Elizabeth Colantuoni

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study

Objectives To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections. Design Collaborative cohort study to implement and evaluate interventions to improve patients’ safety. Setting Intensive care units predominantly in Michigan, USA. Intervention Conceptual model aimed at improving clinicians’ use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders. Main outcome measures Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention). Results Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (−1%, 95% confidence interval −9% to 7%). Conclusions The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.

Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study

Objective To evaluate the association of volume limited and pressure limited (lung protective) mechanical ventilation with two year survival in patients with acute lung injury. Design Prospective cohort study. Setting 13 intensive care units at four hospitals in Baltimore, Maryland, USA. Participants 485 consecutive mechanically ventilated patients with acute lung injury. Main outcome measure Two year survival after onset of acute lung injury. Results 485 patients contributed data for 6240 eligible ventilator settings, as measured twice daily (median of eight eligible ventilator settings per patient; 41% of which adhered to lung protective ventilation). Of these patients, 311 (64%) died within two years. After adjusting for the total duration of ventilation and other relevant covariates, each additional ventilator setting adherent to lung protective ventilation was associated with a 3% decrease in the risk of mortality over two years (hazard ratio 0.97, 95% confidence interval 0.95 to 0.99, P=0.002). Compared with no adherence, the estimated absolute risk reduction in two year mortality for a prototypical patient with 50% adherence to lung protective ventilation was 4.0% (0.8% to 7.2%, P=0.012) and with 100% adherence was 7.8% (1.6% to 14.0%, P=0.011). Conclusions Lung protective mechanical ventilation was associated with a substantial long term survival benefit for patients with acute lung injury. Greater use of lung protective ventilation in routine clinical practice could reduce long term mortality in patients with acute lung injury. Trial registration Clinicaltrials.gov NCT00300248.

Physical complications in acute lung injury survivors: a two-year longitudinal prospective study.

Objective:Survivors of severe critical illness frequently develop substantial and persistent physical complications, including muscle weakness, impaired physical function, and decreased health-related quality of life. Our objective was to determine the longitudinal epidemiology of muscle weakness, physical function, and health-related quality of life and their associations with critical illness and ICU exposures. Design:A multisite prospective study with longitudinal follow-up at 3, 6, 12, and 24 months after acute lung injury. Setting:Thirteen ICUs from four academic teaching hospitals. Patients:Two hundred twenty-two survivors of acute lung injury. Interventions:None. Measurements and Main Results:At each time point, patients underwent standardized clinical evaluations of extremity, hand grip, and respiratory muscle strength; anthropometrics (height, weight, mid-arm circumference, and triceps skin fold thickness); 6-minute walk distance, and the Medical Outcomes Short-Form 36 health-related quality of life survey. During their hospitalization, survivors also had detailed daily evaluation of critical illness and related treatment variables. Over one third of survivors had objective evidence of muscle weakness at hospital discharge, with most improving within 12 months. This weakness was associated with substantial impairments in physical function and health-related quality of life that persisted at 24 months. The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up. The cumulative dose of systematic corticosteroids and use of neuromuscular blockers in the ICU were not associated with weakness. Conclusions:Muscle weakness is common after acute lung injury, usually recovering within 12 months. This weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months. These results provide valuable prognostic information regarding physical recovery after acute lung injury. Evidence-based methods to reduce the duration of bed rest during critical illness may be important for improving these long-term impairments.

Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

OBJECTIVE To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates. DESIGN Collaborative cohort before-after study. SETTING Intensive care units (ICUs) predominantly in Michigan. INTERVENTIONS We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospitals infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first. RESULTS One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16-18 months after implementation (P < .001) and 0 cases (mean, 2.4 cases) at 28-30 months after implementation (P < .001). Compared to baseline, VAP rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41-0.64) at 16-18 months after implementation and 0.29 (95% confidence interval, 0.24-0.34) at 28-30 months after implementation. Compliance with evidence-based therapies increased from 32% at baseline to 75% at 16-18 months after implementation (P < .001) and 84% at 28-30 months after implementation (P < .001). CONCLUSIONS A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial

