Surgical Trauma Intensive Care Unit Research Articles

Understanding Gram-negative Central Line-Associated Blood Stream Infection in a Surgical Trauma ICU

The purpose of this study was to review central line-associated blood stream infection (CLABSI) data from a surgical trauma intensive care unit to better understand patient risk factors, pathogens, and treatment interventions. We performed a retrospective review of all surgical ICU patients who met the Centers for Disease Control definition for Gram-negative CLABSI from 2006 through 2013. Demographics, pathogens, interventions, and outcomes were evaluated. A total of 40 patients were included with an average age of 49.9 ± 19 years and 72.5 per cent male. The average length of central venous line (CVL) was 11 ± 5.9 days with average time from line placement to positive culture 9.4 ± 6.8 days. Most common organisms were Enterobacter species (37.5%) with 17.8 per cent of all cultured organisms considered multidrug resistant. Piperacillin-tazobactam (67.5%) was the most commonly used antibiotic. Overall mortality rate was 22.5 per cent. A total of 11 patients who developed a recurrence did so at 10.7 ± 8 days and were similar to those without recurrence. Predominant pathogens associated with surgical trauma intensive care unit CLABSI in this study are different from those Gram-negative bacteria associated with published studies in the general hospital population. Further investigation into risk factors for infection and relapse is important to minimize such consequences. Understanding appropriate line placement and use as well as clarifying optimal duration of therapy is integral in improving outcomes.

I Am a Critical Care Nurse.

Alisha Burnett, RN, is a staff nurse in the surgical trauma intensive care unit at Tampa General Hospital, Tampa, Florida.

Prevalence of Device-associated Nosocomial Infections Caused By Gram-negative Bacteria in a Trauma Intensive Care Unit in Libya.

Device-associated nosocomial infections (DANIs) have a major impact on patient morbidity and mortality. Our study aimed to determine the distribution rate of DANIs and causative agents and patterns of antibiotic resistance in the trauma-surgical intensive care unit (ICU). . Our study was conducted at Abusalim Trauma Hospital in Tripoli, Libya. All devices associated with nosocomial infections, including central venous catheters (CVC), endotracheal tubes (ETT), Foley's urinary catheters, chest tubes, nasogastric tubes (NGT), and tracheostomy tubes, were removed aseptically and examined for Gram-negative bacteria (GNB). . During a one-year study period, 363 patients were hospitalized; the overall mortality rate was 29%. A total of 79 DANIs were identified, the most common site of infection was ETT (39.2%), followed by urinary catheters (19%), NGTs (18%), tracheostomy tubes (11%), CVCs (10%), and chest tubes (3%). The most frequently isolated organisms were Klebsiella pneumonia, Acinetobacter baumannii, and Pseudomonas aeruginosa (30%, 20%, and 14%, respectively). Extremely high resistance rates were observed among GNB to ampicillin (99%), cefuroxime (95%), amoxicillin-clavulante (92%), and nitrofurantoin (91%). Lower levels of resistance were exhibited to amikacin (38%), imipenem (38%), and colistin (29%). About 39% of the isolates were defined as multi-drug resistant (MDR). Overall, extended spectrum β-lactmase producers were expressed in 39% of isolates mainly among K. pneumonia (88%). A. baumannii isolates exhibited extremely high levels of resistance to all antibiotics except colistin (100% sensitive). In addition, 56.3% of A. baumannii isolates were found to be MDR. P. aeruginosa isolates showed 46%-55% effectiveness to anti-pseudomonas antibiotics. . High rates of DANI's and the emergence of MDR organisms poses a serious threat to patients. There is a need to strengthen infection control within the ICU environment, introduce surveillance systems, and implement evidence-based preventive strategies.

