Measuring service-specific performance and educational value within a general surgery residency: the power of a prospective, anonymous, Web-based rotation evaluation system in the optimization of resident satisfaction.

BACKGROUND: We used a Web-based evaluation system to institute specific changes to various clinical teaching services in our integrated residency in an effort to optimize the overall quality of the educational experience and measured the resident satisfaction in these rotations. METHODS: Residents rated 8 categories of experience on a scale of 1 to 5 (maximum summation score, 40 points). Data were analyzed by t-test for equality of means. A probability value of less than.05 was considered significant. RESULTS: Compliance with completion of the evaluations was 100%. The Chronbach's alpha reliability coefficient of the tool was 0.826. Tukey's estimate of power to achieve additivity was 1.5. Six under-performing services were re-engineered with prominent effects on 7 postgraduate year (PGY) rotations. On 2 general surgery services at 1 hospital, the workload was redistributed, and a dedicated team teaching time was instituted (PGY-3 [a]: before, 22 points/after, 31 points; P =.003; PGY-3 [b]: before, 25 points/after, 31 points; P =.004; PGY-1: before, 24 points/after, 29 points; P =.07). A general surgery service at another hospital redistributed coverage of the attending surgeons to create a nonteaching service (PGY-1: before, 22 points/-after, 27 points; P =.01). The transplantation service (PGY-3) was examined, and the role of the point was redefined (before, 24 points/after, 31 points; P =.01). One vascular service (PGY-2) redistributed cases and workload (before, 27 points/after, 22 points; P =.07). The vascular PGY-2 position was eliminated and replaced by a mid-level practitioner. The cardiothoracic service (PGY-1) rotation was converted into a preceptorship (before, 23 points/after, 30 points; P =.015). CONCLUSIONS: A web-based clinical rotation evaluation provides a means for the assessment of the impact of programmatic changes while preserving resident anonymity and maintaining accountability.

Critical palliative care: intensive care redefined.

In the area of end-of-life bioethical issues, patients, families, and health care providers do not understand basic principles, often leading to anguish, guilt, and anger. Providers lack communication skills, concepts, and practical bedside information. Linking societal values of the sanctity of life and quality of life with medical goals of preservation of life and alleviation of suffering respectively provides an essential structure. Medical care focuses on cure when possible but when the patient is dying, the focus switches to caring for patients and their families. Clinicians need to learn how to balance the benefits and burdens of medications and treatments, control symptoms, and orchestrate withdrawal of treatment. Finally, all need to learn more about the dying process to benefit society, their own families, and themselves.

Beyond requirements: residency management through the Internet.

HYPOTHESIS: An Internet application could collect information to satisfy documentation required by the Residency Review Committee. Beyond replacing a difficult and inefficient paper system, it would collect, process, and distribute information to administration, faculty, and residents. DESIGN: Descriptive study. SETTING: An integrated residency of 18 services at a university teaching hospital with 4 affiliated institutions. PARTICIPANTS: Residency administrators, faculty, and residents. INTERVENTIONS: The application included a procedure recorder, resident evaluation of faculty and rotations, goals and objectives (stratified by service and resident level), and matching faculty evaluation of residents with these goals as competencies. Policies, schedules, research opportunities, clinical site information, and curriculum support were created. MAIN OUTCOME MEASURES: Degree of compliance with Residency Review Committee standards, number of deficiencies corrected, and quantity and quality of information available to administration, faculty, and residents. RESULTS: The Internet system increased resident compliance for faculty and rotation evaluations from 20% and 34%, respectively, to 100%, which was maintained for 22 months. These evaluations can be displayed individually, in summary grids, and as postgraduate year-specific averages. Faculty evaluations of residents can be reviewed throughout the system. The defined category report for procedures, which had deficiencies in the preceding 6 years, had none for the last 2 years. The Internet application provides Accreditation Council for Graduate Medical Education-validated operative logs to regulatory agencies. CONCLUSIONS: A Web-based system can satisfy requirements and provide processed data that are of better quality and more complete than our paper system. We are now able to use scarce time and personnel to nurture developing surgical residents instead of shuffling paper.

