To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.
Prospective cohort study.
Two ...medical ICUs within Montefiore Healthcare Center (Bronx, NY).
One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.
At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).
In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively.
In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.
Postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or long coronavirus disease (COVID) is an emerging syndrome characterized by multiple persisting or newly emergent ...symptoms following the acute phase of SARS-CoV-2 infection. For affected patients, these prolonged symptoms can have a relapsing and remitting course and may be associated with disability and frequent health care utilization. Although many symptom-driven treatments are available, management remains challenging and often requires a multidisciplinary approach. This article summarizes the emerging consensus on definitions, epidemiology, and pathophysiology of long COVID and discusses what is understood about prevention, evaluation, and treatment of this syndrome.
Objectives
To estimate the effect of pre‐intensive care unit (ICU) health categories on mortality during and after critical illness, focusing specifically on the effect of pre‐ICU frailty on short‐ ...and long‐term mortality.
Design
Retrospective cohort study.
Setting
Medicare claims data from 2004 to 2008.
Participants
A nationally representative sample of elderly Medicare beneficiaries admitted to an ICU in 2005.
Measurements
Participants were classified into four pre‐ICU health categories (robust, cancer, chronic organ failure, frailty) using claims data from the year before admission, allowing for assignment to multiple categories. The association between pre‐ICU health category and hospital and 3‐year mortality was assessed using multivariable logistic regression and Cox proportional hazards models.
Results
Of 47,427 elderly individuals in the ICU, 18.8% were robust, 28.6% had cancer, 68.1% had chronic organ failure, and 34.0% were frail; 41.3% qualified for multiple categories. Overall hospital mortality was 12.6%, with the lowest mortality for robust participants (9.7%). Participants with pre‐ICU frailty had higher hospital mortality than those with the same pre‐ICU health categories without frailty. (Adjusted odds ratios ranged from 1.27 (95% confidence interval (CI) 1.10–1.47) to 1.52 (95% CI = 1.35–1.63).) Robust hospital survivors had the lowest 3‐year mortality (24.6%). Pre‐ICU frailty conferred higher 3‐year mortality than pre‐ICU categories without frailty. (Adjusted hazard ratios ranged from 1.54 (95% CI = 1.45–1.64) to 1.84 (95% CI = 1.70–1.99).)
Conclusion
Critically ill elderly adults can be categorized according to pre‐ICU health categories. These categories, particularly pre‐ICU frailty, may be important for understanding risk of death during and after critical illness.
Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers ...that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them.
Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data.
Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents.
Clinicians from 21 sites.
Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising.
Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.
Human Suffering and Armed Conflict Munro, Cindy L; Hope, Aluko A
American journal of critical care,
2024-Jan-01, Letnik:
33, Številka:
1
Journal Article
PDF
