Disease patterns and clinical outcomes of patients admitted in intensive care units of tertiary referral hospitals of Tanzania

Background

In sub-Saharan Africa the availability of intensive care unit (ICU) services is limited by a variety of factors, including lack of financial resources, lack of available technology and well-trained staff. Tanzania has four main referral hospitals, located in zones so as to serve as tertiary level referral centers. All the referral hospitals have some ICU services, operating at varying levels of equipment and qualified staff. We analyzed and describe the disease patterns and clinical outcomes of patients admitted in ICUs of the tertiary referral hospitals of Tanzania.

Methods

This was a retrospective analysis of ICU patient records, for three years (2009 to 2011) from all tertiary referral hospitals of Tanzania, namely Muhimbili National Hospital (MNH), Kilimanjaro Christian Medical Centre (KCMC), Mbeya Referral Hospital (MRH) and Bugando Medical Centre (BMC).

Results

MNH is the largest of the four referral hospitals with 1300 beds, and MRH is the smallest with 480 beds. The ratio of hospital beds to ICU beds is 217:1 at MNH, 54:1 at BMC, 39:1 at KCMC, and 80:1 at MRH. KCMC had no infusion pumps. None of the ICUs had a point-of-care (POC) arterial blood gas (ABG) analyzer. None of the ICUs had an Intensive Care specialist or a nutritionist. A masters-trained critical care nurse was available only at MNH. From 2009–2011, the total number of patients admitted to the four ICUs was 5627, male to female ratio 1.4:1, median age of 34 years. Overall, Trauma (22.2%) was the main disease category followed by infectious disease (19.7%). Intracranial injury (12.5%) was the leading diagnosis in all age groups, while pneumonia (11.7%) was the leading diagnosis in pediatric patients (<18 years). Patients with tetanus (2.4%) had the longest median length ICU stay: 8 (5,13) days. The overall in-ICU mortality rate was 41.4%.

Conclusions

The ICUs in tertiary referral hospitals of Tanzania are severely limited in infrastructure, personnel, and resources, making it difficult or impossible to provide optimum care to critically ill patients and likely contributing to the dauntingly high mortality rates.

     

北京市64家医院重症监护病房设置与管理调查

目的调查北京市重症监护病房的种类、床位、人员配备和管理模式。方法对64家医院的126个ICU，就床位设置、人员配备及管理模式进行问卷调查。结果64家医院平均拥有1．97个ICU；平均每个ICU拥有病床8．7张；综合性ICU与专科ICU的数量及病床数相当；医生：护士：总床位=O．70：1．71：1．00；综合性ICU、呼吸ICU和儿科ICU人员配备相对其他专科ICU充足；57．9％的ICU有专职主任。结论北京市大中型医院基本均设有ICU病房，其性质为综合性与专科性并存，ICU管理模式多样，床位及人员配备既相对不足，又存在低水平重复配置的浪费。ICU应严格“进出”标准，遵循循证医学原则，控制费用，避免过度医疗和高额医疗费用。     

Impact of critical care outreach services on the delivery and organization of hospital care

OBJECTIVES: To evaluate the impact of critical care outreach services on the delivery and organization of hospital care from the perspective of staff working in acute hospitals. METHODS: One hundred semi-structured interviews were undertaken with hospital staff who were either members of, or who came into contact with, the outreach service in eight hospitals in England. RESULTS: Outreach services had two main impacts on the delivery and organization of hospital care, reflecting the organizational and educational aims of the policy. First, on the organization of patient care: it was suggested that care was more timely, there were fewer referrals to the intensive care unit (ICU) and ICUs felt more able to discharge patients to hospital wards. There were also perceived to be improved links between ward nurses and medical teams and improved morale among ICU nurses. Second, on the confidence and skills of ward staff (nurses and junior doctors): increased contact on the wards resulted in more opportunities to share critical care skills. However, there remained concerns about the sustainability of improved skills and some respondents felt that junior doctors were becoming de-skilled. CONCLUSION: Critical care outreach services have had a positive impact on the delivery and organization of hospital care. In attempting to share critical care skills, however, these services can experience a tension between the aims of service delivery and education - a tension which is partly resolved by sharing skills in the clinical and organizational context of direct patient care.     

