Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study.

PURPOSE: Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs. METHODS: Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients' data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score. RESULTS: ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15-0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904-0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased. CONCLUSIONS: In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.

SAPS 3, APACHE IV or GRACE: which score to choose for acute coronary syndrome patients in intensive care units?

CONTEXT AND OBJECTIVE Acute coronary syndromes (ACS) are a common cause of intensive care unit (ICU) admission. Specific prognostic scores have been developed and validated for ACS patients and, among them, GRACE (Global Registry of Acute Coronary Events) has had the best performance. However, intensive care clinicians generally use prognostic scores developed from heterogeneous populations of critically ill patients, such as APACHE IV (Acute Physiologic and Chronic Health Evaluation IV) and SAPS 3 (Simplified Acute Physiology Score 3). The aim of this study was to evaluate and compare the performance of these three scores in a non-selected population of ACS cases. DESIGN AND SETTING Retrospective observational study to evaluate three prognostic scores in a population of ACS patients admitted to three general ICUs in private hospitals in São Paulo. METHODS All patients with ACS admitted from July 2008 to December 2009 were considered for inclusion in the study. Score calibration and discrimination were evaluated in relation to predicting hospital mortality. RESULTS A total of 1065 patients were included. The calibration was appropriate for APACHE IV and GRACE but not for SAPS 3. The discrimination was very good for all scores (area under curve of 0.862 for GRACE, 0.860 for APACHE IV and 0.804 for SAPS 3). CONCLUSIONS In this population of ACS patients admitted to ICUs, GRACE and APACHE IV were adequately calibrated, but SAPS 3 was not. All three scores had very good discrimination. GRACE and APACHE IV may be used for predicting mortality risk among ACS patients.

Caution when using prognostic models: a prospective comparison of 3 recent prognostic models.

PURPOSE: Prognostic models have been developed to estimate mortality and to compare outcomes in different intensive care units. However, these models need to be validated before their use in different populations. In this study, we assessed the performance of 3 recently developed general prognostic models (Acute Physiologic and Chronic Health Evaluation [APACHE] IV, Simplified Acute Physiology Score [SAPS] 3 and Mortality Probability Model III [MPM(0)-III]) in a population admitted at 3 medical-surgical Brazilian intensive care units. MATERIALS AND METHODS: All patients admitted from July 2008 to December 2009 were evaluated for inclusion in the study. Standardized mortality ratios were calculated for all models. Calibration was assessed by the Hosmer-Lemeshow goodness-of-fit test. Discrimination was evaluated using the area under the receiver operator curve. RESULTS: A total of 5780 patients were included. Inhospital mortality was 9.1%. Discrimination was very good for all models (area under the receiver operator curve for APACHE IV, SAPS 3 and MPM(0)-III was 0.883, 0.855 and 0.840, respectively). APACHE IV showed better discrimination than SAPS 3 and MPM(0)-III (P < .001 for both comparisons). All models calibrated poorly and overestimated hospital mortality (Hosmer-Lemeshow statistic was 53.7, 134.2, 226.6 for APACHE IV, MPM(0)-III, and SAPS 3, respectively; P < .001 for all). CONCLUSIONS: In this study, all models showed poor calibration, while discrimination was very good for all of them. As this has been a common finding in validation studies, caution is warranted when using prognostic models for benchmarking.

Influenza A (H1N1) patients admitted to intensive care units during the 2009 pandemics: clinical features and outcomes. / Apresentação clínica e evolução de pacientes com infecção por Influenza A (H1N1) que necessitaram de terapia intensiva durante a pandemia de 2009.

OBJECTIVES: To describe the clinical features and outcomes of patients admitted with influenza A (H1N1) infection in two private hospitals' intensive care units in São Paulo, Brazil, during the 2009 pandemics. METHODS: A retrospective cohort study was conducted to evaluate demographic data, initial clinical presentation, prognostic scores [Simplified Acute Physiology Score (SAPS) 3 and Sequential Organ Failure Assessment (SOFA)], comorbidities, outcomes and treatment of patients with confirmed pandemic influenza diagnosis from July to September 2009. RESULTS: 22 patients were admitted. Median age was 30 (25-43.5) years. Median SAPS 3 and SOFA were 42 (37-49) and 2 (1-3.5), respectively. Comorbidities were common (45.4%), especially obesity (22.7%). Two (9.1%) patients were pregnant. Five (22.7%) patients required invasive mechanical ventilation, with high positive end expiratory pressures (median of 16 cmH2O, interquartile range 10-25cmH2O). There was a 50% incidence of non-invasive ventilation failure. Most (77.2%) of patients were treated with oseltamivir. Hospital mortality was 4.5%. Initial SAPS 3, SOFA and PaO2/FiO2 ratio were associated with mechanical ventilation requirement (p<0.01). CONCLUSIONS: Pandemic influenza infection mainly affected young and obese patients. In this study, patients were less severe than those previously described, what explains our low mortality and mechanical ventilation needs. However, high positive end expiratory pressures were required for mechanically ventilated patients.