Impact of a Multifaceted Intervention on Prescribing of Proton Pump Inhibitors for Stress Ulcer Prophylaxis in the Critically Ill

Background:: Lack of well-supported evidence clearly defining one agent as superior to the other for use in stress ulcer prophylaxis (SUP) has led to an array of treatment strategies. Studies comparing histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) have shown H2RAs to be non-inferior to PPIs at preventing clinically significant gastric bleeding. This, in addition to the decreased cost associated with H2RAs, has led to the adoption of H2RAs as the preferred agent for SUP at our institution. Objectives:: To evaluate the impact of developing a guideline and removing PPIs from computerized order entry PowerPlans on PPI prescribing for SUP in critically ill patients. Patients and Methods:: Members of the critical care service developed a guideline to direct SUP and removed pantoprazole from two critical care admission PowerPlans. In this interventional study with a historical control, adult patients admitted to the medical or surgical-trauma ICU and prescribed a PPI were evaluated during two time periods before and after the interventions. Patients were excluded if they were receiving a PPI for a reason other than SUP. Patients were assessed daily for an indication for SUP. These included mechanical ventilation, high dose steroids, and coagulopathy. Results:: A total of 92 and 60 patients were included in the pre- and post-intervention groups, respectively. PPI use for SUP was reduced from 38% in the pre-intervention group to 15.6% in the post-intervention group (P < 0.0001). PPI days adjusted for LOS were not different between the pre- and post-intervention groups (84% vs 86%, P = 0.5909). Of the total PPI days, 52.4% (95% CI 48.8 - 56.1) were classified as inappropriate because there was no indication, while the remaining 47.6% (95% CI 43.9 - 51.2) had an indication but should have received a H2RA. The total cost associated with guideline non-adherence was $1802. Conclusions:: Our multifaceted intervention reduced the number of days in which a PPI was prescribed for SUP in the overall ICU population; however, it did not impact the duration of PPI therapy. Patients either had no indication for SUP, or had an indication where less costly H2RAs could have been used. Additional opportunity exists to improve cost-effective prescribing of SUP for critically ill patients.

Impact of nursing education by a pharmacist on sedation practice in a trauma surgical intensive care unit.

Benefits of pharmacist-provided education on nurse-driven sedation protocols have not been assessed. Trauma intensive care unit nurses received pharmacist-provided education on the hospital's sedation protocol. Sedation outcomes were assessed for patients in the preeducation (n = 29) and posteducation (n = 33) groups. The primary outcome of sedation scores at goal was not significantly different (41% vs 60%; P = .169), while more patients experienced oversedation (50% vs 32%; P = .013) in the pre- vs posteducation groups, respectively. No patient experienced self-extubation. Despite similar achievement of goal sedation scores before and after pharmacist-provided education, the posteducation group experienced fewer incidences of oversedation with no difference in self-extubation.

Agitation onset, frequency, and associated temporal factors in critically ill adults.

Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs. To describe the incidence, onset, and temporal factors related to agitation in critically ill adults. Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient. Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation. Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days.

Improved Analgesia, Sedation, and Delirium Protocol Associated with Decreased Duration of Delirium and Mechanical Ventilation

Introduction of sedation protocols has been associated with improved patient outcomes. It is not known if an update to an existing high-quality sedation protocol, featuring increased patient assessment and reduced benzodiazepine exposure, is associated with improved patient process and outcome quality metrics. This was an observational before (n = 703) and after (n = 780) cohort study of mechanically ventilated patients in a 24-bed trauma-surgical intensive care unit (ICU) from 2009 to 2011. The three main protocol updates were: (1) requirement to document Richmond Agitation Sedation Scale (RASS) scores every 4 hours, (2) requirement to document Confusion Assessment Method-ICU (CAM ICU) twice daily, and (3) systematic, protocolized deescalation of excess sedation. Multivariable linear regression was used for the primary analysis. The primary outcome was the duration of mechanical ventilation. Prespecified secondary endpoints included days of delirium; the frequency of patient assessment with the RASS and CAM-ICU instruments; benzodiazepine dosing; durations of mechanical ventilation, ICU stay, and hospitalization; and hospital mortality and ventilator associated pneumonia rate. Patients in the updated protocol cohort had 1.22 more RASS assessments per day (5.38 vs. 4.16; 95% confidence interval [CI], 1.05-1.39; P < 0.01) and 1.15 more CAM-ICU assessments per day (1.49 vs. 0.35; 95% CI, 1.08-1.21; P < 0.01) than the baseline cohort. The mean hourly benzodiazepine dose decreased by 34.8% (0.08 mg lorazepam equivalents/h; 0.15 vs. 0.23; P < 0.01). In the multivariable model, the median duration of mechanical ventilation decreased by 17.6% (95% CI, 0.6-31.7%; P = 0.04). The overall odds ratio of delirium was 0.67 (95% CI, 0.49-0.91; P = 0.01) comparing updated versus baseline cohort. A 12.4% reduction in median duration of ICU stay (95% CI, 0.5-22.8%; P = 0.04) and a 14.0% reduction in median duration of hospitalization (95% CI, 2.0-24.5%; P = 0.02) were also seen. No significant association with mortality (odds ratio, 1.18; 95% CI, 0.80-1.76; P = 0.40) was seen. Implementation of an updated ICU analgesia, sedation, and delirium protocol was associated with an increase in RASS and CAM-ICU assessment and documentation; reduced hourly benzodiazepine dose; and decreased delirium and median durations of mechanical ventilation, ICU stay, and hospitalization.

