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Am J Crit Care 2002 Sep;11(5):467-73
Medical University of South Carolina, Charleston, College of Nursing, USA.
[Medline record in process]
BACKGROUND: Care of patients in an intensive care unit is among the most costly in hospitals. Little is known about high-cost patients within the intensive care unit or their outcomes of care. OBJECTIVES: To examine outcomes of and resource consumption by high-cost adult patients who received care in an intensive care unit at an academic medical center. METHODS: Data on patients admitted during the period January 1, 1995, through June 30, 1999, were analyzed retrospectively. An intensive care unit database, the hospital discharge data set, and a cost-accounting data set were used to determine the total intensive care unit cost for the hospitalization. Patients were then stratified into cost deciles. Hospital and intensive care unit outcomes for patients in the top decile were compared with those of patients in the other deciles. RESULTS: Cost data were available on 10,606 of the 11,244 patients who received care in an intensive care unit. Patients in the top decile accounted for 48.7% of all intensive care unit costs, and 67.6% of this group survived to discharge despite prolonged care. Patients transferred from an outside hospital were more likely to be in the top decile, have a longer stay in the intensive care unit, or die than were the other patients. CONCLUSIONS: A small group of patients accounts for a disproportionately higher amount of intensive care unit resources but has a relatively high survival rate. This cohort should be treated as an intact group that is not amenable to traditional cost-cutting measures.
PMID: 12233972, UI: 22218993
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Am J Respir Crit Care Med 2002 Sep 15;166(6):839-42
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
This retrospective study describes the clinical course of 38 patients with idiopathic pulmonary fibrosis (IPF) admitted to the intensive care unit (ICU). There were 25 males and 13 females who were the mean age of 68.3 +/- 11.5 years. Twenty patients were on corticosteroids at the time of admission to the hospital, and 24 had been on home oxygen therapy. The most common reason for ICU admission was respiratory failure. The Acute Physiology and Chronic Health Evaluation III-predicted ICU and hospital mortality rates were 12% and 26%, whereas the actual ICU and hospital mortality rates were 45% and 61%, respectively. We did not find significant differences in pulmonary function or echocardiogram findings between survivors and nonsurvivors. Mechanical ventilation was used in 19 patients (50%). Sepsis developed in nine patients. Multiple organ failure developed in 14% of the survivors and in 43% of the nonsurvivors (p = 0.14). Ninety-two percent of the hospital survivors died at a median of 2 months after discharge. These findings suggest that patients with IPF admitted to the ICU have poor short- and long-term prognosis. Patients with IPF and their families should be informed about the overall outlook when they make decisions about life support and ICU care.
PMID: 12231494, UI: 22217064
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Anaesthesia 2002 Aug;57(8):751-5
Anaesthesia and Critical Care, Norfolk and Norwich University Hospital, Norwich, UK. timleary@lineone.net
Outcome measurement in critical care is difficult because of the wide variety of patients treated and the diverse therapeutic options and pathways available. Individual outcome measures for critical care are available but are naturally limited to only a single aspect of performance. Most importantly, better performance in one aspect of care may compromise the standard of care in another. A global measure of performance would be helpful. For the year 1999-2000, the five hospitals in the East Anglian Critical Care Network provided data on capacity, workload and performance. The data was transformed and displayed graphically on a radar chart so that the area of the polygon within the radar chart was proportional to each unit's overall performance. The results from the five hospitals suggest that there is little overall difference in the units' global performance but the graphical representation highlighted some individual deficiencies. Graphical analysis of complex processes such as critical care delivery may facilitate performance assessment, providing that the measures chosen, weightings assigned and scales used are standardised with care.
