Factors that influence and change medical engagement in Australian not for profit hospitals.

PURPOSE: The study aims to assess medical engagement levels at two teaching hospitals and a 500 bed private hospital in two states operated by the same health care provider and to describe individual and organisational factors that influence and change medical engagement. DESIGN/METHODOLOGY/APPROACH: A survey was emailed to all junior and senior medical staff, seeking responses to 30 pre-determined items. The survey used a valid and reliable instrument which provided an overall index of medical engagement. Qualitative data were also collected by including an open ended question. FINDINGS: Doctors (n = 810) working at all sites are in the top 20-40 percentile when compared to Australia and the United Kingdom. Two sites in one state were in the highest relative engagement band with the other being in the high relative range when compared to the (UK) and the medium relative band when compared to sites in Australia. Senior doctors working at all three were less engaged on feeling valued and empowered, when compared to having purpose and direction or working in a collaborative culture. This appears to be related to work satisfaction and whether they feel encouraged to develop their skills and progress their careers. Junior doctors at 1 site are much less engaged than colleagues working at another. Since their formal training pathways are identical the informal training experience appears to be an engagement factor. ORIGINALITY/VALUE: Despite medical engagement being recognised as crucial, little is known about individual and organisational factors that support doctors to be engaged, particularly for juniors and in the private sector.

The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A Multicenter, Parallel-Group, Open-Label Randomized Clinical Trial.

Rationale: Blood glucose concentrations affect outcomes in critically ill patients, but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objectives: To evaluate the effects of a "liberal" approach to targeted blood glucose range during ICU admission. Methods: This mutlicenter, parallel-group, open-label randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dl and titrated to a target range of 180-252 mg/dl. In the comparator group insulin was commenced at a blood glucose >180 mg/dl and titrated to a target range of 108-180 mg/dl. The primary outcome was incident hypoglycemia (<72 mg/dl). Secondary outcomes included glucose metrics and clinical outcomes. Measurements and Main Results: By Day 28, at least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio, 0.21 [95% confidence interval (CI), 0.09 to 0.49]; P < 0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability, and less relative hypoglycemia (P < 0.001 for all comparisons). By Day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference, 4.6 percentage points [95% CI, -3.9% to 13.2%]; P = 0.29). Conclusions: A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registered with Australian New Zealand Clinical Trials Registry (ACTRN 12616001135404).

Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial.

BACKGROUND: Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes. OBJECTIVE: To detail the protocol, analysis and reporting plans for a randomised clinical trial - the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial - which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0-14.0 mmol/L) or usual care (target 6.0-10.0 mmol/L). MAIN OUTCOME MEASURES: The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes. RESULTS AND CONCLUSION: The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised. TRIAL REGISTRATION: This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.

A novel biometric approach to estimating tidal volume.

BACKGROUND: Low tidal volume ventilation (LTVV) of 4-8 mL/kg of ideal body weight (IBW) reduces mortality in patients with acute respiratory distress syndrome, and, more recently, it has been recommended as the default therapy for all controlled ventilation. However, adherence to LTVV is poor. Barriers to adherence include not having height measurements taken or IBW calculated during admission. The aim of our project was to develop and validate a simple one step biometric measuring tool to directly estimate tidal volume (VT) in ventilated patients based on their demispan. OBJECTIVES: To validate our novel biometric approach for the estimation of VT in mechanically ventilated patients by demonstrating its accuracy as a simple reliable alternative to IBW derived from measured height. DESIGN AND SETTING: A simple computer program was written based on regression equations for demispan, height and IBW which used simple substitution to produce a vector graphic scale with markings in millilitres of 6 mL/kg IBW VT printed onto a paper tape. We performed an observational validation study on ventilated patients after cardiac surgery comparing the VT derived from demispan measurements using our tape with the VT based on IBW calculated from pre-operative vertical height. MAIN OUTCOME MEASURE: We compared compliance with a target VT ≤ 6.5 mL/kg for VT derived using our demispan method and with VT based on IBW calculated from vertical height. RESULTS: Eighty-two patients were studied. The mean age was 65.7 years (SD, 11.4) and 61 patients (74%) were male. Mean height was 170.4 cm (SD, 9.5) and mean body mass index for the group was 28.6 kg/m2 (SD, 5.5). The VT based on 6 mL/kg IBW estimated by traditional height method and using our biometric tape method correlated well (r = 0.8) and was not statistically different, with a mean difference of -7.5 mL (SEM, 8.8). Bland-Altman plot showed 95% limits of agreement from -64 mL to 79 mL around the mean difference of 7.5 mL, with 4 points (4.9%) outside the limits of agreement. Fifty-one of the initial VT (62%) were compliant, with a target of ≤ 6.5 mL/kg IBW using volumes determined from measured height, while 66 of the tape volumes (80%) would have been compliant at a target of ≤ 6.5 mL/kg IBW. CONCLUSION: Estimating VT using of our biometric one step approach based on demispan correlates well with VT derived from vertical height. The simplicity of its use and accuracy could lead to improved adherence in a large cohort of patients who currently do not receive the recommended VT restriction.

