Number Of Patient-days Research Articles

Use of ventilator utilization ratio for stratifying alcohol-based hand-rub consumption data to improve surveillance on intensive care units

Germany has established a nationwide surveillance system of alcohol-based hand-rub consumption (AHC) per patient-day in hospital settings as a surrogate parameter for hand hygiene (HH) compliance. Analysis of AHC data in intensive care units (ICUs) shows not only a wide range of consumption between units of different specialties, but also within units of one specialty. This seems to reflect variation in the number of HH opportunities per patient-day between ICUs due to variation in complexity of care. To investigate whether ventilator utilization ratio (VUR) might be a good surrogate for describing complexity and intensity of care on ICUs and whether stratification by VUR works as a new method of setting benchmarks for AHC data. Data from 365 ICUs participating in the German national nosocomial infection surveillance system (KISS) were used. VUR was calculated by dividing the number of ventilator-days per unit by the number of patient-days per unit. AHC was stratified according to VUR in quartiles. The median AHC was 107mL/patient-day [interquartile range (IQR): 86-134] and the median VUR was 33% (IQR: 22-45%). The Spearman rank correlation coefficient was 0.28 (P<0.0001). After stratifying AHC according to VUR, the AHC in quartile I was significantly lower compared to quartile IV. There was also significant difference between quartile I and quartiles II and III. Stratification of AHC data according to VUR is suggested to improve the quality of benchmark parameters based on AHC data as surrogate parameter for HH compliance in ICUs.

Knowledge Translation Strategy to Reduce the Use of Potentially Inappropriate Medications in Hospitalized Elderly Adults.

To evaluate the effect of a knowledge translation (KT) strategy to reduce potentially inappropriate medication (PIM) use in hospitalized elderly adults. Segmented regression analysis of an interrupted time series. Teaching hospital. Individuals aged 75 and older discharged from the hospital in 2013/14 (mean age 83.3, 54.5% female). The KT strategy comprises the distribution of educational materials, presentations by geriatricians, pharmacist-physician interventions based on alerts from a computerized alert system, and comprehensive geriatric assessments. Rate of PIM use (number of patient-days with use of at least one PIM/number of patient-days of hospitalization for individuals aged ≥75). For 8,622 patients with 14,071 admissions, a total of 145,061 patient-days were analyzed. One or more PIMs were prescribed on 28,776 (19.8%) patient-days; a higher rate was found for individuals aged 75 to 84 (24.0%) than for those aged 85 and older (14.4%) (P<.001), and in women (20.8%) than in men (18.6%) (P<.001). The drug classes most frequently accounting for the PIM were gastrointestinal agents (21%), antihistamines (18%), and antidepressants (17%). An absolute decrease of 3.5% (P<.001) of patient-days with at least one PIM was observed immediately after the intervention. A KT strategy resulted in decreased use of PIM in elderly adults in the hospital. Additional interventions will be implemented to maintain or further reduce PIM use.

Impact of co-payment for outpatient utilization among Medical Aid beneficiaries in Korea: A 5-year time series study

BackgroundThe Korean government implemented an outpatient co-payment scheme in July 2007 to control Medical-Aid beneficiaries⿿ overutilization of healthcare services. ObjectivesTo assess changes in the utilization of medical services resulting from the outpatient co-payment scheme. Methods410,142 subjects were selected and health insurance reimbursement data from July 2006 to June 2011 was examined. We assessed the changes in the total medical cost, total adjusted patient days, inpatient days, inpatient total medical cost, the number of outpatient visits, and outpatient total medical cost using segmented regression analysis. ResultsFollowing the introduction of the policy, the number of outpatient visits per person fell by 0.16 days in July 2008, and by 0.06 days in July 2010, compared to June 2007. The outpatient total medical cost per person rose by $4.11 in July 2010 compared to June 2007. The inpatient utilization increased constantly during the period of the study. So the total medical cost as well as the total adjusted number of patient days also increased constantly. ConclusionThe outpatient co-payment policy was effective for reducing the number of outpatient visits. It could not control the cost per outpatient visit and inpatient utilization. So the total medical cost was increased.

