Glenda Sherman

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.

OBJECTIVE To compare a practice of protocol-directed sedation during mechanical ventilation implemented by nurses with traditional non-protocol-directed sedation administration. DESIGN Randomized, controlled clinical trial. SETTING Medical intensive care unit (19 beds) in an urban teaching hospital. PATIENTS Patients requiring mechanical ventilation (n = 321). INTERVENTIONS Patients were randomly assigned to receive either protocol-directed sedation (n = 162) or non-protocol-directed sedation (n = 159). MEASUREMENTS AND MAIN RESULTS The median duration of mechanical ventilation was 55.9 hrs (95% confidence interval, 41.0-90.0 hrs) for patients managed with protocol-directed sedation and 117.0 hrs (95% confidence interval, 96.0-155.6 hrs) for patients receiving non-protocol-directed sedation. Kaplan-Meier analysis demonstrated that patients in the protocol-directed sedation group had statistically shorter durations of mechanical ventilation than patients in the non-protocol-directed sedation group (chi-square = 7.00, p = .008, log rank test; chi-square = 8.54, p = .004, Wilcoxons test; chi-square = 9.18, p = .003, -2 log test). Lengths of stay in the intensive care unit (5.7+/-5.9 days vs. 7.5+/-6.5 days; p = .013) and hospital (14.0+/-17.3 days vs. 19.9+/-24.2 days; p < .001) were also significantly shorter among patients in the protocol-directed sedation group. Among the 132 patients (41.1%) receiving continuous intravenous sedation, those in the protocol-directed sedation group (n = 66) had a significantly shorter duration of continuous intravenous sedation than those in the non-protocol-directed sedation group (n = 66) (3.5+/-4.0 days vs. 5.6+/-6.4 days; p = .003). Patients in the protocol-directed sedation group also had a significantly lower tracheostomy rate compared with patients in the non-protocol-directed sedation group (10 of 162 patients [6.2%] vs. 21 of 159 patients [13.2%], p = .038). CONCLUSIONS The use of protocol-directed sedation can reduce the duration of mechanical ventilation, the intensive care unit and hospital lengths of stay, and the need for tracheostomy among critically ill patients with acute respiratory failure.

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia.

Objective To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. Design Prospective before-and-after study design. Setting A medical intensive care unit from a university-affiliated, urban teaching hospital. Patients Between April 1999 and January 2000, 102 patients were prospectively evaluated. Interventions Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. Measurements and Main Results The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 ± 5.7 vs. 25.4 ± 8.1, p = .798) and the clinical pulmonary infection scores (6.6 ± 1.0 vs. 6.9 ± 1.2, p = .105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p < .001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 ± 5.1 days vs. 14.8 ± 8.1 days, p < .001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p = .030). Conclusions The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.

Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial

BACKGROUND This study sought to compare 2 strategies for the administration of enteral feeding to mechanically ventilated medical patients. METHODS The prospective, controlled, clinical trial was carried out in a medical intensive care unit (19 beds) in a university-affiliated, urban teaching hospital. Between May 1999 and December 2000, 150 patients were enrolled. Patients were scheduled to receive their estimated total daily enteral nutritional requirements on either day 1 (early-feeding group) or day 5 (late-feeding group) of mechanical ventilation. Patients in the late-feeding group were also scheduled to receive 20% of their estimated daily enteral nutritional requirements during the first 4 days of mechanical ventilation. RESULTS Seventy-five (50%) consecutive eligible patients were entered into the early-feeding group and 75 (50%) patients were enrolled in the late-feeding group. During the 5 five days of mechanical ventilation, the total intake of calories (2370 +/- 2000 kcal versus 629 +/- 575 kcal; p < .001) and protein (93.6 +/- 77.2 g versus 26.7 +/- 26.6 g; p < .001) were statistically greater for patients in the early-feeding group. Patients in the early-feeding group had statistically greater incidences of ventilator-associated pneumonia (49.3% versus 30.7%; p = .020) and diarrhea associated with Clostridium difficile infection (13.3% versus 4.0%; p = .042). The early-feeding group also had statistically longer intensive care unit (13.6 +/- 14.2 days versus 9.8 +/- 7.4 days; p = .043) and hospital lengths of stay (22.9 +/- 19.7 days versus 16.7 +/- 12.5 days; p = .023) compared with patients in the late-feeding group. No statistical difference in hospital mortality was observed between patients in the early-feeding and late-feeding groups (20.0% versus 26.7%; p = .334). CONCLUSIONS The administration of more aggressive early enteral nutrition to mechanically ventilated medical patients is associated with greater infectious complications and prolonged lengths of stay in the hospital. Clinicians must balance the potential for complications resulting from early enteral feeding with the expected benefits of such therapy.

Inadequate treatment of nosocomial infections is associated with certain empiric antibiotic choices.

