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Items 1 - 22 of 22 |
One page. |
Evidence-based colloid use in the critically ill: American Thoracic Society Consensus Statement.
American Thoracic Society.
Publication Types:
- Consensus Development Conference
- Review
PMID: 15563641 [PubMed - indexed for MEDLINE]
[Incidence of transmission of pathogens in intensive care units Ergebnisse der SIR-3-Studie.]
[Article in German]
Barwolff S, Grundmann H, Schwab F, Tami A, Behnke M, Geffers C, Halle E, Gobel U, Schiller R, Jonas D, Klare I, Weist K, Witte W, Dinger E, Beilecke K, Ruden H, Gastmeier P.
Institut fur Hygiene und Umweltmedizin, Charite, Universitatsmedizin, Berlin.
The objective of this study was to determine the incidence of episodes of transmission of nosocomial pathogens and of those pathogens leading to nosocomial infections. Over a period of 18 months all patients from 5 intensive care units (ICUs) who stayed for more than 2 days were included in this study. Surveillance of nosocomial infections was carried out and all isolates of 10 of the most frequent pathogens in ICUs (indicator pathogens) were collected and typed. A total of 28,498 patient days and 431 nosocomial infections were observed (incidence density 15.1 per 1,000 patient days), among them 278 caused by 1 of the selected indicator pathogens. A total of 141 episodes of transmissions were identified, corresponding to an incidence of episodes of transmision of 5.0 per 1,000 patient days and 41 nosocomial infections were transmission-associated, corresponding to 14.5% of all nosocomial infections. The data of this study demonstrate that even in ICUs with average nosocomial infection rates, some nosocomial infections could be avoided.
PMID: 15809853 [PubMed - as supplied by publisher]
Tobramycin in the medical intensive care unit.
Ellinoy BR, Matsuda K, Nguyen TM.
Publication Types:
PMID: 15818142 [PubMed - in process]
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Still a black box: what do we really know about the intensive care unit admission process and its consequences?
Graf J, Janssens U.
Publication Types:
PMID: 15818126 [PubMed - in process]
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Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.
Garrouste-Orgeas M, Montuclard L, Timsit JF, Reignier J, Desmettre T, Karoubi P, Moreau D, Montesino L, Duguet A, Boussat S, Ede C, Monseau Y, Paule T, Misset B, Carlet J; French ADMISSIONREA Study Group.
Medical-Surgical Intensive Care Unit, Saint Joseph Hospital, Paris, France.
OBJECTIVE: To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. DESIGN: Observational, prospective, multiple-center study. SETTING: Four university hospitals and seven primary-care hospitals in France. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. CONCLUSIONS: ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.
PMID: 15818100 [PubMed - in process]
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The effect of prompt physician visits on intensive care unit mortality and cost.
Engoren M.
Departments of Anesthesiology and Internal Medicine, St. Vincent Mercy Medical Center, Toledo, OH, USA.
OBJECTIVE: To determine the effect on mortality, length of stay, and direct variable cost of physician response time to seeing patients after intensive care unit admission. DESIGN: Retrospective analysis of the intensive care unit database. SETTING: Medical center. PATIENTS: Subjects were 840 patients who had complete direct variable cost data and a subset of 316 patients who were matched by propensity scores. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Median time to first visit by a physician was 6 hrs. One hundred thirty-five patients (16.1%) died in hospital compared with 25.0% predicted by Acute Physiology and Chronic Health Evaluation risk (p < .001). Higher Acute Physiology and Chronic Health Evaluation risk, older age, mechanical ventilation on arrival in the intensive care unit, and longer time until seen by a physician were predictors of hospital mortality. Each 1-hr delay in seeing the patient was associated with a 1.6% increased risk of hospital death, which further increased to 2.1% after including propensity score. However, patients seen more promptly (<6 vs. >6 hrs) had greater hospital direct variable cost ($11,992 +/- $12,043 vs. $10,355 +/- $10,368, p = .04), before controlling for acuity of illness and other factors that may have affected time to evaluation. In the subpopulation of propensity-matched patients, patients seen promptly (<6 vs. >6 hrs) had shorter hospital length of stays (11 +/- 11 vs. 13 +/- 14 days, p = .03) but similar direct variable costs ($10,963 +/- 10,778 vs. $13,016 +/- 13,006, p = .16) and similar mortality rates (24 vs. 30, p = .46). CONCLUSIONS: In the total patient population, delay in seeing patients was associated with an increased risk of death. In the propensity-matched patients, promptly seen patients had shorter hospital stays but similar direct variable costs.
