Economies of scale in British intensive care units and combined intensive care/high dependency units

Objective To estimate the relationship between size of intensive care unit and combined intensive care/high dependency units and average costs per patient day.Design Retrospective data analysis. Multiple regression of average costs on critical care unit size, controlling for teaching status, type of unit, occupancy rate and average length of stay.Setting Seventy-two United Kingdom adult intensive care and combined intensive care/high dependency units submitting expenditure data for the financial year 2000–2001 as part of the Critical Care National Cost Block Programme.Interventions None.Measurements and results The main outcome measures were total cost per patient day and the following components: staffing cost, consumables cost and clinical support services costs. Nursing Whole Time Equivalents per patient day were recorded. The unit size variable has a negative and statistically significant (p<0.05) coefficient in regressions for total, staffing and consumables cost. The predicted average cost for a seven-bed unit is about 96% of that predicted for a six-bed critical care unit.Conclusion Policy makers should consider the possibility of economies of scale in planning intensive care and combined intensive care/high dependency units.     

Epidemiology of nosocomial infections in adult intensive care units

Patients in intensive care units (ICUs) are a small subgroup of all hospitalized patients, but they account for approximately 25% of all hospital infections. Nosocomial infection rates among ICU patients are 5–10 times higher than among general ward patients. ICU infection rates are higher due to complex interactions between the patients' underlying disease, severity of illness, type of ICU, duration of stay, and invasive devices used. Antimicrobial resistance is a major clinical problem despite potent and newer antibiotics. Organisms that pose a clinically significant resistance problem among ICU patients include methicillin-resistant staphylococci, enterococci, a wide variety of enterobacteriaceae,Pseudomonas aeruginosa, Pseudomonas cepacia, Xanthomonas maltophila, Acinetobacter andCandida species. Traditional infection control measures include identification of reservoirs, halting transmission between patients, stopping progression from colonization to infection and modifying host risk. In addition, sound selection procedures and guidelines for antibiotic usage are necessary to control the spread of multi-resistant micro-organisms.     

Ventilation bundle compliance in two Australian intensive care units: An observational study

BackgroundThe ventilation bundle has been used in adult intensive care units to decrease harm and improve quality of care for mechanically ventilated patients. The ventilation bundle focuses on prevention of specific complications of mechanical ventilation; ventilator-associated pneumonia, sepsis, barotrauma, pulmonary oedema, pulmonary embolism, and acute respiratory distress syndrome. The Institute for Healthcare Improvement ventilation bundle consists of five structured evidence-based interventions: head of the bed elevation at 30–45°; daily sedation interruptions and assessment of readiness to extubate; peptic ulcer prophylaxis; deep vein thrombosis prophylaxis; and daily oral care with chlorhexidine.ObjectivesThe objective of the study was to evaluate the use of the ventilation bundle in two intensive care units in Victoria, Australia.MethodsThis is a 3-month prospective observational study in two intensive care units. Patient medical records were reviewed on days 3, 4, and 5 of mechanical ventilation using a prevalidated ventilation bundle checklist.ResultsA total of 96 critically ill patients required mechanical ventilation for more than 2 d. Patients had a mean age of 64.50 y (standard deviation = 14.89), with an Acute Physiology, Age, Chronic Health Evaluation (APACHE) III mean score of 79.27 (standard deviation = 27.11). The mean ventilation bundle compliance rate was 88.3% on the three consecutive mechanical ventilation days (day 3 = 79.4%, day 4 = 91.1%, and day 5 = 96.7%). There was a statistically significant difference in the mean APACHE III score between patients who had head of bed elevation and those without head of bed elevation, on days 3 (p = <0.001) and 4 (p = 0.007).ConclusionThe ventilation bundle elements were used in Australian intensive care units. The likelihood of having all ventilation bundle elements on day 3 was low if the patient's APACHE III score was high. However, the ventilation bundle compliance rate increased with mechanical ventilation days.     

Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients

OBJECTIVE: To investigate the effect of standing with assistance of the tilt table on ventilatory parameters and arterial blood gases in intensive care patients. DESIGN: Consecutive sample. SETTING: Tertiary referral hospital. PARTICIPANTS: Fifteen adult patients who had been intubated and mechanically ventilated for more than 5 days (3 subjects successfully weaned, 12 subjects being weaned). INTERVENTION: Passive tilting to 70 degrees from the horizontal for 5 minutes using a tilt table. MAIN OUTCOME MEASURES: Minute ventilation (VE), tidal volume (VT), respiratory rate, and arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2). RESULTS: Standing in the tilted position for 5 minutes produced significant increases in VE (P <.001) and produced both increases in respiratory rate (P <.001) and VT (P =.016) compared with baseline levels. These changes were maintained during the tilt intervention and immediately posttilt. Twenty minutes after the tilt, there were no significant changes in ventilatory measures of VE, VT, or arterial blood gases PaO2 and PaCO2 compared with initial values. CONCLUSIONS: Standing for 5 minutes with assistance of a tilt table significantly increased ventilation in critical care patients during and immediately after the intervention. There were no improvements in gas exchange posttilt. Using a tilt table provided an effective method to increase ventilation in the short term.     

Mobilisation is feasible in intensive care patients receiving vasoactive therapy: An observational study

Background

Mobilisation of intensive care unit (ICU) patients reduces ICU-acquired weakness and is associated with better functional outcomes. However, the prevalence of mobilisation of ICU patients remains low. A known barrier to mobilisation is haemodynamic instability, frequently with patients requiring vasoactive therapy. There is a lack of published data to guide clinicians about the safety and feasibility of mobilising patients receiving vasoactive therapy.

Safety culture in two metropolitan Australian tertiary hospital intensive care units: A cross-sectional survey

BackgroundSafety culture is significant in the complex intensive care environment, where the consequences of human error can be catastrophic. Research within Australian intensive care units has been limited and little is understood about the safety culture of intensive care units in Queensland.AimThe aim was to evaluate and compare safety culture in the intensive care units of two metropolitan tertiary hospitals in Queensland.MethodA cross-sectional survey, Safety Attitudes Questionnaire, was administered to all medical, nursing and allied health professionals in the research sites (A and B) during January and February 2016. Data were collated into six safety culture domains of teamwork climate, safety climate, job satisfaction, stress recognition, working conditions and perceptions of management. Comparison was made using t-tests and between demographic groups using generalising estimating equations.ResultsIn total, 206 surveys were returned from 522 staff (39.5% response rate). The majority of respondents were nurses (80.6%). Site B scored all domains of the safety attitudes questionnaire significantly higher than Site A (p < 0.001). The scores for both site A and B were significantly higher in all domains (p < 0.001) than a previous Australian study conducted in 2013. Both sites returned low scores in the stress recognition domain. Medical staff perceived the teamwork climate as more positive than nursing staff (mean difference 16.6 [Wald χ² = 10383.8, p < 0.001]). Allied health professionals reported poorer perceptions of working conditions than medical staff (mean difference 7.8 [Wald χ² = 775.4, p < 0.001]).ConclusionDespite similar governance and external structures, differences were found in safety culture between the two research sites. This finding emphasises the importance of local, unit-level assessment of safety culture and planning of improvement strategies. This study adds to the evidence and implications for critical care clinical practice that these interventions need to be unit focused, supported by management and multidisciplinary in approach.     

Triggers and nursing influences on delirium in intensive care units

Among care providers, nurses have the most influence on the occurrence of delirium in patients. To identify and investigate the risk factors associated with delirium and analyse the nurse's influence on delirium, a secondary data analysis approach was used with clinical data from the electronic medical record and health care provider data from the management information systems of a university hospital. Data of 3284 patients (delirium = 688, non‐delirium = 2596) hospitalized in the medical and surgical intensive care units containing 2178 variables were analysed. Donabedian's structure‐process‐outcome model was applied to categorize the factors for multilevel hierarchical logistic regression analysis. Sixteen factors (10 patient factors, 1 provider factor, 1 environmental factor, 2 nursing intervention factors and 2 medical intervention factors) were identified as significant in the final model. Longer intensive care unit experience of nurses did not decrease the risk of delirium. Greater number of nursing intervention needs and greater use of restraints were associated with an increased risk of delirium. The duration of nursing career did not affect the reduction of the risk of delirium. Nurses should therefore endeavour to acquire nursing experience specific for delirium care and attend training courses for delirium management.     

Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system

Purpose

The purpose of this study is to estimate the costs and cost-effectiveness of a telemedicine intensive care unit (ICU) (tele-ICU) program.

Materials and Methods

We used an observational study with ICU patients cared for during the pre-tele-ICU period and ICU patients cared for during the post-tele-ICU period in 6 ICUs at 5 hospitals that are part of a large nonprofit health care system in the Gulf Coast region. We obtained data on a sample of 4142 ICU patients: 2034 in the pre-tele-ICU period and 2108 in the post-tele-ICU period. Economic outcomes were hospital costs, ICU costs and floor costs, measured for average daily costs, costs per case, and costs per patient.

