Monica Norena

Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are.

Objective:To determine whether hospital site is independently associated with length of intensive care unit (ICU) stay in those patients who die in hospital after experiencing a cardiac arrest. Design:Retrospective cohort study. Setting:Thirty-one Canadian ICUs, all but one being members of the Critical Care Research Network. Patients:All patients admitted to these ICUs after resuscitation from a cardiac arrest. Interventions:None. Measurements and Main Results:Retrospective analysis of prospectively collected clinical data. Using gamma regression with ICU length of stay as the dependent variable, we found the following variables to be independently associated with ICU length of stay: age, gender, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, hospital size, and hospital site. Conclusions:In this cohort of patients admitted to ICU after cardiac arrest, hospital site was strongly associated with ICU length of stay after controlling for patient-specific factors. Variation in processes of care among ICUs may point to opportunities for improvement.

Association between Source of Infection and Hospital Mortality in Patients Who Have Septic Shock

RATIONALE Mortality caused by septic shock may be determined by a systemic inflammatory response, independent of the inciting infection, but it may also be influenced by the anatomic source of infection. OBJECTIVES To determine the association between the anatomic source of infection and hospital mortality in critically ill patients who have septic shock. METHODS This was a retrospective, multicenter cohort study of 7,974 patients who had septic shock in 29 academic and community intensive care units in Canada, the United States, and Saudi Arabia from January 1989 to May 2008. MEASUREMENTS AND MAIN RESULTS Subjects were assigned 1 of 20 anatomic sources of infection based on clinical diagnosis and/or isolation of pathogens. The primary outcome was hospital mortality. Overall crude hospital mortality was 52% (21-85% across sources of infection). Variation in mortality remained after adjusting for year of admission, geographic source of admission, age, sex, comorbidities, community- versus hospital-acquired infection, and organism type. The source of infection with the highest standardized hospital mortality was ischemic bowel (75%); the lowest was obstructive uropathy-associated urinary tract infection (26%). Residual variation in adjusted hospital mortality was not explained by Acute Physiology and Chronic Health Evaluation II score, number of Day 1 organ failures, bacteremia, appropriateness of empiric antimicrobials, or adjunct therapies. In patients who received appropriate antimicrobials after onset of hypotension, source of infection was associated with death after adjustment for both predisposing and downstream factors. CONCLUSIONS Anatomic source of infection should be considered in future trial designs and analyses, and in development of prognostic scoring systems.

Moral distress in intensive care unit professionals is associated with profession, age, and years of experience

PURPOSE To determine which demographic characteristics are associated with moral distress in intensive care unit (ICU) professionals. METHODS We distributed a self-administered, validated survey to measure moral distress to all clinical personnel in 13 ICUs in British Columbia, Canada. Each respondent to the survey also reported their age, sex, and years of experience in the ICU where they were working. We used multivariate, hierarchical regression to analyze relationships between demographic characteristics and moral distress scores, and to analyze the relationship between moral distress and tendency to leave the workplace. RESULTS Response rates to the surveys were the following: nurses--428/870 (49%); other health professionals (not nurses or physicians)--211/452 (47%); physicians--30/68 (44%). Nurses and other health professionals had higher moral distress scores than physicians. Highest ranked items associated with moral distress were related to cost constraints and end-of-life controversies. Multivariate analyses showed that age is inversely associated with moral distress, but only in other health professionals (rate ratio [95% confidence interval]: -7.3 [-13.4, -1.2]); years of experience is directly associated with moral distress, but only in nurses (rate ratio (95% confidence interval):10.8 [2.6, 18.9]). The moral distress score is directly related to the tendency to leave the ICU job, in both the past and present, but only for nurses and other non-physician health professionals. CONCLUSION Moral distress is higher in ICU nurses and other non-physician professionals than in physicians, is lower with older age for other non-physician professionals but greater with more years of experience in nurses, and is associated with tendency to leave the job.

