Saad Al-Qahtani

Mortality reduction after implementing a clinical practice guidelines-based management protocol for severe traumatic brain injury.

INTRODUCTION The objective of this study was to examine the effect of implementing a clinical practice guidelines-based management protocol on the outcome of patients with severe traumatic brain injury (TBI). METHODS We carried out a pre-post guideline implementation study using previously collected data in the Intensive Care Unit (ICU). All patients older than 12 years with severe TBI, defined as a Glasgow Coma Scale score of 8 or less, from March 1999 to January 2001 (control group) and from February 2001 to December 2006 (protocol group) were identified and included in this study. Patients in the protocol group were managed using a clinical practice guidelines-based management protocol, derived from the guidelines published by the Brain Trauma Foundation. Primary outcome was hospital mortality, whereas the secondary outcome was ICU mortality. To assess whether the ICU protocol might have led to an increase in the number of surviving patients with severe disability, we examined the association of the protocol use and the need for tracheostomies, mechanical ventilation duration, and ICU and hospital length of stay (LOS) among survivors. RESULTS During the study period, a total of 434 patients met the inclusion criteria. After adjustment for several prognostic factors, the use of protocol was independently associated with a significant reduction in hospital and ICU mortality (odds ratio, 0.45; 95% confidence interval, 0.24-0.86; and odds ratio, 0.47; 95% confidence interval, 0.23-0.96, respectively). The use of the protocol was not associated with an increase in the need for tracheostomies, mechanical ventilation duration, ICU LOS, and hospital LOS. CONCLUSION The protocol implementation was associated with a reduction in hospital and ICU mortality. This improvement was not associated with an increase in the frequency of tracheostomies and in ICU or hospital LOS, suggesting that the improved survival was not associated with the increased number of surviving patients with severe disability and that the functional status might have also improved.

Impact of an Intensivist-Led Multidisciplinary Extended Rapid Response Team on Hospital-Wide Cardiopulmonary Arrests and Mortality*

Objective:The effectiveness of rapid response teams remains controversial. However, many studied rapid response teams were not intensivist-led, had limited involvement beyond the initial activations, and did not provide post-ICU follow-up. The objective of this study was to examine the impact of implementing an intensivist-led multidisciplinary extended rapid response team on hospital-wide cardiopulmonary arrests and mortality. Design:This was a pre-post rapid response team implementation study. Setting:Tertiary care academic center in Saudi Arabia. Patients:A total of 98,391 patients in the 2-yr pre-rapid response team and 157,804 patients in the 3-yr post-rapid response team implementation were evaluated. Intervention:The rapid response team was activated by any health care provider based on pre-defined criteria and a four-member intensivist-led multidisciplinary rapid response team responded to provide the necessary management and disposition. The rapid response team function was extended to provide follow-up until clinical stabilization. In addition, the rapid response team provided a mandatory post-ICU follow-up for a minimum of 48 hrs. Measurements and Main Results:The primary outcomes were cardiopulmonary arrests and mortality. After rapid response team implementation, non-ICU cardiopulmonary arrests decreased from 1.4 to 0.9 per 1,000 hospital admissions (relative risk, 0.68; 95% confidence interval, 0.53–0.86; p = 0.001) and total hospital mortality decreased from 22.5 to 20.2 per 1,000 hospital admissions (relative risk, 0.90; 95% confidence interval, 0.85–0.95; p < 0.0001). For patients who required admission to the ICU, there was a significant reduction in the Acute Physiology and Chronic Health Evaluation II scores after rapid response team implementation from 29.3 ± 9.3 to 26.9 ± 8.5 (p < 0.0001), with reduction in hospital mortality from 57.4% to 48.7% (relative risk, 0.85; 95% confidence interval, 0.78–0.92; p < 0.0001). Do-not-resuscitate orders for ward referrals increased from 0.7 to 1.7 per 1,000 hospital admissions (relative risk, 2.58; 95% confidence interval, 1.95–3.42; p < 0.0001) and decreased for patients admitted to ICU from the wards from 30.5% to 26.1% (relative risk, 0.86; 95% confidence interval, 0.74–0.99; p = 0.03). Additionally, ICU readmission rate decreased from 18.6 to 14.3 per 100 ICU alive discharges (relative risk, 0.77; 95% confidence interval, 0.66–0.89; p < 0.0001) and post-ICU hospital mortality from 18.2% to 14.8% (relative risk, 0.85; 95% confidence interval, 0.72–0.99; p = 0.04). Conclusion:The implementation of rapid response team was effective in reducing cardiopulmonary arrests and total hospital mortality for ward patients, improving the outcomes of patients who needed ICU admission and reduced readmissions and mortality of patients who were discharged from the ICU.

