Improving the appropriateness and effectiveness of ICU practices.
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Cost Savings↗
Biomedical subjects
M H Kollef
Publications and source records attributed to M H Kollef.
A rapid assay for the detection of circulating D-dimer is associated with clinical outcomes among critically ill patients.
OBJECTIVE: To determine whether the results of a rapid, semiquantitative assay for the detection of circulating D-dimer in whole blood (SRDD assay) are associated with the occurrence of clinical outcomes among critically ill patients. DESIGN: Prospective, blinded, single-center study. SETTING: Medical intensive care unit (ICU) of Barnes-Jewish Hospital, St. Louis, MO, a university-affiliated teaching hospital. PATIENTS: Three hundred twenty-three adult patients admitted to a medical ICU. INTERVENTIONS: Collection of blood samples within 24 hrs of ICU admission. MEASUREMENTS AND MAIN RESULTS: The main outcome measures evaluated included vascular thrombosis, hospital mortality, and the development of multiorgan dysfunction. Fifty (15.5%) patients were found to have increased concentrations of D-dimer as detected by the SRDD assay within 24 hrs of ICU admission. The concentrations of plasma D-dimer simultaneously measured by an enzyme immunoassay based on the same antibody were significantly greater among patients with a positive SRDD assay compared with patients with a negative SRDD assay (1214+/-483 vs. 405+/-407 ng/mL; p< .001). The hospital mortality rate was significantly greater among SRDD-positive patients compared with SRDD-negative patients (32.0% vs. 15.0%; p=.004). SRDD-positive patients also had significantly greater frequencies of acquired multiorgan dysfunction (48.0% vs. 17.6%; p < .001), severe sepsis or septic shock (56.0% vs. 20.9%; p< .001), and vascular thrombosis (14.0% vs. 4.0%; p=.005) compared with SRDD-negative patients. Multiple logistic regression analysis identified the presence of increased concentrations of D-dimer, detected by a positive SRDD assay, as being independently associated with vascular thrombosis (adjusted odds ratio 5.06; 95% confidence interval 2.96 to 8.65; p=.003) and the development of multiorgan dysfunction (adjusted odds ratio 1.51; 95% confidence interval 1.28 to 1.78; p=.012). CONCLUSIONS: Our preliminary investigation suggests that the results from a rapid whole blood assay for the semiquantitative detection of circulating D-dimer are associated with clinical outcomes among patients admitted to a medical ICU. In addition, the use of D-dimer to identify the presence of active intravascular thrombosis may identify patients likely to benefit from antithrombotic therapies in the ICU setting.
APACHE↗
We should listen to the patient when it comes to timing extubation.
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Critical Care↗
Prolonged use of ventilator circuits and ventilator-associated pneumonia: a model for identifying the optimal clinical practice.
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Centers for Disease Control and Prevention, U.S.↗
The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia.
STUDY OBJECTIVE: To determine the influence of mini-BAL culture results on subsequent changes in antibiotic therapy and patient outcomes. DESIGN: Prospective, single-center, cohort study. SETTING: Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: One hundred thirty mechanically ventilated patients undergoing mini-BAL for suspected ventilator-associated pneumonia (VAP). INTERVENTIONS: Mini-BAL, prospective patient surveillance, and data collection. MEASUREMENTS AND RESULTS: Sixty (46.2%) patients had mini-BAL cultures that yielded at least one pathogen potentially accounting for the clinically suspected episode of VAP (64 bacterial, 3 viral, 2 fungal). Among the 60 patients with microbiologically positive mini-BAL cultures, 44 (73.3%) were classified as receiving inadequate antibiotic therapy (ie, identification of a microorganism resistant to the prescribed antibiotic regimen). Prior antibiotic administration or its absence remained unchanged in 51 (39.2%) patients based on the mini-BAL culture results, while in another 51 (39.2%) patients, antibiotic therapy was either begun (n=7) or the existing antibiotic regimen was changed (n=44), and in the remaining 28 (21.6%) patients, antibiotic therapy was discontinued altogether. The hospital mortality rates of these three groups were statistically different: 33.3%, 60.8%, and 14.3%, respectively (p<0.001). The most common pattern of antibiotic resistance resulting in an antibiotic change following mini-BAL was the identification of a Gram-negative bacteria resistant to a prescribed third-generation cephalosporin in 23 of 44 (52.3%) patients. Twenty-one of these 23 patients (91.3%) received prior therapy with a cephalosporin class antibiotic during the same hospitalization. Having an immunocompromised state (adjusted odds ratio [OR]=2.45; 95% confidence interval, 1.56 to 3.85; p=0.047) and the presence of a pathogen in the mini-BAL culture resistant to the empirically prescribed antibiotic regimen (adjusted OR=3.28; 95% confidence interval, 2.12 to 5.06; p=0.006) were identified as risk factors independently associated with hospital mortality by logistic regression analysis. CONCLUSIONS: These data suggest that antibiotic selection prior to obtaining the results of lower airway cultures is an important determinant of outcome for patients with suspected VAP. A delay in initiating adequate antibiotic therapy was associated with a greater mortality. Therefore, the initial selection of antibiotics for the empiric treatment of VAP should be broad enough to cover all likely pathogens, including antibiotic-resistant bacteria. This appears to be especially important in patients having received prior antibiotics.
