Department of Medicine, University of California, San Francisco, San Francisco, California; and Department of Medicine, University of Washington, Seattle, Washington.
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PMID: 11897638
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Anesth Analg 2002 Jan;94(1 Suppl):S41-3
Department of Neonatology and Pediatric Pulmonology, Hannover Medical School, Germany. poets.christian@mh-hannover.de
[Medline record in process]
PMID: 11900037, UI: 21896703
Br J Anaesth 2001 Nov;87(5):678-81
Publication Types:
PMID: 11878515, UI: 21867291
Br J Anaesth 2001 Nov;87(5):677-8
PMID: 11878514, UI: 21867290
Chest 2002 Feb;121(2):539-48
Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. sirioca@anes.upmc.edu
OBJECTIVE: To compare the utilization and outcomes of critical care services in a cohort of hospitals in the United States and Japan. DESIGN: Prospective data collection on 5,107 patients and detailed organizational characteristics from each of the participating Japanese study hospitals between 1993 and 1995, with comparisons made to prospectively collected data on the 17,440 patients included in the US APACHE (acute physiology and chronic health evaluation) III database. SETTING: Twenty-two Japanese and 40 US hospitals. PATIENTS: Consecutive, unselected patients from medical, surgical, and mixed medical/surgical ICUs. MEASUREMENTS: Severity of illness, predicted risk of in-hospital death, and ICU and hospital length of stay (LOS) were assessed using APACHE III. Japanese ICU directors completed a detailed survey describing their units. MAIN RESULTS: US and Japanese ICUs have a similar array of modalities available for care. Only 1.0% (range, 0.56 to 2.7%) of beds in Japanese hospitals were designated as ICUs. The organization of the Japanese and US ICUs varied by hospital, but Japanese ICUs were more likely to be organized to care for heterogeneous diagnostic populations. Sample case-mix differences reflect different disease prevalence. ICU utilization for women is significantly lower (35.5% vs 44.8% of patients) and there were relatively fewer patients > or = 85 years old in the Japanese ICU cohort (1.2% vs 4.6%), despite a higher per capita rate of individuals > or = 85 years old in Japan. The utilization of ICUs for patients at low risk of death significantly less in Japan (10.2%) than in the United States (12.9%). The APACHE III score stratified patient risk. Overall mortality was similar in both national samples after accounting for differences in hospital LOS, utilizing a model that was highly discriminating (receiver operating characteristic, 0.87) when applied to the Japanese sample. The application of a US-based mortality model to a Japanese sample overestimated mortality across all but the highest (> 90%) deciles of risk. Significant variation in expected performance was noted between hospitals. Risk-adjusted ICU LOS was not significantly longer in Japan; however, total hospital stay was nearly twice that found in the US hospitals, reflecting differences in hospital utilization philosophies. CONCLUSIONS: Similar high-technology critical care is available in both countries. Variations in ICU utilization reflect differences in case-mix and bed availability. Japanese ICU utilization by gender reflects differences in disease prevalence, whereas differences in utilization by age may reflect differences in cultural norms regarding the limits of care. Such differences provide context from which to assess the delivery of care across international borders. Miscalibration of predictive models applied to international data samples highlight the impact that differences in resource use and local practice cultures have on outcomes. Models may require modification in order to account for these differences. Nevertheless, with large databases, it is possible to assess critical care delivery systems between countries accounting for differences in case-mix, severity of illness, and cultural normative standards facilitating the design and management such systems.
PMID: 11834670, UI: 21823578
Chest 2002 Feb;121(2):326-8
PMID: 11834638, UI: 21823546
Crit Care Med 2002 Jan;30(1):256-7
PMID: 11905406, UI: 21898946
Crit Care Med 2002 Jan;30(1):94-9
Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA.
OBJECTIVE: To investigate statewide variation in failure to utilize existing regional pediatric intensive care units (PICUs). METHODS: Deaths of children in hospitals lacking specialized units (non-PICU hospitals) were postulated to represent possible PICU utilization failures. A survey study was performed on hospital inpatient discharges and deaths in 1997, using data obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Children 0-14 yrs old were studied, excluding neonatal Diagnosis-Related Groups and emergency department deaths. Hospitals were considered to have a PICU if they had a board-certified pediatric intensivist on staff, and either New York State designation as a PICU or a separate dedicated unit for children. Non-PICU hospital pediatric death rates were compared for health service areas to determine whether regional variation occurred. RESULTS: Statewide, 157 of 584 (27%) pediatric hospital inpatient deaths occurred in non-PICU hospitals. Significant variation was seen among eight regions in pediatric death rates in non-PICU hospitals (p < .05). The 114 of 328 (35%) New York City inpatient deaths occurring in non-PICU hospitals significantly exceeded the 43 of 256 (17%) throughout the remainder of the state (p < .05). New York City non-PICU hospital death rates also were higher than in the rest of the state, when expressed per 100,000 pediatric population (8.04 vs. 2.00), and per 1,000 non-PICU hospital discharges (2.25 vs. 1.18), respectively (p < .05). Forty percent of New York City non-PICU hospitals experienced a pediatric inpatient death compared with only 13% in the rest of the state (p < .05). CONCLUSIONS: Although the death of some children in hospitals lacking a PICU is expected, the significant regional variation in these deaths suggests that local obstacles, perhaps unique to metropolitan areas, may interfere with access to existing pediatric critical care resources.