Length of stay and mortality due to Clostridium difficile infection acquired in the intensive care unit

PURPOSE The purpose of this study was to determine the attributable intensive care unit (ICU) and hospital length of stay and mortality of ICU-acquired Clostridium difficile infection (CDI). MATERIALS AND METHODS In this retrospective cohort study of 3 tertiary and 3 community ICUs, we screened all patients admitted between April 2006 and December 2011 for ICU-acquired CDI. Using both complete and matched cohort designs and Cox proportional hazards analysis, we determined the association between CDI and ICU and hospital length of stay and mortality. Adjustment or matching variables were site, age, sex, severity of illness, and year of admission; any infection as an ICU admitting or acquired diagnosis before the diagnosis of CDI and diagnosis of CDI were time-dependent exposures. RESULTS Of 15314 patients admitted to the ICUs during the study period, 236 developed CDI in the ICU. In the complete cohort analysis, the hazard ratios (95% confidence interval) for CDI related to ICU and hospital discharge were 0.82 (0.72, 0.94) and 0.83 (0.73, 0.95), respectively (0.5 additional ICU days and 3.4 hospital days), and related to death in ICU and hospital, they were 1.00 (0.73, 1.38) and 1.19 (0.93, 1.52), respectively. In the matched analysis, the hazard ratios for CDI related to ICU and hospital discharge were 0.91 (0.81, 1.03) and 0.98 (0.85, 1.13), respectively, and related to death in ICU and hospital, they were 1.18 (0.85, 1.63) and 1.08 (0.82, 1.43), respectively. CONCLUSIONS C difficile infection acquired in ICU is associated with an increase in length of ICU and hospital stay but not with any difference in ICU or hospital mortality.

Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II score, and predicted probability of mortality in an electronic intensive care unit database☆

BACKGROUND Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied. METHODS Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlains percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A kappa statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality. RESULTS Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by kappa statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71). CONCLUSION Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts.

Adherence to guidelines for management of cerebral perfusion pressure and outcome in patients who have severe traumatic brain injury

PURPOSE The aims of this study are to assess adherence to the Brain Trauma Foundation (BTF) cerebral perfusion pressure (CPP) guidelines and to determine if adherence is associated with mortality in patients who have a severe traumatic brain injury. MATERIALS AND METHODS Retrospective cohort study of 127 patients admitted to one intensive care unit between 2006 and 2012. Adherence to BTF guidelines was measured as the time that the CPP was within 50 to 70 mm Hg divided by the total time of CPP monitoring (CPP time index). RESULTS The percentage of time that the CPP was within the recommended range was 31.6% (SD, 22.2); CPP was greater than 70 mm Hg for 63.9% (SD, 26.2) of the time and less than 50 mm Hg for 4.5% of the time (SD, 16.3). After adjustment for covariates, CPP time index (between 50 and 70 mm Hg) was not associated with hospital mortality (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.98-1.6; P= .079). The time indices for CPP ≥70 and <50 mm Hg were associated with decreased (OR, 0.66; 95%CI, 0.52-0.82; P< .0001) and increased (OR, 9.9; 95% CI, 1.4-69.6; P= .021) mortality, respectively. CONCLUSION Cerebral perfusion pressure was greater than 70 mm Hg for most of the time. This level of CPP was associated with decreased hospital mortality.

Intensive care unit survivors have fewer hospital readmissions and readmission days than other hospitalized patients in British Columbia.

ObjectiveIntensive care unit (ICU) patients who survive their hospital admission have a long-term survival that is similar to that of hospitalized patients who do not require ICU admission. The risk of future readmission to the hospital for these two patient groups is unknown. The objective of this study was to determine the association between ICU admission and number of readmissions to the hospital and number of readmission days. DesignCohort study for 3 yrs between 1994 and 1997. SettingAll acute care hospitals in British Columbia, Canada. PatientsA total of 23,859 patients admitted to the ICU and 40,052 patients admitted to the hospital but not the ICU (5% random sample of total). InterventionNone. Measurements and Main ResultsWe measured the number of readmissions to the hospital and the number of readmission days after discharge from the first admission to the hospital during the study period. For survivors to the end of the study period, patients who had been in the ICU had 0.66 readmissions per year and 5.29 readmission days per year compared with 0.73 readmissions per year and 5.48 readmission days per year for control subjects. After controlling for age, sex, socioeconomic status, number of previous ICU and hospital admissions, major clinical category during index admission, comorbidity score during index admission, length of hospital stay during index admission, size of index hospital, and period of follow-up, ICU admission was associated with fewer readmissions (survivors: rate ratio, 0.80; 95% confidence interval, 0.77–0.82; nonsurvivors: rate ratio, 0.85; 95%, confidence interval, 0.82–0.89) and readmission days (survivors: rate ratio, 0.91; 95% confidence interval, 0.87–0.95; nonsurvivors: rate ratio, 0.87; 95%, confidence interval, 0.81–0.92) than admission to the hospital but not the ICU. ConclusionsSurvivors of a hospital stay that includes admission to an ICU have fewer hospital readmissions and readmission days after their discharge than do survivors of a hospital stay without intensive care.

