Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing.

OBJECTIVES: Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios. DATA SOURCES: A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference. DATA EXTRACTION: A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a "closed" model where the intensivists control triage and patient care. DATA SYNTHESIS AND CONCLUSIONS: The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study.

OBJECTIVES: To determine the impact of rapid response team implementation on the outcome of patients transferred from the regular hospital ward and nonward locations to the ICU. DESIGN: Retrospective before-after cohort study. SETTING: The study was performed in two ICUs, one surgical and one medical, of a tertiary medical center. PATIENTS: We included 4,890 patients transferred from the hospital ward to two ICUs and 15,855 patients admitted from nonward locations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data on each patient were abstracted from the Acute Physiology and Chronic Health Evaluation III and the administrative hospital and rapid response team databases. The study period was divided into pre-rapid response team and rapid response team. A 24/7 critical care consult service and cardiac arrest teams were available for ward patient care during both periods. A total of 20,745 patients were admitted to the two study ICUs, of whom 4,890 were from the ward (2,466 and 2,424 during the pre-rapid response team and rapid response team periods, respectively). The first ICU day severity of illness was higher for the pre-rapid response team period. A multiple logistic regression model that included predicted mortality as a covariate suggested that availability of rapid response team was associated with an increased risk of hospital death in patients transferred to the ICU from the regular ward, odds ratio (95% CI) of 1.273 (1.089-1.490). For the nonward patients, the availability of rapid response team was similarly associated with increased risk of death. The ICU length of stay was shorter during the rapid response team period both in ward transfer and in nonward transfer patients. CONCLUSIONS: Rapid response team implementation is associated with increased numbers of ICU admissions and rates, and transfer from the ward of less severely ill patients. However, rapid response team implementation did not improve the severity-of-illness-adjusted outcome of patients transferred from the ward. Implementation of rapid response team in an institution with a 24/7 ICU consult service may have unforeseen costs without obvious benefit. Our findings highlight that institutions should evaluate the impact of rapid response team on patient outcome and make modifications specific to their practices.

Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors.

BACKGROUND: Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. METHODS: We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. RESULTS: Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. CONCLUSIONS: Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

A scoring model of factors associated with Candida glabrata candidemia among critically ill patients.

Candida species, including Candida glabrata (CG), are common causes of bloodstream infections among intensive care unit (ICU) patients. Many CG isolates have decreased susceptibility to fluconazole. Constructing a scoring model of factors associated with CG candidemia in ICU patients that can be used if fluconazole susceptibility testing is not readily available. We identified patients with candidemia that were admitted to the ICU of the Mayo Clinic in Rochester, Minnesota from 1998 to 2006. Using patient demographical and clinical data abstracted via chart review, a multivariable logistic regression model was developed to distinguish those with CG candidemia. We identified 246 patients with candidemia including 68 CG cases. Multivariable analysis identified four independent factors associated with CG candidemia: absence of renal failure, less than 7 days in the hospital, abdominal surgery and fluconazole use. The predictive ability of the model, based on the c-statistic, was 0.727. In a large ICU cohort, a scoring model that included four risk factors, which are readily ascertainable at the bedside, was created to distinguish candidemia due to CG from other causes of candidemia. The identification of risk factors associated with CG candidemia could aid physicians in the selection of the optimal initial antifungal therapy.

Severity of illness scoring systems in the intensive care unit.

OBJECTIVE: Adult intensive care unit prognostic models have been used for predicting patient outcome for three decades. The goal of this review is to describe the different versions of the main adult intensive care unit prognostic models and discuss their potential roles. DATA SOURCE: PubMed search and review of the relevant medical literature. SUMMARY: The main prognostic models for assessing the overall severity of illness in critically ill adults are Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, and Mortality Probability Model. Simplified Acute Physiology Score and Mortality Probability Model have been updated to their third versions and Acute Physiology and Chronic Health Evaluation to its fourth version. The development of prognostic models is usually followed by internal and external validation and performance assessment. Performance is assessed by area under the receiver operating characteristic curve for discrimination and Hosmer-Lemeshow statistic for calibration. The areas under the receiver operating characteristic curve of Simplified Acute Physiology Score 3, Acute Physiology and Chronic Health Evaluation IV, and Mortality Probability Model0 III were 0.85, 0.88, and 0.82, respectively, and all these three fourth-generation models had good calibration. The models have been extensively used for case-mix adjustment in clinical research and epidemiology, but their role in benchmarking, performance improvement, resource use, and clinical decision support has been less well studied. CONCLUSIONS: The fourth-generation Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score 3, Acute Physiology and Chronic Health Evaluation IV, and Mortality Probability Model0 III adult prognostic models, perform well in predicting mortality. Future studies are needed to determine their roles for benchmarking, performance improvement, resource use, and clinical decision support.

