Challenging Organizational Factors Associated With Admission Delay to Intensive Care Unit-A Novel Quality Indicator.

BACKGROUND: Delays in admitting patients to the intensive care unit (ICU) can defer the timely initiation of life-sustaining therapies and invasive monitoring, jeopardizing the success of the treatment. Nevertheless, the availability of research on interventions that reduce or minimize admission delays is limited. OBJECTIVES: The current study aimed to assess the factors related to delays in admission times of critically ill patients transferred to the ICU. METHODS: A software was designed to follow-up, compare and measure the defined intervals of the time to admission, implemented at the ICU for 6 months. Measurements included 5 time intervals, referral department, and work shift at admission. Data from 1004 patients admitted to the ICU between July 2017 and January 2020 were analyzed in a retrospective observational study. RESULTS: Precisely, 53.9% of total patients were referred from the hospital emergency department, and 44% were admitted during the evening shift. Significant differences were found in time intervals between shifts, showing the morning round had the longer total admission time (median: 67.8 min). Analysis showed that admission time was longer at times of full capacity compared to times of available bed (mean: 56.4 and 40.2 min, respectively; U = 68,722, p < .05). Findings demonstrated a significant shortening of time to admission after implementing a new time monitoring software by the Institutional Quality Control Commission (U = 5072, p < .001). CONCLUSIONS: Our study opens doors for potential studies on applying effective initiatives in critical care settings to improve patient care and outcomes. Additionally, it generates new insights regarding how clinicians and nursing teams can jointly develop and promote multidisciplinary interventions in intensive care work environments.

[Seeing the sounds--chest and lung ultrasonography].

Chest ultrasonography was considered hampered and deficient but it is now taking a prominent role as a bedside tool for the diagnosis of lung ailments. Technological development has made it accurate, fast and reliable to the extent that it is gradually replacing the traditional chest X-ray and sometimes also the computed tomography scan. In this article we review and display in a few images the diagnostic possibilities of the thoracic ultrasound examination in a diverse range of maladies such as pneumonia, pulmonary congestion, pleural effusion and other conditions.

Merging ultrasound in the intensive care routine.

BACKGROUND: Goal-oriented ultrasound examination is gaining a place in the intensive care unit. Some protocols have been proposed but the applicability of ultrasound as part of a routine has not been studied. OBJECTIVES: To assess the influence of ultrasound performed by intensive care physicians. METHODS: This retrospective descriptive clinical study was performed in a medical-surgical intensive care unit of a university-affiliated general hospital. Data were collected from patients undergoing ultrasound examinations performed by a critical care physician during the period 2010 to June 2011. RESULTS: A total of 299 ultrasound exams were performed in 113 mechanically ventilated patients (70 males, mean age 65 years). Exams included trans-cranial Doppler (n = 24), neck evaluation before tracheostomy (n = 15), chest exam (n = 83), focuse cardiac echocardiography (n = 60), abdominal exam (n = 41), and comprehensive screening at patient admission (n = 30). Ultrasound was used to guide invasive procedures for vascular catheter insertion (n = 42), pleural fluid drainage (n = 24), and peritoneal fluid drainage (n = 7). One pneumothorax was seen during central venous line insertion but no complications were observed after pleural or abdominal drainage. The ultrasound study provided good quality visualization in 86% (258 of 299 exams) and was a diagnostic tool that induced a change in treatment in 58% (132 of 226 exams). CONCLUSIONS: Bedside ultrasound examinations performed by critical care physicians provide an important adjunct to diagnostic and therapeutic performance, improving quality of care and patient safety.

Spontaneous Pathologic Splenic Rupture in a Patient with Plasmodium falciparum Infection, First Case Reported in Israel.

Travelers exposed to malaria may develop severe disease and complications. A less well-known complication is spontaneous pathologic splenic rupture, which is still under-reported and has never been reported in Israel. In this paper, we report a 23 years old healthy young man presenting in the emergency department, two weeks after coming back from Sierra Leone, with intermittent fever, mild tachycardia and mild left upper quadrant abdominal pain. The patient was diagnosed with Plasmodium falciparum infection and developed rapidly after hospital admission spleen rupture. He was managed conservatively at first but ultimately underwent splenectomy after being hemodynamically unstable. In the recovery period, the patient developed acute respiratory distress syndrome and was reintubated. A high level of suspicion is recommended in every malaria patient presenting with left upper quadrant abdominal pain, even if minimal. Ultrasonography availability in the internal medicine department may be a critical diagnostic tool, especially in non-endemic areas.