Lemonade from lemons: a program response to RRC-determined probation.

To assess resident satisfaction as a result of changes made to an integrated surgical residency in response to probation.The University of Connecticut Integrated General Surgery Residency (UCIGSR), which consists of 5 hospitals, 18 rotations, and has a complement of 44 residents, was placed on probation by the Residency Review Committee (RRC) in Surgery in November 1998. Among the deficiencies cited by the RRC were inadequate evaluation of the program, rotations, residents, and the faculty by the residents, along with inadequate documentation issues. Lack of organized educational conferences, lack of faculty involvement, excessive service responsibilities and work hours, and hospital environmental issues were also cited. It was also apparent that morale of the residents and faculty had significantly eroded. Rather than trying patchwork "fixes" of deficiencies, we used this opportunity to reengineer the program, rededicating ourselves to educating and developing future surgeons. Task forces, including joint faculty and resident participation, were set up to develop solutions, based on the answer to the question: "Do we want a residency or not?" This focus was especially helpful to create hospital administration and faculty support.A survey was created to assess the changes made in the program. The survey included 65 questions pertaining to the learning environment, hospital and departmental support, and balance between clinical and educational responsibilities and overall working environment. Each resident was asked to fill out 3 identical surveys, 1 just before the RRC report, and the other 2 at 6-month intervals after the probation announcement. A 4-point grading scale was used.Our results were reflective of resident perceptions of improvement and increased satisfaction. These data demonstrated that the changes implemented as a result of the RRC findings had a positive effect on the residency program, and they corresponded to the areas where changes were implemented. This survey also gave us a method to evaluate ongoing changes in our residency.Probation can be a potent stimulus for improvement of a surgical residency. (Curr Surg 57:373-376. Copyright 2000 by the Association of Program Directors in Surgery.)

Cost and morbidity associated with antibiotic prophylaxis in the ICU.

BACKGROUND: Although the high cost and inappropriate use of antibiotics have been documented before, we are not aware of any data on nonsurgical site infectious morbidity associated with prolonged courses of prophylactic antibiotics (PA). STUDY DESIGN: Data regarding antibiotic orders were collected using a custom designed microbiology database in the Surgical Intensive Care Unit of a teaching hospital from October 1, 1995 through April 30, 1997. The database was retrospectively reviewed. The cost of PA in excess of 1 day was calculated. Frequency of bacteremia and line infections were compared in patients receiving 1 day or less of PA versus more than 4 days of PA. RESULTS: Sixty-one percent of PA orders were continued for more than 1 day. Cost of PA beyond 1 day totaled $44,893. Bacteremia and line infection were more frequent in the patients receiving more than 4 days of PA. CONCLUSIONS: There was poor compliance with the protocol of stopping PA at 24 hours. The cost of noncompliance was $44,893. There were more bacteremias and line infections in patients with duration of PA of more than 4 days.

Strategies to prevent organ failure.

The gastrointestinal tract and the generalized inflammatory response initiated by severe injury or infection have been implicated in the pathophysiology of multiple-organ system failure. Once multiple-organ system failure has occurred, treatment focuses on supporting end-organ function. Recent studies have shown, however, that it may be possible to reduce the incidence and prevalence of multiple-organ system failure by controlling the reperfusion injury cascade, normalizing gastrointestinal blood flow and preserving the integrity of the gastrointestinal immune barrier.

Empiric therapy of sepsis in the surgical intensive care unit with broad-spectrum antibiotics for 72 hours does not lead to the emergence of resistant bacteria.

