...in a recent observational study of Australian ICUs, there was a signal for a shorter ICU length of stay for patients cared for in units that had intensivists working fewer consecutive days, ...without increases in ICU readmissions or hospital mortality 4. First is an openness to new considering new models and a willingness to acknowledge that critical care has changed and optimal models for care that balance priorities have therefore also changed 8. ...is more data. ...is recognizing that delivery of critical care has become a team sport; so many other individuals with clinical expertise are essential to the effective care of critically ill patients, that we need to appreciate the roles of all of these individuals.
Large differences exist in the provision of ICU beds worldwide, with a complicated mix of risks and benefits to the population of having either too few or too many beds. Having too few beds can ...result in delayed admission of patients to the ICU or no admission at all, with either scenario potentially increasing mortality. Potential societal benefits of having few beds include lower costs for health care and less futile intensive care at the end of life. With added ICU beds for a population, mortality benefit should accrue, but there is still the question of whether the addition of beds always means that more lives will be saved or whether there is a point at which no additional mortality benefit is gained. With an abundance of ICU beds may come the possibility of increasing harm in the forms of unnecessary costs, poor quality of deaths (ie, excessively intensive), and iatrogenic complications. The possibility of harm may be likened to the concept of falling off a Starling curve, which is traditionally used to describe worsening heart function when overfilling occurs. This commentary examines the possible implications of having too few or too many ICU beds and proposes the concept of a family of Starling curves as a way to conceptualize the balance of societal benefits and harms associated with different availability of ICU beds for a population.
Critical care medicine is a global specialty and epidemiologic research among countries provides important data on availability of critical care resources, best practices, and alternative options for ...delivery of care. Understanding the diversity across healthcare systems allows us to explore that rich variability and understand better the nature of delivery systems and their impact on outcomes. However, because the delivery of ICU services is complex (for example, interplay of bed availability, cultural norms and population case-mix), the diversity among countries also creates challenges when interpreting and applying data. This complexity has profound influences on reported outcomes, often obscuring true differences. Future research should emphasize determination of resource data worldwide in order to understand current practices in different countries; this will permit rational pandemic and disaster planning, allow comparisons of in-ICU processes of care, and facilitate addition of pre- and post-ICU patient data to better interpret outcomes.
The application of prone positioning for acute respiratory distress syndrome (ARDS) has evolved, with recent trials focusing on patients with more severe ARDS, and applying prone ventilation for more ...prolonged periods.
This review evaluates the effect of prone positioning on 28-day mortality (primary outcome) compared with conventional mechanical ventilation in the supine position for adults with ARDS.
We updated the literature search from a systematic review published in 2010, searching MEDLINE, EMBASE, and CENTRAL (through to August 2016). We included randomized, controlled trials (RCTs) comparing prone to supine positioning in mechanically ventilated adults with ARDS, and conducted sensitivity analyses to explore the effects of duration of prone ventilation, concurrent lung-protective ventilation and ARDS severity. Secondary outcomes included Pa
/Fi
ratio on Day 4 and an evaluation of adverse events. Meta-analyses used random effects models. Methodologic quality of the RCTs was evaluated using the Cochrane risk of bias instrument, and methodologic quality of the overall body of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines.
Eight RCTs fulfilled entry criteria, and included 2,129 patients (1,093 51% proned). Meta-analysis revealed no difference in mortality (risk ratio RR, 0.84; 95% confidence interval CI, 0.68-1.04), but subgroup analyses found lower mortality with 12 hours or greater duration prone (five trials; RR, 0.74; 95% CI, 0.56-0.99) and for patients with moderate to severe ARDS (five trials; RR, 0.74; 95% CI, 0.56-0.99). Pa
/Fi
ratio on Day 4 for all patients was significantly higher in the prone positioning group (mean difference, 23.5; 95% CI, 12.4-34.5). Prone positioning was associated with higher rates of endotracheal tube obstruction and pressure sores. Risk of bias was low across the trials.
Prone positioning is likely to reduce mortality among patients with severe ARDS when applied for at least 12 hours daily.
Objectives
To ascertain the absolute number of Medicare beneficiaries surviving at least 3 years after severe sepsis and to estimate their burden of cognitive dysfunction and disability.
Design
...Retrospective cohort analysis of Medicare data.
Setting
All short‐stay inpatient hospitals in the United States, 1996 to 2008.
Participants
Individuals aged 65 and older.
Measurements
Severe sepsis was detected using a standard administrative definition. Case‐fatality, prevalence, and incidence rates were calculated.
Results
Six hundred thirty‐seven thousand eight hundred sixty‐seven Medicare beneficiaries were alive at the end of 2008 who had survived severe sepsis 3 or more years earlier. An estimated 476,862 (95% confidence interval (CI) = 455,026–498,698) had functional disability, with 106,311 (95% CI = 79,692–133,930) survivors having moderate to severe cognitive impairment. The annual number of new 3‐year survivors after severe sepsis rose 119% during 1998 to 2008. The increase in survivorship resulted from more new diagnoses of severe sepsis rather than a change in case‐fatality rates; severe sepsis rates rose from 13.0 per 1,000 Medicare beneficiary‐years to 25.8 (P < .001), whereas 3‐year case fatality rates changed much less, from 73.5% to 71.3% (P < .001) for the same cohort. Increasing rates of organ dysfunction in hospitalized individuals drove the increase in severe sepsis incidence, with an additional small contribution from population aging.