PMID: 11902295, UI: 21898917
Crit Care Med 2002 Jan;30(1):59-64
Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA. coopersmithc@msnotes.wustl.edu
OBJECTIVE: The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections. DESIGN: Pre- and postintervention observational study. SETTING: Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital. PATIENTS: A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000. INTERVENTIONS: A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU. MEASUREMENTS AND MAIN RESULTS: Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between $185,000 and $2.808 million. CONCLUSIONS: A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization.
PMID: 11902288, UI: 21898911
Crit Care Med 2002 Jan;30(1):226-31
Department of Psychiatry, Harvard Medical School, Children's Hospital, Boston, MA 02115-5724 , USA. elaine.meyer@tch.Harvard.edu
OBJECTIVE: To identify priorities for quality end-of-life care from the parents' perspective. DESIGN: Anonymous, self-administered questionnaire. SETTING: Three pediatric intensive care units in Boston. PARTICIPANTS: Parents of children who had died after withdrawal of life support. MEASUREMENT AND MAIN RESULTS: Parents' views of the adequacy of pain management, decision making, and social support during and after the death of their child were measured with the Parental Perspectives Questionnaire. Of 96 eligible households, 56 (58%) responded. In 90% of cases, physicians initiated discussion of withdrawal of life support, although nearly half of parents had considered it independently. Among decision-making factors, parents rated the quality of life, likelihood of improvement, and perception of their child's pain as most important. Twenty percent of parents disagreed that their children were comfortable in their final days. Fifty-five percent of parents felt that they had little to no control during their child's final days, and nearly a quarter reported that, if able, they would have made decisions differently. There were significant differences (p < .001) between the involvement of family, friends, and staff members at the time of death and greater agreement (p < .01) about the decision to withdraw support between parents and staff members than with other family members. CONCLUSIONS: Parents place the highest priorities on quality of life, likelihood of improvement, and perception of their child's pain when considering withdrawal of life support. Parents make such decisions and garner psychosocial support in the context of a social network that changes over time and includes healthcare professionals, family, and friends.
PMID: 11902266, UI: 21898934
Intensive Care Med 2002 Feb;28(2):208-10
Address for correspondence: Department of Neurosurgery, University of Dresden, Fetscherstrasse 74, 01307 Dresden, Germany, ramon.martinez@mailbox.tu-dresden.de
The objective of our study was to assess the value of serum procalcitonin (PCT) monitoring in the differential diagnosis of ventriculitis in adult intensive care (ICU) patients. We analyzed 15 consecutive patients with ventriculitis in which a ventricular catheter had been inserted and contrasted these data with the observations in 10 patients with community-acquired bacterial meningitis. Cerebrospinal fluid (CSF) and blood samples were collected daily to assess serum PCT, C-reactive protein (CRP) and CSF leukocyte count. PCT levels were normal or slightly elevated in patients with ventriculitis with either positive or negative CSF bacterial culture but elevated in patients with bacterial meningitis. A PCT cut-off value of 1.0 ng/ml or more showed a specificity of 77% and a sensitivity of 68% for ventriculitis with positive CSF bacterial culture. Serum PCT levels reflected more accurately the time phases of disease during therapy. We conclude that the monitoring of serum PCT alone is not helpful for the differential diagnosis of ventriculitis, in contrast to that of bacterial meningitis. The value of PCT as an additional marker with which to assess the efficacy of therapy in ventriculitis is suggested, but requires further assessment.
