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Todd Dorman

Publications and source records attributed to Todd Dorman.

At least 37 records · Page 2Linked to original sources
PubMed2004

A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS).

OBJECTIVE: To evaluate the contributing and limiting factors for airway events reported in the Intensive Care Unit Safety Reporting System (ICUSRS) developed in partnership with the Society of Critical Care Medicine. DESIGN: Analysis of system factors in airway vs. nonairway events reported to a voluntary, anonymous, Web-based patient safety reporting system (the ICUSRS). SETTING: Sixteen adult and two pediatric intensive care units (ICU) across the United States. PATIENTS: Incidents reported during the 12-month period ending June 30, 2003. INTERVENTIONS: None MEASUREMENTS: Descriptive characteristics of incidents (defined as events that could have, or did, cause harm), patients, and patient harm; separate multivariable logistic regression analyses of contributing and limiting factors for airway vs. nonairway events. MAIN RESULTS: There were 78 airway and 763 nonairway events reported. More than half of airway events were considered preventable. One patient death was attributed to an airway event. Physical injury, increased hospital length of stay, and family dissatisfaction occurred in at least 20% of airway events. Important factors contributing to reported airway events (odds ratio (OR), 95% confidence interval (CI)) included patients' medical condition (5.24, 3.07-8.95) and age <1 yr old (4.15, 1.79-9.59). Factors limiting the impact of airway events (OR, 95% CI) included adequate ICU staffing (3.60, 1.71-7.56) and use of skilled assistants (3.20, 1.62-6.32). CONCLUSIONS: Patients are harmed by unintended and preventable incidents involving airway management. Prevention efforts should focus on critically ill infants and patients with complex medical conditions. Managers should ensure appropriate ICU staffing to limit the impact of airway events when they occur.

Adolescent↗
PubMed2003

Developing and pilot testing quality indicators in the intensive care unit.

PURPOSE: To develop and implement a set of valid and reliable yet practical measures of intensive care units (ICU) quality of care in a cohort of ICUs and to estimate, based on current performance, the potential opportunity to improve quality. METHODS: We included 13 adult medical and surgical ICUs in urban community teaching and community hospitals. To monitor performance on previously identified quality measures, we developed 3 data collection tools: the Team Leader, Daily Rounding, and Infection Control forms. These tools were pilot tested, validated, and modified before implementation. We used published estimates of efficacy to estimate the clinical and economic effect of our current performance for each of the process measures: appropriate sedation, prevention of ventilator-associated pneumonia, appropriate peptic ulcer disease (PUD) prophylaxis, appropriate deep venous thrombosis (DVT) prophylaxis, and appropriate use of blood transfusions. RESULTS: Performance varied widely among the 13 ICUs and within ICUs. The median percentage of days in which ventilated patients received therapies that ought to was 64% for appropriate sedation, 67% for elevating head of bed, 89% for PUD prophylaxis, and 87% for DVT prophylaxis. The median rate of appropriate transfusion was 33%. The failure to use these therapies may lead to excess morbidity, mortality, and ICU length of stay. CONCLUSION: To improve quality of care, we must measure our performance. This pilot study suggests that it is feasible to implement a broad set of ICU quality measures in a cohort of hospitals. By improving performance on these measures, we may realize reduced mortality, morbidity, and ICU length of stay.

Cohort Studies↗
PubMed2003

Medication reconciliation: a practical tool to reduce the risk of medication errors.

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

Continuity of Patient Care↗
PubMed2003

Improving communication in the ICU using daily goals.

BACKGROUND: Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures. PURPOSE: The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals form. DESIGN: We conducted a prospective cohort study in collaboration with the Volunteer Hospital Association (VHA), Institute for Healthcare Improvement (IHI), and Johns Hopkins Hospital's (JHH) 16-bed surgical oncology ICU. All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percent of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared with measurements of understanding after implementation of a daily goals form. RESULTS: At baseline, less than 10% of residents and nurses understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU LOS decreased from a mean of 2.2 days to 1.1 days. CONCLUSION: Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS. The use of the daily goals form has broad applicability in acute care medicine.

