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1.
J Intensive Care Med ; 35(5): 461-467, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-29458294

RESUMO

BACKGROUND: Various intensivist staffing models have been suggested, but the long-term sustainability and outcomes vary and may not be sustained. We examined the impact of implementing a high-intensity intensivist coverage model with a nighttime in-house nocturnist (non-intensivist) and its effect on intensive care unit (ICU) outcomes. METHODS: We obtained historical control baseline data from 2007 to 2011 and compared the same data from 2011 to 2015. The Acute Physiological and Chronic Health Evaluation outcomes system was utilized to collect clinical, physiological, and outcome data on all adult patients in the medical ICU and to provide severity-adjusted outcome predictions. The model consists of a mandatory in-house daytime intensivist service that leads multidisciplinary rounds, and an in-house nighttime coverage is provided by nocturnist (nonintensivists) with current procedural skills in airways management, vascular access, and commitment to supervise house staff as needed. The intensivist continues to be available remotely at nighttime for house staff and consultation with the nocturnist. A backup intensivist is available for surge management. RESULTS: First year yielded improved throughput (2428 patients/year to 2627 then 2724 at fifth year). Case mix stable at 53.7 versus 55.2. The ICU length of stay decreased from 4.7 days (predicted 4.25 days) to 3.8 days (4.15) in first year; second year: 3.63 days (4.29 days); third year: 3.24 days (4.37), fourth year: 3.34 days (4.45), and fifth year: 3.61 days (4.42). Intensive care unit <24 hours readmission remained at 1%; >24 hours increased from 4% to 6%. Low-risk monitoring admissions remained at an average 17% (benchmark 17.18%). Intensive care unit mortality improved with standardized mortality ration averaging at 0.84. Resident satisfaction surveys improved. CONCLUSIONS: Implementing an intensivist service with nighttime nocturnist staffing in a high-intensity large teaching hospital is feasible and improved ICU outcomes in a sustained manner that persisted after the initial implementation phase. The model resulted in reduced and sustained observed-to-predicted length of ICU stay.


Assuntos
Resultados de Cuidados Críticos , Cuidados Críticos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Corpo Clínico Hospitalar/organização & administração , Assistência Noturna/organização & administração , APACHE , Idoso , Estado Terminal/mortalidade , Bases de Dados Factuais , Estudos de Viabilidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão e Escalonamento de Pessoal , Estudos Prospectivos , Estudos Retrospectivos
2.
J Crit Care ; 53: 107-113, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31228760

RESUMO

PURPOSE: To determine the feasibility of conducting a multicenter ICU RCT of AFS compared to either protocol-directed sedation (PDS) or both PDS and daily sedation interruption (DSI) in North America. MATERIALS AND METHODS: This single-center RCT compared AFS [fentanyl (bolus ± infusions) to reach CPOT ≤2; if RASS ≥1, CPOT ≤2 and additional fentanyl failed to reach RASS goal (-2 to 0), low-dose propofol (up to 6 h) was given] with either PDS or both PDS and DSI daily in adults mechanically ventilated (MV) ≥48 h. Relevant feasibility, safety, and clinical outcomes were defined and evaluated. RESULTS: 90 of 160 eligible patients were enrolled [AFS = 27; PDS = 28; PDS + DSI = 31]; rate = 3/month. Time from intubation to randomization was 17.5 ±â€¯11.6 h. Study days fully adherent to the study intervention [AFS = 95%; PDS = 99%; PDS + DSI = 96%] and time spent in the first 48 h after randomization without pain (CPOT ≤2)[AFS = 82%; PDS = 78%; PDS + DSI = 77%] and at goal RASS[AFS = 88%; PDS = 83%; PDS + DSI = 95%] were high and similar. Nurse-perceived [median (IQR)] study workload (10-point VAS) was higher with AFS [4(2-6)] than PDS [1(1-3)] or PDS + DSI [2(1-5)]; p = .002). Unplanned extubation was rare (AFS = 1; PDS = 0; PDS + DSI = 1). Days [median (IQR)] free of MV in the 28d after intubation [AFS 24(23,26); PDS 24(20,26); PDS + DSI 24(21,26)] was not different (p = .62). CONCLUSION: A multicenter RCT evaluating AFS is feasible to conduct in North America.


Assuntos
Analgesia/métodos , Anestesia/métodos , Estado Terminal/terapia , Dor/prevenção & controle , Respiração Artificial/métodos , Idoso , Analgésicos Opioides/administração & dosagem , California , Protocolos Clínicos , Quimioterapia Combinada , Estudos de Viabilidade , Feminino , Fentanila/administração & dosagem , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Projetos Piloto , Propofol/administração & dosagem , Fatores de Tempo
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