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PubMed1998

Clinical pathways for family-oriented developmental care in the intensive care nursery.

The physiologic and neurodevelopmental benefits of developmentally sensitive nursing care for high-risk infants have been well documented. The remaining challenge is to find ways to introduce developmental care principles into busy intensive care nurseries. The article discusses the development of three clinical pathways designed around five areas for developmental intervention: environmental organization, structuring of nursing care, feeding, family involvement, and family education. Each pathway incorporated developmental principles appropriate for a different level of care; the level III pathway was designed for acutely ill or very premature infants, the level II pathway for infants recovering from acute illness or older premature infants, and the level I pathway for full-term infants. Introduction of the developmental care pathways had an immediate positive impact in the tertiary level intensive care nursery at Allegheny General Hospital.

Child Development↗
PubMed1979

[Interaction between intensive care patients; a comparison of different intensive care units (author's transl)].

A study was made of the extent and type of contact which patients of an intensive care unit established with each other. The information was obtained by interviewing 92 patients in 4 different types of intensive care units. In evaluating and interpreting the results special attention was paid to the possible influence of 10 patient-specific and disease-specific parameters. 81 per cent of the interviewed persons had established contact, mostly of a verbal nature, with their fellow patients. The majority appreciated the companionship and attached a positive value to the contacts made: communication with the other patients relieved the mental stress arising from their condition and detracted from their anxiety and tendency to brooding; on the other hand, they were also, to some extent, worried that too much excitement might adversely affect their condition. Encouraging talks by the medical team greatly helped towards reducing stress. Even severely ill persons who could no longer actively communicate felt happier in a multi-bed ward: they felt less isolated and more involved and therefore, psychically supported. The fact that the great majority of patients preferred multi-bed units to single rooms suggests that the former have a stabilizing effect, both physically and psychically - an aspect of intensive care that has so far been ignored.

Bed Occupancy↗
PubMed2003

Implementing potentially better practices for improving family-centered care in neonatal intensive care units: successes and challenges.

OBJECTIVE: Multidisciplinary teams from 11 medical center neonatal intensive care units collaborated in a quality improvement project with a focus on family-centered care. METHODS: Through a process of self-analysis, literature review, benchmarking site visits, and expert consultation, 10 potentially better practice (PBP) areas were defined. Improvement activities in 4 of the 10 areas are given as examples of successes and challenges that individual centers encountered. The 4 areas are vision and philosophy, unit culture, family participation in care, and families as advisors. RESULTS: Centers were at different places for all of the PBPs at the beginning and throughout the collaboration. Seven centers developed or revised their vision or philosophy of care statements about family-centered care. Incorporating the vision and philosophy of care into performance appraisals, hiring of new personnel, and changing unit culture to a more family-centered practice were more challenging than developing the statements. Full parent participation in care requires unrestricted access to the neonatal intensive care unit. The shift from considering parents to be "visitors" to being partners in caring for their child was more difficult for centers with restricted visitation policies. All centers developed, expanded, or started plans for establishing family advisory councils. The experience of 2 centers is described. CONCLUSIONS: Family-centered care is more of a journey than a destination. Collaborating centers in this project found themselves at different places in that journey. Through perseverance in implementing the PBPs, all have moved further along the path.

Benchmarking↗
PubMed1993

Nurses' attitudes toward computerised care plans in intensive care. Part 1.

The purpose of this quantitative study was to measure nurses' attitudes towards the use of computerised nursing care plans in intensive care. 41 nurses, working in an adult intensive care unit (ICU), completed the closed-structured questionnaire. The results of the study revealed that age, type of shift worked, length of time qualified and length of time employed on the unit influenced nurses' attitudes towards computerised care plans. It was concluded that prior to the introduction of a computerised care planning system, it is essential that nurses' attitudes are identified. In so doing, a system can be introduced that will match the capabilities of and acceptance by the nursing staff.

Attitude of Health Personnel↗
PubMed2005

Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.

OBJECTIVE: To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. DESIGN: Observational, prospective, multiple-center study. SETTING: Four university hospitals and seven primary-care hospitals in France. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. CONCLUSIONS: ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.

Female↗
PubMed2004

[Microbiological isolates associated with nosocomial infections in intensive care units: data of 274 intensive care units participating in the German Nosocomial Infections Surveillance System (KISS)].