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PMID: 12133086, UI: 22128334
Arch Pediatr 2002 May;9(5):489-94
Service de pediatrie 2, CHU Saint-Jacques, 25030 Besancon, France. antoine.burguet@ufc-chu.univ-fcomte.fr
OBJECTIVES: The aim of this study was to describe the intensive care unit neonatologists' attitudes about a neonate with terminal or pre-terminal renal failure. METHODS: A questionnaire was sent to all French neonatal intensive care units. Physicians were asked to describe their attitude about neonatal chronic renal failure (Would you agree with dialysis and graft for these children?). Physicians were also presented with two clinical observations involving neonates with varying degrees of renal insufficiency and a complicating comorbidity, including neurological abnormality or socioeconomic circumstances. RESULTS: Responses were obtained from 92% of the university neonatal care units. The will to take care of a neonate with end-stage renal failure till the renal graft, varied greatly from a centre to another one. Three (9%) university-teams said they had a strong will to bring the baby from the neonatal period to the time of renal graft. Eleven other centres (32%) did not have any will for accompanying the baby till the renal graft. Eight centres (24%) would be rather favourable to the idea of dialysis and graft, and 12 others (35%) would be rather unfavourable. CONCLUSION: The results of this study show great differences between French neonatologists when they are faced to newborns with end stage renal failure. Ethical, medical and organisational difficulties are matters of controversy. The epidemiological impact of the perinatal discussion could be a 20% variation of all the renal grafts in children.
PMID: 12053542, UI: 22049409
BMJ 2002 Aug 31;325(7362):454-5
PMID: 12202313, UI: 22190480
Chest 2002 Aug;122(2):699-711
Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA. maripe@ccm.upmc.edu
Traumatic brain injury (TBI) is a major cause of disability and death in most Western nations and consumes an estimated $100 billion annually in the United States alone. In the last 2 decades, the management of TBI has evolved dramatically, as a result of a more thorough understanding of the physiologic events leading to secondary neuronal injury as well as advances in the care of critically ill patients. However, it is likely that many patients with TBI are not treated according to current treatment principles. This article presents an overview of the current management of patients with TBI.
PMID: 12171853, UI: 22161830
Crit Care Med 2002 Aug;30(8):1906-7
PMID: 12163815, UI: 22153150
Crit Care Med 2002 Aug;30(8):1762-4
Critical Care Directorate, Cardiff and Vale NHS Trust, University Hospital of Wales, Cardiff, UK.
OBJECTIVE: To ascertain the feasibility and the safety of percutaneous dilational tracheostomy in patients with acute respiratory distress syndrome receiving high-frequency oscillatory ventilation. DESIGN: Case series. SETTING: Tertiary adult intensive care unit in a university teaching hospital. PATIENTS: Five patients with acute respiratory distress syndrome. INTERVENTIONS: Percutaneous dilational tracheostomy during high-frequency oscillatory ventilation. MEASUREMENTS AND MAIN RESULTS: Percutaneous dilational tracheostomy was safely performed on all five patients. Hemodynamic and respiratory variables remained stable during the procedure. No complications were attributable to either the percutaneous dilational tracheostomy or high-frequency oscillatory ventilation. CONCLUSIONS: Percutaneous dilational tracheostomy can be safely performed on patients with acute respiratory distress syndrome during high-frequency oscillatory ventilation.
PMID: 12163789, UI: 22153124
Crit Care Med 2002 Jul;30(7):1654-6
PMID: 12130997, UI: 22122895
Crit Care Med 2002 Jul;30(7):1653-4
PMID: 12130996, UI: 22122894
Crit Care Med 2002 Jul;30(7):1636-43
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
OBJECTIVE: To describe the development, organization, and operation of several collaborative groups conducting investigator-initiated multicenter clinical research in adult critical care. DESIGN: To review the process by which investigator-initiated critical care clinical research groups were created using examples from Europe, Australia, the United States, and Canada. Various models of group structure and function are discussed, highlighting complementary approaches to protocol development, multicenter study management, and project funding. DATA SOURCES: Published peer review research and unpublished terms of reference documents on the structure and function of these groups. DATA SYNTHESIS: The overall goal of clinical critical care research groups engaged in multicenter studies is to improve patient outcomes through conducting large, rigorous investigations. Research programs we reviewed included the following: a) multicenter epidemiologic studies and surveys; b) technology evaluations of mechanical ventilation; c) investigations focused on three priority fields (acute lung injury, infection, and acute brain injury); d) a series of randomized trials of treatments for one syndrome (acute respiratory distress syndrome); and e) diverse methodologies addressing several clinical problems. The structure and function of these research groups differ according to their historical development, research culture, and enabling resources. Specific protocols emerge from clinical questions generated by investigators or from collectively prioritized research agendas. Project funding includes government support, peer-review grants, intensive care foundations, industry, local hospital funds, and hybrid models. Infrastructure for study management varies widely. CONCLUSIONS: Several national and international groups have engaged in investigator-initiated multicenter critical care research. The development, organization, and operational methods of these groups illustrate several collaborative models for clinical investigations in the intensive care unit. Common characteristics of these groups are a cohesive spirit, a sense of mission to achieve shared research goals, and acknowledgment that such an organization is much more than the sum of its parts.