PMID: 15818096 [PubMed - in process]
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Adverse effect on a referral intensive care unit's performance of accepting patients transferred from another intensive care unit.
Combes A, Luyt CE, Trouillet JL, Chastre J, Gibert C.
Service de Reanimation Medicale, Hopital Pitie-Salpetriere, Paris, France.
OBJECTIVE: To determine whether observed and predicted mortality for intensive care unit (ICU) transfer admissions is different from non-ICU transfer admissions and how that might affect ICU performance evaluation. DESIGN, SETTING, AND PATIENTS: We retrospectively analyzed the charts of 3,416 patients admitted to our tertiary referral ICU from January 1995 to December 2001 and evaluated the effect on our performance (based on the Simplified Acute Physiology Score II risk model) of accepting patients transferred from another hospital's ICU. MAIN RESULTS: During the study period, 597 patients (17%) had been transferred from a non-ICU setting in another hospital (hospital transfer) and 408 (12%) from another hospital's ICU (ICU transfer). ICU mortality and standardized mortality ratios were significantly higher for ICU-transfer patients than for hospital-transfer or directly admitted patients: 34% vs. 23% vs. 17% (p < .0001) and 0.95 (95% confidence interval, 0.83-1.08), 0.82 (95% confidence interval, 0.71-0.95), and 0.62 (95% confidence interval, 0.55-0.68), respectively. ICU-transfer patients had 3.6-fold longer mean ICU stays and 1.9-fold longer durations of mechanical ventilation than directly admitted patients. Hospital-transfer (odds ratio = 1.89) and ICU-transfer patients (odds ratio = 2.41) had significantly higher mortality rates, even after adjustment for case mix and disease severity. Consequently, a benchmarking program adjusting only for these latter variables, but not admission source, would penalize our ICU by 39 excess deaths per 1,000 admissions as compared with another ICU admitting no transfer patients. Finally, patients transferred from the ward of another hospital had significantly higher mortality rates (odds ratio = 1.56) as compared with patients directly admitted from the ward of our hospital, confirming the "transfer effect" for this homogeneous patients' subgroup. CONCLUSIONS: Admission source remains a strong and independent predictor of ICU death, despite adjustment for case mix and disease severity at ICU admission. Specifically, accepting numerous ICU-transfer patients, for whom the probability of ICU death is the most underestimated by a system adjusting only for case mix and disease severity, can adversely affect the evaluation of referral centers' performance. Future benchmarking and profiling systems should evaluate and adequately account for the ICU-transfer factor to provide healthcare payers and consumers with more accurate and valid information on the true performance of referral centers.
PMID: 15818092 [PubMed - in process]
Comment on:
Critical care physicians are proponents of early, aggressive, multifaceted therapy.
Wager GC.
Publication Types:
PMID: 15753786 [PubMed - indexed for MEDLINE]
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Culturally-competent nursing care for American Indian clients in a critical care setting.
Flowers DL.
ECU, Southeastern Department of Nursing, Southeastern Oklahoma State University, Durant, Okla, USA.
Publication Types:
PMID: 15754564 [PubMed - indexed for MEDLINE]
Comment on:
Advocate for our patients.
Peers H.
Publication Types:
PMID: 15754561 [PubMed - indexed for MEDLINE]
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Randomised controlled trial comparing cisatracurium and vecuronium infusions in a paediatric intensive care unit.
Burmester M, Mok Q.
Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA, Margarita.Burmester@CARDIO.CHBOSTON.ORG.
