Supporting Smokers in Difficult Settings: Suggestions for Better Education and Counseling in Cancer Centers in Jordan.

Continued smoking in cancer patients is commonly observed in Jordan. In a country that exhibits some of the highest smoking rates globally, enhancing patient education regarding the value of smoking cessation for cancer care is vital. The objectives of our study were to describe sociodemographic and clinical factors associated with continued smoking in Jordanian smokers after a cancer diagnosis; to identify reasons for smoking and knowledge regarding smoking's impact on care; to examine in a multivariable manner the factors associated with continued smoking, and to accordingly generate patient counseling recommendations. An interviewer-administered survey using the Theoretical Domains Framework was employed. Among 350 subjects (mean age 51.0, median 52.7), approximately 38% of patients had quit or were in the process of quitting; 61.7% remained smokers. Substantial knowledge gaps with regard to the impact of continued smoking on cancer care were observed. Remaining a smoker after diagnosis was associated with being employed, not receiving chemotherapy or surgery, having lower confidence in quitting, and having a lower number of identified reasons for smoking. Interventions to promote cessation in Jordanian cancer patients who smoke should focus on enhancing patient awareness about the impact of smoking in cancer care and raising perceived self-efficacy to quit.

Cessation experiences and quitting perspectives of Jordanian cancer patients who smoke.

OBJECTIVES: To describe quitting experiences of cancer patients in a Cancer Center in Jordan; to study patients' perceptions regarding the process of smoking cessation; and to provide insights about patients in this difficult setting in order to inform oncology practitioners with regards to how improve perceptions and skills related to quitting. METHODS: An Arabic cross-sectional questionnaire was developed to evaluate smoking and quitting behaviors in the context of cancer. The tool used as its framework the Theoretical Domains Framework to capture quitting perceptions of cancer patients who smoke, as well as social, environmental, and system-level factors that influence quitting. Eligible patients who were treated at the Center (both in-patient and out-patient settings) and who were current smokers or who smoked up to the time of cancer diagnosis were eligible. Patients were interviewed between July, 2018 and January 2020 using two versions of the questionnaire: an 'ex-smokers' version, and a 'current smokers' version. RESULTS: Only a third of subjects (104/350) had been smoke-free for at least 30 days. Both smokers and ex-smokers generally felt that quitting was important, but mean importance and confidence scores (out of 10) were significantly lower in current smokers (8.2 versus 9.1, p-value=0.002; 6.4 versus 8.7, p-value=0.000). Roughly 31% of subjects believed smoking harms were exaggerated and that smoking was not an addiction. About 62% of subjects agreed quitting required skills, and 78.5% felt the steps to quit were clear, but across several listed strategies for quitting, use of these was limited (even in ex-smokers). Among current smokers, roughly a third exhibited forms of cessation fatigue. CONCLUSION: Jordanian cancer patients who smoke present with limited knowledge about the quitting process. Even when some success is observed, low rates of utilization of specific quitting strategies were observed, highlighting the need for better counseling about quitting.

The inevitability of Covid-19 related distress among healthcare workers: Findings from a low caseload country under lockdown.

