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1.
Jonathan Rosenson Carter Clements Barry Simon Jules Vieaux Sarah Graffman Farnaz Vahidnia Bitou Cisse Joseph Lam Harrison Alter 《The Journal of emergency medicine》2013
Background
Acute alcohol withdrawal syndrome (AAWS) is encountered in patients presenting acutely to the Emergency Department (ED) and often requires pharmacologic management.Objective
We investigated whether a single dose of intravenous (i.v.) phenobarbital combined with a standardized lorazepam-based alcohol withdrawal protocol decreases intensive care unit (ICU) admission in ED patients with acute alcohol withdrawal.Methods
This was a prospective, randomized, double-blind, placebo-controlled study. Patients were randomized to receive either a single dose of i.v. phenobarbital (10 mg/kg in 100 mL normal saline) or placebo (100 mL normal saline). All patients were placed on the institutional symptom-guided lorazepam-based alcohol withdrawal protocol. The primary outcome was initial level of hospital admission (ICU vs. telemetry vs. floor ward).Results
There were 198 patients enrolled in the study, and 102 met inclusion criteria for analysis. Fifty-one patients received phenobarbital and 51 received placebo. Baseline characteristics and severity were similar in both groups. Patients that received phenobarbital had fewer ICU admissions (8% vs. 25%, 95% confidence interval 4–32). There were no differences in adverse events.Conclusions
A single dose of i.v. phenobarbital combined with a symptom-guided lorazepam-based alcohol withdrawal protocol resulted in decreased ICU admission and did not cause increased adverse outcomes. 相似文献2.
Fernando Godinho Zampieri José Paulo Ladeira Marcelo Park Douglas Haib Cintia Lovatto Pastore Cristiane M. Santoro Fernando Colombari 《Journal of critical care》2014
Purpose
To describe the admission factors associated with prolonged (> 14 days) intensive care unit (ICU) stay (PIS).Materials and Methods
Retrospective analysis of 3257 admissions during a 1.5-year period in a tertiary hospital. We tested the association between clinically relevant variables and PIS (> 14 days) through binary logistic regression using the backward method. A Kaplan-Meier curve and the log-rank test were used to compare hospital outcomes for ICU survivors between patients with and without PIS.Results
In total, 6.6% of all admissions had a prolonged stay, consuming over 40% of all ICU bed-days. Illness severity; respiratory support at admission; performance status; readmission; admission from a ward, emergency room or other hospital; admission due to intracranial mass effect; severe chronic obstructive pulmonary disease; and the temperature at admission were all associated with PIS in a multivariate analysis. The created model had a good area under the curve (0.82) and was calibrated (Hosmer-Lemeshow test p = 0.431). Post hoc analysis on ICU survivors on in patients with at least two days of ICU stay yielded similar results. Hospital survival after ICU discharge was similar for patients with and without PIS (log-rank test p = 0.50).Conclusion
A small number of ICU admissions consume a great proportion of ICU bed-days. Illness severity, a need for support and performance status are important predictors of PIS. Patients who survive a PIS have similar hospital mortality to patients with a shorter stay. 相似文献3.
Background
Score systems for severity of illness and organ dysfunction have been validated and used as tools to predict the risk of death in intensive care unit (ICU) patients, but their usefulness in patients with suspected infection in the emergency department (ED) or hospital ward is unclear.Objectives
The objective of this systematic review was to establish the accuracy of score systems in the prediction of mortality in patients with suspected infection in hospital settings compared to the ICU.Methods
Three researchers independently performed a systematic search and a review of related articles and their references using the PubMed database. The articles were selected by consensus, based on previously defined inclusion and exclusion criteria.Results
In total, 21 studies were included, 19 of which were carried out in the ED. The researchers found that the operative characteristics to evaluate the accuracy (calibration and discrimination) of the different scores were insufficiently assessed in most studies. Only two studies evaluated the calibration, using the Hosmer-Lemeshow goodness-of-fit test, and less than half of the studies evaluated the discrimination, using the area under the receiver operator characteristics curve.Conclusions
The reviewed literature did not provide enough information to assess the accuracy of the prognostic models in patients with suspected infection admitted to the ED and hospital ward. Some reports suggest a better accuracy with new scores like the MEDS (Mortality in Emergency Department Sepsis score), but the results are not consistent. 相似文献4.
Rationale
Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes.Objective
To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the “active bed management” (ABM) intervention.Methods
A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow.Measurement
Throughput time for patients presenting to the ED requiring ICU admission was analyzed.Main Results
The ED census was higher during the intervention period as compared with the control period, 17?573 versus 16?148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant.Conclusion
Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety. 相似文献5.
Folafoluwa O. Odetola MD MPH Sarah J. Clark MPH James G. Gurney PhD Ronald E. Dechert DrPH Thomas P. Shanley MD FCCM Gary L. Freed MD MPH 《Journal of critical care》2009,24(3):379-386
Purpose
The study aimed to examine the effect of interhospital transfer on resource utilization and clinical outcomes at a tertiary pediatric intensive care unit (PICU) among patients with sepsis or respiratory failure.Materials and methods
Data on 2146 consecutive admissions with respiratory failure or sepsis to the PICU were analyzed. Data included demographics, admission source, and outcomes. Admission source was classified as interhospital transfer from the emergency departments (ED), wards, or PICUs of referring hospitals; or from the study hospital ED (direct).Results
Compared with direct admissions, inter-PICU transfers had higher crude mortality (odds ratio, 1.93; 95% confidence interval, 1.31-2.84) but not significant mortality difference (odds ratio, 1.16; 95% confidence interval, 0.71-1.86) after adjusting for illness severity, age, and sex. Conversely, ED transfers had lower PICU mortality than direct ED admissions. Children with transfer admissions stayed significantly longer and used more intensive care technology in the study PICU than children directly admitted (P < .01). In comparisons within quartiles of mortality risk, inter-PICU transfers had longer hospitalization and higher mortality in all but the highest quartile.Conclusions
Interhospital transfer, particularly inter-PICU transfer, was associated with significant hospital resource consumption that often correlated with admission illness severity. Future prospective studies should identify determinants of pretransfer illness severity and investigate decision making underlying interhospital transfer. 相似文献6.
