frequent organism was Acinetobacter baumannii (61,9%), followed by Pseudomonas aeruginosa (22,5%), Enterococcus fecalis (4,2%) and Candida albicans (4,2%). The crude mortality was 35% among ICU-infected patients. VAP was the most common nosocomial infection in our ICU. Gram-negative organisms were more commonly reported as etiologic agents of ICU infections.

Decreased respiratory rate variability during mechanical ventilation is associated with increased mortality

Patients on ventilatory support often experience significant changes in respiratory rate. Our aim was to determine the possible association between respiratory rate variability (RRV) and outcomes in these patients. A longitudinal, prospective, observational study of patients mechanically ventilated for at least 12h performed in a medical-surgical intensive care unit. Patients were enrolled within 24h of the initiation of ventilatory support. We measured airway signals continuously for the duration of ventilatory support and calculated expiratory flow frequency spectra at 2.5-min intervals. We assessed RRV using the amplitude ratio of the flow spectrum's first harmonic to the zero frequency component. Measures of the amplitude ratio were averaged over the total monitored time. Patients with time-averaged amplitude ratios <40% were classified as high RRV and those ≥40% as low RRV. All-cause mortality rates were assessed at 28 and 180days from enrollment with a Cox proportional hazards model adjusted for disease acuity by the simplified acute physiology score II. We enrolled 178 patients, of whom 47 had high RRV and 131 low RRV. Both groups had similar disease acuity upon enrollment. The 28- and 180-day mortality rates were greater for low RRV patients with hazard ratios of 4.81 (95% CI 1.85-12.65, p=0.001) and 2.26 (95% CI 1.21-4.20, p=0.01), respectively. Independent predictors of 28-day mortality were low RRV, i.v. vasopressin, and SAPS II. Decreased RRV during ventilatory support is associated with increased mortality. The mechanisms responsible for this finding remain to be determined.

Outcomes of Upper Extremity Versus Lower Extremity Placed Percutaneously Inserted Central Catheters in a Medical-Surgical Neonatal Intensive Care Unit

Outcomes of Upper Extremity Versus Lower Extremity Placed Percutaneously Inserted Central Catheters in a Medical-Surgical Neonatal Intensive Care Unit

A simple widespread computer help improves nutrition support orders and decreases infection complications in critically ill patients.

AimsTo assess the impact of a simple computer-based decision-support system (computer help) on the quality of nutrition support orders and patients' outcome in Intensive-Care Unit (ICU).MethodsThis quality-improvement study was carried out in a 16-bed medical-surgical ICU in a French university hospital. All consecutive patients who stayed in ICU more than 10 days with non-oral feeding for more than 5 days were retrospectively included during two 12-month periods. Prescriptions of nutrition support were collected and compared to French national guidelines as a quality-improvement process. A computer help was constructed using a simple Excel-sheet (MicrosoftTM) to guide physicians' prescriptions according to guidelines. This computer help was displayed in computers previously used for medical orders. Physicians were informed but no systematic protocol was implemented. Patients included during the first (control group) and second period (computer help group) were compared for achievement of nutrition goals and ICU outcomes.ResultsThe control and computer help groups respectively included 71 and 95 patients. Patients' characteristics were not significantly different between groups. In the computer help group, prescriptions achieved significantly more often 80% of nutrition goals for calorie (45% vs. 79% p<0.001) and nitrogen intake (3% vs. 37%, p<0.001). Incidence of nosocomial infections decreased significantly between the two groups (59% vs. 41%, p = 0.03). Mortality did not significantly differ between control (21%) and computer help groups (15%, p = 0.30).ConclusionsUse of a widespread inexpensive computer help is associated with significant improvements in nutrition support orders and decreased nosocomial infections in ICU patients. This computer-help is provided in electronic supplement.

Achieving and Maintaining 'Zero' Central Line-Associated Blood Stream Infection for over a Year in a Medical-Surgical Intensive Care Unit

LESSON LEARNED: Though our hospital’s SSI rate following csection had not yet exceeded the NHSN mean, responding early to a trend likely prevented additional SSI and has resulted in a substantial decrease in infections. Infection Preventionists should collaborate with their peers in surgery and sterile processing to ensure that surgical instruments are subjected to proper care, inspection and preventive maintenance.

Current prevention practice for venous thromboembolism in Japanese intensive care units

Venous thromboembolism (VTE) is a well-recognized life-threatening complication in the intensive care unit (ICU). However, no data have been reported regarding the prevalence and methods of prevention of VTE in Japanese ICUs. This study aimed to document the current practice of VTE prevention across a broad sample of medical-surgical ICU patients in Japan. In November 2010, we performed a point-prevalence survey of Japanese ICUs in training facilities for intensive care specialists. We recorded data from five consecutive ICU patients in each facility at any time on the day of the survey. A total of 470 patients were registered in this study. VTE prophylaxis was received by 85.3 % of participants. Of these, 69.8 % received mechanical prophylaxis and 12.5 % received pharmacological methods, with 17.7 % receiving both methods. Analyzing a comparison of the presence or absence of a hospital prevention protocol, the protocol group had higher rates of receiving prophylaxis (88.8 % vs. 80.0 %, P < 0.01) than the no-protocol group. In conclusion, VTE prophylaxis by mechanical methods was the main method in a high number of medical-surgical ICU patients in Japan. The ICUs with a hospital VTE prevention protocol in place performed significantly higher rates of prophylaxis than those without a protocol.

Role of dexmedetomidine in adults in the intensive care unit: An update

The role of dexmedetomidine for the management of pain, agitation, and delirium in adult patients in the intensive care unit (ICU) is reviewed and updated. Searches of MEDLINE (July 2006-March 2012) and an extensive manual review of journals were performed. Relevant literature with a focus on data published since our last review in 2007 was evaluated for topic relevance and clinical applicability. Optimal management of pain, agitation, and delirium in ICUs requires a systematic and multimodal approach aimed at providing comfort while maximizing outcomes. Dexmedetomidine is among multiple agents, including opioids, propofol, benzodiazepines, and antipsychotics, used to facilitate and increase patients' tolerability of mechanical ventilation. This article reviews the newest evidence available for dexmedetomidine use for sedation and analgesia in medical-surgical ICUs. Adverse effects associated with dexmedetomidine were similar among the studies examined herein. The most common adverse effects with dexmedetomidine were bradycardia and hypotension, in some cases severe enough to warrant the use of vasoactive support. Due to the adverse events associated with rapid dosage adjustment and bolus therapy, dexmedetomidine may not be the best agent for treating acute agitation. In medical-surgical ICUs, dexmedetomidine may be a viable non-benzodiazepine option for patients with a need for light sedation. In cardiac surgery patients, dexmedetomidine appears to offer no advantage over propofol as the initial sedative. The role of dexmedetomidine in unique patient populations such as neurosurgical, trauma, and obstetrics is yet to be established.