重症监护临床信息系统在急诊重症监护室中的应用

目的探讨重症监护临床信息系统(ICIS)在急诊重症监护室(EICU)中的应用效果。方法将本院急诊医学部重症监护室2014年8月—2015年1月收治的重症患者366例设为对照组,2015年2月—2015年7月收治的重症患者353例设为观察组。对照组患者应用"军卫一号",观察组应用重症监护临床信息系统,观察比较2组病情记录时间、观察项维护时间、出入量维护时间、核对确认医嘱时间及病情记录差错率、观察项维护差错率、出入量维护差错率和核对确认医嘱差错率。结果观察组护理记录时间、核对确认医嘱时间、护理工作记录差错率及核对确认医嘱差错率均显著低于对照组(P0.05)。结论 ICIS的应用提高了临床工作效率,节省了护理记录时间,降低了护理差错率,明显提高了临床护理质量和患者满意度。     

Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system

OBJECTIVE To determine the percentage of time that intensive care unit (ICU) nurses spend on documentation and other nursing activities before and after installation of a third-generation ICU information system. DESIGN: Prospective data collection using real-time time-motion analysis, before and after installation of the ICU information system. SETTING: A ten-bed surgical ICU at a Veterans Affairs medical center. SUBJECTS: ICU nurses. INTERVENTIONS: Installation of a third-generation ICU information system. MEASUREMENTS AND MAIN RESULTS: Ten ICU nurses were studied before and after installation of the ICU information system. Each ICU nurse's activities and tasks, during 4-hr observation periods, were categorized in real-time by a nurse observer and recorded in a laptop computer. Each recorded task was automatically time-stamped and logged into a data file. The percentage of time spent on documentation decreased from 35.1 +/- 8.3% to 24.2 +/- 7.6% (p =.025) after the ICU information system was installed. The percentage of time providing direct patient care increased from 31.3 +/- 9.2% to 40.1 +/- 11.7% (p =.085). The percentage of time doing patient assessment, a direct patient care task, increased from 4.0 +/- 4.7% to 9.4 +/- 4.4% (p =.001). CONCLUSIONS: Installation of a third-generation ICU information system decreased the percentage of time ICU nurses spent on documentation by >30%. Almost half of the time saved on documentation was spent on patient assessment, a direct patient care task.     

A computer-assisted monitoring system for arrhythmia detection in a medical intensive care unit

The arrhythmia detection capability of a computer-assisted monitoring system (CAMS) was studied in a large multidisciplinary ICU during an 18-month period. Four patient categories were evaluated: critically ill patients on mechanical volume respirators (group 1), patients with uncomplicated acute myocardial infarction (group 2), pacemaker-dependent patients (group 3), and patients on telemetry monitoring (group 4). ECG abnormalities were interpreted by the computer algorithm and recorded on paper. The same ECG abnormalities were analyzed independently by at least two critical care physicians unaware of the computer interpretations. The incidence of false-positive diagnoses (computer system errors) ranged from 10 in 1000 beats in groups 1, 2, and 4, to 20 in 1000 beats in group 3. Movement artifact accounted for 55.3% of all false-positive diagnoses. Of the total number of beats interpreted by the computer, 0.8% were false negatives and 3.8% were true positives. The most frequent true positive was pacemaker malfunction, which was diagnosed with 94% accuracy by the arrhythmia detection system. Significantly, rhythm abnormalities occurred as frequently in patients ventilated with mechanical respirators as in patients with acute myocardial infarction.     

Clinical information systems and the electronic medical record in the intensive care unit

The integration of computers into critical care is by no means a new concept. Clinical information systems have evolved in the critical care setting over the past three decades. Their use by critical care healthcare providers has increased exponentially in the past few years. More recently, with the advent of the electronic medical record, clinicians in the ICU may obtain and share useful information both bedside and remotely. Clinical information systems and the electronic medical record in the ICU have the potential to improve medical record movement problems, to improve quality and coherence of the patient care process, to automate guidelines and care pathways, and to assist in clinical care and research, outcome management, and process improvement. In this article, we provide some historical background on the clinical information system and the electronic medical record and describe their current utilization in the ICU and their role in the practice of critical care medicine in decades to come.     

Impact of hemodynamic monitoring in a medical intensive care unit

Previous reports have shown hemodynamic data inaccurately predicted by physical examination and x-ray findings. Although invasive hemodynamic monitoring has been shown to significantly alter the management of critically ill patients, the impact on mortality has been difficult to assess. In a prospective study of 35 patients, we found inaccurate predictions of left and right heart filling pressures by clinical assessment. However, cardiac output was accurately estimated. Management was altered 34% of the time because of invasive hemodynamic assessment; however, mortality was not affected by a change in therapy.     

