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Biomedical subjects

Rolf D Hubmayr

Publications and source records attributed to Rolf D Hubmayr.

At least 19 recordsLinked to original sources
PubMed2006

Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study.

INTRODUCTION: The role of non-invasive positive pressure ventilation (NIPPV) in the treatment of acute lung injury (ALI) is controversial. We sought to assess the outcome of ALI that was initially treated with NIPPV and to identify specific risk factors for NIPPV failure. METHODS: In this observational cohort study at the two intensive care units of a tertiary center, we identified consecutive patients with ALI who were initially treated with NIPPV. Data on demographics, APACHE III scores, degree of hypoxemia, ALI risk factors and NIPPV respiratory parameters were recorded. Univariate and multivariate regression analyses were performed to identify risk factors for NIPPV failure. RESULTS: Of 79 consecutive patients who met the inclusion criteria, 23 were excluded because of a do not resuscitate order and two did not give research authorization. Of the remaining 54 patients, 38 (70.3%) failed NIPPV, among them all 19 patients with shock. In a stepwise logistic regression restricted to patients without shock, metabolic acidosis (odds ratio 1.27, 95% confidence interval (CI) 1.03 to 0.07 per unit of base deficit) and severe hypoxemia (odds ratio 1.03, 95%CI 1.01 to 1.05 per unit decrease in ratio of arterial partial pressure of O2 and inspired O2 concentration--PaO2/FiO2) predicted NIPPV failure. In patients who failed NIPPV, the observed mortality was higher than APACHE predicted mortality (68% versus 39%, p < 0.01). CONCLUSION: NIPPV should be tried very cautiously or not at all in patients with ALI who have shock, metabolic acidosis or profound hypoxemia.

Acute Disease↗
PubMed2006

Interpretation of airway pressure waveforms.

Most mechanical ventilators display tracings of airway pressure (Paw) volume (V) and flow (V). In volume preset modes, Paw informs about the mechanical properties of the respiratory system and about the activity of respiratory muscles acting on the system. When monitoring ventilator waveforms, it is important to appropriately scale the tracing so that nuances in time profiles may be appreciated. In this short monograph, we offer three examples of how clinicians may use this information for patient assessment and care.

Data Display↗
PubMed2006

Bronchoscopy in ventilator-associated pneumonia: agreement of calibrated loop and serial dilution.

RATIONALE: Although the serial dilution technique for quantitative culture of bronchoalveolar fluid is considered to be the gold standard for the diagnosis of ventilator-associated pneumonia, it is more labor intensive than the calibrated loop technique. OBJECTIVE: We sought to determine the agreement between the calibrated loop and serial dilution techniques in the diagnosis of ventilator-associated pneumonia. METHODS: We prospectively measured bacterial colony counts by the serial dilution and calibrated loop techniques in 121 bronchoalveolar lavage samples of 104 patients with suspected ventilator-associated pneumonia. MEASUREMENTS AND MAIN RESULTS: At the time of bronchoscopy, patients had received mechanical ventilation for a median of 8 d. Patients were receiving antibiotics when 90 of the 121 (74.4%) bronchoalveolar samples were obtained. The colony counts of 13 bacterial isolates were too numerous to count by the calibrated loop technique; by serial dilution technique, their counts ranged from 4.70 to 6.74 log10 cfu/ml. Fifty other bacteria had paired colony counts measured by each of the two techniques: the bias (95% confidence interval) between the two techniques was -0.380 (-0.665 to -0.095) log10 cfu/ml, with precision of 1.002 log10 cfu/ml and 95% limits of agreement of -2.344 to 1.584 log10 cfu/ml. Using the threshold of 4 log10 cfu/ml as a criterion for the diagnosis of ventilator-associated pneumonia, there was discordance only for one bacterial organism between the two techniques. CONCLUSIONS: The calibrated loop technique can be used for the diagnosis of ventilator-associated pneumonia using bronchoalveolar lavage fluid.

