Intensive Care Med 2003 Apr 24;
Department of Otolaryngology-Head and Neck Surgery, Edith Wolfson Medical Center, P.O. Box 5, 58100, Holon, Israel.
[Record supplied by publisher]
OBJECTIVE. An overview of common otorhinolaryngological (ORL) problems and procedures in the intensive care unit (ICU) is presented. FOCUS. Diagnostic, management, and treatment aspects of some conditions are discussed with emphasis on the potential difficulties encountered in the ICU. Approach recommendations are outlined as well as a list of required basic equipment. CONCLUSIONS. Otorhinolaryngology should be included in intensive care continuing medical education programs.
PMID: 12712242
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J Trauma 2003 Apr;54(4):633-9
[Medline record in process]
BACKGROUNDRecent literature supports the notion that bronchoalveolar lavage (BAL) in ventilated trauma patients may improve our ability to diagnose and treat ventilator-associated pneumonia (VAP). We hypothesized that BAL would decrease the number of cases of VAP diagnosed and impact our antibiotic use and ventilator days.METHODSProspective data on all infectious complications were collected for patients admitted to the trauma-burn service for the year 2001. All VAPs between January 1, 2001, through June 30, 2001, were diagnosed without BAL (No BAL group) using clinical signs of fever, sputum production, leukocytosis, chest radiographs, and sputum culture. After July 1, 2001, VAP was diagnosed with the use of BAL.RESULTSThere were 37 cases of VAP in the No BAL group (11%) and 29 cases of VAP (8%) in the BAL group. There were no statistical differences in Injury Severity Score, hospital length of stay, ventilator days, or mortality between the two groups. The time to initial treatment of VAP was shorter for the BAL group, but did not reach significance. The number of patients who had their VAP pathogens correctly treated with empiric antibiotics was also the same between the two groups. There was no difference in the rate of recurrent pneumonias. The antibiotic costs and respiratory therapy/ventilator costs were not statistically different between the groups for trauma patients, although antibiotic costs were higher for burn patients.CONCLUSIONThe routine use of BAL to diagnose VAP in our mixed trauma-burn population did not impact on clinical outcomes or antibiotic use. Our results do not justify the additional costs and potential risks of BAL for all patients. The means of VAP diagnosis may not be as important as choosing the appropriate antibiotics for common VAP organisms in any given intensive care unit.
PMID: 12707523, UI: 22593472
JAMA 2003 Apr 16;289(15):1963-8
Section of Pulmonary and Critical Care Medicine, the Pritzker School of Medicine, and the Office of Risk Management, University of Chicago, Chicago, Ill 60637, USA.
CONTEXT: Invasive procedures are often performed emergently in the intensive care unit (ICU), and patients or their proxies may not be available to provide informed consent. Little is known about the effectiveness of intensivists in obtaining informed consent. OBJECTIVES: To describe the nature of informed consent in the ICU and to determine if simple interventions could enhance the process. DESIGN, SETTING, AND PATIENTS: Prospective study of 2 cohorts of consecutively admitted patients (N = 270) in a 16-bed ICU at a university hospital. All patients admitted to the ICU during the baseline period from November 1, 2001, to December 31, 2001, and during the intervention period from March 1, 2002, to April 30, 2002, were included. INTERVENTION: A hospital-approved universal consent form for 8 commonly performed procedures (arterial catheter, central venous catheter, pulmonary artery catheter, or peripherally inserted central catheter placement; lumbar puncture; thoracentesis; paracentesis; and intubation/mechanical ventilation) was administered to patients or proxies. Handouts describing each procedure were available in the ICU waiting area. Physicians and nurses were introduced to the universal consent form during orientation to the ICU. MAIN OUTCOME MEASURES: Incidence of informed consent for invasive procedures at baseline and after intervention; whether the patient or proxy provided informed consent; and understanding by the consenter of the procedure as determined by the responses on a questionnaire. RESULTS: Fifty-three percent of procedures (155/292) were performed after consent had been obtained during the baseline period compared with 90% (308/340) during the intervention period (absolute difference, 37.4%; P<.001). During baseline, the majority (71.6%; 111/155) of consents were provided by proxies. This was also the case during the intervention period in which 65.6% (202/308) of consents were provided by proxies (absolute difference, 6.0%; P =.23). Comprehension by consenters of indications for and risks of the procedures was high and not different between the 2 periods (P =.75). CONCLUSIONS: Invasive procedures are frequent in the ICU and consent for them is often obtained by proxy. Providing a universal consent form to patients, proxies, and health care clinicians significantly increased the frequency with which consent was obtained without compromising comprehension of the process by the consenter.
PMID: 12697799, UI: 22584124
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Pediatrics 2003 Apr;111(4 Pt 2):e534-41
Neonatal Intensive Care Unit, Providence St Vincent Medical Center, Portland, Oregon 97225, USA. joe@nnspc.com
OBJECTIVE: The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially better practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD). METHODS: This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia. RESULTS: The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay. CONCLUSIONS: Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks' postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented.
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PMID: 12671173, UI: 22558453
Pediatrics 2003 Apr;111(4 Pt 2):e519-33
Children's Mercy Hospitals and Clinics, University of Missouri, Kansas City School of Medicine, Kansas City, Missouri 64108, USA. hkilbride@cmh.edu
OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. Nosocomial infection is a significant area for improvement in most NICUs. METHODS: Six NICUs participating in the Vermont Oxford Network made clinical changes to address 3 areas of consensus: handwashing, line management, and accuracy of diagnosis. The summary statements were widely communicated. Review of the literature, internal assessments, and benchmarking visits all contributed to ideas for change. RESULTS: The principle outcome was the incidence of coagulase-negative staphylococcus bacteremia. There was an observed reduction from 24.6% in 1997 to 16.4% in 2000. CONCLUSIONS: The collaborative process for clinical quality improvement can result in effective practice changes.