Feasibility of Using Convalescent Plasma Immunotherapy for MERS-CoV Infection, Saudi Arabia.

Efficacy testing will be challenging because of the small pool of donors with sufficiently high antibody titers.

Even Mild Hyperlactatemia Is Associated with Increased Mortality in Critically Ill Patients

IntroductionThe clinical significance of elevation of lactate levels within the reference range is not well studied. The objective of this study was to determine the best cutoff threshold for serum lactate within the reference range (0.01 to 2.00 mM) that best discriminated between survivors and nonsurvivors of critical illness and to examine the association between relative hyperlactatemia (lactate above the identified threshold) and mortality.MethodsThis was a retrospective cohort study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care academic center. Youden index was calculated to identify the best lactate cutoff threshold that discriminated between survivors and nonsurvivors. Patients with lactate above the identified threshold were defined as having relative hyperlactatemia. Multivariate logistic regression, adjusting for baseline variables, was performed to determine the relationship between the above two ranges of lactate levels and mortality. In addition, a test of interaction was performed to assess the effect of selected subgroups on the association between relative hyperlactatemia and hospital mortality.ResultsDuring the study period, 2,157 patients were included in the study with mean lactate of 1.3 ± 0.4 mM, age of 55.1 ± 20.3 years, and acute physiology and chronic health evaluation (APACHE) II score of 22.1 ± 8.2. Vasopressors were required in 42.4%. Lactate of 1.35 mM was found to be the best cutoff threshold for the whole cohort. Relative hyperlactatemia was associated with increased hospital mortality (adjusted odds ratio (aOR), 1.60, 95% confidence interval (CI) 1.29 to 1.98), and ICU mortality (aOR, 1.66; 95% CI, 1.26 to 2.17) compared with a lactate level of 0.01 to 1.35 mM. This association was consistent among all examined subgroups.ConclusionsRelative hyperlactatemia (lactate of 1.36 to 2.00 mM) within the first 24 hours of ICU admission is an independent predictor of hospital and ICU mortality in critically ill patients.

Rapid response systems in acute hospital care.

The RRT is based on the notion of early and rapid intervention and is originally inspired by the management strategies of severe trauma, which included two key elements: the early detection of deterioration coupled to a rapid response. More recently, deployment of such teams was one of the main interventions recommended by the Institute for Healthcare Improvement in its ‘100,000 Lives Campaign’ that was launched in 2005.

Trauma profile at a tertiary intensive care unit in Saudi Arabia.

BACKGROUND AND OBJECTIVES Trauma is a leading cause of death worldwide and in Saudi Arabia. This study describes the injury profiles and ICU outcomes of patients in a tertiary trauma care referral center in Riyadh, Saudi Arabia. DESIGN AND SETTING A retrospective analysis of ICU data collected prospectively over 5 years in a 21-bed medical and surgical intensive care unit (ICU) in a tertiary care teaching hospital. PATIENTS AND METHODS We collected ICU data on all patients admitted secondary to motor vehicle accidents (MVAs), excluding patients younger than 18 years, brain dead patients and readmissions. We collected data on age, gender, and Glasgow coma scale score at admission, injury severity scores, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and other data. Multivariate logistic regression was used to identify predictors of mortality. RESULTS During the study period, of 1659 patients, MVA was the most common cause of injury (78.4%), followed by pedestrian accident (12.7%). ICU mortality included 221 patients (13.3%) during the study period. Severe head injury, age > 60 years, Glascow coma scale score, injury severity scores, APACHE II and international normalized ratio were independent predictors of mortality. CONCLUSION MVA is very common in our country and leads to significant mortality and morbidity. Public education and strict law enforcement are needed to reduce these adverse events.

