Surgical Critical Care Service Research Articles

Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya.

We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03). The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.

Risk factors for extubation failure at a level I trauma center: does the specialty of the intensivist matter?

IntroductionExtubation failure in critically ill patients is associated with higher morbidity and mortality. Although predictors of failed extubation have been previously determined in intensive care unit (ICU) cohorts, relatively less...

Telemedicine coverage for post-operative ICU patients

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical care service from January 1st 2008 to July 31st 2011 was conducted at an urban, academic, tertiary centre and level 1 trauma centre. Results Compared to the SICU group (n = 6652), patients in the VICU group (n = 1037) were slightly older (median age 60 (IQR 47–69) versus 58 (IQR 44–70) years, p = 0.002) and had lower acute physiology and chronic health evaluation (APACHE) II scores (median 10 (IQR 7–14) versus 15 (IQR 11–21), p < 0.001). The average amount of time patients spent in the VICU was 13.7 + /–9.6 hours. In the VICU group, 750 (72%) of patients were able to be transferred directly to the floor; 287 (28%) required subsequent admission to the surgical intensive care unit. All patients in the VICU group were alive upon transfer out of the PACU while mortality in the surgical intensive unit cohort was 5.5%. Discussion A collaborative care model between a surgical critical care service and a telemedicine ICU service may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation.

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Introduction: Demand for intensive care unit (ICU) resources is predicted to expand as the population ages and life support technologies improve. Intensivists frequently must arbitrate ICU beds to the most acutely ill patients leaving little room for those less sick. Hypothesis: We hypothesized collaborative care between a Surgical Critical Care Service (SCCS) and a Telemedicine ICU Service (TIS) could provide virtual ICU (VICU) coverage for postoperative patients managed in Post-Anesthesia Care Unit (PACU) beds during times of peak ICU bed demand. Methods: We performed a retrospective review of all patients seen by the SCCS from 01/08-07/11. Patients were divided into two groups: those admitted directly to the SICU vs. those admitted to a VICU bed. The VICU group was managed jointly by a SCCS and a TIS, utilizing four PACU beds at a location remote from the SICU for ‘surge capacity’. VICU patients were managed by a SCCS nurse practitioner and an in-house intensivist from 07:00-18:59 and by a TIS from 19:00-06:59. Patients with lower-intensity postoperative needs were preferentially boarded in VICU. Patients were boarded in VICU beds until SICU beds became available or until patients’ critical care needs resolved. Groups were compared using Kruskal-Wallis or Chi squared as appropriate. Statistical significance was set at p=0.05. Results: Compared to those in the SICU group (n=6932), patients in the VICU group (n=1046) were slightly older (median age 60 (IQR47-69) vs. 58 (IQR 44-70) years, p = 0.01) but had lower APACHE II scores (median 10 (IQR7-14) vs. 15 (IQR 11-21), p <0.001). The average time VICU patients spent in PACU was 13.7 +/- 9.6 hours. In the VICU group, 761 (72.5%) of patients were able to be transferred directly to the ward from the PACU; 288 (27.5%) required subsequent SICU admission. All patients in the VICU group were alive upon ICU discharge or transfer to the floor; mortality in the SICU cohort was 5.3%. Conclusions: A collaborative care model between SCCS and TIS may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation.

