Impact of the Staffing Structure of Intensive Care Units and High Care Units on In-Hospital Mortality Among Patients with Sepsis: A Retrospective Analysis of Japanese Nationwide Claims Data

Mapping Intimacies ◽

10.21203/rs.3.rs-796517/v1 ◽

2021 ◽

Author(s):

Kota Nishimoto ◽

Takeshi Umegaki ◽

Takahiko Kamibayashi

Keyword(s):

Critical Care ◽

Intensive Care ◽

Hospital Mortality ◽

Intensive Care Units ◽

Acute Care ◽

Patient Outcomes ◽

Acute Care Hospitals ◽

High Care

Abstract Background: Critical care in Japan is provided in intensive care units (ICUs) and high care units (HCUs), which are categorized based on their fulfillment of different staffing criteria. Under Japan’s medical fee reimbursement system, units with higher staffing levels are eligible to receive higher reimbursements. However, the different staffing structure of these units may affect the quality of care and patient outcomes. This study aimed to analyze the impact of ICU/HCU staffing structure on in-hospital mortality among septic patients in Japan’s acute care hospitals using a nationwide claims database.Methods: We conducted a large-scale multicenter retrospective cohort study of adult septic patients (aged ≥18 years) who received critical care in acute care hospitals throughout Japan between April 2018 and March 2019. Patients were categorized into three groups according to the type of unit in which they received critical care: Type 1 ICUs (fulfilling stringent staffing criteria such as experienced intensivists and high nurse-to-patient ratios), Type 2 ICUs (fulfilling less stringent criteria), and HCUs (fulfilling the least stringent criteria). A Cox proportional hazards regression model was constructed with in-hospital mortality as the dependent variable and the ICU/HCU groups as the main independent variable of interest. Other covariates included age, emergency or non-emergency admission, major diagnostic categories, mechanical ventilation, noninvasive positive airway pressure ventilation, oxygen therapy, and renal replacement therapy.Results: We analyzed 2411 patients (178 hospitals) in the Type 1 ICU group, 3653 patients (422 hospitals) in the Type 2 ICU group, and 4904 patients (521 hospitals) in the HCU group. When compared with the HCU group, the adjusted hazard ratios for in-hospital mortality were 0.74 (95% confidence interval: 0.71–0.77; P<0.001) for the Type 1 ICU group and 0.83 (0.80–0.85; P<0.001) for the Type 2 ICU group. Emergency hospital admission had the highest hazard ratio for in-hospital mortality (hazard ratio: 4.78; P<0.001).Conclusions: ICUs that fulfill more stringent staffing criteria were associated with lower in-hospital mortality in septic patients than HCUs after adjusting for confounders. Optimizing the staffing structure of these units may contribute to the improvement of patient outcomes.

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Long-term weaning centres in critical care

10.1093/med/9780199600830.003.0384 ◽

2016 ◽

Author(s):

Jeremy M. Kahn

Keyword(s):

Mechanical Ventilation ◽

Intensive Care ◽

Acute Care ◽

Patient Outcomes ◽

Prolonged Mechanical Ventilation ◽

Multidisciplinary Care ◽

Acute Care Hospitals ◽

Optimal Timing ◽

Physician Staffing ◽

Multidisciplinary Care Team

Successfully weaning patients from prolonged mechanical ventilation requires the varied expertise of a dedicated multidisciplinary care team. Traditionally, this care was provided in acute care hospitals, increasingly these patients are transferred to specialized weaning centres. These may improve patient outcomes by concentrating weaning expertise in a low-acuity environment and implementing protocols for liberation from mechanical ventilation. However, these centres might also worsen patient outcomes because they typically offer less intense nurse and physician staffing compared with traditional intensive care units. Generally, the clinical evidence is mixed, with the best studies suggesting that weaning centres offer similar outcomes as acute care hospitals, but at lower costs. Health systems also might stand to gain from dedicated weaning centres, because they can release intensive care unit beds for more acutely-ill patients. Many gaps remain in our understanding of which patients should be transferred to dedicated weaning centres, the optimal timing of transfer, and the best approach to care for patients in this highly specialized setting.