BACKGROUND: It is our practice to treat suspected sepsis with imipenem/cilastatin and gentamicin (IMP/GENT) for 72 hours while awaiting culture results. We wanted to determine if this practice engenders antimicrobial resistance. METHODS: Review of prospectively collected data regarding use of IMP/GENT and microbial sensitivity to imipenem/cilastatin during the first and last 7 months of a 19-month study period (October 1, 1995, to April 30, 1997). RESULTS: The susceptibility of appropriate organisms to imipenem/cilastatin was 76% in the early period and 80% in the late period (p = 0.42). Pseudomonas aeruginosa was more susceptible in the late period (88 vs. 62%; p = 0.007). Resistance to gentamicin (30% early vs. 21% late; p = 0.02) and representative cephalosporins (cefoxitin, 52% early vs. 61% late; p = 0.35; ceftazidime, 26% early vs. 23% late; p = 0.76) did not develop during the study period. The incidence of fungemia was the same in both periods (4 of 467 admissions vs. 3 of 599 admissions; p = 0.48). CONCLUSION: This protocol did not lead to the emergence of resistant bacteria.

Failure of splanchnic resuscitation in the acutely injured trauma patient correlates with multiple organ system failure and length of stay in the ICU.

INTRODUCTION: The purpose of our study was to evaluate the relationship between the state of splanchnic perfusion and morbidity and mortality in the hemodynamically unstable trauma patient acutely resuscitated in the ICU. METHODS: Gastric intramucosal pH (pHi) was monitored in a blinded fashion in 19 consecutive critically ill trauma patients with evidence of systemic hypoperfusion (arterial pH [pHa] <7.35, base excess >2.3 mmol/L, lactic acid >2.3 mEq/L) who received right heart catheters to guide resuscitation and subsequent hemodynamic monitoring. DESIGN: Prospective randomized consecutive series with retrospective analysis of data. SETTING: University hospital, surgical ICU. RESULTS: The mean values of APACHE II (acute physiology and chronic health evaluation) Injury Severity Score, pHa, arterial base excess, cardiac index, oxygen delivery index, and oxygen consumption index by 24 h were similar (Student's t test, p>0.1) between survivors and nonsurvivors and between those who developed at most a single (SOF) vs multiple organ system failure (MOSF). Supranormal oxygen delivery and utilization parameters were evenly distributed among survivors and nonsurvivors and patients with SOF and MOSF (chi2, p>0.5). Ten patients had a pHi <7.32 and nine patients had a pHi > or = 7.32 by 24 h. Fifty percent of patients with a pHi <7.32 died, compared with 11% of patients with a pH > or = 7.32 (chi2, p=0.07). Sixty percent of patients with a pHi <7.32 developed MOSF compared with 11% of patients with a pHi > or = 7.32 (chi2, p=0.03). The one patient who developed MOSF and died in the pHi > or = 7.32 cohort suffered from massive head trauma and had all futile medical interventions halted. No other patients who achieved a pH > or = 7.32 by hour 24 developed MOSF. Survivors with a pHi <7.32 at hour 24 had an increased ICU stay (pHi <7.32=46+/-15 days, pHi > or = 7.32=13+/-9 days; p<0.01). A pHi <7.32 carried a relative risk of 4.5 for death and 5.4 for the occurrence of MOSF. CONCLUSION: Attainment of a pHi > or = 7.32 at hour 24 carried a significantly reduced likelihood of MOSF. Being an inference of the state of regional perfusion, in a high-risk microvascular bed, gastric intraluminal tonometry should identify perfusion states of compensated or uncompensated shock during hemodynamic resuscitation of the critically ill injury patient. A low pHi appears to be a marker of postresuscitative morbidity and subsequent increased length of stay.

The impact of antioxidant and splanchnic-directed therapy on persistent uncorrected gastric mucosal pH in the critically injured trauma patient.

