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Biomedical subjects

Sean P Keenan

Publications and source records attributed to Sean P Keenan.

At least 19 recordsLinked to original sources
PubMed2006

Adjustment of intensive care unit outcomes for severity of illness and comorbidity scores.

PURPOSE: Comparison of outcomes among intensive care units (ICUs) requires adjustment for patient variables. Severity of illness scores are associated with hospital mortality, but administrative databases rarely include the elements of these scores. However, these databases include the elements of comorbidity scores. The purpose of this study was to compare the value of these scores as adjustment variables in statistical models of hospital mortality and hospital and ICU length of stay after adjustment for other covariates. MATERIALS AND METHODS: We used multivariable regression to study 1808 patients admitted to a 13-bed medical-surgical ICU in a 400-bed tertiary hospital between December 1998 and August 2003. RESULTS: For all patients, after adjusting for age, sex, major clinical category, source of admission, and socioeconomic determinants of health, we found that Acute Physiology and Chronic Health Evaluation (APACHE) II and comorbidity scores were significantly associated with hospital mortality and that comorbidity but not APACHE II was significantly associated with hospital length of stay. Separate analysis of hospital survivors and nonsurvivors showed that both APACHE II and comorbidity scores were significantly associated with hospital length of stay and APACHE II score was associated with ICU length of stay. CONCLUSION: The value of APACHE II and comorbidity scores as adjustment variables depends on the outcome and population of interest.

APACHE↗
PubMed2006

Do specialist transport personnel improve hospital outcome in critically ill patients transferred to higher centers? A systematic review.

PURPOSE: The aim of the study was to determine whether the use of specialist transport personnel improves patient outcome at the receiving hospital for critically ill patients transferred to higher centers. MATERIALS AND METHODS: A search of 6 electronic databases, 15 relevant journals, and the reference lists of all retrieved articles was conducted for studies comparing outcome at the receiving hospital for critically ill adult or pediatric patients transported by dedicated transport crews or tertiary-based specialists with other forms of transport personnel including referring house staff. All potentially relevant articles were retrieved in full and reviewed independently by 2 reviewers to determine eligibility for inclusion. Data were tabulated and results were summarized. RESULTS: Six cohort studies (n = 4534) were included. When patients of equal severity were assessed, only 1 study demonstrated an improvement in outcome at the receiving hospital (survival to 6 hours) when specialist personnel transported the patients. Methodological limitations and interstudy differences in participants and transport personnel precluded pooling of results. CONCLUSIONS: Current data are insufficient. The study designs used create opportunity for significant bias, preventing any useful inferences to be drawn. Further study is warranted.

Critical Illness↗
PubMed2005

Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial.

OBJECTIVES: To determine the effect of the addition of noninvasive positive-pressure ventilation (NPPV) to standard medical therapy on length of hospital stay among patients presenting with mild exacerbations of chronic obstructive pulmonary disease (COPD) requiring hospitalization. DESIGN: Randomized controlled unblinded study with concealed allocation. SETTING: Respiratory ward of a single-center, academic, tertiary-care hospital. PARTICIPANTS: Patients with a prior history of COPD who presented with a recent onset of shortness of breath and a pH of > 7.30 were eligible for inclusion in the study. INTERVENTIONS: NPPV daily for 3 days for intervals of 8, 6, and 4 hours, respectively, plus standard therapy, versus standard therapy alone. MEASUREMENTS: Borg dyspnea index at baseline, 1 hour, and daily. Length of hospital stay, endotracheal intubation, hospital survival. RESULTS: We found that NPPV was generally poorly tolerated, with only 12 of 25 patients wearing it for the prescribed 3 days. With the exception of a decrease in dyspnea at 1 hour and 2 days, significant between-group differences were not seen for any measured variable. CONCLUSIONS: The effectiveness and cost-effectiveness of the addition of NPPV to standard therapy in milder COPD exacerbations remains unclear. P(aCO(2)) related to this increased WOB that requires intervention with some form of assisted ventilation. All patients developing an exacerbation of COPD that requires hospitalization have an increased WOB and, we hypothesize, potentially develop some degree of associated respiratory muscle fatigue. We further hypothesize that adding intermittent NPPV during the initial days of hospital stay would afford respiratory muscle rest for patients with milder COPD exacerbations and that this rest would allow these patients to recover more quickly and to be discharged home earlier. The objective of this trial was to determine whether the addition of NPPV to standard therapy during the first 3 days of admission in milder COPD exacerbations could decrease length of hospital stay.

