Intensive Care Utilization for Hematopoietic Cell Transplant Recipients.

Blood and marrow transplantation (BMT) is a potentially curative therapy for a number of malignant and nonmalignant diseases. Multiple variables, including age, comorbid conditions, disease, disease stage, prior therapies, degree of donor-recipient matching, type of transplantation, and dose intensity of the preparative regimen, affect both morbidity and mortality. Despite tremendous gains in supportive care, BMT remains a high-risk medical therapy. A critically ill BMT recipient may require transfer to an intensive care unit (ICU) and the specialized medical and nursing care that can be provided, such as mechanical ventilation and vasopressor support. Mortality for BMT recipients requiring care in an ICU is high. This paper will describe the experience of the Stanford Blood and Marrow Transplant Program in developing and implementing guidelines to maximize the benefit of intensive care for critically ill BMT recipients.

Focused transthoracic echocardiography during critical care medicine training: curriculum implementation and evaluation of proficiency*.

OBJECTIVES: We designed and implemented a focused transthoracic echocardiography curriculum for critical care medicine fellows participating in 1- and 2-year training programs. We quantitatively evaluated their proficiency in focused transthoracic echocardiography. DESIGN: Prospective study evaluating curriculum implementation and objective assessment of focused transthoracic echocardiography proficiency. SETTING: Medical and surgical ICUs at an academic teaching hospital. Simulation laboratory. SUBJECTS: Eighteen critical care medicine fellows. INTERVENTIONS: Training in focused transthoracic echocardiography followed by proficiency testing. MEASUREMENTS AND MAIN RESULTS: We assessed the ability of critical care medicine fellows to obtain and interpret focused transthoracic echocardiography images from critically ill patients and a from transthoracic echocardiography simulator. Using a cognitive examination test, we also evaluated each fellow's knowledge with regard to focused transthoracic echocardiography and each fellow's ability to interpret prerecorded focused transthoracic echocardiography images. After training, critical care medicine fellows were able to rapidly obtain five essential focused transthoracic echocardiography views: parasternal long axis, parasternal short axis, apical four chamber, subcostal four chamber, and subcostal inferior vena cava. Fellows were also able to expeditiously identify four important abnormalities: asystole, left ventricular dysfunction, right ventricular dilation and dysfunction, and a large pericardial effusion. CONCLUSIONS: A focused transthoracic echocardiography curriculum that includes quantitative measures of proficiency can be integrated into critical care medicine fellowship training programs.

Computerized physician order entry in the critical care environment: a review of current literature.

The implementation of health information technology (HIT) is accelerating, driven in part by a growing interest in computerized physician order entry (CPOE) as a tool for improving the quality and safety of patient care. Computerized physician order entry could have a substantial impact on patients in intensive care, where the potential for medical error is high, and the clinical workflow is complex. In 2009, only 17% of hospitals had functional CPOE systems in place. In intensive care unit (ICU) settings, CPOE has been shown to reduce the occurrence of some medication errors, but evidence of a beneficial effect on clinical outcomes remains limited. In some cases, new error types have arisen with the use of CPOE. Intensive care unit workflow and staff relationships have been affected by CPOE, often in unanticipated ways. The design of CPOE software has a strong impact on user acceptance. Intensive care unit-specific order sets lessen the cognitive workload associated with the use of CPOE and improve user acceptance. The diffusion of new technological innovations in the ICU can have unintended consequences, including changes in workflow, staff roles, and patient outcomes. When implementing CPOE in critical care areas, both organizational and technical factors should be considered. Further research is needed to inform the design and management of CPOE systems in the ICU and to better assess their impact on clinical end points, cost-effectiveness, and user satisfaction.

Unmet quality indicators for metastatic cancer patients admitted to intensive care unit in the last two weeks of life.

