Intensive care patients receiving vasoactive medications: A retrospective cohort study

BackgroundVasoactive medications are high-risk drugs commonly used in intensive care units (ICUs), which have wide variations in clinical management.ObjectivesThe aim of this study was to describe the patient population, treatment, and clinical characteristics of patients who did and did not receive vasoactive medications while in the ICU and to develop a predictive tool to identify patients needing vasoactive medications.MethodsA retrospective cohort study of patients admitted to a level three tertiary referral ICU over a 12-month period from October 2018 to September 2019 was undertaken. Data from electronic medical records were analysed to describe patient characteristics in an adult ICU. Chi square and Mann–Whitney U tests were used to analyse data relating to patients who did and did not receive vasoactive medications. Univariate analysis and Pearson's r² were used to determine inclusion in multivariable logistic regression.ResultsOf 1276 patients in the cohort, 40% (512/1276) received a vasoactive medication for haemodynamic support, with 84% (428/512) receiving noradrenaline. Older patients (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.01–1.02; p < 0.001) with higher Acute Physiology and Chronic Health Evaluation (APACHE) III scores (OR = 1.04; 95% CI = 1.03–1.04; p < 0.001) were more likely to receive vasoactive medications than those not treated with vasoactive medications during an intensive care admission. A model developed using multivariable analysis predicted that patients admitted with sepsis (OR = 2.43; 95% CI = 1.43–4.12; p = 0.001) or shock (OR = 4.05; 95% CI = 2.68–6.10; p < 0.001) and managed on mechanical ventilation (OR = 3.76; 95% CI = 2.81–5.02; p < 0.001) were more likely to receive vasoactive medications.ConclusionsMechanically ventilated patients admitted to intensive care for sepsis and shock with higher APACHE III scores were more likely to receive vasoactive medications. Predictors identified in the multivariable model can be used to direct resources to patients most at risk of receiving vasoactive medications.     

Poor outcomes of delirium in the intensive care units are amplified by increasing age: A retrospective cohort study

BACKGROUND: Delirium in patients in intensive care units(ICUs) is an acute disturbance and fluctuation of cognition and consciousness. Though increasing age has been found to be related to ICU delirium, there is limited evidence of the effect of age on delirium outcomes. The aim of this study is to investigate the relationship between age categories and outcomes among ICU delirium patients.METHODS: Data were extracted from the electronic ICU(e ICU) Collaborative Research Database with records from 3,931 patients with delirium. Patients were classified into non-aged(<65 years), youngold(65–74 years), middle-old(75–84 years), and very-old(≥85 years) groups. A Cox regression model was built to examine the role of age in death in ICU and in hospital after controlling covariates. RESULTS: The sample included 1,667(42.4%) non-aged, 891(22.7%) young-old, 848(21.6%) middle-old, and 525(13.3%) very-old patients. The ICU mortality rate was 8.3% and the hospital mortality rate was 15.4%. Compared with the non-aged group, the elderly patients(≥65 yeras) had higher mortality at ICU discharge(χ2=13.726, P=0.001) and hospital discharge(χ2=56.347, P<0.001). The Cox regression analysis showed that age was an independent risk factor for death at ICU discharge(hazard ratio [HR]=1.502, 1.675, 1.840, 95% confidence interval [CI] 1.138–1.983, 1.250–2.244, 1.260–2.687;P=0.004, 0.001, 0.002 for the young-, middle-and very-old group, respectively) as well as death at hospital discharge(HR=1.801, 2.036, 2.642, 95% CI 1.454–2.230, 1.638–2.530, 2.047–3.409;all P<0.001).CONCLUSIONS: The risks of death in the ICU and hospital increase with age among delirious patients.     

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom

Objective To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.Design and setting Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.Patients 118,199 adult admissions to ICUs.Measurements and results The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7–96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.Conclusions Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.All work was completed at the Intensive Care National Audit & Research Centre, which also provided financial support     

Mortality rates under the care of junior and senior surgery residents in a surgical intensive care unit/neurologic intensive care unit: A 5-year retrospective cohort study at Taoyuan Armed Forces General Hospital

Background

The quality and outcome of health care administered in intensive care units (ICUs) of teaching hospitals are dependent on a myriad of factors; however, few studies have assessed mortality rates and length of stay in surgical intensive care and neurologic intensive care units (SICU/NICU) in relation to the experience of junior and senior surgery residents.

Objective

The aim of this study was to determine whether there were differences in the outcomes of ICU patients cared for by junior surgery residents or senior surgery residents by assessing mortality rates and length of stay in the SICU/NICU.

