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Missed Opportunities during Family Conferences about End-of-life Care in the Intensive Care Unit.
Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rubenfeld GD.
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA; Department of Biobehavioral Nursing and Health Systems, University of Washington, School of Nursing, Seattle, WA, USA.
Background: Improved communication with family members of critically ill patients can decrease the prolongation of dying in the ICU, but few data exist to guide the conduct of this communication. Objective: Our objective was to identify missed opportunities for physicians to provide support for family during family conferences. Methods: We identified ICU family conferences in 4 hospitals that included discussions about withdrawing life support or delivery of bad news. Fifty-one conferences were audiotaped including 214 family members. Thirty-six different physicians led the conferences as some physicians led more than one. We used qualitative methods to identify and categorize missed opportunities, defined as an occurrence when the physician had an opportunity to provide support or information to the family and did not. Main Results: Fifteen family conferences (29%) had missed opportunities identified. These fell into three categories: opportunities to listen and respond to family; opportunities to acknowledge and address emotions; and opportunities to pursue key tenets of palliative care, including exploration of patient preferences, explanation of surrogate decision-making, and affirmation of non-abandonment. The most common missed opportunities were those to listen and respond, but examples from the other categories suggest value in being aware of these opportunities. Conclusions: Identification of missed opportunities during ICU family conferences provides suggestions for improving communication during these conferences. Future studies are needed to determine whether addressing these opportunities will improve quality of care.
PMID: 15640361 [PubMed - as supplied by publisher]
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Salivary cortisol concentration in the intensive care population: correlation with plasma cortisol values.
Cohen J, Venkatesh B, Galligan J, Thomas P.
Publication Types:
PMID: 15649003 [PubMed - in process]
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Bloodless intensive care: a case series and review of Jehovah's Witnesses in ICU.
MacLaren G, Anderson M.
Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria.
The objective of this study was to assess the outcome of Jehovah's Witness (JW) patients admitted to a major Australasian ICU and to review the literature regarding the management of critically ill Jehovah's Witness patients. All Jehovah's Witness patients admitted to the ICU between January 1999 and September 2003 were identified from a prospective database. Their ICU mortality, APACHE II scores, APACHE II risk of death and ICU length of stay were compared to the general ICU population. Twenty-one (0.24%) out of 8869 patients (excluding re-admissions) admitted to the ICU over this period were Jehovah's Witness patients. Their mean APACHE II score was 14.1 (+/- 7.0), the mean APACHE II risk of death was 21.2% (+/- 16.6), and the mean nadir haemoglobin (Hb) was 80.2 g/l (+/- 36.4). Four out of 21 Jehovah's Witness patients died in ICU compared to 782 out of 8848 non- Jehovah's Witness patients (19.0% vs 8.8%, P = 0.10, chi square). The median ICU length of stay in both groups was two days (P = 0.64, Wilcoxon rank sum). The lowest Hb recorded in a survivor was 23 g/l. Jehovah's Witness patients appear to be an uncommon patient population in a major Australasian ICU but are not over-represented when compared with their prevalence in the community. Despite similar severity of illness scores and predicted mortality to those in the general ICU population, there was a trend towards higher mortality in Jehovah's Witness patients.
PMID: 15648990 [PubMed - in process]
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Cost calculation and prediction in adult intensive care: a ground-up utilization study.
Moran JL, Peisach AR, Solomon PJ, Martin J.
Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia.
The ability of various proxy cost measures, including therapeutic activity scores (TISS and Omega) and cumulative daily severity of illness scores, to predict individual ICU patient costs was assessed in a prospective "ground-up" utilization costing study over a six month period in 1991. Daily activity (TISS and Omega scores) and utilization in consecutive admissions to three adult university associated ICUs was recorded by dedicated data collectors. Cost prediction used linear regression with determination (80%) and validation (20%) data sets. The cohort, 1333 patients, had a mean (SD) age 57.5 (19.4) years, (41% female) and admission APACHE III score of 58 (27). ICU length of stay and mortality were 3.9 (6.1) days and 17.6% respectively. Mean total TISS and Omega scores were 117 (157) and 72 (113) respectively. Mean patient costs per ICU episode (1991 dollar AUS) were dollar 6801 (dollar 10311), with median costs of dollar 2534, range dollar 106 to dollar 95,602. Dominant cost fractions were nursing 43.3% and overheads 16.9%. Inflation adjusted year 2002 (mean) costs were dollar 9343 (dollar AUS). Total costs in survivors were predicted by Omega score, summed APACHE III score and ICU length of stay; determination R2, 0.91; validation 0.88. Omega was the preferred activity score. Without the Omega score, predictors were age, summed APACHE III score and ICU length of stay; determination R2, 0.73; validation 0.73. In non-survivors, predictors were age and ICU length of stay (plus interaction), and Omega score (determination R2, 0.97; validation 0.91). Patient costs may be predicted by a combination of ICU activity indices and severity scores.