Adult↗
A randomized clinical trial comparing an extended-use hygroscopic condenser humidifier with heated-water humidification in mechanically ventilated patients.
STUDY OBJECTIVE: To determine the safety and cost-effectiveness of mechanical ventilation with an extended-use hygroscopic condenser humidifier (Duration; Nellcor Puritan-Bennett; Eden Prairie, Minn) compared with mechanical ventilation with heated-water humidification. DESIGN: Prospective randomized clinical trial. SETTING: Medical and surgical ICUs of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: Three hundred ten consecutive qualified patients undergoing mechanical ventilation. INTERVENTIONS: Patients requiring mechanical ventilation were randomly assigned to receive humidification with either an extended-use hygroscopic condenser humidifier (for up to the first 7 days of mechanical ventilation) or heated-water humidification. MEASUREMENTS: Occurrence of ventilator-associated pneumonia, endotracheal tube occlusion, duration of mechanical ventilation, lengths of intensive care and hospitalization, acquired multiorgan dysfunction, and hospital mortality. RESULTS: One hundred sixty-three patients were randomly assigned to receive humidification with an extended-use hygroscopic condenser humidifier, and 147 patients were randomly assigned to receive heated-water humidification. The two groups were similar at the time of randomization with regard to demographic characteristics, ICU admission diagnoses, and severity of illness. Risk factors for the development of ventilator-associated pneumonia were also similar during the study period for both treatment groups. Ventilator-associated pneumonia was seen in 15 (9.2%) patients receiving humidification with an extended-use hygroscopic condenser humidifier and in 15 (10.2%) patients receiving heated-water humidification (relative risk, 0.90; 95% confidence interval=0.46 to 1.78; p=0.766). No statistically significant differences for hospital mortality, duration of mechanical ventilation, lengths of stay in the hospital ICU, or acquired organ system derangements were found between the two treatment groups. No episode of endotracheal tube occlusion occurred during the study period in either treatment group. The total cost of providing humidification was $2,605 for patients receiving a hygroscopic condenser humidifier compared with $5,625 for patients receiving heated-water humidification. CONCLUSION: Our findings suggest that the initial application of an extended-use hygroscopic condenser humidifier is a safe and more cost-effective method of providing humidification to patients requiring mechanical ventilation compared with heated-water humidification.
Adolescent↗
The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial.