Cohort Studies↗
PubMed2003

Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000.

OBJECTIVE: The epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients. DESIGN: Observational study using a state discharge database. SETTING: All hospitals in Maryland. PATIENTS: We obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18-29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0-5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5-8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8-10), and increased total hospital charges (estimated mean increase of 22,000 US dollars; 95% confidence interval, 19,000 US dollars-25,000 US dollars). CONCLUSIONS: Aspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.

Adolescent↗
PubMed2003

Sensitivity of routine intensive care unit surveillance for detecting myocardial ischemia.

OBJECTIVE: To assess the effectiveness of routine intensive care unit surveillance compared with frequent 12-lead electrocardiogram monitoring for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia in vascular surgery patients. DESIGN: Prospective cohort trial. SETTING: Intensive care unit. PARTICIPANTS: We studied 149 patients undergoing elective infrainguinal or aortic vascular surgery who were admitted to the intensive care unit postoperatively. INTERVENTIONS: Patients were simultaneously monitored with a 10-electrode/12-lead electrocardiogram obtained every 2 mins (criterion standard) and routine intensive care unit surveillance that included standard monitoring (five-electrode/two-lead electrocardiogram with ST segment trends and routine 12-lead electrocardiogram) and clinical assessment for detecting myocardial ischemia. The results of the criterion standard were not available to the caregivers. MEASUREMENTS AND MAIN RESULTS: We measured the ability of routine intensive care unit surveillance to detect the first 20 mins of electrocardiogram evidence suggestive of myocardial ischemia, defined as ST segment depression or elevation of >/=1 mm in two consecutive leads, during the first postoperative day. Seventeen patients (11%) had electrocardiogram evidence suggestive of prolonged myocardial ischemia, the majority of which occurred in leads V2-V4. The sensitivity of routine intensive care unit surveillance for detecting the first episode of electrocardiogram evidence suggestive of prolonged myocardial ischemia in a patient was 12% (95% confidence interval, 7-17%), and the specificity was 98% (95% confidence interval, 95-100%) with a positive predictive value of 40% (95% confidence interval, 32-48%), a negative predictive value of 90% (95% confidence interval, 85-94%), a positive likelihood ratio of 6, and a negative likelihood ratio of 1. The sensitivity of routine intensive care unit surveillance for detecting all episodes was 3% (95% confidence interval, 2-3%) and the specificity 99% (95% confidence interval, 99-100%) per 20-min monitoring interval, with a positive predictive value of 17% (95% confidence interval, 16-18%), negative predictive value of 95% (95% confidence interval, 95-96%), positive likelihood ratio of 3, and negative likelihood ratio of 1. CONCLUSIONS: Routine intensive care unit surveillance has low sensitivity for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia compared with frequent 12-lead electrocardiograms. Because detecting electrocardiogram evidence suggestive of prolonged postoperative myocardial ischemia is important, physicians should consider alternative strategies to detect myocardial ischemia.

Aged↗
PubMed2003

Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies--American College of Critical Care Medicine Task Force 2001-2002.

OBJECTIVE: To develop clinical practice guidelines for the use of restraining therapies to maintain physical and psychological safety of adult and pediatric patients in the intensive care unit. PARTICIPANTS: A multidisciplinary, multispecialty task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM), the Society of Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses (AACN). EVIDENCE: The task force members reviewed the published literature (MEDLINE articles, textbooks, etc.) and provided expert opinion from which consensus was derived. Relevant published articles were reviewed individually for validity using the Cochrane methodology (http://hiru.mcmaster.ca/cochrane/ or www.cochrane.org). CONSENSUS PROCESS: The task force met as a group and by teleconference to identify the pertinent literature and derive consensus recommendations. Consideration was given to both the weight of scientific information within the literature and expert opinion. Draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft then was reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. CONCLUSIONS: The task force developed nine recommendations with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the intensive care unit.

Adult↗
PubMed2002

Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.

CONTEXT: Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear. OBJECTIVE: To evaluate the association between ICU physician staffing and patient outcomes. DATA SOURCES: We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001). STUDY SELECTION: We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU. DATA SYNTHESIS: We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment. CONCLUSIONS: High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.

