Survival and quality of life after intensive care

Objective To determine survival and changes in quality of life (QOL) after hospital discharge in patients who had stayed in an intensive care unit (ICU).Design Prospective study by direct interviews during ICU stay and 6 months after hospital discharge.Setting Surgical-medical ICU.Patients and methods We interviewed cooperative, adult patients admitted consecutively to the ICU for more than 24 h, living near the hospital, who gave informed consent. The following QOL domains were investigated: residence, physical activity, social life, perceived QOL, oral communication and functional limitation.Results One-year survival was 82.4% (predicted 84%). Mortality was 36.3% after urgent neoplastic surgery, 19.4% for medical admissions and 4.9% after non-neoplastic surgery. Of 160 patients studied, eight cases, older and already deteriorated at the first interview, could not respond to the perceived QOL item after ICU discharge. In the other 152 patients, physical activity was reduced in 31% (usually slightly), social life had worsened in 32% and functional limitation increased in 30%. The perceived QOL did not change.Conclusions After hospital discharge, the survival of ICU-admitted patients is comparable to that of the general population and not related to ICU treatments. Most patients maintain their physical activity and social status at the preadmission level. Any worsening, if present, is slight and does not influence perceived QOL.     

International variation in length of stay in intensive care units and the impact of patient-to-nurse ratios

ObjectiveTo assess variation in ICU length of stay between countries with varying patient-to-nurse ratios; to compare ICU length of stay of individual countries against an international benchmark.DesignSecondary analysis of the DecubICUs trial (performed on 15 May 2018).SettingThe study cohort included 12,794 adult ICU patients (57 countries). Only countries with minimally twenty patients discharged (or deceased) within 30 days of ICU admission were included.Main outcome measureMultivariate Cox regression was used to evaluate ICU length of stay, censored at 30 days, across countries and for patient-to-nurse ratio, adjusted for sex, age, admission type and Simplified Acute Physiology Score II. The resulting hazard ratios for countries, indicating longer or shorter length of stay than average, were plotted on a forest plot. Results by country were benchmarked against the overall length of stay using Kaplan-Meier curves.ResultsPatients had a median ICU length of stay of 11 days (interquartile range, 4–27). Hazard ratio by country ranged from minimally 0.42 (95% confidence interval 0.35–0.51) for Greece, to maximaly1.94 (1.28–2.93) for Lithuania. The hazard ratio for patient-to-nurse was 0.96 (0.94–0.98), indicating that higher patient-to-nurse ratio results in longer length of stay.ConclusionsDespite adjustment for case-mix, we observed significant heterogeneity of ICU length of stay in-between countries, and a significantly longer length of stay when patient-to-nurse ratio increases. Future studies determining underlying characteristics of individual ICUs and broader organisation of healthcare infrastructure within countries may further explain the observed heterogeneity in ICU length of stay.     

老年内科ICU中心静脉内导管相关感染的调查

目的 观察老年ICU中心静脉内导管相关感染(CRI)发生率的临床特征. 方法调查了老年内科ICU内66例患者143例次中心静脉留置导管情况.结果 共31例患者发生CRI 46例次,累积感染率为28.57/千导管日,发生感染的中位时间为8.5d;CRI发生率与基础疾病无关,是否卧床、置管部位不同、导管腔道数不同及是否进行血液滤过治疗者CRI发生率的差异有统计学意义(P<0.05).导管培养阳性率为43.18%,导管血培养阳性率为31.82%. 结论老年内科ICU内CRI感染发生率较其他科室更高,置管部位、置管腔道数及是否正经历增加接触导管的各种操作(如血液滤过)等不同,CRI的感染风险也不一样.     

The management of bereavement on intensive care units

Objective To investigate the management of the bereaved on Intensive Care Units (ICU) throughout the United Kingdom, and to identify inadequacies that may exist either in the provision of staff training in dealing with bereavement or in the facilities or support available for the bereaved.Design Questionnaires were sent to the senior nurse and senior doctor in all general ICUs with more than four beds nationwide. The questions asked about nursing and medical practice around the time of a patient's death, as well as about staff attitudes towards, and training in, dealing with bereavement and the support they received for this role.Results We obtained a 68% (293/430) response rate. Most ICUs had facilities for relatives, but little for the specific needs of the bereaved. Only 6% of doctors and 21% of nurses had training in dealing with bereavement and grieving. A staff support group was available in 23% of ICUs, and 75% of the remainder thought it would be useful to have one. Lack of staff training and poor facilities for relatives were identified as the major concerns of ICU staff.Conclusion Many doctors and nurses working in Intensive Care Units feel inadequately trained to deal confidently with the bereaved. A minority of ICUs have support mechanisms available for their staff, inspite of the perceived need for them. Furthermore, many ICU staff feel the facilities they are able to offer the bereaved are inadequate. We have identified the major inadequacies and the needs of ICU staff for improved training. Meeting these needs would play a significant role not only in reducing staff stress but also minimising the morbidity in surviving relatives.     

