Maria I. Rudis

Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model

Patients receiving medical care in intensive care units (ICUs) account for nearly 30% of acute care hospital costs, yet these patients occupy only 10% of inpatient beds (1, 2). In 1984, the Office of Technology Assessment concluded that 80% of hospitals in the United States had ICUs, >20% of hospital budgets were expended on the care of intensive care patients, and approximately 1% of the gross national product was expended for intensive care services (3). With the aging of the U.S. population, greater demand for critical care services will occur. At the same time, market forces are evolving that may constrain both hospitals’ and practitioners’ abilities to provide this increasing need for critical care services. In addition, managed care organizations are requesting justification for services provided in the ICU and for demonstration of both efficiency and efficacy. Hospital administrators are continually seeking methods to provide effective and efficient care to their ICU patients. As a result of these social and economic pressures, there is a need to provide more data about the type and quality of clinical care provided in the ICU. In response, two task forces were convened by the Society of Critical Care Medicine leadership. One task force (models task force) was asked to review available information on critical care delivery in the ICU and to ascertain, if possible, a “best” practice model. The other task force was asked to define the role and practice of an intensivist. The task force memberships were diverse, representing all the disciplines that actively participate in the delivery of health care to patients in the ICU. The models task force membership consisted of 31 healthcare professionals and practitioners, including statisticians and representatives from industry, pharmacy, nursing, respiratory care, and physicians from the specialties of surgery, internal medicine, pediatrics, and anesthesia. These healthcare professionals represented the practice of critical care medicine in multiple settings, including nonteaching community hospitals, community hospitals with teaching programs, academic institutions, military hospitals, critical care medicine private practice, full-time academic practice, and consultative critical care practice. This article is the consensus report of the two task forces. The objectives of this report include the following: (1) to describe the types and settings of critical care practice (2); to describe the clinical roles of members of the ICU healthcare team (3); to examine available outcome data pertaining to the types of critical care practice (4); to attempt to define a “best” practice model; and (5) to propose additional research that should be undertaken to answer important questions regarding the practice of critical care medicine. The data and recommendations contained within this report are sometimes based on consensus expert opinion; however, where possible, recommendations are promulgated based on levels of evidence as outlined by Sacket in 1989 (4) and further modified by Taylor in 1997 (5) (see Appendix 1).

Is it time to reposition vasopressors and inotropes in sepsis

OBJECTIVES To review the literature on the current use of vasopressors and inotropes in patients with sepsis and sepsis syndrome with respect to the choice of agent, therapeutic end points, and safe and effective doses to be used. To examine the available evidence that supports or refutes goal-directed therapy toward supranormal oxygen transport in optimizing the outcome of critically ill sepsis syndrome patients. DATA SOURCES All pertinent English and French articles dealing with hemodynamic support with selected vasopressors and inotropic agents in human sepsis and sepsis syndrome retrieved from a computerized MEDLINE search from 1985 to 1994. STUDY SELECTION Clinical studies with norepinephrine, epinephrine, phenylephrine, dopamine, and dobutamine in sepsis syndrome were considered if goal-directed therapy with oxygen transport variables was utilized. Emphasis was placed on prospective, randomized, controlled comparative trials. However, open-label, observational, and comparative studies, or case series, were also evaluated when limited data were available. DATA EXTRACTION From the selected studies, information was obtained regarding patient population, dosing regimen, type of therapeutic goals or end points (hemodynamic, or normal vs. supranormal oxygen transport variables) and outcome data (e.g., achievement of goals, resolution of the episode, mortality rate, and development of end-organ dysfunction). DATA SYNTHESIS When used in larger than usual doses, epinephrine, norepinephrine, and phenylephrine uniformly increased hemodynamic values. Epinephrine may increase oxygen transport values more reliably than norepinephrine. Dobutamine doses in the range of 2.5 to 6 microgram/kg/min increase oxygen transport variables and hemodynamics to predetermined goals in only 30% to 70% of patients. Larger infusion rates offer no further benefits. CONCLUSIONS Insufficient evidence exists to support goal-directed therapy with vasopressors and inotropes in the treatment of sepsis syndrome. No definitive recommendations can be made about the superiority of a vasopressor or inotropic agent due to the lack of data. However, it may be that evaluation of vasopressors earlier in sepsis syndrome will yield more promising results. Large, comparative, controlled trials assessing mortality rate and development of multiple organ system dysfunction are needed.

Position paper on critical care pharmacy services

ObjectiveThe goal of the Task Force on Critical Care Pharmacy Services was to identify and describe the scope of practice that characterizes the critical care pharmacist and critical care pharmacy services. Specifically, the aims were to define the level of clinical practice and specialized skills c

Economic impact of prolonged motor weakness complicating neuromuscular blockade in the intensive care unit

OBJECTIVE We compared a case-series of ten patients who developed prolonged neuromuscular weakness after continuous, nondepolarizing, neuromuscular blockade with a group of controls without neuromuscular weakness to determine the economic impact of the neuromuscular weakness. DESIGN Frequency-matched case control trial. SETTING Medical and surgical intensive care units of a 937-bed tertiary care, university-affiliated teaching hospital. PATIENTS Ten patients developed prolonged neuromuscular weakness after continuous administration of nondepolarizing neuromuscular blockers. Ten patients from a 1994 drug utilization database who did not develop motor weakness after paralysis were identified to serve as controls. MEASUREMENTS AND MAIN RESULTS The medical and accounting records of the patients were retrospectively reviewed. Charge data were obtained from patient accounts. Institutional ratios to convert charges to full costs and marginal costs were obtained from the Hospital Finance Department of Henry Ford Hospital. The economic impact of the diagnosis and recovery of the motor weakness was estimated for the intensive care unit (ICU) and hospital stays and compared with those values for control patients. Median hospital charges (excluding rehabilitation), totaling

Effect of once-daily dosing vs. multiple daily dosing of tobramycin on enzyme markers of nephrotoxicity

91,476, were attributed to the patients who developed neuromuscular weakness and included charges for neuromuscular blocking agents, continuous mechanical ventilation, ICU and hospital beds, neurologic studies, and physical therapy services. In the control patients, median charges were

Critical Care Pharmacy Services in United States Hospitals

22,191 (p = .001). The total median cost differential for a patient in the neuromuscular weakness group was in excess of

Comparing intravenous amiodarone or lidocaine, or both, outcomes for inpatients with pulseless ventricular arrhythmias.

66,713 (95% confidence interval

Angiotensin II receptor antagonists : The prototype losartan

23,485 to

Clinical Experience with Ketorolac in Children

189,214, p = .001). Significant differences were also found for patient charges, full costs, and marginal costs for mechanical ventilation (p = .002), neurologic studies (p = .014), as well as ICU (p = .002) and hospital (p = .001) stays. CONCLUSIONS The development of motor weakness was associated with an increase in ICU and hospital stays, continued mechanical ventilation, and disproportionate healthcare expenditures in excess of

Technical and Interpretive Problems of Peripheral Nerve Stimulation in Monitoring Neuromuscular Blockade in the Intensive Care Unit

66,000 per patient. A prospective evaluation of the true prevalence of neuromuscular weakness after neuromuscular blockade and of the costs to the healthcare system is needed.