Continuous care and patients’ basic needs during weaning from mechanical ventilation: A qualitative study
Intensive and Critical Care Nursing
Khalafi Ali et al
Mechanical ventilation is associated with a number of risks and
complications. Thus, rapid and safe weaning from mechanical ventilation
is of great importance. Weaning is a complex and challenging process,
requiring continuous care and knowledge of the patient.
The aim of the present study was to describe the continuous care process
during weaning as well as to analyse the facilitators and obstacles to
the weaning process from start to finish from the perspective of
intensive care unit (ICU) staff, particularly nurses.
Thursday, 18 August 2016
Surviving Severe Sepsis: Is That Enough?
Surviving Severe Sepsis: Is That Enough?
Critical Care Medicine
Anderson-Shaw, L
Sepsis and severe forms of sepsis is a frequent diagnosis in the ICU setting. “Sepsis is one of the oldest and most elusive syndromes in medicine”. The definition of severe sepsis includes a systemic inflammatory response to infection complicated by acute organ dysfunction . “Over 1,665,000 cases of sepsis occur in the United States each year, with a mortality rate up to 50%” . In the ICU setting survival of severe sepsis is a primary goal, however, quality-of-life (QoL) issues for these patients after discharge is of great concern to the patient and to their family and physicians who will be providing the follow-up care that may be complex and ongoing . Long after hospitalization, survivors of severe sepsis experience an impaired QoL and an ongoing feeling that they may be imposing a burden of care to their family and loved ones................
Critical Care Medicine
Anderson-Shaw, L
Sepsis and severe forms of sepsis is a frequent diagnosis in the ICU setting. “Sepsis is one of the oldest and most elusive syndromes in medicine”. The definition of severe sepsis includes a systemic inflammatory response to infection complicated by acute organ dysfunction . “Over 1,665,000 cases of sepsis occur in the United States each year, with a mortality rate up to 50%” . In the ICU setting survival of severe sepsis is a primary goal, however, quality-of-life (QoL) issues for these patients after discharge is of great concern to the patient and to their family and physicians who will be providing the follow-up care that may be complex and ongoing . Long after hospitalization, survivors of severe sepsis experience an impaired QoL and an ongoing feeling that they may be imposing a burden of care to their family and loved ones................
Sepsis-3: What is the Meaning of a Definition?
Sepsis-3: What is the Meaning of a Definition?
Critical Care Medicine
Marshall, J C
The recent publication of Sepsis-3–the latest iteration of an effort to define sepsis–has evoked an impressive response . To date it has been viewed more than one million times on the JAMA website, making it one of the most highly accessed articles there in recent years. It has also generated a flurry of commentaries–some supportive, some opposing, and almost all thoughtful . Indeed recognizing as the original paper did that the new definition is simply the next step in the evolution of a challenging process, the controversy is as important as the Sepsis-3 document in clarifying what has been accomplished and what remains undone.
Critical Care Medicine
Marshall, J C
The recent publication of Sepsis-3–the latest iteration of an effort to define sepsis–has evoked an impressive response . To date it has been viewed more than one million times on the JAMA website, making it one of the most highly accessed articles there in recent years. It has also generated a flurry of commentaries–some supportive, some opposing, and almost all thoughtful . Indeed recognizing as the original paper did that the new definition is simply the next step in the evolution of a challenging process, the controversy is as important as the Sepsis-3 document in clarifying what has been accomplished and what remains undone.
Long-Term Quality of Life Among Survivors of Severe Sepsis: Analyses of Two International Trials
Long-Term Quality of Life Among Survivors of Severe Sepsis: Analyses of Two International Trials
Critical Care Medicine
Yende, S et al
Objectives: To describe the quality of life among sepsis survivors. Design: Secondary analyses of two international, randomized clinical trials (A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis [derivation cohort] and PROWESS-SHOCK [validation cohort]). Setting: ICUs in North and South America, Europe, Africa, Asia, and Australia. Patients: Adults with severe sepsis. We analyzed only patients who were functional and living at home without help before sepsis hospitalization (n = 1,143 and 987 from A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis and PROWESS-SHOCK, respectively). Interventions: None. Measurements and Main Results: In A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis and PROWESS-SHOCK, the average age of patients living at home independently was 63 and 61 years; 400 (34.9%) and 298 (30.2%) died by 6 months. In A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis, 580 patients had a quality of life measured using EQ-5D at 6 months. Of these, 41.6% could not live independently (22.7% were home but required help, 5.1% were in nursing home or rehabilitation facilities, and 5.3% were in acute care hospitals). Poor quality of life at 6 months, as evidenced by problems in mobility, usual activities, and self-care domains were reported in 37.4%, 43.7%, and 20.5%, respectively, and the high incidence of poor quality of life was also seen in patients in PROWESS-SHOCK. Over 45% of patients with mobility and self-care problems at 6 months in A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis died or reported persistent problems at 1 year. Conclusions: Among individuals enrolled in a clinical trial who lived independently prior to severe sepsis, one third had died and of those who survived, a further one third had not returned to independent living by 6 months. Both mortality and quality of life should be considered when designing new interventions and considering endpoints for sepsis trials.