OBJECTIVE: To describe the frequency and distribution of microbiological isolates in association with nosocomial infections (NI) in intensive care units (ICUs) in Germany. METHODS: The hospital infection surveillance system (KISS = Krankenhaus-Infektions-Surveillance-System) started in Germany in January 1997 as a nationwide surveillance project for the voluntary registration of nosocomial infections. For ICUs reporting focuses on device-associated primary bloodstream infections, urinary tract infections, as well as on pneumonia and bronchitis. The data collected for each patient who acquires a nosocomial infection include the site of infection and patient demographics. Up to 4 pathogens can be recorded for each infection. RESULTS: From 1997 until 2002 274 ICUs were participating. The data of 590 695 patients with 18 073 device associated infections (ventilator-associated pneumonia and bronchitis, central line-associated bloodstream infection (BSI) and urinary catheter-associated urinary tract infection (UTI)) were analyzed. In the group of device-associated NI S. aureus was most frequently isolated (16.5/100NI) followed by Ps. aeruginosa (14.2/100NI), E. coli (13.9/100NI), enterococci (13.4/100NI) and C. albicans (11.2/100NI). Of all S. aureus isolates 20.0 % were MRSA. There was an increase of the MRSA rate from 8 % in 1997 to 26.9 % in 2002. The most frequent pathogen in BSI was coagulase-negative staphylococcus (31.0/100NI). In ventilator-associated pneumonia and bronchitis S. aureus was the most frequent pathogen (24.2 and 24.9/100NI). In more than half of all catheter-associated UTI E. coli (25.7/100NI) and enterococci (25.4/100NI) were found. After stratification for the type of ICU differences in the distribution of pathogens could be shown. CONCLUSIONS: The KISS data give an overview of the most important pathogens associated with nosocomial infections on ICUs in Germany.

Cross Infection↗
PubMed2006

Measuring success of interventions to improve the quality of end-of-life care in the intensive care unit.

Because of the severity of illness, the intensive care unit (ICU) is a setting where death is common. Although optimal palliative care should prevent many terminal ICU admissions, the ICU will always remain an important setting for end-of-life care because of the severity of illness of patients in the ICU and because many patients with chronic, life-limiting diseases and their families opt for a trial of intensive care. Therefore, improving the quality of end-of-life care in the ICU is an important endeavor. Furthermore, there are data to suggest that current quality of end-of-life care in the ICU is often poor and that this is an important target for quality improvement. However, as interventions are designed to improve the quality of end-of-life care in the ICU, researchers, clinicians, and quality improvement personnel will need reliable and valid measures to determine whether these interventions do improve the quality of care. In this article, we examine some of the data supporting potential process and outcome measures that could be used to evaluate the success of interventions designed to improve end-of-life care in the ICU.

Communication↗
PubMed1998

Outcome of intensive care patients in a group of British intensive care units.

OBJECTIVE: To identify priorities for intensive care unit (ICU) intervention and research. DESIGN: Analysis of a large intensive care database. SETTING: Twenty-four ICUs in the North Thames region of the United Kingdom. PATIENTS: All patients admitted to an ICU between January 1, 1992, and April 31, 1996, on whom data had been entered into the database. Patients who were admitted after cardiac surgery, who had burns, or were <16 yrs of age were excluded from the study, as were data from patients with a previous ICU admission within 6 mos or where ICU or hospital outcome was unknown. Data were excluded from units that had entered <300 patients into the database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 23,331 admissions with complete records were available. After exclusions, 12,762 admissions from 15 ICUs were selected for analysis. Hospital mortality was 32.5% with a mortality ratio of 1.14 (95% confidence interval 1.10 to 1.17). Nonsurvivors were older than survivors and had longer ICU stays. Patients admitted from wards had a higher mortality than patients from the operating room/recovery or the emergency department. Observed percentage mortality increased linearly with mortality predicted by Acute Physiology and Chronic Health Evaluation II, although the number of patients who died remained broadly constant across the range of predicted mortality. Twenty-seven percent of all deaths occurred after discharge from the ICU. Patients admitted after cardiopulmonary resuscitation constituted 30% of all deaths. Thirty-four percent of patients were in the ICU for >2 days, and they accounted for nearly 81% of bed days. CONCLUSIONS: Early identification of patients at risk, both before admission and after discharge from the ICU, may allow treatment to decrease mortality. Research and resources may be best directed at patients who die, despite a relatively low predicted mortality. Although these patients are a small percentage of the low-risk admissions, they constitute a large number of ICU deaths. Many patients die after discharge from ICU and this mortality may be decreased by minimizing inappropriate early discharge to the ward, by the provision of high-dependency and step-down units, and by continuing advice and follow-up by the ICU team after the patient has been discharged. Intervention before ICU admission and support of patients after discharge from the ICU should be part of the effort to decrease mortality for ICU patients. Inadequate provision of resources for critically ill patients may result in excess intensive care mortality that is not detected with ICU outcome prediction methods.