A retrospective review of fluid balance control in CRRT

IntroductionAn effect of severe acute kidney injury (AKI) is the development of oliguria and subsequent retention of fluid. Recent studies have reported an association between fluid overload and increased mortality in critically ill patients. Achieving fluid balance control through haemofiltration is an important part of dialysis dose delivery in continuous renal replacement therapy (CRRT). Aims(1) Compare the prescribed dose with the delivered dose of dialysis and haemofiltration for CRRT. (2) Identify how interruptions and delays in treatment delivery impact on fluid balance management. MethodA retrospective cohort study was undertaken of daily fluid balance and fluid removal for patients who required CRRT. Each observation chart and prescription order for every treatment day was reviewed. Each patient was exposed to the same treatment mode, predilutional continuous veno-venous haemodiafiltration (CVVHDf). A comparison was made of fluid balance control delivered to the patient over 24h against the dose of fluid removal prescribed. ResultsThe observation charts of 46 consecutive patients were reviewed for total of 288 treatment days. Median number of days patients received CRRT was 5 (range 1–31). Median circuit life was 16h (range 0–66). Fluid removal targets did not occur in 75 (26%) treatment days. Median daily fluid removal shortfall was 300mL (range 25–3800mL). Mean number of daily treatment interruptions 1.25, SD±0.49. The most frequent cause of treatment downtime was circuit clotting (45%). Mean length of treatment down time was 3.71, SD±4.36h excluding delays attributed to assessment of renal function. ConclusionIn over a quarter of treatment days prescribed fluid removal was not achieved. Frequency of interruptions and delays in resumption of treatment compromised fluid balance control. Daily targets for fluid removal which are not achieved contribute to fluid overload and may compromise the outcome of patients who require CRRT.

Review of Patient Transfers from Spinal Surgery to the Spinal Injuries Unit

Introduction To review the length of time patients are awaiting spinal injury reviews on the spinal surgery ward and awaiting beds on the spinal injuries unit. Materials and Methods A list of all spinal surgery patients with a spinal injuries episode within the same spell during the period 01/04/12 to 26/11/14 were gained by coding ( n = 37). Three patients were excluded from the data (one under neurosurgery, two were transferred from the spinal injuries unit (SIU) and were both discharged from the spinal surgery ward) ( n = 34). Data was obtained via a case note review. Results The mean number of days patients were awaiting a SIU bed (calculated from spinal injuries review to transfer) was 19 (+/−14). The maximum time waiting on the spinal surgery ward was 39 days, and one patient waited 48 days for a ventilator bed. The later the admission the longer patients were waiting, with a positive correlation but this was not significant (r = 0.28, p = 0.18). The mean waiting time was 9 days in 2012, 17 days in 2013 and 24 days in 2014. There was a positive correlation between the length of time patients were awaiting a SIU bed and their length of spinal injuries stay (r = 0.105, p = 0.39). The mean time awaiting a spinal injuries review was 5.9 days. However often there was limited documentation regarding how patients were referred and so was not clear when referrals were received by the spinal injuries team. Two patients had no documented review before transfer. The most frequent type of injury which resulted in patients requiring transfer for rehabilitation was fracture (44%), followed by infection (29%). 47% of injuries were in the thoracic spine. 71% received surgery during their admission. Conclusions This review shows patients are waiting considerable amounts of time awaiting SIU beds and the delays are increasing each year. Delays cause significant implications for patients such as psychological issues and risk of complications including pressure sores, contractures and infections, all of which can impact on functional outcomes. Delays are a high cost to the NHS (the cost of a critical care bed is over £800 more than a ventilated SIU bed). Further work can be performed reviewing reasons for delays and to look at delays in SIU discharges. Patients could benefit from an increase in spinal injury reviews while beds are awaited. An audit on the management of SCI patients while they are on an orthopaedic ward could ensure care meets current recommendations.

Handrub Consumption Mirrors Hand Hygiene Compliance.

We assessed handrub consumption as a surrogate marker for hand hygiene compliance from 2007 to 2014. Handrub consumption varied substantially between departments but correlated in a mixed effects regression model with the number of patient-days and the observed hand hygiene compliance. Handrub consumption may supplement traditional hand hygiene observations. Infect Control Hosp Epidemiol 2016;37:707-710.