Aged↗
PubMed2004

Clinical practice guideline for the use of noninvasive positive pressure ventilation in COPD patients with acute respiratory failure.

Noninvasive positive pressure ventilation has been demonstrated to be of benefit in preventing endotracheal intubation and reducing mortality in specific patients in the setting of acute exacerbations of chronic obstructive pulmonary disease. The successful application of noninvasive positive pressure ventilation depends on a multitude of factors, including patient selection, choice of interface, physician experience, and patient-ventilator synchrony. The use of clinical practice guidelines has been shown to improve the process and outcomes of care. This paper presents a guideline for the use of noninvasive positive pressure ventilation in the setting of acute ventilatory failure in patients with acute exacerbations of chronic obstructive pulmonary disease.

Acute Disease↗
PubMed2004

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

OBJECTIVE: Intensive 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. DESIGN: Cohort study for 3 yrs between 1994 and 1997. SETTING: All acute care hospitals in British Columbia, Canada. PATIENTS: A 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). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We 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. CONCLUSIONS: Survivors 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.

Adolescent↗
PubMed2004

Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review.

CONTEXT: The results of studies on noninvasive positive pressure ventilation (NPPV) for acute hypoxemic respiratory failure unrelated to cardiogenic pulmonary edema have been inconsistent. OBJECTIVE: To assess the effect of NPPV on the rate of endotracheal intubation, intensive care unit and hospital length of stay, and mortality for patients with acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema. DATA SOURCE: We searched the databases of MEDLINE (1980 to October 2003) and EMBASE (1990 to October 2003). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. STUDY SELECTION: We included studies if a) the design was a randomized controlled trial; b) patients had acute hypoxemic respiratory failure not due to cardiogenic pulmonary edema; c) the interventions compared noninvasive ventilation and standard therapy with standard therapy alone; and d) outcomes included need for endotracheal intubation, length of intensive care unit or hospital stay, or intensive care unit or hospital survival. DATA EXTRACTION: In duplicate and independently, we abstracted data to evaluate methodological quality and results. DATA SYNTHESIS: The addition of NPPV to standard care in the setting of acute hypoxemic respiratory failure reduced the rate of endotracheal intubation (absolute risk reduction 23%, 95% confidence interval 10-35%), ICU length of stay (absolute reduction 2 days, 95% confidence interval 1-3 days), and ICU mortality (absolute risk reduction 17%, 95% confidence interval 8-26%). However, trial results were significantly heterogeneous. CONCLUSION: Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy. However, the effect on mortality is less clear, and the heterogeneity found among studies suggests that effectiveness varies among different populations. As a result, the literature does not support the routine use of NPPV in all patients with acute hypoxemic respiratory failure.

Adult↗
PubMed2003

Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature.