第二次全国中医医院重症医学科现状调查

目的分析我国中医医院ICU现状,为提高全国中医医院ICU总体水平提供依据。方法采用表格问卷调查形式,收集分析全国三级甲等中医医院ICU的资料。结果 ICU平均床位数为（20.7±10.3）张,占医院总床位数的2%;88%为综合ICU,12%为专科ICU;床位平均使用率为84%。呼吸机、床旁多功能持续心电监护仪、血液净化仪与纤维支气管镜平均数与ICU平均床位数比值为分别为0.69、1.02、0.09与0.07。ICU医生与护士配置平均人数与ICU床位数比值分别为0.69与1.70。大多数中医医院ICU能够独立开展常见器官功能监测及功能支持。结论我国大部分三级甲等中医医院ICU规模及性质、设备配置和技术开展情况基本上符合《指南》要求,但人员配备未达标,核心医疗指标尚有较大进步空间。     

Quality Improvement Strategies and Best Practices in Critical Access Hospitals

ABSTRACT: Context: Critical access hospitals (CAHs) face many challenges in implementing quality improvement (QI) initiatives, which include limited resources, low volume of patients, small staffs, and inadequate information technology. A primary goal of the Medicare Rural Hospital Flexibility Program is to improve the quality of care provided by CAHs. Purpose: This article describes key quality improvement initiatives for a national sample of CAHs that are actively involved in implementing quality-related initiatives in collaboration with support hospitals and statewide organizations. Methods: Researchers conducted a national telephone survey of 72 CAHs and 2 in-depth case studies of CAHs. Findings: The survey and case studies demonstrate that many CAHs are successfully implementing QI activities, including patient safety initiatives, improvements in overall QI processes and peer review processes, and implementation of QI projects focused on treatment of 1 or more specific diseases. The CAHs are involved with multiple external organizations in these activities. The administrators of the 2 case study CAHs have made QI a priority for their hospitals; ensured that resources are available for QI activities; and worked with their support hospitals, statewide organizations, and other CAHs to develop and implement rural-relevant QI initiatives. Conclusions: Cost-based Medicare reimbursement has been a key factor in the ability of CAHs to fund additional staff, staff training, and equipment to improve patient care. The commitment of hospital leaders and key staff is a crucial factor in moving QI initiatives forward in CAHs.     

Evaluating daily nursing use and needs in the intensive care unit: a method to assess the rate and appropriateness of ICU resource use

BACKGROUND: We designed a tool to measure the rate and appropriateness of intensive care unit (ICU) nursing coverage as a proxy for the use of resources. METHODS: We tested the tool in 32 Italian ICUs during a cross-sectional study (4 days/week, October 2001 and April 2002). The level of care was classified as high or low. The appropriate patient-to-nurse ratio for both levels (2/1 and 3/1 in this ICU mix) was defined. The provided and theoretical nurse assistance was computed, the difference between the two quantifying the ICU use of personnel: a positive difference means over-utilization, a negative one under-utilization. We calculated the maximum number of high-level and low-level care days available for ICU and the relative utilization rates. These two rates quantify the appropriateness of resource use in relation to the planned use. RESULTS: Analysing 5783 treatment-days, the tool identified units using almost all available resources (five), overcrowded (14: too small units) or empty (16: too big). Units were overcrowded on account of the high-level of care required (five: utilization rate >100%) or reallocated too much of their residual high-care nursing capacity to low-level care (six). In empty units both utilization rates were lower than expected. CONCLUSIONS: The method quantifies the rate and appropriateness of resource usage and suggests the best management in units with fixed human resources or a fixed number of beds.     

The decline of ischemic heart disease mortality in Texas

This is a study of the decline of ischemic heart disease (IHD) mortality in the State ofTexas, from 1970 to 1977. The data were collected and analyzed at three different levels: state, health service area (HSA), and county. The study was designed to test hypotheses pertaining to the role of the medical care system as a possible factor associated with the changing IHD mortality trends. The results suggest that factors such as emergency medical services (EMS), intensive care units (ICU) and coronary care units (CCUs) in hospitals, intensive care and coronary care beds and medical specialists are associated with the observed decline in heart disease mortality in Texas.     