OBJECTIVES: To characterize psychological distress and factors associated with distress in healthcare practitioners working during a stringent lockdown in a country (Jordan) that had exhibited one of the lowest incidence rates of Covid-19 globally at the time of the survey. METHODS: A cross-sectional online survey sent to healthcare practitioners working in various hospitals and community pharmacies. Demographic, professional and psychological characteristics (distress using Kessler-6 questionnaire, anxiety, depression, burnout, sleep issues, exhaustion) were measured as were sources of fear. Descriptive and multivariable statistics were performed using level of distress as the outcome. RESULTS: We surveyed 937 practitioners (56.1% females). Approximately 68%, 14%, and 18% were nurses/technicians, physicians, and pharmacists (respectively). 32% suffered from high distress while 20% suffered from severe distress. Exhaustion, anxiety, depression, and sleep disturbances were reported (in past seven days) by approximately 34%, 34%, 19%, and 29% of subjects (respectively). Being older or male, a positive perception of communications with peers, and being satisfied at work, were significantly associated with lower distress. Conversely, suffering burnout; reporting sleep-related functional problems; exhaustion; being a pharmacist (relative to a physician); working in a cancer center; harboring fear about virus spreading; fear that the virus threatened life; fear of alienation from family/friends; and fear of workload increases, were significantly associated with higher distress. CONCLUSION: Despite low caseloads, Jordanian practitioners still experienced high levels of distress. Identified demographic, professional and psychological factors influencing distress should inform interventions to improve medical professionals' resilience and distress likelihood, regardless of the variable Covid-19 situation.

Evaluating the Predictive Value of Lactate in Patients With Cancer Having Septic Shock.

PURPOSE: Limited studies evaluated the predictive value of serum lactate (LA) in critically ill patients with cancer. The main objective of this study was to evaluate the predictive validity of LA single measurements as well as LA clearance in predicting mortality in patients with cancer having septic shock. The study also aimed to determine the LA measurement over the first 24 hours with the highest predictability for hospital mortality. MATERIALS AND METHODS: A retrospective cohort study of adult patients with cancer having septic shock and LA measurements during the first 24 hours. Three receiver-operating characteristic (ROC) curves were constructed to evaluate the predictive validity for hospital mortality of LA at baseline, at 6 hours and at 24 hours after identifying septic shock. The ROC with the largest area under the curve was analyzed to determine LA level with the highest predictability for hospital mortality. In addition, the ability of LA normalization (LA <2 mmol/L at 6 hours and at 24 hours) and the degree of LA elimination (>10% and >20% at 24 hours) to predict hospital mortality were evaluated by determining the predictive values for each clearance end point. RESULTS: The study included 401 patients. LA >2.5 mmol/L at 24 hours showed the largest area under the ROC curve to predict hospital mortality (ROC area: 0.648; 95% confidence interval: 0.585-0.711) with a sensitivity of 58.4% and specificity of 62.8%. The LA normalization, LA clearance >10%, and LA clearance >20% were also predictors of hospital mortality, with the highest sensitivity for LA normalization at 6 hours (74%) and LA normalization at 24 hours (73.4%). CONCLUSION: In patients with cancer having septic shock, LA >2.5 mmol/L at 24 hours of septic shock had the highest predictability for hospital mortality. The LA normalization and clearance were also predictors of hospital mortality. However, all LA end points were not strong predictors.

ICU readmission of patients with cancer: Incidence, risk factors and mortality.

PURPOSE: Few studies evaluated ICU readmission in cancer patients. This study aimed to describe the incidence and risk factors for ICU readmission in cancer patients and the association with mortality. MATERIALS AND METHODS: A retrospective cohort study at a comprehensive cancer center, which included cancer patients who were discharged after their initial ICU admission over a 5-year period. The characteristics and outcomes of patients who required ICU readmission within 30 days of discharge were compared to those who did not require readmission during the study period. Multivariate analyses were performed to identify factors associated with readmission and to evaluate the association between readmission and mortality. RESULTS: Among 1582 patients discharged from the ICU, 313(19.8%) were readmitted after a median of 6 days. The most common readmission diagnoses were respiratory failure and sepsis. Mechanical ventilation (OR 5.80; 95% CI 4.29-7.84) and thrombocytopenia (OR 1.66; 95% CI 1.16-2.38), on the first ICU admission were associated with readmission. Readmission was associated with a higher risk of 28-day and 90-day mortality, (OR 3.02; CI 2.3-4.00) and (OR 3.47; 95% CI 2.69-4.49), respectively. CONCLUSIONS: ICU readmission was associated with increased mortality. Mechanical ventilation and thrombocytopenia at the first admission were associated with ICU readmission.