Critical Care Medicine
Yende, S et al
Objectives: To describe the quality of life among sepsis survivors. Design: Secondary analyses of two international, randomized clinical trials (A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis [derivation cohort] and PROWESS-SHOCK [validation cohort]). Setting: ICUs in North and South America, Europe, Africa, Asia, and Australia. Patients: Adults with severe sepsis. We analyzed only patients who were functional and living at home without help before sepsis hospitalization (n = 1,143 and 987 from A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis and PROWESS-SHOCK, respectively). Interventions: None. Measurements and Main Results: In A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis and PROWESS-SHOCK, the average age of patients living at home independently was 63 and 61 years; 400 (34.9%) and 298 (30.2%) died by 6 months. In A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis, 580 patients had a quality of life measured using EQ-5D at 6 months. Of these, 41.6% could not live independently (22.7% were home but required help, 5.1% were in nursing home or rehabilitation facilities, and 5.3% were in acute care hospitals). Poor quality of life at 6 months, as evidenced by problems in mobility, usual activities, and self-care domains were reported in 37.4%, 43.7%, and 20.5%, respectively, and the high incidence of poor quality of life was also seen in patients in PROWESS-SHOCK. Over 45% of patients with mobility and self-care problems at 6 months in A Controlled Comparison of Eritoran and placebo in patients with Severe Sepsis died or reported persistent problems at 1 year. Conclusions: Among individuals enrolled in a clinical trial who lived independently prior to severe sepsis, one third had died and of those who survived, a further one third had not returned to independent living by 6 months. Both mortality and quality of life should be considered when designing new interventions and considering endpoints for sepsis trials.
Real-Time Risk Prediction on the Wards: A Feasibility Study
Real-Time Risk Prediction on the Wards: A Feasibility Study
Critical Care Medicine
Kang MA et al
Objective: Failure to detect clinical deterioration in the hospital is common and associated with poor patient outcomes and increased healthcare costs. Our objective was to evaluate the feasibility and accuracy of real-time risk stratification using the electronic Cardiac Arrest Risk Triage score, an electronic health record-based early warning score. Design: We conducted a prospective black-box validation study. Data were transmitted via HL7 feed in real time to an integration engine and database server wherein the scores were calculated and stored without visualization for clinical providers. The high-risk threshold was set a priori. Timing and sensitivity of electronic Cardiac Arrest Risk Triage score activation were compared with standard-of-care Rapid Response Team activation for patients who experienced a ward cardiac arrest or ICU transfer. Setting: Three general care wards at an academic medical center. Patients: A total of 3,889 adult inpatients. Measurements and Main Results: The system generated 5,925 segments during 5,751 admissions. The area under the receiver operating characteristic curve for electronic Cardiac Arrest Risk Triage score was 0.88 for cardiac arrest and 0.80 for ICU transfer, consistent with previously published derivation results. During the study period, eight of 10 patients with a cardiac arrest had high-risk electronic Cardiac Arrest Risk Triage scores, whereas the Rapid Response Team was activated on two of these patients (p < 0.05). Furthermore, electronic Cardiac Arrest Risk Triage score identified 52% (n = 201) of the ICU transfers compared with 34% (n = 129) by the current system (p < 0.001). Patients met the high-risk electronic Cardiac Arrest Risk Triage score threshold a median of 30 hours prior to cardiac arrest or ICU transfer versus 1.7 hours for standard Rapid Response Team activation. Conclusions: Electronic Cardiac Arrest Risk Triage score identified significantly more cardiac arrests and ICU transfers than standard Rapid Response Team activation and did so many hours in advance.
