RESUMO
OBJECTIVES: We implemented a computerized protocol for low tidal volume ventilation (LTVV) to improve management and outcomes of mechanically ventilated patients with, and without, the acute respiratory distress syndrome (ARDS). DESIGN: Pragmatic, nonrandomized stepped wedge type II hybrid implementation/effectiveness trial. SETTING: Twelve hospitals in an integrated healthcare system over a 2-year period. PATIENTS: Patients greater than or equal to 18 years old who had initiation of mechanical ventilation in the emergency department or ICU. We excluded patients who died or transitioned to comfort care on the day of admission to the ICU. We defined a subgroup of patients with ARDS for analysis. INTERVENTIONS: Implementation of ventilator protocols for LTVV in the ICU. MEASUREMENTS AND MAIN RESULTS: Our primary clinical outcome was ventilator-free days (VFDs) to day 28. Our primary process outcome was median initial set tidal volume. We included 8,692 mechanically ventilated patients, 3,282 (38%) of whom had ARDS. After implementation, set tidal volume reported as mL/kg predicted body weight decreased from median 6.1 mL/kg (interquartile range [IQR], 6.0-6.8 mL/kg) to 6.0 mL/kg (IQR, 6.0-6.6 mL/kg) ( p = 0.009). The percent of patients receiving LTVV (tidal volume ≤ 6.5 mL/kg) increased from 69.8% ( n = 1,721) to 72.5% ( n = 1,846) ( p = 0.036) after implementation. The percent of patients receiving greater than 8 mL/kg initial set tidal volume was reduced from 9.0% ( n = 222) to 6.7% ( n = 174) ( p = 0.005) after implementation. Among patients with ARDS, day 1 positive end-expiratory pressure increased from 6.7 to 8.0 cm H 2 O ( p < 0.001). We observed no difference in VFD (adjusted odds ratio, 1.06; 95% CI, 0.91-1.24; p = 0.44), or in secondary outcomes of length of stay or mortality, either within the main cohort or the subgroup of patients with ARDS. CONCLUSIONS: We observed improved adherence to optimal ventilator management with implementation of a computerized protocol and reduction in the number of patients receiving tidal volumes greater than 8 mL/kg. We did not observe improvement in clinical outcomes.
Assuntos
Síndrome do Desconforto Respiratório , Insuficiência Respiratória , Humanos , Pulmão , Respiração com Pressão Positiva/métodos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Insuficiência Respiratória/terapia , Volume de Ventilação PulmonarRESUMO
Objective: Computer-aided decision tools may speed recognition of acute respiratory distress syndrome (ARDS) and promote consistent, timely treatment using lung-protective ventilation (LPV). This study evaluated implementation and service (process) outcomes with deployment and use of a clinical decision support (CDS) synchronous alert tool associated with existing computerized ventilator protocols and targeted patients with possible ARDS not receiving LPV. Materials and Methods: We performed an explanatory mixed methods study from December 2019 to November 2020 to evaluate CDS alert implementation outcomes across 13 intensive care units (ICU) in an integrated healthcare system with >4000 mechanically ventilated patients annually. We utilized quantitative methods to measure service outcomes including CDS alert tool utilization, accuracy, and implementation effectiveness. Attitudes regarding the appropriateness and acceptability of the CDS tool were assessed via an electronic field survey of physicians and advanced practice providers. Results: Thirty-eight percent of study encounters had at least one episode of LPV nonadherence. Addition of LPV treatment detection logic prevented an estimated 1812 alert messages (41%) over use of disease detection logic alone. Forty-eight percent of alert recommendations were implemented within 2 h. Alert accuracy was estimated at 63% when compared to gold standard ARDS adjudication, with sensitivity of 85% and positive predictive value of 62%. Fifty-seven percent of survey respondents observed one or more benefits associated with the alert. Conclusion: Introduction of a CDS alert tool based upon ARDS risk factors and integrated with computerized ventilator protocol instructions increased visibility to gaps in LPV use and promoted increased adherence to LPV.