Influence of social deprivation on intensive care outcome

Objective: To assess the influence of social deprivation on outcome from admission to the intensive care unit. Design: Retrospective cohort study. Setting: Tertiary referral centre mixed adult intensive care unit (ICU). Patients: Seven hundred seventy-four consecutive admissions to the ICU over a 2-year period. Interventions: None.¶Measurements and results: Age, admission illness severity measured by APACHE II score, predicted hospital mortality, actual hospital mortality and length of ICU stay were obtained for all patients. Social deprivation was assessed by Carstairs Score for postcode sector of residence categorised from 1 (most affluent ) to 7 (most deprived). Carstairs Scores were obtained for 716 patients. When patients in categories 6 and 7 were compared with the others there were no significant differences in age, admission illness severity, predicted or actual hospital mortality and length of ICU stay. On multivariate analysis there was no evidence of an increased mortality risk for patients in categories 6 and 7 (p = 0.256, odds ratio 1.2, 95 % confidence interval 0.9–1.7). Conclusions: Social deprivation does not influence outcome in patients admitted to the ICU.     

重症监护病房护士职业危害发生情况、担心程度及应对的相关性研究

目的了解重症监护病房护士职业危害的发生现状、对职业危害的担心程度及经常采取的应对方式,探讨重症监护病房护士职业危害发生情况与担心程度、发生情况与应对、担心程度与应对的相关性。方法采用自编的一般资料调查表、重症监护病房护士职业危害发生情况及担心程度调查问卷和简易应对方式量表,对沈阳市三级甲等医院211名重症监护病房护士进行调查。结果重症监护病房护士职业危害发生情况和担心程度以人体工效学、心理社会和组织因素得分最高;职业危害发生情况与担心程度和消极应对呈正相关,担心程度与消极应对呈正相关。结论医院各级管理者应重视重症监护病房护士的职业危害,特别是人体工效学、心理社会和组织因素危害。采取有针对性的防护措施减少重症监护病房护士职业危害的发生;改进以前的培训方式和丰富培训课程内容,正确引导护士认识职业危害并予以积极的应对。     

ICU限制性探视结合预约探视制度的实施及安全管理

为了更好地满足ICU患者和家属的探视需求,贯彻以人为本的服务理念,采用限制性探视与预约探视相结合的方法,接受5160名家属对综合ICU 853例患者进行探视。效果:患者对护理工作的满意度由95.0%提高到98.5%,感染率由2.5%下降为2.3%,纠纷发生率为0。ICU实施限制式探视与预约探视相结合的方法,更好地满足了患者和家属的需要。     

移动ICU的构建和应用效果

目的 提高重症患者院内转运的安全性和可行性,加强对危重患者转运的管理,确保危重患者的安全.方法 针对重症患者转运中存在的问题,在2012年构建并实施按监护室标准配备的移动ICU,以专业化转运人员、监护和生命支持设备、二级救护站点、转运流程和预案为要素,严格进行质量控制,完成患者院内安全转运.结果 共成功转运患者214例次,一次转运成功211例次.本组中有3例机械通气患者在转运起始阶段脉搏血氧饱和度下降至90％以下,即刻返回ICU,病情稳定后再次转运成功.本组无人工气道移位和意外死亡等情况发生.结论 移动ICU转运延续了监护室环境和危重病管理水平,可降低危重患者转运不良事件的发生,提高转运的安全性.     

The impact of age on outcome after major surgical procedures

Purpose

The aim of this study was to investigate the effects of age on outcome in a large cohort of surgical intensive care unit (ICU) patients.

Methods

In this retrospective analysis of prospectively collected data, all 11?537 adult patients admitted directly from the operating room to our 50-bed surgical ICU between January 1, 2004, and January 31, 2009, were included. Patients were classified into 5 subgroups according to age (18-50 [reference category], 51-65, 66-75, 76-85, > 85 years).