BACKGROUND: The majority of U.S. cancer patients express the desire to die at home, though most do not, and are often subjected to ineffective therapies near the end of life (EOL). In 2008 the U.K. Department of Health and National Health Care Service implemented a set of 10 quality markers to improve EOL care (EOLC) for seriously ill persons. Data show that this intervention has had a positive impact on patients' EOLC. PURPOSE: The study assessed the quality of EOLC received by terminally ill cancer patients admitted to the intensive care unit (ICU) in the last two weeks of life. DESIGN: A retrospective chart review was done of the electronic medical record (EMR) of 2498 patients admitted to the ICU from January to August 2011. The six U.K. quality indicators pertaining to patients were used to assess quality of EOLC. SETTING: The setting was a tertiary academic medical center with 663 beds and 66 adult ICU beds in northern California. PATIENTS: EMR analysis identified 2498 patients admitted to the ICU during the study period--232 died within two weeks of admission. Sixty-nine decedents had metastatic cancer. Of the patients, 58% were male, average age 59.8 years (range 25-91). RESULTS: Quality indicators were met in a relatively small percentage of patients admitted to the ICU in the last two weeks of life: prognostication 67%, advance care planning 32%, goals of care 42%, caregiver needs 0%, coordination of care across organizational boundaries 7%, and standardized care pathway implementation 58%. Palliative care consultations occurred in 28 patients. CONCLUSIONS: Quality indicators for EOLC were unmet in cancer patients admitted to the ICU in the last two weeks of life. Hospital-wide provider education about the need for early advance care planning with all seriously ill patients has been implemented in an effort to improve quality of care at EOL.

Adverse outcomes associated with delayed intensive care unit transfers in an integrated healthcare system.

BACKGROUND: Patients with intensive care unit (ICU) transfers from hospital wards have higher mortality than those directly admitted from the emergency department. OBJECTIVE: To describe the association between the timing of unplanned ICU transfers and hospital outcomes. DESIGN, SETTING, PATIENTS: Evaluation of 6369 early (within 24 hours of hospital admission) unplanned ICU transfer cases and matched directly admitted ICU controls from an integrated healthcare system. Cohorts were matched by predicted mortality, age, gender, diagnosis, and admission characteristics. Hospital mortality of cases and controls were compared based on elapsed time and diagnosis. RESULTS: More than 5% of patients admitted through the emergency department experienced an unplanned ICU transfer; the incidence and rates of transfers were highest within the first 24 hours of hospitalization. Multivariable matching produced 5839 (92%) case-control pairs. Median length of stay was higher among cases (5.0 days) than controls (4.1 days, P < 0.01); mortality was also higher among cases (11.6%) than controls (8.5%, P < 0.01). Patients with early unplanned transfers were at an increased risk of death (odds ratio, 1.44; 95% confidence interval, 1.26-1.64; P < 0.01); an increased risk of death was observed even among patients transferred within 8 hours of hospitalization. Hospital mortality differed based on admitting diagnosis categories. While it was higher among cases admitted for respiratory infections and gastrointestinal bleeding, it was not different for those with acute myocardial infarction, sepsis, and stroke. CONCLUSIONS: Early unplanned ICU transfers-even within 8 hours of hospitalization-are associated with increased mortality; outcomes vary by elapsed time to transfer and admitting diagnosis.

The association between sepsis and potential medical injury among hospitalized patients.

BACKGROUND: Patient safety remains a national priority, but the role of disease-specific characteristics in safety is not well characterized. METHODS: We identified potentially preventable medical injuries using patient safety indicators (PSIs) and annual data from the Nationwide Inpatient Sample between 2003 and 2007. We compared the rate of selected PSIs among patients hospitalized with and without sepsis. Among patients with sepsis, we also compared PSI rates across severity strata. Using multivariable case-control matching and regression analyses, we estimated the excess adverse outcomes associated with PSI events in patients with sepsis. RESULTS: Patients hospitalized with sepsis accounted for 2% to 4% of hospital discharges; however, they accounted for 9% to 26% of all potential medical injuries. PSI rates varied considerably; among patients hospitalized for sepsis, they were lowest for accidental puncture or laceration and highest for postoperative respiratory failure. Nearly all PSI rates were higher among patients with sepsis compared with patients without sepsis. Among those with sepsis, most PSI rates increased as sepsis severity increased. Compared with matched sepsis control subjects, increased length of stay and hospital charges were associated with PSI events in sepsis cases. However, only decubitus ulcer, iatrogenic pneumothorax, and postoperative metabolic and physiologic derangement or respiratory failure were associated with excess mortality. CONCLUSION: Patients hospitalized for sepsis, compared with the general hospital population, were at a substantially increased risk of potential medical injury; their risk rose as disease severity increased. Future patient safety efforts may benefit from focusing on medically vulnerable populations.