PMID: 15648989 [PubMed - in process]
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Withholding and withdrawal of therapy in New Zealand intensive care units (ICUs): a survey of clinical directors.
Ho KM, Liang J.
Department of Anaesthesia and Intensive Care, North Shore Hospital, Auckland 1309, New Zealand.
Withdrawing and withholding life-support therapy in patients who are unlikely to survive despite treatment are common practices in intensive care units (ICUs). The literature suggests there is a large variation in practice between different ICUs in different parts of the world. We conducted a postal survey among all public ICUs in New Zealand to investigate the pattern of practice in withholding and withdrawal of therapy. Nineteen ICUs responded to this survey and they represented 74% of all the public ICU beds and 83% of the annual ICU admissions. The percentage of ICU admissions with therapy withdrawn or withheld was less than 10% in most ICUs. Only a small percentage (21%) of ICUs had a formal policy in withholding and withdrawal of therapy. The timing of making the decision to withhold or withdraw therapy was very variable. The patient and/or the family, the primary medical team consultant, two or more ICU consultants, and ICU nurses were usually involved in the decision making process. ICU nurses were more commonly involved in the decision making process in smaller ICUs (5 beds vs 10 beds, P = 0.03). The patient's pre-ICU quality of life, medical comorbidities, predicted mortality, predicted post-ICU quality of life, and the family's wishes were important factors in deciding whether ICU therapy would be withheld or withdrawn. Hospice ward or the patient's home was the preferred place for palliative care in 32% of the responses.
PMID: 15648988 [PubMed - in process]
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Blood usage in an Australian intensive care unit: have we met best practice goals?
Farrar D, Robertson MS, Hogan CJ, Roy S, Boyce CA, Howe BD, Presneill JJ, Cade JF.
Intensive Care Unit and Haematology Department, The Royal Melbourne Hospital, Melbourne, Victoria.
The transfusion of blood products, especially red cell concentrates, in critically ill patients is controversial and benefits of red cell concentrate transfusion in these patients have not been clearly demonstrated. We performed a prospective observational study to compare best evidence to actual practice of red cell concentrate and other blood product administration in an intensive care unit (ICU) in a university-associated tertiary hospital. All primary admissions during a 28-day period were included in the study and data collected included transfusion of red cells and blood products, patient demographics and ICU and hospital outcome. One hundred and seventy-five admissions were studied; 44% followed cardiac surgery. Forty-one patients (23%) received red cell concentrates in ICU, with 120 units transfused in 61 separate episodes. Other blood product usage was minimal. One third (20/61) of red cell concentrate transfusion episodes were of a single unit. The mean (+/- SD) pre-transfusion haemoglobin was 7.9 +/- 1.1 g/dl. Despite transfusion, such patients left ICU with a lower haemoglobin concentration compared with untransfused ICU patients (9.5 +/- 1.0 versus 10.5 +/- 2.1 g/dl; P < 0.001). Cardiac surgical patients received similar red cell transfusion to general ICU patients. Univariate analysis showed no significant difference in mortality between patients who did or did not receive red cell concentrate transfusion (P = 0.17). However, red cell concentrate transfusion was associated with a reduced adjusted mortality both in ICU (OR 0.13, 95% CI 0.02-0.73) and in hospital at 28 days (OR 0.10, 95% CI 0.02-0.58). The low red cell concentrate and blood product usage in our ICU were consistent with restrictive transfusion practice and selective red cell concentrate transfusion was associated with reduced mortality.
PMID: 15648987 [PubMed - in process]
Comment on:
Paediatric cardiac surgical mortality after Bristol: paediatric cardiac hospital episode statistics are unreliable.
Gibbs JL, Cunningham D, de Leval M, Monro J, Keogh B.
Publication Types:
PMID: 15626810 [PubMed - indexed for MEDLINE]
An agent-based and spatially explicit model of pathogen dissemination in the intensive care unit.
Hotchkiss JR, Strike DG, Simonson DA, Broccard AF, Crooke PS.
CRISMA Laboratory, Department of Critical Care, University of Pittsburgh, USA.