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How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study

American Journal of Epidemiology ◽

10.1093/aje/kwaa247 ◽

2020 ◽

Author(s):

Bruce Y Lee ◽

Sarah M Bartsch ◽

Michael Y Lin ◽

Lindsey Asti ◽

Joel Welling ◽

...

Keyword(s):

Intensive Care ◽

Intensive Care Units ◽

Acute Care ◽

Acute Care Hospitals ◽

Control Measures ◽

Metropolitan Region ◽

Drug Resistant ◽

Carbapenem Resistant ◽

Carbapenem Resistant Enterobacteriaceae

Abstract Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%–17.1%, averted 1,090–2,795 new carriers, 273–722 infections and 37–87 deaths over 3 years and saved $30.5–$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.

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After-Hours/Nighttime Transfers Out of the Intensive Care Unit and Patient Outcomes: A Systematic Review and Meta-Analysis

Journal of Intensive Care Medicine ◽

10.1177/0885066620984410 ◽

2020 ◽

pp. 088506662098441

Author(s):

Anton I. Moshynskyy ◽

Jonathan F. Mailman ◽

Eric J. Sy

Keyword(s):

Systematic Review ◽

Critical Care ◽

Intensive Care ◽

Hospital Mortality ◽

Patient Outcomes ◽

Meta Analysis ◽

Case Series ◽

Hospital Length Of Stay ◽

Cochrane Library ◽

After Hours

Purpose: We evaluated the effects of after-hours/nighttime patient transfers out of the ICU on patient outcomes, by performing a systematic review and meta-analysis (PROSPERO CRD 42017074082). Data Sources: MEDLINE, PubMed, EMBASE, Google Scholar, CINAHL, and the Cochrane Library from 1987-November 2019. Conference abstracts from the Society of Critical Care Medicine, American Thoracic Society, CHEST, Critical Care Canada Forum, and European Society of Intensive Care Medicine from 2011-2019. Data Extraction: Observational or randomized studies of adult ICU patients were selected if they compared after-hours transfer out of the ICU to daytime transfer on patient outcomes. Case reports, case series, letters, and reviews were excluded. Study year, country, design, co-variates for adjustment, definitions of after-hours, mortality rates, ICU readmission rates, and hospital length of stay (LOS) were extracted. Data Synthesis: We identified 3,398 studies. Thirty-one observational studies (1,418,924 patients) were selected for the systematic review and meta-analysis. Included studies had varying definitions of after-hours, with the after-hours period starting anytime between 16:00-22:00 and ending between 06:00-09:00. Approximately 16% of transfers occurred after-hours. After-hours transfers were associated with increased in-hospital mortality for both unadjusted (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.30-1.75, I2 = 96%, number of studies [n] = 26, P < 0.001, low certainty) and adjusted (OR 1.32, 95% CI 1.25-1.38, I 2 = 33%, n = 10, P < 0.001, low certainty) data, compared to daytime transfers. They were also associated with increased ICU readmission (pooled unadjusted OR 1.28, 95% CI 1.18-1.38, I2 = 85%, n = 17, P < 0.001, low certainty) and longer hospital LOS (standardized mean difference 0.13, 95% CI 0.09-0.18, I 2 = 93%, n = 9, P < 0.001, low certainty), compared to daytime transfers. Conclusions: After-hours transfers out of the ICU are associated with increased in-hospital mortality, ICU readmission, and hospital LOS, across many settings. While the certainty of evidence is low, future research is needed to reduce the number and effects of after-hours transfers.

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High sensitivity troponin measurement in critical care: Flattering to deceive or ‘never means nothing’?