Nicotine replacement therapy in critically ill patients: a prospective observational cohort study.

OBJECTIVE: Smokers admitted to the intensive care unit may receive nicotine replacement therapy to prevent nicotine withdrawal. However, recent studies have questioned the safety of this practice. The objective of this study was to determine the impact of nicotine replacement therapy on the outcomes of critically ill patients. DESIGN: Prospective observational cohort. SETTING: The medical intensive care unit of a tertiary academic hospital. PATIENTS: Active smokers admitted to the intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After excluding 2,411 patients who did not meet the study inclusion criteria, 330 were included in the study, of which 174 patients received and 156 did not receive nicotine replacement therapy. There were no significant differences in the unadjusted hospital mortality between the two groups: 14 patients (7.8%; 95% confidence interval, 4-12) died in the nicotine replacement therapy group as compared with ten patients (6.3%; 95% confidence interval, 2.6-10.3) in the nonnicotine replacement therapy group (p = .59). After adjusting for severity of illness and propensity score for administration of nicotine replacement therapy on intensive care unit admission, nicotine replacement therapy was not associated with increased hospital mortality (odds ratio, 1.4; 95% confidence interval, 0.5-3.9; p = .51). LIMITATIONS: Single-center observational study. CONCLUSIONS: Nicotine replacement therapy is not associated with increased hospital mortality in critically ill patients. However, we were not able to demonstrate any clinically significant benefit from its use in the intensive care unit setting.

Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality.

OBJECTIVE: To evaluate the impact of weekly feedback to clinicians and the activation of a sepsis response team on the process of care and hospital mortality in patients with severe sepsis or septic shock. DESIGN: Prospective, interventional cohort study. SETTING: The medical intensive care unit of a tertiary, academic medical center. STUDY SUBJECTS: Patients with severe sepsis or septic shock consecutively treated in a medical intensive care unit. INTERVENTIONS: Daily auditing and weekly feedback, and sepsis response team activation. MEASUREMENTS AND MAIN RESULTS: During a 33-month study period, from January 2007 through September 2009, we performed daily screening of patients for severe sepsis or septic shock. Study periods were divided into baseline (screening only), daily auditing with weekly feedback, and sepsis response team activation. Comparisons among the three periods were made by using univariate and multiple logistic regression analyses. Compliance with the overall sepsis resuscitation bundle and its individual elements and hospital mortality were used as outcome measures. A total of 984 episodes of severe sepsis and septic shock were identified during the study periods, severe sepsis in 52 (5.3%) and septic shock in 932 (94.7%). The compliance rate with all elements of the sepsis resuscitation bundle increased from 12.7% at baseline to 37.7% and 53.7% during the weekly feedback and sepsis response team activation periods, respectively (p < .001). Overall hospital mortality rate was 30.3%, 28.3%, and 22.0% during baseline, weekly feedback, and sepsis response team periods, respectively (p = .029). Multiple logistic regression analysis showed that the sepsis response team was associated with reduced risk of hospital death (odds ratio, 0.657; 95% confidence interval, 0.456-0.945; p = .023) whereas hepatic cirrhosis, hepatic failure, leukemia, multiple myeloma, transfer from the same hospital ward, do-not-resuscitate status at the recognition of severe sepsis/septic shock, and lactate level were associated with increased risk of death. CONCLUSIONS: In septic shock, the activation of the sepsis response team in combination with weekly feedback increases the compliance with the process of care and reduces hospital mortality rate.

Activity of a silver-coated endotracheal tube in preclinical models of ventilator-associated pneumonia and a study after extubation.