APACHE↗
PubMed1989

Outbreak of multiply resistant Staphylococcus aureus in a pediatric intensive care unit after consolidation with a surgical intensive care unit.

Patients in a pediatric intensive care unit were placed with patients in an adult surgical intensive care unit (SICU) in a large, 12-bed room previously occupied exclusively by the adult patients. The occurrence of multiply resistant Staphylococcus aureus (MRSA) in pediatric patients increased from zero cases during the preceding 12 months to seven cases (p less than 0.001) for the 95 days that the units were combined. The rate of acquisition of MRSA by the patients in the SICU remained unchanged. Pediatric patients who acquired MRSA had longer lengths of stay (p less than 0.001) and underwent more surgical (p less than 0.01) and invasive procedures than did pediatric patients who did not acquire MRSA. Removal of the pediatric patients to their own unit returned their rate of MRSA acquisition to the previous low level.

Adult↗
PubMed1996

Full-cost determination of different levels of care in the intensive care unit. An activity-based costing approach.

We applied an activity-based costing methodology to determine the full cost of intensive care service at a community hospital, a university hospital and a health maintenance organisation (HMO)-affiliated hospital. A total of 5 patient care units were analysed: the intensive care unit (ICU) and surgical ICU (SICU) at the university setting, the ICU at the community setting, and the SICU and cardiac care unit at the HMO setting. The selection of the different ICU types was based on the types of critical care units that were found in each setting (e.g. the HMO did not have an ICU). Institution-specific cost data and clinical management parameters were collected through surveys and site visits from the 3 respective organisation types. The analysis revealed a marked increase in patient-minute cost associated with mechanical ventilation. Higher costs associated with prolonged neuromuscular blockade have important economic implications with respect to selection of an appropriate neuromuscular blocking agent.

Coronary Care Units↗
PubMed2000

A profile of European intensive care unit physiotherapists. European Society of Intensive Care Medicine.

OBJECTIVE: To determine the profile and role of the physiotherapist in European intensive care units (ICUs). DESIGN: Postal questionnaire. SETTING: 460 ICUs in 17 western European countries. PARTICIPANTS: Heads of intensive care physiotherapy. RESULTS: One hundred and two completed questionnaires were analyzed, representing 22% of the questionnaires sent: 48% were from university hospitals, 45% of the hospitals had more than 700 beds, and 50% had more than 24 ICU beds. 38% of the hospitals had more than 30 physiotherapists working in the hospital, but 25% had no exclusive ICU physiotherapist. 34% had a physiotherapist available during the night, and 85% during the weekend. In almost 100% of ICUs the physiotherapist performed respiratory therapy, mobilization, and positioning. The physiotherapist played an active role in the adjustment of mechanical ventilation in 12% of the respondent's units, in weaning from mechanical ventilation in 22% of units, in extubation in 25%, and in the implementation of non-invasive mechanical ventilation (NIV) in 46%. Among the physiotherapists, there were equivalent numbers of university and non-university graduates. Differences in the role of the physiotherapist were apparent between countries. For example, 80% of respondents from the United Kingdom stated that physiotherapists were available during the night, while in Germany and Sweden physiotherapists were available at night in none of the respondent's units. CONCLUSIONS: Even though the response rate was limited, variations in the role and profile of the ICU physiotherapist are apparent across Europe. The involvement of physiotherapists in more specialized techniques is also a function of the number of physiotherapists working exclusively in an ICU.

Data Collection↗
PubMed2001

The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement.