PMID: 12671172, UI: 22558452
Pediatrics 2003 Apr;111(4 Pt 2):e504-18
OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs. METHODS: The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback. This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management. RESULTS: These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates. CONCLUSIONS: The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.
PMID: 12671171, UI: 22558451
Pediatrics 2003 Apr;111(4 Pt 2):e497-503
New Hanover Regional Medical Center, Wilmington, North Carolina 28402, USA. debra_mclendon@yahoo.com
OBJECTIVE: Using an evidence-based approach, a Vermont Oxford Network focus group whose goal was to reduce brain injury developed and implemented a number of potentially better practices. Each center approached implementation of the practices differently. Reducing the incidence of intraventricular hemorrhage and periventricular leukomalacia are important for improving long-term outcomes for low birth weight infants. METHODS: Implementation approaches for some but not all of the practices at the various centers are discussed. The practices reviewed include optimal peripartum management, such as resuscitation, avoidance of hypothermia, optimal surfactant delivery, early neonatal management by the most experienced providers, and measures to minimize pain and stress. Additional practices include maintenance of neutral head positioning, fluid volume therapy for hypotension, indomethacin prophylaxis, ventilator management, avoidance of routine suctioning, and limiting the use of sodium bicarbonate and postnatal dexamethasone. RESULTS: Approaches to implementation were center specific, and results vary. Although some practices were easier to implement than others, communication, education, and leadership were critical to the process. CONCLUSIONS: The quality improvement multidisciplinary approach is a useful tool for finding ways to reduce the incidence of intraventricular hemorrhage and periventricular leukomalacia.
PMID: 12671170, UI: 22558450
Pediatrics 2003 Apr;111(4 Pt 2):e489-96
Parkview Hospital, Fort Wayne, Indiana, USA.
OBJECTIVE: Neonatal care providers from 5 institutions formed a multidisciplinary focus group with the purpose of identifying potentially better practices, the implementation of which would lead to a reduction in the incidence of intracranial hemorrhage and periventricular leukomalacia in very low birth weight infants. METHODS: Practices were analyzed, 4 benchmark neonatal intensive care units were identified and evaluated, and the literature was assessed using an evidence-based approach. The work was also reviewed by a nationally respected expert. RESULTS: Ten potentially better clinical practices were identified. In addition, variability in cranial ultrasound practice, related to both procedural process and interpretation, was identified as a confounding problem in evaluating quality. Using the same process, potentially better cranial ultrasound practices were also identified. CONCLUSIONS: Implementation of these practices will improve clinical outcomes as well as the reliability of sonogram interpretation, the basis for evaluating the quality of the team's work.
PMID: 12671169, UI: 22558449
Pediatrics 2003 Apr;111(4 Pt 2):e432-6
St John's Mercy Medical Center, St Louis, Missouri 63141, USA. burckj@mercy.stlo.net
OBJECTIVE: Adherence to basic quality improvement principles enhances the implementation of potentially better practices (PBPs) and requires extensive planning and education. Even after PBPs have been identified and acknowledged as desirable, effective implementation of these practices does not occur easily. The objective of this study was to identify and assess implementation strategies that facilitate quality improvements in the respiratory care of extremely low birth weight infants. METHODS: The 9 members of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 Reducing Lung Injury focus group identified 9 PBPs in a evidence-based manner to decrease chronic lung disease in extremely low birth weight newborns. Each site implemented several or all PBPs based on a site-specific selection process. Each site was asked to submit 1 or more examples of experiences that highlighted effective implementation strategies. This article reports these examples and emphasizes the principles on which they are based. RESULTS: The 9 participating institutions implemented a total of 57 PBPs (range: 1-9; median: 5). Including previous implementation, the 9 participating institutions implemented a total of 70 of a possible 81 PBPs before or during the study period (range: 5-9; median: 8). We report 7 approaches that facilitated PBP implementation: information availability, feedback, perseverance, collaboration, imitation, recognition of implementation complexity, and tracking of process indicators. CONCLUSIONS: Quality improvement efforts are enhanced by identifying and then implementing PBPs. In our experience, implementation of these PBPs can be difficult. Implementation strategies, such as those identified in this article, can improve the chances that quality improvement efforts will be effective.
PMID: 12671163, UI: 22558443
Pediatrics 2003 Apr;111(4 Pt 2):e426-31
Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA. psharek@stanford.edu
OBJECTIVE: Despite increased knowledge and improving technology, chronic lung disease (CLD) rates in extremely low birth weight infants have remained constant for 20 years. One reason for this is an ineffective translation of research-proven improvements into practice. The Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was created to provide participating nurseries the tools necessary to effect change. The objective of this study was to develop and implement a process that uses quality improvement techniques to collaboratively improve CLD rates. METHODS: Nine member hospitals of the NIC/Q 2000 collaborative formed a focus group aiming to decrease CLD rates. The focus group established goals and outcome measures, created a list of potentially better practices (PBPs) based on available literature, benchmarked and performed site visits, encouraged individual site implementation of PBPs, developed a database, and measured outcomes. RESULTS: The goal "decrease CLD rates in extremely low birth weight infants" was established. Nine PBPs were identified, and 57 PBPs were implemented by the 9 participating sites. Twelve site visits were conducted, and a 435-patient database of infants with a mean birth weight of 789 g was established. CONCLUSIONS: Collaborative use of quality improvement techniques resulted in creation of a logical, efficient, and effective process to improve CLD rates. Group creation of PBPs, based on literature review and reinforced with site visits, internal data analysis, and improved individual site outcomes, resulted in accelerated and effective change, unlikely to occur if attempted outside of the collaborative.
PMID: 12671162, UI: 22558442