Intensive Care Unit Utilization and Interhospital Transfers As Potential Indicators of Rural Hospital Quality

CONTEXT: Obtaining meaningful information from statistically valid and reliable measures of the quality of care for disease-specific care provided in small rural hospitals is limited by small numbers of cases and different definitive care capacities. An alternative approach may be to aggregate and analyze patient services that reflect more generalized care processes. PURPOSE: To evaluate the applicability of intensive care unit (ICU) utilization and interhospital transfers as potential indicators of quality in rural hospitals. METHODS: Secondary data analysis of ICU utilization and interhospital transfer practices in Iowa's Critical Access (CAH), rural, rural referral, and urban hospitals. FINDINGS: Rural hospitals have fewer resources, provide a more limited range of definitive care services, and rely to a greater extent on transferring patients to other hospitals capable of providing the required definitive care. Examining ICU utilization and interhospital transfer patterns we found (1) that lower percentages of patients receive ICU care in smaller facilities; (2) higher transfer rates for both ICU and non-ICU patients in CAH hospitals; (3) shorter average lengths of stay for ICU patients from smaller hospitals who were transferred; and (4) lower mortality rates for CAH and rural hospital ICU patients. CONCLUSIONS: Examining ICU utilization and interhospital transfer patterns offers potential insights into rural hospital quality measurement and comparisons.     

FluSurge--a tool to estimate demand for hospital services during the next pandemic influenza.

PURPOSE: To assess the impact of pandemic influenza on hospital services. METHODS: Based on census data and estimates of hospital resources (non-ICU [intensive care unit] beds, ICU beds, and mechanical ventilators) in a given area, FluSurge software estimates the number of hospital admissions and deaths due to pandemic influenza under variable duration and virulence scenarios and compares hospital resources needed during a pandemic with existing hospital resources. RESULTS: Sample results from Metropolitan Atlanta illustrate how the next influenza pandemic may overwhelm existing hospital resources, given that hospitals increasingly operate at nearly full capacity. CONCLUSIONS: Hospitals need to consider and plan for a surge in demand for hospital services during the next influenza pandemic.     

Epidemiology of intensive care.

It is difficult to study the epidemiology of ICUs, as they lack a uniform nomenclature and/or classification. The organization and distribution of intensive care medicine depend on the size and function of the hospital. The patients in ICUs are predominantly men, with a high proportion of elderly patients (greater than or equal to 70 years) constituting 25-30% of the total. Case-mix, severity of illness and outcome differ from one unit to another, and can be compared only if the patients are classified with a common classification system. Most survivors of intensive care seem to return to normal or near normal functional level within one year. Compared to Western Europe, the United States has more ICU beds and a nearly ten times higher admission rate to intensive care. These variations can be seen as a result of a fundamental difference in the attitudes toward withdrawing or withholding life support.     

心脏外科ICU病人睡眠质量及影响因素的归因分析

[目的]了解心脏外科ICU病人的睡眠质量及其影响因素,对影响因素进行归因系数分析。[方法]100例心脏手术病人,采用VSH睡眠质量评分表(Verran and Snyder-Halpern,VSH)和采用改良的ICU环境应激因素评分表(ICUESS)进行问卷调查。数据采用Logistic回归分析进行统计学分析。[结果]与手术前2d比较,VSH8项指标中睡眠中断、睡眠长度、睡眠潜伏期、睡眠深度、达到休息的程度、醒来方式、主观感觉睡眠质量ICU中的得分均比手术前高(P﹤0.01)。睡眠干扰因素评分表中有14项对睡眠有影响(回归系数﹥1),影响睡眠的因素(回归系数)依次为口渴;鼻腔或口腔内有管道,感到不舒服;没有穿衣服,隐私被暴露;不能表达自己的意愿;双手被固定不能随意地挪动;不知道手术是否顺利完成;思念亲人等。[结论]心脏外科ICU病人的睡眠质量差,护理人员应给于充分重视;影响睡眠的因素是多方面的,这些因素大部分可以通过护理模式的改变来解除或缓解。     