Conclusions
Sepsis survivorship, which has substantial long‐term morbidity, is a common and rapidly growing public health problem for older Americans. There has been little change in long‐term case‐fatality, despite changes in practice. Clinicians should anticipate more‐frequent sequelae of severe sepsis in their patient populations.
To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.
We used the Council of Medical Specialty Societies principles for the ...development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
CONTEXT Although hospital mortality has decreased over time in the United States for patients who receive intensive care, little is known about subsequent outcomes for those discharged alive. ...OBJECTIVE To assess 3-year outcomes for Medicare beneficiaries who survive intensive care. DESIGN, SETTING, AND PATIENTS A matched, retrospective cohort study was conducted using a 5% sample of Medicare beneficiaries older than 65 years. A random half of all patients were selected who received intensive care and survived to hospital discharge in 2003 with 3-year follow-up through 2006. From the other half of the sample, 2 matched control groups were generated: hospitalized patients who survived to discharge (hospital controls) and the general population (general controls), individually matched on age, sex, race, and whether they had surgery (for hospital controls). MAIN OUTCOME MEASURE Three-year mortality after hospital discharge. RESULTS There were 35 308 intensive care unit (ICU) patients who survived to hospital discharge. The ICU survivors had a higher 3-year mortality (39.5%; n = 13 950) than hospital controls (34.5%; n = 12 173) (adjusted hazard ratio AHR, 1.07 95% confidence interval {CI}, 1.04-1.10; P < .001) and general controls (14.9%; n = 5266) (AHR, 2.39 95% CI, 2.31-2.48; P < .001). The ICU survivors who did not receive mechanical ventilation had minimal increased risk compared with hospital controls (3-year mortality, 38.3% n = 12 716 vs 34.6% n=11 470, respectively; AHR, 1.04 95% CI, 1.02-1.07). Those receiving mechanical ventilation had substantially increased mortality (57.6% 1234 ICU survivors vs 32.8% 703 hospital controls; AHR, 1.56 95% CI, 1.40-1.73), with risk concentrated in the 6 months after the quarter of hospital discharge (6-month mortality, 30.1% (n = 645) for those receiving mechanical ventilation vs 9.6% (n = 206) for hospital controls; AHR, 2.26 95% CI, 1.90-2.69). Discharge to a skilled care facility for ICU survivors (33.0%; n = 11 634) and hospital controls (26.4%; n = 9328) also was associated with high 6-month mortality (24.1% for ICU survivors and hospital controls discharged to a skilled care facility vs 7.5% for ICU survivors and hospital controls discharged home; AHR, 2.62 95% CI, 2.50-2.74; P < .001 for ICU survivors and hospital controls combined). CONCLUSIONS There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls. The risk is concentrated early after hospital discharge among those who require mechanical ventilation.
OBJECTIVES:Detailed data on occupancy and use of mechanical ventilators in U. S. ICU over time and across unit types are lacking. We sought to describe the hourly bed occupancy and use of ventilators ...in U.S. ICUs to improve future planning of both the routine and disaster provision of intensive care.
DESIGN:Retrospective cohort study. We calculated mean hourly bed occupancy in each ICU and hourly bed occupancy for patients on mechanical ventilators. We assessed trends in overall occupancy over the 3 years. We also assessed occupancy and mechanical ventilation rates across different types and sizes of ICUs.
SETTING:Ninety-seven U.S. ICUs participating in Project IMPACT from 2005 to 2007.
PATIENTS:A total of 226,942 consecutive admissions to ICUs.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:Over the 3 years studied, total ICU occupancy ranged from 57.4% to 82.1% and the number of beds filled with mechanically ventilated patients ranged from 20.7% to 38.9%. There was no change in occupancy across years and no increase in occupancy during influenza seasons. Mean hourly occupancy across ICUs was 68.2% ± 21.3% (SD) and was substantially higher in ICUs with fewer beds (mean, 75.8% ± 16.5% for 5–14 beds vs 60.9% ± 22.1% for 20+ beds, p = 0.001) and in academic hospitals (78.7% ± 15.9% vs 65.3% ± 21.3% for community not-for-profit hospitals, p < 0.001). More than half of ICUs (53.6%) had 4+ beds available more than half the time. The mean percentage of ICU patients receiving mechanical ventilation in any given hour was 39.5% (± 15.2%), and a mean of 29.0% (± 15.9%) of ICU beds were filled with a patient on a ventilator.
CONCLUSIONS:Occupancy of U.S. ICUs was stable over time, but there is uneven distribution across different types and sizes of units. Only three of 10 beds were filled at any time with mechanically ventilated patients, suggesting substantial surge capacity throughout the system to care for acutely critically ill patients.
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