Reclaiming the value of pictorial health warning labels in Jordan.

BACKGROUND: In Jordan, four non-graphic pictorial health warning labels (PHWLs) concerning a limited selection of tobacco-caused harms have been used since 2011; however, research suggests that they may be ineffective. OBJECTIVES: To explore Jordanian smokers' reactions to novel PHWLs featuring various health themes and/or graphic and symbolic imagery and to discuss existing PHWLs in light of the novel PHWLs. METHODS: We conducted 14 focus groups (FGs) with smokers who assessed 12 novel PHWLs and commented on four existing PHWLs. Data were analysed using an inductive approach. RESULTS: Six themes emerged from the FG discussions: understanding the overall meaning of PHWLs, the impact of graphic images, magnitude and controllability of harm, personal or vicarious experiences, the futility of quitting and fatalism. PHWLs depicting graphic respiratory and oral tobacco-caused harms resonated with most smokers. Smokers also sought direct, harm-specific taglines when trying to understand the overall PHWL. Some smokers viewed the PHWLs as exaggerated, and while the majority acknowledged that smoking was harmful, they felt that PHWLs would not accomplish their goal of inducing quitting. CONCLUSIONS: Our findings support the use of graphic imagery to communicate tobacco-caused harms (particularly respiratory ones) and the use of specific taglines explaining the mechanism of harm depicted.

Informing tobacco control policy in Jordan: assessing the effectiveness of pictorial warning labels on cigarette packs.

BACKGROUND: Pictorial warning labels (PWLs) deter initiation and motivate quitting. Assessing PWLs is important to track effectiveness and wear out. Jordan introduced an updated set of PWLs in 2013. This study assessed the effectiveness of the set after 2.5 years on the market. METHODS: We administered a survey in a cross-sectional sample of young adults aged 17-26 years. For convenience, respondents were recruited on university campuses. For heterogeneity, respondents were solicited from the different schools in four geographically diverse university campuses. The study compared perceptions of effectiveness surveyed in 2015 to perceptions gauged in 2010 during a pre-launch evaluation exercise. Outcomes of interest were: salience, fear evocation, adding information, and ability to motivate quitting smoking (for smokers) or deterring starting (for non-smokers). RESULTS: Results indicate awareness of the set among smokers and non-smokers, and their recall of at least one PWL message. Results also indicate effectiveness of the set: (1) 1/3 smokers who frequently saw them reported PWLs to trigger considering quitting, (2) and among both smokers and non-smokers the set in 2015 sustained ability to motivate quitting and staying smoke-free. However, results uncover erosion of salience, suggesting that the set has reached its end of life. Finally, results reveal variability in performance among PWLs; the one PWL that depicts human suffering significantly outperformed the others, and its ability to motivate was most strongly associated with its ability to evoke fear. CONCLUSION: Based on the early signs of wear-out (i.e. erosion of salience), and understanding the importance of sustaining upstream outcomes (especially fear evocation) to sustain motivation, we recommend retiring this set of PWLs and replacing it with a stronger set in line with proven standards.

Coverage of tobacco control in Jordanian newspapers: implications for strengthening the role of news media.

News media play a critical role in tobacco control. To strengthen this role in Jordan, four newspapers were searched and 1 145 articles between 2011 and 2015 were coded for mention of MPOWER topics and for tone of coverage (neutral, pro-, or anti-tobacco control). Monthly counts, mention of tobacco control topics and the tones were examined. The monthly count of tobacco control-related news items showed an upward trend with an average monthly growth of 16%. Peaks in coverage were observed in synchrony with national tobacco control developments. 'Warn' was the topic most frequently mentioned (46%). 'Protect' was the only topic that showed a statistically significant upward trend over time. A pro-tobacco control tone was more prevalent than an antitobacco control or neutral tone. Thus, efforts are needed to enhance the newsworthiness of certain topics, boost influence on decision-makers and pre-empt industry interference.