Design

This was a retrospective cohort analysis. Mortality rates, length of SICU/NICU stay, and baseline characteristics were assessed in 2 patient groups: group 1, patients managed by junior surgical residents; group 2, patients managed by senior surgical residents. Categorical variables were compared by χ²/Fisher exact test, and continuous data (age and ICU stay) were compared using the Mann-Whitney U test. Acute Physiology and Chronic Health Evaluation II score was used for ICU prognostic models.

Setting

The Taoyuan Armed Forces General Hospital (Taoyuan, Taiwan, ROC) consists of an 8-bed SICU and an 8-bed NICU.

Patients

Data were collected from 2274 patients from January 1, 2002, to December 31, 2006, from the intensive care units (SICU/NICU) of the department of surgery.

Interventions

None.

Results

Significant differences between the 2 groups were found in total patient mortality and the duration of intensive care unit stay. Of 1806 patients in group 1, 446 (24.7%) died, whereas 83 (17.7%) of 468 in group 2 died (P = .002). The major difference of mortality rate was in the division of neurology surgery; 291 (26.6%) of 1092 patients in group 1 died, whereas 55 (19.2%) of 287 in group 2 died (P = .009), with most deaths due to spontaneous intracranial hemorrhage (P = .012) and central nervous system tumors (P = .048). Median length of SICU/NICU stay for group 1 was 3.0 days vs 3.5 days for group 2 (P = .003).

Conclusions

The quality of care of critically ill patients is improved when more experienced residents are providing care. We suggest that residents rotated into the special units such as SICU/NICU for care of critically ill patients should be at least at third year of training.     

The association between deprivation and hospital mortality for admissions to critical care units in England

Introduction

Few studies have investigated the association between level of social deprivation and acute hospital outcome for admissions to adult general critical care units. It is important to be aware if an association exists because risk prediction models do not adjust for deprivation.

Materials and Methods

Deprivation was measured using the Index of Multiple Deprivation (IMD) 2004, developed using 2001 census data in England. Eighty-four thousand four hundred twenty-three admissions to 138 adult general critical care units in England were selected from the Case Mix Programme Database from 1 year before to 1 year after the census date and linked to the IMD using postcodes. Logistic regression analysis was used to investigate a possible association between quintile of IMD and acute hospital mortality.

Results

As deprivation increased, acute hospital mortality also increased (P < .001). This association remained after adjusting for age, sex, acute severity, medial history, source of admission, and reason for admission to critical care (adjusted odds ratio for most vs least deprived quintile, 1.19; 95% confidence interval, 1.10-1.28).

Conclusions

There is an association between increasing deprivation and increasing risk of mortality for admissions to adult general critical care unit units in England. Further research is required to identify other unmeasured potential confounders (eg, smoking, alcohol consumption) as possible explanations for this association.     

The characterisation of workloads and nursing staff allocation in intensive care units: A descriptive study using the Nursing Activities Score for the first time in Norway

Objective

This study compares the Nine Equivalents of Nursing Manpower Use Score (NEMS) to the Nursing Activities Score (NAS) in terms of characterising the nursing workload by examining and calculating the per-nurse NAS% over a 24-h period.

Method

The sample consisted of 235 patients from four volunteered for the study multidisciplinary ICUs in Norway. The daily NEMS, NAS and number of nurses who were involved in patient care per ICU were measured over one month from 2008 to 2009.

Results

The average length of stay for the included patients was 5 days, and the mean patient age was 52.8 years. The mean NEMS was 32.7 points (S.D., 8.98 points), and the mean NAS was 96.24% (S.D., 22.35%). Several nurses exhibited mean NEMS points that ranged from 16 to 39.7 per ICU per day. The correlation between the NEMS and NAS could only be separately determined for each ICU. The correlation was r = 0.16–0.40 [significant at the 0.01 level (2-tailed)] per unit. Depending on which unit was investigated, each nurse was observed to perform of capacity with a NAS as high as 75–90%.

Conclusion

The study suggests that the actual numbers of nurses might explain the calculated NAS of 75–90% per nurse.     

Predicting mortality in intensive care unit patients infected with Klebsiella pneumoniae: A retrospective cohort study

