Ellen B. Rudy

Patient outcomes for the chronically critically ill: special care unit versus intensive care unit.

The purpose of this study was to compare the effects of a low-technology environment of care and a nurse case management case delivery system (special care unit, SCU) with the traditional high-technology environment (ICU) and primary nursing care delivery system on the patient outcomes of length of stay, mortality, readmission, complications, satisfaction, and cost. A sample of 220 chronically critically ill patients were randomly assigned to either the SCU (n = 145) or the ICU (n = 75). Few significant differences were found between the two groups in length of stay, mortality, or complications. However, the findings showed significant cost savings in the SCU group in the charges accrued during the study period and in the charges and costs to produce a survivor. The average total cost of delivering care was

Relationship between arterial carbon dioxide and end-tidal carbon dioxide in mechanically ventilated adults with severe head trauma.

5,000 less per patient in the SCU than in the traditional ICU. In addition, the cost to produce a survivor was

The cost-effectiveness of a special care unit to care for the chronically critically ill.

19,000 less in the SCU. Results from this 4-year clinical trial demonstrate that nurse case managers in a SCU setting can produce patient outcomes equal to or better than those in the traditional ICU care environment for long-term critically ill patients.

EFFECT OF SHORT-DURATION HYPERVENTILATION DURING ENDOTRACHEAL SUCTIONING ON INTRACRANIAL PRESSURE IN SEVERE HEAD-INJURED ADULTS

OBJECTIVE To examine the agreement and association of a noninvasive method of measuring CO2 (using end-tidal PCO2) with PaCO2 in mechanically ventilated adults with severe head trauma. DESIGN A prospective, quasi-experimental, repeated-measures study was used to compare end-tidal PCO2 and PaCO2 at two time points: before and after a standardized endotracheal suctioning procedure. INTERVENTIONS Controlled intervention of endotracheal suctioning. SETTING The study was conducted at two intensive care units designated as Level 1 trauma centers. PATIENTS A consecutive sample of 35 severe head-injured patients with a Glasgow Coma Scale score of < or = 8. MEASUREMENTS AND MAIN RESULTS End-tidal PCO2 and PaC02 values were simultaneously obtained and compared. End-tidal PCO2 was measured, using a sidestream sensor placed in line of the ventilator circuits deadspace. Arterial gases were drawn from an indwelling arterial catheter. No relationship was found between arterial and end-tidal measures (range r2 = .09 to r2 = .11). Using the Bland-Altman technique, agreement decreased as the amount of positive end-expiratory pressure increased. When a subset of patients (mechanically ventilated, with positive end-expiratory pressures of < 5 cm H2O, paralyzed, and sedated) were examined (n = 12), the correlation between the CO2 measures improved (r2 = .77). CONCLUSIONS This study indicated that end-tidal PCO2 monitoring correlated well with PaCO2 in patients without respiratory complications or without spontaneous breathing, resulting in rebreathing of gases. However, its clinical validity is questionable in patients who have the greatest need for end-tidal PCO2 monitoring (i.e., patients who have respiratory distress or who are breathing spontaneously and overriding the ventilator.

Survival experience of chronically critically ill patients.

To assess the relative value of healthcare programs, technologic innovations, and clinical decisions, policymakers are searching for ways to evaluate cost-effectiveness. What constitutes cost-effectiveness and how should it be measured? The authors discuss ways in which the cost-effectiveness of clinical programs can be measured and describes various methods of assessing both costs and effectiveness. Comparison of the cost-effectiveness of a nurse managed special care unit with that of traditional intensive care units illustrates some of these methods.

Staffing and pattern of mechanical restraint use across a multiple hospital system.

A repeated measures randomized within-group design was used to determine the effectiveness of controlled short-duration hyperventilation (HV) in blunting the increase of intracranial pressure (ICP) during endotracheal suctioning (ETS). A multimodal continuous real-time computerized data acquisition procedure was used to compare the effects of two HV ETS protocols on ICP, arterial pressure, cerebral perfusion pressure (CPP), heart rate, and arterial oxygen saturation in severe head-injured adult patients. The results indicated that short-duration HV for 1 minute, which decreases the PaCO2, reduced ETS-induced elevations in ICP while maintaining CPP. However, it is not clear whether short-duration HV is neuroprotective, particularly in ischemic regions of the brain. Therefore, before a change in practice is implemented on the use of short-duration HV as a prophylactic treatment against ETS-induced elevations in ICP, additional questions on cerebral oxygen delivery and uptake need to be answered.