PMID: 12130991, UI: 22122889
Crit Care Med 2002 Jul;30(7):1429-35
Department of Medicine, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada.
CONTEXT: Gastrointestinal promotility agents may improve tolerance to enteral nutrition, reduce gastroesophageal reflux and pulmonary aspiration, and therefore have the potential to improve outcomes of critically ill patients. OBJECTIVE: To systematically review and critically appraise studies of promotility agents in the critical care setting. DATA SOURCES: Computerized bibliographic search of published research (1980-2001), citation review of relevant articles, and contact with primary investigators. STUDY SELECTION: Randomized trials of critically ill adult patients that evaluated the effect of promotility agents on measures of gastrointestinal motility were included. DATA EXTRACTION: Relevant methods and outcome data were abstracted in duplicate by independent investigators. DATA SYNTHESIS: We reviewed 60 citations; 18 articles met the inclusion criteria (six studies of feeding tube placement, 11 studies evaluating gastrointestinal function, and one study of clinical outcomes). The heterogeneity of study methods and outcomes measured precluded a quantitative synthesis of the data. Although there are conflicting studies, the larger and more methodologically robust studies suggest that metoclopramide has no effect on feeding tube placement. Erythromycin has been shown to increase success rates with small-bowel tube placement in two studies. Eight of ten studies evaluating the effect of cisapride, metoclopramide, or erythromycin on measures of gastrointestinal transit demonstrated positive effects; the two studies that did not were relatively small (n = 27 and 10) and likely had inadequate power to detect a difference in treatment effect. No study demonstrated a positive effect on clinical outcomes. CONCLUSIONS: As a class of drugs, promotility agents appear to have a beneficial effect on gastrointestinal motility in critically ill patients. A one-time dose of erythromycin may facilitate small-bowel feeding tube insertion. Administration of metoclopramide appears to increase physiologic indexes of gastrointestinal transit and feeding tolerance. Concerns about safety and lack of effect on clinically important outcomes preclude strong treatment recommendations.
PMID: 12130957, UI: 22122855
Nurs Crit Care 2002 Jul-Aug;7(4):185-92
Paediatric Intensive Care Unit, Sheffield Children's Hospital, University of Sheffield, Western Bank. helen.bailey@sch.nhs.uk
It has been recommended that nursing staff who are new to paediatric intensive care should be offered an orientation programme There is no guidance currently available to influence the content or duration of such a programme on a national level A multi-centre research study was carried out to identify the existing provision of orientation programmes and how beneficial these are perceived to be Supernumerary status and effective mentoring are seen as essential to the success of these programmes Many new starters perceive that they receive inadequate preparation on stress management and psychosocial issues National communication between paediatric intensive care educators will help to improve and develop orientation programme provision.
PMID: 12238710, UI: 22223464
Nurs Crit Care 2002 Jul-Aug;7(4):176-84
The Royal North Shore Hospital, Sydney, NSW, Australia. sydnerroad@talk21.com
To ensure that intensive care is both cost-effective and humanitarian depends on a willingness to withdraw treatment once the prognosis is recognised as being hopeless, as the process of dying may be prolonged if futile treatment is continued Continuing advances in technology, science and professional care, raising new ethical, economic and legislative dilemmas, mean the decision to withdraw treatment in intensive care has become an issue of renewed concern These advances require both the development of scientific methods to support the decision-making process and an understanding of the ethical balance that underpins such decisions with particular reference to the intensive care nurse Whilst there is recognition that the families of patients who die in intensive care require ongoing support and bereavement care, there is little to suggest that the needs of the multidisciplinary personnel caring for these patients are understood or provided for This paper aims to explore quality end-of-life care, common medical practices, research into the role of the expert nurse in caring for the dying patient and new strategies for the incorporation of palliative care Strategies are proposed to translate the shared ownership, responsibility and accountability of clinical governance regarding these decisions into positive action, consensus and collaboration at both local and national level.
PMID: 12238709, UI: 22223463
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