IntroductionAlthough several models to predict intensive care unit (ICU) mortality are available, their performance decreases in certain subpopulations because specific factors are not included. Moreover, these models often involve complex techniques and are not applicable in low-resource settings. We developed a prediction model and simplified risk score to predict 14-day mortality in ICU patients infected with Klebsiella pneumoniae.MethodologyA retrospective cohort study was conducted using data of ICU patients infected with Klebsiella pneumoniae at the largest tertiary hospital in Northern Vietnam during 2016–2018. Logistic regression was used to develop our prediction model. Model performance was assessed by calibration (area under the receiver operating characteristic curve-AUC) and discrimination (Hosmer-Lemeshow goodness-of-fit test). A simplified risk score was also constructed.ResultsTwo hundred forty-nine patients were included, with an overall 14-day mortality of 28.9%. The final prediction model comprised six predictors: age, referral route, SOFA score, central venous catheter, intracerebral haemorrhage surgery and absence of adjunctive therapy. The model showed high predictive accuracy (AUC = 0.83; p-value Hosmer-Lemeshow test = 0.92). The risk score has a range of 0–12 corresponding to mortality risk 0–100%, which produced similar predictive performance as the original model.ConclusionsThe developed prediction model and risk score provide an objective quantitative estimation of individual 14-day mortality in ICU patients infected with Klebsiella pneumoniae. The tool is highly applicable in practice to help facilitate patient stratification and management, evaluation of further interventions and allocation of resources and care, especially in low-resource settings where electronic systems to support complex models are missing.     

Person-centred care among intensive care unit nurses: A cross-sectional study

ObjectivePractising person-centred care is crucial for nurses in the intensive care unit, as patients have high physical and psychological care needs. We aimed to identify the predictors of person-centred care among nurses working in intensive care settings.MethodsIn this cross-sectional study, 188 intensive care unit nurses at four tertiary hospitals in two cities of South Korea were included. They completed self-reported questionnaires on emotional intelligence, compassion satisfaction, secondary traumatic stress, burnout, and person-centred care. Emotional intelligence was measured using the Korean version of the Wong and Law’s emotional intelligence scale. Compassion satisfaction, secondary traumatic stress, and burnout were measured by the Professional Quality of Life questionnaire (version 5). Person-centred care was measured using the person-centred critical care nursing scale.ResultsMultiple regression identified compassion satisfaction (β = 0.49, p <.001) as the most powerful predictor of person-centred care, followed by emotional intelligence (β = 0.21, p =.004) and intensive care unit career length (β = 0.17, p =.021). These three variables accounted for 31.0 % of the variance in person-centred care.ConclusionsThis study highlights the importance of career length, emotional intelligence, and compassion satisfaction in the promotion of person-centred care among intensive care unit nurses. Nursing management should contemplate specific measures to reduce turnover among experienced intensive care unit nurses and to enhance the factors that promote person-centred care, such as compassion satisfaction and emotional intelligence.     

Hospital mortality associated with day and time of admission to intensive care units

Objective To investigate whether hospital mortality of patients was associated with the day of the week or time of admission to intensive care units (ICUs).Design Cohort study.Setting One hundred two adult, general (mixed medical/surgical) ICUs in England, Wales and Northern Ireland.Patients and participants A total of 56,250 admissions from 1995 to 2000 that fit the inclusion criteria for calculation of the APACHE II probability of hospital mortality.Interventions None.Measurements and results Crude and case mix adjusted hospital mortality were examined by day of the week and time of day of admission to ICU. Patients admitted on Saturday and Sunday had higher crude hospital mortality compared with admissions on Wednesday [Saturday crude odds ratio (OR) 1.41, 95% CI 1.32–1.52; Sunday OR 1.56, 1.45–1.68]. The association was still significant after adjustment using the UK APACHE II model (Saturday OR 1.16, 1.1.07–1.26; Sunday OR 1.24, 1.14–1.35) but not after adjustment using individual components of the APACHE II model (Saturday OR 1.03, 0.95–1.12; Sunday OR 1.09, 1.00–1.19). Night admissions were also associated with higher mortality compared with day both before and after adjustment for case mix using the UK APACHE II model (crude OR 1.43, 1.37–1.51; adjusted OR 1.16, 1.10–1.23) but not after adjustment using components of the APACHE II model (OR 1.02, 95% CI 0.96–1.09).Conclusions After appropriate adjustment for case mix, day of the week and time of day of admission of patients to ICU were not associated with significant differences in hospital mortality.     

Preadmission quality of life can predict mortality in intensive care unit—A prospective cohort study

Purpose

We sought to investigate whether preadmission quality of life could act as a predictor of mortality among patients admitted to the intensive care unit (ICU).

Materials and methods

This is a prospective observational study of all patients above the age of 18 years admitted to the ICU with a length of stay longer than 24 hours. Short form 36 (SF-36) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were used. Mortality was assessed during ICU admission, 30, and 90 days hereafter.

Results

We included 318 patients. No patients were lost to follow-up. Using the physical component summary of short form 12 (SF-12) as a predictor of ICU mortality, the area under the curve (0.70; confidence interval, 0.62-0.77) was comparable with that of APACHE II (0.74; confidence interval, 0.67-0.82). The difference between SF-12 and SF-36 was nonsignificant.

Conclusions

Preadmission quality of life, assessed by SF-36 and SF-12, is as good at predicting ICU, 30-, and 90-day mortality as APACHE II in patients admitted to the ICU for longer than 24 hours. This indicates that estimated preadmission quality of life, potentially available in the pre-ICU setting, could aid decision making regarding ICU admission and deserves more attention by those caring for critically ill patients.     

