Relation of Reported Sedation and Ventilator Weaning Practices to Ventilator Time in Norwegian Intensive Care Units

Background. Guidelines for sedation, ventilator weaning, and delirium screening are helpful to avoid too deep sedation and to identify signs of delirium in the intensive care unit (ICU). Methods. National ICU registry members (n=37) were surveyed regarding use of scoring instruments and guidelines for sedation and ventilator weaning, choice of drugs, and daily sedation interruption practices. Results were merged with registry data on ventilator time and length of stay for ICU patients ventilated >24 hours (7.075 ICU stays). Results. Eighty-five percent of the 33 responding ICUs used sedation scales and 39% and 55% had sedation and weaning protocols, respectively. An association was found between using protocols and longer mean ventilator time and mean length of ICU stay. Thirty three percent (11/33) practiced daily sedation interruption. Regular delirium assessment was associated with significantly shorter mean ventilator time and mean length of ICU stay but used by few. Conclusion. More ICUs had guidelines for weaning than for sedation. The ventilator time and length of ICU stay compared well with other studies. Although having guidelines was associated with longer ventilator time and ICU stay, the differences were rather small. Daily sedation interruption was seldom used. Few units used delirium scoring instruments.

The Reduction of Catheter-Related Blood Stream Infections through the Implementation of an Interdisciplinary Healthcare Team

In December 2012, a multidisciplinary task force was implemented to address the elevated number of central line associated boodstream infections (CLABSIs) at Newark Beth Israel Medical Center from January 2012 to December 2012. Sixty-eight CLABSIs were documented within the adult inpatient population, resulting in a rate of 14.7 CLABSIs/1,000 central line days in the adult inpatient population. This was well above the national average of 1.87 infections per 1,000 central line days. Most of these infections were noted to be within the critical care units where the rate was at 2.86 CLABSIs/1,000 central line days. However, in 2013, the annual rate was decreased to 0.709 CLABSIs/1000 line days (P<0.001) with similar trends observed across the critical care units. Analysis of CLASBI data indicates that the implementation of a multidisciplinary task force dedicated to appropriate central line insertion, maintenance, and the removal of unnecessary central venous catheters can have an impact on reducing rates of CLASBIs throughout the adult inpatient population, including those within critical care units.

Prolonged Emergency Department Length of Stay as a Predictor of Adverse Outcomes in Patients with Intracranial Hemorrhage

Objectives. Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH). Methods. Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08–6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival. Results. Of the 162 patients included, 60 (37.0%) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED ≥5 hours was a significant independent predictor of discharge mRS 4–6 (OR 3.638, 95% CI 1.531–8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95% CI 1.491–6.236, and P = 0.0023) but not death. Conclusions. Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.

Validation of Factors Affecting the Outcome of Cardiopulmonary Arrest in a Large, Urban, Academic Medical Center

Background. Recent studies of risks in cardiopulmonary arrest (CPA) have been performed using large databases from a broad mix of hospital settings. However, these risks might be different in a large, urban, academic medical center. We attempted to validate factors influencing outcomes from CPA at the University of Maryland Medical Center (UMMC). Methods. Retrospective chart review of all adult patients who underwent CPA between 2000 and 2005 at UMMC. Risk factors and outcomes were analyzed with appropriate statistical analysis and compared with published results. Results. 729 episodes of CPA were examined during the study period. Surgical patients had better survival than medical or cardiac patients. Intensive care unit' (ICU) patients had poor survival, but there was no difference on monitored or unmonitored floors. Respiratory etiologies survived better than cardiac etiologies. CPR duration and obesity were negatively correlated with outcome, while neurologic disease, trauma, and electrolyte imbalances improved survival. Age, gender, race, presence of a witness, presence of a monitor, comorbidities, or time of day of CPA did not influence survival, although age was associated with differences in comorbidities. Conclusions. UMMC risk factors for CPA survival differed from those in more broad-based studies. Care should be used when applying the results of database studies to specific medical institutions.

A National Survey of Pediatric Intensive Care Units in Pakistan

Purpose. To describe the structure, staffing resources, equipment, academic activities, and characteristics of pediatric population of pediatric intensive care units across the country. Material & Method. This was a prospective, descriptive, and observational survey of pediatric intensive care units from January to December 2009 across Pakistan. A questionnaire survey was emailed to director of each unit. Results. 16 PICUs were participated in this survey (100% response rate). A total of units with 155 beds were identified (1.1 bed /500,000 children). Regarding the categories, 12 (75%) were medical, 3 (19%) were pure cardiac intensive care units, and one unit (6%) was combined multidisciplinary cardiothoracic unit. 13 (81%) units were in public sector as compared to 3 (19%) were in private sector. The mean unit size was 9.7 (range 4–28) beds. Twelve (75%) units were located in three large cities. Only 3 (19%) units have trained intensivist. 37% (6/16) had nurse to patient ratio of 1 : 1-1 : 2 while others had ratios of 1 : 3–1 : 5 with all nurses specialized trained for pediatric intensive care units with bachelor degree or diploma in nursing. Only 50% had capacity for invasive monitoring. Conclusion. We found inadequacies in several aspects of PICUs in Pakistan including fewer PICUs, inadequate PICU beds, and lack of trained personal to look after critically ill pediatric population.

Refractory Status Epilepticus: Experience in a Neurological Intensive Care Unit

Introduction. Refractory status epilepticus (RSE) has significant morbidity and mortality, and its management requires an accurate diagnosis and aggressive treatment. Objectives. To describe the experience of management of RSE in a neurological intensive care unit (NeuroICU) and determine predictors of short-term clinical outcome. Methods. We reviewed cases of RSE from September 2007 to December 2008. Management was titrated to findings on continuous video EEG (cVEEG). We collected patients’ demographics, RSE etiology, characteristics of seizures, cVEEG findings, treatments, and short-term outcome. Control of RSE was to achieve burst suppression pattern or electrographic cessation of ictal activity. Results. We included 80 patients; 63.8% were in coma, 25% had subclinical seizures, and 11.3% had focal activity. 51.3% were male and mean age was 45 years. Etiology was neurological lesion in 75.1%, uncontrolled epilepsy in 20%, and systemic derangements in 4.9%. 78.8% were treated with general anesthesia and concomitant anticonvulsant drugs. The control of RSE was 87.5% of patients. In-hospital mortality was 22.5%. The factors associated with unfavorable short-term outcome were coma and age over 60 years. Conclusions. RSE management guided by cVEEG is associated with a good seizure control. A multidisciplinary approach can help achieve a better short-term functional outcome in noncomatose patients.