The Jordanian primary healthcare practitioner in cancer control.

Aim To measure the knowledge, perceptions, and practices of Jordanian primary healthcare practitioners (PHCPs) (physicians, nurses, midwives, and nurse aids) employed in Jordanian Ministry of Health (MoH) primary health clinics with respect to counseling on cancer (cancer screening, the signs and symptoms of cancer, and referral for specialized care). BACKGROUND: Integration of oncology services within primary care is a means of enhancing cancer early detection, and requires involvement of skilled. In the Middle East, little is known about PHCPs' potential to be providers of such services. METHODS: A questionnaire measuring PHCP perceptions and practices related to counseling on cancer screening and diagnosis was distributed to PHCPs across MoH clinics covering the main regions of Jordan. Findings A total of 322 practitioners responded (75.1% response). Across most activities involving cancer detection, no more than 30% reported performing activities. Roughly half of PHCPs expressed discomfort at providing cancer-related counseling and at least 43% of non-physicians expressed limited confidence in cancer-related counseling. Confidence was a consistent predictor of provision of counseling and confidence in turn was associated with having greater knowledge, having positive a valuation of counseling, and being a physician. Results reveal points where educational efforts can strengthen PHCPs' provision of cancer control-related services.

Predictors of ICU Admission in Patients With Cancer and the Related Characteristics and Outcomes: A 5-Year Registry-Based Study.

OBJECTIVE: To identify factors predictive of admission of patients with cancer to an ICU. In addition, the study aimed to describe the characteristics and outcomes, both short-term and long-term, of patients with cancer admitted to the ICU. DESIGN: Retrospective case-control study, utilizing the institution's cancer registry. SETTING: Comprehensive cancer center. PATIENTS: Patients with cancer. The case group consisted of patients who required ICU admission during the study period, whereas the control group consisted of patients who did not require ICU admission. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The patient characteristics and outcomes were recorded. Univariate and multivariate analyses were conducted to determine factors associated with ICU admission. The registry included 10,792 patients, and among those, 2,439 patients (22.6%) required ICU admission after a median of 10.1 months (interquartile range, 3.28-25.2). The following factors were associated with ICU admission: hematologic malignancy (odds ratio, 1.51; 95% CI, 1.26-1.81), chemotherapy (odds ratio, 1.74; 95% CI, 1.48-2.03), advanced cancer (odds ratio, 2.57; 95% CI, 1.44-4.60), and smoking (odds ratio, 1.38; 95% CI, 1.20-1.61). The most common ICU admission diagnoses were sepsis (21.5%) and respiratory insufficiency/failure (25.7%). The ICU mortality was 36.5%, whereas the 1-year and 5-year survival rates were 22.8% and 14.2%, respectively. CONCLUSION: In a comprehensive cancer center, about one fourth of the patients required ICU admission. Addressing modifiable risk factors associated with ICU admission is essential to potentially reduce ICU admissions and improve long-term survival.

Public support for smoke-free policies in Jordan, a high tobacco burden country with weak implementation of policies: Status, opportunities, and challenges.

Several Eastern Mediterranean (EM) countries, including Jordan, suffer from high smoking prevalence but weak implementation of smoking bans (SB). Public support (PS) influences successful implementation of SB, but little is known about PS for SB in EM countries with weak SB implementation. We conducted a cross-sectional survey measuring knowledge and perceptions of a large purposive sample of the Jordanian public regarding tobacco harms and anti-tobacco laws. Among 1169 respondents, 46% of whom used tobacco, PS for SB varied from 98% to 39% based on venue, being highest for health facilities and lowest for coffee shops. In venues with relatively lower PS (restaurants, coffee shops), lower educational groups, older age groups, nonsmokers, and those who had more knowledge regarding tobacco and secondhand smoke harms were significantly more likely to support SB than the highest educational group, the youngest age group, smokers, and those who had less knowledge (respectively). Our results suggest that aggressive promotion of SB is needed in countries like Jordan (where smoking is increasing), tailored to venue and specific sociodemographic characteristics of the public accessing these venues, particularly restaurants and coffee shops. Multifaceted health messages that enhance public knowledge can be of benefit in improving PS for SB.