Faculty Practice" Creating a New Culture

Intensive care unit (ICU) patients were randomly assigned to either a traditional ICU or a special care unit (SCU) for chronically critically ill patients. The SCU used a low-technology, family-oriented environment, nursing case management, no physician house staff, and a shared governance model. In comparison, the ICU used high technology, limited family visiting, primary care nursing, and a bureaucratic management model. The survival experience of chronically critically ill patients in the two environments during hospitalization, as well as after hospital discharge, was examined. Using survival analytic techniques, the 1-year cumulative mortality for all patients in the study was found to be 59.9%. Risk of death was significantly lower after discharge than during hospitalization. Similar mortality experiences were found for SCU and ICU patients. Thus, the high-technology ICU environment did not produce better outcomes than the SCU environment.

Do-not-resuscitate practices in the chronically critically ill

BackgroundIn an effort to enhance patient safety in acute care settings, governmental and regulatory agencies have established initiatives aimed at limiting the use of mechanical restraints. Concurrently, hospital staffing levels are undergoing changes raising concerns about the impact these changes may have on restraint use. No studies to date have described the impact these two initiatives have had on restraint use in acute care hospitals. ObjectivesTo determine across a multiple hospital system: (a) the rates, frequencies, duration, and timing of restraint use, and (b) the relationship between restraint use and staffing. MethodsThis was a secondary analysis of prospective, observational data from a large outcomes database for 10 acute care hospitals. Monthly data were obtained from 94 patient care units for periods ranging from 1–12 months for a total of 566 cumulative months during 1999. ResultsThe system restraint application duration rate (total restraint hours/total possible hours) was 2.8% (hospital ranges: 0.3–4.4%). More restraints were applied on night shifts (48.8%;n = 5,296) than on day (33.5%;n = 3,634) or evening shifts (17.7%;n = 1,926) (p < .0001) and most applied at midnight (31.7%;n = 3,441) followed by 0600–0900 (33.3%;n = 3,614). There was a weak positive relationship between staffing and restraint use (r = 0.276, p = .0001) at the system level and units with higher staffing levels also had higher baseline restraint use (p < .0001). ConclusionsRestraint frequency, duration, and timing may have been altered by recent initiatives, and there is beginning evidence that differences exist between community, rural, and tertiary hospitals. While there is a weak positive relationship between higher staffing and restraint use at the system and unit level, further exploration of the influence of other factors, specifically patient acuity, are in order. The finding of unit variability and consistent restraint application times provides a starting point for further quality initiatives or research interventions aimed at restraint reduction.

Head-injured adults: recommendations for endotracheal suctioning.

This article provides specifics on the development of a clinical track for faculty appointments at the University of Pittsburgh. The criteria to be used for appointment and promotion on the clinical track are discussed along with the practice requirements of 60 hours per term of participation in and responsibility for direct care of patients. The purposes of faculty practice are set forth along with the formation and functioning of a Faculty Practice Council which handles decisions related to faculty practice. Results of the first year after implementation of a clinical track showed that 64 per cent (18) of the faculty had met all of their faculty practice obligations; of the remaining 36 percent (10) who had not, a variety of circumstances were cited. The Income to the School of Nursing for faculty practice, although modest, has helped to highlight that practice is valued and an integral part of the faculty role.

Developing a Multi-institutional Nursing Report Card

OBJECTIVES To determine the frequency of do-not-resuscitate (DNR) orders in the chronically critically ill; to identify the differences in clinical and demographic characteristics of chronically critically ill patients who have DNR orders and those who do not; to identify the differences in the cost of care between patients with and without DNR orders; and to identify the differences in DNR practices between an experimental special care unit and the traditional intensive care unit (ICU). DESIGN Randomized, prospective design with a block randomization scheme. SUBJECTS Two hundred twenty patients who met the following eligibility criteria for enrollment in a parent study of the special care unit: an ICU stay of at least 5 days, an absence of pulmonary artery monitoring, an absence of frequent titration of intravenous vasopressors, an Acute Physiology and Chronic Health Evaluation II score of less than 18, and a Therapeutic Intervention Scoring System score of less than 39. SETTING A large, urban academic medical center. MEASURES Clinical and demographic variables describing the study populations, mental status, and timing of DNR orders, mortality rates, and cost of hospitalization. RESULTS There was no difference in the frequency of DNR orders between the special care unit versus the intensive care unit--although patients in the special care unit had a longer interval between hospital admission and initiation of the DNR order. DNR patients differed from non-DNR in that they were older, less likely to be married, and had a higher Acute Physiology and Chronic Health Evaluation II score on admission to the study. The mortality rate in the DNR group was 71% versus 6% in the non-DNR group. There was no difference in total costs. DNR patients were also more likely to have an impaired mental status on admission, and more likely to have deterioration in mental status by the time of discharge than the non-DNR patients.