804

Introduction: Hospital-acquired Clostridium difficile infection remains a leading source of morbidity and mortality among hospitalized patients. The purpose of this study was to explore antibiotics use as a risk factor for a cluster of C. difficile cases in trauma-surgical intensive care unit (TSICU

736

Introduction: Trauma patients typically have numerous injuries that require the use of opioid narcotics to control pain. The repeated use of these agents has been associated with decreased bowel motility which leads to a lack of bowel movements and constipation. There have been several agents used to try and combat opioid induced constipation. This study retrospectively evaluates the use of two specific enteral regimens: senna and docusate or naloxone and docusate. Methods: This is a retrospective review of patients admitted to the surgical-trauma intensive care unit (STICU) at CAMC General Division in Charleston, West Virginia between 1/1/2007 until 8/15/2012. All patients included in this analysis received enteral regimens of either naloxone and docusate or senna and docusate to facilitate bowel movements. Study endpoints included the number of days until the first bowel movement, the frequency of subsequent bowel movements, and toleration of tube feedings following initiation of the study medications. Additional assessments were made comparing opioid analgesic exposure between the study groups. Administered narcotic analgesics were converted to equipotent doses of morphine for the purpose of this comparison. Results: Seventy-seven patients were included in the study with 23 receiving naloxone and docusate and 54 receiving senna and docusate. Following the initiation of a bowel regimen the median length of time until the first bowel movement was 5 days in the naloxone and docusate arm and 2 days in the senna and docusate arm (p=0.01). The frequency of bowel movements also differed significantly between the study arms. The median number of bowel movements per week for patients receiving senna and docusate was 4 versus 1 in the naloxone and docusate arm (p=0.02). There were no differences seen in tube feed toleration between the study arms. A significant difference was seen in the amount of narcotic exposure between the study arms. Patients in the naloxone and docusate arm received a median amount of 188mg morphine exposure per day compared to 45mg for the senna and docusate arm (p=0.001). Conclusions: The use of senna and docusate was superior to naloxone and docusate at producing bowel movements in patients receiving continuous or scheduled opioid analgesics. Senna and docusate was also found to promote more frequent bowel movements in this patient population. Patients in the naloxone and docusate group were exposed to significantly larger daily doses of opioid narcotics which may have influenced the superior effects noted with senna and docusate.

Predicting the need for urgent intubation in a surgical/trauma intensive care unit

Analysis and modeling of data monitoring vital signs and waveforms in patients in a surgical/trauma intensive care unit (STICU) may allow for early identification and treatment of patients with evolving respiratory failure. Between February 2011 and March 2012, data of vital signs and waveforms for STICU patients were collected. Every-15-minute calculations (n = 172,326) of means and standard deviations of heart rate (HR), respiratory rate (RR), pulse-oxygen saturation (SpO2), cross-correlation coefficients, and cross-sample entropy for HR-RR, RR-SpO2, and HR-SpO2, and cardiorespiratory coupling were calculated. Urgent intubations were recorded. Univariate analyses were performed for the periods <24and ≥24 hours before intubation. Multivariate predictive models for the risk of unplanned intubation were developed and validated internally by subsequent sample and bootstrapping techniques. Fifty unplanned intubations (41 patients) were identified from 798 STICU patients. The optimal multivariate predictive model (HR, RR, and SpO2 means, and RR-SpO2 correlation coefficient) had a receiving operating characteristic (ROC) area of 0.770 (95% confidence interval [CI], 0.712-0.841). For this model, relative risks of intubation in the next 24 hours for the lowest and highest quintiles were 0.20 and 2.95, respectively (15-fold increase, baseline risk 1.46%). Adding age and days since previous extubation to this model increased ROC area to 0.865 (95 % CI, 0.821-0.910). Among STICU patients, a multivariate model predicted increases in risk of intubation in the following 24 hours based on vital sign data available currently on bedside monitors. Further refinement could allow for earlier detection of respiratory decompensation and intervention to decrease preventable morbidity and mortality in surgical/trauma patients.