Interviewer-administered TLFB vs. self-administered computerized (A-CASI) drug use frequency questions: a comparison in HIV-infected drug users

BackgroundSubstance use can have major consequences among HIV patients. Interviewer- or self-administered modalities are widely used to measure drug use frequency. This often involves Timeline Follow-Back (TLFB) interviewer-administered measures, or self-administered computerized questions assessing similar information via Audio Computer-Assisted Self Interview (A-CASI). Little is known about agreement between these two modalities on drug use frequency in HIV-infected samples. MethodsPrior to randomization into a trial of brief interventions to reduce drug use, 240HIV patients completed a baseline A-CASI assessment battery that included questions on drug use frequency, followed by an interviewer-administered TLFB. Each measure generated number of days patients used their primary drug in the prior 30 days. Agreement between TLFB and A-CASI modalities on days using primary drug was determined using intraclass correlation coefficients (ICC). Regression analysis tested the association of patient characteristics with discrepancies between TLFB and A-CASI modalities. ResultsOverall agreement was excellent (ICC=.80), with little variation by primary drug, education, race, current drug treatment, binge drinking or years since HIV diagnosis. Gender, ethnicity (Hispanic vs. non-Hispanic) and age predicted differences in days used (p<0.05); the A-CASI modality reflected more days used than TLFB. ConclusionsMeasures of days used primary drug showed high agreement whether assessed by interviewer-administered TLFB or by questions self-administered via the A-CASI modality. Differences by gender, ethnicity and age suggest some caution in using the TLFB, although additional studies are needed. However, findings generally indicate that studies based on one assessment method or the other can be compared with reasonable confidence.

Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation.

IntroductionDexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation.MethodsThe total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only.ResultsBased on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs—€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)—and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam).ConclusionsFrom an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation.Trial registrationClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX).Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0787-y) contains supplementary material, which is available to authorized users.

Health care–associated infection surveillance in a tertiary neonatal intensive care unit: A prospective clinical study after moving to a new building

There are very few prospective clinical studies on neonatal health care-associated infection (HAI) surveillance. HAI surveillance helps reduce not only mortality, but also morbidity, length of hospital stay, and health care costs. This prospective clinical study covered a period of 12 months in a tertiary neonatal intensive care unit (NICU). HAI rates were calculated using different denominators: number of patients hospitalized in the NICU, number of patient-days, and number of specific device-days. The HAI rate was 18%, and the incidence density was 17/1,000 patient-days. The most common HAI was bloodstream infection (n = 34; 50%). The most common pathogen was coagulase-negative staphylococci (CoNS; 54.9%) in gram-positive bacteria and in general. Methicillin resistance was 96.4% for CoNS. Klebsiella spp (13.7%) was the most common gram-negative bacteria. Extended-spectrum β-lactamase positivity was 14.3% for Klebsiella spp and 25% for Escherichia coli. HAI-related mortality was 0.3%. NICUs should perform their own HAI surveillance with prospective clinical design. Attention paid to handwashing, disinfection and sanitizing, complying with the terms of asepsis, extending in-service training, increasing the number of medical staff, preventing frequent changes in health care staff positions, and improving physical environmental conditions in NICUs might eventually decrease HAI rates.

The European Society for Immunodeficiencies (ESID) registry 2014.

The current European Society for Immunodeficiencies (ESID) registry was established 10 years ago in 2004, when the system was moved from a paper-based to an online system. The purpose of the registry is to collect data on European patients with primary immunodeficiencies (PIDs) and their treatment, with the aim of building an easily accessible database for use by physicians and researchers.

Transmission-based contact precautions for multidrug-resistant organisms in trauma patients: fewer days in isolation with no increase in hospital-associated infections.

Our hospital transitioned from routine to selective contact isolation of patients based not on history or diagnosis of multidrug-resistant organisms (MDROs) but rather on the likelihood the patient was soiling their environment. We hypothesized that the change to true transmission-based contact isolation would not be associated with an increase in hospital-associated infections with MDROs. We performed a retrospective study of trauma admissions during two periods: the first period (March to August 2011, PRE group) before and the second period (March to August 2012, POST group) after implementation of the new transmission-based contact isolation guidelines. We compared the PRE and POST groups for admission demographics and physiology as well as mechanism and severity of injury. The primary outcome was the number of patients placed in contact isolation. There were 1,465 and 1,617 trauma admissions during the PRE and POST periods, respectively. The PRE and POST groups were similar for age, sex, admission physiology, mechanism of injury, and injury severity. Overall, 3.3% (n = 49) of the patients in the PRE group were placed in contact isolation as compared with 1.7% (n = 25) in the POST group (p = 0.001). More than double the number of patient days were spent in isolation in the PRE period than the POST period (3.8% [n = 246 days] vs. 1.7% [n = 131 days], p < 0.001). There was no difference between the PRE and POST groups in the rates of developing hospital-acquired MDRO infections (0.2% [n = 3] vs. 0.2% [n = 4], p = 0.99). Transitioning from routine MDRO contact precautions to transmission-based MDRO contact precautions can reduce the number of trauma patients requiring isolation without an increase in hospital-acquired MDRO infections. Therapeutic/care management, level IV.