Results

Severity scores and the incidence of comorbid conditions on ICU admission increased steadily with age. Intensive care unit and hospital mortality rates were 4.4% and 8.7%, respectively, and increased with age to reach 12.4% and 28.2%, respectively, in patients older than 85 years. In multivariate logistic regression analysis, age was an independent risk factor for in-hospital death (odds ratio, 1.04; 95% confidence interval, 1.03-1.04, per year; P < .001). Gastrointestinal surgery was independently associated with a higher risk of in-hospital mortality in patients older than 50 years, whereas neurosurgery was associated with a higher risk of in-hospital death only in patients older than 65 years.

Conclusions

Mortality rates increase with age, with an exponential increase in patients older than 65 years. Age is an independent risk factor for in-hospital death, irrespective of the type of surgical intervention.     

ICU每日质量查检单的优化设计及临床应用

目的通过优化设计ICU每日质量查检单(简称查检单),指导医护人员在临床实践中进行质量查检,以提高监护质量,保证护理安全。方法 2011年12月至2012年2月,将查检单应用于ICU的危重患者,对重症患者的治疗护理措施进行每日查检,观察各具体项目的执行情况。结果重症医疗护理团队对查检单涉及的11项基本治疗及监护措施执行率为85%~99%。结论将查检单应用于ICU重症患者的质量管理,有助于提高ICU的监护质量。     

Risk factors for prolonged stay in cardiac surgery intensive care units

Aims and objectives: To identify the factors that might affect the length of stay in the intensive care unit (ICU‐LOS) among cardiac surgery patients. Background: ICU‐LOS forms an important factor for assessing the effectiveness of the provided nursing care. A number of factors can be accused for increasing patient hospitalization. The nursing workload (NWL), among others, was found to play a significant role as it is closely associated with the quality of care. Design: An observational cohort study among 313 consecutive patients who were admitted to the cardiac surgery intensive care unit of a general, tertiary hospital of Athens, Greece from November 2008 to November 2009. Methods: Data collection was performed by using a short questionnaire (for basic demographic information) and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE, for assessing the NWL and the perioperative risk for each patient respectively. Results: ICU‐LOS of more than 2 days increased with age and was more common among females (p < 0·001 and p = 0·02, respectively). Multivariate logistic regression analysis revealed a positive association between increased perioperative risk and the increased ICU‐LOS [odd ratio (OR) 1·9, 95% confidence interval (CI) 1·0–3·5, p = 0·04], while patients with a first day NAS of more than 61·6% had an almost 5·2 times greater probability to stay in the cardiac surgery unit for more than 2 days (OR 5·2, 95% CI 3·0–8·8, p < 0·001). Conclusions: Increased level of NWL and patient perioperative risk are closely associated with increased ICU‐LOS. Relevance to clinical practice: The correlation between patient perioperative risk and ICU‐LOS encourages the early identification of high‐risk patients for prolonged hospitalization. Furthermore, the relationship between NWL and ICU‐LOS allows the early identification of these patients with the use of an independent nursing tool.     

Outcome and costs of intensive care

A retrospective follow-up study was performed on 238 consecutive admissions in the surgical ICU. The patients were grouped into four categories according to the therapeutic intervention scoring system: 14 in class I, 13 in class II, 81 in class III and 130 in class IV. The mortality rate during their stay in the ICU (5.4%), after discharge from the ICU (2.1%) and 2 years after discharge from the hospital (7.6%) was estimated. The functional state after discharge from the hospital showed that 74% of the patients resumed their normal work, 10% were handicapped but self-reliant, and 1.3% were dependent on others in order to pursue their daily activities. Fifty-two percent of the total hospitalization costs were generated during the ICU stage which accounted for 17.5% of the hospitalization period. Sixty percent of the total financial investment was spent on the group of survivors who resumed normal work. The mean cost per was $ 7095 or $ 1 per survivor per day of active life over an average span of 15 years survival after discharge from the hospital.     

导管交接表在ICU安全管理中的应用

目的探讨导管班情交接表在重症监护室导管安全管理中的应用方法及效果。方法 2011年1⁵月住院患者219例为对照组,采用传统模式床边交接班法;2011年65月住院患者219例为对照组,采用传统模式床边交接班法;2011年6¹0月住院患者223例为试验组,使用导管班情交接表进行床边交接。比较两组导管不良事件发生情况和护士对患者导管情况的掌握程度。结果试验组发生导管不良事件率低于对照组(P<0.01)。使用导管班情交接表后护士对于导管掌握情况有所提高(P<0.01)。结论使用导管班情交接表可以帮助护士进行导管的安全管理,有效减少导管不良事件的发生。     

Effect of adverse drug reactions on length of stay in surgical intensive care units