BACKGROUND: Over the past decade, noninvasive positive-pressure ventilation (NPPV) in the setting of acute exacerbations of chronic obstructive pulmonary disease (COPD) has increased in popularity. Although several trials have been published on the relative effectiveness of this treatment, apparent inconsistencies in study results remain. PURPOSE: To assess the effect of NPPV on rate of endotracheal intubation, length of hospital stay, and in-hospital mortality rate in patients with an acute exacerbation of COPD and to determine the effect of exacerbation severity on these outcomes. DATA SOURCES: MEDLINE (1966 to 2002) and EMBASE (1990 to 2002). Additional data sources included the Cochrane Library, personal files, abstract proceedings, reference lists of selected articles, and expert contact. There were no language restrictions. STUDY SELECTION: The researchers selected randomized, controlled trials that 1) examined patients with acute exacerbation of COPD; 2) compared noninvasive ventilation and standard therapy with standard therapy alone; and 3) included need for endotracheal intubation, length of hospital stay, or hospital survival as an outcome. DATA EXTRACTION: Methodologic quality and results were abstracted independently and in duplicate. DATA SYNTHESIS: The addition of NPPV to standard care in patients with an acute exacerbation of COPD decreased the rate of endotracheal intubation (risk reduction, 28% [95% CI, 15% to 40%]), length of hospital stay (absolute reduction, 4.57 days [CI, 2.30 to 6.83 days]), and in-hospital mortality rate (risk reduction, 10% [CI, 5% to 15%]). However, subgroup analysis showed that these beneficial effects occurred only in patients with severe exacerbations, not in those with milder exacerbations. CONCLUSIONS: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.

Hospital Mortality↗
PubMed2003

Length of ICU stay for chronic obstructive pulmonary disease varies among large community hospitals.

OBJECTIVE: To determine whether differences exist among large community hospitals in length of Intensive Care Unit (ICU) stay, hospital stay or hospital mortality for patients admitted to ICU and whose most responsible diagnosis was chronic obstructive pulmonary disease (COPD). DESIGN: Retrospective cohort study. SETTING: All seven large community hospitals in British Columbia, Canada. PATIENTS. All 296 patients who were admitted to ICUs and whose most responsible diagnosis was COPD during the 3 fiscal years 1994-1997. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After adjusting for age, gender, case-mix group, and co-morbidity, we found a significant difference in length of ICU stay for these patients among hospitals ( P <0.03). No differences were found in hospital mortality or length of hospital stay for the same patients among the same hospitals. CONCLUSIONS: There is significant variation in length of ICU stay for patients who are admitted to ICU and whose most responsible diagnosis is COPD, among large community hospitals. These small area variations may point to opportunities to improve efficiency of care. Further prospective, detailed data collection is required to validate these observations and to identify factors responsible for any differences found.

Aged↗
PubMed2003

Interhospital variability in satisfaction with withdrawal of life support: room for improvement?

OBJECTIVE: To develop instruments to measure the current level of satisfaction with the withdrawal of life support among nurses and respiratory therapists and to use these instruments to determine whether differences in satisfaction levels with the withdrawal of life support could be found among different institutions. DESIGN: A multicenter, self-administered, questionnaire-based study. SETTING: The intensive care units of three academic and 11 community hospitals. SUBJECTS: A total of 412 critical care nurses and 117 respiratory therapists working in these intensive care units. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After developing two similar questionnaires for critical care nurses and respiratory therapists, we assessed the reliability of the individual items for each questionnaire and only used those found to be reliable in the analyses. We found variability in the satisfaction level of critical care nurses among different intensive care units and among academic and community hospital intensive care units. Being involved in the plan for withdrawal of life support, comfort with the way discussions with the family had gone, comfort with patient sedation, and increasing experience with withdrawal of life support were items associated with increased nurse satisfaction. For respiratory therapists, there seemed to be similar differences among institutions in satisfaction level, although numbers were limited. Having the physician explain the plan to them and becoming more comfortable with withdrawal of life support as a result of increased experience were found to be associated with increased satisfaction levels for respiratory therapists. CONCLUSIONS: Satisfaction levels of intensive care unit nurses and respiratory therapists with the process of withdrawing life support vary among institutions. This variation may represent an opportunity for improvement in the process of withdrawing life support within this region.

Euthanasia, Passive↗
PubMed2002

Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial.