Regional variation in urinary catheter use and catheter-associated urinary tract infection: results from a national collaborative.

To examine regional variation in the use and appropriateness of indwelling urinary catheters and catheter-associated urinary tract infection (CAUTI). Cross-sectional study. US acute care hospitals. Hospitals were divided into 4 regions according to the US Census Bureau. Baseline data on urinary catheter use, catheter appropriateness, and CAUTI were collected from participating units. The catheter utilization ratio was calculated by dividing the number of catheter-days by the number of patient-days. We used the National Healthcare Safety Network (NHSN) definition (number of CAUTIs per 1,000 catheter-days) and a population-based definition (number of CAUTIs per 10,000 patient-days) to calculate CAUTI rates. Logistic and Poisson regression models were used to assess regional differences. Data on 434,207 catheter-days over 1,400,770 patient-days were collected from 1,101 units within 726 hospitals across 34 states. Overall catheter utilization was 31%. Catheter utilization was significantly higher in non-intensive care units (ICUs) in the West compared with non-ICUs in all other regions. Approximately 30%-40% of catheters in non-ICUs were placed without an appropriate indication. Catheter appropriateness was the lowest in the West. A total of 1,099 CAUTIs were observed (NHSN rate of 2.5 per 1,000 catheter-days and a population-based rate of 7.8 per 10,000 patient-days). The population-based CAUTI rate was highest in the West (8.9 CAUTIs per 10,000 patient-days) and was significantly higher compared with the Midwest, even after adjusting for hospital characteristics (P = .02). Regional differences in catheter use, appropriateness, and CAUTI rates were detected across US hospitals.

Identification and nursing management of dysphagia in individuals with acute neurological impairment

Background: Dysphagia, that is, difficulty in swallowing, is a serious and life-threatening condition that affects a significant number of individuals with acute neurological impairment. Objective: To find the best available evidence regarding: 1. The nursing role in the recognition and management of dysphagia in adults with acute neurological impairment. 2. The evidence on the effectiveness of nursing interventions in the recognition and management of dysphagia. Methods: In light of the new evidence we used Joanna Briggs Institute standard systematic review methods to update our previously published review. We included any quantitative research, published in English after 2008, focusing on the nursing role in the identification and nursing management of adults with neurogenic dysphagia. Results: Four new studies were added by this update. Dysphagia screening by nurses significantly reduces the number of chest infections in patients with stroke (OR 0.45, 95% CI 0.33 to 0.62, P < 0.00001). The presence of formal dysphagia care guidelines is effective for reducing inpatient death (OR 0.60, 95% CI 0.43 to 0.84, P = 0.003) and reducing chest infections (OR 0.68, 95% CI 0.51 to 0.90, P = 0.008). Formal dysphagia guidelines also increased the number of screens conducted and the number of screens within 24 hours of admission. Discussion: There is strong evidence to support the role of nurses in the detection and management of patients with neurogenic dysphagia. Suitable tools are available and there seems little reason for healthcare organisations not to have nurses trained in dysphagia screening. Conclusion: A considerable body of research now exists on this subject; however, some gaps still remain. High quality research is needed to provide evidence about the effect of nurse-initiated dysphagia screening on the number of days patients spend nil by mouth, the time patients wait for assessment, and the effect of nurse-initiated dysphagia screening on length of stay and discharge destination.