OBJECTIVE: To determine whether the use of noninvasive positive pressure ventilation (NPPV) in the emergency department (ED) will reduce the need for tracheal intubation and mechanical ventilation. DESIGN: Randomized, controlled, prospective clinical trial. SETTING: ED of Barnes-Jewish Hospital, a university-affiliated teaching hospital. PATIENTS: Twenty-seven patients meeting a predetermined definition of acute respiratory distress requiring hospital admission. INTERVENTIONS: Conventional medical therapy for the various etiologies of acute respiratory distress and the application of NPPV. MEASUREMENTS AND RESULTS: The primary outcome measure was the need for tracheal intubation and mechanical ventilation. Secondary outcomes also assessed included hospital mortality, hospital length of stay, acquired organ system derangements, and the utilization of respiratory care personnel. Sixteen patients (59.3%) were randomly assigned to receive conventional medical therapy plus NPPV, and 11 patients (40.7%) were randomly assigned to receive conventional medical therapy without NPPV. The two groups were similar at the time of randomization in the ED with regard to demographic characteristics, hospital admission diagnoses, and severity of illness. Tracheal intubation and mechanical ventilation was required in seven patients (43.8%) receiving conventional medical therapy plus NPPV and in five patients (45.5%) receiving conventional medical therapy alone (relative risk=0.96; 95% confidence interval=0.41 to 2.26; p=0.930). There was a trend towards a greater hospital mortality rate among patients in the NPPV group (25%) compared to patients in the conventional medical therapy group (0.0%) (p=0.123). Among patients who subsequently required mechanical ventilation, those in the NPPV group had a longer time interval from ED arrival to the start of mechanical ventilation compared to patients in the conventional medical therapy group (26.0+/-27.0 h vs 4.8+/-6.9 h; p=0.055). CONCLUSIONS: We conclude that the application of NPPV in the ED may delay tracheal intubation and the initiation of mechanical ventilation in some patients with acute respiratory distress. We also demonstrated that the application of NPPV was associated with an increased hospital mortality rate. Based on these preliminary observations, larger clinical investigations are required to determine if adverse patient outcomes can be attributed to the early application of NPPV in the ED. Additionally, improved patient selection criteria for the optimal administration of NPPV in the ED need to be developed.
Acute Disease↗
The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation.
STUDY OBJECTIVE: To determine whether the use of continuous i.v. sedation is associated with prolongation of the duration of mechanical ventilation. DESIGN: Prospective observational cohort study. SETTING: The medical ICU of Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS: Two hundred forty-two consecutive ICU patients requiring mechanical ventilation. INTERVENTIONS: Patient surveillance and data collection. MEASUREMENTS AND RESULTS: The primary outcome measure was the duration of mechanical ventilation. Secondary outcome measures included ICU and hospital lengths of stay, hospital mortality, and acquired organ system derangements. A total of 93 (38.4%) mechanically ventilated patients received continuous i.v. sedation while 149 (61.6%) patients received either bolus administration of i.v. sedation (n=64) or no i.v. sedation (n=85) following intubation. The duration of mechanical ventilation was significantly longer for patients receiving continuous i.v. sedation compared with patients not receiving continuous i.v. sedation (185+/-190 h vs 55.6+/-75.6 h; p<0.001). Similarly, the lengths of intensive care (13.5+/-33.7 days vs 4.8+/-4.1 days; p<0.001) and hospitalization (21.0+/-25.1 days vs 12.8+/-14.1 days; p<0.001) were statistically longer among patients receiving continuous i.v. sedation. Multiple linear regression analysis, adjusting for age, gender, severity of illness, mortality, indication for mechanical ventilation, use of chemical paralysis, presence of a tracheostomy, and the number of acquired organ system derangements, found the adjusted duration of mechanical ventilation to be significantly longer for patients receiving continuous i.v. sedation compared with patients who did not receive continuous i.v. sedation (148 h [95% confidence interval: 121, 175 h] vs 78.7 h [95% confidence interval: 68.9, 88.6 h]; p<0.001). CONCLUSION: We conclude from these preliminary observational data that the use of continuous i.v. sedation may be associated with the prolongation of mechanical ventilation. This study suggests that strategies targeted at reducing the use of continuous i.v. sedation could shorten the duration of mechanical ventilation for some patients. Prospective randomized clinical trials, using well-designed sedation guidelines and protocols, are required to determine whether patient-specific outcomes (eg, duration of mechanical ventilation, patient comfort) can be improved compared with conventional sedation practices.
Adolescent↗
Utility of transbronchial biopsy in patients with acute respiratory failure: a postmortem study.