Journal of the Intensive Care Society ◽

10.1177/1751143719870095 ◽

2019 ◽

Vol 21 (3) ◽

pp. 232-240 ◽

Cited By ~ 3

Author(s):

Jonathan Hinton ◽

Mark Mariathas ◽

Michael PW Grocott ◽

Nick Curzen

Keyword(s):

Myocardial Infarction ◽

Critical Care ◽

Intensive Care ◽

High Sensitivity ◽

Acute Type ◽

Ongoing Research ◽

Troponin Elevation

Introduction Troponin elevation is central to the diagnosis of acute type 1 myocardial infarction. It is, however, elevated in a range of other conditions, including type 2 myocardial infarction, and this setting is increasingly associated with adverse clinical outcomes. Patients within intensive care frequently have at least one organ failure together with a range of co-morbidities. Interpretation of troponin assay results in this population is challenging. This clinical uncertainty is compounded by the introduction of ever more sensitive troponin assays. Areas covered The aims of this review are to (a) describe the currently available literature about the use of troponin assays in intensive care, (b) analyse the challenges presented by the introduction of increasingly sensitive troponin assays and (c) assess whether the role of troponin assays in intensive care may change in the future, dependent upon recent and ongoing research suggesting that they are predictive of outcome regardless of the underlying cause: the ‘never means nothing’ hypothesis.

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Faculty Opinions recommendation of Association between arterial catheter use and hospital mortality in intensive care units.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718768114.793500247 ◽

2014 ◽

Author(s):

Jay Koyner

Keyword(s):

Intensive Care ◽

Hospital Mortality ◽

Intensive Care Units ◽

Arterial Catheter

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Paediatric admissions to a district general hospital adult intensive care unit over a six year period: A single centre retrospective case series, with review of practitioner confidence and competence in paediatric critical care

Journal of the Intensive Care Society ◽

10.1177/17511437211012151 ◽

2021 ◽

pp. 175114372110121

Author(s):

Stephen A Spencer ◽

Joanna S Gumley ◽

Marcin Pachucki

Keyword(s):

Critical Care ◽

Intensive Care ◽

Intensive Care Units ◽

Case Series ◽

Critically Ill Children ◽

Single Centre ◽

Retrospective Case ◽

Retrospective Case Series ◽

Paediatric Critical Care ◽

Doctors And Nurses

Background Critically ill children presenting to district general hospitals (DGH) are admitted to adult intensive care units (AICUs) for stabilisation prior to transfer to paediatric intensive care units (PICUs). Current training in PICU for adult intensive care physicians is only three months. This single centre retrospective case series examines the case mix of children presenting to a DGH AICU and a multidisciplinary survey assesses confidence and previous experience, highlighting continued training needs for DGH AICU staff. Methods all paediatric admissions to AICU and paediatric retrievals were reviewed over a 6-year period (2014-2019). Cases were identified from the Electronic Patient Record (EPR) and from data provided by the regional paediatric retrieval service. A questionnaire survey was sent to AICU doctors and nurses to assess confidence and competence in paediatric critical care. Results Between 2014-2019, 284 children were managed by AICU. In total 35% of cases were <1 y, 48% of cases were <2 y and 64% of cases were <5 y, and 166/284 (58%) children were retrieved. Retrieval reduced with increasing age (OR 0.49 [0.40-0.60], p < 0.0001). The survey had an 82% response rate, and highlighted that only 13% of AICU nurses and 50% of doctors had received prior PICU training. Conclusion At least one critically unwell child presents to the AICU each week. Assessment, stabilisation and management of critically unwell children are vital skills for DGH AICU staff, but confidence and competence are lacking. Formalised strategies are required to develop and maintain paediatric competencies for AICU doctors and nurses.

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The Organizational Structure of Intensive Care Units and its Influence on Patient Outcomes

Healthcare Management Forum ◽

10.1016/s0840-4704(10)60422-x ◽

2001 ◽

Vol 14 (4) ◽

pp. 28-34 ◽

Cited By ~ 6

Author(s):

D.J. Kutsogiannis ◽

C. Hague ◽

O.H. Triska ◽

R.G. Johnston ◽

T. Noseworthy

Keyword(s):

Intensive Care ◽

Organizational Structure ◽

Intensive Care Units ◽

Patient Outcomes

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Score for Neonatal Acute Physiology: Validation in Three Kaiser Permanente Neonatal Intensive Care Units