OBJECTIVE: To develop and disseminate a spatially explicit model of contact transmission of pathogens in the intensive care unit. DESIGN: A model simulating the spread of a pathogen transmitted by direct contact (such as methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus) was constructed. The modulation of pathogen dissemination attending changes in clinically relevant pathogen- and institution-specific factors was then systematically examined. SETTING AND PATIENTS: The model was configured as a hypothetical 24-bed intensive care unit. The model can be parameterized with different pathogen transmissibilities, durations of caregiver and/or patient contamination, and caregiver allocation and flow patterns. INTERVENTIONS: Pathogen- and institution-specific factors examined included pathogen transmissibility, duration of caregiver contamination, regional cohorting of contaminated or infected patients, delayed detection and isolation of newly contaminated patients, reduction of the number of caregiver visits, and alteration of caregiver allocation among patients. MEASUREMENTS AND MAIN RESULTS: The model predicts the probability that a given fraction of the population will become contaminated or infected with the pathogen of interest under specified spatial, initial prevalence, and dynamic conditions. Per-encounter pathogen acquisition risk and the duration of caregiver pathogen carriage most strongly affect dissemination. Regional cohorting and rapid detection and isolation of contaminated patients each markedly diminish the likelihood of dissemination even absent other interventions. Strategies reducing "crossover" between caregiver domains diminish the likelihood of more widespread dissemination. CONCLUSIONS: Spatially explicit discrete element models, such as the model presented, may prove useful for analyzing the transmission of pathogens within the intensive care unit.
PMID: 15644665 [PubMed - in process]
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The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population.
Deshpande KS, Hatem C, Ulrich HL, Currie BP, Aldrich TK, Bryan-Brown CW, Kvetan V.
Montefiore Medical Center and the Jacobi Medical Center, The Albert Einstein College of Medicine, USA.
OBJECTIVE: The objective was to assess the risk of central venous catheter infection with respect to the site of insertion in an intensive care unit population. The subclavian, internal jugular, and femoral sites were studied. DESIGN: An epidemiologic, prospective, observational study. SETTING: The setting is a well-functioning intensive care unit under a unified critical care medicine division in a university teaching hospital. Critical care medicine attendings and fellows covered on site 17 and 24 hrs per day, respectively. PATIENTS: Patients were critically ill. All patients were triaged into the intensive care unit by on-site critical care medicine fellows. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In an intensive care unit population, we prospectively studied the incidence of central venous catheter infection and colonization at the subclavian, internal jugular, and femoral sites. The optimal insertion site for each individual patient was selected by experienced intensive care physicians (critical care medicine attendings and fellows). All of the operators were proficient in inserting catheters at all three sites. Confounding factors were eliminated; there were a limited number of experienced operators inserting the catheters, a uniform protocol stressing strict sterile insertion was enforced, and standardized continuous catheter care was provided by dedicated intensive care nurses proficient in all aspects of central venous catheter care.Two groups of patients were analyzed. Group 1 was patients with one catheter at one site, and group 2 was patients with catheters at multiple sites. Group 1 was the primary analysis, whereas group 2 was supporting.A total of 831 central venous catheters and 4,735 catheter days in 657 patients were studied. The incidence of catheter infection (4.01/1,000 catheter days, 2.29% catheters) and colonization (5.07/1,000 catheter days, 2.89% catheters) was low overall.In group 1, the incidence of infection was subclavian: 0.881 infections/1,000 catheter days (0.45%), internal jugular: 0/1,000 (0%), and femoral: 2.98/1,000 (1.44%; p = .2635). The incidence of colonization was subclavian: 0.881 colonization/1,000 catheter days (0.45%), internal jugular: 2.00/1,000 (1.05%), and femoral: 5.96/1,000 (2.88%, p = .1338). There was no statistically significant difference in the incidence of infection and colonization or duration of catheters (p = .8907) among the insertion sites.In group 2, there was also no statistically significant difference in the incidence of infection and colonization among the three insertion sites. CONCLUSION: In an intensive care unit population, the incidence of central venous catheter infection and colonization is low overall and, clinically and statistically, is not different at all three sites when optimal insertion sites are selected, experienced operators insert the catheters, strict sterile technique is present, and trained intensive care unit nursing staff perform catheter care.
PMID: 15644643 [PubMed - in process]
Comment on:
The use of protocols for nutritional support is definitely needed in the intensive care unit.
Preiser JC, Ledoux D.
Publication Types:
- Comment
- Editorial
- Review
- Review, Tutorial
PMID: 15640660 [PubMed - indexed for MEDLINE]
Comment on:
Delirium in the intensive care unit is bad: what is the confusion?
Thomason JW, Ely EW.
Publication Types:
- Comment
- Editorial
- Review
- Review, Tutorial
PMID: 15640659 [PubMed - indexed for MEDLINE]
Comment on:
Intensive care unit resource utilization by Medicare patients: margin and mission meet public policy and practice economics.
Szalados JE.
Publication Types:
- Comment
- Editorial
- Review
- Review, Tutorial
PMID: 15640658 [PubMed - indexed for MEDLINE]
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Family-physician interactions in the intensive care unit.