Objective To evaluate the effect of initial low energy permissive underfeeding (“trophic feeding”) versus full energy enteral feeding (“full feeding”) on physical function and secondary outcomes in patients with acute lung injury. Design Prospective longitudinal follow-up evaluation of the NHLBI ARDS Clinical Trials Network’s EDEN trial Setting 41hospitals in the United States. Participants 525 patients with acute lung injury. Interventions Randomised assignment to trophic or full feeding for up to six days; thereafter, all patients still receiving mechanical ventilation received full feeding. Measurements Blinded assessment of the age and sex adjusted physical function domain of the SF-36 instrument at 12 months after acute lung injury. Secondary outcome measures included survival; physical, psychological, and cognitive functioning; quality of life; and employment status at six and 12 months. Results After acute lung injury, patients had substantial physical, psychological, and cognitive impairments, reduced quality of life, and impaired return to work. Initial trophic versus full feeding did not affect mean SF-36 physical function at 12 months (55 (SD 33) v 55 (31), P=0.54), survival to 12 months (65% v 63%, P=0.63), or nearly all of the secondary outcomes. Conclusion In survivors of acute lung injury, there was no difference in physical function, survival, or multiple secondary outcomes at 6 and 12 month follow-up after initial trophic or full enteral feeding. Trial Registration NCT No 00719446

Reducing PICU Central Line–Associated Bloodstream Infections: 3-Year Results

OBJECTIVES: To evaluate the long-term impact of pediatric central line care practices in reducing PICU central line–associated bloodstream infection (CLA-BSI) rates and to evaluate the added impact of chlorhexidine scrub and chlorhexidine-impregnated sponges. METHODS: A 3-year, multi-institutional, interrupted time-series design (October 2006 to September 2009), with historical control data, was used. A nested, 18-month, nonrandomized, factorial design was used to evaluate 2 additional interventions. Twenty-nine PICUs were included. Two central line care bundles (insertion and maintenance bundles) and 2 additional interventions (chlorhexidine scrub and chlorhexidine-impregnated sponges) were used. CLA-BSI rates (January 2004 to September 2009), insertion and maintenance bundle compliance rates (October 2006 to September 2009), and chlorhexidine scrub and chlorhexidine-impregnated sponge compliance rates (January 2008 to June 2009) were assessed. RESULTS: The average aggregate baseline PICU CLA-BSI rate decreased 56% over 36 months from 5.2 CLA-BSIs per 1000 line-days (95% confidence interval [CI]: 4.4–6.2 CLA-BSIs per 1000 line-days) to 2.3 CLA-BSIs per 1000 line-days (95% CI: 1.9–2.9 CLA-BSIs per 1000 line-days) (rate ratio: 0.44 [95% CI: 0.37–0.53]; P < .0001). No statistically significant differences in CLA-BSI rate decreases between PICUs using or not using either of the 2 additional interventions were found. CONCLUSIONS: Focused attention on consistent adherence to the use of pediatrics-specific central line insertion and maintenance bundles produced sustained, continually decreasing PICU CLA-BSI rates. Additional use of either chlorhexidine for central line entry scrub or chlorhexidine-impregnated sponges did not produce any statistically significant additional reduction in PICU CLA-BSI rates.

The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU.

Objectives:To determine if a quality improvement intervention improves sleep and delirium/cognition. Design:Observational, pre–post design. Setting:A tertiary academic hospital in the United States. Patients:300 medical ICU patients. Interventions:This medical ICU-wide project involved a “usual care” baseline stage, followed by a quality improvement stage incorporating multifaceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff. Measurements and Main Results:Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0–100 scale using the valid and reliable Richards–Campbell Sleep Questionnaire) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep quality improvement stages, there were 122 and 178 patients, respectively, with more than one night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day quality improvement period, checklist item completion rates ranged from 86% to 94%. In multivariable regression analysis of the quality improvement vs. baseline stages, improvements in overall Richards-Campbell Sleep Questionnaire sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± SD: 65.9±26.6 vs. 60.5±26.3, p = 0.001), incidence of delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23–0.89; p = 0.02), and daily delirium/coma-free status (odds ratio: 1.64; 95% confidence interval, 1.04–2.58; p = 0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance. Conclusions:An ICU-wide quality improvement intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Objective To evaluate whether implementation of the Michigan Keystone ICU project, a comprehensive statewide quality improvement initiative focused on reduction of infections, was associated with reductions in hospital mortality and length of stay for adults aged 65 or more admitted to intensive care units. Design Retrospective comparative study, using data from Medicare claims. Setting Michigan and Midwest region, United States. Population The study period (October 2001 to December 2006) spanned two years before the project was initiated to 22 months after its implementation. The study sample included hospital admissions for patients treated in 95 study hospitals in Michigan (238 937 total admissions) compared with 364 hospitals in the surrounding Midwest region (1 091 547 total admissions). Main outcome measures Hospital mortality and length of hospital stay. Results The overall trajectory of mortality outcomes differed significantly between the two groups upon implementation of the project (Wald test χ2=8.73, P=0.033). Reductions in mortality were significantly greater for the study group than for the comparison group 1-12 months (odds ratio 0.83, 95% confidence interval 0.79 to 0.87 v 0.88, 0.85 to 0.90, P=0.041) and 13-22 months (0.76, 0.72 to 0.81 v 0.84, 0.81 to 0.86, P=0.007) after implementation of the project. The overall trajectory of length of stay did not differ significantly between the groups upon implementation of the project (Wald test χ2=2.05, P=0.560). Group differences in adjusted length of stay compared with baseline did not reach significance during implementation of the project (−0.45 days, 95% confidence interval −0.62 to −0.28 v −0.35, −0.52 to −0.19) or during post-implementation months 1-12 (−0.59, −0.80 to −0.37 v −0.42, −0.59 to −0.25) and 13-22 (−0.67, −0.91 to −0.43 v −0.54, −0.72 to −0.37). Conclusions Implementation of the Keystone ICU project was associated with a significant decrease in hospital mortality in Michigan compared with the surrounding area. The project was not, however, sufficiently powered to show a significant difference in length of stay.