High-dose colistin for microbiologically documented serious respiratory infections associated with carbapenem-resistant Acinetobacter baummannii in critically ill cancer patients: a retrospective cohort study.

BACKGROUND: Recent studies suggested that high doses of colistin are necessary in the treatment of serious infections. However, few studies have evaluated such treatment. The objective of this study was to evaluate the effectiveness and nephrotoxicity of high-dose colistin in critically ill patients with respiratory infections associated with carbapenem-resistant Acinetobacter baumannii (CRAB). METHODS: This was a retrospective cohort study of critically ill cancer patients who received high-dose intravenous colistin for treatment of CRAB-related respiratory infections. Patients received colistimethate sodium 9 million IU/day or an equivalent dose, adjusted for renal function. Treatment effectiveness was evaluated by determining the microbiological clearance, recurrent and new CRAB-related infections, and mortality in the intensive care unit (ICU). Nephrotoxicity was defined according to the RIFLE (risk, injury, failure, loss, and end-stage kidney disease) criteria. RESULTS: A total of 89 patients met the inclusion criteria. Microbiological clearance was observed in 51 (66.2%) subjects who had at least 2 follow-up cultures (n = 77). In patients who achieved microbiological clearance, recurrent and new CRAB-related infections occurred in 3 (5.9%) and 9 (17.6%) subjects, respectively. Fifty-seven patients (64%) died in the ICU. Thirty-five (39.3%) subjects developed nephrotoxicity according to the RIFLE criteria, which was classified as risk in 4 (11.4%) subjects, injury in 8 (22.8%) subjects, and failure in 21 (60%) subjects. CONCLUSIONS: In critically ill cancer patients, high-dose colistin was associated with microbiological clearance in about two-thirds of the subjects with CRAB-related respiratory infections but mortality was high. A significant portion of patients developed nephrotoxicity while receiving colistin therapy.

Effect of nebulized colistin on the ventilator circuit: a prospective pilot case- control study from a single cancer center.

Nebulized colistin (NC) is used for the treatment of pneumonia due to multidrug- resistant Gram-negative bacteria. In this one-year case-control study, our objective was to evaluate the effect of NC on the ventilator circuit (VC) components. The case group consisted of 25 mechanically-ventilated patients who received NC for the treatment of nosocomial pneumonia while the control group was 25 mechanically-ventilated patients who did not receive NC. Respiratory therapists inspected the VC every 4 hrs and whenever a ventilator alarm was reported. The VC component was changed if the alarm did not subside after necessary measures were performed. Patients from both groups were treated at the adult medical/surgical intensive care unit at King Hussein Cancer Center. In the case group, 22 (88%) patients required changing at least one of the circuit components (flow sensor, exhalation membrane, or nebulizer kit). The median number of changes (range) per patient of the flow sensor, exhalation membrane, and nebulizer kit were: 2 (1-3), 2 (1-6), and 1 (1-2), respectively. Large amounts of white crystals, which resembled the colistin powder, were reported on the replaced VC components. The flow sensor was changed in 2 control patients, but white crystals were absent. Crystals obtained from one case subject were confirmed to be colistin by chromatographic mass spectroscopy. Further studies are needed to evaluate the effect of crystal formation on the efficacy of NC and clinical outcomes.

Advancing Tobacco Dependence Treatment Services in the Eastern Mediterranean Region: International collaboration for training and capacity-building.