Prospective evaluation of self-extubations in a medical intensive care unit

Objective To evaluate the incidence, associated factors and gravity of self-extubations.Design Prospective study about all patients intubated over an 8 month period.Setting A medical intensive care unit of a University Hospital.Patients Patients were divided into two groups: self-extubated and those that did not. The self-extubations were separated into deliberate acts by the patients and accidental.Results 24 of the 197 patients included presented a total of 27 extubations (12%). There were 21 deliberate incidents and 6 accidental. The only differences between the cases and the rest of the population were a higher mean age (67 vs 59 years) and a larger proportion of chronic respiratory failure (66% versus 35%). Reintubation was necessary in 20 cases (74%) within 30 min in 16 cases. The main indication for reintubation was acute respiratory distress (90%). Reintubation was associated with one death.Conclusion Self-extubation is a frequent and serious complication of mechanical ventilation. Deliberate self-extubation, the most frequent type of incident could possibly be reduced by better sedation of agitated patients and accidental self-extubation by better training of the nursing staff.     

Acute abdomen in the medical intensive care unit

OBJECTIVE: Acute abdominal complication in the medical intensive care unit may be underdiagnosed and can add significant risk of death. We hypothesize that delays in surgery because of atypical presentation, such as the absence of peritoneal signs, may contribute to mortality. DESIGN: Retrospective cohort study (1995-2000). SETTING: Medical intensive care unit in a tertiary care center. PATIENTS: Medical intensive care unit patients with clinical, surgical, or autopsy diagnosis of acute abdominal catastrophe (gangrenous or perforated viscus). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients (1.3%) met inclusion criteria. Ischemic bowel was the most common diagnosis, followed by perforated ulcer, bowel obstruction, and cholecystitis. Actual mortality rate was higher than predicted by Acute Physiology and Chronic Health Evaluation (APACHE) III scores at the time of medical intensive care unit admission (63% vs. 31%). Twenty-six patients (34%) did not have surgery, and none of these survived. Fifty-one patients underwent surgery and 28 survived (56%). Delay in surgical evaluation (p <.01) and intervention (p <.03), APACHE III scores (p <.01), renal insufficiency (p <.01), and a diagnosis of ischemic bowel (p <.01) were associated with increased mortality rates. Surgical delay was more likely to occur in patients with altered mental state (p <.01), no peritoneal signs (p <.01), previous opioids (p <.03), antibiotics (p <.02), and mechanical ventilation (p <.02). CONCLUSION: Delays in surgical evaluation and intervention are critical contributors to mortality rate in patients who develop acute abdominal complications in a medical intensive care unit.     

Visiting preferences of patients in the intensive care unit and in a complex care medical unit.

BACKGROUND: Within the challenging healthcare environment are nurses, patients, and patients' families. Families want proximity to their loved ones, but the benefits of such proximity depend on patients' conditions and family-patient dynamics. OBJECTIVES: To describe patients' preferences for family visiting in an intensive care unit and a complex care medical unit. METHODS: Sixty-two patients participated in a structured interview that assessed patients' preferences for visiting, stressors and benefits of visiting, and patients' perceived satisfaction with hospital guidelines for visiting. RESULTS: Patients in both units rated visiting as a nonstressful experience because visitors offered moderate levels of reassurance, comfort, and calming. Patients in the intensive care unit worried more about their families than did patients in the complex care medical unit but valued the fact that visitors could interpret information for the patients while providing information to assist the nurse in understanding the patients. Patients in the intensive care unit were more satisfied with visiting practices than were patients in the complex care medical unit, although both groups preferred visits of 35 to 55 minutes, 3 to 4 times a day, and with usually no more than 3 visitors. CONCLUSIONS: These data provide the input of patients in the ongoing discussion of visiting practices in both intensive care units and complex care medical units. Patients were very satisfied with a visiting guideline that is flexible enough to meet their needs and those of their family members.     

Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study

ObjectiveEvaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes.MethodsThis was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3.ResultThe establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63–0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54–0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28–0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70–0.99, p = 0.046).ConclusionFollowing the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.     

A narrative-based study on communication by family members in intensive care unit

Purpose

This study investigates how informative stories are, as written by patients' families in an intensive care unit (ICU) guest book, in terms of families' emotional responses, needs, perceptions, and satisfaction with the quality of care supplied.

Materials and Methods

Design was retrospective observational. Spontaneously written stories (440), gathered between 2009 and 2011, described experiences of 332 family members and 258 patients. Multivariate information from stories was analyzed using cluster analysis.