Adult↗
PubMed2002

Cardiac troponin I predicts short-term mortality in vascular surgery patients.

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts outcomes in patients with acute coronary syndromes. Cardiovascular complications are the leading cause of morbidity and mortality in patients who have undergone vascular surgery. However, postoperative surveillance with cardiac enzymes is not routinely performed in these patients. We evaluated the association between postoperative cTnI levels and 6-month mortality and perioperative myocardial infarction (MI) after vascular surgery. METHODS AND RESULTS: Two hundred twenty-nine patients having aortic or infrainguinal vascular surgery or lower extremity amputation were included in this study. Blood samples were analyzed for cTnI immediately after surgery and the mornings of postoperative days 1, 2, and 3. An elevated cTnI was defined as serum concentrations >1.5 ng/mL in any of the 4 samples. Twenty-eight patients (12%) had postoperative cTnI >1.5 ng/mL, which was associated with a 6-fold increased risk of 6-month mortality (adjusted OR, 5.9; 95% CI, 1.6 to 22.4) and a 27-fold increased risk of MI (OR, 27.1; 95% CI, 5.2 to 142.7). Furthermore, we observed a dose-response relation between cTnI concentration and mortality. Patients with cTnI >3.0 ng/mL had a significantly greater risk of death compared with patients with levels < or =0.35 ng/mL (OR, 4.9; 95% CI, 1.3 to 19.0). CONCLUSIONS: Routine postoperative surveillance for cTnI is useful for identifying patients who have undergone vascular surgery who have an increased risk for short-term mortality and perioperative MI. Further research is needed to determine whether intervention in these patients can improve outcome.

Aged↗
PubMed2002

Reducing failed extubations in the intensive care unit.

BACKGROUND: Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital. METHODS: Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline. RESULTS: Significant factors associated with failed extubation included suctioning more frequently than every 4 hours versus the current model of "every 4 hours or greater" (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5-88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2-14.7), and oxygen saturation < or = 95% versus > or = 95% (OR 4.0; CI: 1.2-13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000). DISCUSSION: The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.

Academic Medical Centers↗
PubMed2002

Predictors of transfusion for spinal surgery in Maryland, 1997 to 2000.

BACKGROUND: The purpose of this study was to identify preoperative patient, hospital, and surgeon characteristics associated with transfusion for spinal surgery. STUDY DESIGN AND METHODS: Discharge data were obtained from 39 Maryland hospitals for adult patients (n = 3988) who had a primary procedure code for spinal surgery between July 1997 through June 2000, and with these codes, surgeons and hospitals were characterized by annual patient volume. Outcome variables included any allogeneic transfusion, any transfusion, RBCs, autologous blood, FFP, or platelet transfusion. Logistic regression was used for univariate and multivariate analyses. RESULTS: Characteristics independently associated with an increased risk of receiving any allogeneic transfusion (n = 786) included age >54 (OR, 1.6; 95% CI, 1.3-2.1), age >66 (OR, 2.7; 95% CI, 2.0-3.5), female sex (OR, 1.6; 95% CI, 1.2-2.0), diabetes with chronic complications (OR, 2.5; 95% CI, 1.3-4.9), and metastatic tumor (OR, 4.9; 95% CI, 2.3-10.5), emergency room admission (OR, 2.3; 95% CI, 1.4-3.8), and greater hospital volume (OR, 4.0; 95% CI, 1.8-8.6). Characteristics independently associated with increased autologous transfusions (n = 574) included white race (OR, 1.7; 95% CI, 1.2-2.4), female sex (OR, 1.4; 95% CI, 1.1-1.8), and greater surgeon volume (OR, 3.5; 95% CI, 1.4-9.1). DISCUSSION: This information can be used to provide informed risk-benefit discussions with patients regarding the risk for blood transfusion as well as to target high-risk patients and institutions for interventions to reduce the risk of exposure to blood components.

Adult↗
PubMed2002

Qualitative review of intensive care unit quality indicators.