RESUMO
OBJECTIVE: To determine whether heart rate variability (HRV; a physiological measure of acute stress) is associated with persistent psychological distress among family members of adult intensive care unit (ICU) patients. METHODS: This prospective study investigated family members of patients admitted to a study ICU. Participants' variability in heart rate tracings were measured by low frequency (LF)/high frequency (HF) ratio and detrended fluctuation analysis (DFA). Questionnaires were completed 3 months after enrollment to ascertain outcome rates of anxiety, depression, and post-traumatic stress disorder (PTSD). RESULTS: Ninety-nine participants were enrolled (median LF/HF ratio, 0.92 [interquartile range, 0.64-1.38]). Of 92 participants who completed the 3-month follow-up, 29 (32%) had persistent anxiety. Logistic regression showed that LF/HF ratio (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.43, 1.53) was not associated with 3-month outcomes. In an exploratory analysis, DFA α (OR 0.93, 95% CI 0.87, 0.99), α1 (OR 0.97, 95% CI 0.94, 0.99), and α2 (OR 0.94, 95% CI 0.88, 0.99) scaling components were associated with PTSD development. CONCLUSION: Almost one-third of family members experienced anxiety at three months after enrollment. HRV, measured by LF/HF ratio, was not a predictor of psychologic distress, however, exploratory analyses indicated that DFA may be associated with PTSD outcomes.
Assuntos
Angústia Psicológica , Transtornos de Estresse Pós-Traumáticos , Adulto , Família , Frequência Cardíaca , Humanos , Unidades de Terapia Intensiva , Estudos Prospectivos , Transtornos de Estresse Pós-Traumáticos/diagnósticoRESUMO
The COVID-19 pandemic required rapid implementation testing at large scale. We describe our approach to creating an efficient and highly scalable end-to-end testing and reporting workflow. We utilized a combination of consumer-driven workflows, a consistent ordering and data collection EMR user interface, an EMR independent entry point for affiliated providers, and rapidly evolving automation of screening, registration, patient identification, curbside specimen management, and prioritization logic. Our agile approach allowed us to transition from people-driven processes and gain efficiencies utilizing previously developed informatics infrastructure, new solutions and emerging consumer digital tools. We supported over 1,000,000 tests with >200 prioritization logic changes without requiring education or changing the provider ordering workflows, handled patient-driven screening, data collection, and ordering of up to 9 patients/minute while decreasing curbside specimen collection from more than 39 to less than 17 minutes per patient. The approach supported texting consumers and standards-based reporting to public health agencies.
Assuntos
COVID-19 , Humanos , Pandemias , Saúde Pública , Fluxo de TrabalhoRESUMO
BACKGROUND: Family members of patients in intensive care units may experience psychological distress and substantial caregiver burden. OBJECTIVE: To evaluate whether change in caregiver burden from intensive care unit admission to 3-month follow-up is associated with caregiver depression at 3 months. METHODS: Caregiver burden was assessed at enrollment and 3 months later, and caregiver depression was assessed at 3 months. Depression was measured with the Hospital Anxiety and Depression Score. The primary analysis was the association between depression at 3 months and change in caregiver burden, controlling for a history of caregiver depression. RESULTS: One hundred one participants were enrolled; 65 participants had a surviving loved one and completed 3-month follow-up. At 3-month follow-up, 12% of participants met criteria for depression. Increased caregiver burden over time was significantly associated with depression at follow-up (Fisher exact test, P = .004), although this association was not significant after controlling for self-reported history of depression at baseline (Cochran-Mantel-Haenszel test, P = .23). CONCLUSIONS: Family members are increasingly recognized as a vulnerable population susceptible to negative psychological outcomes after a loved one's admission to the intensive care unit. In this small sample, no significant association was found between change in caregiver burden and depression at 3 months after controlling for baseline depression.