Intensive care units in the triage mode: an organizational perspective

Decisions to admit and discharge patients to and from the intensive care unit (ICU) when beds are scarce should be made in accordance with the triage principle--that is, allocate resources on the basis of the ability to benefit from intensive care. However, uncertainty over resource capacity and patient prognosis limits the ability of decision makers to use this prioritization principle and results in ICUs containing inappropriately placed patients who are denying or delaying care to patients who could benefit more. Using Jay Galbraith's "information processing" model, ICU admission and discharge decision making is described. Organizational strategies to reduce uncertainty and improve decision making are discussed, including strengthening the management role of the ICU physician director and employing prognostic instruments (e.g., mortality prediction models) to share and process information.     

全国重症医学专业医疗服务与质量安全调查

目的了解我国重症医学专业医疗服务与质量安全现况。方法采用结构化抽样方法,对全国3 425家不同级别医院重症医学科进行调查,调查内容包括:医疗质量与服务结构指标（床位数、医护人员配备）、控制指标（ICU患者收治率、病死率等）及其完成率等。结果不同级别医院的重症医学专业质量指标存在较大差异,重症医学科资源配置尚不合理,重症医学质量安全仍有待进一步改进提高。结论建立完善的激励和培养机制,加强人才队伍建设,进而壮大和稳定ICU医护队伍。建设远程医疗中心网络,完善区域协同医疗信息平台等智慧医疗设施,探索远程ICU诊疗模式。     

A country-level analysis comparing hospital capacity and utilisation during the first COVID-19 wave across Europe

BackgroundThe exponential increase in SARS-CoV-2 infections during the first wave of the pandemic created an extraordinary overload and demand on hospitals, especially intensive care units (ICUs), across Europe. European countries have implemented different measures to address the surge ICU capacity, but little is known about the extent. The aim of this paper is to compare the rates of hospitalised COVID-19 patients in acute and ICU care and the levels of national surge capacity for intensive care beds across 16 European countries and Lombardy region during the first wave of the pandemic (28 February to 31 July).MethodsFor this country level analysis, we used data on SARS-CoV-2 cases, current and/or cumulative hospitalised COVID-19 patients and current and/or cumulative COVID-19 patients in ICU care. To analyse whether capacities were exceeded, we also retrieved information on the numbers of hospital beds, and on (surge) capacity of ICU beds during the first wave of the COVID-19 pandemic from the COVID-19 Health System Response Monitor (HSRM). Treatment days and mean length of hospital stay were calculated to assess hospital utilisation.ResultsHospital and ICU capacity varied widely across countries. Our results show that utilisation of acute care bed capacity by patients with COVID-19 did not exceed 38.3% in any studied country. However, the Netherlands, Sweden, and Lombardy would not have been able to treat all patients with COVID-19 requiring intensive care during the first wave without an ICU surge capacity. Indicators of hospital utilisation were not consistently related to the number of SARS-CoV-2 infections. The mean number of hospital days associated with one SARS-CoV-2 case ranged from 1.3 (Norway) to 11.8 (France).ConclusionIn many countries, the increase in ICU capacity was important to accommodate the high demand for intensive care during the first COVID-19 wave.     

三级综合性医院监护室护理人力资源分层配置标准探讨

目的 建立三级综合性医院监护室护理人力资源能级划分体系与能级配置标准,以期在保证患者监护质量的同时,提高护理人力资源利用效率.方法 运用专家会议、专家咨询的方法,确定监护室护理人力资源能级划分体系;采用便利抽样法,选择上海市5所三级综合性医院重症监护室进行现场实验与研究.结果 将监护室护理人员分为4个等级,确立4个层次护士的工作职责和工作内容,形成护理人员能级划分体系,并建立了三级综合性医院监护室各级护理人力资源配置标准.结论 三级综合性医院监护室护理人力资源分层配置标准为护理管理者合理配置及有效利用不同等级护理人员提供了科学依据.     