Antibiotic Consumption and the Development of Antibiotic Resistance in Surgical Units

Antibiotic resistence is increasing worldwide. A longitudinal analysis of the influence of the density of antibiotic use on the development of resistance in surgical units was undertaken. Over five years the incidence of pathogens and the resistance rates of isolates from patients of normal surgical units and those of a surgical ICU at a university hospital were examined. The resistence rates were correlated with the density of antibiotic use - calculated from the antibiotic consumption (in DDD) and the number of patient-days. At both units, Enterobacteriaceae and Enterococci were mostly cultured. Among the Enterobacteriaceae, E. coli, Klebsiella spp., Proteus mirabilis and Enterobacter predominated. In the group of Enterococci, E. faecalis predominated at wards whereas at ICU E. faecium was the most frequent. Anaerobes ranked third at normal wards and Candida spp. at ICU. From 2007 to 2011, there was an increasing resistance against ciprofloxacin in P. mirabilis (r = 0.87; p = 0.054) and against imipenem (r = 0.86; p = 0.06) and piperacillin (r = 0.81; p = 0.09) in P. aeruginosa at normal wards. At ICU, the resistance rates of imipenem in P. aeruginosa rose (r = 0.88; p = 0.049). Resistance against ciprofloxacin in E. coli increased (r = 0.65; p = 0.23). Due to the increasing use of ciprofloxacin and meropenem at normal wards, the density of antibiotic usage rose 1.4 %/year (r = 0.94; p = 0.02). Despite the increase of meropenem use at ICU (r = 0.9; p = 0.035), the total antibiotic uptake rate remained almost constant. The antibiotic usage density was 3-fold higher at ICU than at normal wards. At normal wards, the ciprofloxacin usage correlated with the rate of resistance against ciprofloxacin in P. mirabilis P. m. At ICU, an association was detected between the uptake rate of ceftazidime and the rate of resistance against cefotaxime in the CES group. In P. aeruginosa, the use of piperacillin and the rate of resistance against piperacillin correlated. The high uptake rates of fluoroquinolones and carbapenems were accompanied by increases in resistances. The resistance rates are influenced by hygiene management and microbiological diagnostics. The extensive use of carbapenems should be reassessed on both units to counter further development of antibiotic resistance.

Impact of palifermin on incidence of oral mucositis and healthcare utilization in children undergoing autologous hematopoietic stem cell transplantation for malignant diseases.

Palifermin has been demonstrated to decrease the incidence of severe oral mucositis in adults following TBI containing conditioning regimens prior to AHSCT. The impact of palifermin on the incidence of oral mucositis in children undergoing AHSCT has never been studied. We compared the effect of palifermin on the incidence of oral mucositis and supportive care in 58 children undergoing myeloablative AHSCT; 25 children received palifermin and 33 children did not receive palifermin (control arm). Oral mucositis was graded as per WHO criteria. The demographic characteristics were comparable between the two arms. Results comparing the palifermin vs. control arm showed that the incidence of grade III-IV oral mucositis was 20% vs. 42.4% (p = 0.072). The number of days patients received patient-controlled analgesia and total parenteral nutrition in the palifermin vs. control arm were 8.80 ± 8.39 vs. 8.30 ± 8.54 (p = 0.826) and 13.52 ± 11.32 vs. 11.55 ± 9.63 (p = 0.484), respectively. The average length of hospitalization in the palifermin vs. control arm was 31.44 ± 7.42 vs. 28.61 ± 10.38 (p = 0.252), respectively. In this study, we were unable to demonstrate a statistical difference in the incidence of oral mucositis and other supportive care needs or a decrease in hospital stay between the two arms.

A telephone-based case-management intervention reduces healthcare utilization for frequent emergency department visitors

A small group of frequent visitors to emergency departments accounts for a disproportional large number of total emergency department visits. Previous interventions in this population have shown mixed results. To determine whether a nurse-managed telephone-based case-management intervention can reduce healthcare utilization and improve self-assessed health status in frequent emergency department users. We carried out a Zelen-design randomized-controlled trial among patients who were identified as frequent emergency department users (≥ 3 visits during the 6 months before inclusion) at the Karolinska University Hospital in Stockholm (Sweden). Patients included in the study (n = 268) were randomized to either the intervention group or the control group and followed for 1 year. Patients who declined to participate or could not be reached were also followed for the study outcome. The telephone-based case-management intervention reduced the total number of outpatient visits (relative risk 0.80; 95% confidence interval 0.75-0.84), the number of emergency department visits (relative risk 0.77; 95% confidence interval 0.69-0.86), the number of days patients were admitted to hospitals as well as the total healthcare costs for hospital admissions. There was no difference in mortality or other identified adverse outcomes between the intervention and the control groups. Patient self-assessed health status improved for the patients who received the case-management intervention. Our results indicate that the nurse-managed telephone-based case-management intervention represents a possible strategy to improve care for frequent emergency department users as well as decrease outpatient visits, admission days and healthcare costs.