Assuntos
Sobrecarga do Cuidador/epidemiologia , Cuidadores/psicologia , Depressão/epidemiologia , Unidades de Terapia Intensiva , Sobreviventes , APACHE , Adaptação Psicológica , Adulto , Idoso , Estado Terminal , Família/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desempenho Físico Funcional , Qualidade de Vida , Fatores Socioeconômicos , Estresse Psicológico/epidemiologiaRESUMO
The Choosing Wisely (CW) initiative provides recommendations for healthcare providers, aimed at reducing unnecessary or inappropriate tests and procedures. A clinical decision support (CDS) alert in the electronic health record was developed to reflect organizational CW guidelines regarding blood chemistry panel ordering in the primary care setting. An interrupted time series design was used to analyze the weekly proportion of inappropriate blood chemistry panel orders prior to and after implementation of the CDS alert in treatment and control groups. Implementation of the CDS alert significantly decreased the average weekly proportion of inappropriate blood chemistry panels from 28.64% to 15.69% in the treatment group (p < .001). Apart from other efforts implemented simultaneously to reduce inappropriate lab ordering, the CDS alert produced a significant reduction in inappropriate lab ordering. We conclude that CDS alerts can be an effective strategy for healthcare organizations seeking to more closely adhere to CW guidelines.
Assuntos
Análise Química do Sangue/estatística & dados numéricos , Análise Química do Sangue/normas , Sistemas de Apoio a Decisões Clínicas , Testes Diagnósticos de Rotina/estatística & dados numéricos , Testes Diagnósticos de Rotina/normas , Guias como Assunto , Procedimentos Desnecessários/estatística & dados numéricos , Procedimentos Desnecessários/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Idaho , Masculino , Pessoa de Meia-Idade , UtahRESUMO
OBJECTIVES: Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual's resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission. DESIGN: Retrospective cohort of patients admitted to an ICU during one calendar year (2012) in a multipayer healthcare system. We assessed mortality, hospital readmissions (categorized by ambulatory care sensitive conditions and emergency department), and outpatient visits. We compared the proportion of patients with visits during the pre-ICU year versus the post-ICU year. PATIENTS: People admitted to an Intermountain healthcare ICU for greater than 48 hours in the year 2012 INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS: Among 4,074 ICU survivors, 45% had increased resource utilization. Readmission rates at 30-day, 90-day, and 1-year were 15%, 26%, and 43%. The proportion of patients with a hospital admission increased significantly in the post-ICU period (43% vs 29%; p < 0.001). Of patients with a readmission in the post-ICU period, 24% were ambulatory care sensitive condition. Patients with increased utilization differed by socioeconomic status, insurance type, and severity of illness. Sixteen percent of patients had either an emergency department or inpatient admission, but no outpatient visits during the post-ICU period. CONCLUSIONS: An ICU admission is associated with increased resource utilization including hospital readmissions, with many due to an ambulatory care sensitive condition. Lower socioeconomic status and higher severity of illness are associated with increased resource utilization. After an ICU visit patients seem to use hospital resources over outpatient resources. Interventions to improve and coordinate care after ICU discharge are needed.
Assuntos
Estado Terminal/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva , Alta do Paciente , Readmissão do Paciente/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Idaho/epidemiologia , Seguro Saúde/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Serviços de Saúde Mental/estatística & dados numéricos , Pessoa de Meia-Idade , Terapia Ocupacional/estatística & dados numéricos , Modalidades de Fisioterapia/estatística & dados numéricos , Estudos Retrospectivos , Sepse/epidemiologia , Índice de Gravidade de Doença , Choque Séptico/epidemiologia , Classe Social , Estados Unidos , Utah/epidemiologiaRESUMO
A real-time electronic CDS for pneumonia (ePNa) identifies possible pneumonia patients, measures severity and antimicrobial resistance risk, and then recommends disposition, antibiotics, and microbiology studies. Use is voluntary, and clinicians may modify treatment recommendations. ePNa was associated with lower mortality in emergency department (ED) patients versus usual care (Annals EM 66:511). We adapted ePNa for the Cerner EHR, and implemented it across Intermountain Healthcare EDs (Utah, USA) throughout 2018. We introduced ePNa through didactic, interactive presentations to ED clinicians; follow-up visits identified barriers and facilitators to use. Email reminded clinicians and answered questions. Hospital admitting clinicians encouraged ePNa use to smooth care transitions. Audit-and-feedback measured utilization, showing variations from best practice when ePNa and associated electronic order sets were not used. Use was initially low, but gradually increased especially at larger hospitals. A user-friendly interface, frequent reminders, audit-and- feedback, a user survey, a nurse educator, and local physician champions are additive towards implementation success.