Results

Most frequently, stories were written in the form of letters addressed to patients (38%, 168 stories). Family members wrote mainly to give encouragement and to motivate patients to live (34%, 150 stories), expressing love or affection (56%, 245 stories). Feedback to ICU staff was provided in 65 stories, and competence was the most relevant skill recognized (31%, 20 stories). Cluster analysis highlighted links between positive feedback and families' positive emotional responses.

Conclusions

The study suggests that ICU guest books can be an effective and simple means of communication between the family, the patient, and the ICU staff. Families shared thoughts, feelings, or opinions, which were meant to be supportive for the patients or rewarding for the staff.     

新生儿监护室医护人员早产儿互动知识调查

[目的]了解新生儿监护室医护人员早产儿互动知识掌握状况.[方法]采用早产儿互动知识量表及方便取样方法,调查上海市4所三级医院新生儿监护室的60名医生和68名护士对早产儿互动知识的掌握情况.[结果]医护人员早产儿互动知识得分为14.21分±2.03分,正确率为71.1%.医生组早产儿意识状态知识得分(3.53分±0.93分)显著高于护士组(2.99分±0.82分)(P<0.05).[结论]新生儿监护室医护人员对早产儿互动知识的掌握有待提高,医护人员应更加重视与早产儿互动,促进早产儿发育支持性照护和开展以家庭为中心的照护.     

Nursing home patients admitted to a medical intensive care unit

To investigate admissions from nursing homes to a medical intensive care unit (ICU), the authors detailed the major interventions, costs, and outcomes for such patients (n = 67) over a 3-year period and then compared them with those for ICU patients receiving home care or visiting nurse services (240 patients) before admission and all others older than 65 years of age (949 patients). These three groups comprised 37% of total ICU admissions. In contrast to younger patients admitted primarily with acute ischemic heart disease, nursing home patients were more likely to be admitted with cardiopulmonary arrest, infection, and gastrointestinal bleeding. Major interventions of intubation and mechanical ventilation were most frequent for nursing home patients, but total hospital charges differed little among the groups. In-hospital mortality for the nursing home group (28%) was significantly higher than for the home care group (7%) and others older than 65 years of age (7%). Cumulative mortality for the nursing home group reached 66% by 8 months, versus 32% and 26% in the other groups, respectively.     

Usefulness of intra-abdominal pressure in a predominantly medical intensive care unit

Background

The deleterious effects of elevated intra-abdominal pressure (IAP) have been known for more than a century. The proposed objectives were to measure changes in IAP and analyze increase-related factors and complications and whether high IAP and its persistence are related to complications and mortality in a predominantly medical intensive care unit.

Methods

Over a 1-year period, we conducted a prospective cohort study in which IAP was measured using the bladder method. Hospitalization time, demographic variables, diagnosis on admission, APACHE II score, and clinical complications were recorded.

Results

A total of 130 patients were studied. Overall mean IAP was 12.3 mm Hg (standard deviation [SD], 3.79; 95% confidence interval [CI], 11.7-13), and on the first day, 12.68 mm Hg (SD, 5.32; 95% CI, 11.8-13.6); maximum IAP was 16.4 mm Hg (SD, 4.6; 95% CI, 15.6-17.2). A positive correlation was found between IAP, APACHE (Acute Physiology And Chronic Health Evaluation) II, and age. Higher IAP values were independently associated with higher age, prolonged activated partial thromboplastin time, need for dialysis, and intolerance to enteral feeding. The value showing the best sensitivity and specificity in predicting mortality was persistence of IAP 20 mm Hg or greater for 4 days or more. The number of days with IAP 20 mm Hg or greater was a factor associated with a higher risk of death (odds ratio, 2.3). Patients who died showed a tendency to increased IAP.

Conclusion

In this study, a threshold IAP of 20 mm Hg and its permanence over time were the best predictive factors of complications and mortality. Among other relationships, we also observed that older patients had higher IAP. High IAP was a cause of intolerance to enteral nutrition.     

Improving medical student intensive care unit communication skills: a novel educational initiative using standardized family members

OBJECTIVE: To determine whether intensive care unit (ICU) communication skills of fourth-year medical students could be improved by an educational intervention using a standardized family member. DESIGN: Prospective study conducted from August 2003 to May 2004. SETTING: Tertiary care university teaching hospital. PARTICIPANTS: All fourth-year students were eligible to participate during their mandatory four-week critical care medicine clerkship. INTERVENTIONS: The educational intervention focused on the initial meeting with the family member of an ICU patient and included formal teaching of a communication framework followed by a practice session with an actor playing the role of a standardized family member of a fictional patient. At the beginning of the critical care medicine rotation, the intervention group received the educational session, whereas students in the control group did not. MEASUREMENTS AND MAIN RESULTS: At the end of each critical care medicine rotation, all students interacted with a different standardized family member portraying a different fictional scenario. Sessions were videotaped and were scored by an investigator blinded to treatment assignment using a standardized grading tool across four domains: a) introduction; b) gathering information; c) imparting information; and d) setting goals and expectations. A total of 106 (97% of eligible) medical students agreed to participate in the study. The total mean score as well as the scores for the gathering information, imparting information, setting goals, and expectations domains for the intervention group were significantly higher than for the control group (p < .01). CONCLUSIONS: The communication skills of fourth-year medical students can be improved by teaching and then practicing a framework for an initial ICU communication episode with a standardized family member.     