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.     

Long-term cognitive impairment and delirium in intensive care: A prospective cohort study

Background

Whilst there is a growing body of research exploring the effect of delirium in intensive care unit (ICU) patients, the relationship between patient delirium and long-term cognitive impairment has not been investigated in settings where low rates of delirium have been reported.

Association between nurse staffing levels and rotavirus infection in neonatal intensive care units: A retrospective observational study

ObjectivesTo explore the relationship between nurse staffing levels and rotavirus infection in neonatal intensive care units.Research MethodologyThis study adopted a retrospective observational design with data from the Health Insurance Review and Assessment Service (2018) database in South Korea. Participants were 35,308 infants in neonatal intensive care units. Multiple logistic regression analyses were employed to examine the association between nurse staffing levels and rotavirus infection in neonatal intensive care units after adjusting for confounding variables such as patient and hospital-related characteristics.ResultsA total of 1,514 (4.3%) infants developed rotavirus infection. Among the confounding variables, infectious disease, and being admitted from January to March and in December significantly increased the risk of rotavirus infection, whereas low birth weight, cardiovascular disorders, neonatal jaundice, receiving breastmilk, central line insertion, and ventilator usage significantly decreased the risk. Neonatal intensive care units with a grade 5 nurse staffing level (compared with grades 1–4) had a higher risk of rotavirus infection.ConclusionsThe results suggest that neonatal intensive care units with higher (vs lower) nurse staffing levels are associated with lower rotavirus infection rates among infants. High-risk infants are extremely susceptible to hospital-acquired infections, and more intensive nursing care that differs from that provided to adult or paediatric patients is required. Therefore, nurse staffing levels with less than a 2:1 patient-to-nurse ratio are needed to control and prevent rotavirus infection in neonatal intensive care units.     

A cross-sectional study of predictors of pain control during the transition from the surgical intensive care unit to surgical ward

Background

The transition of patients from the intensive care unit (ICU) to the ward is a complicated process and patients may be at risk of increased levels of pain.

An investigation of light and sound levels on intensive care units in China

BackgroundThe intensive care units’ (ICU) environment is considered clinically relevant sources of stress for patients.ObjectivesTo measure 24-h sound and light levels in 7 ICUs in China [four medical (MICU), two surgical (SICU) and one coronary (CCU) ICUs] and to identify the main sources related to increased sound levels.MethodsSound pressure and light levels were monitored for specific times over a 24-h period using a digital sound level meter and a light detector in 7 ICUs. Sound pressure levels were measured for 20 min every hour. The main events at the time of peak noise levels were recorded. Light levels were measured every 2 h at three locations for each ICU: near a window, in the centre of the room, at eye level of a patient receiving assisted ventilation.ResultsThe mean value of 24-h sound pressure levels exceeded 50 dB(A) in all ICUs, ranging from 56.5 to 70.1 dB(A). The SICUs and CCU had higher sound pressure readings from 0700 h to 1600 h, compared to the MICUs where the sound pressure readings reflected less variability across the 24-h period. Marked differences were observed in luminance levels among various ICUs and also across the 24-h period for all three locations. The mean highest level of nocturnal luminance at eye level of patients receiving assisted ventilation ranged from 15 to 489 lx before midnight (1800–2400 h) and 10 to 239 lx after midnight (2401–0759 h).ConclusionsHigh sound pressure levels are prevalent throughout 24 h in the ICUs, especially in the SICU. Many of the readings exceeded international standards. Peak sound pressure levels were related primarily to staff activities and the alarm sounds of machines. ICU patients are exposed to high levels of artificial light continuously throughout the day and night.     

Us and them: Experiences of agency nurses in intensive care units

ObjectiveThis qualitative case study describes the work experiences of agency nurses from their perspective. It explores their interactions with intensive care unit managers to whom they report in their designated intensive care units and their relationships with fellow permanent nurses.MethodsA qualitative study was undertaken in three intensive care units at a public hospital in South Africa. Face-to-face interviews were used to collect data from eleven agency nurses. Thematic analysis of the data was undertaken.FindingsThe challenges of agency nursing work were haphazard clinical allocation, a lack of self-efficacy and competence, and feelings of exclusion. Positive aspects of the agency nurse experience included feedback and support from permanent nurses and intensive care unit managers and occurrences of belonging and acceptance.ConclusionThe findings of this study point to the importance of agency nurse relationships with managers and fellow permanent nurses. To ensure patient care is not compromised, managers and nurse managers have a responsibility to ensure a welcoming, inclusive and nurturing environment for all staff tasked with intensive care unit responsibilities.     

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.