CONTEXT: Noninvasive positive-pressure ventilation (NPPV) has been demonstrated to be effective in preventing the need for endotracheal intubation in some patients who present with acute respiratory failure. It is also used for patients who develop acute respiratory distress after extubation, but there are no randomized controlled trials that address its effectiveness in this population. OBJECTIVE: To determine the effectiveness of NPPV compared with standard medical therapy in preventing the need for endotracheal reintubation in high-risk patients who develop respiratory distress during the first 48 hours after extubation. DESIGN: Randomized, controlled, unblinded study with concealed allocation conducted between August 1, 1996 and October 31, 1999. SETTING: An intensive care unit (ICU) in an academic, tertiary care hospital in Ontario. PATIENTS: Eighty-one patients with a history of cardiac or respiratory disease or who initially required ventilatory support for more than 2 days and who developed respiratory distress within 48 hours of extubation. INTERVENTIONS: Patients were randomly assigned to receive standard medical therapy alone (supplemental oxygen to maintain oxygen saturation by pulse oximetry > or = 95%; n = 42) or NPPV by face mask plus standard medical therapy (n = 39). MAIN OUTCOME MEASURES: Rates of reintubation, duration of mechanical ventilation, lengths of ICU and hospital stay, and hospital mortality. RESULTS: Comparing the NPPV group with the standard-therapy group, there was no difference in the rate of reintubation (72% vs 69%; relative risk, 1.04; 95% confidence interval, 0.78-1.38) or hospital mortality (31% for both groups; relative risk, 0.99; 95% confidence interval, 0.52-1.91). Similarly, no difference was found in duration of mechanical ventilation or length of ICU or hospital stay. CONCLUSIONS: The addition of NPPV to standard medical therapy does not improve outcome in heterogeneous groups of patients who develop respiratory distress during the first 48 hours after extubation.

APACHE↗
PubMed2002

Ventilator-associated pneumonia. Prevention, diagnosis, and therapy.

Ventilator-associated pneumonia remains the nosocomial ICU infection of greatest concern. The authors have summarized the clinical trials that have assessed specific strategies to prevent VAP and the current controversies regarding the diagnosis and therapeutic approach to this condition. Improvements in care of patients who are at risk for or who have developed VAP will depend on the judicious application of this information for individual patients.

Humans↗
PubMed2002

Attitudes regarding organ donation from non-heart-beating donors.

PURPOSE: To determine the attitudes toward organ donation from non-heart-beating cadaver donors in a sample of the general public and health care workers. MATERIALS AND METHODS: A moderator-administered questionnaire was completed by members of the general public, recruited randomly from a professional consumer research group's database, and health care workers recruited from the same database, family practice clinics, and local hospitals. Two primary scenarios were tested: (1) patient in coma, not going to survive intensive care unit (ICU), and (2) patient lapsing in and out of consciousness, lifetime institutional care. RESULTS: Sixty members of the general public and 68 health care workers completed the questionnaire. The majority of both groups were aware life support could be withdrawn in Scenario 1, however, significantly fewer were aware life support could also be withdrawn in Scenario 2 (83% general public vs 34% general public, P <.001 and 94% health care workers vs 78% health care workers, P =.012). Uncertainty in prognosis was cited as the primary concern. The issue of organ donation was directly linked with withdrawal of life support. The majority of both groups believed that organ donation would be permissible if further life support were deemed to be not in the patient's best interest because of poor short-term prognosis (94% health care workers and 98% general public for Scenario 1 and 87% health care workers and 81% general public for Scenario 2). The greatest difficulty arose in defining futility of care. Expected quality of life, patient's and family's values, opinions, and religious beliefs were felt to be most important in determining decisions regarding futility and withdrawal of life support. Physician beliefs and values were felt to influence decisions more than they should. CONCLUSIONS: Both the general public and health care workers support the use of non-heart-beating cadaver donors once a decision has been made to withdraw life support. However, both groups raised concerns regarding how the decision to withdraw life support is made.

Attitude of Health Personnel↗
PubMed2002

Use of ultrasound to place central lines.