OBJECTIVE: To elucidate the mechanism of action of the silver-coated endotracheal tube in models of the early pathogenesis of ventilator-associated pneumonia. DESIGN: Open-labeled, prospective, controlled, sequentially conducted, preclinical studies, and in vitro assessment of tubes from patients. SETTING: Microbiology laboratory of a device manufacturer, animal research facility of a university, and a tertiary medical center. INTERVENTIONS: Endotracheal tubes were similar except for the silver coating. In the 21-day in vitro elution model, tube samples were incubated in saline solution at 37.8 degrees C. In the in vitro adherence model, coated and uncoated tubes were exposed to 21 respiratory isolates of radiolabeled microorganisms for 2-4 hrs. In the animal model, 12 healthy white rabbits were intubated for 16 hrs with noncuffed silver-coated or uncoated tubes and challenged with buccal administration of Pseudomonas aeruginosa. In the in vitro assessment, tubes from 16 patients underwent quantitative culture assessment and qualitative confocal laser scanning microscopy. MEASUREMENTS AND MAIN RESULTS: After in vitro incubation, the mean residual silver concentration was 2.6 microg/cm, confirming that the coating was not entirely depleted. In vitro adherence to the silver-coated endotracheal tube was less than that of the uncoated tube for 12 of 21 isolates and equivalent for seven. For example, adherence to the silver-coated endotracheal tube was reduced >90% for all five isolates of P. aeruginosa (p < .05). In rabbits, P. aeruginosa colonization on the silver-coated endotracheal tube was reduced 99.9% compared with that on the uncoated tube (p < .0001); colonization in the tracheal and lung tissue was reduced > or =99% (p < .05). In the in vitro assessment, pathogens were detected on none of nine silver-coated tubes from patients and three of seven control tubes (p > .05). CONCLUSIONS: : The collective findings of this series of studies demonstrated that the silver-coated endotracheal tube was active in models designed to mimic the early pathogenesis of ventilator-associated pneumonia.

Critical care support of patients with nicotine addiction.

Over 500 million of the current world population will die from diseases caused by smoking cigarettes. The symptoms and signs of nicotine withdrawal are not well described in the critically ill. Since the various conditions of critical illness may lead to clinical manifestations mimicking nicotine withdrawal, describing its specific manifestations may not be easy. A few case reports suggest that nicotine replacement therapy may ameliorate nicotine withdrawal in the critically ill. However, retrospective studies have found that it may increase mortality. Despite the abundance of active smokers, there is a paucity of data describing nicotine withdrawal, and its prevention and treatment options in the critically ill. Future studies are warranted to address these issues.

The impact of adding 1 month of intensive care unit training in a categorical internal medicine residency program.

OBJECTIVE: To determine the impact of adding a month of critical care training in the postgraduate year (PGY)-2 on the critical care skills of PGY-3 residents. DESIGN: Prospective, nonrandomized. SETTING: The internal medicine (IM) residency program of a tertiary care medical center. STUDY SUBJECTS: The study subjects included the 2005/2006 and 2006/2007 academic year IM residents. INTERVENTIONS: The 2005/2006 IM residents (control group, n = 48) had 1 month of critical care training (internship year) before their 1-month PGY-3 rotations. The 2006/2007 residents (intervention group, n = 47) had an additional 1-month rotation in a multispecialty intensive care unit (ICU) during their second year. MEASUREMENTS AND MAIN RESULTS: At the beginning of their last ICU month rotation, the intervention group's self-assessment (1-5 Likert scale) of their skills in internal jugular venous catheterization (3.4 vs. 2.4, p < 0.001) and management of severe sepsis (4.0 vs. 2.4, p < 0.001) and acute lung injury (3.3 vs. 2.6, p < 0.001) was higher than that of the control group. However, the observed success rates of endotracheal intubation (55.4% vs. 54.9%, p = 0.953) and central venous catheterization (78.1% vs. 80.8%, p = 0.488) were similar between the two groups. No difference was noted in the complication rates for endotracheal intubation or central venous catheterization between the control and intervention groups. End of ICU rotation examination results, attending evaluations, and the observed application of evidence-based practice in the management of severe sepsis were similar between the two groups. CONCLUSIONS: Increasing IM residents' experience in the ICU resulted in modest, transient improvement of their perceived clinical skills in critical care procedures and management of severe sepsis and acute lung injury. However, no statistically significant and sustained improvement was noted in the observed cognitive or clinical skills.

