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Biomedical subjects

Nicholas S Ward

Publications and source records attributed to Nicholas S Ward.

10 recordsLinked to original sources
PubMed2005

Rationing critical care medicine: recent studies and current trends.

PURPOSE OF REVIEW: This paper reviews the literature on the rationing of critical care resources. RECENT FINDINGS: Although much has been written about the concept of rationing, there have been few scientific studies as to its prevalence. A recent meta-analysis reviewed all previously published studies on rationing access to intensive care units but little is known about practices within the intensive care unit. Much literature in the past few years has focused on the growing use of critical care resources and projections for the future. Several authors suggest there may be a crisis in financial or personnel resources if some rationing does not take place. Other papers have argued that the methods of rationing critical care previously proposed, such as limiting the care of dying patients or using cost-effectiveness analysis to determine care, may not be effective or viewed as ethical by some. Finally, several recent papers review how critical care is practiced and allocated in India and Asian countries that already practice open rationing in their health care systems. SUMMARY: There is currently no published evidence that overt rationing is taking place in critical care medicine. There is growing evidence that in the future, the need for critical care may outstrip financial resources unless some form of rationing takes place. It is also clear from the literature that choosing how to ration critical care will be a difficult task.

Critical Care↗
PubMed2004

Blood transfusion practice today.

In trying to develop a cohesive and logical transfusion strategy, one must try to keep all of the previously mentioned information in mind. While recognizing that RBC transfusions are an integral part of care for critically ill patients, one also must recognize that there are large amounts of data that associate multiple transfusions of allogeneic blood with increased risk of morbidity and mortality. Some data exist showing causation and association, such as studies demonstrating the immunomodulatory effects of allogeneic transfusions. In addition, the blood supply is a limited resource that should not be used indiscriminately. It therefore behooves clinicians to subject each unit of blood transfused to scrutiny. In all likelihood, patients who are not actively bleeding and who are not hypovolemic probably get little to no benefit from allogeneic blood transfusions while their hemoglobin is greater than 7 g/dL. They do, however, get needless exposure to a potentially toxic substance. Although it is the authors' hope that more research will be performed to clarify the risks and benefits of blood transfusion, the authors also hope that knowledge of already published studies will continue to spread and replace the unfounded practices of the past.

Clinical Trials as Topic↗
PubMed2004

Comparison of a commercially available clinical information system with other methods of measuring critical care outcomes data.

PURPOSE: To compare the quality of data recorded by a commercially available clinical information system (CIS) to other commonly used methods for obtaining large amounts of patient data. MATERIALS AND METHODS: Five sets of clinical patient data were chosen as a cross-section of all the data collected by a CIS in our intensive care unit (ICU): 1) Length of stay in the ICU, 2) Vital signs, 3) Days of mechanical ventilation, 4) medications, and 5) diagnoses. Data generated by our ICU CIS was compared with other parallel data sets commonly used to obtain the same data for clinical research. RESULTS: When compared with our CIS, the hospital database recorded a length of stay at least 1 day longer than the actual length of stay 53% of the time. A search of 139,387 sets of vital signs showed less than 0.1% rate of suspected artifact. When compared to direct observation, our CIS correctly recorded days of mechanical ventilation in 23 of 26 patients (88%). Two other data sets, medical diagnoses and medications given showed significant differences with other commonly used databases of the same information collected outside the ICU (billing codes and pharmacy records respectively CONCLUSIONS: Compared to other commonly used data sources for clinical research, a commercially available CIS is an acceptable source of ICU patient data.

Decision Support Systems, Clinical↗
PubMed2004

The accuracy of clinical information systems.

The clinical information system (CIS) is becoming more common in intensive care units. These systems have the ability to record, store, and retrieve large amounts of clinical patient data with great ease. This should greatly facilitate outcomes research and quality assurance. Unfortunately, there is not much information available about the accuracy of the data coming from these systems. True accuracy of a patient record requires both completeness of data and correctness of data as well as legibility. Automated systems are clearly superior to human entered data in terms of completeness and legibility but the correctness of entered data remains unclear. There are aspects of automated data entry that facilitate erroneous data entry. This article reviews the existing literature on accuracy of CISs with special attention to the qualities of automated data entry that can lead to false data. Additionally, data are presented from a newly published study by the author evaluating the validity of data from a commercially available CIS.

Computers↗
PubMed2004

Using computers for intensive care unit research.