Anti-Bacterial Agents↗
PubMed2006

The initial Mayo Clinic experience using high-frequency oscillatory ventilation for adult patients: a retrospective study.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) was introduced in our institution in June 2003. Since then, there has been no protocol to guide the use of HFOV, and all decisions regarding ventilation strategies and settings of HFOV were made by the treating intensivist. The aim of this study is to report our first year of experience using HFOV. METHODS: In this retrospective study, we reviewed all 14 adult patients, who were consecutively ventilated with HFOV in the intensive care units of a tertiary medical center, from June 2003 to July 2004. RESULTS: The mean age of the patients was 56 years, 10 were males, and all were whites. The first day median APACHE II score and its predicted hospital mortality were 35 and 83%, respectively, and the median SOFA score was 11.5. Eleven patients had ARDS, two unilateral pneumonia with septic shock, and one pulmonary edema. Patients received conventional ventilation for a median of 1.8 days before HFOV. HFOV was used 16 times for a median of 3.2 days. Improvements in oxygenation parameters were observed after 24 hours of HFOV (mean PaO2/FIO2 increased from 82 to 107, P < 0.05; and the mean oxygenation index decreased from 42 to 29; P < 0.05). In two patients HFOV was discontinued, in one because of equipment failure and in another because of severe hypotension that was unresponsive to fluids. No change in mean arterial pressure, or vasopressor requirements was noted after the initiation of HFOV. Eight patients died (57 %, 95% CI: 33-79); life support was withdrawn in six and two suffered cardiac arrest. CONCLUSION: During our first year of experience, HFOV was used as a rescue therapy in very sick patients with refractory hypoxemia, and improvement in oxygenation was observed after 24 hours of this technique. HFOV is a reasonable alternative when a protective lung strategy could not be achieved on conventional ventilation.

Journal Article↗
PubMed2006

Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy.

BACKGROUND: Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. The authors hypothesized that intraoperative mechanical ventilation with large tidal volumes (VTs) would be associated with increased risk of postpneumonectomy respiratory failure. METHODS: Patients undergoing elective pneumonectomy at the authors' institution from January 1999 to January 2003 were studied. The authors collected data on demographics, relevant comorbidities, neoadjuvant therapy, pulmonary function tests, site and type of operation, duration of surgery, intraoperative ventilator settings, and intraoperative fluid administration. The primary outcome measure was postoperative respiratory failure, defined as the need for continuation of mechanical ventilation for greater than 48 h postoperatively or the need for reinstitution of mechanical ventilation after extubation. RESULTS: Of 170 pneumonectomy patients who met inclusion criteria, 30 (18%) developed postoperative respiratory failure. Causes of postoperative respiratory failure were acute lung injury in 50% (n = 15), cardiogenic pulmonary edema in 17% (n = 5), pneumonia in 23% (n = 7), bronchopleural fistula in 7% (n = 2), and pulmonary thromboembolism in 3% (n = 1). Patients who developed respiratory failure were ventilated with larger intraoperative VT than those who did not (median, 8.3 vs. 6.7 ml/kg predicted body weight; P < 0.001). In a multivariate regression analysis, larger intraoperative VT (odds ratio, 1.56 for each ml/kg increase; 95% confidence interval, 1.12-2.23) was associated with development of postoperative respiratory failure. The interaction between larger VT and fluid administration was also statistically significant (odds ratio, 1.36; 95% confidence interval, 1.05-1.97). CONCLUSION: Mechanical ventilation with large intraoperative VT is associated with increased risk of postpneumonectomy respiratory failure.

Aged↗
PubMed2006

Pulmonary edema after transfusion: how to differentiate transfusion-associated circulatory overload from transfusion-related acute lung injury.

OBJECTIVE: Pulmonary edema is an under-recognized and potentially serious complication of blood transfusion. Distinct mechanisms include adverse immune reactions and circulatory overload. The former is associated with increased pulmonary vascular permeability and is commonly referred to as transfusion-related acute lung injury (TRALI). The latter causes hydrostatic pulmonary edema and is commonly referred to as transfusion-associated circulatory overload (TACO). In this review article we searched the National Library of Medicine PubMed database as well as references of retrieved articles and summarized the methods for differentiating between hydrostatic and permeability pulmonary edema. RESULTS: The clinical and radiologic manifestations of TACO and TRALI are similar. Although echocardiography and B-type natriuretic peptide measurements may aid in the differential diagnosis between hydrostatic and permeability pulmonary edema, invasive techniques such as right heart catheterization and the sampling of alveolar fluid protein are sometimes necessary. The diagnostic differentiation is especially difficult in critically ill patients will multiple comorbidities so that the cause of edema may only be determined post hoc based on the clinical course and response to therapy. Guided by available evidence, we present an algorithm for establishing the pretest probability of TRALI as opposed to TACO. The decision to test donor and recipient blood for immunocompatibility may be made on this basis. CONCLUSIONS: The distinction between hydrostatic (TACO) and permeability (TRALI) pulmonary edema after transfusion is difficult, in part because the two conditions may coexist. Knowledge of strengths and limitations of different diagnostic techniques is necessary before initiation of complex TRALI workup.