SAPS 3, APACHE IV or GRACE: which score to choose for acute coronary syndrome patients in intensive care units? / SAPS 3, APACHE IV ou GRACE: qual escore escolher para pacientes com sindromes coronarianas agudas na unidade de terapia intensiva?

CONTEXT AND OBJECTIVE Acute coronary syndromes (ACS) are a common cause of intensive care unit (ICU) admission. Specific prognostic scores have been developed and validated for ACS patients and, among them, GRACE (Global Registry of Acute Coronary Events) has had the best performance. However, intensive care clinicians generally use prognostic scores developed from heterogeneous populations of critically ill patients, such as APACHE IV (Acute Physiologic and Chronic Health Evaluation IV) and SAPS 3 (Simplified Acute Physiology Score 3). The aim of this study was to evaluate and compare the performance of these three scores in a non-selected population of ACS cases. DESIGN AND SETTING Retrospective observational study to evaluate three prognostic scores in a population of ACS patients admitted to three general ICUs in private hospitals in São Paulo. METHODS All patients with ACS admitted from July 2008 to December 2009 were considered for inclusion in the study. Score calibration and discrimination were evaluated in relation to predicting hospital mortality. RESULTS A total of 1065 patients were included. The calibration was appropriate for APACHE IV and GRACE but not for SAPS 3. The discrimination was very good for all scores (area under curve of 0.862 for GRACE, 0.860 for APACHE IV and 0.804 for SAPS 3). CONCLUSIONS In this population of ACS patients admitted to ICUs, GRACE and APACHE IV were adequately calibrated, but SAPS 3 was not. All three scores had very good discrimination. GRACE and APACHE IV may be used for predicting mortality risk among ACS patients. .

CONTEXTO E OBJETIVO Síndromes coronarianas agudas (SCA) são causa comum de admissão à unidade de terapia intensiva (UTI). Escores prognósticos específicos foram desenvolvidos e validados para pacientes com SCA e, dentre esses, o GRACE (Registro Global de Eventos Coronarianos Agudos) tem tido a melhor performance. No entanto, os intensivistas normalmente usam escores desenvolvidos para populações heterogêneas de pacientes graves, como o APACHE IV (Avaliação de Saúde Crônica e Fisiologia Aguda IV) e o SAPS 3 (Escore Fisiológico Agudo Simplificado 3). O presente estudo objetiva avaliar e comparar a performance desses três escores em uma população não selecionada admitida com diagnóstico de SCA. TIPO DE ESTUDO E LOCAL Estudo retrospectivo observacional para a avaliação de três escores prognósticos em uma população admitida com SCA em três UTIs gerais de hospitais particulares em São Paulo. MÉTODOS Todos os pacientes admitidos com SCA de julho de 2008 a dezembro de 2009 foram avaliados para inclusão no estudo. Foram avaliadas a calibração e a discriminação dos escores em predizer a mortalidade hospitalar. RESULTADOS Um total de 1.065 pacientes foi incluído. A calibração foi adequada para o APACHE IV e para o GRACE, mas não para o SAPS 3. A discriminação foi muito boa para todos os escores (área sob a curva de 0,862; 0,860 e 0,804 para GRACE, APACHE IV e SAPS 3). CONCLUSÕES Nesta população de pacientes com SCA admitidos à UTI, os escores GRACE e APACHE IV apresentaram uma calibração adequada, mas o SAPS 3 não. Todos os escores tiveram uma discriminação muito boa. O GRACE e o APACHE IV podem ser usados para pre...

Apresentação clínica e evolução de pacientes com infecção por Influenza A (H1N1) que necessitaram de terapia intensiva durante a pandemia de 2009 / Influenza A (H1N1) patients admitted to intensive care units during the 2009 pandemics: clinical features and outcomes