Opinions and practices of blood glucose control in critically ill patients with pre-existing type 2 diabetes in Australian and New Zealand intensive care units.

BACKGROUND: Approximately 9000 patients with type-2 diabetes mellitus (T2DM) are admitted to an intensive care unit (ICU) in Australia and New Zealand annually. For these patients, recent exploratory data suggest that targeting a more liberal blood glucose range during ICU admission may be safe and potentially beneficial. However, the current approach to blood glucose management of patients with T2DM in Australia and New Zealand ICUs is not well described, and there is uncertainty about clinician equipoise for trials of liberal glycaemic control in these patients. AIM: The aim is to describe self-reported blood glucose management in patients with T2DM by intensivists working in Australian and New Zealand ICUs and to establish whether equipoise exists for a trial of liberal versus standard glycaemic control in such patients. METHOD: An online questionnaire of Australia and New Zealand intensivists conducted in July-September 2016. RESULTS: Seventy-one intensivists responded. Forty-five (63%) used a basic nomogram to titrate insulin. Sixty-six (93%) reported that insulin was commenced at blood glucose concentrations >10 mmol/L and titrated to achieve a blood glucose concentration between 6.0 and 10.0 mmol/L. A majority of respondents (75%) indicated that there was insufficient evidence to define optimal blood glucose targets in patients with T2DM, and 59 (83%) were prepared to enrol such patients in a clinical trial to evaluate a more liberal approach. CONCLUSION: A majority of respondents were uncertain about the optimal blood glucose target range for patients with T2DM and would enrol such patients in a comparative trial of conventional versus liberal blood glucose control.

Protection against severe hypokalemia but impaired cardiac repolarization after intense rowing exercise in healthy humans receiving salbutamol.

Intense exercise induces pronounced hyperkalemia, followed by transient hypokalemia in recovery. We investigated whether the ß2 agonist salbutamol attenuated the exercise hyperkalemia and exacerbated the postexercise hypokalemia, and whether hypokalemia was associated with impaired cardiac repolarization (QT hysteresis). Eleven healthy adults participated in a randomized, counterbalanced, double-blind trial receiving either 1,000 µg salbutamol (SAL) or placebo (PLAC) by inhalation. Arterial plasma potassium concentration ([K+]a) was measured at rest, during 3 min of intense rowing exercise, and during 60 min of recovery. QT hysteresis was calculated from ECG ( n = 8). [K+]a increased above baseline during exercise (rest, 3.72 ± 0.7 vs. end-exercise, 6.81 ± 1.4 mM, P < 0.001, mean ± SD) and decreased rapidly during early recovery to below baseline; restoration was incomplete at 60 min postexercise ( P < 0.05). [K+]a was less during SAL than PLAC (4.39 ± 0.13 vs. 4.73 ± 0.19 mM, pooled across all times, P = 0.001, treatment main effect). [K+]a was lower after SAL than PLAC, from 2 min preexercise until 2.5 min during exercise, and at 50 and 60 min postexercise ( P < 0.05). The postexercise decline in [K+]a was correlated with QT hysteresis ( r = 0.343, n = 112, pooled data, P = 0.001). Therefore, the decrease in [K+]a from end-exercise by ~4 mM was associated with reduced QT hysteresis by ~75 ms. Although salbutamol lowered [K+]a during exercise, no additive hypokalemic effects occurred in early recovery, suggesting there may be a protective mechanism against severe or prolonged hypokalemia after exercise when treated by salbutamol. This is important because postexercise hypokalemia impaired cardiac repolarization, which could potentially trigger arrhythmias and sudden cardiac death in susceptible individuals with preexisting hypokalemia and/or heart disease. NEW & NOTEWORTHY Intense rowing exercise induced a marked increase in arterial potassium, followed by a pronounced decline to hypokalemic levels. The ß2 agonist salbutamol lowered potassium during exercise and late recovery but not during early postexercise, suggesting a protective effect against severe hypokalemia. The decreased potassium in recovery was associated with impaired cardiac QT hysteresis, suggesting a link between postexercise potassium and the heart, with implications for increased risk of cardiac arrhythmias and, potentially, sudden cardiac death.