Blood Circulation↗
PubMed2006

B-type natriuretic peptide in the assessment of acute lung injury and cardiogenic pulmonary edema.

OBJECTIVE: The role of plasma B-type natriuretic peptide (BNP) in critically ill patients with acute pulmonary edema is controversial. We postulated that a low BNP level would exclude cardiac dysfunction as the principal cause of pulmonary edema and therefore help in the diagnosis of acute lung injury. DESIGN: A retrospective derivation cohort was followed by a prospective validation cohort of consecutive patients with acute pulmonary edema admitted to three intensive care units. BNP was measured within 24 hrs from onset. Critical care experts blinded to BNP results integrated clinical data with the course of disease and response to therapy and served as the reference standard. SETTING: Three intensive care units at the tertiary center. PATIENTS: Consecutive critically ill patients with acute pulmonary edema. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In a derivation cohort of 84 patients, a BNP threshold of <or=250 pg/mL had a specificity of 87% and sensitivity of 48% for the diagnosis of acute lung injury. High specificity of BNP (90%, likelihood ratio of 3.9) was confirmed in a validation cohort of 120 consecutive patients, 52 (43%) of whom had acute lung injury. Notably, 32% of patients with acute lung injury had concomitant cardiac dysfunction. The median time from the onset of pulmonary edema to BNP testing was 3 hrs. The accuracy of BNP (area under receiver operator curve, 0.71) was comparable with pulmonary artery occlusion pressure (area under receiver operator curve, 0.66) and superior to ejection fraction (area under receiver operator curve, 0.60) in subgroups of patients in whom these tests were performed. The accuracy of BNP improved when patients with renal insufficiency were excluded (area under receiver operator curve, 0.82). CONCLUSION: When measured early after the onset of acute pulmonary edema, a BNP level of <250 pg/mL supports the diagnosis of acute lung injury. The high rate of cardiac and renal dysfunction in critically ill patients limits the discriminative role of BNP. No level of BNP could completely exclude cardiac dysfunction.

Acute Disease↗
PubMed2006

Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.

OBJECTIVE: The implementation of evidence-based practice poses a significant challenge in the intensive care unit. In this quality improvement intervention we assessed the effect of an institutional protocol and computerized decision support for red cell transfusion in the critically ill. DESIGN: We compared processes of care and outcomes during the two 3-month periods before and after the introduction of a multidisciplinary quality improvement intervention. SETTING: Multidisciplinary intensive care units--medical, surgical, and mixed--in a tertiary academic center. PATIENTS: Consecutive critically ill patients with anemia (hemoglobin of <10 g/dL). INTERVENTION: Using the computerized provider order entry, we developed an evidence-based decision algorithm for red cell transfusion in adult intensive care units. MEASUREMENTS AND MAIN RESULTS: We collected information on demographics, diagnosis, severity of illness, transfusion complications, and laboratory values. The main outcome measures were number of transfusions, proportion of patients who were transfused outside evidence-based indications, transfusion complications, and adjusted hospital mortality. The mean number of red cell transfusions per intensive care unit admission decreased from 1.08 +/- 2.3 units before to 0.86 +/- 2.3 units after the protocol (p<.001). We observed a marked decrease in the percentage of patients receiving inappropriate transfusions (17.7% vs. 4.5%, p< .001). The rate of transfusion complications was also lower in the period after the protocol (6.1% vs. 2.7%, p = .015). In the multivariate analysis, protocol introduction was associated with decreased likelihood of red cell transfusion (odds ratio, 0.43; 95% confidence interval, 0.30 to 0.62). Adjusted hospital mortality did not differ before and after protocol implementation (odds ratio, 1.12; 95% confidence interval, 0.69 to 1.8). CONCLUSIONS: The implementation of an institutional protocol and decision support through a computerized provider order entry effectively decreased inappropriate red cell transfusions.

Algorithms↗
PubMed2006

The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery.