Tobacco use negatively affects health and is a major risk factor for non-communicable diseases (NCDs). Today, tobacco use ranks third among risk factors in North Africa and the Middle East in terms of disease burden. Despite the established need for these services, tobacco dependence treatment (TDT) services are still inadequate in the Eastern Mediterranean region (EMR). Among the main challenges hindering their expansion is the current lack of training opportunities. The provision of training and capacity-building-a key enabler of TDT-offers an excellent catalyst to launch TDT services in the region. This review discusses the need for TDT training in the EMR and describes a model for providing regional evidence-based training in line with international standards. The King Hussein Cancer Center in Amman, Jordan, is the regional host for Global Bridges, a worldwide TDT initiative. Using this model, they have trained 1,500 professionals and advocates from the EMR over the past three years.

The acute effects of waterpipe smoking on lung function and exercise capacity in a pilot study of healthy participants.

CONTEXT: Waterpipe tobacco smoking (WTS) has gained popularity, but its physiologic effects have not been extensively studied: rather, studies have focused on WTS's chronic effects or have evaluated limited respiratory/cardiac parameters. OBJECTIVE: We sought to characterize in a more detailed manner the acute effects of WTS on lung function and exercise capacity. METHOD: We recruited 24 healthy WTS males. We used a pilot single-group pre-test (abstained from WTS for ≥48 h) post-test (within 0.5 h of a 45-min WTS session) design. We performed spirometry, diffusing lung capacity and time-limited CPE testing (CPET; cycloergometer; 2-min 20-Watt warm-up and 25-Watt increase every 2-min for 10 min). RESULTS: Mean age was 20.4 years; Post-WTS, the following significant changes were observed: CO level increased from 3.7 ppm to 24.4; oxygen consumption decreased (from 1.86 L/min to 1.7); baseline respiratory rate increased (from 17.7 breath/min to 19.7); forced expiratory flow over the middle half of the forced vital capacity decreased (from 5.51 L to 5.29); and perceived exertion (measured by Borg scale) at mid and peak exercise increased. Baseline resting systolic blood pressure, pulse pressure, and pulse pressure product increased post-WTS (from 118.9 mmHg to 129.2; from 45.3 mmHg to 55.6; and from 9.9 mmHg/min to 11.1 post-WTS, respectively). During exercise, a decrease in oxygen pulse was observed post-WTS (from 10.89 ml/beat to 9.97), while the heart rate-oxygen consumption relationship increased post-WTS (from 3.52 beats/ml/kg to 3.91). CONCLUSION: Acute WTS appears to induce impairment in lung function and exercise capacity. Larger studies are warranted to further characterize the nature and extent of such impairment.

Adverse drug events resulting in admission to the intensive care unit in oncology patients: Incidence, characteristics and associated cost.

PURPOSE: Describe the incidence, characteristics and cost of adverse drug events that necessitate admission to the intensive care unit in oncology patients. METHODS: This was a prospective observational 5-months study at a medical/surgical intensive care unit of a comprehensive teaching cancer center. Patients admitted to the intensive care unit were screened to determine whether the admission was due to an adverse drug event. The adverse drug events were characterized based on the suspected medication, system involved and preventability. Patient demographics, length of stay, mortality and the total patient charges during their intensive care unit stay were recorded. RESULTS: During the study period, 249 patients were screened and an adverse drug event was the primary cause of 57 (22.9%) admissions. The most common medications associated with an adverse drug event requiring intensive care unit admission were antineoplastics (n = 37), analgesics (n = 9) and anticoagulants (n = 4). Ten adverse drug events were considered preventable. The average length of stay for patients with adverse drug events resulting in intensive care unit admission was 6.2 days ±9.8 (SD) and the mortality rate was 28.1%. Hematological malignancy was independently associated with adverse drug events resulting in intensive care unit admission. The average patient charges for the intensive care unit stay was US$11,692 ± 17,529 (SD), which corresponded to about US$1.5 million in annual patient charges for a 12-bed intensive care unit at a cancer institution. CONCLUSIONS: Adverse drug events resulting in intensive care unit admission in oncology patients are common and often associated with significant morbidity, mortality, and cost.