CONTEXT: Placement of central venous catheters (CVCs) is an integral part of care for the critically ill patient but is associated with significant morbidity when using the traditional landmark method. The use of real-time ultrasound to guide line placement has been developed in hopes of avoiding this morbidity. OBJECTIVE: The objectives of this article are 2-fold. The first is to determine the relative effectiveness of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to discuss the merits of future study to increase the use of this technology. DATA SOURCES: Medline from 1966 to 2001, personal files, 2 prior systematic reviews, and reference lists of selected articles. STUDY SELECTION: Studies were included if: (1) study design was a controlled trial, (2) patients required placement of a CVC, (3) the interventions were real-time ultrasound versus standard landmark-guided line placement, and (4) outcomes included at least 1 of failure to place catheter, success of first attempt, number of attempts, time to catheter placement, or complication rate. DATA SYNTHESIS: Eighteen trials were identified. Pooled results showed a significant reduction in failure rate (risk difference, -.12, 95% confidence interval [CI], -.18 to -.06), number of attempts (risk reduction, 1.41, 95% CI, 1.15-1.67), and arterial puncture rate (risk difference, -.07, 95% CI, -.10 to -.03). The number of successful venous cannulations on first attempt were higher using ultrasound (risk difference,.24, 95% CI,.08-.39). No difference was found in time to insertion. Significant heterogeneity of study results was found for most analyses. Subgroup analyses suggested that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. CONCLUSIONS: Adoption of real-time ultrasound to guide CVC placement has the potential to improve successful line placement and minimized complications. It can improve patient safety. However, there are significant cost concerns and the reported adverse events are generally minor and easy to treat. Before creating study protocols to increase usage of this technology, both current usage and cost effectiveness should be determined.

Catheterization, Central Venous↗
PubMed2002

Intensive care unit admission has minimal impact on long-term mortality.

OBJECTIVE: To measure the association between intensive care unit (ICU) admission and both hospital and long-term mortality, separate from the effect of hospital admission alone. DESIGN: Retrospective cohort study. SETTING: All hospitals in British Columbia, Canada, during 3 fiscal years, 1994 to 1996. PATIENTS: A total of 27,103 patients admitted to ICU and 41,308 (5% random sample) patients admitted to hospital but not to ICU. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Although ICU admission was an important factor associated with hospital mortality (odds ratio: 9.12; 95% confidence interval: 8.34-9.96), the association between ICU admission and mortality after discharge was relatively minimal (hazard ratio: 1.21; 95% confidence interval: 1.17-1.27) and was completely overshadowed by the effect of age, gender, and diagnosis. CONCLUSIONS: After controlling for the effect of hospital admission, admission to ICU has minimal independent effect on mortality after discharge.

Adult↗
PubMedDate not supplied

Treatment of idiopathic clubfoot utilizing botulinum A toxin: a new method and its short-term outcomes.

A pivotal point in most clubfoot management protocols is Achilles tendon lengthening or tenotomy to address hindfoot deformity. The effectiveness of botulinum A toxin (BTX-A) in attenuating the function of the triceps surae muscle complex as an alternative to tenotomy was investigated. Fifty-one patients with 73 idiopathic clubfeet were recruited. Outcome measures included surgical rate, Pirani clubfoot score, ankle dorsiflexion with knee in flexion and extension, and recurrences. Patients were divided according to age: group 1 (<30 days old) and group 2 (>30 days and <8 months old). Ankle dorsiflexion in knee flexion and extension remained above 20 degrees and 15 degrees, respectively, and Pirani scores below 0.5 following BTX-A injection for both groups. One of the 51 patients required limited posterior release and 9 patients required repeat manipulation and casting plus or minus BTX-A injection. The use of BTX-A as an adjunctive therapy in the noninvasive approach of manipulation and casting in idiopathic clubfoot is a safe and effective treatment.

Botulinum Toxins, Type A↗