Abnormalities in gas exchange that occur during anesthesia are mostly caused by atelectasis, and these alterations are more pronounced in morbidly obese than in normal weight subjects. Sustained lung insufflation is capable of recruiting the collapsed areas and improving oxygenation in healthy patients of normal weight. We tested the effect of this ventilatory strategy on arterial oxygenation (Pao2) in patients undergoing laparoscopic bariatric surgery. After pneumoperitoneum was accomplished, the recruitment group received up to 4 sustained lung inflations with peak inspiratory pressures up to 50 cm H2O, which was followed by ventilation with 12 cm H2O positive end-expiratory pressure (PEEP). The patient's lungs in the control group were ventilated in a standard fashion with PEEP of 4 cm H2O. Variables related to gas exchange, respiratory mechanics, and hemodynamics were compared between recruitment and control groups. We found that alveolar recruitment effectively increased intraoperative Pao2 and temporarily increased respiratory system dynamic compliance (both P < 0.01). The effects of alveolar recruitment on oxygenation lasted as long as the trachea was intubated, and lungs were ventilated with high PEEP, but soon after tracheal extubation, all the beneficial effects on oxygenation disappeared. The mean number of vasopressor treatments given during surgery was larger in the recruitment group compared with the control group (3.0 versus 0.8; P = 0.04). In conclusion, our data suggest that the use of alveolar recruitment may be an effective mode of improving intraoperative oxygenation in morbidly obese patients. Our results showed the effect to be short lived and associated with more frequent intraoperative use of vasopressors.

Adult↗
PubMed2005

The influence of missing components of the Acute Physiology Score of APACHE III on the measurement of ICU performance.

OBJECTIVE: To determine the impact of missing Acute Physiology Score (APS) values on risk-adjusted mortality. DESIGN: Retrospective review of prospectively collected Acute Physiology and Chronic Health Evaluation (APACHE) III database. SETTING: The intensive care units (ICUs) of an academic medical center. PATIENTS: 38,411 patients admitted to ICU between October 1994 and December 2003. MEASUREMENTS AND RESULTS: Data were collected on ICU type, missing first ICU day APS values, predicted and observed hospital mortality, standardized mortality ratio (SMR), 95% confidence interval (CI), odds ratio (OR). The overall observed and predicted hospital mortality rates were 8.7% and 10.8%, respectively, with SMR of 0.806 (95% CI 0.779-0.834). Complete data were available in 829 (2.2%). Vital signs were missing in almost none and serum albumin and bilirubin in over 80% of the patients. The number of missing variables was higher in less sick and surgical ICU patients. Logistic regression analysis showed that the risk of dying in the hospital was significantly associated with the number of missing APS variables (OR 1.058, 95% CI 1.027-1.090) when adjusted for the severity of illness. The risk of death was also associated with the type of missing variables. CONCLUSIONS: Since missing APS values may lead to underestimation of the predicted mortality rates, the number and type of missing variables should be taken into consideration when assessing the performance of an ICU. Unless data collection is standardized, future prognostic models should use variables that are routinely measured in most critically ill patients without sacrificing statistical precision.

APACHE↗
PubMed2005

Ventilator settings as a risk factor for acute respiratory distress syndrome in mechanically ventilated patients.

OBJECTIVE: A single-center retrospective study initial recently identified ventilator settings as a major risk factor for the development of acute respiratory distress syndrome (ARDS) in mechanically ventilated patients who do not have ARDS from the outset. We tested this hypothesis in a larger sample of patients prospectively enrolled in a multicenter study on mechanical ventilation. DESIGN AND SETTING: From a large international mechanical ventilation study database we identified patients who required mechanical ventilation for 48 h or more but did not have ARDS at the onset of mechanical ventilation. We extracted information on demographics, initial severity of illness, ventilator settings and major underlying ARDS risk factors. Primary outcome was development of ARDS after the onset of mechanical ventilation. MEASUREMENTS AND RESULTS: Of 3,261 mechanically ventilated patients who did not have ARDS at the outset 205 (6.2%) developed ARDS 48 h or more after the onset of mechanical ventilation. Multivariate logistic regression analysis adjusted for baseline patient characteristics (age, gender, Simplified Acute Physiology Score, hypoxemia) and underlying ARDS risk factors (sepsis, trauma, pneumonia) found the development of ARDS to be associated with the initial ventilator settings: high tidal volume (odds ratio 2.6 for tidal volume>700 ml), high peak airway pressure (odds ratio 1.6 for peak airway pressure>30 cmH2O), and high positive end-expiratory pressure (odds ratio 1.7 for end-expiratory pressure>5 cmH2O). CONCLUSIONS: The association with the potentially injurious initial ventilator settings, in particular large tidal volumes, suggests that ARDS in mechanically ventilated patients is in part a preventable complication. This hypothesis needs to be tested in a prospective study.