BACKGROUND: Critically ill trauma patients with gastric intramucosal acidosis, as measured by gastric tonometry, have an increased incidence of multiple organ dysfunction syndrome despite supranormal O2 delivery. We altered our resuscitation protocol to maximize splanchnic blood flow and decrease oxygen-derived free radical damage. DESIGN: Prospective clinical trial with historical controls. METHODS: The protocol differed from control by including administration of folate, mannitol, and low-dose isoproterenol. All patients had gastric tonometers and pulmonary artery catheters. If the intramucosal pH (pHi) was less than 7.25, splanchnic-sparing inotropic and vasodilatory agents were used to optimize systemic cardiac output. Two groups of trauma patients with persistent intramucosal acidosis at 24 hours (pHi < 7.25) were compared: a control group (n = 7), and patients who received the splanchnic/antioxidant protocol (n = 13). RESULTS: The two groups were similar based on Acute Physiology and Chronic Health Evaluation II score, Injury Severity Score, age, cardiac index, oxygen delivery, and oxygen consumption. The "splanchnic therapy" group had fewer organ system failures as well as shortened length of intensive care unit and hospital stay. Three of 7 patients in the control group and 2 of 13 patients in the splanchnic therapy group had a final pHi < 7.25. CONCLUSION: Gastric tonometry-guided resuscitation and antioxidant/splanchnic therapy in critically ill trauma patients with persistent gastric mucosal acidosis may decrease multiple organ dysfunction syndrome.

A reappraisal of the role of Gram's stains of tracheal aspirates in guiding antibiotic selection in the surgical intensive care unit.

BACKGROUND: Tracheal aspirate Gram's stains are used to guide antibiotic selection in empiric pneumonia treatment in the surgical intensive care unit (SICU). We questioned whether Gram's stains predict the organism cultured. METHODS: A retrospective review of prospectively collected data. RESULTS: Gram's stains correlated with the cultured organism in 284 of 543 (52%) SICU cultures and in 226 of 403 (56%) trauma intensive care unit (TICU) cultures. Gram-negative rod (GNR) stains yielded GNR organisms in 182 of 205 (89%) SICU cultures and in 160 of 176 (91%) TICU cultures. Gram-positive coccus (GPC) stains yielded GPC organisms in 75 of 228 (33%) SICU cultures and in 52 of 149 (35%) TICU cultures. Noncorrelates in the GPC group were predominantly GNRs (185 of 250 (74%)). CONCLUSION: When the clinical decision has been made that empiric antibiotic coverage is necessary, GNR coverage should be instituted regardless of Gram's stain result. The decision to institute GPC coverage needs to be supported by clinical data other than the Gram's stain.

A prospective, randomized comparison of an in-line heat moisture exchange filter and heated wire humidifiers: rates of ventilator-associated early-onset (community-acquired) or late-onset (hospital-acquired) pneumonia and incidence of endotracheal tube occlusion.