重症监护病房医护人员导管相关性血流感染现状与预防控制措施认知的调查

目的调查上海市重症监护病房(ICU)医护人员对导管相关性血流感染(CRBSI)感染率的了解,及其对预防控制目标及措施的认知情况。方法 2010年1月在上海ICU进行问卷抽样调查。结果 52所医院的89名医护人员参加了调查,有效答卷82份;对感染率有准确认识的仅为9.8%,48.8%的受访者认为应该进一步降低感染率,认为控制目标为"零宽容"者仅占19.5%;认同移除不必要的中心静脉导管、严格执行手卫生规则和留置导管术时采用最大无菌屏障的比例分别为91.5%、93.9%和95.1%,而对2%氯己定进行皮肤消毒、尽量使用锁骨下静脉留置和集束化策略的认同比例则较低,分别为67.1%、61.0%和58.5%。结论上海市ICU医护人员对CRBSI现状及控制目标的认识还有待提高,预防控制措施的推动重点在于2%氯己定进行皮肤消毒、尽量使用锁骨下静脉留置,以及集束化策略。     

Estimating the nursing staff required in a new hospital

Opening a new hospital poses a complex and consequential set of challenges. One of these challenges is to estimate the nursing staff. The aim of this article is to report the entire process adopted to estimate the required nursing staff for a new Hospital in Brazil. The nursing staff was projected according to the Brazilian Federal Nursing Council (Cofen). We applied an equation to estimate nursing staff and compared the results with two other existing hospitals. A significant difference (p<0.05) was observed when comparing the Nurse-License Practice Nurse ratio recommended by Cofen between the new Hospital and other hospitals. This statistical difference is mostly due to reduced nurse staff in intensive care units. Almost one year after the hospital opened its doors, it is necessary to review nursing staff hours with the real information to reinforce the expenditure on these personnel and to evaluate the decisions made so far.     

Impact of a computerized information system on quality of nutritional support in the ICU

OBJECTIVE: In intensive care units (ICUs), patient outcome depends on quality of nutritional support. We investigated the effect of computerized information systems (CISs) on quality of nutritional support by comparing two ICUs with or without CIS and burned patients before and after CIS implementation. METHODS: Part 1 was a 2-wk prospective survey in two units of a surgical ICU: unit A (11 beds) without CIS and unit B (four beds) with CIS. Part 2 consisted of two 18-mo periods in burn patients before and after CIS implementation. Nurses and doctors belonged to the same team; procedures were identical. A computer page was configured to retrieve data related to nutritional support. RESULTS: A total of 1313 ICU days were analyzed in 109 patients. Patients' characteristics were similar in parts 1 and 2. In part 1, nutritional support was required 38% of days. Nutritional route was similar but data were more frequently missing in unit A. Energy delivery was higher with CIS but below target values in both units (31+/-11% of target in unit A, 77+/-4% in unit B). Computations were incomplete and time consuming for unit A versus B (11+/-2 versus 2+/-1 min/patient, P<0.0001). In part 2, in the 54 burn patients, use of postpyloric feeding tubes and energy delivery increased with CIS, resulting in less weight loss. CONCLUSION: Computerized information systems favored standardization of nutritional care and monitoring, thus decreasing time required for writing and computations. Follow-up was improved and nutrient delivery was closer to target values, thus increasing quality of care. In burn patients, the better data visibility was associated with a significant improvement in nutrient delivery.     

In Context: The Cosmic Muffin Hypothesis: Implications for Public Policy

The authors examined the relationships among hospital size and unit type, the prevalence of pressure ulcers, and rates of ventilator-associated pneumonia and catheter-related bloodstream infections in 25 intensive care units (ICUs) in 8 hospitals. Data came from the American Hospital Association survey, and nursing and infection control databases. Multiple regression was the main statistical technique. Pressure ulcer prevalence and catheter-related bloodstream infection rates were higher in large hospitals; ventilator-associated pneumonia rates were higher in surgical ICUs. Future researchers should include factors often hidden within hospital and unit characteristics to expose possible relationships that may be incorporated into interventions to prevent adverse outcomes.