Intensive care medicine.
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Critical Care↗
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Intensive caring in intensive care.
A bereavement follow-up program has been instituted through the efforts of a group of interested nurses. A self-help booklet, along with a sympathy note, is sent to those who have lost a loved one. A response form provides for answering of questions and requests for further assistance. A one-year anniversary note reminds them that their loved one is not forgotten.
Critical Care↗
[Contributions of ethics to the practice of intensive care].
Intensive care, one of the greatest achievements of modern medicine, is not without its problems. In what sense could ethics contribute towards an intensive care medicine which would be humane and respectful of what it means to be sick? After having presented a phenomenology of what it means to be sick and in intensive care, the author proposes an ethical framework which could guide the decision-making of physicians specialized in the field. This framework has three levels. Level one deals with the basic values of benevolence and autonomy which are those of medicine itself. Level two deals with the implementation of these values, which bioethics sees as conflicting. Implementation is achieved by "conversation" between the physician and the patient. Finally, the physician is invited to question his or her own attitude towards the unavoidable dilemmas created by the paradoxes and contradictions of modern medicine.
Attitude of Health Personnel↗
Computer assisted data analysis in intensive care: the ICDEV project--development of a scientific database system for intensive care (Intensive Care Data Evaluation Project).
INTRODUCTION: Patient Data Management Systems (PDMS) for ICUs collect, present and store clinical data. Various intentions make analysis of those digitally stored data desirable, such as quality control or scientific purposes. The aim of the Intensive Care Data Evaluation project (ICDEV), was to provide a database tool for the analysis of data recorded at various ICUs at the University Clinics of Vienna. SETTINGS: General Hospital of Vienna, with two different PDMSs used: CareVue 9000 (Hewlett Packard, Andover, USA) at two ICUs (one medical ICU and one neonatal ICU) and PICIS Chart+ (PICIS, Paris, France) at one Cardiothoracic ICU. CONCEPT AND METHODS: Clinically oriented analysis of the data collected in a PDMS at an ICU was the beginning of the development. After defining the database structure we established a client-server based database system under Microsoft Windows NI and developed a user friendly data quering application using Microsoft Visual C++ and Visual Basic; RESULTS: ICDEV was successfully installed at three different ICUs, adjustment to the different PDMS configurations were done within a few days. The database structure developed by us enables a powerful query concept representing an 'EXPERT QUESTION COMPILER' which may help to answer almost any clinical questions. Several program modules facilitate queries at the patient, group and unit level. Results from ICDEV-queries are automatically transferred to Microsoft Excel for display (in form of configurable tables and graphs) and further processing. CONCLUSIONS: The ICDEV concept is configurable for adjustment to different intensive care information systems and can be used to support computerized quality control. However, as long as there exists no sufficient artifact recognition or data validation software for automatically recorded patient data, the reliability of these data and their usage for computer assisted quality control remain unclear and should be further studied.
Austria↗
Descriptive patient data as an explanation for the variation in average daily costs in intensive care.
Intensive care patients require therapy that can vary considerably in type, duration and cost, so making it extremely difficult to predict patient resource use. Few studies measure actual costs; usually average daily costs are calculated and these do not reflect the variation in resource use between individual patients. The aim of this study was to analyse a data set of 193 critically ill adult patients to look for associations between routinely collected descriptive data and patient-specific costs. Regression analysis was used to explore any relationships between average daily patient-specific costs and the following variables: duration of intensive care unit stay, Acute Physiology and Chronic Health Evaluation II scores in the first 24 h, gender, age, mechanical ventilation at any point during the stay, postoperative status, emergency admission and mortality. Overall, this analysis explained 33.6% of the variation in average daily costs. The additional costs of an extra day of care, mechanical ventilation, an extra point on the Acute Physiology and Chronic Health Evaluation II score, and survival were obtained.
APACHE↗
The development of a method for comparative costing of individual intensive care units. The Intensive Care Working Group on Costing.
Intensive care is one of the most costly areas of hospital care. Unfortunately, because of the diversity of case mix, costing intensive care is difficult. Many described costing methods previously are limited by being cumbersome, laborious to apply and expensive. The aim of this study was to develop a method for costing intensive care which can be applied with ease but facilitate meaningful cost comparisons between intensive care units. The method developed was based on cost blocks where the major components were identified and costed in a 'top-down' manner. Using strict definitions, the cost blocks attempted to measure the costs of equipment, estates, nonclinical support services (such as hospital management costs), clinical support services (such as physiotherapy, laboratory services), consumables (such as drugs, fluids and disposables) and staff. The study found that clinical support services, consumables and staff costs accounted for approximately 85% of the total costs.