Long-term prognostic significance of elevated cardiac troponin levels in critically ill patients with acute gastrointestinal bleeding.

BACKGROUND: Elevations in troponin level have prognostic importance in critically ill patients, including those with gastrointestinal (GI) bleeding. However, there are no data addressing the independent association of troponin levels and mortality, adjusted for the severity of the underlying disease, in patients with GI bleeding. OBJECTIVE: This study was designed to determine whether troponin T elevations are independently associated with in-hospital, short-term (30 days), and long-term mortality in medical intensive care unit patients with GI bleeding after adjusting for the severity of disease measured by the Acute Physiology, Age, and Chronic Health Evaluation score prognostic system. DESIGN: Retrospective study. SETTING: We examined the Acute Physiology, Age, and Chronic Health Evaluation III database and cardiac troponin T levels from patients consecutively admitted to the medical intensive care unit at Mayo Clinic, Rochester, MN, with acute GI bleeding. PATIENTS: Between August 2000 and July 2005, 1076 patients with acute GI bleeding consecutively admitted to the medical intensive care units. MEASUREMENTS: In-hospital, short-term (30 days), and long-term all-cause mortality. RESULTS: During hospitalization, 8.0% of deaths occurred in patients with troponin T < 0.01% and 11.9% with troponin T > or = 0.01 (p = 0.083). At 30 days, mortality was 10.1% and 18.8% in patients without and with elevations of troponins, respectively (p < 0.001). The Kaplan-Meier expected probability of survival at 1-, 2-, and 3-yr follow-up was 54.2%, 40.8%, and 30.4% with troponin T > or = 0.01 microg/L and 78.3%, 69.3%, and 61.5% with troponin T < 0.01 microg/L (p < 0.001). After adjustment for severity of disease and baseline characteristics, cardiac troponin levels were associated only with long-term mortality (p < 0.001). LIMITATIONS: This is a retrospective, single-center study which included only patients in whom troponin level was determined upon admission. CONCLUSIONS: In patients with GI bleeding severe enough to require admission to the medical intensive care unit, admission troponin T elevations are associated with long-term but not short-term mortality.

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage.

BACKGROUND: Cardiopulmonary complications are common after endoscopy for upper GI (UGI) hemorrhage in the intensive care unit (ICU). OBJECTIVE: To evaluate the practice and outcome of elective prophylactic endotracheal intubation before endoscopy for UGI hemorrhage in the ICU. DESIGN: Retrospective, propensity-matched case-control study. SETTING: A 24-bed medical ICU in a tertiary center. PATIENTS: ICU patients who underwent endoscopy for UGI hemorrhage. MAIN OUTCOME MEASUREMENTS: Cardiopulmonary complications, ICU and hospital length of stay, and mortality. In a propensity analysis, patients who were intubated for airway protection before UGI endoscopy were matched by probability of intubation to controls who were not intubated before UGI endoscopy. RESULTS: Of 307 patients, 53 underwent elective prophylactic intubation before UGI endoscopy. The probability of intubation depended on the Acute Physiology and Chronic Health Evaluation III (APACHE III) score (OR 1.4; 95% CI, 1.2-1.6), age (OR 0.97; 95% CI, 0.95-0.09), the presence of hemetemesis (OR 1.9; 95% CI, 0.8-5.1), previous lung disease (OR 2.1; 95% CI, 0.8-4.9), and the number of transfusions (OR 1.1; 95% CI, 1.0-1.1 per unit). Nonintubated matched controls were identified for all but 4 patients with active massive hemetemesis, who were excluded from matched analysis. Cumulative incidence of cardiopulmonary complications (53% vs 45%, P = .414), ICU length of stay (median 2.2 vs 1.8 days, P = .138), hospital length of stay (6.9 vs 5.9 days, P = .785), and hospital mortality (14% vs 20%, P = .366) were similar. CONCLUSIONS: Cardiopulmonary complications are frequent after endoscopy for acute UGI bleeding in ICU patients and are largely unaffected by the practice of prophylactic intubation.