PURPOSE: The purpose of this study was to (1) conduct a systematic review of the literature to identify interventions that improve patient outcomes in the intensive care unit (ICU); (2) evaluate potential measures of quality based on the impact, feasibility, variability, and the strength of evidence to support each measure and to categorize these measures as outcome, process, access, or complication measures; and (3) select a list of candidate quality measures that can be broadly applied to improve ICU care. METHODS: We identified and independently reviewed all studies in Medline (1965-2000) and The Cochrane Library (Issue 3, 2001) that met the following criteria: design: observational studies, experimental trials, or systematic reviews; population: critically ill adults; and intervention: process or structure measure that was associated with improved patient outcomes: morbidity, mortality, complications, errors, costs, length of stay (LOS), and patient reported outcomes. Studies were grouped into categories by the type of outcome that was improved by the intervention. Potential quality measures were evaluated for: impact on morbidity, mortality, and costs; feasibility of the measure; and variability in the measure. We evaluated the strength of evidence for each intervention used to improve outcomes and using the Delphi method, assigned an over-all recommendation for each quality measure. RESULTS: A total of 3,014 citations were identified. Sixty-six studies that met selection criteria reported on a variety of interventions that were associated with improved patient outcomes. We identified 6 outcome measures: ICU mortality rate, ICU LOS greater than 7 days, average ICU LOS, average days on mechanical ventilation, suboptimal management of pain, and patient/family satisfaction; 6 process measures: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator-associated pneumonia, appropriate sedation, appropriate peptic ulcer disease prophylaxis, and appropriate deep venous thrombosis prophylaxis; 4 access measures: rate of delayed admissions, rate of delayed discharges, cancelled surgical cases, and emergency department by-pass hours; and 3 complication measures: rate of unplanned ICU readmission, rate of catheter-related blood stream infections, and rate of resistant infections. CONCLUSIONS: Further work is needed to create operational definitions and to pilot test the selected measures. The value of these measures will be determined by our ability to evaluate our current performance and implement interventions designed to improve the quality of ICU care.

Adrenergic beta-Antagonists↗
PubMed2002

Building safety into ICU care.

The Institute of Medicine's (IOMs) report, "To Err is Human," recently addressed patient safety in the United States, alerting the nation to the need for improved systems of health care. Seven main findings were addressed in this report, we focus on 3: (1) patient safety is a nationwide problem, (2) health care workers are not to blame, and (3) safety and harm are products of care systems. This article discusses systems in intensive care units (ICUs) and how these systems affect patient safety. We use a case example to outline the complex chain of medical and administrative system failures that can result in an adverse event. Then we discuss evidence linking ICU organizational characteristics with patient safety, focusing on how safer systems in ICUs can directly improve patient care.

Aged↗
PubMed2002

Phase I collaborative pilot study: Waste anesthetic gas levels in the PACU.

The National Institute of Occupational Safety and Health (NIOSH) recommends that exposure to waste anesthetic gas (WAG) be minimized to the greatest extent possible. Current recommendations include 2 parts per million (ppm) for 1 hour sample to halogenated agents level or 25 ppm based on nitrous oxide level or combination of 0.5 ppm for halogenated agents and 25 ppm nitrous oxide. The Occupational Safety Health Administration requires that work practices and engineering controls be implemented so that occupational exposure to WAG is controlled. This pilot study was conducted to (1) evaluate the level of WAG in the PACU, (2) analyze the relationship between nurse exposure and self-reported symptoms, and (3) test methods used to describe occupational exposure of PACU staff to WAG. Air sampling to measure levels of WAG in the patient and PACU nurse environment was performed with MIRAN SapphRE (Foxboro Company, Foxboro, MA), a nondispersive infrared spectrophotometer. A personal sampling method was used to measure the level of nurse exposure to WAG on 2 separate days. Self-report of 9 health symptoms using a 10-cm visual analogue scale was obtained before and after the shift from 6 (PACU) nurses. Three nurses from the Medical Intensive Care Unit (MICU) served as a control. Descriptive statistics summarized exhaled gas level and staff exposure. The highest concentrations of nitrous oxide were 283 to 295 ppm in the patient's breathing zone, whereas halogenated agents were below the limit of detection. Staff exposure to nitrous oxide ranged from 2.9 to 8.2 ppm, averaged over the work shift. T test of the pre- and postshift symptoms showed no significant difference in both PACU and MICU nurses. This pilot study identified the potential for staff exposure to WAG in the PACU setting. The methods to detect this exposure were also evaluated. It is recommended that further study be conducted to evaluate PACU staff exposure to WAG. Modifications in some of the measurement methods tested here are also suggested, including the use of procedures to measure the efficacy of air exchange and other engineering controls related to staff exposure.