Salbutamol effects on systemic potassium dynamics during and following intense continuous and intermittent exercise.

PURPOSE: Salbutamol inhalation is permissible by WADA in athletic competition for asthma management and affects potassium regulation, which is vital for muscle function. Salbutamol effects on arterial potassium concentration ([K+]a) during and after high-intensity continuous exercise (HIcont) and intermittent exercise comprising repeated, brief sprints (HIint), and on performance during HIint are unknown and were investigated. METHODS: Seven recreationally active men participated in a double-blind, randomised, cross-over design, inhaling 1000 µg salbutamol or placebo. Participants cycled continuously for 5 min at 40 % [Formula: see text]O2peak and 60 % [Formula: see text]O2peak, then HIcont (90 s at 130 % [Formula: see text]O2peak), 20 min recovery, and then HIint (3 sets, 5 × 4 s sprints), with 30 min recovery. RESULTS: Plasma [K+]a increased throughout exercise and subsequently declined below baseline (P < 0.001). Plasma [K+]a was greater during HIcont than HIint (P < 0.001, HIcont 5.94 ± 0.65 vs HIint set 1, 4.71 ± 0.40 mM); the change in [K+]a from baseline (Δ[K+]a) was 2.6-fold greater during HIcont than HIint (P < 0.001). The Δ[K+] throughout the trial was less with salbutamol than placebo (P < 0.001, treatment main effect, 0.03 ± 0.67 vs 0.22 ± 0.69 mM, respectively); and remained less after correction for fluid shifts (P < 0.001). The Δ[K+] during HIcont was less after salbutamol (P < 0.05), but not during HIint. Blood lactate, plasma pH, and the work output during HIint did not differ between trials. CONCLUSIONS: Inhaled salbutamol modulated the [K+]a rise across the trial, comprising intense continuous and intermittent exercise and recovery, lowering Δ[K+] during HIcont. The limited [K+]a changes during HIint suggest that salbutamol is unlikely to influence systemic [K+] during periods of intense effort in intermittent sports.

The impact of an education program and written guideline on adherence to low tidal volume ventilation.

BACKGROUND: Low tidal volume ventilation reduces mortality in patients with acute lung injury (ALI) and may reduce the risk of ALI in ventilated patients. A previous audit of our ventilation practices showed poor adherence to low tidal volume ventilation, and we subsequently introduced written ventilation guidelines and an education program to change practice. OBJECTIVES: To determine if adherence to low tidal volume ventilation (defined as mandatory tidal volumes of =?6.5 mL/ kg predicted body weight [PBW]) in ventilated patients was improved with a written guideline and staff education. DESIGN AND SETTING: Retrospective analysis of recorded mandatory ventilator settings from the clinical information system of a tertiary referral intensive care unit from 1 January 2012 to 31 December 2015, involving analysis of mandatory ventilator settings in relation to PBW to determine adherence to guidelines, and interrupted time-series analysis to assess the impact of education. MAIN OUTCOME MEASURE: Adherence to low tidal volume ventilation. RESULTS: The mean tidal volume for the cohort was 7.4 mL/ kg (SD, 1.3 mL/kg) PBW, and 760 patients (26.9%) received an average tidal volume during mandatory ventilation of ≤6.5 mL/kg PBW. Interrupted time-series analysis showed improved adherence after education, with an increase in adherence of 29.4% (95% CI, 19.3%-39.5%) from baseline. Multivariate logistic analysis found height, weight and staff education, but not sex, were associated with adherence to low tidal volume ventilation. CONCLUSION: Written protocols and education can influence clinician behaviour, with substantial improvements in adherence to low tidal volume ventilation. Efforts to improve adherence through ward-based education appear warranted and necessary. Adherence was strongly associated with patient height, which suggested that adherence was partly the result of chance rather than design.