ObjectiveThe purpose of this study was to determine the impact of scheduled changes of antibiotic classes, used for the empirical treatment of suspected or documented Gram-negative bacterial infections, on the occurrence of inadequate antimicrobial treatment of nosocomial infections. DesignProspective observational study. SettingMedical (19-bed) and surgical (18-bed) intensive care units in an urban teaching hospital. PatientsA total of 3,668 patients requiring intensive care unit admission were prospectively evaluated during three consecutive time periods. InterventionsDuring each time period, one antibiotic class was selected for the empirical treatment of Gram-negative bacterial infections as follows: time period 1 (baseline period) (1,323 patients), ceftazidime; time period 2 (1,243 patients), ciprofloxacin; and time period 3 (1,102 patients), cefepime. Measurements and Main ResultsThe overall administration of inadequate antimicrobial treatment for nosocomial infections decreased during the course of the study (6.1%, 4.7%, and 4.5%;p = .15). This was primarily because of a statistically significant decrease in the administration of inadequate antibiotic treatment for Gram-negative bacterial infections (4.4%, 2.1%, and 1.6%;p < .001). There were no statistically significant differences in the overall hospital mortality rate among the three time periods (15.6%, 16.4%, and 16.2%;p = .828) despite a significant increase in severity of illness as measured with Acute Physiology and Chronic Health Evaluation (APACHE) II scores (15.3 ± 7.6, 15.7 ± 8.0, and 20.7 ± 8.6;p < .001). The hospital mortality rate decreased significantly during time period 3 (20.6%) compared with time period 1 (28.4%;p < .001) and time period 2 (29.5%;p < .001) for patients with an APACHE II score ≥15. ConclusionsThese data suggest that scheduled changes of antibiotic classes for the empirical treatment of Gram-negative bacterial infections can reduce the occurrence of inadequate antibiotic treatment for nosocomial infections. Reducing inadequate antibiotic administration may improve the outcomes of critically ill patients with APACHE II scores ≥15.

Deep vein thrombosis during prolonged mechanical ventilation despite prophylaxis

Objective To determine the prevalence of deep vein thrombosis (DVT) among patients requiring prolonged mechanical ventilation in the intensive care unit. Design Prospective cohort study. Setting Medical intensive care unit of a university-affiliated urban teaching hospital. Patients Patients requiring mechanical ventilation for >7 days. Interventions All patients admitted to the medical intensive care unit requiring prolonged mechanical ventilation underwent duplex ultrasonography of their lower extremities and upper extremities every 7 days. The main outcome identified was the presence of DVT. Secondary outcomes included hospital mortality, hospital and intensive care unit lengths of stay, and the occurrence of pulmonary embolism. Measurements and Main Results A total of 110 patients requiring mechanical ventilation for >7 days were enrolled. Prophylaxis against DVT was employed in 110 of the patients (100%). A total of 26 patients (23.6%) developed DVT. Patients with DVT were statistically more likely to have underlying malignancy (30.8% vs. 8.3%;p = .004) and longer durations of central venous catheterization (26.9 ± 22.2 days vs. 14.5 ± 12.1 days;p = .024) compared with patients without DVT. There were no statistically significant differences in hospital mortality or lengths of stay in the hospital and intensive care unit for patients with and without DVT. Patients documented to have DVT by using duplex ultrasonography had a statistically greater frequency of subsequent pulmonary embolism during their hospitalization (11.5% vs. 0.0%;p = .012). Conclusion The occurrence of DVT is common among patients requiring prolonged mechanical ventilation in the intensive care unit setting despite the use of prophylaxis measures. These data suggest that alternative strategies for the prevention of DVT should be evaluated. Additionally, early detection methods should be considered to reduce the potential morbidity associated with untreated DVT in this high-risk population.

Ambulatory care-sensitive conditions: clinical outcomes and impact on intensive care unit resource use.

Background We identified risk factors and clinical outcomes associated with ambulatory care-sensitive conditions requiring intensive care unit (ICU) admission. Methods This prospective cohort study included 4,144 patients admitted to the medical ICU of an urban teaching hospital during a 3-year period. Results A total of 627 patients were classified as having ambulatory care-sensitive conditions (ie, potentially preventable ICU admissions). Black race, decreasing Acute Physiology and Chronic Health Evaluation II (APACHE II) score, younger age, female sex, and absence of immunodeficiency were independently associated with ambulatory care-sensitive conditions. Patients classified as having ambulatory care-sensitive conditions accounted for 2,006 ventilator days, 2,508 ICU days, and 5,392 hospital days. The hospital mortality rate was statistically lower for patients with ambulatory care-sensitive conditions than for patients without these conditions. Patients classified as having ambulatory care-sensitive conditions were also statistically more likely than other patients to lack health insurance and to sign out of the hospital against medical advice. Conclusion Patients with ambulatory care-sensitive conditions account for a substantial portion of all admissions to the intensive care unit. These data suggest that interventions aimed at preventing such admissions could improve ICU bed use.