OBJETIVOS: Descrever a apresentação clínica e a evolução dos pacientes admitidos com diagnóstico de infecção por influenza pandêmica (H1N1) em duas unidades de terapia intensiva de hospitais privados de São Paulo. MÉTODOS: Foi realizada coorte retrospectiva com a avaliação de dados demográficos, da apresentação clínica inicial, escores prognósticos [Simplified Acute Physiology Score (SAPS) 3 e Sequential Organ Failure Assessment (SOFA)], comorbidades, de evolução e de tratamento de todos os pacientes que foram admitidos com diagnóstico confirmado de infecção por influenza pandêmico entre Julho e Setembro de 2009. RESULTADOS: Durante o período analisado, foram admitidos 22 pacientes. A mediana de idade foi de 30 (25-43,5) anos. As medianas do SAPS 3 e do SOFA foram, respectivamente de 42 (37-49) e 2 (1-3,5). Comorbidades foram comuns (50 por cento), especialmente a obesidade (22,7 por cento). Duas (9,1 por cento) pacientes eram gestantes. Cinco (22,7 por cento) pacientes foram submetidos à ventilação mecânica, mas houve necessidade de altas pressões expiratórias nestes (mediana de 16cm H2O e intervalos interquartis 10-25cmH2O). A taxa de falha de ventilação não-invasiva foi de 50 por cento. A maior parte (77,2 por cento) dos pacientes foi tratada com oseltamivir. A mortalidade hospitalar foi de 4,5 por cento. SAPS 3, SOFA e relação PaO2/FiO2 iniciais associaram-se com a necessidade de ventilação mecânica (p<0,01). CONCLUSÕES: A infecção por influenza pandêmico acometeu principalmente indivíduos jovens, especialmente obesos. Neste estudo, os pacientes eram menos graves que os descritos anteriormente, o que explica as menores mortalidade e necessidade de ventilação mecânica. No entanto, uma necessidade de altas pressões expiratórias nos pacientes que precisaram de ventilação mecânica.

OBJECTIVES: To describe the clinical features and outcomes of patients admitted with influenza A (H1N1) infection in two private hospitals' intensive care units in São Paulo, Brazil, during the 2009 pandemics. METHODS: A retrospective cohort study was conducted to evaluate demographic data, initial clinical presentation, prognostic scores [Simplified Acute Physiology Score (SAPS) 3 and Sequential Organ Failure Assessment (SOFA)], comorbidities, outcomes and treatment of patients with confirmed pandemic influenza diagnosis from July to September 2009. RESULTS: 22 patients were admitted. Median age was 30 (25-43.5) years. Median SAPS 3 and SOFA were 42 (37-49) and 2 (1-3.5), respectively. Comorbidities were common (45.4 percent), especially obesity (22.7 percent). Two (9.1 percent) patients were pregnant. Five (22.7 percent) patients required invasive mechanical ventilation, with high positive end expiratory pressures (median of 16 cmH2O, interquartile range 10-25cmH2O). There was a 50 percent incidence of non-invasive ventilation failure. Most (77.2 percent) of patients were treated with oseltamivir. Hospital mortality was 4.5 percent. Initial SAPS 3, SOFA and PaO2/FiO2 ratio were associated with mechanical ventilation requirement (p<0.01). CONCLUSIONS: Pandemic influenza infection mainly affected young and obese patients. In this study, patients were less severe than those previously described, what explains our low mortality and mechanical ventilation needs. However, high positive end expiratory pressures were required for mechanically ventilated patients.

Traqueostomia percutânea no doente crítico: a experiência de uma unidade de terapia intensiva clínica / Percutaneous Tracheostomy in Critically-ill Patients: the Experience of a Medical Intensive Care Unit

INTRODUÇAO: A traqueostomia é um procedimento realizado freqüentemente na terapia intensiva. Nas duas últimas décadas o procedimento percutâneo vem sendo cada vez mais utilizado. OBJETIVO: Descrever nossa experiência, em uma unidade de terapia intensiva clínica. MÉTODO: Levantamento retrospectivo de nosso banco de dados prospectivo de 78 traqueostomias percutâneas realizadas desde janeiro de 2000 até julho de 2003. Foram utilizadas as técnicas de dilatação progressiva com velas múltiplas (36 pacientes) e com pinça fórceps (42 pacientes). Os dados são mostrados como número de ocorrência ou mediana com intervalos interquartis. RESULTADOS: Nossospacientes tinham em média idade de 66 (43 a 75) anos e APACHE II com mediana de 16 (12 a 21), tiveram um período de ventilação mecânica com mediana de 14 (10 a 17) dias antes da traqueostomia, e 23 por cento faleceram na unidade de terapia intensiva. As causas mais freqüentes de internação na unidade de terapia intensiva foram as encefalopatias agudas (45 por cento), e o motivo que mais freqüentemente levou à indicação do procedimento foi o desmame difícil (50 por cento), seguido do Glasgow Coma Score persistentemente abaixo de 8 (49 por cento). Em 6 pacientes a broncoscopia não foi utilizada como guia. Ocorreram complicações em 33 por cento dos procedimentos. As complicações mais comuns foram pequenas hemorragias, sem necessidade de transfusão de sangue. Nenhum paciente morreu devido à complicação do procedimento. CONCLUSAO: Em uma unidade de terapia intensiva clínica, o procedimento da traqueostomia percutânea a beira leito é factível e seguro.