The Impact of Fluid Balance on the Detection, Classification and Outcome of Acute Kidney Injury After Cardiac Surgery.

OBJECTIVE: To assess whether or not a positive fluid balance masks acute kidney injury (AKI) and is associated with adverse outcomes after cardiac surgery. DESIGN: Retrospective analysis. SETTING: Tertiary university-affiliated metropolitan hospital: single center. PARTICIPANTS: Three thousand two hundred seven consecutive cardiac surgical patients admitted to the ICU from July 1, 2004 to June 30, 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors used AKI Network criteria to classify AKI. They then adjusted creatinine levels for weight-corrected fluid balance and categorized patients into 3 groups: group A (No AKI); group B (AKI only after adjustment); group C (AKI before and after adjustment). No patients had "AKI" before but "No AKI" after adjustment. Among 2,171 patients with weight and baseline creatinine available, after adjusting for fluid balance, the proportion of patients classified with AKI increased from 25.3% to 37.2% (p<0.001). In patients with AKI only after adjustment (group B), ICU mortality approximated that of group C (1.9% v 3.1%, p = 0.35) but was almost 3 times greater than group A (1.9% v 0.7%, p = 0.04). For group B, use of renal replacement therapy also was greater than group A (4.3% v 1.5%, p = 0.004) but less than group C (4.3% v 14.4%, p<0.001). The same trend was found for ICU length of stay (p≤0.001) and other adverse outcomes. CONCLUSIONS: Patients with AKI diagnosed after correction for the effect of a positive fluid balance on serum creatinine concentration have more adverse outcomes than patients without AKI by conventional criteria, but fewer than patients with AKI by conventional criteria.

Do we practise low tidal-volume ventilation in the intensive care unit? a 14-year audit.

BACKGROUND: Low tidal volume ventilation (LTVV) has been shown to reduce mortality of patients with acute lung injury (ALI) but uptake by clinicians has been low. Recent studies have shown that LTVV results in survival benefit at 24 months after discharge and, importantly, benefits patients without ALI. OBJECTIVE: To determine adherence to LTVV in patients on mechanical ventilation (MV). DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of ventilator settings recorded within the clinical information system of a 15-bed general ICU in a tertiary referral hospital, between 1 January 2000 and 31 May 2013. METHODS: Analysis of mandatory MV with volume or pressure control. MAIN OUTCOME MEASURES: Adherence to LTVV (_6.5 mL/ kg predicted body weight [PBW]). RESULTS: We studied 4923 patients with a median age of 66 years (interquartile range [IQR], 57-74 years), and a median Acute Physiology and Chronic Health Evaluation II score of 16 (IQR, 13-19). Included were 3486 men (70.8%), and 3386 (66.8%) had undergone cardiac surgery. There were 249 450 ventilator measurements, with a median per patient of 75 measurements (IQR, 17-255 measurements). The median tidal volume was 8.15 mL/kg PBW (IQR, 7.15- 9.34 mL/kg PBW) for an adherence of 13.4%. Independent factors associated with adherence were sex, high inspiratory pressures, high positive end expiratory pressure and low PaO2/FiO2 ratio. CONCLUSION: Adherence to LTVV in a general cohort of ICU patients was low, but it was better in patients with more severe lung disease. Overestimation of PBW may have contributed to our findings. Regular auditing of LTVV adherence might be considered a clinical indicator of good MV practice.

The duration of hospitalization before review by the rapid response team: A retrospective cohort study.

PURPOSE: The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS: This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS: Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS: Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.

Computed tomography pulmonary angiogram as a result of medical emergency team calls: a 5-year retrospective audit.