Maintaining quality of care 24/7 in a nontrauma surgical intensive care unit

Most surgical critical care literature reflects practices at trauma centers and tertiary hospitals. Surgical critical care needs and practices may be quite different at nontrauma center teaching hospitals. As acute care surgery develops as a component of surgical critical care and trauma, the opportunities and challenges of the nontrauma centers should be considered. In 2001, a new surgical critical care service was created for an 800-bed urban teaching hospital with a 12-bed surgical intensive care unit (SICU). Consults, daily rounds, daily notes, and adherence to best practices were standardized over the next 9 years for a team of postgraduate year-1 and -2 surgical residents, physician assistants and surgical intensivists. The Fundamentals of Critical Care Support course was given as basic introduction, and published guidelines for ventilators, hemodynamics, cardiac, infections, and nutrition management were implemented. A "beyond FCCS" curriculum was repeated every resident rotation. A 12-bed stepdown unit was developed for the more stable patients, mostly run by SICU physician assistants with SICU attending coverage. The first 5 years, night coverage was by the daytime intensivist from home. The last 4 years, night coverage was in-unit surgical intensivists or cardiac surgeons. Data for 13,020 patients drawn from 152,154 operations over 9 years is reported. Surgery grew 89% to 24,000 cases/year in 2010. Half the patients were general, gastrointestinal oncology, or vascular surgery. Ninety-two percent were perioperative. The 8% nonoperative patients were mostly gastrointestinal bleeding, abdominal pain, or pancreatitis. In the first year, annual SICU mortality decreased from an average of 4.5% the 5 previous years to 1.96% (2002) and remained 1.75% (2003), 2.1% (2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2% (2008), 2.4% (2009), and 2.1% (2010). Annual mortality immediately improved at a busy nontrauma hospital with rapid, structured consultation by the SICU team, comprehensive daily rounds guided by critical care best practices, and daytime in-unit surgical intensivists. Low mortality was maintained over 9 years as surgery volume nearly doubled but did not improve further with 24/7 in-unit coverage by surgical intensivists and cardiac surgeons. The process of care in an SICU may be more important than 24 hour a day, 7 days a week intensivists. Therapeutic study, level II.

Errors in Administrative-Reported Ventilator-Associated Pneumonia Rates: Are Never Events Really So?

Ventilator-associated pneumonia (VAP) is a common problem in an intensive care unit (ICU), although the incidence is not well established. This study aims to compare the VAP incidence as determined by the treating surgical intensivist with that detected by the hospital Infection Control Service (ICS). Trauma and surgical patients admitted to the surgical critical care service were prospectively evaluated for VAP during a 5-month time period. Collected data included the surgical intensivist's clinical VAP (SIS-VAP) assessment using Centers for Disease Control and Prevention (CDC) VAP criteria. As part of the hospital's VAP surveillance program, these patients' medical records were also reviewed by the ICS for VAP (ICS-VAP) using the same CDC VAP criteria. All patients suspected of having VAP underwent bronchioalveolar lavage (BAL). The SIS-VAP and ICS-VAP were then compared with BAL-VAP. Three hundred twenty-nine patients were admitted to the ICU during the study period. One hundred thirty-three were intubated longer than 48 hours and comprised our study population. Sixty-two patients underwent BAL evaluation for the presence of VAP on 89 occasions. SIS-VAP was diagnosed in 38 (28.5%) patients. ICS-VAP was identified in 11 (8.3%) patients (P < 0.001). The incidence of VAP by BAL criteria was 23.3 per cent. When compared with BAL, SIS-VAP had 61.3 per cent sensitivity and ICS-VAP had 29 per cent sensitivity. VAP rates reported by hospital administrative sources are significantly less accurate than physician-reported rates and dramatically underestimate the incidence of VAP. Proclaiming VAP as a never event for critically ill for surgical and trauma patients appears to be a fallacy.

Impact of a Hospital-Acquired/Ventilator-Associated/Healthcare-Associated Pneumonia Practice Guideline on Outcomes in Surgical Trauma Patients

Evidence-based guidelines for managing nosocomial pneumonia were published in 2005. Subsequently, our surgical critical care service developed and implemented an adaptation of this guideline for use in our surgical trauma intensive care unit (STICU). This study examined outcomes for two STICU cohorts treated for pneumonia before and after guideline implementation. A total of 130 charts were evaluated. The guideline cohort (GC) consisted of 65 patients with pneumonia managed by the surgical critical care service. These patients were prospectively identified for inclusion if they met specified clinical criteria for pneumonia diagnosis. The historical control cohort was identified retrospectively using ICD-9 coding. The primary outcome measure was ICU length of stay (LOS). Secondary outcome measures included overall LOS, mechanical ventilation days, mortality, and total cost of admission. The study was designed to have 80% power to detect a 1-day decrease in mean ICU LOS in a multivariable regression analysis. Descriptive differences were compared using two-sample t tests for continuous variables and chi for categorical variables. Baseline characteristics were not significantly different between cohorts. The multivariable regression analysis indicated a mean decrease of 4.6 days, 9.5 days, and 3.9 days for ICU LOS, overall LOS, and mechanical ventilation days, respectively, in the GC, with an expected mean cost reduction per admission of $23,322 (all significant at p <or= 0.0001). There was a 5% difference in hospital mortality in favor of the GC, but this difference was not statistically significant. The STICU pneumonia practice guideline significantly improved outcomes and cost of care.