STUDY OBJECTIVE: To determine the diagnostic yield of histologic specimens obtained by postmortem transbronchial biopsy (TBB) in patients with acute respiratory failure requiring mechanical ventilation. DESIGN: Standard postmortem histologic examination of lung tissue specimens. SETTING: An urban university-affiliated hospital. PATIENTS OR PARTICIPANTS: Thirty patients with diffuse pulmonary infiltrates and acute respiratory failure, who underwent postmortem examination. INTERVENTIONS: Following removal of the lungs from the thorax. TBBs were obtained from the lower lobe of each deflated lung and comparison was made to a 1-cm3 tissue block obtained from the ipsilateral lower lobe. MEASUREMENTS AND RESULTS: Standard postmortem histologic examination provided a specific diagnosis in 85% of the 60 lungs examined, and histologic evidence of acute pneumonia was present in 30% of the lungs. The overall yield of TBB was 48% for establishing a specific histologic diagnosis and 15% for the diagnosis of acute pneumonia. Using standard postmortem histologic examination as the gold standard, the sensitivity and specificity of TBB for making a specific diagnosis were 57% and 100% respectively, with corresponding positive and negative predictive values of 100% and 29%. For the histologic diagnosis of acute pneumonia, the sensitivity of TBB was 50%, the specificity was 100%, and the positive and negative predictive values were 100% and 82%, respectively. The kappa statistic for the agreement between the two diagnostic methods was 0.28 for establishing a specific diagnosis and 0.58 for the diagnosis of acute pneumonia. Obtaining 12 TBBs rather than six TBBs did not increase the diagnostic yield for TBB. CONCLUSIONS: These findings suggest poor overall agreement between standard postmortem histologic examination and TBB specimens. Although not performed in a clinical setting, this postmortem investigation suggests that TBB may be of limited value in mechanically ventilated patients with acute respiratory failure because of its low sensitivity.
Acute Disease↗
The impact of comorbidity on mortality following in-hospital diagnosis of tuberculosis.
STUDY OBJECTIVES: Despite the availability of curative chemotherapy, mortality remains high among patients hospitalized for tuberculosis. Although the elevated mortality rate is often attributed to the presence of multidrug resistant tuberculosis (MDRTB) or concomitant infection with the HIV, other factors must be contributory, especially among the HIV-negative population. Therefore, we performed a study to define the factors associated with mortality following the in-hospital diagnosis of tuberculosis in a region with low levels of MDRTB and coinfection with HIV. DESIGN: Retrospective cohort study. SETTING: The eight hospitals in the Barnes-Jewish-Christian (BJC) Health System, which is a network of community and tertiary-care level facilities serving the St. Louis, MO, metropolitan area. PATIENTS: All 203 patients hospitalized with culture-positive tuberculosis at one of the BJC system hospitals between 1988 and 1996. INTERVENTIONS: Follow-up information was obtained by telephone interview and review of medical and public health records. Death was verified through a search of the death certificate registry of Missouri and the records of the Social Security Administration. Mortality was defined as death from any cause during the 14 months following the initial date of hospitalization. MEASUREMENTS AND RESULTS: The cumulative all-cause mortality rate for this cohort was 28.1%. The incidence of HIV positivity was 7.9% and of MDRTB was 1.5%. Multiple logistic regression analysis demonstrated that respiratory failure requiring mechanical ventilation (adjusted odds ratio [AOR] = 6.5; 95% confidence interval [CI] = 6.0 to 7.0; p < 0.001) and the presence of end-stage renal disease requiring dialysis (AOR = 7.0; 95% CI = 3.7 to 13.3; p = 0.002) were the largest contributors to mortality. Other variables independently associated with mortality included the presence of malnutrition (AOR = 3.2; 95% CI = 2.1 to 4.9; p = 0.007), age > 60 years (AOR = 3.5; 95% CI = 2.4 to 5.2; p < 0.001), drug-induced immunosuppression (AOR = 3.2; 95% CI = 1.6 to 5.2; p = 0.018), and dyspnea at the time of hospital presentation (AOR = 2.1; 95% CI = 1.4 to 3.1; p = 0.048). Overall, 45.3% of the patients had a > 7-day delay in the suspicion of the diagnosis of tuberculosis and the institution of antituberculosis therapy following hospital admission. There was no association between the presence of these delays and mortality. CONCLUSIONS: Our data suggest that the 14-month mortality rate is high among patients diagnosed as having tuberculosis during hospitalization, despite low incidences of HIV infection and multidrug resistant disease. The factors that appear to contribute to this elevated mortality rate are markers of disease chronicity and severity of not only the tuberculosis, but also of the patient's underlying health status. Thus, while HIV positivity and multidrug resistance can be important determinants of mortality in some populations, other demographic factors and comorbid conditions may play a role as well. These data also suggest that tuberculosis is often superimposed on chronic illnesses that are important determinants of patient outcomes.