PEDIATRICS ◽

10.1542/peds.96.5.918 ◽

1995 ◽

Vol 96 (5) ◽

pp. 918-922 ◽

Cited By ~ 6

Author(s):

Gabriel J. Escobar ◽

Allen Fischer ◽

De Kun Li ◽

Robert Kremers ◽

Mary Anne Armstrong

Keyword(s):

Intensive Care ◽

Birth Weight ◽

Hospital Mortality ◽

Intensive Care Units ◽

Neonatal Intensive Care ◽

Severity Of Illness ◽

Predictive Ability ◽

Neonatal Intensive Care Units ◽

Total Hospital ◽

Total Hospital Stay

Background. Measurement of the severity of illness is a research area of growing importance in neonatal intensive care. Most severity of illness scales have been developed in tertiary care settings. Their applicability in community neonatal intensive care units has not been tested. Objectives. Our goal was to assess the operational characteristics of the score for neonatal acute physiology (SNAP): the relationship to birth weight, the length of total hospital stay, and in-hospital mortality. Methods. We assigned SNAP scores prospectively to all inborn admissions at three community neonatal intensive care units during an 11-month period. Data on other neonatal predictors (eg, birth weight and the presence of congenital heart disease) were also collected. We measured in-hospital mortality, the experience of interhospital transport to a higher level of care, and total hospital stay. Results. We found that the SNAP's relationship to birth weight was similar to previous reports. The SNAP's perinatal extension is a reliable predictor of newborn in-hospital mortality, with an area under the receiver operator characteristic curve of 0.95. The SNAP is also a good predictor of total hospital length of stay, whether by itself (by which it can explain 31% of the total stay) or in combination with other variables. Its predictive ability is better among infants of low birth weight (<2500 g) than among those of normal birth weight (≥2500 g). The SNAP's predictive power was most limited among infants admitted to rule out sepsis. The predictive ability of a model containing birth weight, the SNAP, and transport status was not improved by the inclusion of two major diagnostic categories, the presence of congenital heart disease or complex illness. Conclusion. Although it has definite limitations among infants who weigh 2500 g or more, the SNAP is a potent tool for outcomes research. Modification of some of its parameters could result in a multifunctional scale suitable for use with all birth weights.

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Post–Intensive Care Syndrome in Family Decision Makers of Long-term Acute Care Hospital Patients

American Journal of Critical Care ◽

10.4037/ajcc2017414 ◽

2017 ◽

Vol 26 (5) ◽

pp. 416-422 ◽

Cited By ~ 3

Author(s):

Amy Petrinec

Keyword(s):

Quality Of Life ◽

Intensive Care ◽

Acute Care ◽

Acute Care Hospitals ◽

Summary Score ◽

Decision Makers ◽

Family Decision ◽

Post Intensive Care Syndrome

Background Family members of critically ill patients experience indications of post–intensive care syndrome, including anxiety, depression, and posttraumatic stress disorder. Despite increased use of long-term acute care hospitals for critically ill patients, little is known about the impact of long-term hospitalization on patients’ family members. Objectives To examine indications of post–intensive care syndrome, coping strategies, and health-related quality of life among family decision makers during and after patients’ long-term hospitalization. Methods A single-center, prospective, longitudinal descriptive study was undertaken of family decision makers of adult patients admitted to long-term acute care hospitals. Indications of post–intensive care syndrome and coping strategies were measured on the day of hospital admission and 30 and 60 days later. Health-related quality of life was measured by using the Short Form-36, version 2, at admission and 60 days later. Results The sample consisted of 30 family decision makers. On admission, 27% reported moderate to severe anxiety, and 20% reported moderate to severe depression. Among the decision makers, 10% met criteria for a provisional diagnosis of posttraumatic stress disorder. At admission, the mean physical summary score for quality of life was 47.8 (SD, 9.91) and the mean mental summary score was 48.00 (SD, 10.28). No significant changes occurred during the study period. Problem-focused coping was the most frequently used coping strategy at all time points. Conclusion Family decision makers of patients in long-term acute care hospitals have a significant prevalence of indications of post–intensive care syndrome.

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