APACHE III outcome prediction in patients admitted to the intensive care unit after liver transplantation: a retrospective cohort study.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT METHODS: A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III. RESULTS: APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively. There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom). CONCLUSION: APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution - if used at all - in recipients of liver transplantation.

Noninfectious pneumonitis after blood and marrow transplant.

PURPOSE OF REVIEW: Blood and marrow transplant recipients are predisposed to infectious and noninfectious pulmonary complications. Such complications can develop in 30-60% of blood and marrow transplant recipients and are the immediate cause of death in approximately 61%. This review will summarize recent developments in noninfectious complications that manifest as pulmonary infiltrates. RECENT FINDINGS: Recent data in blood and marrow transplant recipients suggest that noninfectious pulmonary diseases may be more common than infectious complications. The main noninfectious pulmonary complications that present as pulmonary infiltrates include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome and diffuse alveolar hemorrhage. Bronchoalveolar lavage fluid shows progressively bloodier return and/or over 20% hemosiderin-laden macrophages in diffuse alveolar hemorrhage. Peri-engraftment respiratory distress syndrome differs from idiopathic pneumonia syndrome by its occurrence during the neutrophil peri-engraftment period and favorable response to corticosteroid therapy. The treatment of noninfectious pulmonary complications is not based on randomized clinical trials. SUMMARY: Noninfectious pulmonary complications develop frequently in blood and marrow transplant recipients. The clinical presentations of idiopathic pneumonia syndrome, Peri-engraftment respiratory distress syndrome and diffuse alveolar hemorrhage may mimic pneumonia of infectious etiology. The therapeutic and prognostic implications mean that accurate diagnosis of these conditions is important.

Comparison of community and referral intensive care unit patients in a tertiary medical center: evidence for referral bias in the critically ill.

OBJECTIVE: To determine the existence of referral bias in the critically ill by comparing the clinical and epidemiologic characteristics of community (Olmsted County, MN residents) and referral (non-Olmsted County residents) patients admitted to the intensive care unit. DESIGN: Retrospective, cohort study. SETTING: Academic tertiary care medical center. PATIENTS: Patients admitted to the medical and surgical intensive care units at Mayo Medical Center from 1995 to 2004. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Residency status, demographics, Acute Physiology and Chronic Health Evaluation III score, intensive care unit admission diagnosis and treatment status, intensive care unit and hospital mortality, length of stay, and travel distances to Mayo Clinic. Referral patients with a medical intensive care unit admission were more severely ill, had greater mortality rates and length of stay and were more likely to receive an active intensive care unit intervention compared with community patients (p < 0.0001). Referral and community patients who had a surgical intensive care unit admission had similar severity of illness, length of stay, and intensive care unit mortality rate. Hospital mortality rate was lower in the referral surgical patients compared with community surgical patients (p = 0.0001). When adjusted for severity of illness, intensity of treatment, and admission source, community and referral medical intensive care unit patients had a similar risk of hospital death, whereas referral surgical patients had a lower risk of hospital death compared with community patients. Referral patients who had a medical intensive care unit admission and traveled greater distances to Mayo Clinic had greater mortality rates and length of stay; those who had a surgical intensive care unit admission and traveled greater distances had lower mortalities and length of stay. CONCLUSIONS: Patients who resided outside of our local community and who had medical admissions to the intensive care unit were more severely ill, had greater mortality rates, and had longer length of stay compared with community patients. Our findings support the existence of referral bias in critically ill medical patients at our tertiary medical center.

The association between nighttime transfer from the intensive care unit and patient outcome.