Efficacy of a Chronic Disease Management Model for Patients With Chronic Liver Failure

Despite the economic impacts of chronic liver failure (CLF) and the success of chronic disease management (CDM) programs in routine clinical practice, there have been no randomized controlled trials of CDM for CLF. We investigated the efficacy of CDM programs for CLF patients in a prospective, controlled trial. Sixty consecutive patients with cirrhosis and complications from CLF were assigned randomly to groups given intervention (n = 40) or usual care (n = 20), from 2009 to 2010. The 12-month intervention comprised 4 CDM components: delivery system redesign, self-management support, decision support, and clinical information systems. The primary outcome was the number of days spent in a hospital bed for liver-related reasons. Secondary outcomes were rates of other hospital use measures, rate of attendance at planned outpatient care, disease severity, quality of life, and quality of care. The intervention did not reduce the number of days patients spent in hospital beds for liver-related reasons, compared with usual care (17.8 vs 11.0 bed days/person/y, respectively; incidence rate ratio, 1.6; 95% confidence interval, 0.5-4.8; P = .39), or affect other measures of hospitalization. Patients given the intervention had a 30% higher rate of attendance at outpatient care (incidence rate ratio, 1.3; 95% confidence interval, 1.1-1.5; P = .004) and significant increases in quality of care, based on adherence to hepatoma screening, osteoporosis and vaccination guidelines, and referral to transplant centers (P < .05 for all). In a pilot study to determine the efficacy of CDM for patients with CLF, patients receiving CDM had significant increases in attendance at outpatient centers and quality of care, compared with patients who did not receive CDM. However, CDM did not appear to reduce hospital admission rates or disease severity or improve patient quality of life. Larger trials with longer follow-up periods are required to confirm these findings and assess cost effectiveness.

Attributable costs of ventilator-associated lower respiratory tract infection (LRTI) acquired on intensive care units: a retrospectively matched cohort study

BackgroundLower respiratory tract infections (LRTI) are the most common hospital-acquired infections on ICUs. They have not only an impact on each patient’s individual health but also result in a considerable financial burden for the healthcare system. Our aim was to determine the costs and the length of stay of patients with ICU-acquired LRTI.MethodsWe used a retrospectively matched cohort design, comparing patients with ICU-acquired LRTI and ICU patients without LRTI. LRTI was diagnosed using the definitions of the Centers for Disease Control and Prevention (CDC). Study period was from January to December 2010 analyzing patients from 10 different ICUs (medical, surgical, interdisciplinary). The device utilization ratio was defined as number of ventilator days divided by number of patient days and the device-associated LRTI rate was defined as number of ventilator associated LRTI divided by number of ventilator days. Patients were matched by age, sex, and prospectively obtained Simplified Acute Physiology Score II (SAPS II). The length of ICU stay of control patients needed to be at least as long as that of LRTI-patients before onset of LRTI. We used the Wilcoxon signed-rank test for continuous variables and the McNemar’s test for categorical variables.ResultsThe analyzed ICUs had 40,772 patient days in the study period with a median ventilation utilization ratio of 56 (IQR 42–65). The median device-associated LRTI rate was 3.35 (IQR 0.96-5.36) per 1,000 ventilation days. We analyzed 49 patients with ICU-acquired LRTI and 49 respective controls without LRTI. The median hospital costs for LRTI patients were significantly higher than for patients without LRTI (45,041 € vs. 26,467 €; p < .001). The attributable costs per LRTI patient were 17,015 € (p < .001). Patients with ICU acquired LRTI stayed longer in the hospital than patients without (36 days vs. 24 days; p = 0.011). An LRTI lead to an attributable increase in length of stay by 9 days (p = 0.011).ConclusionsICU-acquired LRTI is associated with increased hospital costs and prolonged hospital stay. Hospital management should therefore implement control measurements to keep the incidence of ICU-acquired LRTI as low as possible.

