Christian Danneels

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients

Background:We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients. Methods:In a single-center, historical cohort study (1992–2006), we compared middle-aged (45–64 years; n = 524), old (65–74 years; n = 326), and very old ICU patients (≥75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay. Results:Although the total number of ICU admissions (patients aged ≥45 years) decreased by ∼10%, the number of very old patients increased by 33% between the periods 1992–1996 and 2002–2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992–1996) to 13.5% (1997–2001) and 17.4% (2002–2006) (p < 0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4‰ in middle-aged, 5.5‰ in old, and 4.6‰ in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0–1.5) and significant for very old age (hazard ratio, 1.8; 95% confidence interval, 1.4–2.4). Conclusion:Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

IMPLEMENTATION OF A REAL-TIME ELECTRONIC ALERT BASED ON THE RIFLE CRITERIA FOR ACUTE KIDNEY INJURY IN ICU PATIENTS

Abstract Acute kidney injury (AKI) is very common among critically-ill patients and is correlated with significant morbidity and mortality. The RIFLE criteria (an acronym comprising Risk, Injury, Failure, Loss and End-stage kidney disease), were developed by a panel of experts aiming at standardizing the definition of AKI and to subdivide AKI into different categories of severity. However, although these criteria are clear and easy to understand, they are still complex and labour-intensive, and therefore mostly used in retrospective. The use of an electronic alert based on the RIFLE criteria, which warns the physician in real-time when kidney function is deteriorating can help to implement these criteria in daily clinical practice. In this paper we describe the successful implementation of such an alert system. Not only were there technological barriers to solve; also acceptance of the alert by the end user was of pivotal importance. Further research is currently performed to investigate whether the implementation of real-time electronic RIFLE alerts induce faster therapeutic intervention, and to evaluate the impact of a more timely intervention on improved preservation of kidney function and patients’ outcome.

COSARA: Integrated Service Platform for Infection Surveillance and Antibiotic Management in the ICU

The Intensive Care Unit is a data intensive environment where large volumes of patient monitoring and observational data are daily generated. Today, there is a lack of an integrated clinical platform for automated decision support and analysis. Despite the potential of electronic records for infection surveillance and antibiotic management, different parts of the clinical data are stored across databases in their own formats with specific parameters, making access to all data a complex and time-consuming challenge. Moreover, the motivation behind physicians’ therapy decisions is currently not captured in existing information systems. The COSARA research project offers automated data integration and services for infection control and antibiotic management for Ghent University Hospital. The platform not only gathers and integrates all relevant data, it also presents the information visually at the point of care. In this paper, we describe the design and value of COSARA for clinical treatment and infectious diseases monitoring. On the one hand, this platform can facilitate daily bedside follow-up of infections, antibiotic therapies and clinical decisions for the individual patient, while on the other hand, the platform serves as management view for infection surveillance and care quality improvement within the complete ICU ward. It is shown that COSARA is valuable for registration, real-time presentation and management of infection-related and antibiotics data.

Service-oriented Subscription Management of Medical Decision Data in the Intensive Care Unit

OBJECTIVES This paper addresses the design of a platform for the management of medical decision data in the ICU. Whenever new medical data from laboratories or monitors is available or at fixed times, the appropriate medical support services are activated and generate a medical alert or suggestion to the bedside terminal, the physicians PDA, smart phone or mailbox. Since future ICU systems will rely ever more on medical decision support, a generic and flexible subscription platform is of high importance. METHODS Our platform is designed based on the principles of service-oriented architectures, and is fundamental for service deployment since the medical support services only need to implement their algorithm and can rely on the platform for general functionalities. A secure communication and execution environment are also provided. RESULTS A prototype, where medical support services can be easily plugged in, has been implemented using Web service technology and is currently being evaluated by the Department of Intensive Care of the Ghent University Hospital. To illustrate the platform operation and performance, two prototype medical support services are used, showing that the extra response time introduced by the platform is less than 150 ms. CONCLUSIONS The platform allows for easy integration with hospital information systems. The platform is generic and offers user-friendly patient/service subscription, transparent data and service resource management and priority-based filtering of messages. The performance has been evaluated and it was shown that the response time of platform components is negligible compared to the execution time of the medical support services.

Design of a JAIN SLEE/ESB-based platform for routing medical data in the ICU

The importance of computer aided decision making is continuously increasing. In the ICU, medical decision support services gather and process medical data of patients and present results and suggestions to the medical staff. The medical decision support services can monitor for example blood pressure, creatinine levels or the usage of antibiotics. If certain levels are crossed, they raise alerts so that the medical staff can take appropriate actions if required. This significantly reduces the amount of data needing to be processed by the medical staff. To handle the large amount of data that is generated by the ICU on a daily basis, a platform for routing and processing this data is necessary. In this paper we propose a platform based on JAIN SLEE and an Enterprise Service Bus. The platform takes care of the routing of the data to the appropriate services and allows to easily deploy and manage services. In this paper, we present the design details and the evaluation results. Furthermore, it is shown that the platform is capable of routing and processing all the events generated by the ICU within strict time constraints.