OBJECTIVE: To determine the impact of nighttime transfer of patients from the intensive care unit (ICU) on clinical outcome. DESIGN: Retrospective, observational. SETTING: Three intensive care units of a tertiary care medical center. PATIENTS: We used prospectively collected information from the Acute Physiology and Chronic Health Evaluation III database of 11,659 patients transferred from the ICU to the regular ward. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on the time of transfer, patients who were transferred from the ICU to the regular ward were categorized into daytime (7:00 am-6:59 pm) and nighttime (7:00 pm-6:59 am) transfers. Patients who were transferred to other ICUs or other facilities, died in the ICU, were discharged home, or did not authorize their medical records to be reviewed for research were excluded. Only the first ICU admission of each patient was considered for outcome analysis. Of the 11,659 study patients, 418 (3.6%) were transferred at night. The first ICU day predicted mortality rate and the last ICU day Acute Physiology Score and Acute Physiology and Chronic Health Evaluation III scores in the nighttime transfer group were higher compared with the daytime transfers. The hospital mortality rate of the nighttime transfers was 5.3% compared with 4.5% of the daytime transfers (p = 0.478). There was no statistically significant difference between the two groups in severity adjusted hospital mortality rate. The ICU readmission rate of the nighttime transfers was higher (12.2% compared with 9.0%, p = 0.027) and the median (interquartile range) hospital length of stay longer (8 [5-15] vs. 7 [4-13] days, p = 0.013) compared with the daytime transfer group. CONCLUSIONS: Our study did not find an association between nighttime ICU discharge and hospital mortality. However, the ICU readmission rate was higher and the hospital length of stay longer in the nighttime transfer group.

Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study.

OBJECTIVE: Almost half of the patients with septic shock develop acute lung injury (ALI). The understanding why some patients do and others do not develop ALI is limited. The objective of this study was to test the hypothesis that delayed treatment of septic shock is associated with the development of ALI. DESIGN: Observational cohort study. SETTING: Medical intensive care unit in a tertiary medical center. PATIENTS: Prospectively identified patients with septic shock who did not have ALI at the outset, excluding those who denied research authorization. MEASUREMENTS AND MAIN RESULTS: High frequency cardio-respiratory monitoring, arterial gas analysis, and portable chest radiographs were reviewed to identify the timing of ALI development. Risk factors present before ALI development were identified by review of electronic medical records and analyzed in univariate and multivariate analyses. Seventy-one of 160 patients (44%) developed ALI at a median of 5 (range 2-94) hours after the onset of septic shock. Multivariate logistic regression analysis identified the following predictors of ALI development: delayed goal-directed resuscitation (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.52-8.63, p = .004), delayed antibiotics (OR 2.39, 95% CI 1.06 -5.59, p = .039), transfusion (OR 2.75, 95% CI 1.22-6.37, p = .016), alcohol abuse (OR 2.09, 95% CI .88-5.10, p = 0.098), recent chemotherapy (OR 6.47, 95% CI 1.99-24.9, p = 0.003), diabetes mellitus (OR .44, 95% CI .17-1.07, p = .076), and baseline respiratory rate (OR 2.03 per sd, 95% CI 1.38-3.08, p < .001). CONCLUSION: When adjusted for known modifiers of ALI expression, delayed treatment of shock and infection were associated with development of ALI.

The Stability and Workload Index for Transfer score predicts unplanned intensive care unit patient readmission: initial development and validation.

OBJECTIVE: Unplanned readmission of hospitalized patients to an intensive care unit (ICU) is associated with a worse outcome, but our ability to identify who is likely to deteriorate after ICU dismissal is limited. The objective of this study is to develop and validate a numerical index, named the Stability and Workload Index for Transfer, to predict ICU readmission. DESIGN: In this prospective cohort study, risk factors for ICU readmission were identified from a broad range of patients' admission and discharge characteristics, specific ICU interventions, and in-patient workload measurements. The prediction score was validated in two independent ICUs. SETTING: One medical and one mixed medical-surgical ICU in two tertiary centers. PATIENTS: Consecutive patients requiring >24 hrs of ICU care. INTERVENTIONS: None. MEASUREMENTS: Unplanned ICU readmission or unexpected death following ICU dismissal. RESULTS: In a derivation cohort of 1,131 medical ICU patients, 100 patients had unplanned readmissions, and five died unexpectedly in the hospital following ICU discharge. Predictors of readmission/unexpected death identified in a logistic regression analysis were ICU admission source, ICU length of stay, and day of discharge neurologic (Glasgow Coma Scale) and respiratory (hypoxemia, hypercapnia, or nursing requirements for complex respiratory care) impairment. The Stability and Workload Index for Transfer score predicted readmission more precisely (area under the curve [AUC], 0.75; 95% confidence interval [CI], 0.70-0.80) than the day of discharge Acute Physiology and Chronic Health Evaluation III score (AUC, 0.62; 95% CI, 0.56-0.68). In the two validation cohorts, the Stability and Workload Index for Transfer score predicted readmission similarly in a North American medical ICU (AUC, 0.74; 95% CI, 0.67-0.80) and a European medical-surgical ICU (AUC, 0.70; 95% CI, 0.64-0.76), but was less well calibrated in the medical-surgical ICU. CONCLUSION: The Stability and Workload Index for Transfer score is derived from information readily available at the time of ICU dismissal and acceptably predicts ICU readmission. It is not known if discharge decisions based on this prediction score will decrease the number of ICU readmissions and/or improve outcome.