A collaborative project: initiating a family intervention program in a medical intensive care unit

Common needs of family members of critically ill patients were identified. Each member of the family may react differently to the stress caused by hospitalization of a loved one. Dealing with families in crisis requires the coordination of the health care team. A clinical nurse specialist can act as a coordinator and continue to integrate the efforts of the nursing staff to ensure a team approach in providing a structured yet individual way to deliver emotional support to families of the critically ill. The purpose, design, implementation, and evaluation of a family intervention program in an MICU as well as suggestions for its continuation were described. Evaluations of the program revealed positive responses by the majority of families participating in the program. Findings indicated that a structured and well-planned family intervention program can increase the staff nurse's knowledge and sensitivity to the needs of families who are in a crisis situation. Further research is necessary to identify needs of a family when they are faced with an acute illness of a family member and the required nursing interventions to assure the desired outcome of care. Replication and reporting of similar intervention programs, such as the family intervention program, would help nurses plan and implement appropriate interventions to support the family during critical illness of a family member.     

Electronic medical record in the intensive care unit.

The EMR in the ICU has the utility of providing the necessary information to make sound clinical decisions for critically ill patients. For it to be optimized, the EMR must be more than just what is being replicated in the written record or merely a documentation tool; it must add value that supports and enhances clinical decision support. The EMR is too expensive a tool just to be a computer designed to ease documentation and retrieve data faster. Gardner and Huff have suggested that the EMR must answer three questions: Why, What, and So What. The "Why" is relatively easy to answer, but the "What" data to use so that the information is meaningful to a provider and the "So What" are more difficult to answer. Provided one can qualitatively assess "What" information is important for a health care provider, then "So What" becomes an important objective in the empirical quantification of the benefits that the EMR provides. It is clear that to analyze some of the outcomes that health care delivery provides, one needs some mechanism to automate the information at the point of care, particularly now that the regulatory agencies are requiring it. Given the fact that there is no single integrated computerized patient record, this becomes the daunting task for the next century. Making it easier for health care providers to interact with the system and providing them with instantaneous feedback that changes their medical decision so they can deliver better care (clinical pathways, clinical practice guidelines) will be the task required of the next generation of CISs.     

Evaluation of an intensive insulin protocol for septic patients in a medical intensive care unit

OBJECTIVE: Intensive insulin therapy to normalize blood glucose may improve outcome in intensive care unit patients. We prospectively evaluated the implementation of an intensive insulin protocol in medical intensive care patients to identify and overcome obstacles that this complex therapy creates. DESIGN: This prospective, quality assessment study was designed to establish a standard protocol for glucose control in critically ill patients. SETTING: The study took place in the medical intensive care unit at the Medical University of South Carolina, a tertiary care center. PATIENTS: Patients diagnosed with sepsis and two consecutive blood glucose measurements of >120 mg/dL were included in the study. INTERVENTIONS: The protocol, targeting blood glucose of 80-120 mg/dL, was a multidisciplinary initiative involving extensive education of house staff before subject enrollment. Based on predefined criteria, patients were monitored daily for glycemic control, inclusion criteria, and protocol adherence. Protocol improvements were assessed at 6 and 12 months via nursing surveys. MEASUREMENTS AND MAIN RESULTS: Seventy patients receiving insulin infusion for >8 hrs were included in data analysis, accounting for 4,920 glucose readings. Eighty-six hypoglycemic events were recorded, with the number of events decreasing from 7.6% to 0.3% by the final version of the protocol. Average duration on protocol was 6 days, and average time to target range was 5.4 hrs. Identifiable causes of hypoglycemia and survey results led to four protocol revisions by study completion. CONCLUSIONS: In comparison to studies suggesting that normoglycemia is an easily achievable goal, our protocol often recorded glucose values <80 mg/dL, although values <60 mg/dL were rare and usually due to protocol violations. In the interval before automated glucose-sensing insulin infusion devices become available for the intensive care unit, the current protocol is available to assist others in achieving target glucose levels shown to improve mortality rate in an intensive care unit population.