The intensive care unit (ICU) represents a hospital setting in which death and discussion about end-of-life care are common, yet these conversations are often difficult. Such difficulties arise, in part, because a family may be facing an unexpected poor prognosis associated with an acute illness or exacerbation and, in part, because the ICU orientation is one of saving lives. Understanding and improving communication about end-of-life care between clinicians and families in the ICU is an important focus for improving the quality of care in the ICU. This communication often occurs in the "family conference" attended by several family members and members of the ICU team, including physicians, nurses, and social workers. In this article, we review the importance of communication about end-of-life care during the family conference and make specific recommendations for physicians and nurses interested in improving the quality of their communication about end-of-life care with family members. Because excellent end-of-life care is an important part of high-quality intensive care, ICU clinicians should approach the family conference with the same care and planning that they approach other ICU procedures. This article outlines specific steps that may facilitate good communication about end-of-life care in the ICU before, during, and after the conference. The article also provides direction for the future to improve physician-family and nurse-family communication about end-of-life care in the ICU and a research agenda to improve this communication. Research to examine and improve communication about end-of-life care in the ICU must proceed in conjunction with ongoing empiric efforts to improve the quality of care we provide to patients who die during or shortly after a stay in the ICU.

Advance Directives↗
PubMed2005

An opportunity: critical care beyond the intensive care unit.

INTRODUCTION: Development of formal systems of critical care follow-up is an essential expansion of critical care services. BACKGROUND: The impact of critical illness and intensive care services extends beyond the temporal and physical confines of critical care units. With the exception of neonatalogy, however, follow-up assessment and services have traditionally been provided through primary care or targeted subspecialist referral. As patient mortality rates decrease, intensivists have recognized the need to focus on alternative, patient-centered outcomes. Models of care with collaboration between critical care and rehabilitation services have developed, recognizing the unique skills and contributions of critical care continuity. Quality of life, symptom and morbidity assessment, socioeconomic and family impact, satisfaction, and other variables have been integrated into clinical and health services research. Critical care follow-up, however, is not standard of care. IMPLICATIONS AND CONCLUSIONS: The benefit of integrating critical care services in the prehospital setting, in the form of triage, transport, and educational efforts, has been demonstrated. Establishing greater critical care follow-up is the next logical step in the care continuum. Intensivists should assist outpatient and intermediate care providers to improve patient care while simultaneously creating a crucial feedback mechanism for quality improvement and research efforts within intensive care.

Continuity of Patient Care↗
PubMed1992

Covering the costs of care in neonatal intensive care units.

The continued rise of health care costs, despite private and governmental control efforts, has sustained cost containment as a central issue for health care researchers and policy makers. In keeping with these concerns, the Florida Health Care Cost Containment Board conducted a study of neonatal intensive care units (NICUs) in Florida to ascertain the costs, charges, and net revenues associated with NICU services in individual hospitals, to document cost shifting and cross-subsidization as a means of financing NICU care for indigent populations, and to assess the fiscal impact of NICUs in state-sponsored vs non-state-sponsored Regional Perinatal Intensive Care Center hospitals providing NICU care. Hospitals in the state-sponsored program reported a loss of approximately $16.5 million in contrast to the non-state-sponsored hospitals, which reported a gain of $1 million. Payment being generated by private-pay patients amounted to almost 60% of total revenues but constituted less than one third of the costs in state-sponsored hospitals, indicating a high level of cost shifting. Government support of state-sponsored NICUs, while substantial, has been insufficient; increasing constraints on this funding source would likely worsen the deficit and increase the necessity of cost shifting.

Ancillary Services, Hospital↗
PubMed1997

Critically ill children: the case for short-term care in general intensive care units.

This paper contests the claim that all children should be nursed in paediatric intensive care units (PICUs). Although there is an undoubted need for prolonged care to be undertaken within PICUs, they are a scarce resource and many children's critical illness is of short duration. Following a discussion on the negative aspects of transferring a critically ill child this paper then establishes how a general intensive care unit (GICU) can maintain-awareness and standards which make it a safe environment for children with a short-term critical illness, as well as contribute towards future management and practice.

Child↗
PubMed2001

[Activity registration in intensive care units].

Intensive care treatment is expensive and its capacity is limited. The population of elderly patients with greater need for intensive care increases. It has become more important to evaluate the use of intensive care resources and to compare it with the results of treatment. Diagnoses do not provide a satisfactory description of the stay in the intensive care unit. Scoring systems for severity of illness and for resource needs are therefore of great value. The Norwegian Board of Health has requested all intensive care units in Norway to describe their activities by scoring systems for severity of illness, SAPS II (Simplified Acute Physiology Score II) and for use of resources NEMS (Nine Equivalents of Nursing Manpower Use Score). The systems are generally well recognised, easy to learn and not time-consuming. Through SAPS II and NEMS it is possible to compare results of treatment and use of resources across intensive care units or against a standard.

APACHE↗