OBJECTIVE: To determine the proportion of computed tomography pulmonary angiograms (CTPAs), performed after medical emergency team (MET) calls, that are positive for pulmonary embolism (PE), and whether there are useful clinical predictors of positive CTPA results. DESIGN: All patients from a tertiary referral hospital in Melbourne who had an MET response and an associated CTPA within 6 hours, from 2009 to 2013, were included. We reviewed medical records to assess indications for CTPA, including MET clinical triggers, time of day of the MET (implying the seniority of decision making), chest x-ray results and Wells scores as a clinical decision rule for PE. RESULTS: There were 4578 MET responses (in 3136 patients) over the 5-year study period, from which 70 CTPAs were ordered (2.2% of all patients). A PE was identified in 12 patients (17.1%). The median age of CTPA patients was 70 years (interquartile range, 60-76 years) and most were surgical patients (80%). The major MET triggers for CTPA were hypoxia (42.9%) and hypotension (28.6%). An abnormal chest x-ray was associated with a low likelihood of PE. The Wells scores and MET indications of hypoxia, hypotension and tachycardia were not accurate in predicting the presence or extent of PE. CONCLUSION: Clinical decision rules and MET indications were not significantly associated with the presence of PE on CTPA. However, an abnormal chest x-ray has a high negative predictive value and therefore may be helpful in preventing unnecessary CTPAs.

Do outlier inpatients experience more emergency calls in hospital? An observational cohort study.

OBJECTIVE: To determine the effect of spending time as an outlier (ie, an inpatient who spends time away from his or her "home" ward) on the frequency of emergency calls for patients admitted to a tertiary referral hospital. DESIGN, SETTING AND PATIENTS: Observational cohort study of all patients admitted to a university-affiliated tertiary referral hospital in Melbourne, Victoria, between 1 July 2009 and 30 November 2011. MAIN OUTCOME MEASURE: The number of emergency calls per hospital admission, with reference to location within the hospital. RESULTS: There were 58,158 admissions during the study period. The median age of admitted patients was 61 years, 55% were male, and the inhospital mortality was 1.40%. In 11,034 admissions (18.97%), patients spent time as outliers. Inhospital mortality was 2.57% in the outlier group versus 1.12% in the non-outlier group (P < 0.001). After adjusting for age, same-day admission, 10-year predicted mortality, interhospital transfer and high-risk clinical units, outlier status was associated with a 53% increase in emergency calls (P < 0.001). CONCLUSIONS: This study found a strong association between time spent away from a patient's home ward and the number of emergency calls. We postulate that outlier patients are at risk as they may have therapeutic and monitoring needs that are only available on their home ward. With increasing pressure to move patients out of the emergency department, the number of outlier patients may increase.

Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data.

INTRODUCTION: Medical emergency teams (MET) are implemented to ensure prompt clinical review of patients with deteriorating physiology with the intention of averting further deterioration, cardiac arrest and death. We sought to determine if MET implementation has led to reductions in hospital mortality across a large metropolitan health network utilising routine administrative data submitted by hospitals to the Department of Health Victoria. METHODS: The Victorian admissions episodes data set (VAED) contains data on all individual hospital separations in the State of Victoria, Australia. After gaining institutional ethics approval, we extracted data on all acute admissions to metropolitan hospitals for which we had information on the presence and timing of a MET system. Using logistic regression we determined whether there was an effect of MET implementation on mortality controlling for age, gender, Charlson comorbidity diagnostic groupings, emergency admission, same day admission, ICU admission, mechanical ventilation, year, indigenous ethnicity, liaison nurse service and hospital designation. RESULTS: 5911533 individual admissions and 73,599 associated deaths from July 1999 to June 2010 were included in the analysis. 52.2% were male and median age was 57(42-72 IQR). Mortality rates for MET and non-MET periods were 3.92 (3.88-3.95 95%CI) and 4.56 (4.51-4.61 95%CI) deaths per 1000 patient days with a rate ratio after adjustment for year of 0.88 (0.86-0.89 95%CI) P < 0.001. In a multivariable logistic regression, mortality was associated with a MET team being active in the hospital for more than 2 years. The odds ratio for mortality in hospitals where a MET system had been in place for greater than 4 years duration was 0.90 (0.88-0.92). Mortality during the first 2 years of a MET system being in place was not statistically different from pre-MET periods. CONCLUSIONS: Utilising routinely collected administrative data we demonstrated that the presence of a hospital MET system for greater than 2 years was associated with an independent reduction in hospital mortality across a major metropolitan health network. Mortality benefits after the introduction of a MET system take time to become apparent.