Primary objective
The primary objective of the study is to determine if the mortality for adult patients visiting US emergency departments (EDs) is greater on weekends than weekdays.Secondary objectives
The secondary objective of the study is to examine whether patient factors (diagnosis, income, insurance status) or hospital characteristics (ownership, ED volume, teaching status) are associated with increased weekend mortality.Methods
We used a retrospective cohort analysis of the 2008 Nationwide Emergency Department Sample. Evaluating 4 225 973 adults admitted through the ED to the hospital, signifying a 20% representative sample of US ED admissions. Logistic regression was used to examine associations of weekend mortality with patient and hospital characteristics, accounting for clustering by hospital.Results
Emergency department patients admitted to the hospital on the weekend are significantly more likely to die than those admitted on weekdays (odds ratio, 1.073; 95% confidence interval, 1.061-1.084). A significant weekend effect persisted after controlling for patient characteristics (odds ratio, 1.026; 95% confidence interval, 1.005-1.048). The top 10 primary diagnoses for patients dying did not identify any specific medical condition that explained the higher weekend admission mortality. The weekend effect was also relatively consistent across patient income, insurance status, hospital ownership, ED volume, and hospital teaching status.Conclusion
Patients are more likely to die when admitted through the ED on the weekend. We were unable to identify specific circumstances or hospital attributes that help explain this phenomenon. Although the relative increased risk per case is small, our study demonstrates a significant number of potentially preventable weekend deaths occurring annually in the United States. 相似文献7.
Scott D. Cline MD Robyn A.K. Schertz MD Eric C. Feucht MD 《The American journal of emergency medicine》2009,27(7):843-846
Background
To determine if expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the emergency department (ED) to the intensive care unit (ICU) decreases ICU and hospital length of stay.Methods
Patients with respiratory failure that required intubation and mechanical ventilation who were admitted to the hospital between June 2004 and May 2006 were retrospectively identified from the Project IMPACT database. Patients were divided into 2 groups based on ED length of stay: expedited (<2 hours) or nonexpedited (>2 hours).Results
The expedited (n = 12) and nonexpedited (n = 66) groups were comparable in demographics, medical conditions, and disease severity. Mean duration of mechanical ventilation was significantly shorter in the expedited group (28.4 hours vs 67.9 hours; P = .0431), as was mean ICU length of stay (2.4 days vs 4.9 days; P = .0209). Length of hospital stay tended to be shorter for the patients in the expedited group (6.8 days vs 8.9 days; P = .0609).Conclusions
Expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was associated with shorter durations of mechanical ventilation and ICU length of stay, suggesting that prompt ICU admission results in improved use of resources. 相似文献8.
Ewai Zhang Shih-Chiang Hung Chien-Hung Wu Ling-Ling Chen Ming-Ta Tsai Wen-Huei Lee 《The American journal of emergency medicine》2017,35(3):479-483
Objectives
Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety.Methods
This prospective observational study enrolled adult non-trauma patients with unexpected life-threatening events within 24 h of general ward admission from the ED of a medical center in Taiwan. The period of study was one year (in 2013); the medical records of enrolled patients were reviewed to identify adverse events and errors. We measured the incidence rate of adverse events or errors. Preventability, type, and physical injury severity of adverse events were investigated.Results
Of 33,224 adult non-trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication adverse events (6.7%).Conclusions
Unexpected life-threatening events within 24 h of admission from the ED could be a useful trigger tool to identify preventable adverse events with serious physical injury in ED. 相似文献9.
Using administrative data to develop a nomogram for individualising risk of unplanned admission to intensive care 总被引:1,自引:0,他引:1
AIM: Although unplanned admissions to the intensive care unit (ICU) are associated with poorer prognoses, there is no published prognostic tool available for predicting this risk in an individual patient. We developed a nomogram for calculating the individualised absolute risk of unplanned ICU admission during a hospital stay. METHOD: Hospital administrative data from a large district hospital of consecutive admissions from 1 January 2000 to 31 December 2006 of aged over 14 years was used. Patient data was extracted from 94,482 hospital admissions consisted of demographic and clinical variables, including diagnostic categories, types of admission and time and day of admission. Multivariate logistic regression coefficients were used to develop a predictive nomogram of individual risk to patients admitted to the study hospital of unplanned ICU admission. RESULTS: A total of 672 incident unplanned ICU admissions were identified over this period. Independent predictors of unplanned ICU admissions included being male, older age, emergency department (ED) admissions, after-hour admissions, weekend admissions and six principal diagnosis groups: fractured femur, acute pancreatitis, liver disease, chronic airway disease, pneumonia and heart failure. The area under the receiver operating characteristic curve was 0.81. CONCLUSION: The use of a nomogram to accurately identify at-risk patients using information that is readily available to clinicians has the potential to be a useful tool in reducing unplanned ICU admissions, which in turn may contribute to the reduction of adverse events of patients in the general wards. 相似文献
10.
Otavio T. Ranzani Fernando Godinho Zampieri Leandro Utino Taniguchi Daniel Neves Forte Luciano César Pontes Azevedo Marcelo Park 《Journal of critical care》2014