PURPOSE: To compare the performance of an in-line heat moisture exchanging filter (HMEF) (Pall BB-100; Pall Corporation; East Hills, NY) to a conventional heated wire humidifier (H-wH) (Marquest Medical Products Inc., Englewood, Colo) in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and the rate of endotracheal tube occlusion. METHODS: This report describes a prospective, randomized trial of 280 consecutive trauma patients in a 20-bed trauma ICU (TICU). All intubated patients not ventilated elsewhere in the medical center prior to their TICU admission were randomized to either an in-line HMEF or a H-wH in the breathing circuit. Ventilator circuits were changed routinely every 7 days, and closed system suction catheters were changed every 3 days. HMEFs were changed every 24 h, or more frequently if necessary. A specific endotracheal tube suction and lavage protocol was not employed. Patients were dropped from the HMEF group if the filter was changed more than three times a day or the patient was placed on a regimen of ultra high-frequency ventilation. The Centers for Disease Control and Prevention (CDC) criteria for diagnosis of pneumonia were used; early-onset, community-acquired pneumonia was defined if CDC criteria were met in < or =3 days, and late-onset, hospital-acquired pneumonia was defined if criteria were met in >3 days. Laboratory and chest radiograph interpretation were blinded. RESULTS: The patient ages ranged from 15 to 95 years in the HMEF group and 16 to 87 years in the H-wH group (p=not significant), with a mean age of 46 years and 48 years, respectively. The male to female ratio ranged between 78 to 82%/22 to 18%, respectively, and 55% of all admissions were related to blunt trauma, 40% secondary to penetrating trauma, and 5% to major burns. There was no difference in Injury Severity Score (ISS) between the two groups. Moreover, there was no significant difference in mean ISS among those who did not develop pneumonia and those patients who developed either early-onset, community-acquired or late-onset, hospital-acquired pneumonia. The HMEF nosocomial VAP rate was 6% compared to 16% for the H-wH group (p<0.05), and total ventilator circuit costs (per group) were reduced. There were no differences in duration of ventilation (mean+/-SD) if the patient did not develop pneumonia or if the patient developed an early-onset, community-acquired or a late-onset, hospital-acquired pneumonia. Moreover, total TICU days were reduced in the HMEF group. In addition, the incidence of partial endotracheal tube occlusion was not significantly different between the H-wH and the HMEF groups. CONCLUSIONS: The HMEF used in this study reduced the incidence of late-onset, hospital-acquired VAP, but not early-onset, community-acquired VAP, compared to the conventional H-wH circuit. This was associated with a significant reduction in total ICU stay. Disposable ventilator circuit costs in the HMEF group were reduced compared to the H-wH group in whom circuit changes occurred at 7-day intervals. CLINICAL IMPLICATIONS: The use of the HMEF is a cost-effective clinical practice associated with fewer late-onset, hospital-acquired VAPs, and should result in improved resource allocation and utilization.

Do pulmonary artery catheters alter outcome in trauma patients?

OBJECTIVE: To review the literature addressing the use of the pulmonary artery catheter (PAC) in victims of blunt and penetrating trauma and examine the available evidence that supports or refutes the claim that PAC use alters outcome in this patient population. Furthermore, to determine what additional research should be done in this area. DATA SOURCE: All pertinent English language articles dealing with pulmonary artery catheterization in trauma patients were retrieved from 1979 through 1996. STUDY SELECTION: Clinical studies were considered if PACs were used to establish a cardiopulmonary diagnosis, optimize or achieve endpoints of oxygen transport and utilization indices, or guide and/or determine response to therapy. Emphasis was placed on prospective, randomized, controlled trials. However, descriptive case series and retrospectively-analyzed, uncontrolled reviews comprise the majority of available literature. DATA EXTRACTION: From these selective studies, information was obtained regarding patient demographics, therapeutic endpoints, and achieved outcome. DATA SYNTHESIS: Insufficient evidence exists to support a true survival benefit. However, recommendations for indications can be proposed where a reduction in morbidity or improvement in functional outcome is suggested. CONCLUSION: Hemodynamic data obtained from the PAC appear to be beneficial for the following indications: a) to ascertain the status of underlying cardiovascular performance and/or the need for improvement; b) to direct therapy when noninvasive monitoring may be inadequate, misleading, or the endpoints of resuscitation difficult to define; c) to assess response to resuscitation; d) to potentially decrease secondary injury when severe closed-head or acute spinal cord injuries are components of multisystem trauma; e) to augment clinical decision-making when major trauma is complicated by severe adult respiratory distress syndrome, progressive oliguria/anuria, myocardial ischemia, congestive heart failure, or major thermal injury; and f) to establish futility of care.

Management of paroxysmal atrioventricular nodal reentrant tachycardia in the critically ill surgical patient.