Clinical Course and Outcomes of Severe Covid-19: A National Scale Study.

Knowledge of the outcomes of critically ill patients is crucial for health and government officials who are planning how to address local outbreaks. The factors associated with outcomes of critically ill patients with coronavirus disease 2019 (Covid-19) who required treatment in an intensive care unit (ICU) are yet to be determined. METHODS: This was a retrospective registry-based case series of patients with laboratory-confirmed SARS-CoV-2 who were referred for ICU admission and treated in the ICUs of the 13 participating centers in Israel between 5 March and 27 April 2020. Demographic and clinical data including clinical management were collected and subjected to a multivariable analysis; primary outcome was mortality. RESULTS: This study included 156 patients (median age = 72 years (range = 22-97 years)); 69% (108 of 156) were male. Eighty-nine percent (139 of 156) of patients had at least one comorbidity. One hundred three patients (66%) required invasive mechanical ventilation. As of 8 May 2020, the median length of stay in the ICU was 10 days (range = 0-37 days). The overall mortality rate was 56%; a multivariable regression model revealed that increasing age (OR = 1.08 for each year of age, 95%CI = 1.03-1.13), the presence of sepsis (OR = 1.08 for each year of age, 95%CI = 1.03-1.13), and a shorter ICU stay(OR = 0.90 for each day, 95% CI = 0.84-0.96) were independent prognostic factors. CONCLUSIONS: In our case series, we found lower mortality rates than those in exhausted health systems. The results of our multivariable model suggest that further evaluation is needed of antiviral and antibacterial agents in the treatment of sepsis and secondary infection.

Speckle tracking technology for quantifying lung sliding.

Ultrasound (US) is gaining recognition as a useful tool for assessing lung physiology and pathology. Yet, currently the skill of performing lung US is taught by experienced operators to novice ones, mainly by recognizing expected patterns. Recognizing the latter may be difficult and subjective. In this hypothesis we propose to apply a well-known and used image processing technology in echocardiography, speckle tracking (ST), to lung sliding - the marker of normal lung function. If implementing ST to lung sliding is technically feasible, several outcomes are expected: (1) Lung sliding will become an objective, operator-independent marker of normal lung function. (2) Subsequently, ST will provide normal values for lung sliding. (3) Lastly, the effects of pulmonary pathologies on lung sliding may be assessed. It is stressed, however, that the preliminary idea suggested here is limited to a single physiological phenomenon (lung sliding). Only when technical feasibility is demonstrated then ST technology may potentially be applied and investigated in other clinical settings of lung diseases.

Evaluation of changes in forgoing life-sustaining treatment in Israeli ICU patients.

INTRODUCTION: Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel. METHODS: The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999). RESULTS: During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods. CONCLUSIONS: There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

End-of-life intensive care unit decisions, communication, and documentation: an evaluation of physician training.

PURPOSE: The majority of patients dying in intensive care units (ICUs) do so after the forgoing of life-sustaining therapies (FLST). Communication between physicians, patients, and their families regarding the decision to FLST has not been evaluated in Israel. MATERIALS AND METHODS: All patients who had FLST in a general ICU were enrolled in the study. We evaluated whether physicians communicated and documented the FLST decisions with patients or the patients' families. We also assessed the effect of the physician's geographic place of training on communication behavior. RESULTS: Over a period of 8.5 months, 385 patients were admitted to a general ICU in Israel. Fifty-seven patients died or had FLST. Twelve of these 57 were excluded from the study. Thus, 45 (79%) patients had FLST and were enrolled in the study. All patients were deemed medically incompetent to make FLST decisions. In 24 (53%) patients, FLST was discussed with the family before the decision to forgo therapy. Discussion occurred later with 6 other families, who were unavailable at the time the FLST decision was made. In 15 patients, there were no discussions with families. American-trained physicians discussed FLST with 22 of 29 families initially and 5 other families later (93%), whereas the Eastern European-trained physicians discussed FLST with only 3 of 16 (19%) families (P <.001). Documentation of FLST was present in 26 (90%) patients of American-trained physicians and 8 (50%) patients of Eastern European-trained physicians (P <.001). CONCLUSIONS: FLST is common in an Israeli ICU. Patients are not medically competent to make FLST decisions. American-trained physicians discuss and document FLST more often than Eastern European-trained physicians.