Retrospective analysis of levetiracetam compared to phenytoin for seizure prophylaxis in adults with traumatic brain injury.

Phenytoin is standard of care for seizure prophylaxis following traumatic brain injury (TBI). Levetiracetam, an alternative antiepileptic drug, is utilized for seizure prophylaxis despite limited data supporting its use. Our primary outcome was post-TBI seizure activity measured by electroencephalogram (EEG) for levetiracetam versus phenytoin. Secondary outcomes were length of intensive care unit (ICU) stay, requirement for additional antiepileptic drugs (AED), and drug and monitoring costs. A retrospective review was performed of patients admitted to neurosurgical or surgical trauma ICU. Adult patients with at least 1 day of EEG monitoring were included. Patients were excluded if they had history of epilepsy, prior TBI, less than 48 hours of AED therapy, or additional AED prior to EEG monitoring. A total 90 patients met inclusion criteria, with 18 receiving levetiracetam and 72 receiving phenytoin. Prevalence of EEG-confirmed seizure activity was similar between the levetiracetam and phenytoin groups (28% vs 29%; P = .99). ICU length of stay (13 vs 18 days; P = .28), time to EEG-confirmed seizure activity (4 vs 6 days; P = .24), and duration of seizure prophylaxis (9 vs 14 days; P = .18) were also similar. The median daily cost of levetiracetam therapy was $43 compared to $55 for phenytoin therapy and monitoring (P = .08). When all anticonvulsant therapy and monitoring were included, costs were lower for the levetiracetam group ($45 vs $83; P = .02). Levetiracetam may provide an alternative treatment option for seizure prevention in TBI patients in the ICU. Total antiepileptic drug and monitoring costs were lower for levetiracetam patients.

Medicine versus surgery/anesthesiology intensivists: a retrospective review and comparison of outcomes in a mixed medical–surgical–trauma ICU

With various types of complex patients being treated in a mixed medical- surgical- trauma intensive care unit (ICU), we hypothesized that there should be no difference in patient mortality with respect to the core training of the intensivist. We reviewed the cases of all patients admitted to a mixed medical-surgical-trauma ICU at a Canadian university teaching hospital in 2007. Patients were assigned to 1 of 2 treatment groups (internal medicine, surgery/anesthesiology) based on the treating intensivist's training. Our primary outcome was to compare patient mortality in the ICU between the groups. We used generalized estimating equations to determine 10-day mortality after admission to the ICU. A multivariate Cox hazard model was used to determine statistical significance and 95% confidence intervals (CIs) for 11- to 60-day mortality in the ICU. A total of 961 patients were admitted from January to December, 2007. We found no significant difference between the groups in 10-day mortality (odds ratio 0.73, 95% CI 0.46-1.18, p = 0.20) and 11- to 60-day mortality (hazard ratio 1.43, 95% CI 0.62-3.30, p = 0.40) after admission to the ICU. In a large university trauma centre that operates a mixed medicine- surgical-trauma ICU, there was no significant difference in mortality between patients managed by intensivists with core training in internal medicine and those managed by intensivists with training in surgery/anesthesiology.

Evaluating Pain, Sedation, and Delirium in the Neurologically Critically Ill—Feasibility and Reliability of Standardized Tools