Assuntos
Sistemas de Apoio a Decisões Clínicas , Serviço Hospitalar de Emergência , Pneumonia , Atitude do Pessoal de Saúde , Pesquisas sobre Atenção à Saúde , Instalações de Saúde , Hospitalização , Humanos , Gravidade do Paciente , Pneumonia/classificação , Pneumonia/diagnóstico , Pneumonia/tratamento farmacológico , Interface Usuário-Computador , UtahRESUMO
OBJECTIVES: The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients. DESIGN: This is a prospective, observational study of family members of adult ICU patients. SETTING: Adult medical and surgical ICU in a tertiary care center. SUBJECTS: Family members of ICU patients. INTERVENTIONS: Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and posttraumatic stress disorder. MEASUREMENTS AND MAIN RESULTS: Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported posttraumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02). CONCLUSIONS: Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and posttraumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.
Assuntos
Ansiedade/etiologia , Saúde da Família , Estresse Fisiológico , Estresse Psicológico/complicações , Doença Aguda , Ansiedade/diagnóstico , Feminino , Humanos , Hidrocortisona/análise , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Saliva/química , Estresse Psicológico/diagnóstico , Fatores de TempoRESUMO
OBJECTIVES: To develop a quantitative tool for identifying outpatients most likely to require life support with mechanical ventilation within 5 years. DESIGN: Retrospective cohort study. SETTING: Framingham Heart Study (FHS) 1991 to 2009 and Intermountain Healthcare clinics 2008 to 2013. PARTICIPANTS: FHS participants (n = 3,666; mean age 74; 58% female) in a derivation cohort and Intermountain Healthcare outpatients aged 65 and older (n = 88,302; mean age 73, 57% female) in an external validation cohort. MEASUREMENTS: Information on demographic characteristics and comorbidities collected during FHS examinations to derive a 5-year risk score for receiving mechanical ventilation in an intensive care unit, with external validation using administrative data from outpatients seen at Intermountain Healthcare. A sensitivity analysis investigating model performance for a composite outcome of mechanical ventilation or death was performed. RESULTS: Eighty (2%) FHS participants were mechanically ventilated within 5 years after a FHS examination. Age, sex, diabetes mellitus, hypertension, atrial fibrillation, alcohol use, chronic pulmonary disease, and hospitalization within the prior year predicted need for mechanical ventilation within 5 years (c-statistic = 0.74, 95% confidence interval (CI) = 0.68-0.80). One thousand seven hundred twenty-five (2%) Intermountain Healthcare outpatients underwent mechanical ventilation. The validation model c-statistic was 0.67 (95% CI = 0.66-0.68). Approximately 1% of individuals identified as low risk and 5% to 12% identified as high risk required mechanical ventilation within 5 years. Sensitivity analysis demonstrated a c-statistic of 0.75 (95% CI = 0.75-0.75) for risk prediction of a composite outcome of mechanical ventilation or death. CONCLUSION: A simple risk score using clinical examination data or administrative data may be used to predict 5-year risk of mechanical ventilation or death. Further study is necessary to determine whether use of a risk score enhances advance care planning or improves quality of care of older adults.
Assuntos
Cuidados para Prolongar a Vida/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Medição de Risco , Fatores Etários , Idoso , Consumo de Bebidas Alcoólicas/epidemiologia , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Hipertensão/epidemiologia , Pneumopatias/epidemiologia , Masculino , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores Sexuais , Utah/epidemiologiaRESUMO
INTRODUCTION: Sepsis is a devastating condition that is generally treated as a single disease. Identification of meaningfully distinct clusters may improve research, treatment and prognostication among septic patients. We therefore sought to identify clusters among patients with severe sepsis or septic shock. METHODS: We retrospectively studied all patients with severe sepsis or septic shock admitted directly from the emergency department to the intensive care units (ICUs) of three hospitals, 2006-2013. Using age and Sequential Organ Failure Assessment (SOFA) subscores, we defined clusters utilizing self-organizing maps, a method for representing multidimensional data in intuitive two-dimensional grids to facilitate cluster identification. RESULTS: We identified 2533 patients with severe sepsis or septic shock. Overall mortality was 17 %, with a mean APACHE II score of 24, mean SOFA score of 8 and a mean ICU stay of 5.4 days. Four distinct clusters were identified; (1) shock with elevated creatinine, (2) minimal multi-organ dysfunction syndrome (MODS), (3) shock with hypoxemia and altered mental status, and (4) hepatic disease. Mortality (95 % confidence intervals) for these clusters was 11 (8-14), 12 (11-14), 28 (25-32), and 21 (16-26) %, respectively (p < 0.0001). Regression modeling demonstrated that the clusters differed in the association between clinical outcomes and predictors, including APACHE II score. CONCLUSIONS: We identified four distinct clusters of MODS among patients with severe sepsis or septic shock. These clusters may reflect underlying pathophysiological differences and could potentially facilitate tailored treatments or directed research.