Intensive care unit admissions for community-acquired pneumonia are seasonal but are not associated with weather or reports of influenza-like illness in the community

PURPOSE The aims of this study were to determine if there is seasonal variation in the number of intensive care unit (ICU) admissions for community-acquired pneumonia (CAP) and if there is a relationship between these admissions and weather or reports of influenza-like illness in the community. MATERIALS AND METHODS In this time series analysis in 3 medical-surgical ICUs (8, 13, and 20 beds) in the Vancouver region, we included patients admitted to adult ICUs for CAP between January 2002 and March 2006. We used Poisson regression to analyze the association between weekly number of ICU admissions for CAP, and average temperature, range in temperature, total precipitation, and cases of influenza-like illness/100 physician visits reported by sentinel physicians in the community. RESULTS In 740 patients admitted to ICUs for CAP, admissions peaked each year in the winter-spring months. In multivariate models, a sine function with a single annual peak was independently associated with number of patients admitted to ICU for CAP (rate ratio [95% confidence interval], 1.12 [1.00, 1.26]), but neither the weather measurements nor the weekly rate of reported influenza-like illness was significantly associated. CONCLUSION Intensive care unit admissions for CAP are seasonal, but neither weather measurements nor weekly rate of reported influenza-like illness in the community is associated with these admissions.

Review of a Large Clinical Series: Structure, Process, and Outcome of all Intensive Care Units Within the Province of British Columbia, Canada

Purpose: To describe the total and regional capacity for critical care in British Columbia (BC), Canada, and to describe regional variation in number of intensive care units (ICUs), size of ICUs, length of ICU stay, ICU occupancy, key processes of critical care, and hospital mortality for ICU patients in B.C. Methods: In this cross-sectional study, we used retrospectively collected data from all patients admitted to an ICU in BC between April1, 1998, and March 31, 1999, and responses to a survey about organizational factors for all ICUs in BC that was done in 2001 and updated in 2008. Results: The number of ICU beds in each geographic region in BC is inversely related to the population density and population growth within those regions. In addition, the distribution of ICU beds does not match the distribution of specialized and high-risk clinical services. There is wide variation by geographic region and by size of ICU in physician and nurse staffing, physician model of care, availability and participation of respiratory therapists, and other support services in clinical care and in reported use of clinical practice guidelines. Conclusion: Variation and lack of availability of key processes for care of critically ill patients in this population identifies opportunities for knowledge translation and systematic improvement including regionalization of care.

Early veno-venous extracorporeal membrane oxygenation is associated with lower mortality in patients who have severe hypoxemic respiratory failure: A retrospective multicenter cohort study

PURPOSE The purpose of the study is to compare outcomes in patients who had severe hypoxemic respiratory failure (Pao2/fraction of inspired oxygen <100) who received early veno-venous extracorporeal membrane oxygenation (ECMO) as an adjunct to mechanical ventilation, to those in patients who received conventional mechanical ventilation alone. MATERIALS AND METHODS This is a multicenter, retrospective unmatched and matched cohort study of patients admitted between April 2006 and December 2013. Generalized logistic mixed-effects models and Cox proportional hazards models were used to determine the association between treatment with ECMO that was started within 3 days of intensive care unit (ICU) admission and ICU and hospital mortality and length of stay, respectively. RESULTS A total of 2440 patients who had severe hypoxemic respiratory failure due to various etiologies were included, 46 who received early veno-venous ECMO and 2394 unmatched and 398 matched controls who received conventional ventilation alone. Compared to matched controls, ECMO was associated with a lower odds of ICU (odds ratio [95% confidence interval], 0.30 [0.13-0.67]) and inhospital death (odds ratio 0.30 [0.14-0.67]). In addition, ECMO was associated with longer times to discharge from ICU and hospital (hazard ratio, 0.42 [0.37-0.47] and 0.53 [0.38-0.73], respectively). CONCLUSIONS In this observational study, use of early ECMO compared to conventional mechanical ventilation alone in patients who had severe hypoxemic respiratory failure was associated with a lower risk of mortality and a longer length of stay.