Melsen W.G.,University Utrecht |
Rovers M.M.,University Utrecht |
Rovers M.M.,Radboud University Nijmegen |
Groenwold R.H.H.,University Utrecht |
And 27 more authors.
The Lancet Infectious Diseases | Year: 2013
Background: Estimating attributable mortality of ventilator-associated pneumonia has been hampered by confounding factors, small sample sizes, and the difficulty of doing relevant subgroup analyses. We estimated the attributable mortality using the individual original patient data of published randomised trials of ventilator-associated pneumonia prevention. Methods: We identified relevant studies through systematic review. We analysed individual patient data in a one-stage meta-analytical approach (in which we defined attributable mortality as the ratio between the relative risk reductions [RRR] of mortality and ventilator-associated pneumonia) and in competing risk analyses. Predefined subgroups included surgical, trauma, and medical patients, and patients with different categories of severity of illness scores. Findings: Individual patient data were available for 6284 patients from 24 trials. The overall attributable mortality was 13%, with higher mortality rates in surgical patients and patients with mid-range severity scores at admission (ie, acute physiology and chronic health evaluation score [APACHE] 20-29 and simplified acute physiology score [SAPS 2] 35-58). Attributable mortality was close to zero in trauma, medical patients, and patients with low or high severity of illness scores. Competing risk analyses could be done for 5162 patients from 19 studies, and the overall daily hazard for intensive care unit (ICU) mortality after ventilator-associated pneumonia was 1·13 (95% CI 0·98-1·31). The overall daily risk of discharge after ventilator-associated pneumonia was 0·74 (0·68-0·80), leading to an overall cumulative risk for dying in the ICU of 2·20 (1·91-2·54). Highest cumulative risks for dying from ventilator-associated pneumonia were noted for surgical patients (2·97, 95% CI 2·24-3·94) and patients with mid-range severity scores at admission (ie, cumulative risks of 2·49 [1·81-3·44] for patients with APACHE scores of 20-29 and 2·72 [1·95-3·78] for those with SAPS 2 scores of 35-58). Interpretation: The overall attributable mortality of ventilator-associated pneumonia is 13%, with higher rates for surgical patients and patients with a mid-range severity score at admission. Attributable mortality is mainly caused by prolonged exposure to the risk of dying due to increased length of ICU stay. Funding: None. © 2013 Elsevier Ltd.
News Article | November 17, 2016
The Mount Sinai Hospital has been recognized for meritorious outcomes for surgical patient care for the third consecutive year by The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®), one of 60 ACS NSQIP participating hospitals in the nation to achieve this recognition. As a participant in ACS NSQIP, The Mount Sinai Hospital is required to track the outcomes of inpatient and outpatient surgical procedures and collect data that directs patient safety and the quality of surgical care improvements. The Mount Sinai Hospital is one of only 18 hospitals to have received meritorious status two years in a row, and one of only five hospitals to receive the status in three consecutive years, out of 615 domestic and international hospitals that were analyzed for the most current outcomes measures. “Mount Sinai is honored to once again receive this distinction, which clearly positions our surgeons as industry leaders,” said Michael L. Marin, MD, Professor of Surgery at Icahn School of Medicine at Mount Sinai and System Chair of Surgery at Mount Sinai Health System. “Our faculty provide the highest quality surgical care for patients of all ages and are dedicated to advancing treatments and outcomes through innovative research and state-of-the-art technology. “This recognition is only possible through the outstanding efforts of our surgeons and the detailed precision of our Surgical Outcomes and Quality Improvement (SOQI) team,” said Celia Divino, MD, Professor of Surgery at Icahn School of Medicine at Mount Sinai, Chief of the Aufses Division of General Surgery at Mount Sinai Health System, and ACS NSQIP Surgeon Champion for The Mount Sinai Hospital. “The SOQI team continuously abstracts longitudinal data to ensure optimal performance, and pinpoints opportunities to innovate new standards in patient care.” The ACS NSQIP recognition program commends a select group of hospitals for achieving a composite meritorious outcome related to patient management in eight clinical areas: mortality, unplanned intubation, ventilator > 48 hours, renal failure, cardiac incidents (cardiac arrest and myocardial infarction); respiratory (pneumonia); SSI (surgical site infections-superficial and deep incisional and organ-space SSIs); or urinary tract infection. The 60 hospitals commended achieved the distinction based on their outstanding composite quality score across the eight areas listed above. Risk-adjusted data from the July 2016 ACS NSQIP Semiannual Report, which presents data from the 2015 calendar year, were used to determine which hospitals demonstrated meritorious outcomes. ACS NSQIP is the only nationally validated quality improvement program that measures and enhances the care of surgical patients. This program measures the actual surgical results 30 days postoperatively as well as risk adjusts patient characteristics to compensate for differences among patient populations and acuity levels. The goal of ACS NSQIP is to reduce surgical morbidity (infection or illness related to a surgical procedure) and surgical mortality (death related to a surgical procedure) and to provide a firm foundation for surgeons to apply what is known as the “best scientific evidence” to the practice of surgery. Furthermore, when adverse effects from surgical procedures are reduced and/or eliminated, a reduction in health care costs follows. ACS NSQIP is a major program of the American College of Surgeons and is currently used in over 770 adult and pediatric hospitals. The Surgical Outcomes and Quality Improvement (SOQI) office is a centralized group within the Department of Surgery that focuses on improving clinical outcomes and patient experience through dedicated data collection/analysis, innovative process engineering, and targeted quality improvement projects. The office monitors a broad range of surgical procedures including general surgery, vascular, plastics, surgical oncology, colorectal and pediatrics. The department’s relatively high case volume fosters the ability to impact a large population of surgical candidates and implement improvements that are tailored to specific patients’ needs. The Ruth J. & Maxwell Hauser and Harriet & Arthur H. Aufses, Jr., MD, Department of Surgery at The Mount Sinai Hospital is nationally recognized for its excellence in surgical care for a broad spectrum of specialties. The Department includes the Divisions of Colon and Rectal Surgery, General Surgery, Metabolic Surgery, Endocrine and Minimally Invasive Surgery, Pediatric Surgery, Plastic and Reconstructive Surgery, the Surgical Intensive Care Unit, Surgical Oncology and Vascular and Endovascular Surgery. The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 78,000 members and it is the largest organization of surgeons in the world. About the Mount Sinai Health System The Mount Sinai Health System is an integrated health system committed to providing distinguished care, conducting transformative research, and advancing biomedical education. Structured around seven hospital campuses and a single medical school, the Health System has an extensive ambulatory network and a range of inpatient and outpatient services—from community-based facilities to tertiary and quaternary care. The System includes approximately 7,100 primary and specialty care physicians; 12 joint-venture ambulatory surgery centers; more than 140 ambulatory practices throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and 31 affiliated community health centers. Physicians are affiliated with the renowned Icahn School of Medicine at Mount Sinai, which is ranked among the highest in the nation in National Institutes of Health funding per investigator. The Mount Sinai Hospital is on the “Honor Roll” of best hospitals in America, ranked No. 15 nationally in the 2016-2017 “Best Hospitals” issue of U.S. News & World Report. The Mount Sinai Hospital is also ranked as one of the nation’s top 20 hospitals in Geriatrics, Gastroenterology/GI Surgery, Cardiology/Heart Surgery, Diabetes/Endocrinology, Nephrology, Neurology/Neurosurgery, and Ear, Nose & Throat, and is in the top 50 in four other specialties. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 10 nationally for Ophthalmology, while Mount Sinai Beth Israel, Mount Sinai St. Luke's, and Mount Sinai West are ranked regionally. Mount Sinai’s Kravis Children’s Hospital is ranked in seven out of ten pediatric specialties by U.S. News & World Report in "Best Children's Hospitals. Mount Sinai Health System was ranked number 3 in the Top Ten hospitals and health systems in DiversityInc in 2016". For more information, visit http://www.mountsinai.org/, or find Mount Sinai on Facebook, Twitter and YouTube.