Assuntos
Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/mortalidade , Fenótipo , Sepse/diagnóstico , Sepse/mortalidade , Choque Séptico/diagnóstico , Choque Séptico/mortalidade , APACHE , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Estudos Retrospectivos , Sepse/epidemiologia , Utah/epidemiologiaRESUMO
BACKGROUND: Patients' perceptions of the quality of their hospitalization have become important to the American healthcare system. Standard surveys of perceived quality of healthcare do not focus on the Intensive Care Unit (ICU) portion of the stay. Our objective was to evaluate the construct validity and internal consistency of the Intermountain Patient Perception of Quality (PPQ) survey among patients discharged from the ICU. METHODS: We analyzed prospectively collected results from the ICU PPQ survey of all inpatients at Intermountain Medical Center whose hospitalization included an ICU stay. We employed principal components analysis to determine the constructs present in the PPQ survey, and Cronbach's alpha to evaluate the internal consistency (reliability) of the items representing each construct. RESULTS: We identified 5,680 patients who had completed the PPQ survey. There were three basic domains measured: nursing care, physician care, and overall perception of quality. Most of the variability was explained with the first two principal components. Constructs did not vary by type of respondent. CONCLUSIONS: The Intermountain ICU PPQ survey demonstrated excellent construct validity across three distinct constructs. This, in addition to its previously established content validity, suggests the utility of the PPQ survey as an assay of the perceived quality of the ICU experience.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Unidades de Terapia Intensiva , Satisfação do Paciente , Qualidade da Assistência à Saúde , Inquéritos e Questionários/normas , Sobreviventes , Cuidados Críticos , Pesquisas sobre Atenção à Saúde , Humanos , Alta do Paciente , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
Severe shock is a life-threatening condition with very high short-term mortality. Whether the long-term outcomes among survivors of severe shock are similar to long-term outcomes of other critical illness survivors is unknown. We therefore sought to assess long-term survival and functional outcomes among 90-day survivors of severe shock and determine whether clinical predictors were associated with outcomes. Seventy-six patients who were alive 90 days after severe shock (received ≥1 µg/kg per minute of norepinephrine equivalent) were eligible for the study. We measured 3-year survival and long-term functional outcomes using the Medical Outcomes Study 36-Item Short-Form Health Survey, the EuroQOL 5-D-3L, the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised, and an employment instrument. We also assessed the relationship between in-hospital predictors and long-term outcomes. The mean long-term survival was 5.1 years; 82% (62 of 76) of patients survived, of whom 49 were eligible for follow-up. Patients who died were older than patients who survived. Thirty-six patients completed a telephone interview a mean of 5 years after hospital admission. The patients' Physical Functioning scores were below U.S. population norms (P < 0.001), whereas mental health scores were similar to population norms. Nineteen percent of the patients had symptoms of depression, 39% had symptoms of anxiety, and 8% had symptoms of posttraumatic stress disorder. Thirty-six percent were disabled, and 17% were working full-time. Early survivors of severe shock had a high 3-year survival rate. Patients' long-term physical and psychological outcomes were similar to those reported for cohorts of less severely ill intensive care unit survivors. Anxiety and depression were relatively common, but only a few patients had symptoms of posttraumatic stress disorder. This study supports the observation that acute illness severity does not determine long-term outcomes. Even extremely critically ill patients have similar outcomes to general intensive care unit survivor populations.