Results

After the implementation of the tele-ICU, the hospital daily cost increased from $4302 to $5340 (24%); the hospital cost per case, from $21 967 to $31 318 (43%); and the cost per patient, from $20 231 to $25 846 (28%). Although the tele-ICU intervention was not cost-effective in patients with Simplified Acute Physiology Score II 50 or less, it was cost-effective in the sickest patients with Simplified Acute Physiology Score II more than 50 (17% of patients) because it decreased hospital mortality without increasing costs significantly.

Conclusions

Hospital administrators may conclude that a tele-ICU program aimed at the sickest patients is cost-effective.     

Continuous end-tidal carbon dioxide monitoring in pediatric intensive care units

Purpose

End-tidal carbon dioxide (ETCO₂) monitoring has a variety of clinical applications in critically ill pediatric patients. This study was designed to explore the current availability and utilization patterns for continuous ETCO₂ monitoring in pediatric intensive care units.

Methods

A Web-based survey was distributed to directors of all accredited pediatric critical care fellowship programs in the United States.

Results

Sixty-six percent of directors completed this survey. One hundred percent of directors had access to ETCO₂ monitoring for intubated patients and 57% for nonintubated patients. Eighty-three percent of respondents used ETCO₂ monitoring “always” or “often” for endotracheal tube confirmation. Fifty percent of respondents used ETCO₂ monitoring “always” or “often” for cardiopulmonary resuscitation, 38% for moderate sedation, and 5% for acid-base disturbances. All respondents who used ETCO₂ monitoring felt that it was easy to use. The most common reason for not using ETCO₂ monitoring was lack of availability (75%).

Conclusions

End-tidal carbon dioxide monitoring is widely available and used for intubated patients. However, it could be applied more frequently in other clinical situations in pediatric intensive care units.     

超声造影在重症监护病房中的应用现状

常规超声监测在危重症患者中已广泛应用,但在某些特殊情况如器官血流灌注下易出现误诊和漏诊。超声造影可以反映器官组织的血流灌注情况,特别是微灌注情况,在监测危重症患者时可弥补常规超声血流灌注的不足。本文初步总结超声造影在重症监护病房中的应用现状及进展。     

Surveillance of antimicrobial use and antimicrobial resistance in intensive care units (SARI): 1. Antimicrobial use in German intensive care units

Objective To study antimicrobial use for benchmarking and ensuring quality of antimicrobial treatment and to identify risk factors associated with the high use of antimicrobials in German intensive care units (ICUs) through implementation of the SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in ICUs) system.Design Prospective, unit-based surveillance on antimicrobial use from February, 2000, until June, 2002. The data are standardised by use of the defined daily dose (DDD) for each antimicrobial defined by the WHO and by calculating use per 1000 patient days.Setting The data were obtained from 35 German ICUs and stratified by type of ICU (medical, surgical, interdisciplinary).Results To date, the project covers a total of 266,013 patient days in 744 reported ICU months and 354,356 DDDs. Mean antimicrobial use density (AD) was 1,332 DDD/1000 patient days and was correlated with length of stay. Penicillins with beta-lactamase inhibitor (AD 338.3) and quinolones (155.5) were the antimicrobial group with the highest ADs. Comparison with US ICARE (Intensive Care Antimicrobial Resistance Epidemiology)/AUR (Antimicrobial Use and Resistance) data revealed a higher AD for glycopeptides and 3rd generation cephalosporins in ICARE/AUR ICUs, but a higher AD for carbapenems in German SARI ICUs regardless of the type of ICU. In the multivariate analysis, length of stay was an independent risk factor for an AD above the 75% percentile of the total amount of antimicrobials used (OR 1.96 per day); likewise, for the AD above the 75% percentile of carbapenems (OR 1.90 per day) and penicillins with extended spectrum (OR 2.01 per day). High use of glycopeptides and quinolones (AD >75% percentile) correlated with central venous catheter (CVC) rate (OR 1.14 per CVC day per 100 patient days and 1.16, respectively).Conclusion The SARI data on antimicrobials serve ICUs as a benchmark by which to improve the quality of antimicrobial drug administration and for international comparison.Electronic Supplementary Material Supplementary material is available in the online version of this article at http://dx.doi.org/10.1007/s00134-004-2266-9     