OBJECTIVE: To evaluate and compare the efficacy, infusion rate and recovery profile of vecuronium and cisatracurium continuous infusion in critically ill children requiring mechanical ventilation.DESIGN AND SETTING: Prospective, randomised, double-blind, single-centre study in critically ill children in a paediatric intensive care unit in a tertiary children's hospital.METHODS: Thirty-seven children from 3 months to 16 years old (median 4.1 year) were randomised to receive either drug; those already receiving more than 6 h of neuromuscular blocking drugs were excluded. The Train-of-Four (TOF) Watch maintained neuromuscular blockade to at least one twitch in the TOF response. Recovery time was measured from cessation of infusion until spontaneous TOF ratio recovery of 70%.RESULTS: The cisatracurium infusion rate in nineteen children averaged 3.9+/-1.3 microg kg(-1) min(-1) with a median duration of 63 h (IQR 23-88). The vecuronium infusion rate in 18 children averaged mean 2.6+/-1.3 microg kg(-1) min(-1) with a median duration of 40 h (IQR 27-72). Median time to recovery was significantly shorter with cisatracurium (52 min, 35-73) than with vecuronium (123 min, 80-480). Prolonged recovery of neuromuscular function (>24 h) occurred in one child (6%) on vecuronium.CONCLUSIONS: Recovery of neuromuscular function after discontinuation of neuromuscular blocking drug infusion in children is significantly faster with cisatracurium than vecuronium. Neuromuscular monitoring was not sufficient to eliminate prolonged recovery in children on vecuronium infusions.
PMID: 15815895 [PubMed - as supplied by publisher]
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Tissue capnometry: does the answer lie under the tongue?
Maciel AT, Creteur J, Vincent JL.
Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, 1070 Brussels, Belgium.
Increases in tissue partial pressure of carbon dioxide (PCO(2)) can reflect an abnormal oxygen supply to the cells, so that monitoring tissue PCO(2) may help identify circulatory abnormalities and guide their correction. Gastric tonometry aims at monitoring regional PCO(2) in the stomach, an easily accessible organ that becomes ischemic quite early when the circulatory status is jeopardized. Despite substantial initial enthusiasm, this technique has never been widely implemented due to various technical problems and artifacts during measurement. Experimental studies have suggested that sublingual PCO(2 )(P(sl)CO(2)) is a reliable marker of tissue perfusion. Clinical studies have demonstrated that high P(sl)CO(2) values and, especially, high gradients between P(sl)CO(2) and arterial PCO(2) (DeltaP(sl-a)CO(2)) are associated with impaired microcirculatory blood flow and a worse prognosis in critically ill patients. Although some questions remain to be answered about sublingual capnometry and its utility, this technique could offer new hope for tissue PCO(2) monitoring in clinical practice.
Publication Types:
PMID: 15650865 [PubMed - indexed for MEDLINE]
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Consensus meeting on microdialysis in neurointensive care.
Bellander BM, Cantais E, Enblad P, Hutchinson P, Nordstrom CH, Robertson C, Sahuquillo J, Smith M, Stocchetti N, Ungerstedt U, Unterberg A, Olsen NV.
Section of Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet and Hospital, Stockholm, Sweden.
BACKGROUND: Microdialysis is used in many European neurointensive care units to monitor brain chemistry in patients suffering subarachnoid hemorrhage (SAH) or traumatic brain injury (TBI). DISCUSSION: We present a consensus agreement achieved at a meeting in Stockholm by a group of experienced users of microdialysis in neurointensive care, defining the use of microdialysis, placement of catheters, unreliable values, chemical markers, and clinical use in SAH and in TBI. CONCLUSIONS: As microdialysis is maturing into a clinically useful technique for early detection of cerebral ischemia and secondary brain damage, there is a need to following such definition regarding when and how to use microdialysis after SAH and TBI.
Publication Types:
- Consensus Development Conference
- Review
PMID: 15549254 [PubMed - indexed for MEDLINE]
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Antibiotic pharmacokinetic and pharmacodynamic considerations in critical illness.
Mehrotra R, De Gaudio R, Palazzo M.
Department Critical Care Medicine, Charing Cross Hospital, London, UK.
BACKGROUND: Many factors over which there may be little control may influence the response of a patient to therapy. However, therapy with antibiotics can be readily optimised. DISCUSSION: Concentration-dependent agents such as aminoglycosides appear effective and to entail fewer side effects when given in large, infrequent doses. There is also evidence that time-dependent antibiotics often fail to reach adequate concentrations throughout the treatment period. To date no randomised controlled prospective trial has demonstrated improvement in clinical outcome following infusion rather than intermittent boluses of time-dependent antibiotics. Critical illness alters antibiotic pharmacokinetics principally through increases in volume of distribution. Other than glycopeptides and aminoglycosides, antibiotic blood concentrations are rarely monitored and therefore adequate concentrations can only be inferred from clinical response. CONCLUSIONS: Failure to respond within the first few days of empirical treatment may be due to antibiotic resistance or inadequate doses. Therefore the same rigor should be applied to achieving adequate antibiotic concentrations as is applied to inotropes, which are titrated to achieve predetermined physiological targets.