Cost Allocation↗
[Computerized prescription service for pediatric intensive care].
Intensive care medicine relies on the fast and flawless organization of data. In addition, control of therapy requires many calculations. The computer program presented here improves and facilitates documentation of medical prescriptions on the ICU. The program can be run on affordable personal computers. Fluid balances can be managed easily while the program calculates the intake of calories, carbohydrates, protein, fat and electrolytes in the background. On entry of medications suggestions for the pediatric dosage are given automatically. Use of this program provides a flexible way of reusing and editing prescriptions, thus adding up to a time-gaining and precise way of writing intensive care prescriptions.
Child↗
Point-of-care testing in the intensive care unit. The intensive care physician's perspective.
Technological advancements have, for the first time, made the entire laboratory testing process feasible at the bedside. Physicians working in the intensive care unit have always had immediate access to patients' medical history, physical examination, and physiologic monitoring data, but had to wait for laboratory results. Using point-of-care testing, laboratory parameters targeted to critical illnesses can now be integrated into initial diagnostic assessments, on patient rounds, and during therapeutic maneuvers. The concept of point-of-care testing in the intensive care unit is relatively new, but as technology progresses, physicians will undoubtedly become aware and use it in the intensive care unit. This article focuses on the intensive care physician's perspective on laboratory testing, the evolution of the intensive care unit laboratory, advantages of point-of-care testing in that setting, new developments in arterial blood gas analyzers and monitors, and cost-effectiveness and incorporation of point-of-care testing.
Attitude of Health Personnel↗
Patterns of resource consumption in medical intensive care.
Intensive care is being scrutinized as a major factor in increasing health care costs. We examined 404 consecutive admissions to the medical ICUs at a university medical center to study patterns of consumption of ICU resources and the proportion of resources used by patients admitted for monitoring only. We found a skewed distribution of ICU resource consumption, with the "high-cost" 8 percent using as many ICU resources as the "low-cost" 92 percent. Forty-one percent of admissions did not receive acute ICU treatments, but these admissions consumed less than 10 percent of ICU resources. Reducing the number of patients admitted for monitoring will have a relatively small impact on hospital charges. Since over 70 percent of the high-cost patients died, improved understanding of prognosis and better physician-patient communication may substantially reduce the proportion of critical care resources expended on futile treatment.
Academic Medical Centers↗
Comparison of perceived needs of family members between registered nurses and family members of critically ill patients in intensive care and neonatal intensive care units.
Using the Norris and Grove (1986) questionnaire of perceived needs of families of critically ill patients, 11 registered nurses working in the neonatal intensive care unit and 19 registered nurses working in the intensive care unit of two mid-northern community hospitals provided their perceptions of family needs. Their responses were compared with responses of family members of patients in the intensive care unit (n = 25) and the (n = 24). Results suggest that regardless of unit, registered nurses' perceptions of family needs are congruent. Family members collectively and by unit ranked their needs consistently higher and in some areas differently than did the registered nurses.
Adult↗
Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries.
Accidental extubation is a potentially serious event for pediatric or neonatal patients with respiratory failure, especially in clinical settings in which personnel capable of performing reintubation may not be readily available. Thus the rate of accidental extubation in small intensive care units that operate without 24-hour in-house physician availability may be an important quality assurance indicator. The objective of this study were to determine the accidental extubation rate at a single small pediatric intensive care unit (PICU) and compare it with published reports. This study was carried out in a six-bed PICU at Washoe Medical Center in Reno, Nevada, with a relatively low level of patient acuity, as measured by PRISM score and the frequency of intubation, and without 24-hour in-house physician availability. All intubated patients admitted during the 5-year period from January 1, 1989 to December 31, 1993 were included. The primary outcome measure was the occurrence of accidental extubation. We observed only two accidental extubations in 1,749 intubated-patient-days (IPD) (0.114 accidental extubations/100 IPD [95% confidence interval 0.014-0.413 accidental extubations/ 100 IPD]). This rate of accidental extubation was compared with data in published reports from neonatal intensive care units (NICUs) and PICUs, which ranged from 0.14 accidental extubations/100 IPD to 4.36 accidental extubations/100 IPD. The dependence of the observed accidental extubation rate on unit size and institutional experience with intubated patients, as measured by the average number of intubated patients, was examined. We found no evidence that the accidental extubation rate is higher in smaller units or units with less institutional experience. Low rates can be achieved in small units with low acuity.