PMID: 11907666, UI: 21904276
Intensive Care Med 2002 Feb;28(2):204-7
Department of Pediatric Intensive Care, Free University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands, rjbj.gemke@vumc.nl
OBJECTIVE: To compare the performance of two different clinical scoring systems that were developed to assess mortality probability in pediatric intensive care. DESIGN AND METHODS: Prospective cohort study in a multidisciplinary tertiary pediatric intensive care unit. The Pediatric Risk of Mortality score (PRISM III) and the Pediatric Index of Mortality (PIM) were collected for each patient. Standardized mortality rate (SMR), discrimination and calibration of both scoring systems were compared by goodness-of-fit tests and receiver operating characteristic (ROC) curves. RESULTS: Data from 303 patients were collected over a 9-month period. Twenty patients (6.6%) died in the PICU. Expected mortality based on PRISM III (12 h) was 6.96% (SMR 0.95; 95% CI 0.68-1.23), based on PRISM III (24 h) was 6.95% (SMR 0.95; 0.67-1.22) and based on PIM was 7.5% (SMR 0.88; 0.55-1.20). Calibration by Hosmer-Lemeshow goodness-of-fit test showed for PRISM III (12 h), p=0.21; for PRISM III (24 h), p=0.21 and for the PIM score, p=0.77. Discriminatory performance assessed by ROC curves showed an area under the curve of 0.78 (95% CI 0.67-0.89) for the PRISM III score both after 12 and 24 h and 0.74 (0.63-0.85) for the PIM score. CONCLUSION: PRISM III and PIM scores are both adequate indicators of mortality probability for heterogeneous patient groups in pediatric intensive care. Possibly in larger studies (equivalence trial) a significant and relevant difference between these scores would be demonstrated.
PMID: 11907665, UI: 21904275
Intensive Care Med 2002 Feb;28(2):154-63
Departement d'Anesthesie Reanimation, CHU de Bicetre, 78 rue du General Leclerc, 94275 Le Kremlin Bicetre cedex, France, pierre.moine1@fnac.net
OBJECTIVE: To evaluate the attributable mortality associated with late-onset nosocomial pneumonia (LOP) while taking into account the severity at admission, the evolution of the patients during the first 4 days after admission to the ICU and the appropriateness of initial empiric antibiotic treatment. DESIGN: Multicenter cohort study with prospective standardization of diagnostic interventions when nosocomial pneumonia develops. SETTING: Medical and surgical ICUs of four university-affiliated teaching hospitals. PATIENTS: Seven hundred sixty-four consecutive patients requiring ICU hospitalization for at least 4 days. MAIN OUTCOME MEASURES: The clinical and biological data as well as the therapeutic data and the outcome were prospectively recorded from the day of admission to ICU discharge. Simplified Acute Physiologic Score (SAPS II) and Logistic Organ Dysfunction (LOD) score were collected and computed within the first 4 calendar days of ICU admission. Variables associated with the outcome were selected using a stepwise Cox model. The time to acquisition of the first LOP was then introduced in the final model as a time-dependent covariate. The analysis was stratified by ICU center. Finally, as initial antibiotic therapy could have an impact on the increased risk of death induced by LOP, the Cox model was applied again introducing LOP immediately adequately treated and LOP not immediately adequately treated as two different time-dependent covariates. RESULTS: Late-onset pneumonia developed in 89 patients (12%). A McCabe score of more than 1, SAPS II score and increases in SAPS between days 1 and 2, days 2 and 3, and days 3 and 4 were significantly associated with an increased risk of death. When the time to acquisition of the first episode of LOP was introduced into the Cox model, the LOP occurrence was associated with increased mortality, even adjusted over the selected prognostic parameters and after stratification by center (hazard ratio (HR)=1.53, 95% CI 1.02-2.3, p=0.04). When LOP immediately adequately treated and LOP not immediately adequately treated were separately introduced into the Cox model, inappropriately treated LOP remained significantly associated with an increased risk of mortality (HR=1.69, 95% CI 1.08-2.65, p=0.022), whereas appropriately treated LOP did not (HR=1.44, 95% CI 0.75-2.76, p=0.27). CONCLUSION: These data suggest that, in addition to severity scores, the underlying medical conditions and the evolution of severity within the first 4 days in ICU, late-onset pneumonia independently contribute to ICU patient mortality when empirical antibiotic treatment is not immediately appropriate.
PMID: 11907658, UI: 21904268
Intensive Care Med 2002 Feb;28(2):101-2
Reanimation Medicale, Hopital Henri Mondor, 94000 Creteil, France, journal.icm@hmn.ap-hop-paris.fr
PMID: 11907650, UI: 21904260
Intensive Care Med 2002 Mar;28(3):332-5
Service d'Anesthesie Reanimation Chirurgicale 1, rue Henri Le Guilloux, Hopital de Pontchaillou, 35033 Rennes Cedex, France, yannick.malledant@chu-rennes.fr
OBJECTIVE: To determine if daily information on the price of common laboratory tests and chest X-ray could significantly influence test ordering by physicians and decrease the costs. DESIGN: A prospective observational and sequential study. SETTING: A 21-bed surgical intensive care unit of a university hospital. PATIENTS: All patients admitted during a 4-month period. INTERVENTIONS: A 2-month period served as control (period I). During a consecutive 2-month period (period II) physicians were informed about the costs of seven common diagnostic tests (plasma and urinary electrolytes, arterial blood gases, blood count, coagulation test, liver function test and chest X-ray). The number of tests ordered and costs during the two periods were compared. MEASUREMENTS AND RESULTS: A total of 287 patients were included (128 in period I and 159 in period II). Information about age, gender, Severe Acute Physiologic Score II, McCabe score, intensive care unit length of stay and mortality were collected and were not statistically different between the two study periods. Except for liver function tests, all the tests evaluated were less frequently prescribed when physicians were aware of the charges, irrespective of whether the tests were routine or requested during an emergency. Nevertheless, a significant reduction was obtained only for arterial blood gases and urinary electrolytes. Overall analysis of the expenditures (in Euros) showed a significant 22% decrease in period II (341+/-500 versus 266+/-372 Euros, p<0.05). CONCLUSION: Providing price information to physicians was associated with a significant reduction for arterial blood gases and urinary electrolytes tests ordered and was significantly cost-saving.