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

OBJECTIVE: To determine the long-term impact of a medical emergency team on survival and to assess the utility of administrative data to monitor outcomes. DESIGN: Prospective study of cardiac arrests and survival. Retrospective study of administrative data. SETTING: University affiliated tertiary referral hospital in Melbourne, Australia. PATIENTS: All patients admitted to hospital in three 6-month periods between 2002-2007 (prospective) and 1993-2007 (retrospective). INTERVENTION: Implementation of a medical emergency team in November 2002. MEASUREMENTS AND MAIN RESULTS: In the prospective analysis, rates of unexpected cardiac arrest and hospital mortality (referenced to 1000 patient-care days) were measured before (July-August 2002) and after (December 2002-May 2003, December 2004-May 2005, December 2006-May 2007) the introduction of the medical emergency team. Cardiac arrest rates decreased progressively from 0.78 per 1000 (95% confidence interval, 0.50-1.16) to 0.25 per 1000 (95% confidence interval, 0.15-0.39, p < .001), and hospital mortality from 0.58 per 1000 (95% confidence interval, 0.35-0.92) to 0.30 per 1000 (95% confidence interval, 0.20-0.46, p < .05); cardiac arrest rates achieved statistical significance at 2 yrs and hospital mortality at 4 yrs. Using administrative data adjusted for age, sex, case-mix, and comorbidity, hazard ratios for mortality for the three post implementation periods were statistically lower than for the 10 yrs pre implementation (0.85, 0.74, 0.65). The intensity of calling (calls/1000 patient-days) inversely correlated with cardiac arrest rate, unexpected mortality rate, and total hospital mortality rate. CONCLUSIONS: The introduction of a medical emergency team was associated with a progressive decline of unexpected cardiac arrests within 2 yrs, and of unexpected mortality within 4 yrs. This suggests that changes to organizational practice take time and benefits may not be immediately obvious. Such changes are reflected in total hospital mortality measured from administrative data and make monitoring simpler in the longer term. Finally, efforts to increase calling of emergency teams should reduce cardiac arrests and mortality.

An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study.

INTRODUCTION: Without specific strategies to address tracheostomy care on the wards, patients discharged from the intensive care unit (ICU) with a tracheostomy may receive suboptimal care. We formed an intensivist-led multidisciplinary team to oversee ward management of such patients. To evaluate the service, we compared outcomes for the first 3 years of the service with those in the year preceding the service. METHODS: Data were prospectively collected over the course of 3 years on ICU patients not under the care of the ear, nose, and throat unit who were discharged to the ward with a tracheostomy and compared with outcomes in the year preceding the introduction of the service. Principal outcomes were decannulation time, length of stay after ICU discharge, and stay of less than 43 days (upper trim point for the disease-related group [DRG] for tracheostomy). Analysis included trend by year and multivariable analysis using a Cox proportional hazards model. P values of less than 0.05 were assumed to indicate statistical significance. As this was a quality assurance project, ethics approval was not required. RESULTS: Two hundred eighty patients were discharged with a tracheostomy over the course of a 4-year period: 41 in 2003, 60 in 2004, 95 in 2005, and 84 in 2006. Mean age was 61.8 (13.1) years, 176 (62.9%) were male, and mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 20.4 (6.4). Length of stay after ICU decreased over time (30 [13 to 52] versus 19 [10 to 34] days; P < 0.05 for trend), and a higher proportion of decannulated patients were discharged under the upper DRG trim point of 43 days (48% versus 66%; P < 0.05). Time to decannulation after ICU discharge decreased (14 [7 to 31] versus 7 [3 to 17] days; P < 0.01 for trend). Multivariate analysis showed that the hazard for decannulation increased by 24% (3% to 49%) per year. CONCLUSION: An intensivist-led tracheostomy team is associated with shorter decannulation time and length of stay which may result in financial savings for institutions.