OBJECTIVE: To determine the frequency of adverse drug reactions in surgical intensive care units and evaluate their effect on the length of stay. DESIGN: Prospective cohort study. Between May 1997 and December 1999, while the patients were staying in the surgical intensive care unit, data were gathered regarding suspected adverse drug reactions and on different variables related to the length of stay. SETTING: Surgical intensive care units of our hospital. PATIENTS: A total of 401 patients hospitalized in the surgical intensive care unit. MAIN RESULTS: In 37 of the 401 patients seen (9.2%; 95% confidence interval, 6.6-12.5), 39 different adverse drug reactions were detected. The adverse drug reactions were most frequently caused by the following drugs: morphine hydrochloride (n = 13), meperidine hydrochloride (n = 9), and metamizole (n = 7). Five adverse drug reactions were severe, the suspected medication had to be discontinued in 14 cases, and new drugs were necessary to manage the adverse drug reaction in 28 cases. The crude estimation of the effect of adverse drug reactions performed on the length of stay with a bivariant regression model indicated that each adverse drug reaction was related to an increase of 3.39 days (95% confidence interval, 1.47-5.31) in the length of stay. This estimation was reduced to 2.31 days (95% confidence interval, 0.64-3.99) when considering other variables that might cause confusion for analysis, although it is still important. CONCLUSIONS: Adverse drug reactions are a significant clinical and economic problem in surgical intensive care units.     

Delirium incidents in three Danish intensive care units

Background: Delirium as a result of hospitalization in an intensive care unit (ICU) is defined by a mental state different from the patients' normal state and an acute fluctuating course. Both morbidity and mortality are increased in relation to delirium. The incidence of delirium has been reported from 16% to 87% in international studies primarily in elderly patients. Aims: The purpose of this study was to evaluate the incidence of delirium in adult intensive care patients in Denmark and to identify correlations between delirium, sedatives, opiod analgesics and age. Methods: In a prospective follow‐up study, 139 adult patients were screened for delirium using the confusion assessment method for the ICU (CAM‐ICU) from 48 h after admission to ICU, twice a day until discharged. Results: A total of 41 patients had at least one positive score for delirium, 61 had only negative scores and 37 were too heavily sedated to be scored during the study period. Thus, the incidence of delirium was 40% among patients who were able to be CAM‐ICU scored. Patients who were lightly sedated had a 10‐fold increased risk of delirium. There was no difference in incidence by age. Patients who received Fentanyl were more at risk of developing delirium compared with patients who received other or no analgesics. Sedative drugs did not influence the incidence. Conclusion: In this study delirium occurred in 40% of adult ICU patients of all ages.     

Managing intensive care units: Make LOVE,not war!

Objective

Describe a program set up in a French intensive care unit (ICU) aimed at improving communication inside the team and communication information given to patients and their relatives; explain how those actions can improve communication inside the ICU and ultimately why it could improve patient's outcome.

Design and Methods

Position paper.

Intervention

Progressive implementation of multifaceted quality improvement program.

Results

The program Leadership, Ownership, Values, and Evaluation (LOVE) was developed over 10 years. It was usually well accepted by the members of the team, patients, and relatives, in particular the 24-hour visiting program that was prospectively evaluated. Information and decisions were shared with the patients or more often with the relatives, who became for some of them really “part of the team.” Additional actions such as participation to some of the simplest cares by the families are under investigation. A prospective evaluation of such programs, although difficult to perform, remains probably necessary.

Conclusion

Quality of life within the ICU is based on many factors including a strong and positive leadership, an absolute respect of individuals, and a rigorous evaluation of quality of care, which could influence heavily the quality of life in the ICU for patients, relatives, and health care professionals and facilitate team work. Whether this could really influence outcome remains to be demonstrated.     

重症监护病房病人和护士对病人ICU环境压力源感知的比较

目的:比较ICU内接受治疗的病人感知到的ICU环境压力与护士对于病人所感知到的ICU环境压力源评价的异同。方法:采取目的抽样法抽取北京市某三级甲等医院ICU接受治疗的病人50名以及直接参与其护理的护士50名,采用一般资料问卷、ICU环境压力源量表进行调查。结果:该研究中病人感知到的ICU环境压力与护士评价病人所感知到的ICU环境压力源的部分条目、压力源排序存在差异,且病人组的ICU环境压力源的得分(85.08±21.16)高于护士组(78.08±12.71),两组ICU环境压力源的评价差异有统计学意义(P=0.048)。结论:护士对于病人所面临的ICU环境压力源的评价低于病人自身,ICU护士作为病人的主要照顾者,其对于病人在ICU内所面临的ICU环境压力源的认知直接关系到护士能否为病人提供恰当的医疗、护理服务,应给予足够的重视。