OBJECTIVES: Paroxysmal atrioventricular nodal reentrant tachycardia is an infrequently encountered supraventricular arrhythmia that continues to present difficult management problems in the critically ill surgical patient. The purpose of this study was to evaluate the efficacy of a new treatment algorithm involving the sequential administration of different classes of antiarrhythmic agents until conversion to sinus rhythm was achieved. DESIGN: Nonrandomized, consecutive, protocol-driven descriptive cohort. SETTING: University hospital surgical and trauma intensive care unit (ICU). PATIENTS: During an 11-month period, we prospectively evaluated all hemodynamically stable patients who sustained new-onset atrioventricular nodal reentrant tachycardia. INTERVENTIONS: Vagal maneuver, followed by the rapid, sequential infusion of antiarrhythmic agents (i.e., adenosine, verapamil, and esmolol, respectively) until the arrhythmia was terminated. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (4% of all admissions) were evaluated, including 16 trauma patients (injury Severity Score of 20 +/- 8) and 11 general surgical patients (Acute Physiology and Chronic Health Evaluation II score of 17 +/- 7). Time from ICU admission to onset of atrioventricular nodal reentrant tachycardia was 4.5 +/- 5 days (median 2.5). Arrhythmia termination was achieved in all patients within minutes (mean 13 +/- 10 [SD]). Incremental sequential adenosine administration alone, however, was successful in affecting conversion to sinus rhythm in only 44% of initial episodes of atrioventricular nodal reentrant tachycardia (95% confidence interval 21% to 67%). A total of 14 (52%) patients developed 38 relapses of paroxysmal supraventricular tachycardia in the ICU after initial conversion to sinus rhythm. These relapses required additional antiarrhythmic therapy. Adenosine was only effective in 34% of the relapses (95% confidence interval 17% to 53%). Seven (50%) of these 14 patients developed multiple relapses. However, only two patients were receiving suppressive calcium-channel or beta-adrenergic receptor blockade at the time of relapse. CONCLUSIONS: The use of a multiagent algorithm was effective for the initial conversion of new-onset atrioventricular nodal reentrant tachycardia to sinus rhythm in critically ill surgical and trauma patients. This preliminary report suggests that adenosine has marginal efficacy in the critically ill surgical or trauma patient. Given the high frequency of relapses, regardless of the agents used to achieve initial control, suppression therapy for the arrhythmia during the period of maximal cardiovascular stress is essential.

Stab wounds to the back and flank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification.

PURPOSE: The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. PATIENTS AND METHODS: One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. RESULTS: There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. CONCLUSIONS: Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.

Decreasing catheter-related infection and hospital costs by continuous quality improvement.