Perceptions of young Jordanian adults to proposed anti-tobacco pictorial warning labels.

BACKGROUND: In commitment to the Framework Convention on Tobacco Control (FCTC), four new pictorial warnings are now being proposed for display on cigarette packages sold in Jordan. The aim of this study was to gauge the immediate perceptions of young Jordanian adults towards these new pictorials and compare these perceptions to those of the pictorial currently being used in the country. METHODS: A cross-sectional survey was conducted on a convenience sample of youth aged 17-26. The interviewer-administered survey gauged participants' perceptions of salience, fear elicitation, and gained information as well as participants' motivation to remain non-smokers or quit smoking after viewing each of the four proposed new pictorials as well as the current pictorial used in Jordan. Perceptions regarding each new pictorial were compared to the current pictorial. RESULTS: A total of 450 surveys were included in the analysis. The sample (mean age 20.9) was 51.6% female and 31.3% cigarette (regular or occasional) smokers. In smokers, only one proposed pictorial had significantly more smokers perceiving it as salient or adding to information when compared to the current pictorial. More smokers reported fear when observing the proposed pictorials compared with current pictorial, but overall proportions reporting fear were generally less than 50%. Furthermore, all new pictorials motivated significantly more smokers to consider quitting compared with the current pictorial; however, the overall proportion of smokers reporting motivation was < 25%. Among nonsmokers, significantly more respondents perceived the new pictorials as salient and fear-eliciting compared to the old pictorial, but there were no major differences in information added. Motivation to remain non-smokers was comparable between the old and new pictorials. CONCLUSION: Given the variability of response across both smokers and nonsmokers, and across the three elements of perception (salience, added information, fear) for each pictorial, further testing of the pictorials in a more diverse sample of Jordanian young adults prior to launch is recommended.

The effect of implementing high-intensity intensive care unit staffing model on outcome of critically ill oncology patients.

OBJECTIVE: Implementing high-intensity staffing model improves outcome in general intensive care units (ICUs). We studied the effect of implementing such a model on the outcome of critically ill medical patients in an oncology ICU. DESIGN: We compared admission rates, ICU mortality rates (MRs), 28-day MRs, length of stay (LOS) for patients discharged alive, and bed turnover rates of medical patients admitted to the ICU in the year 2004 (before an intensivist model was established) with those in the years 2006 and 2007 (after the model was established). We allowed for 1 year of transition to implement the changes required including the transformation of the ICU to a closed ICU with daily multidisciplinary rounds led by an intensivist as described in the Leapfrog model. RESULTS: ICU admissions increased from 236 patients (2004) to 388 (2006) and 446 (2007). There was no significant difference in the disease severity of illness when compared by Acute Physiology and Chronic Health Evaluation II scores, 20.6 (before) vs. 20.9 (after) (p = 0.386). ICU MR for the consecutive years decreased from 35.17% (95% confidence interval [CI]: 29.08-41.26) to 23.97% (95% CI: 19.72-28.22) and 22.87% (95% CI: 18.97-26.77), and 28-day MRs decreased from 47.69% (95% CI: 40.68-54.7) to 38.24% (95% CI: 32.91-43.58) and 29.84% (95% CI: 24.79-34.89). LOS (for patients who survived) decreased from a mean of 4.26 days (95% CI: 3.19-5.33) to 2.63 (95% CI: 2.4-2.86) and 2.63 (95% CI: 2.4-2.86). Bed turnover rates increased from 5.0 patient/bed (95% CI: 4.22-5.78) to 6.9 patient/bed (95% CI: 6.04-7.77) and 7.56 patient/bed (95% CI: 6.67-8.44). CONCLUSION: Implementing a high-intensity staffing model is associated with significant improvements in MRs, LOS, and bed utilization of critically ill oncology patients.