Serum urea concentration is probably not related to outcome in ICU patients with AKI and renal replacement therapy

BACKGROUND Acute kidney injury (AKI) is a common complication in patients admitted to the intensive care unit (ICU). Among other variables, serum urea concentrations are recommended for timing of initiation of renal replacement therapy (RRT). The aim of this study was to evaluate whether serum urea concentration or different serum urea concentration cutoffs as recommended in the literature were associated with in-hospital mortality at time of initiation of RRT for AKI. METHODS This is a retrospective single- centre study during a 3-year period (2004-07), in a 44-bed tertiary care centre ICU of adult AKI patients who were treated with RRT. RESULTS Three hundred and two patients were included: 68.9% male, median age 65 years and an APACHE II score of 21. The overall in-hospital mortality was 57.9%. Non-survivors were older (67 versus 64 years, P = 0.016) and had a higher APACHE II score (22 versus 20, P < 0.001). At time of initiation of RRT, they were more severely ill and had a lower serum urea concentration compared to survivors (130 versus 141 mg/dL, P = 0.038). Serum urea concentration, as well as the different historical serum urea concentration cut-offs had low area under the curves for the receiver operating characteristic curve for prediction of mortality. In multivariate analysis, age, and at time of initiation of RRT, potassium, SOFA score with exclusion of points for AKI and RIFLE class were associated with mortality, but serum urea concentration and the different cut-offs were not. CONCLUSIONS This retrospective study suggests that serum urea concentration and serum urea concentration cut-offs at time of initiation of RRT have no predictive value for in-hospital mortality in ICU patients with AKI.

Has information technology finally been adopted in Flemish intensive care units

BackgroundInformation technology (IT) may improve the quality, safety and efficiency of medicine, and is especially useful in intensive Care Units (ICUs) as these are extremely data-rich environments with round-the-clock changing parameters. However, data regarding the implementation rates of IT in ICUs are scarce, and restricted to non-European countries. The current paper aims to provide relevant information regarding implementation of IT in Flemish ICUs (Flanders, Belgium).MethodsThe current study is based on two separate but complementary surveys conducted in the region of Flanders (Belgium): a written questionnaire in 2005 followed by a telephone survey in October 2008. We have evaluated the actual health IT adoption rate, as well as its evolution over a 3-year time frame. In addition, we documented the main benefits and obstacles for taking the decision to implement an Intensive Care Information System (ICIS).ResultsCurrently, the computerized display of laboratory and radiology results is almost omnipresent in Flemish ICUs, (100% and 93.5%, respectively), but the computerized physician order entry (CPOE) of these examinations is rarely used. Sixty-five % of Flemish ICUs use an electronic patient record, 41.3% use CPOE for medication prescriptions, and 27% use computerized medication administration recording. The implementation rate of a dedicated ICIS has doubled over the last 3 years from 9.3% to 19%, and another 31.7% have plans to implement an ICIS within the next 3 years. Half of the tertiary non-academic hospitals and all university hospitals have implemented an ICIS, general hospitals are lagging behind with 8% implementation, however. The main reasons for postponing ICIS implementation are: (i) the substantial initial investment costs, (ii) integration problems with the hospital information system, (iii) concerns about user-friendly interfaces, (iv) the need for dedicated personnel and (v) the questionable cost-benefit ratio.ConclusionsMost ICUs in Flanders use hospital IT systems such as computerized laboratory and radiology displays. The adoption rate of ICISs has doubled over the last 3 years but is still surprisingly low, especially in general hospitals. The major reason for not implementing an ICIS is the substantial financial cost, together with the lack of arguments to ensure the cost/benefit.

Design and Evaluation of a Service Oriented Architecture for Paperless ICU Tarification

The computerization of Intensive Care Units provides an overwhelming amount of electronic data for both medical and financial analysis. However, the current tarification, which is the process to tick and count patients’ procedures, is still a repetitive, time-consuming process on paper. Nurses and secretaries keep track manually of the patients’ medical procedures. This paper describes the design methodology and implementation of automated tarification services. In this study we investigate if the tarification can be modeled in service oriented architecture as a composition of interacting services. Services are responsible for data collection, automatic assignment of records to physicians and application of rules. Performance is evaluated in terms of execution time, cost evaluation and return on investment based on tracking of real procedures. The services provide high flexibility in terms of maintenance, integration and rules support. It is shown that services offer a more accurate, less time-consuming and cost-effective tarification.

Automated generation and deployment of clinical guidelines in the ICU

The complexity and amount of medical information and data keeps increasing, which makes it difficult to maintain the same quality of care in the Intensive Care Unit, without significant cost increases. In order to contain this complexity, clinical guidelines are used to structure best practices and patient care, but they also support physicians and nurses in the diagnostic and treatment process. Currently, no standardized format exists to represent these guidelines. Moreover, they are often handwritten. Translating guidelines into a computer interpretable format can overcome problems in their workflow and improve clinicians uptake. To this end, we developed an automated generation and execution engine. Based on the requirements, both functional and non-functional, an architecture using the microkernel pattern is presented. This allows us to easily add and modify functionality. This architecture was evaluated with the guideline for the calculation of calorie need for burn patients, used on a daily basis in the Intensive Care Unit of the University Hospital of Ghent.

Granularity of Medical Software Agents in ICU -Trade-off Performance versus Flexibility

Intelligent computing opens new opportunities to assist physicians with automatic medical decision support. Today, physicians still experience manual time-consuming data analysis of medical records while evaluating the patient’s outcome. Especially in the Intensive Care Unit (ICU), large amounts of data per patient per day are generated, making manual data analysis a very complex task. Early detection of changes in patients’ conditions is a major challenge in health care. To achieve this, agent technology and a service-oriented architecture have been deployed for medical decision support. In this paper, the choice of the level of service granularity is studied in detail. Fine-grained granularity of services seems an attractive idea to establish extreme reuse and flexibility but we need to be aware of possible performance implications. The modular design of an antibiotic switch therapy agent is presented and trade-offs between performance and flexibility are thoroughly evaluated.