Erin Rosenberg

Validation of the Critical Care Pain Observation Tool in Critically Ill Patients With Delirium: A Prospective Cohort Study.

ObjectivesThe 2013 clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the ICU suggest that pain be routinely assessed using a validated pain assessment tool. Currently available tools have only been evaluated in nondelirious critically ill patients, yet delirium can affect as many as 80% of ICU patients. The validated pain assessment tool adopted by our institution is the Critical Care Pain Observation Tool, and the objective of this study was to investigate the validity of this tool in patients with evidence of delirium. Design:Prospective cohort study. Setting:Two ICUs within a Canadian tertiary healthcare center. Patients:Forty consecutive adult patients deemed delirious on the day of enrollment using the Confusion Assessment Method for ICU. Measurements and Main Results:Serial Critical Care Pain Observation Tool assessments were conducted simultaneously by study personnel and objective nurses at baseline and after nonpainful and painful stimuli. Subjective opinions about pain and objective physical variables (including mean arterial pressure, heart rate, respiratory rate, and oxygen saturation) were collected at the same time points. Discriminant validity was described using paired t tests, whereas internal consistency was described using the Cronbach &agr; statistic. Responsiveness of the Critical Care Pain Observation Tool was measured by effect size, and reliability was described as the agreement between raters. Comparisons between the Critical Care Pain Observation Tool and the subjective assessments and objective measurements were based on positive and negative percent agreement. Critical Care Pain Observation Tool demonstrated excellent discriminant validity as evidenced by a highly statistically and clinically significant change in mean Critical Care Pain Observation Tool scores between baseline and painful procedures (mean difference, 3.13 ± 1.56; p < 0.001; Cohen D, 2.0). Interrater agreement was also excellent (&kgr; > 0.6), and scores between raters were highly correlated (r = 0.957). The Critical Care Pain Observation Tool possessed a high level of internal consistency (overall Cronbach &agr;, 0.778). Percent agreement was found to be greater between the Critical Care Pain Observation Tool and the nurse’s subjective opinion of the presence or absence of pain when compared with that between the Critical Care Pain Observation Tool and physiologic variables (80.5% vs 67.5%, respectively). Conclusions:The Critical Care Pain Observation Tool is a valid pain assessment tool in noncomatose, delirious adult ICU patients who are unable to reliably self-report the presence or absence of pain.

Outcomes and Costs of Patients Admitted to the Intensive Care Unit Due to Accidental or Intentional Poisoning

Introduction: Acute poisoning represents a major cause of morbidity and mortality, and many of these patients are admitted to the intensive care unit (ICU). However, little is known regarding ICU costs of acute poisoning. Methods: This was a retrospective matched database analysis of patients admitted to the ICU with acute poisoning from 2011 to 2014. It was performed in 2 ICUs within a single tertiary care hospital system. All patient information, outcomes, and costs were stored in the hospital data warehouse. Control patients were defined as randomly selected age-, sex-, severity index-, and comorbidity index-matched nonpoisoned ICU patients (1:4 matching ratio). Results: A total of 8452 critically ill patients were admitted during the study period, of whom 277 had a diagnosis of acute poisoning. The mean age was 44.5 years, and the most common xenobiotics implicated were sedative hypnotics (20.2%), antidepressants (15.2%), and opioids (10.5%). Of these, 73.6% of poisonings were deemed intentional. In-hospital mortality of poisoned patients was 5.1%, compared to 11.1% for control patients (P < .01). The median ICU length of stay (LOS) for poisoned patients was 3.0 days, compared with 4.0 days for control patients (P < .01). The mean total cost for poisoned patients was CAD

Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis

18 958. Control patients had a significantly higher mean total cost of CAD

Dynamic Assessment of Fluid Responsiveness in Surgical ICU Patients Through Stroke Volume Variation is Associated With Decreased Length of Stay and Costs: A Systematic Review and Meta-Analysis

60 628 (P < .01). The xenobiotics associated with the highest costs were acetaminophen (CAD

Factors associated with delayed rapid response team activation

18 585), toxic alcohols (CAD

Characteristics, Outcomes, and Cost Patterns of High-Cost Patients in the Intensive Care Unit

16 771), and opioids (CAD

Outcomes and Costs of Patients Admitted to the ICU Due to Spontaneous Intracranial Hemorrhage

12 967). Conclusions: In our cohort, we confirmed the long-held belief that patients admitted to the ICU with a primary diagnosis of poisoning have a lower mortality rate, ICU LOS, and overall cost per ICU admission than nonpoisoned patients. However, poisoned patients still accrue significant daily costs, with the highest costs attributed to xenobiotics with known antidotes, such as acetaminophen, toxic alcohols, and opioids.

1177: AUTOMATED VERSUS NONAUTOMATED VENTILATION WEANING IN THE ICU

Introduction: With an aging population and increasing numbers of intensive care unit admissions, novel ways of providing quality care at reduced cost are required. Closed neurointensive care units improve outcomes for patients with critical neurological conditions, including decreased mortality and length of stay (LOS). Small studies have demonstrated the safety of intermediate-level units for selected patient populations. However, few studies analyze both cost and safety outcomes of these units. This retrospective study assessed clinical and cost-related outcomes in an intermediate-level neurosciences acute care unit (NACU) before and after the addition of an intensivist to the unit’s care team. Methods: Starting in October 2011, an intensivist-led model was adopted in a 16-bed NACU unit, including daytime coverage by a dedicated intensivist. Data were obtained from all patients admitted 1 year prior to and 2 years after this intervention. Primary outcomes were LOS and hospital costs. Safety outcomes included mortality and readmissions. Descriptive and analytic statistics were calculated. Individual and total patient costs were calculated based on per-day NACU and ward cost estimates and significance measured using bootstrapping. Results: A total of 2931 patients were included over the study period. Patients were on average 59.5 years and 53% male. The most common reasons for admission were central nervous system (CNS) tumor (27.6%), ischemic stroke (27%), and subarachnoid hemorrhage (11%). Following the introduction of an intensivist, there was a significant reduction in NACU and hospital LOS, by 1 day and 3 days, respectively. There were no differences in readmissions or mortality. Adding an intensivist produced an individual cost savings of US

501: ICU DELIRIUM, CLINICAL OUTCOMES, AND COST

963 in NACU and US

1413: OUTCOMES AND COSTS OF PATIENTS WITH SEPSIS TRANSFERRED TO A TERTIARY CARE INTENSIVE CARE UNIT

2687 per patient total hospital stay. Conclusion: An intensivist-led model of intermediate-level neurointensive care staffed by intensivists is safe, decreases LOS, and produces cost savings in a system increasingly strained to provide quality neurocritical care.