Panosh N.,Oregon Health And Science University |
Drew R.,Campbell University |
Drew R.,Duke University |
Sharpe M.,Surgical Intensive Care Unit
American Journal of Health-System Pharmacy | Year: 2012
Purpose. The results of a study comparing the average time to initiation of i.v. antimicrobial therapy with closed- versus open-loop order entry and processing are reported. Methods. A retrospective cohort study was performed to compare order-to-administration times for initial doses of i.v. antimicrobials before and after a closed-loop order-processing system including computerized prescriber order entry (CPOE) was implemented at a large medical center. A total of 741 i.v. antimicrobial administrations to adult patients during designated five-month preimplementation and postimplementation study periods were assessed. Drug-use reports generated by the pharmacy database were used to identify order-entry times, and medication administration records were reviewed to determine times of i.v. antimicrobial administration. Results. The mean ± S.D. order-to-administration times before and after the implementation of the CPOE system and closed-loop order processing were 3.18 ± 2.60 and 2.00 ± 1.89 hours, respectively, a reduction of 1.18 hours ( p < 0.0001). Closed-loop order processing was associated with significant reductions in the average time to initiation of i.v. therapy in all patient care areas evaluated (cardiology, general medicine, and oncology). The study results suggest that CPOE-based closed-loop order processing can play an important role in achieving compliance with current practice guidelines calling for increased efforts to ensure the prompt initiation of i.v. antimicrobials for severe infections (e.g., sepsis, meningitis). Conclusion. Implementation of a closedloop order-processing system resulted in a significant decrease in order-to-administration times for i.v. antimicrobial therapy. Copyright © 2012, American Society of Health-System Pharmacists, Inc. All rights reserved.
Lunardi N.,University of Virginia |
Bryant M.,Surgical Intensive Care Unit |
Smith K.,University of Virginia |
Lowson S.,University of Virginia
ICU Director | Year: 2012
Mortality in the ICU has dramatically decreased over the past decades because of a clearer understanding of disease pathophysiology, improved technology, and novel therapies. This success has led to the new challenge of treating patients with chronic disabilities resulting from prolonged ICU stays. In this review, the authors (a) describe the emerging understanding of the basis for ICU-acquired weakness, including contributing factors such as prolonged bed rest; (b) provide the background for the safety and efficacy of early mobilization; and (c) give practical guidance for the implementation of ICU early mobilization based on their experience over the past 8 years. © 2012 SAGE Publications.
Masri Y.,Surgical Intensive Care Unit |
Abubaker J.,Rashid Hospital Trauma Center |
Ahmed R.,Rashid Hospital Trauma Center
Annals of Thoracic Medicine | Year: 2010
Background : This study was designed to evaluate the use of laxative prophylaxis for constipation in intensive care unit (ICU) and the impact of early versus late bowel movement on patient's outcome. Methods : The study was a prospective, randomized controlled trial in critically ill ventilated adult patients, who were expected to stay on ventilator for >72 h. Control group did not receive any intervention for bowel movement for the first 72 h, whereas interventional group received prophylactic dose of lactulose 20 cc enterally every 12 h for the first 72 h. The parameters measured during the study were admission diagnosis, age, gender, comorbid conditions, admission Simplified Acute Physiologic Score (SAPS II), sedative and narcotic agents with doses and duration, timing and tolerance of nutrition, daily assessment of bowel movement, total use of prokinetic, doses of suppositories, and enema for first bowel movement, total number of days on ventilator, weaning failures, extubation or tracheostomy, ICU length of stay, and death or discharge. Results : A total of 100 patients were enrolled, 50 patients in each control and interventional group. Mean age was 38.8 years, and both groups had male predominance. Mean SAPS II score for both was 35. Mean dose of Fentanyl (323.8 108.89 mcg/h in control and 345.83 94.43 mcg/h in interventional group) and mean dose of Midazolam (11.1 4.04 mg/h in control and 12.4 3.19 mg/h in interventional group). There were only two (4%) patients in control, while nine (18%) patients in interventional group who had bowel movement in <72 h (P < 0.05). Mean ventilator days were 16.19, and 17.36 days in control and interventional groups, respectively. Subgroup analysis showed that the patients who moved bowel in <5 days in both groups had mean ventilator days of 18.5, whereas it was 15.88 days for the patients who moved bowel after 5 days in both groups (P< 0.05). Mean ICU days for control was 21.15 10.44 and 20.77 8.33 days for interventional group. Forty-eight (96%) patients in each group were discharged from the ICU. Two (4%) patients died in ICU in each group. Conclusions : Laxative prophylaxis can be used successfully to prevent constipation in ICU patients. Late bowel movement >5 days is associated with less ventilator days, compared to early <5 days bowel movement.