Assuntos
Choque/diagnóstico , APACHE , Adulto , Idoso , Emprego/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Prognóstico , Psicometria , Qualidade de Vida , Estudos Retrospectivos , Choque/mortalidade , Choque/psicologia , Choque/terapia , Análise de Sobrevida , Resultado do Tratamento , Utah/epidemiologia , Vasoconstritores/uso terapêuticoRESUMO
PURPOSE: To determine whether variability of coarsely sampled heart rate and blood pressure early in the course of severe sepsis and septic shock predicts successful resuscitation, defined as vasopressor independence at 24 hours after admission. METHODS: In an observational study of patients admitted with severe sepsis or septic shock from 2009 to 2011 to either of 2 intensive care units (ICUs) at a tertiary-care hospital, in whom blood pressure was measured via an arterial catheter, we sampled heart rate and blood pressure every 30 seconds over the first 6 hours of ICU admission and calculated the coefficient of variability of those measurements. Primary outcome was vasopressor independence at 24 hours; and secondary outcome was 28-day mortality. RESULTS: We studied 165 patients, of which 97 (59%) achieved vasopressor independence at 24 hours. Overall, 28-day mortality was 15%. Significant predictors of vasopressor independence at 24 hours included the coefficient of variation of heart rate, age, Acute Physiology and Chronic Health Evaluation II, the number of increases in vasopressor dose, mean vasopressin dose, mean blood pressure, and time-pressure integral of mean blood pressure less than 60 mm Hg. Lower sampling frequencies (up to once every 5 minutes) did not affect the findings. CONCLUSIONS: Increased variability of coarsely sampled heart rate was associated with vasopressor independence at 24 hours after controlling for possible confounders. Sampling frequencies of once in 5 minutes may be similar to once in 30 seconds.
Assuntos
Pressão Sanguínea , Frequência Cardíaca , Sepse/fisiopatologia , Choque Séptico/fisiopatologia , APACHE , Idoso , Cuidados Críticos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Sepse/tratamento farmacológico , Choque Séptico/tratamento farmacológico , Fatores de Tempo , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVE: Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration. MATERIALS AND METHODS: A 2-year prospective, observational study at a large level 1 trauma center. All patients admitted to a 33-bed medical and oncology floor (A) and a 33-bed non-intensive care unit (ICU) surgical trauma floor (B) were monitored. During the intervention year, pager alerts of early physiologic deterioration were automatically sent to charge nurses along with access to a graphical point-of-care web page to facilitate patient evaluation. RESULTS: Nurses reported the positive predictive value of alerts was 91-100% depending on erroneous data presence. Unit A patients were significantly older and had significantly more comorbidities than unit B patients. During the intervention year, unit A patients had a significant increase in length of stay, more transfers to ICU (p = 0.23), and significantly more medical emergency team (MET) calls (p = 0.0008), and significantly fewer died (p = 0.044) compared to the pre-intervention year. No significant differences were found on unit B. CONCLUSIONS: We monitored patients every 5 min and provided automated pages of early physiologic deterioration. This before-after study found a significant increase in MET calls and a significant decrease in mortality only in the unit with older patients with multiple comorbidities, and thus further study is warranted to detect potential confounding. Moreover, nurses reported the graphical alerts provided information needed to quickly evaluate patients, and they felt more confident about their assessment and more comfortable requesting help.
Assuntos
Sistemas de Apoio a Decisões Clínicas , Monitorização Fisiológica/métodos , Comorbidade , Progressão da Doença , Emergências/epidemiologia , Hospitalização , Humanos , Recursos Humanos de Enfermagem Hospitalar , Equipe de Assistência ao Paciente , Estudos Prospectivos , Centros de TraumatologiaRESUMO
OBJECTIVE: The Sequential Organ Failure Assessment (SOFA) score, a measure of multiple-organ dysfunction syndrome, is used to predict mortality in critically ill patients by assigning equally weighted scores across 6 different organ systems. We hypothesized that specific organ systems would have a greater association with mortality than others. DESIGN: We retrospectively studied patients admitted over a period of 4.2 years to a mixed-profile intensive care unit (ICU). We recorded age and comorbidities, and calculated SOFA organ scores. The primary outcome was 30-day all-cause mortality. We determined which organ subscores of the SOFA score were most associated with mortality using multiple analytic methods: random forests, conditional inference trees, distanced-based clustering techniques, and logistic regression. SETTING: A 24-bed mixed-profile adult ICU that cares for medical, surgical, and trauma (level 1) patients at an academic referral center. PATIENTS: All patients' first admission to the study ICU during the study period. MEASUREMENTS AND MAIN RESULTS: We identified 9120 first admissions during the study period. Overall 30-day mortality was 12%. Multiple analytical methods all demonstrated that the best initial prediction variables were age and the central nervous system SOFA subscore, which is determined solely by Glasgow Coma Scale score. CONCLUSIONS: In a mixed population of critically ill patients, the Glasgow Coma Scale score dominates the association between admission SOFA score and 30-day mortality. Future research into outcomes from multiple-organ dysfunction may benefit from new models for measuring organ dysfunction with special attention to neurologic dysfunction.