Air Pollutants, Occupational↗
PubMed2002

Phase II collaborative pilot study: preliminary analysis of central neural effects from exposure to volatile anesthetics in the PACU.

Nurses working in the PACU are occupationally exposed to volatile anesthetics that are exhaled by patients. Few studies have quantified this exposure using breath analysis or have characterized biological effects associated with this exposure. Isoflurane is a widely used anesthetic and is a strong respiratory depressant. Exposure to isoflurane has been shown to cause changes in breathing patterns at low doses. However, biological effects of isoflurane exposure have never been addressed in the occupational setting. This study investigates whether occupational exposure to anesthetic gases has a depressive effect on central neural control of breathing. In this study, concentrations of halogenated anesthetics were quantified in pre- and postshift breath samples of nurses working in the PACU on a Friday and the following Monday. After each breath sample was collected, an occlusion pressure measurement was taken as an indicator of central inspiratory drive. Cumulative nitrous oxide and halogenated anesthetics exposure was measured each day using personal sampling monitors placed close to the nurse's mouth. Exposure to nitrous oxide and isoflurane was significantly higher on Monday than on Friday (P <.001). Monday breath isoflurane concentrations (mean +/- SD) increased significantly from 43 +/- 30 parts per billion (ppb) in preshift breath samples to 124 +/- 57 ppb in postshift breath samples (P <.002). On Monday, there was a significant decrease in occlusion pressure from 1.2 +/- 0.37 cm H(2)O in preshift samples to 0.85 +/- 0.43 cm H(2)O in postshift samples (P =.05). There was no statistical difference in pre- versus postbreath isoflurane or occlusion pressure on Friday. These data indicate that after increased exposure to isoflurane, central neurorespiratory activity was depressed.

Anesthetics, Inhalation↗
PubMed2002

Intensive care unit errors: detection and reporting to improve outcomes.

Most efforts to identify and investigate errors in medicine have focused on active failures and general provider behaviors. We believe that the greatest improvements in error identification and management in the intensive care unit will be achieved by focusing on the intensive care unit's organizational characteristics. The results of three recent studies suggest that differences in intensive care unit organizational characteristics are significantly related to variation in the risk-adjusted morbidity and mortality. Physicians must assume greater leadership in creation of these safe systems for intensive care patients. We encourage the creation of multi-institutional communities to work collaboratively to advance patient safety in high-risk environments like the intensive care unit.

Journal Article↗
PubMed2000

Remote access to critical care.

As we all begin to focus more on errors in medicine, telemedicine applications will expand. Remote access to experts will be required. Although telemedicine has always existed as a component of medicine, it was usually designed for niche areas. Telemedicine consists of information sharing between at least two physically and geographically disparate sites for educational or health purposes. Although telemedicine in the intensive care unit may at first seem absurd to many clinicians, most care providers have, in fact, used some form of telemedicine to provide care for decades. All of us have managed patients by telephone communication with nurses, residents, or other physicians. Besides augmenting routine care in the intensive care unit, telemedicine is providing essential tools that improve the efficiency of health care communication and add safety for the health care provider by making health care available under less than ideal circumstances, such as a terrorist attack with biologic weapons. The future appears quite bright for telemedicine systems, but much work is still required. How payers, lawyers, and ethicists view telemedicine is not yet completely understood. As intensivists, we should expect our practice to be directly impacted by this maturing technology. We should wholeheartedly embrace it and help lead its use in this new millennium.

Journal Article↗