To assess the feasibility and reliability of systematic evaluations of analgesia, sedation level, and delirium features in the neurologically critically ill and to determine whether delirium features are linked to clinical outcomes in this population. Multicentered prospective observational study. Neurological, Neurosurgical, Neurosciences or Surgical Trauma ICUs from three hospitals (two in Canada and one in the United States). A convenience sample of adult NICU or neurologic, neurosurgical, neurosciences, or surgical trauma ICU patients admitted for greater than 12 hours from November 2011 to April 2012. Systematic assessments were simultaneously and independently performed by a neurologist, intensivists, or trauma surgeon, and a nurse in three multispecialty ICUs. Pain was evaluated with the numeric rating scale or behavioral pain scale. Sedation was assessed using the Richmond Agitation-Sedation Scale. Patients with Richmond Agitation-Sedation Scale greater than or equal to -4 were screened for features of delirium with the Intensive Care Delirium Screening Checklist. Intraclass correlation coefficient was used to evaluate inter-rater reliability between the nurse and the physician for pain and sedation scales, and the kappa coefficient was calculated for concordance of the Intensive Care Delirium Screening Checklist items. 151 patients had 439 assessments. Pain and sedation were always assessable with excellent inter-rater reliability (numeric rating scale intraclass correlation coefficient, 0.92; behavior pain scale intraclass correlation coefficient, 0.83; and Richmond Agitation-Sedation Scale intraclass correlation coefficient, 0.92). Patients were sufficiently alert for delirium screening 3/4 of the time; Intensive Care Delirium Screening Checklist items had good concordance (kappa coefficients between 0.58 and 0.91 for the eight Intensive Care Delirium Screening Checklist items). Nonevaluable items were most often orientation, hallucinations, and speech or mood content. Furthermore, each additional Intensive Care Delirium Screening Checklist item present in proportion to the total evaluable Intensive Care Delirium Screening Checklist score was associated with a 10% increase in ICU length of stay. Pain and sedation can be systematically assessed in the neurologically critically ill; the majority can also be screened for delirium features with excellent inter-rater reliability. Increased proportion of Intensive Care Delirium Screening Checklist items is associated with worse outcomes.

Evaluation of glucose variability when converting from insulin infusion to basal-bolus regimen in a surgical-trauma intensive care unit

PurposeThis study aimed to identify predictive factors resulting in glucose values greater than 200 mg/dL in patients with trauma transitioned from an insulin infusion to a basal-bolus subcutaneous insulin regimen. Materials and MethodsThirty-nine patients with trauma on goal enteral nutrition in the intensive care unit receiving an insulin infusion for at least 48 hours and transitioned to a basal-bolus regimen were retrospectively identified. ResultsTen patients had hyperglycemic events after transition. Hyperglycemia was significantly associated with increased age (42 [17] years vs 56 [13] years, P = .02), admission glucose (128 [39] mg/dL vs 214 [91] mg/dL, P = .015), and insulin drip rate 48 hours before transition (87 [38] units/d vs 127 [49] units/d, P = .012). There was no difference between groups with respect to injury severity, demographics, or physiologic parameters. Multiple regression analysis revealed that increased age (odds ratio [OR], 1.215 [1.000-1.477]; P =.05), increased admission blood glucose (OR, 1.053 [1.006-1.101]; P =.025), and higher insulin infusion rates 48 hours before transition (OR, 1.061 [1.009-1.116]; P =.020) predisposed patients to severe hyperglycemic episodes. ConclusionsOlder patients with trauma and patients with higher blood glucose on admission are more likely to experience severe hyperglycemia when transitioned to basal-bolus glucose control. Higher insulin infusion rates at 48 hours before transition are also associated with severe hyperglycemia.