Publication Types:
PMID: 15536528 [PubMed - indexed for MEDLINE]
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Dynamic microsimulation to model multiple outcomes in cohorts of critically ill patients.
Clermont G, Kaplan V, Moreno R, Vincent JL, Linde-Zwirble WT, Hout BV, Angus DC.
Room 606B, Scaife Hall, Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA. clermontg@ccm.upmc.edu
BACKGROUND: Existing intensive care unit (ICU) prediction tools forecast single outcomes, (e.g., risk of death) and do not provide information on timing. OBJECTIVE: To build a model that predicts the temporal patterns of multiple outcomes, such as survival, organ dysfunction, and ICU length of stay, from the profile of organ dysfunction observed on admission. DESIGN: Dynamic microsimulation of a cohort of ICU patients. SETTING: 49Forty-nine ICUs in 11 countries. PATIENTS: One thousand four hundred and forty-nine patients admitted to the ICU in May 1995. INTERVENTIONS: None. MODEL CONSTRUCTION: We developed the model on all patients (n=989) from 37 randomly-selected ICUs using daily Sequential Organ Function Assessment (SOFA) scores. We validated the model on all patients (n=460) from the remaining 12 ICUs, comparing predicted-to-actual ICU mortality, SOFA scores, and ICU length of stay (LOS). MAIN RESULTS: In the validation cohort, the predicted and actual mortality were 20.1% (95%CI: 16.2%-24.0%) and 19.9% at 30 days. The predicted and actual mean ICU LOS were 7.7 (7.0-8.3) and 8.1 (7.4-8.8) days, leading to a 5.5% underestimation of total ICU bed-days. The predicted and actual cumulative SOFA scores per patient were 45.2 (39.8-50.6) and 48.2 (41.6-54.8). Predicted and actual mean daily SOFA scores were close (5.1 vs 5.5, P=0.32). Several organ-organ interactions were significant. Cardiovascular dysfunction was most, and neurological dysfunction was least, linked to scores in other organ systems. CONCLUSIONS: Dynamic microsimulation can predict the time course of multiple short-term outcomes in cohorts of critical illness from the profile of organ dysfunction observed on admission. Such a technique may prove practical as a prediction tool that evaluates ICU performance on additional dimensions besides the risk of death.
Publication Types:
PMID: 15502934 [PubMed - indexed for MEDLINE]
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Changes in lung volume with three systems of endotracheal suctioning with and without pre-oxygenation in patients with mild-to-moderate lung failure.
Fernandez MD, Piacentini E, Blanch L, Fernandez R.
Critical Care Center, Hospital de Sabadell, Parc Tauli s/n, 08208 Sabadell, Spain. rfernandez@cspt.es
OBJECTIVE: To compare changes in lung volume, oxygenation, airway pressure, and hemodynamic effects induced by suctioning with three systems in critically ill patients with mild-to-moderate lung disease, and also to evaluate the effects of hyperoxygenation applied prior to the maneuver as suggested by some guidelines. DESIGN: Prospective crossover study. SETTING: General intensive care department of a university-affiliated hospital. PATIENTS: Ten mechanically ventilated patients with mild-to-moderate acute respiratory failure. INTERVENTIONS: Patients were ventilated in volume control mode with a mean tidal volume of 490+/-88 ml, PEEP 7+/-4 cmH2O and FiO(2) 0.36+/-0.05. Suctioning was performed sequentially with a quasi-closed system, with an open system 10 min later, and finally with a closed system. Thereafter, pure oxygen was applied for 2 min and the whole suctioning sequence was repeated in reverse order. MEASUREMENTS AND MAIN RESULTS: Patients' mean PaO(2)/FiO(2) ratio was 273+/-28 mmHg. The reductions in lung volume during suctioning were similar with the quasi-closed (386+/-124 ml) and closed system (497+/-338 ml), but significantly higher with the open system (1281+/-656 ml, P=0.022). We found no significant hemodynamic adverse effects, and no significant SpO(2) reductions with all the studied suctioning techniques. Pre-oxygenation with pure oxygen did not induce additive effects in lung volume changes. With and without pre-oxygenation, lung volume returned to baseline in every patient within 10 min. CONCLUSIONS: Suctioning with closed and quasi-closed systems reduces the substantial losses in lung volume observed with the open system. Nevertheless, in patients without severe lung disease these changes were transient and rapidly reversible.