AIDS-Related Opportunistic Infections↗
Acute respiratory failure: a gender-based outcomes analysis.
OBJECTIVE: To determine the influence of gender on patient outcomes and the delivery of medical care during mechanical ventilation for acute respiratory failure. DESIGN: A prospective cohort study. SETTING: Medical intensive care unit of a university-affiliated urban teaching hospital. PATIENTS: Three hundred twenty-one patients with acute respiratory failure requiring mechanical ventilation. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS: One hundred six patients (33.0%) died during hospitalization. No statistically significant difference in mortality rates was observed between male and female patients (36.1% versus 30.1%; P = .252). The duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay were also similar between men and women with acute respiratory failure. The presence of the acute respiratory distress syndrome (ARDS; adjusted odds ratio [AOR] = 3.65; 95% confidence interval [CI] = 2.34 to 5.71; P = .004), the number of acquired organ system derangements (AOR = 1.36; 95% CI = 1.20 to 1.53; P = .013), the predicted hospital mortality using acute physiology and chronic health evaluation (APACHE) II scores (AOR = 1.05; 95% CI = 1.04 to 1.05; P < .001), and patient age (AOR = 1.02; 95% CI = 1.01 to 1.03; P = .016) were found to be independent determinants of hospital mortality using multiple logistic regression analysis. CONCLUSIONS: These data suggest that important gender-specific differences in outcome do not occur among patients with respiratory failure requiring mechanical ventilation. Severity of illness, patient age, and acquired organ system derangements appear to be the most important determinants of mortality for patients with acute respiratory failure, regardless of patient gender.
APACHE↗
The role of outcomes research in the intensive care unit setting.
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Critical Care↗
Reducing the duration of mechanical ventilation: three examples of change in the intensive care unit.
Mechanical ventilation is one of the most common medical therapies administered within ICUs. Similarly, the "weaning" or "liberation" of patients from mechanical ventilation is a common and extremely important task performed in ICUs and specialized ventilator units within hospitals. Various methods exist for assessing a patient's readiness to be liberated from mechanical ventilation and for conducting the weaning process. Clinicians working in ICUs frequently develop their own personal preferences regarding the best approach to weaning patients from ventilatory support. Therefore, variability in the practice of weaning patients from mechanical ventilation is frequently demonstrated, even within a single ICU. Recently, several randomized clinical trials have produced conflicting results regarding the best technique for carrying out the weaning process (e.g., spontaneous breathing trials, intermittent mandatory ventilation, pressure-support ventilation). Such conflicting findings have further illustrated the complexity of the weaning process and the difficulties in identifying the "best" medical practices for carrying out this endeavor. However, other investigations have suggested that the selection of an individual technique for weaning patients from mechanical ventilation may not be as important as employing a systematic approach to this medical process. Protocol-guided weaning of mechanical ventilation in the ICU setting, often performed by nonphysicians, has gained in acceptance as a result of these investigations. We describe the recent experiences of three ICUs which have demonstrated significant improvements in patient outcomes (e.g., shorter durations of mechanical ventilation, lower incidence of ventilator-associated pneumonia, fewer patient complications) as a result of implementing formal weaning protocols. Our hope is that these data will assist other hospitals in developing their own systematic guidelines and protocols for weaning patients from mechanical ventilation.
Clinical Protocols↗
Outcomes research as a tool for defining the role of respiratory care practitioners in the intensive care unit setting.