Critical Care Medicine
Kang MA et al
Objective: Failure to detect clinical deterioration in the hospital is common and associated with poor patient outcomes and increased healthcare costs. Our objective was to evaluate the feasibility and accuracy of real-time risk stratification using the electronic Cardiac Arrest Risk Triage score, an electronic health record-based early warning score. Design: We conducted a prospective black-box validation study. Data were transmitted via HL7 feed in real time to an integration engine and database server wherein the scores were calculated and stored without visualization for clinical providers. The high-risk threshold was set a priori. Timing and sensitivity of electronic Cardiac Arrest Risk Triage score activation were compared with standard-of-care Rapid Response Team activation for patients who experienced a ward cardiac arrest or ICU transfer. Setting: Three general care wards at an academic medical center. Patients: A total of 3,889 adult inpatients. Measurements and Main Results: The system generated 5,925 segments during 5,751 admissions. The area under the receiver operating characteristic curve for electronic Cardiac Arrest Risk Triage score was 0.88 for cardiac arrest and 0.80 for ICU transfer, consistent with previously published derivation results. During the study period, eight of 10 patients with a cardiac arrest had high-risk electronic Cardiac Arrest Risk Triage scores, whereas the Rapid Response Team was activated on two of these patients (p < 0.05). Furthermore, electronic Cardiac Arrest Risk Triage score identified 52% (n = 201) of the ICU transfers compared with 34% (n = 129) by the current system (p < 0.001). Patients met the high-risk electronic Cardiac Arrest Risk Triage score threshold a median of 30 hours prior to cardiac arrest or ICU transfer versus 1.7 hours for standard Rapid Response Team activation. Conclusions: Electronic Cardiac Arrest Risk Triage score identified significantly more cardiac arrests and ICU transfers than standard Rapid Response Team activation and did so many hours in advance.
Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness
Potential Influence
of Advance Care Planning and Palliative Care Consultation on ICU Costs
for Patients With Chronic and Serious Illness
Critical Care Medicine
Khandelwal, N et al
Objectives: To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. Design and Setting: Decision analysis using literature estimates and inpatient administrative data from Premier. Patients: Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. Interventions: None. Measurements and Main Results: Using Premier data (2008–2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions’ efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. Conclusions: In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.
Critical Care Medicine
Khandelwal, N et al
Objectives: To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. Design and Setting: Decision analysis using literature estimates and inpatient administrative data from Premier. Patients: Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. Interventions: None. Measurements and Main Results: Using Premier data (2008–2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions’ efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. Conclusions: In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers.
Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome
Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome
Critical Care Medicine
Weiss CHet al
Objective: Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use. Design: Retrospective cross-sectional study. Setting: One academic and three community hospitals in the Chicago region. Patients: A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013. Measurements and Main Results: Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight. Conclusions: More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.
Critical Care Medicine
Weiss CHet al
Objective: Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use. Design: Retrospective cross-sectional study. Setting: One academic and three community hospitals in the Chicago region. Patients: A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013. Measurements and Main Results: Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight. Conclusions: More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.
ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research
ICU Admission,
Discharge, and Triage Guidelines: A Framework to Enhance Clinical
Operations, Development of Institutional Policies, and Further Research
Critical Care Medicine
Nates JL
Objectives: To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research. Design: An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines. Measurements and Main Results: The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion: Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.
Critical Care Medicine
Nates JL
Objectives: To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research. Design: An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines. Measurements and Main Results: The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion: Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.
Impact of an aseptic procedure for breaking the integrity of the urinary drainage system on the development of catheter-associated urinary tract infections in the intensive care unit
Impact of
an aseptic procedure for breaking the integrity of the urinary drainage
system on the development of catheter-associated urinary tract
infections in the intensive care unit
Intensive and Critical Care Nursing
Powers J
Catheter associated urinary tract infections (CAUTI) are a common complication in the hospital, especially in intensive care units (ICU). These infections are directly linked to the use of an indwelling urinary catheter. One commonly identified factor related to the development of CAUTI has been thought to be violating the integrity of the closed drainage system. However, a paucity of research exists to support or refute this practice.
Intensive and Critical Care Nursing
Powers J
Catheter associated urinary tract infections (CAUTI) are a common complication in the hospital, especially in intensive care units (ICU). These infections are directly linked to the use of an indwelling urinary catheter. One commonly identified factor related to the development of CAUTI has been thought to be violating the integrity of the closed drainage system. However, a paucity of research exists to support or refute this practice.
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