A computerized clinical information system (CIS) is potentially a very important information tool for research and improving health care processes as well as for optimizing data management and thereby minimizing health care costs. The newest CISs automatically collect patient data from various sources, including monitors, the laboratory, radiology, and patient notes, and make the data highly organized and readily accessible. In the future CISs may be able to conduct signal analysis, assist in care decisions, provide advanced graphical data presentation, and generate warnings to clinicians. Most CIS systems include large databases, and the advent of relational databases has improved data retrieval and manipulation and thus made the data a powerful tool in outcomes research. On the whole CISs collect more frequent and more accurate data than do clinicians using paper-based data collection systems, but research continues on how accurate CIS data is, how to improve that accuracy, and how much data checking and correction is needed. At my institution we have used CIS data to study changes in patients' code status and to evaluate a protocol for arterial blood gas (ABG) testing. The primary challenges to optimizing a CIS are ensuring accurate data entry, learning to query the data so as to avoid misleading conclusions, and to administer and maintain the hardware and software so as to minimize the chance of data loss and system down time. CISs are in a relatively early stage of their development, and engineering improvements will eventually make CIS data highly accurate and easily accessible and queryable so that CISs become even more valuable for research.

Computer Systems↗
PubMed2002

Effects of prone position ventilation in ARDS. An evidence-based review of the literature.

In summary, the many studies done on PPV show that the technique improves oxygenation most of the time. The mechanisms behind this effect are probably numerous and have yet to be elucidated completely. In addition, PPV is a safe procedure that rarely worsens a patient's respiratory status or causes other complications and is thus a welcome additional therapeutic option when treating patients with ARDS. Despite the recent large, randomized, controlled trial showing no improvement in mortality rate or organ dysfunction overall, there is evidence suggesting that PPV may be of most benefit in more severely ill patients. Further studies will be useful.

Adolescent↗
PubMed2002

Successful determination of lower inflection point and maximal compliance in a population of patients with acute respiratory distress syndrome.

OBJECTIVE: To compare the ease and efficacy of two commonly used methods for choosing optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome: a static pressure-volume curve to determine the lower inflection point (P(flex)) and the "best PEEP" (PEEP(best)) as determined by the maximal compliance curve. DESIGN: Prospective study. SETTING: Medical and respiratory intensive care units of university-associated tertiary care hospital. PATIENTS: Twenty-eight patients on mechanical ventilation with acute respiratory distress syndrome. INTERVENTIONS: A critical care attending physician or fellow and an experienced respiratory therapist attempted to obtain both static pressure-volume curves and maximal compliance curves on 28 patients with acute respiratory distress syndrome by using established methods that were practical to everyday use. The curves then were used to determine both P(flex) and PEEP(best), and the results were compared. MEASUREMENT AND MAIN RESULTS: Our results showed at least one value for optimal PEEP was obtained in 26 of 28 patients (93%). P(flex) was determined in 19 (68%), a PEEP(best) in 24 (86%), and both values in 17 (61%). In patients who had both P(flex) and PEEP(best) determined, there was a close concordance (+/-3 cm H2O) in 60%. When the values of P(flex) and PEEP(best) were interpreted by two additional investigators, there was unanimous agreement on the P(flex) (+/-3) only 64% of the time. There was agreement on the value of PEEP(best) 93% of the time. CONCLUSIONS: Our data show that optimal PEEP, as determined by a pressure-volume curve and a maximal compliance curve, are sometimes unobtainable by practical means but, when obtained, often correspond. A maximal compliance is more often identified, has less interobserver variability, and poses less risk to the patient. We conclude that determining optimal PEEP by maximal static compliance may be easier to measure and more frequently obtained at the bedside than by using a static pressure-volume curve.

Adult↗
PubMed2002

Steroid therapy in chronic obstructive pulmonary disease.

COPD is a prevalent disease, with an increasing attributable mortality. Because inflammation plays a significant role in the pathogenesis of this disease, the use of anti-inflammatory therapies would appear indicated; hence the widespread use of corticosteroids in COPD. Although the majority of patients with stable COPD do not benefit from systemic steroids, there is good evidence supporting the use of short courses of systemic steroids for COPD exacerbations. With respect to inhaled corticosteroids, the studies are conflicting. Those patients with an asthmatic component to their disease, or with a positive bronchodilator test, appear to benefit most from inhaled steroids. Those with irreversible disease do not benefit from short-term inhaled steroids. Long-term inhaled corticosteroids, though not having a significant effect on the rate of decline in spirometric indices, do appear to decrease the number of exacerbations and the rate of decline in health status, reduce respiratory symptoms, decrease use of health care services, and improve airway reactivity. These effects appear more marked in patients with moderate-to-severe disease. Because very few therapies offer significant benefits to patients with COPD, and until a test is developed that will distinguish between potential steroid responders from non-responders, it is worthwhile giving all patients with COPD a trial (3-6 months) of inhaled corticosteroids to determine whether they are responsive.

Administration, Inhalation↗