Study of paediatric intensive care units in Spain

Objective: To describe the organisation of paediatric intensive care units in Spain and the medical assistance provided during 1996.¶Methods: A written questionnaire was sent to all the paediatric ICUs linked to or within the Spanish public health system.¶Results: Thirty-one of the 34 paediatric ICUs replied. All are medico-surgical units. Eighteen treat only paediatric patients, 12 paediatric and neonatal patients, and one paediatric and adult patients. Fifteen units have fewer than seven beds, eight have between 7 and 12 beds, and eight between 13 and 18 beds. Of the paediatric ICUs, 83.8 % are staffed by paediatricians specialised in paediatric intensive care. The mean number of on-call on site periods of duty for each member of the medical staff was 5.1 ± 1.7 per month. Thirty of the 31 units undertake paediatric resident training, 13 train residents specialising in paediatric intensive care and 12 participate in medical student training.¶In 1996 there were 9,585 admissions (309 ± 182 patients per ICU) signifying 35.3 ± 14 patients/bed. Of the patients, 65.9 % were medical and 34.1 % surgical. The mean duration of stay was 5.6 ± 2.1 days. The mortality rate was 5.4 ± 3.2 %. The main causes of death were multiple organ failure and brain death.¶Conclusions: In Spain, paediatric intensive care is principally performed by specialised paediatricians. Although the general results for 1996 are similar to those of other European countries, efficiency studies are necessary to plan and re-organise the paediatric intensive care units in Spain.     

Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model

Purpose

The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture.

Materials and Methods

In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture.

Results

Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = −0.46; P = .03), and teamwork across hospital units (r = −0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture.

Conclusion

Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs.     

The impact of mass casualty incidents on intensive care units

ObjectivesMass casualty incidents occur worldwide and have the capacity to overwhelm local healthcare facilities. There has been much research into how these events are managed in the prehospital environment and in the emergency department. However, there is a paucity in research addressing the impact that mass casualty incidents have on adult intensive care units. This review seeks to identify what literature is available that addresses the impact that mass casualty incidents have on intensive care units.Review method usedIntegrative Review Data sources: Electronic databases MEDLINE, CINAHL, PubMed and Scopus.Review MethodsElectronic databases were searched using terms such as "Intensive Care Unit" OR "Intensive Care" OR "Critical Care" OR "ICU" AND "Mass Casualty Incidents" OR "MCI" OR "Mass Casualty Event" OR "Mass Casualty Management" OR "Disaster". Articles that were published in the preceding 10 years in English as case studies or addressing real world events were included. Editorials, theoretical papers and research involving paediatrics were excluded from the results.ResultsSeven articles met the search criteria. Results identified four key areas in ICU that were impacted by mass casualty incidents. These areas include the impact on facilities, on resources, on staff and of training on the management of mass casualty incidents.ConclusionsThis review has demonstrated a paucity in research and reporting practices on the impact that mass casualty incidents have on intensive care units. The returned articles have identified four areas that were seen as influencing management of real-world mass casualty incidents. By increasing reporting and research into factors that impact mass casualty incident management in intensive care units, policy and training can be enhanced to ensure better preparedness for future incidents.     

An investigation of the use of passive movements in intensive care by UK physiotherapists

Objectives

To investigate the current use of passive movements (PMs) by National Health Service (NHS) physiotherapists working with sedated and ventilated patients in critical care settings.

Design

Postal questionnaire.

Setting

All open NHS critical/intensive care units in England, Northern Ireland, Scotland and Wales.

Participants

Physiotherapists working in UK NHS critical/intensive care units.

Results

Questionnaires were posted to 246 physiotherapists working in intensive care units; 165 (67%) were returned. One hundred and fifty-two respondents routinely treated ventilated and sedated patients, of which 151 (99%) reported utilising PMs. They were used most commonly (>70%) in patients admitted to critical care with medical, neurological or surgical problems. Respondents reported using a median of five repetitions of PMs once daily, and the majority of respondents took joints to the end of range (>78%). Joints most commonly treated included the shoulder, hip, knee, elbow and ankle. Heart rate and blood pressure were monitored by over 84% of respondents during treatment.

Conclusions

Whilst there is little empirical evidence to underpin the use of PMs, this study found that PMs were used regularly by 99% of respondents working in NHS critical care settings. Further work is now needed to evaluate the immediate and long-term effects of PMs in critically ill patients to inform and develop future practice.