Diagnostic errors in the intensive care unit: a systematic review of autopsy studies

Context Misdiagnoses may be an underappreciated cause of preventable morbidity and mortality in the intensive care unit (ICU). Their prevalence, nature, and impact remain largely unknown. Objectives To determine whether potentially fatal ICU misdiagnoses would be more common than in the general inpatient population (∼5%), and would involve more infections or vascular events. Data sources Systematic review of studies identified by electronic (MEDLINE, etc.) and manual searches (references in eligible articles) without language restriction (1966 through 2011). Study selection and data abstraction Observational studies examining autopsy-confirmed diagnostic errors in the adult ICU were included. Studies analysing misdiagnosis of one specific disease were excluded. Study results (autopsy rate, misdiagnosis prevalence, Goldman error class, diseases misdiagnosed) were abstracted and descriptive statistics calculated. We modelled the prevalence of Class I (potentially lethal) misdiagnoses as a non-linear function of the autopsy rate. Results Of 276 screened abstracts, 31 studies describing 5863 autopsies (median rate 43%) were analysed. The prevalence of misdiagnoses ranged from 5.5%–100% with 28% of autopsies reporting at least one misdiagnosis and 8% identifying a Class I diagnostic error. The projected prevalence of Class I misdiagnoses for a hypothetical autopsy rate of 100% was 6.3% (95% CI 4.0% to 7.5%). Vascular events and infections were the leading lethal misdiagnoses (41% each). The most common individual Class I misdiagnoses were PE, MI, pneumonia, and aspergillosis. Conclusions Our data suggest that as many as 40 500 adult patients in an ICU in USA may die with an ICU misdiagnoses annually. Despite this, diagnostic errors receive relatively little attention and research funding. Future studies should seek to prospectively measure the prevalence and impact of diagnostic errors and potential strategies to reduce them.

A soluble activin type IIB receptor improves function in a mouse model of amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a neurologic disease characterized by progressive weakness that results in death within a few years of onset by respiratory failure. Myostatin is a member of the TGF-beta superfamily that is predominantly expressed in muscle and acts as a negative regulator of muscle growth. Attenuating myostatin has previously been shown to produce increased muscle mass and strength in normal and disease animal models. In this study, a mouse model of ALS (SOD1(G93A) transgenic mice) was treated with a soluble activin receptor, type IIB (ActRIIB.mFc) which is a putative endogenous signaling receptor for myostatin in addition to other ligands of the TGF-beta superfamily. ActRIIB.mFc treatment produces a delay in the onset of weakness, an increase in body weight and grip strength, and an enlargement of muscle size whether initiated pre-symptomatically or after symptom onset. Treatment with ActRIIB.mFc did not increase survival or neuromuscular junction innervation in SOD1(G93A) transgenic mice. Pharmacologic treatment with ActRIIB.mFc was superior in all measurements to genetic deletion of myostatin in SOD1(G93A) transgenic mice. The improved function of SOD1(G93A) transgenic mice following treatment with ActRIIB.mFc is encouraging for the development of TGF-beta pathway inhibitors to increase muscle strength in patients with ALS.