Female↗
PubMed2005

Hypercapnic acidosis impairs plasma membrane wound resealing in ventilator-injured lungs.

The objective of this study was to assess the effects of hypercapnic acidosis on lung cell injury and repair by confocal microscopy in a model of ventilator-induced lung injury. Three groups of normocapnic, hypocapnic, and hypercapnic rat lungs were perfused ex vivo, either during or after injurious ventilation, with a solution containing the membrane-impermeant label propidium iodide. In lungs labeled during injurious ventilation, propidium iodide fluorescence identifies all cells with plasma membrane wounds, both permanent and transient, whereas in lungs labeled after injurious ventilation propidium iodide fluorescence identifies only cells with permanent plasma membrane wounds. Hypercapnia minimized the adverse effects of high-volume ventilation on vascular barrier function, whereas hypocapnia had the opposite effect. Despite CO2-dependent differences in lung mechanics and edema the number of injured subpleural cells per alveolus was similar in the three groups (0.48 +/- 0.34 versus 0.51 +/- 0.19 versus 0.43 +/- 0.20 for hypocapnia, normocapnia, and hypercapnia, respectively). However, compared with normocapnia the probability of wound repair was significantly reduced in hypercapnic lungs (63 versus 38%; p < 0.02). This finding was subsequently confirmed in alveolar epithelial cell scratch models. The potential relevance of these observations for lung inflammation and remodeling after mechanical injury is discussed.

Acidosis, Respiratory↗
PubMed2005

Cellular stress failure in ventilator-injured lungs.

The clinical and experimental literature has unequivocally established that mechanical ventilation with large tidal volumes is injurious to the lung. However, uncertainty about the micromechanics of injured lungs and the numerous degrees of freedom in ventilator settings leave many unanswered questions about the biophysical determinants of lung injury. In this review we focus on experimental evidence for lung cells as injury targets and the relevance of these studies for human ventilator-associated lung injury. In vitro, the stress-induced mechanical interactions between matrix and adherent cells are important for cellular remodeling as a means for preventing compromise of cell structure and ultimately cell injury or death. In vivo, these same principles apply. Large tidal volume mechanical ventilation results in physical breaks in alveolar epithelial and endothelial plasma membrane integrity and subsequent triggering of proinflammatory signaling cascades resulting in the cytokine milieu and pathologic and physiologic findings of ventilator-associated lung injury. Importantly, though, alveolar cells possess cellular repair and remodeling mechanisms that in addition to protecting the stressed cell provide potential molecular targets for the prevention and treatment of ventilator-associated lung injury in the future.

Animals↗
PubMed2005

New insights into the pathology of acute respiratory failure.

PURPOSE OF REVIEW: The purpose of this review is to provide a historical perspective and to analyze the recent advances in the understanding of the cellular and tissue pathology of acute respiratory failure, specifically of the acute respiratory distress syndrome. The scope of mechanisms involved in acute lung injury and acute respiratory distress syndrome is far too great to do it justice in a single review. Therefore, this review will focus only on recent advances in the understanding of the morphologic changes that occur in acute lung injury, acute respiratory distress syndrome, and ventilator-induced lung injury. RECENT FINDINGS: The use of fluorescent labels brought a novel method to identify and quantify cell wounding in the whole organ animal model of ventilator-induced lung injury. Real-time in vivo microscopy demonstrated the injurious effects of alveolar instability in the pathogenesis of ventilator-induced lung injury. Lipid tether mechanics, using laser tweezers, have advanced the understanding of the mechanical properties of the plasma membrane in response to mechanical stress. New animal injury models have brought forward new insights into the pathogenesis and structural abnormalities seen in acute respiratory distress syndrome. Apoptosis and epithelial wounding and repair have been examined in novel methods, and new mechanisms in lung edema formation have been proposed. SUMMARY: New mechanisms in the pathology of acute respiratory failure have shifted the focus to lung mechanics, tissue damage, remodeling, and the systemic effects derived from the mechanical stress imposed by the ventilator in patients with adult respiratory distress syndrome.