OBJECTIVES: a) To reduce the rate of catheter-related infection, using improved skin preparation and catheters impregnated with silver sulfadiazine and chlorhexidine; b) to decrease the number of unnecessary guidewire exchanges of existing catheters by substituting suspected catheter-related sepsis for fever alone as an indication to change an indwelling catheter; and c) to decrease the hospital costs associated with guidewire exchanges and new catheter insertions. DESIGN: Sequential, prospective, descriptive studies using a continuous quality management approach. SETTING: A 20-bed trauma intensive care unit at a university teaching hospital. PATIENTS: Patients (n = 147) admitted from July 1 to December 31, 1992 (phase 1); 34 patients admitted in June and September 1993 (phase 2); and 156 patients admitted between January 1 and June 30, 1994 (phase 3). INTERVENTIONS: Phase 1: Proportions of catheter-related infections and catheter-related bacteremia were compared with our prior reported results. Indications for guidewire exchange were analyzed, and the rate of catheter-related infection for each indication was derived. Phase 2: The rate of catheter-related infection was determined for a trial group of triple-lumen catheters impregnated with silver sulfadiazine and chlorhexidine. Phase 3: Four components were altered. Impregnated triple-lumen catheters were used instead of unprotected catheters. Chlorhexidine skin cleanser was substituted for povidone-iodine solution during initial aseptic preparation during catheter insertion and subsequent guidewire exchange. Suspected catheter-related sepsis was substituted for fever as an indication for guidewire exchange. The "safe" period (the time before considering changing a catheter because catheter-related sepsis was suspected) was extended from 2 to 4 days. MEASUREMENTS AND MAIN RESULTS: The overall rate of catheter-related infection in phase 1 was 15% (15% for triple-lumen catheters and 16% for introducers). Catheters changed for site inflammation had a 46% rate of catheter-related infection, significantly higher than for all other indications, including fever (p < .03). The rate of catheter-related infection was significantly (p = .0002) higher for catheters in place for > 10 days compared with lesser durations. Fever was the indication for 42% of all guidewire exchanges. In phase 2, the catheter-related infection rate was 2% (one positive of 48 catheters), significantly (p = .0231) lower than the phase 1 rate. In phase 3, the overall rate of catheter-related infection was 8.6%, significantly (p = .0067) lower than the 15% rate in phase 1. The proportion of protected triple-lumen catheter catheter-related infections decreased significantly (p = .0024) from 15% to 6%. The rate of catheter-related infection for introducers was the same in both phases (p = .33). The days of catheterization for all catheters increased from 4.5 +/- 2.6 to 5.4 +/- 3.6 (p < .0001). The days for triple-lumen catheters increased from 4.7 +/- 2.7 to 7.0 +/- 3.9 (p < .0001). For introducers, there was no difference in the days of catheterization. The proportion of catheters changed for suspected catheter-related sepsis decreased significantly (p < .0001) to 23% from the 42% changed for fever in phase 1. The proportion of catheter-related infections for catheters changed for fever was 18% in phase 1. The proportion of catheter-related infections for catheters changed for suspected catheter-related sepsis was 13% in phase 3 (p = .43). The total number of catheters used per patient in phase 3 was 1.9 +/- 1.4, significantly lower than the 2.6 +/- 2.7 catheters used in phase 1 (p = .0018). The number of triple-lumen catheters decreased from 1.8 +/- 1.2 to 1.0 +/- 1.2 in phase 3 (p = .0001). CONCLUSIONS: Catheters impregnated with silver sulfadiazine and chlorhexidine had a smaller proportion of catheter-related infection compared with unprotected catheters. Fever alone as an indication for guidewire exchange resu

Re-engineering ventilatory support to decrease days and improve resource utilization.

OBJECTIVE: The objective of this study was to describe the development of a cost-effective ventilatory strategy using a portable microprocessor-controlled respiratory monitor (Bicore CP-100; Allied Healthcare Products, Riverside, CA.) SUMMARY BACKGROUND DATA: Until recently, clinicians have had to accept the uncertainties of clinical judgment, which unfortunately, often biased the patient to a prolonged ventilatory course to avoid extubation failures, necessitating reintubation. METHODS: Over a 4-year period, the authors attempted to re-engineer the process of ventilatory support based on measured work of breathing (WOB), including physiologic (WOBPhys), imposed (WOBImp) and total (WOBTot). RESULTS: The authors made 90 determinations of WOB in 31 patients. The coefficient of determination (i2) of WOBTot, with the breathing frequency was 0.35, with tidal volume was 0.10, and with the rapid shallow breathing index (f/V(tau)) was 0.23; therefore, the authors discarded them as reliable inferences. Of 27 patients ventilated for > 2 days with satisfactory blood gases, but with breathing frequency > 30 breaths/minute, 6 had WOBTot < 0.8 J/L and were extubated successfully. In 21 patients, WOBTot was elevated to 1.6 +/- 0.83 J/L, WOBImp was 1.1 +/- 0.64 J/L, approximately twice the WOBPhys (0.5 +/- 0.26 J/L), a normal value. Extubation was successful in 20 of those 21 patients. This approach was extended to the spontaneous breathing pre-extubation trial. In addition, the ventilator was adjusted so that the patient sustained a WOBTot of 0.6 to 1 J/L during the ventilatory support. This evolution was tracked for 18 months in a series of 838 trauma intensive care unit patients. Average duration of ventilation decreased from 8.2 to 4.2 days (49%; p < 0.01). This translated into approximately 2400 decreased ventilator days per year. CONCLUSION: Objective measurement to guide the adequacy of ventilatory support and interpret apparent clinical weaning failures decreased total ventilatory time by 50%, permitting extubation in nearly 20% of patients previously considered failures.