Publication Types:
PMID: 15480564 [PubMed - indexed for MEDLINE]
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Preferred plasma volume expanders for critically ill patients: results of an international survey.
Schortgen F, Deye N, Brochard L; CRYCO Study Group.
Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Teaching Hospital, 75018 Paris, France. frederique.schortgen@bch.ap-hop-paris.fr
OBJECTIVE: Criteria for plasma volume expander selection in critically ill patients remain controversial. This study evaluated preferences of intensivists regarding plasma volume expanders. DESIGN: International survey using a 75-item questionnaire. PARTICIPANTS AND SETTING: All members of the European and French Societies of Intensive Care Medicine (n=2,415 in 1,610 adult ICUs in Europe and elsewhere) were invited to participate, and 577 (24%) working in 515 ICUs (32%) returned completed questionnaires. RESULTS: Among respondents, 17% used crystalloids alone as their first-choice strategy, 18% colloids alone, and 65% both. Colloids alone were often chosen in patients with cirrhosis (42%), coagulation disorders (42%), or adult respiratory distress syndrome (39%); and crystalloids in patients with dehydration (85%), drug overdose (59%), or acute renal failure (49%). First-line plasma expanders were as follows: isotonic crystalloids (81%), starches (55%), gelatins (35%), albumin (7%), plasma (6%), dextrans (4%), and hypertonic crystalloids (2%). Colloids alone were used more frequently in the United Kingdom (40%), starches in Germany (81%) and The Netherlands (66%), and gelatins in the United Kingdom (68%). The main factors behind preferences for first-line plasma volume expanders were time to volume loss correction, duration of effect, adverse events, and cost. CONCLUSIONS: Colloids are widely used as first-line treatment, usually in combination with crystalloids. Starches are the most widely used colloids in Europe, where albumin use is declining. However, strategies vary widely across clinical situations and countries.
PMID: 15452693 [PubMed - indexed for MEDLINE]
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Matching total body oxygen consumption and delivery: a crucial objective?
Squara P.
CERIC Clinique Ambroise Pare, 27 Boulevard Victor Hugo, 92200 Neuilly-sur-Seine, France. pierre.squara@wanadoo.fr
The strength of the rationale for incorporating total body oxygen consumption (VO(2)) and delivery (DO(2)) into our decision making strategies contrasts with the absence of demonstrated benefits of bedside calculations in clinical practice. This situation mandates a careful reappraisal of the theoretical limitations of bedside calculations of DO(2) and VO(2), including a re-evaluation of the clinical situations in which these calculations are valid. Three levels of complexity can be distinguished when analysing a patient's hemodynamic status: 1) simple cases where investigations can be limited to clinical monitoring, including lactate changes over time; 2) intermediate situations requiring invasive investigations in which continuous monitoring of VO(2)-related variables such as cardiac output and mixed venous oxygen saturation often provide enough information to guide clinical decision; and 3) complex situations where assessment of VO(2) and VO(2)/DO(2) analysis might be recommended. Although studies that support such recommendations are limited they are based on a widely accepted physiological model. VO(2) and DO(2) analysis is also limited by theoretical and technical difficulties. In this article, we discuss the validity of these limitations in the bedside assessment of VO(2) and DO(2), and review data supporting the use of VO(2)/DO(2) analysis in the clinical evaluation of complex cases.
Publication Types:
PMID: 15448891 [PubMed - indexed for MEDLINE]
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Post-traumatic mutism caused by corpus callosum injury diagnosed by fluid-attenuated inversion recovery on magnetic resonance imaging.
Yanagawa Y, Itoh Y, Sakamoto T, Okada Y, Tokumaru AM.
Department of Traumatology and Critical Care Medicine, National Defense Medical College, Namiki Tokorozawa Saitama, Japan.
Publication Types:
PMID: 15761364 [PubMed - indexed for MEDLINE]
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Acute care surgery: trauma, critical care, and emergency surgery.
Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.
PMID: 15761359 [PubMed - indexed for MEDLINE]
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Summary report on current clinical trauma care fellowship training programs.
Chiu WC, Scalea TM, Rotondo MF.
R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA. wchiu@umm.edu
BACKGROUND: Almost 10 years ago, the Careers in Trauma Committee of the Eastern Association for the Surgery of Trauma (EAST) identified four main problems with trauma fellowships: (1) lack of specified educational objectives, (2) undefined curricula, (3) inconsistent emphasis on research, and (4) inconsistent surgical exposure. These perceived problems still exist and may threaten the future of trauma surgery as a career. The objective of this study was to examine these issues in a profile of the current active clinical trauma care fellowship training programs. METHODS: The database foundation was the Trauma Fellowships Listing at the EAST Web site (http://www.east.org). All active clinical trauma training programs on this list were identified, and descriptive information was updated and abstracted. A supplemental survey was sent to each program contact person with specific questions regarding program organization, educational material, fellow responsibilities, and scholarly opportunities. In 2003, the entire database was updated, and the survey process was repeated. RESULTS: The number of active trauma care fellowship programs was 39 (1996), 43 (1999), and 50 (2003). From 1996 to 2003, 15 new programs came into existence, and 4 programs became inactive. Current programs are located in 23 states, Washington DC, Canada, and Australia. California has seven; Pennsylvania has four; and three states have three programs each. The annual trauma admissions for most programs (42 of 50, 84%) vary between 750 and 4,000, with six programs admitting more than 4,000. The most common program format (20 of 50, 40%) offers combined trauma and critical care training, whereas only three programs (6%) offer a choice of trauma only, critical care only, or combined trauma and critical care. A Residency Review Committee (RRC)-approved surgical critical care program was an integral component in 54% (1996), 76% (1999), and 78% (2003). The majority of programs (39 of 50, 78%) are of 1-year duration, with some (22 of 50, 44%) having an optional second year. Most programs (40 of 50, 80%) have one or two positions per year, with the largest program having eight fellows per year. The total number of positions available per year was 66 (1996), 89 (1999), and 95 (2003). Most fellows lead and direct a team of residents and medical students. More programs reported that fellows direct the initial resuscitation of all trauma patients admitted, and more programs are requiring in-house call requirements for fellows. CONCLUSIONS: There is steady growth in trauma fellowship training, with an emphasis on direct clinical management. An RRC-approved surgical critical care program is an important link, but one not essential to the trauma fellowship. Expected radical changes in surgical and trauma training are on the horizon. It is imperative that leaders in trauma surgery continue to monitor these trends for successful integration of trauma care training into surgical residency redesign efforts, and for facilitation of programmatic improvement in trauma care as a career.
PMID: 15761358 [PubMed - indexed for MEDLINE]
Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients.
Elward AM, Hollenbeak CS, Warren DK, Fraser VJ.
Departments of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA. elward_a@kids.wustl.edu
OBJECTIVE: To determine the attributable cost of nosocomial primary bloodstream infections (BSIs) in PICU patients. METHODS: A prospective cohort study was conducted of the PICU of the St Louis Children's Hospital, a 235-bed academic tertiary care center. All patients who were admitted to the PICU were included unless they met the following exclusion criteria: age >18 years, death within 24 hours of PICU admission, admission to the NICU service. Total and direct medical costs of PICU and hospital stay for patients with and without nosocomial primary BSI were measured. RESULTS: Fifty-seven children developed 65 episodes of primary BSIs during their PICU stay. The rate of BSI in this population was 13.8 per 1000 central venous catheter days. In multiple linear regression analysis, severity of illness as measured by the admission Pediatric Risk of Mortality Score III, congenital heart disease, underlying lung disease, ventilator days, transplant (solid organ and bone marrow), and nosocomial primary BSI were independent predictors of PICU direct costs. The direct cost of PICU admission for patients with nosocomial primary BSI was 45,615 dollars and for the patients without primary BSI was 6396 dollars. CONCLUSIONS: After controlling for age, severity of illness, underlying disease, and ventilator days, we found that the direct cost of PICU admission attributable to nosocomial primary BSI was 39,219 dollars. The prevention of these infections through specific interventions is likely to be cost-effective.
PMID: 15805357 [PubMed - in process]
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