Assuntos
Cuidados Críticos/estatística & dados numéricos , Escala de Coma de Glasgow , Mortalidade Hospitalar , Insuficiência de Múltiplos Órgãos/mortalidade , Escores de Disfunção Orgânica , Adulto , Fatores Etários , Idoso , Causas de Morte , Estado Terminal , Feminino , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de TempoRESUMO
Electronic problem lists are essential to modern health record systems, with a primary goal to serve as the repository of a patient's current health issues. Additionally, coded problems can be used to drive downstream activities such as decision support, evidence-based medicine, billing, and cohort generation for research. Meaningful Use also requires use of a coded problem list. Over the course of three years, Intermountain Healthcare developed a problem management module (PMM) that provided innovative functionality to improve clinical workflow and boost problem list adoption, e.g. smart search, user customizable views, problem evolution, and problem timelines. In 23 months of clinical use, clinicians entered over 70,000 health issues, the percentage of free-text items dropped to 1.2%, completeness of problem list items increased by 14%, and more collaborative habits were initiated.
Assuntos
Registros Médicos Orientados a Problemas , Interface Usuário-Computador , Fluxo de Trabalho , Prestação Integrada de Cuidados de Saúde , Humanos , UtahRESUMO
INTRODUCTION: Heart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis. METHODS: We prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality. RESULTS: We studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality (P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence. CONCLUSIONS: Loss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis.
Assuntos
Fractais , Frequência Cardíaca/fisiologia , Ressuscitação/métodos , Sepse/fisiopatologia , Sepse/terapia , APACHE , Adulto , Teorema de Bayes , Eletrocardiografia , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sepse/mortalidade , Choque Séptico/mortalidade , Choque Séptico/fisiopatologia , Choque Séptico/terapia , Taxa de Sobrevida , Resultado do Tratamento , Utah/epidemiologia , Vasoconstritores/administração & dosagemRESUMO
RATIONALE: Severe sepsis and septic shock are leading causes of intensive care unit (ICU) admission, morbidity, and mortality. The effect of compliance with sepsis management guidelines on outcomes is unclear. OBJECTIVES: To assess the effect on mortality of compliance with a severe sepsis and septic shock management bundle. METHODS: Observational study of a severe sepsis and septic shock bundle as part of a quality improvement project in 18 ICUs in 11 hospitals in Utah and Idaho. MEASUREMENTS AND MAIN RESULTS: Among 4,329 adult subjects with severe sepsis or septic shock admitted to study ICUs from the emergency department between January 2004 and December 2010, hospital mortality was 12.1%, declining from 21.2% in 2004 to 8.7% in 2010. All-or-none total bundle compliance increased from 4.9-73.4% simultaneously. Mortality declined from 21.7% in 2004 to 9.7% in 2010 among subjects noncompliant with one or more bundle element. Regression models adjusting for age, severity of illness, and comorbidities identified an association between mortality and compliance with each of inotropes and red cell transfusions, glucocorticoids, and lung-protective ventilation. Compliance with early resuscitation elements during the first 3 hours after emergency department admission caused ineligibility, through lower subsequent severity of illness, for these later bundle elements. CONCLUSIONS: Total severe sepsis and septic shock bundle compliances increased substantially and were associated with a marked reduction in hospital mortality after adjustment for age, severity of illness, and comorbidities in a multicenter ICU cohort. Early resuscitation bundle element compliance predicted ineligibility for subsequent bundle elements.