Outcomes Associated With Delirium in Older Patients in Surgical ICUs

We previously noted that older adults admitted to surgical ICUs (SICUs) are at high risk for delirium. In the current study, we describe the association between the presence of delirium and complications in older SICU patients, and describe the association between delirium occurring in the SICU and functional ability and discharge placement for older patients. Secondary analysis of prospective, observational, cohort study. Subjects were 114 consecutive patients >or= 65 years old admitted to a surgical critical care service. All subjects underwent daily delirium and sedation/agitation screening during hospitalization. Outcomes prospectively recorded included SICU complication development, discharge location, and functional ability (as measured by the Katz activities of daily living instrument). Nearly one third of older adults (31.6%) admitted to an SICU had a complication during ICU stay. There was a strong association between SICU delirium and complication occurrence (p = 0.001). Complication occurrence preceded delirium diagnosis for 16 of 20 subjects. Subjects with delirium in the SICU were more likely to be discharged to a place other than home (61.3% vs 20.5%, p < 0.0001) and have greater functional decline (67.7% vs 43.6%, p = 0.023) than nondelirious subjects. After adjusting for covariates including severity of illness and mechanical ventilation use, delirium was found to be strongly and independently associated with greater odds of being discharged to a place other than home (odds ratio, 7.20; 95% confidence interval, 1.93 to 26.82). Delirium in older surgical ICU patients is associated with complications and an increased likelihood of discharge to a place other than home.

Delirium in Older Patients in Surgical Intensive Care Units

To examine the frequency and course of delirium in older adults admitted to a surgical intensive care unit (SICU). Prospective, observational cohort study of 114 English-speaking participants and their surrogates, aged 65 and older, admitted to an SICU, and managed by a surgical critical care service. Chart reviews and surrogate interviews were conducted within 24 hours of SICU admission to collect information regarding evidence of dementia using the short form of the Informant Questionnaire on Cognitive Decline in the Elderly. Participants were also screened for delirium daily throughout their hospitalization with either the Confusion Assessment Method-ICU (CAM-ICU) while in the SICU or the CAM while on medical/surgical units. In this population of older adults, 18.4% had evidence of dementia on admission to the SICU. Few older adults (2.6%) were admitted to the hospital with evidence of preexisting delirium, but 28.3% developed delirium in the SICU and 22.7% during the post-SICU period. A total of 52 of 114 (45.6%) participants were delirious sometime during their hospital stay or 24 hours before hospital admission. Episodes of deep sedation and nonarousal were uncommon, occurring in only 9.7% of the sample. Older adults admitted to SICUs were at high risk for developing delirium during hospitalization. Further research is needed to elucidate the risk factors for, and outcomes of, delirium in this uniquely vulnerable population.

Improved nurse job satisfaction and job retention with the transition from a “mandatory consultation” model to a “semiclosed” surgical intensive care unit: A 1-year prospective evaluation*

The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). Prospective longitudinal survey. Tertiary-care university hospital. SICU staff nurses. Change from mandatory consultation to semiclosed SICU. We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001). Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.