Adolescent↗
Improving palliative care in intensive care units: identifying strategies and interventions that work.
The disciplines of critical care and palliative care may initially seem to be polar opposites, yet they share fundamental features. Both focus on the sickest patients in the healthcare system. Each discipline's primary goal-extending life for critical care and comfort and quality of life for palliative care-represents an important secondary goal for the other. A tremendous body of work in the last decade has laid the foundation for improving palliative care in intensive care units of the future. Pioneering projects have demonstrated the feasibility and acceptance of integrating palliative aspects of care within critical care settings and practice. This article introduces this special supplement of Critical Care Medicine, which describes the developments that have occurred moving us toward integration of palliative and critical care, and lays the foundation for the articles published in this supplement.
Critical Care↗
Expanding intensive care medicine beyond the intensive care unit.
Intensive care medicine probably requires the artificial boundaries of an intensive care unit to nurture and legitimize the specialty. The next major step in intensive care medicine is to explore ways of optimizing the outcome of seriously ill patients by recognizing and resuscitating them at an earlier stage. Some of these ways include better education of existing staff; earlier consultation; and automatic calling by intensive care staff to abnormalities identifying at-risk patients. Some of these interventions are currently being evaluated and results should soon indicate their relative effectiveness.
Acute Disease↗
Do intensive care nurses consider intensive care less useful than their patients or patient's family?
Do Intensive Care Nurses feel that Intensive Care (IC) treatment is worthwhile for their patients? Can they speak for their patients, when considering how useful IC would be, in the event of life-threatening illness? And, do quality of life (QOL) considerations affect IC nurses', and patients', and patients' family perceptions of the usefulness of IC treatment? To determine how useful they perceived IC treatment to be 44 ex-patients (or their family if the patient had died) were asked how willing they would be to return to IC (or have their relative return to IC) if again threatened by critical illness. 16 Registered Nurses (RNs) were asked how useful they considered IC would be for patients they had nursed, if those patients' treatment in IC could be done all over again. RNs were also asked how useful they considered IC to be if they themselves required it. Patient (or family) responses were matched with the corresponding RN responses and compared (39 matched pairs). The comparison showed, 1--Patients and families did not consider QOL effected their judgement of the usefulness of IC; 2--Patients and families considered IC useful for all periods of survival; 3--RNs considered IC much less useful than patients and families; 4--QOL was a significant consideration for RNs when assessing the usefulness of IC for their patients. These results have implications for RNs who attempt to represent the patients' view when assessing the usefulness of IC.
Attitude of Health Personnel↗
Psychiatric nurses' views on criteria for psychiatric intensive care: acute and intensive care staff compared.
AIM: To explore and investigate differences between the views of qualified nurses working in psychiatric intensive care units (PICUs) and acute care wards on which patients are appropriate for PICU care. BACKGROUND: Previous research on the area of psychiatric intensive care highlights the great differences that exist in all aspects of service provision, from unit size and staffing levels to treatment approaches and physical environment. One of the most common areas of controversy is the type of client behaviour that warrants admission to the PICU. METHOD: Structured interviews of 100 qualified nursing staff (in the London area, England) working on either acute or PICU wards were used to gather data on appropriate and inappropriate referral to PICUs. Comments made during the course of the interviews were also collected and subjected to content analysis. FINDINGS: There was evidence to support the hypothesis that acute ward staff considered patients suitable for PICU care at a lower level of risk than PICU staff thought appropriate. In comparison to acute ward nurses, those working in PICUs attended to a broader range of factors when considering suitability for admission to PICU. Appropriate reasons for transfer fell into five groups: risk to others; risk of intentional harm to self; risk of unintentional harm to self; therapeutic benefit from the PICU environment; and legitimate acute ward care problem. Inappropriate reasons for transfer fell into four groups: low risk to others and/or self; illegitimate acute admission care problems; patient belongs elsewhere; policy issues. CONCLUSION: The study opens up a range of issues not previously studied in relation to the use of PICUs and the intricate relationship of this use with the available acute care wards and other services. These findings and their implications for the care of acute and disturbed psychiatric patients are discussed.