Haddad S.H.,Surgical Intensive Care Unit |
Arabi Y.M.,King Saud bin Abdulaziz University for Health Sciences
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine | Year: 2012
Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP. © 2012 Haddad and Arabi; licensee BioMed Central Ltd.
McMillian W.D.,Fletcher Allen Health Care FAHC |
Trombley B.J.,Alice Hyde Medical Center |
Charash W.E.,Surgical Intensive Care Unit |
Christian R.C.,University of Vermont
American Journal of Health-System Pharmacy | Year: 2011
Purpose. Use of continuous phentolamine infusion therapy for management of serious cardiovascular complications during adrenalectomy for pheochromocytoma is reported. Summary. In preparation for surgical resection of a pheochromocytoma, a 38-yearold woman received outpatient oral therapy with the α-adrenergic-receptor blocker phenoxybenzamine for 25 days with the goal of reducing cardiovascular risks associated with catecholamine surge during surgery. Due to inappropriate dosage adjustment, however, outpatient phenoxybenzamine therapy did not achieve adequate α-adrenergic-receptor blockade; during the laparoscopic resection procedure, the woman developed severe hypertension, leading to cardiac arrest and discontinuation of the operation. After resuscitative measures, the patient was admitted to the surgical intensive care unit for mechanical ventilation, medical management (including intermittent bolus injections of phentolamine and a continuous i.v. infusion of esmolol for control of blood pressure and heart rate), and hemodynamic monitoring; despite those measures, cardiovascular instability persisted during the immediate postoperative period. The day after the abortive surgery attempt, a continuous infusion of phentolamine mesylate (1 mg/hr, adjusted hourly to achieve the blood pressure target) was initiated. Four days after initiation of continuous phentolamine infusion, the patient was deemed to be hemodynamically stable, and the surgery was successfully performed. Conclusion. A continuous infusion of phentolamine was used in a patient with pheochromocytoma to control perioperative hypertensive episodes during surgical adrenalectomy. Copyright © 2011, American Society of Health-System Pharmacists, Inc. All rights reserved.
Constantin J.-M.,University Hospital of Clermont Ferrand |
Grasso S.,University of Bari |
Chanques G.,Surgical Intensive Care Unit |
Aufort S.,Montpellier University |
And 7 more authors.
Critical Care Medicine | Year: 2010
Objectives: The impact of recruitment maneuvers on gas exchange, hemodynamics, alveolar recruitment, and hyperinflation is highly variable among patients with acute respiratory distress syndrome. The objective was to determine whether differences in lung morphology, defined as differences in the pulmonary distribution of aeration loss, predict the response to recruitment maneuvers. Design: Prospective study. Setting: A 16-bed medical-surgical intensive care unit in a university hospital. Measurements and Main Results: Nineteen consecutive patients with early acute lung injury/acute respiratory distress syndrome were studied. Computed tomography scans, respiratory mechanics, hemodynamics, and gas exchange were obtained at zero end-expiratory pressure during an open-lung ventilation (controlled mode, tidal volume 6 mL/kg of ideal body weight, positive end-expiratory pressure set 2 cm H2O above the lower inflection point of the inspiratory pressure volume curve at zero end-expiratory pressure) during a recruitment maneuver (continuous positive airway pressure of 40 cm H2O for 40 secs), and, finally, 5 mins after the recruitment maneuver during open-lung ventilation. Nine patients presented focal and 10 presented nonfocal lung morphology at zero end-expiratory pressure. Recruitment maneuver-induced recruited volume after 5 mins of open-lung ventilation was 48 ± 66 mL and 417 ± 293 mL in patients with focal and nonfocal lung morphology, respectively (p =.0009). Recruitment maneuver-induced alveolar hyperinflation represented 23% ± 14% and 8% ± 9% of total lung volume in patients with focal and nonfocal morphology, respectively (p =.007). In patients with focal lung morphology, hyperinflated lung volume was significantly greater during and 5 mins after (316 ± 155 mL) than immediately before recruitment maneuvers (150 ± 175 mL; p =.0407. CONCLUSION: Lung morphology at zero end-expiratory pressure predicts the response to recruitment maneuvers. Patients with focal lung morphology are at risk for significant hyperinflation during the recruitment maneuvers, and lung recruitment is rather limited. © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.