The impact of respiratory care practitioners on the outcomes of critically ill patients has not been examined in a systematic manner. This is in contrast to clinical investigations which have demonstrated the beneficial influence of specially trained critical care physicians and nurses on patient outcomes in the ICU setting. Outcomes research represents a method for the formal evaluation of various healthcare provider staffing patterns within the ICU. Specific patient outcomes including hospital mortality, respiratory complications, lengths of stay, and medical care costs can be used to determine the optimal ICU staffing strategy for respiratory care practitioners. Until recently, we have lacked good outcomes data for assessing the role of respiratory care practitioners in the ICU. Several barriers have contributed to this deficiency of data including a lack of funding, absence of a national research initiative aimed at this specific issue, and the paucity of clinical investigators in this area of study. Good outcomes research requires appropriate levels of funding, adequately trained and experienced clinical investigators from various disciplines (e.g., statistics, epidemiology, general medical sciences), and the support of both local and national organizations with an interest in respiratory care services and their impact on patient outcomes. To accomplish these research goals, an organized and dedicated approach must be developed based upon strong research proposals. This will allow advances to be made in the area of outcomes research as it relates to the role of respiratory care practitioners in the ICU. Similarly, the methods of outcomes research can be employed to better define the benefits and limitations of other ICU practices.
Critical Care↗
Safety and yield of transbronchial biopsy in mechanically ventilated patients.
OBJECTIVE: To evaluate the safety and diagnostic yield of transbronchial biopsy performed in mechanically ventilated patients. DESIGN: Retrospective, cohort analysis. SETTING: A university-affiliated teaching hospital. PATIENTS: Seventy-one consecutive, mechanically ventilated patients requiring lung tissue examination. INTERVENTIONS: Transbronchial lung biopsy. MEASUREMENTS AND MAIN RESULTS: We evaluated complications associated with transbronchial biopsy, diagnostic yield of the procedure, and changes in patient management based on the results of the transbronchial lung biopsies. Eighty-three transbronchial lung biopsy procedures were performed in this patient cohort. Complications associated with these procedures included the following: ten (14.3%) pneumothoraces in patients without preexisting chest tubes; five (6.0%) episodes of bronchial hemorrhage of > 30 mL; transient oxygen desaturation to < 90% in seven (8.4%) patients; hypotension with a mean arterial pressure of < 60 mm Hg in six (7.2%) patients; and three (3.6%) episodes of tachycardia, with a heart rate of > 140 beats/min. No patient deaths, episodes of pneumonia, or sepsis could be attributed to the transbronchial lung biopsy procedures. Specific histologic diagnoses were made with 29 (34.9%) of the transbronchial biopsies, and patient management was changed as a direct result of the lung tissue examination in 34 (41.0%) instances. Pathologic correlation between the transbronchial biopsy specimens and lung tissue obtained by open-lung biopsy or post mortem examination occurred in 11 (84.6%) of 13 paired samples. CONCLUSION: Transbronchial lung biopsy can be performed with an acceptable risk and reasonable diagnostic yield in certain types of mechanically ventilated patients, often obviating the need to perform open-lung biopsy.
Adolescent↗
A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation.
OBJECTIVE: To compare a practice of protocol-directed weaning from mechanical ventilation implemented by nurses and respiratory therapists with traditional physician-directed weaning. DESIGN: Randomized, controlled trial. SETTING: Medical and surgical intensive care units in two university-affiliated teaching hospitals. PATIENTS: Patients requiring mechanical ventilation (n = 357). INTERVENTIONS: Patients were randomly assigned to receive either protocol-directed (n = 179) or physician-directed (n = 178) weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the duration of mechanical ventilation from tracheal intubation until discontinuation of mechanical ventilation. Other outcome measures included need for reintubation, length of hospital stay, hospital mortality rate, and hospital costs. The median duration of mechanical ventilation was 35 hrs for the protocol-directed group (first quartile 15 hrs; third quartile 114 hrs) compared with 44 hrs for the physician-directed group (first quartile 21 hrs; third quartile 209 hrs). Kaplan-Meier analysis demonstrated that patients randomized to protocol-directed weaning had significantly shorter durations of mechanical ventilation compared with patients randomized to physician-directed weaning (chi 2 = 3.62, p = .057, log-rank test; chi 2 = 5.12, p = .024, Wilcoxon test). Cox proportional-hazards regression analysis, adjusting for other covariates, showed that the rate of successful weaning was significantly greater for patients receiving protocol-directed weaning compared with patients receiving physician-directed weaning (risk ratio 1.31; 95% confidence interval 1.15 to 1.50; p = .039). The hospital mortality rates for the two treatment groups were similar (protocol-directed 22.3% vs. physician-directed 23.6%; p = .779). Hospital cost savings for patients in the protocol-directed group were $42,960 compared with hospital costs for patients in the physician-directed group. CONCLUSION: Protocol-guided weaning of mechanical ventilation, as performed by nurses and respiratory therapists, is safe and led to extubation more rapidly than physician-directed weaning.