Aggressive versus conservative initiation of antibiotics – Authors' reply

We appreciate the comments in response to our recent publication. However, before addressing the specific concerns, we wish to place the study in a clinical context. We work in a 15-bed, surgical trauma intensive-care unit (ICU). As we write this letter, 13 of our patients meet at least two of the criteria for systemic inflammatory response syndrome and they all have at least one organ system dysfunction. Five are being treated for a documented infection, and the remaining eight could possibly be infected and are in various stages of assessment. The question is do we need to give antimicrobials to all these patients, who meet criteria for severe sepsis but not septic shock? We don’t think so, yet the misinterpretation of previous retrospective studies implies this is the case. A more conservative approach, based on our data,1 seems to be safe. Our research showed improved mortality in haemodynamically stable, surgical ICU patients after waiting for objective evidence of infection before starting empirical antimicrobials. These findings might be related to our study of traumatised and postsurgical patients in whom persistent inflammation is common, decreasing the specificity of many signs of infection, including hyperthermia and leucocytosis. Additionally, our analysis excluded patients admitted to the ICU with sepsis, which was often the focus of past publications. Since infections in our study were all ICU-acquired, they were secondary events and, therefore, their characteristics might be different from those in which infection is the primary problem. Delay in empirical antibiotic administration (12 h in the aggressive treatment group) might have confounded our study’s results. How ever, these data are similar to the 17 h delay documented by Barie and colleagues2 in a similar ICU. As a pragmatic, protocol implementation trial, these findings are probably typical in patients in whom diagnosis is not clear. Additionally, the timing data were based on time to definitive intervention, not antimicrobial admini stration. Thus, a patient who had blood cultures sent and antimicrobials started 1 h later, but 24 h later underwent drain placement, was considered as having their therapy started 24 h after blood culture, not 1 h. In terms of empirical antibiotics, we used piperacillin/tazobactam and vancomycin according to institutional antibiotic stewardship guidelines. The most common pathogens that were treated inadequately were vancomycin-resistant enterococci (VRE) and yeast (predominantly Candida albicans). Whether substituting linezolid or daptomycin for vancomycin to empirically treat VRE would improve outcomes is unclear. Antifungal drugs were started empirically in patients with a high suspicion of a fungal infection (eg, upper gastrointestinal leak), but antifungal agents are unlikely to benefit all normotensive patients suspected of having a new infection. Finally, prophylactic perioperative antibiotics might have changed culture results. Most infections, however, occurred many days after an operation and this confounder might be of less importance. Ideally, we would have done the study in two equivalent ICUs, where patients in one unit would have been treated under the aggressive protocol throughout the study to control for other changes in therapy, but we only have access to one surgical ICU. Also, we could have incorporated all patients admitted to the ICU into our data analysis, but ultimately chose to focus on those with infections. An expanded, multicentre study has been proposed to collect such variables. Finally, a randomised controlled study would have been an alternative trial design, but would not have answered questions of effectiveness (as opposed to efficacy) and would not have allowed a full understanding of the effect of the different approaches on unit-wide epidemiology. We hope to address these concerns in a multicentre study that will use cluster randomisation.

369

Introduction: An increase in central line associated bacteremias (CLABs) in patients on total parenteral nutrition (TPN) in our Surgical / Trauma Intensive Care Unit (STICU) prompted further investigation. Hypothesis: Increased CLABs with TPN in ICU patients may be associated with TPN related metabolic derangements, patient acuity and catheter management. Methods: 71 STICU patients on TPN between January 2009 and March 2012 were reviewed. Demographics including age and gender, diagnosis, ICU length of stay, TPN indication, catheter site and duration were collected. Triglyceride and serum glucose levels during TPN were recorded as metabolic indicators. The need for mechanical ventilation and vasopressors were used as acuity indicators. We determined CLABs by our Infection Prevention and Control criteria. All STICU CLABs were reviewed. Antimicrobial catheters were placed using a standardized central line bundle kit. The above data was compared to non STICU patients on TPN. Results: 10% of TPN patients developed CLABs over a period of 4 years, representing 30% of all STICU CLABs. The diagnoses were: 20% traumatic injuries, 18% GI perforation, 8.5% pancreatitis, 15.5% sepsis, 10% intestinal obstruction, 7% GI malignancy, 8.5% ischemic bowel and 12.6% other. There was no difference in age, gender, need for mechanical ventilation or vasopressors between CLABs and non CLABs patients. Triglyceride and glucose levels were elevated in CLABs patients but not significantly. There was no difference in catheter site with the internal jugular being most common in both groups. Catheters in patients with CLABs were in place for 11.8 days on average vs. 8.3 days in noninfected ones (p=0.0034). CLABs developed on an average of 11 days from catheter insertion. STICU length of stay was significantly longer in the CLABs patients (p= 0.0066) as was duration of TPN (p= 0.0033). No CLABs were identified in 95 non ICU patients that received TPN. Conclusions: In ICUs, TPN plays a significant role in CLABs development. Since no CLABs were identified in non ICU patients on TPN this may be due to patient acuity and catheter manipulation. In the ICU, catheters used for TPN should be closely monitored and may require more frequent replacement.