Elevated cardiac troponin is an independent risk factor for short- and long-term mortality in medical intensive care unit patients.

BACKGROUND: Troponin elevations are common in critically ill patients. Whether they are predictors of mortality independent of the severity of the underlying disease is unclear. OBJECTIVE: To determine whether troponin elevations predict in-hospital, short-term, and long-term mortality in medical intensive care unit patients independent of the severity of the underlying disease as measured by Acute Physiology and Chronic Health Evaluation III prognostic system. DESIGN: Retrospective study. SETTING: We examined the Acute Physiology and Chronic Health Evaluation III database and cardiac troponin T levels of medical intensive care unit patients at Mayo Clinic, Rochester, MN. PATIENTS: In all, 1,657 patients consecutively admitted to medical intensive care units between August 2000 and December 2001. MEASUREMENTS: In-hospital, short-term (30-day), and long-term all-cause mortality. RESULTS: During hospitalization, 12.5% of patients with a cardiac troponin T < 0.01 microg/L suffered deaths compared with 29.5% among those with cardiac troponin T > or = 0.01 microg/L (p < .001). At 30 days, mortality was 13.7% without and 34.6% with elevations (p < .001). The expected probability of survival at 1-, 2-, and 3-yr follow-up was 43.7%, 33.8%, and 25.7% among patients with cardiac troponin T > or = 0.01 microg/L and 75.3%, 67.6%, and 62.9% in those with cardiac troponin T < 0.01 microg/L, respectively (p < .001). After adjustment for the severity of disease and baseline characteristics, cardiac troponin levels were still associated with in-hospital, short-term, and long-term mortality (p = .006, p = .007, and p = .001, respectively). LIMITATIONS: This is a single-site retrospective study that included only patients in whom a troponin level was obtained on admission. CONCLUSIONS: In medical intensive care unit patients, admission troponin levels are independently associated with short- and long-term mortality, even after adjustment for severity of disease.

Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital.

OBJECTIVE: The benefit of continuous on-site presence by a staff academic critical care specialist in the intensive care unit of a teaching hospital is not known. We compared the quality of care and patient/family and provider satisfaction before and after changing the staffing model from on-demand to continuous 24-hr critical care specialist presence in the intensive care unit. DESIGN: Two-year prospective cohort study of patient outcomes, processes of care, and family and provider survey of satisfaction, organization, and culture in the intensive care unit. SETTING: Intensive care unit of a teaching hospital. PATIENTS: Consecutive critically ill patients, their families, and their caregivers. INTERVENTIONS: Introduction of night-shift coverage to provide continuous 24-hr on-site, as opposed to on-demand, critical care specialist presence. MEASUREMENTS AND MAIN RESULTS: Of 2,622 patients included in the study, 1,301 were admitted before and 1,321 after the staffing model change. Baseline characteristics and adjusted intensive care unit and hospital mortality were similar between the two groups. The nonadherence to evidence-based care processes improved from 24% to 16% per patient-day after the staffing change (p = .002). The rate of intensive care unit complications decreased from 11% to 7% per patient-day (p = .023). When adjusted for predicted hospital length of stay, admission source, and do-not-resuscitate status, hospital length of stay significantly decreased during the second period (adjusted mean difference -1.4, 95% confidence interval -0.3 to -2.5 days, p = .017). The new model was considered optimal for patient care by the majority of the providers (78% vs. 38% before the intervention, p < .001). Family satisfaction was excellent during both study periods (mean score 5.87 +/- 1.7 vs. 5.95 +/- 2.0, p = .777). CONCLUSIONS: The introduction of continuous (24-hr) on-site presence by a staff academic critical care specialist was associated with improved processes of care and staff satisfaction and decreased intensive care unit complication rate and hospital length of stay.