Utilization of Intensive Care Resources in Bariatric Surgery

Obese patients occasionally require either elective or emergency critical care services following bariatric surgery. We describe this subgroup of patients. From July 1, 1991 to July 31, 2004, we performed 1,279 bariatric operations; 241 (19%) required admission to the surgical critical care service. We retrospectively reviewed medical records for gender, body mass index (BMI), age, whether the operation was initial or revisional, and whether critical care admission was elective or emergent. 3 complication clusters (thromboembolic, pulmonary, and anastomotic) were identified using discharge ICD-9 codes. The costs and length of stay of these subpopulations was calculated. Patients were on average 46+/-10 years old, with BMI 59+/-13. Critical care admission was emergent in 52.7% (n=127) of cases. Revisional cases did not differ from the initial cases in BMI (56.4 vs 59.2, P=0.42) and they were no more likely to require emergent critical care admission than initial cases (P=0.16). Revisional cases were hospitalized longer (27.2+/-25.6 vs 12.5+/-18.7 days, P=0.003); had higher total hospital costs (US$ 60,631+/-78,337 vs 27,697+/-52,351, P=0.025); and were more likely to die from their complications (revisional surgery mortality 6.5% vs 1.9% for initial surgery [P=0.002]). An increasing number of surgical revisions will likely accompany the recent increase in popularity of bariatric surgery. In our experience, these patients require significant critical care services, and have longer, complicated, and more costly hospitalizations.

Decreased laboratory utilization in an “intensivist managed” surgical intensive care unit: A prospective study

Abstract Introduction: Phlebotomy accounts for 30% of blood transfused in the ICU. Organ dysfunction correlates with number of blood draws and total blood volume drawn. In order to improve quality of patient care, our SICU changed from a traditional open SICU to an managed SICU. We hypothesized that coordination of all orders by a dedicated managed surgical critical care service (SCCS) would decrease the number of labs performed, improve lab utilization, and decrease lab costs. Methods: We prospectively studied two distinct critical care delivery systems. The same intensivist team simultaneously treated two patient cohorts. One cohort was managed (only the SCCS wrote patient care orders). The open cohort had orders written by both the SCCS and the primary surgical service. Data were collected in a prospective, blinded fashion. Cohorts were compared by 24-hour APACHE II scores, number and type of daily labs, and lab costs. Student's t-test and chi-square were used. Results: Data were accrued for 1746 SICU patient days over a 4-month period. APACHE II scores were higher in the managed cohort. There were significantly fewer lab studies and lower costs per patient per SICU day in the managed patients. There was no difference in mortality. Table 1Decreased lab utilization and cost in an managed surgical ICUManaged cohortOpen cohortp ValueNumber of patient SICU days998748APACHE 2 score at 24 hours15.9∗12.7p Conclusions: Intensivist managed SICU patients had fewer lab tests than patients in the open SICU system. There was no negative impact on mortality. This improved lab utilization cost $59,000 less over 4 months and has a projected yearly saving of $369,000.

Defining surgical critical care as an integrated specialty

PurposeAmong general surgeons, resistance to incorporating critical care specialists into the mainstream of surgical critical care is well documented. Loss of control, fragmentation of care, added cost, and the abdication of expertise are frequently cited as objections to this approach. In 1992, we began to explore the feasibility of developing a fully integrated, multidisciplinary surgical critical care program, structured to avoid these pitfalls. The conversion from a traditional nonintegrated surgical model was completed in 1993. This report summarizes the structural changes and results of this effort. MethodsThe Surgical Critical Care Service was converted from a combined trauma/critical care service into a multidisciplinary section of the Department of Surgery, composed of 12 full-time faculty (7 surgeons, 5 nonsurgeons). All (surgeons and nonsurgeons) are active full-time members of the department with a director (nonsurgeon) and a residency program director (surgeon) who report to the chairman of the department. Patient care is both vertically (surgical team) and horizontally (intensive-care-unit team) integrated with a surgical/critical care resident functioning as the key crossover member of both teams. Educational programs are organized and administered by the residency program director with faculty choice based on ability rather than training background. A work group composed of the chairman, key section directors (anesthesiology, critical care, trauma, burns, and cardiac surgery), and the assistant vice president of nursing meet monthly to provide global direction and resolve differences of opinion. ResultsTension between general surgeons and critical care specialists has been eliminated. Objective performance parameters have significantly improved since the conversion. Resident evaluations and American Board of Surgery In-Service Training Examination (ABSITE) performance remained constant or improved after conversion. ConclusionThe development of a multidisciplinary critical care program based in the Department of Surgery relieves professional tensions, improves the quality of care, and enhances educational and research opportunities for both critical care and general surgery residents.