PMID: 11904664, UI: 21901385
Intensive Care Med 2002 Mar;28(3):324-31
Medical Clinic I, University Hospital Aachen, Pauwelsstrasse 30, D-52074 Aachen, Germany, jgraf@gmx.de
OBJECTIVE: Evaluation of resource use and costs of a medical intensive care unit (ICU) utilising the simplified Therapeutic Intervention Scoring System (TISS-28). DESIGN: Prospective observational study. SETTING:: Medical ICU of a tertiary care centre. PATIENTS: Consecutive patients with an ICU length of stay (LOS) more than 24 h. INTERVENTIONS: Over a 3 month period SAPS II, TISS-28 and SOFA were determined daily. Patients were retrospectively classified as receiving active (AT) or non-active (NAT) treatment according to TISS-28 variables, with AT representing a therapeutic intervention that could not be performed outside the ICU. Individual expenditure for all patients was calculated using a modified 'top-down' method. MEASUREMENTS AND RESULTS: Out of 303 consecutive patients, 241 (79.5%), including all non-survivors, were categorised AT. The hospital mortality was 14.5%. TISS-28 and ICU LOS were higher in patients receiving AT ( p<0.001). Patient-specific costs accounted for 36 EUR per TISS-point and daily treatment costs 1336 EUR for all patients. Daily costs of care were 68 EUR higher for AT, compared to NAT, patients ( p<0.001). There was no association between ICU costs and measures of severity of illness (SAPS II, SOFA). CONCLUSIONS: TISS-28 is a fast, reliable and readily applicable tool to identify patients receiving AT. Although total and daily costs of care were significantly higher in patients receiving AT, the difference of the daily costs was, albeit statistically significant, economically negligible. The main difference in ICU costs was attributable to ICU LOS. Therefore cost-saving strategies must aim at reducing ICU LOS, without compromising quality of care.
PMID: 11904663, UI: 21901384
J Trauma 2002 Mar;52(3):463-8
Department of Surgery, University of New Mexico Health Sciences Center, and General Clinical Research Center (C.R.Q.), University of New Mexico, Albuquerque, New Mexico.
BACKGROUND: Febrile trauma patients have repeated blood cultures drawn during a prolonged hospitalization. We examined the diagnostic yield of blood cultures in severely injured patients to determine whether concurrent antimicrobial therapy or prophylactic administration of antibiotics affects blood culture growth. We also determined how rapidly growth changed to determine whether total numbers of blood cultures could be decreased. The hypotheses of the study were that concurrent antimicrobial administration affects blood culture yield, prophylactic administration alters the culture result, and repetitive culturing is unnecessary. METHODS: A retrospective chart review of trauma patients with minimum Injury Severity Score of 15 and minimum 5-day intensive care unit length of stay was performed. The dates and results of blood cultures and antibiotic type and administration dates were recorded. "Prophylactic" antibiotics were defined as antibiotics administered on admission to the unit. Computer software was used to match the blood culture date to the period of antimicrobial administration. Categorical data were compared using Fisher's exact test. RESULTS: Two hundred fifty-eight patients met entry criteria, and 208 charts were complete for review. One hundred twenty-nine patients had 347 sets of blood cultures drawn. The positive blood culture rate was 10.8% in patients off antibiotics, and 13.9% in patients on antibiotics (p = 0.68). All prophylactic antibiotics included a beta-lactam. Only 18% of positive blood cultures in patients receiving prophylactic antibiotics were sensitive to beta-lactams as opposed to 59% sensitivity in those who did not receive prophylaxis (p = 0.03). One hundred seventy-six sets of blood cultures were performed after an initial positive culture. Only three patients with an initial positive culture had a second positive culture with a different organism. The mean time to culturing a new organism after initial growth was 19 days. CONCLUSION: Concurrent antimicrobial administration does not alter blood culture yield. Prophylactic administration alters the type of organism cultured. Little new information is gained from repetitive culturing.
PMID: 11901320, UI: 21898477
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