Information technology to improve patient safety: A round table discussion from the 5th International Patient Safety Forum, Riyadh, Saudi Arabia, April 14–16, 2015

Information technology (IT) has wide‐ranging spectrum applications in patient safety in the acute care setting and, in particular, the Intensive Care Unit (ICU) setting. Throughout this paper, we provide a summary of the discussion from the roundtable meeting from the 5th International Patient Safety Forum, held in Riyadh, Saudi Arabia on April 14–16, 2015 that covered several aspects of how IT can improve patient safety, with a focus on the ICU setting. The format of the roundtable included presentations and general discussions. The potential risks associated with novel IT methods and technologies were also discussed. The meeting provided evidence by showcasing specific successful IT projects.

Do not resuscitate: An expanding role for critical care response team

Background: Do not resuscitate (DNR) order is an important aspect of medical practice. Since the implementation of critical care response team (CCRT), frequently we have encountered with patients in the wards that should have been made DNR. Initiating DNR became an important part of CCRT activity. We were obliged to extended the role of CCRT - beyond managing seriously ill patients - in addressing the code status for patients after discussion with the managing teams. Purpose: We compare the trend of initiation of DNR orders in the regular ward before and after implementing CCRT. Methods: Our hospital is 1200 bed tertiary care center. CCRT has been launched in January 1, 2008. The CCRT is 24/7 service led by in-house North American certified intensivists. Cohort analysis of prospectively collected data of 5406 CCRT activation from January 1, 2008, to September 30, 2013. Data before implementation of CCRT was available for 299 patients from the period of June 1, 2007, to December 31, 2007. A comparison made between the two groups (before and after implementation of CCRT) for demographic data and percentage of patients in whom DNR order initiated. Results: Before CCRT implementation, 299 patients were attended by Intensive Care Unit physician for regular consultation, 41.1% were females and 52.4% were males with mean of age 58.44 ± 18.47 standard deviation (SD). DNR was initiated in 2.7% of patients. After CCRT implementation, 5904 CCRT activations, 47.6% females and 52.4% males with mean of age 59.17 ± 20.07 SD DNR initiated in 468 (7.9%) of cases. There was 5.2% increase in DNR orders initiation and completion after CCRT introduced to our institute.

Appreciating the complexity of rapid response teams: not all are the same.

Critical Care Medicine www.ccmjournal.org e255 ICU may allow shifting severely ill patients to die in the ICU. Whether the RRT was involved in addressing end-oflife issues and possibly in avoiding futile admissions is not addressed in the article (2). Third, with the low number of RRT calls: 1.45/d in the first year and 1.84/d in the last year, it appears that the RRT staff (attending fellow, nurse, and respiratory therapist) were not fully dedicated to RRT (although this is not mentioned explicitly in the article). Could the addition of assignment to the existing ICU staff to run RRT have diverted resources from ICU and lead to worse ICU outcomes? Fourth, there are no data comparing the case mix of hospitalized patients between the pre-RRT and post-RRT periods. However, the number of hospital admissions declined which may be an indirect sign of a change of acuity of illness, which may contribute to some of the observed findings. Fifth, there was an increase in the number of medical patients admitted to surgical ICU from 4% to 8.6%, which is another confounding change that may contribute to the findings. This study illustrates the complexity of RRT systems and highlights that not all RRTs are the same. In our study (3), RRT was implemented in a hospital that had critical care on-site intensivists 24/7 in the preand post-RRT periods (4). RRT had its dedicated staff and RRT activation preceded all admissions from the wards. In this setting, we demonstrated that the number of admissions from the wards actually declined and ICU mortality for admissions from the wards decreased. Mortality from admissions from the emergency department and operating room did not change as one would expect with RRT. It is critical when reviewing RRT studies to appreciate the details of how RRT was designed and implemented in order to make an informed interpretation of the findings and in order, for those of us who plan to implement RRT, to get a clear sense of the features of RRT that are likely or unlikely to lead to positive outcomes. The authors have disclosed that they do not have any potential conflicts of interest.