Statewide Ban on Recreational Fires Resulted in a Significant Decrease in Campfire-Related Summer Burn Center Admissions

Every summer, there is an increase in the number of burn injuries caused by accidents around campfires. Because of the prevalence of drought, high winds, and uncontrolled wild fires, a statewide ban on recreational fires was instituted in New Mexico from June to July 2011. We hypothesized that this legislation would have a significant impact on burn admissions caused by campfire-related injuries. A retrospective review of summer admissions to a state burn center was conducted to assess the effect of this ban on recreational fire injuries, and these data were compared with that of the previous summer when no ban was in effect. All burn admissions to a state burn center were reviewed from Memorial Day to Labor Day in 2010 and 2011. Data collected included cause, % TBSA, age, days of hospitalization, intensive care unit days, and total surface area grafted. Nonparametric statistical analysis was performed with Fisher exact test for dichotomous data and Mann-Whitney test for continuous data with significance at P < .05. There were 164 burn center admissions between Memorial Day and Labor Day in 2010 (n = 82) and 2011 (n = 82). Compared with all summer burn center admissions, patients injured by campfires were younger (18 vs 37 years; P = .002) with smaller total surface area burns (3.2 vs 6.2%; P = .41) and had shorter lengths of stay (10-11 vs 6-7 days; P = .62). There was more than a 3-fold decrease in burn admissions due to recreational fires during the study period (n = 14 [17%] in 2010 and 4 [5%] in 2011; P = .02). This resulted in a decrease in the number of patient-days from 91 in 2010 to 25 in 2011. Half of the camp fire admissions required skin grafts to definitively close the wounds (6/14 in 2010 and 2/4 in 2011). Recreational fire bans targeted at controlling wildfires during conditions favoring rapid spread were associated with a 3- to 4-fold decrease in campfire-related burn admissions. Compared with a summer when no fire ban was in effect, the number of patient-days decreased from 91 to 25.

Immunosuppression in Patients Who Die of Sepsis and Multiple Organ Failure

Context Severe sepsis is typically characterized by initial cytokine-mediated hyperinflammation. Whether this hyperinflammatory phase is followed by immunosuppression is controversial. Animal studies suggest that multiple immune defects occur in sepsis, but data from humans remain conflicting. Objectives To determine the association of sepsis with changes in host innate and adaptive immunity and to examine potential mechanisms for putative immunosuppression. Design, Setting, and Participants Rapid postmortem spleen and lung tissue harvest was performed at the bedsides of 40 patients who died in intensive care units (ICUs) of academic medical centers with active severe sepsis to characterize their immune status at the time of death (2009-2011). Control spleens (n = 29) were obtained from patients who were declared brain-dead or had emergent splenectomy due to trauma; control lungs (n = 20) were obtained from transplant donors or from lung cancer resections. Main Outcome Measures Cytokine secretion assays and immunophenotyping of cell surface receptor-ligand expression profiles were performed to identify potential mechanisms of immune dysfunction. Immunohistochemical staining was performed to evaluate the loss of immune effector cells. Results The mean ages of patients with sepsis and controls were 71.7 (SD, 15.9) and 52.7 (SD, 15.0) years, respectively. The median number of ICU days for patients with sepsis was 8 (range, 1-195 days), while control patients were in ICUs for 4 or fewer days. The median duration of sepsis was 4 days (range, 1-40 days). Compared with controls, anti-CD3/anti-CD28–stimulated splenocytes from sepsis patients had significant reductions in cytokine secretion at 5 hours: tumor necrosis factor, 5361 (95% CI, 3327-7485) pg/mL vs 418 (95% CI, 98-738) pg/mL; interferon γ, 1374 (95% CI, 550-2197) pg/mL vs 37.5 (95% CI, −5 to 80) pg/mL; interleukin 6, 3691 (95% CI, 2313-5070) vs 365 (95% CI, 87-642) pg/mL; and interleukin 10, 633 (95% CI, −269 to 1534) vs 58 (95% CI, −39 to 156) pg/mL; (P Conclusions Patients who die in the ICU following sepsis compared with patients who die of nonsepsis etiologies have biochemical, flow cytometric, and immunohistochemical findings consistent with immunosuppression. Targeted immune-enhancing therapy may be a valid approach in selected patients with sepsis.