Chang M.-Y.,Surgical Intensive Care Unit |
Chang L.-Y.,Taichung Veterans General Hospital |
Huang Y.-C.,Chung Shan Medical University |
Lin K.-M.,Chung Shan Medical University |
Cheng C.-H.,Hungkuang University
Respiratory Care | Year: 2011
BACKGROUND: Chair-sitting may allow for more readily activated scalene, sternocleidomastoid, and parasternal intercostal muscles, and may raise and enlarge the upper thoracic cage, thereby allowing the thoracic cage to be more easily compressed. OBJECTIVE: To evaluate the effect of chair-sitting during exercise training on respiratory muscle function in mechanically ventilated patients. METHODS: We randomized 16 patients to a control group and 18 patients to a chairsitting group. The patients in the chair-sitting group were transferred by 2 intensive care unit nurses from bed to armchair and rested for at least 30 min, based on the individual patient's tolerance. We measured heart rate, blood pressure, S pO2, and respiratory rate. In the treatment group, before transferring the patient from bed to armchair, and 30 min after the completion of chair-sitting we measured respiratory muscle function variables, including the ratio of respiratory rate (f) to tidal volume (V T), S pO2, maximum inspiratory pressure (P Imax) and maximum expiratory pressure (P Emax). In the control patients we took those same measurements while the patient was in semirecumbent position, before and after treatments, for at least 6 days or until the patient was discharged from the intensive care unit or died. RESULTS: The 2 groups did not significantly differ in age, sex, or clinical outcomes. Respiratory rate, V T, f/V T, S pO2, P Imax, and P Emax were not significantly better in the chair-sitting group. The study period significantly improved respiratory rate, V T, P Imax, and P Emax (all P <.001), but not f/V T. CONCLUSIONS: Six days of chair-sitting exercise training did not significantly improve respiratory muscle function in mechanically ventilated patients. © 2011 Daedalus Enterprises.
Maxson P.M.,Surgical Intensive Care Unit
Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses | Year: 2012
Nurse-to-nurse beside handoff allows the oncoming nurse to visualize the patient and ask questions of the previous nurse. It encourages pateints to be involved actively in their care and allows standardized communication between nursing shifts. Patient handoff between nurses at shift change has been an important process in clinical nursing practice, allowing nurses to exchange necessary patient information to ensure continuity of care and patient safety. Bedside handoff allows the patient the ability to contribute to his or her plan of care. It also allows the oncoming nurse an opportunity to visualize the patient and ask questions. This is critical in meeting the Joint Commission's 2009 National Patient Safety Goals. It encourages patients to be involved actively in their care and it implements standardized handoff communication between nursing shifts. Bedside handoff promotes patient safety and allows an opportunity for patients to correct misconceptions. A convenience sample of 60 patients was enrolled, 30 before the practice change and 30 after the change. All nursing staff were invited to participate. Both patients and staff were given self-designed surveys before and after the practice change. Fifteen nurses with a mean of 2 years in the profession completed the pre- and post-survey. A majority of staff were not satisfied with the current shift change report, but statistical improvement was achieved after the practice change. Also, statistical improvement was achieved with patients' satisfaction with involvement in their plan of care. Use of bedside nursing handoff promotes staff accountability, two-person IV medication reconciliation, and patient satisfaction.