Animals↗
PubMed2005

Introduction of a 14-hour work shift model for housestaff in the medical ICU.

STUDY OBJECTIVE: To describe the outcomes of switching housestaff from a traditional model of "long-call" every 4 days to a 14-h work-shift model in a medical ICU (MICU) over a 5-week pilot period. DESIGN: Retrospective comparison of a 5-week pilot period for a 14-h work-shift model vs a 4-month period for the traditional model. SETTING: The MICU of a tertiary medical center. PARTICIPANTS: A total of 626 patients admitted to the MICU and 34 internal medicine residents taking care of them. INTERVENTIONS: None. MEASUREMENTS: Severity-adjusted patient outcomes, housestaff performance on end-of-rotation examinations, and scheduled duty hours during the 5-week 14-h work-shift pilot period compared to a 16-week traditional nonpilot work period. RESULTS: There were no statistically significant differences in patients' adjusted mortality rates, hospital lengths of stay, or housestaff performance on end-of-rotation knowledge assessment examinations between the pilot and nonpilot periods. During the pilot period, each resident was scheduled to work for an average of 61.3 h weekly, and each fellow for 65.3 h weekly. In comparison, each resident and fellow was scheduled to work for an average of 73.3 h weekly during the nonpilot period. CONCLUSIONS: The 14-h work shift is a feasible option for housestaff rotation in the MICU. Although the power of our study to detect significant differences in mortality, length of stay, and educational outcomes was low, there was no evidence of compromised patient care or housestaff education associated with the 14-h shift model over the course of this 5-week pilot study.

Adult↗
PubMed2005

Tracheostomy in critically ill patients.

Tracheostomy is a common critical care procedure in patients with acute respiratory failure who require prolonged mechanical ventilatory support. Tracheostomy usually is considered if weaning from mechanical ventilation has been unsuccessful for 14 to 21 days. A recent clinical trial suggested that early tracheostomy may benefit patients who are not improving and who are expected to require prolonged respiratory support. In this study, early tracheostomy improved survival and shortened duration of mechanical ventilation. Minimally invasive bedside percutaneous tracheostomy was introduced recently as an alternative to the traditional surgical technique. In expert hands, the 2 techniques are equivalent in complications and safety; however, the bedside percutaneous approach may be more cost-effective. Tracheostomy should be considered early (within the first week of mechanical ventilation) in patients with a high likelihood of prolonged mechanical ventilation. Depending on local medical expertise and costs, either the percutaneous or the surgical technique may be used.

Acute Disease↗
PubMed2005

Evaluating the performance of an institution using an intensive care unit benchmark.

OBJECTIVES: To describe the performances of selected intensive care units (ICUs) in a single institution using the Acute Physiology and Chronic Health Evaluation (APACHE) III benchmark and to propose interventions that may improve performance. PATIENTS AND METHODS: In this retrospective study, we analyzed APACHE III data from critically ill patients admitted to ICUs at the Mayo Clinic in Rochester, Minn, between October 1994 and December 2003. We retrieved ICU performance measures based on first ICU day APACHE III values. Standardized ratios were defined as ratios of measured to predicted values. The primary performance measure was the standardized mortality ratio, and secondary performance measures were length of stay (LOS) ratios, low-risk monitor ICU admission rates, and ICU readmission rates. We calculated 95% confidence intervals (CIs) for each performance, graded as good, average, or poor. RESULTS: Among 46,381 patients admitted during the study period, 57.5% were in surgical ICUs, 24.8% in a medical ICU, and 17.7% in a surgical-medical ICU. Low-risk monitoring accounted for 37.2% of admissions. Hospital standardized mortality ratios (95% CI) were 0.95 (0.90-0.99), 0.86 (0.81-0.91), and 0.70 (0.66-0.74) for medical, multispecialty, and surgical ICUs, respectively. Hospital LOS ratios (95% CI) were 0.83 (0.81-0.85), 0.91 (0.88-0.93), and 0.99 (0.97-1.00) for medical, multispecialty, and surgical ICUs, respectively. The ICU readmission rate for each ICU was higher than the 6.7% reported in the medical literature. Performances were good in mortality, average to good in LOS, average in low-risk admission, and poor in ICU readmission. CONCLUSIONS: A national benchmarking database can highlight the strengths and weaknesses of ICUs. The performances of ICUs in a single institution may differ; therefore, the performance of each unit should be evaluated individually.

APACHE↗