Adult↗
BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage.
OBJECTIVE: To develop an outcome prediction tool (BLEED: ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, unstable comorbid disease) for clinical use in patients with either acute upper or acute lower gastrointestinal (GI) hemorrhage. DESIGN: A cohort study. SETTING: Barnes Hospital and Jewish Hospital, two private university-affiliated teaching hospitals in St. Louis, MO. PATIENTS: Four hundred sixty-five patients with either acute upper or acute lower GI hemorrhage admitted from the emergency department. INTERVENTIONS: Admission of patients to the intensive care unit or hospital ward was determined by emergency department physicians, without use or knowledge of BLEED criteria. Patients meeting any BLEED criteria at their initial assessment in the emergency department were classified as "high-risk." All other patients were classified as "low-risk." MEASUREMENTS AND MAIN RESULTS: The main outcome measure was the occurrence of an inhospital complication, defined as recurrent GI hemorrhage, surgery to control the source of hemorrhage, and hospital mortality. Patients classified as high-risk had significantly greater rates of inhospital complications at both Barnes Hospital (relative risk, 2.47; 95% confidence interval, 1.38 to 4.44; p < .001) and Jewish Hospital (relative risk, 8.94; 95% confidence interval, 3.92 to 20.41; p < .001) compared with patients classified as low-risk. Patients classified as high-risk at either hospital were significantly more likely to develop additional organ system derangements, require a greater number of transfused units of packed red blood cells, and have longer hospital stays compared with patients classified as low-risk (p < .006). The BLEED classification also identified a greater frequency of intensive care admission for both low-risk (RR, 4.21; 95% Cl, 2.24 to 7.89) and high-risk (relative risk, 1.58; 95% confidence interval, 1.23 to 2.02) patients at Barnes Hospital compared with those patients at Jewish Hospital, although no beneficial effects on patient outcome were reported. CONCLUSIONS: The BLEED classification, applied at initial emergency department evaluation and before admission, predicts hospital outcomes for patients with acute upper or lower GI hemorrhage. This outcome prediction tool also identified variations in intensive care utilization between two hospitals.
APACHE↗
Outcome in medical intensive care unit patients requiring abdominal surgery: prospective validation of a risk classification system.
To prospectively validate a previously developed two-factor logistic regression model as a predictor of mortality, we studied its effectiveness in predicting outcome for patients in medical intensive care units (ICUs) who had surgical laparotomy. A high-risk classification was assigned to patients with an Organ System Failure Index (OSFI) > or = 3 or an APACHE (Acute Physiology and Chronic Health Evaluation) II score > 18 within 24 hours of surgery. The in-hospital mortality rate of surgical patients classified as high risk (n = 32) was significantly greater than that of surgical patients classified as low risk (n = 42) (62.5% versus 9.5%; relative risk, 6.6; 95% confidence interval, 2.5 to 17.3). Mortality after surgery correlated with presence or absence of the two variables from the logistic regression model: neither present, 9.5%; APACHE II > 18 present, 68.0%; OSFI > or = 3 present, 75.0%; both present, 88.2%. We showed that a two-factor risk classification at the time of surgical evaluation can be used to stratify medical ICU patients according to risk of in-hospital mortality.
APACHE↗