Improving Glycemic Control With the Adjunct Use of a Data Management Software Program

Background Published studies have supported the implementation of tight glucose control (TGC) programs to improve patient outcomes and reduce mortality rates. However, measuring a program’s efficiency is challenging, because of a lack of systems that capture data, allow access to data, and support analysis and interpretation in a near prospective time frame. We hypothesized that providing clinicians access to real-time blood glucose (BG) results reports could improve the efficacy of our TGC program. Methods We performed a retrospective review of BG data during a 12-month period in a surgical trauma intensive care unit at a level I trauma center. A unit-specific insulin algorithm was used throughout the study. We compared BG values before and after the implementation of a data management software program that allowed clinicians access to real-time BG results reports. Reports were run daily and weekly to monitor the unit’s TGC program. Results A total of 70 616 BG values from 1044 patients were analyzed. An overall decrease was observed in the BG level mean, from 121 mg/ dL to 112 mg/dL (P&amp;lt;.001), as well as a decrease in the aggregated mean across patients, from 132 mg/dL to 119 mg/dL (P&amp;lt;.001), after implementation of the software. The percentage of values within the target range of 80 to 110 mg/dL increased from 38.9% to 50.4% (P&amp;lt;.001). The percentage of BG values less than 70 increased from 2.7% to 3.4% (P&amp;lt;.001). However, the percentage of severe hypoglyce-mic episodes (≤40 mg/dL) remained unchanged. Conclusions Access to real-time aggregated BG data reports through the use of a data management software program improved the efficacy of our TGC program.

Checklists change communication about key elements of patient care

Combat casualty care is distributed across professions and echelons of care. Communication within it is fragmented, inconsistent, and prone to failure. Daily checklists used during intensive care unit (ICU) rounds have been shown to improve compliance with evidence-based practices, enhance communication, promote consistency of care, and improve outcomes. Checklists are criticized because it is difficult to establish a causal link between them and their effect on outcomes. We investigated how checklists used during ICU rounds affect communication. We conducted this project in two military ICUs (burn and surgical/trauma). Checklists contained up to 21 questions grouped according to patient population. We recorded which checklist items were discussed during rounds before and after implementation of a "must address" checklist and compared the frequency of discussing items before checklist prompting. Patient discussions addressed more checklist items before prompting at the end of the 2-week evaluation compared with the 2-week preimplementation period (surgical trauma ICU, 36% vs. 77%, p < 0.0001; burn ICU, 47% vs. 72 %, p < 0.001). Most items were addressed more frequently in both ICUs after implementation. Key items such as central line removal, reduction of laboratory testing, medication reconciliation, medication interactions, bowel movements, sedation holidays, breathing trials, and lung protective ventilation showed significant improvements. Checklists modify communication patterns. Improved communication facilitated by checklists may be one mechanism behind their effectiveness. Checklists are powerful tools that can rapidly alter patient care delivery. Implementing checklists could facilitate the rapid dissemination of clinical practice changes, improve communication between echelons of care and between individuals involved in patient care, and reduce missed information.

Conducting a Multidisciplinary Morbidity and Mortality Conference in the Trauma-Surgical Intensive Care Unit

The trauma-surgical intensive care unit at Harborview Medical Center has developed a multidisciplinary case review process to allow discussion of complications and issues in an open forum among multiple services. Conducted monthly, this meeting provides a forum for clear communication between members of the patient care team with the goal of developing best practices, system changes, and policies that will minimize risk for the patients and provide education for the staff.

Liénard-type dynamical system models for the simulation of the human heart atrium

on the instantaneous health status of the patient. Most of these data are lost soon after it is recorded. The objective of this project is to develop a computing cluster to record and process all physiological data from all ICU bedside monitors within a hospital. Methods: Custom informatics server software was written to link 10 off-the-shelf commodity computers into a cluster computing system. An SQL database was constructed to organize the physiological and clinical data of patients. A graphical user interface was constructed in MATLAB to allow for easy data inspection, visualization, and markup. Physiological data are distributed to the nodes of this system each night. Results: The informatics cluster computing system has been online since January 2009 at the University of Virginia Medical Center. The system contains 80 processors, 40 GB of RAM and 100 TB of hard-drive capacity, including redundant data storage. Approximately 100 MB of data are recorded per bed per day and are composed of 3 electrocardiograms, chest impedance, oxygen saturation, heart rate, blood pressure, as well as other vital signs and waveforms. The system contains a largely complete physiological record of the approximately 1200 patients admitted to the neonatal ICU, pediatric ICU, and surgical trauma ICU since the system became operational. This system is currently being rolled out at Texas Children's Hospital. Conclusions: We have successfully deployed a cluster computing system to capture and process physiological data from bedside monitors within an ICU environment. We are using this system to develop new metrics for patient health, which can eventually be presented to the physician at the bedside to better guide their care.