Intensive Care Units↗
Planning patient services for intermediate care units: insights based on care for intensive care unit low-risk monitor admissions.
OBJECTIVE: To describe the technology and nursing services that would be required to care for intensive care unit (ICU) low-risk monitor admissions in an intermediate unit. DESIGN: Prospective, multicenter, inception cohort analysis. SETTING: Forty U.S. hospitals with > 200 beds, including 26 hospitals that were randomly selected and 14 that volunteered for the study. PATIENTS: A sample of 8,040 ICU patients admitted to the ICU for monitoring, who received no active life-support treatment on ICU day 1. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, physiologic, and treatment information were obtained during ICU days 1 to 7. A previously validated multivariate equation was used to identify 6,180 monitor admissions at low (< 10%) risk for receiving active treatment during their entire ICU stay. We used daily Therapeutic intervention Scoring System (TISS) data to identify the equipment, type and amount of nursing care, and the types of active treatment that would have been used had these ICU patients been admitted to an intermediate care unit. Mean day-1 ICU TISS scores were as follows: 16.4 for all patients; 18.3 for surgical patients; and 13.5 for medical admissions. Concentrated nursing care accounted for 89% and technologic monitoring for 11% of day-1 TISS points. Surgical admissions had a 2.8-day mean ICU length of stay and received an average of 16.5 TISS points per patient per day. Medical admissions had a 2.7-day mean ICU length of stay and received an average of 12.3 TISS points per patient per day. Subsequent active life-support therapy was received by 4.4% of these ICU low-risk monitor admissions. CONCLUSIONS: The services received by ICU low-risk monitor admissions provide insight regarding the equipment and nursing care that might be required, and the kinds of emergencies that might occur, if these patients were cared for in medical and surgical intermediate care units. Our data suggest that if ICU low-risk monitor patients were admitted to an intermediate care unit, they would mainly require concentrated nursing care (nurse/patient ratio of 1:3 to 1:4) and limited technologic monitoring.
APACHE↗
Metabolic changes during prolonged total parenteral nutrition in intensive care.
Intensive care patients receiving prolonged total parenteral nutrition (TPN) developed alterations of liver function tests, seen in the activity of certain serum enzymes. Hepatomegaly and jaundice sometimes appeared. The changes in chemical pathology were in serum transaminases activity (GOT, GPT, GDH); alkaline phosphatase and gamma-glutamyltranspeptidase as indices of cholestasis; lactate dehydrogenase, hydroxybutyrate dehydrogenase and creatine phosphokinase, as enzymes related to energy metabolism; pseudocholinesterase, as a protein metabolism-related enzyme. The possible causes of these alterations in critically ill patients undergoing TPN are considered and a functional final metabolic interpretation is proposed.
Alanine Transaminase↗
Problems following discharge after intensive care.
Intensive care units (ICUs) are now present in most acute care hospitals. While long-term studies on patients admitted to these units have been performed to identify mortality, functional outcome and quality of life, there is little information on the recovery period in the weeks immediately following discharge. The aim of this study was to identify and describe the sequelae found in patients at 3 months after leaving the ICU. The study was conducted over a 6-month period during 1991, in a university teaching hospital in Sydney, Australia. 54 patients with a length stay (LOS) of greater than 48 hours in the ICU were included. Each patient was interviewed in an outpatient clinic attached to the ICU. Information collected included pre-admission details, reason for admission, treatments provided and complications encountered. General health state, social and employment details, functional status, referral patterns since discharge and recollection of ICU stay were studied. The major findings indicated that many of the patients interviewed were returning towards near normal general health, but were suffering mild to moderate physical and psychosocial sequelae. In the majority of cases the problems were not incapacitating. The predominant complaints were minor to severe pain, sleeping difficulties, tiredness and breathlessness. Financial problems were reported by a small number of patients. Depression, irritability or a feeling of loneliness were present in over one-third of the group. More than half the patients required referral for further assessment. 34% of patients had no recollection of their ICU stay. 16 patients (29.6%) reported unpleasant memories including nightmares and hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS)
Critical Care↗