Azoulay E, Sprung CL.
Medical ICU, Saint-Louis Teaching Hospital, and Paris 7 University Paris, France.
Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.
Publication Types:
PMID: 15640649 [PubMed - indexed for MEDLINE]
Comment in:
Medicare intensive care unit use: analysis of incidence, cost, and payment.
Cooper LM, Linde-Zwirble WT.
U.S. Outcomes Research, U.S. Medical Division, Eli Lilly and Company, Indianapolis, IN, USA.
OBJECTIVE: To determine the incidence, cost, and payment for intensive care unit services among Medicare beneficiaries. DESIGN: Retrospective observational database cohort study. SETTING: All nonfederal hospitals with intensive care unit beds (n = 5003) paid through the inpatient prospective payment system (IPPS). PATIENTS: We used all fiscal year 2000 Medicare IPPS hospitalizations with consistent payment information (n = 10,657,587). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined the distribution of cost and payments overall, by hospital type, and by diagnosis related group. Intensive care was used in 2,353,208 cases (21.1%). The overall incidence was 59.8 cases per thousand beneficiaries in the aged (65+) population, increasing with age from 36.2 (65-69) to 91.6 (85+). Intensive care unit patients cost nearly three times floor patients (4,135 dollars vs. 5,571 dollars), with two thirds of costs associated with the intensive care unit portion of the stay, 2,278 dollars per intensive care unit day. However, intensive care unit cases were paid at a rate only twice floor cases (11,704 dollars vs. 5,835 dollars). Only 83% of costs were paid for intensive care unit patients, compared with 105% for floor patients, generating a 5.8 billion dollars loss to hospitals when intensive care unit care is required. There was a linear association between the percent intensive care unit in a diagnosis related group and the percent paid, with payment >90% of cost only in diagnosis related groups with >/=60% intensive care unit cases. We found that teaching hospitals were better paid than nonteaching hospitals (87% vs. 78% of costs, respectively), but this was only due to indirect medical education payments. CONCLUSIONS: Intensive care is common, expensive, and poorly paid in the Medicare population. Few diagnosis related groups have a large enough intensive care unit population to ensure adequate payment. Additional diagnosis related groups for conditions common to the intensive care unit would improve payment and enable incentives for efficiency.
PMID: 15640637 [PubMed - indexed for MEDLINE]
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Prolonged isoflurane sedation of intensive care unit patients with the Anesthetic Conserving Device.
Sackey PV, Martling CR, Granath F, Radell PJ.
Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital Solna, Stockholm, Sweden.
OBJECTIVE: To test the efficacy and patient safety of a new method for administering isoflurane for prolonged sedation in the intensive care unit. DESIGN: Randomized controlled trial. SETTING: Multidisciplinary university intensive care unit, January 2002 to July 2003. PATIENTS: Forty ventilator-dependent intensive care unit patients 18-80 yrs old, expected to need >12 hrs sedation. INTERVENTIONS: Patients were randomized to sedation with inhaled isoflurane via the Anesthetic Conserving Device or intravenous midazolam infusion. Study duration was 96 hrs or until extubation. MEASUREMENTS AND MAIN RESULTS: Primary end points were wake-up times from termination of sedative administration and proportion of time within a predefined desired interval on a sedation scale (Bloomsbury Sedation Score). Practical and patient-related complications with the Anesthetic Conserving Device were noted. Hemodynamic, hepatic, and renal side effects were monitored. Wake-up times were significantly shorter in the isoflurane group than in the control group (time to extubation [mean +/- sd] 10 +/- 5 vs. 252 +/- 271 mins, time to follow verbal command 10 +/- 8 vs. 110 +/- 132 mins). Proportion of time within the desired sedation interval was comparable between groups (isoflurane 54%, midazolam 59% of sedation time). Few minor practical problems with this new method for isoflurane administration were noted. No serious complications related to either sedative drug occurred. We found no hemodynamic, hepatic, or renal adverse effects related to either sedative protocol. CONCLUSIONS: Isoflurane via the Anesthetic Conserving Device is a safe and efficacious method for sedation in the intensive care unit, with short wake-up times after termination of administration. The Anesthetic Conserving Device allows easily titratable administration of isoflurane without costly equipment and can be safely managed by nursing staff.
Publication Types:
- Clinical Trial
- Randomized Controlled Trial
PMID: 15640636 [PubMed - indexed for MEDLINE]
Comment in:
A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS).
Needham DM, Thompson DA, Holzmueller CG, Dorman T, Lubomski LH, Wu AW, Morlock LL, Pronovost PJ.
Pulmonary & Critical Care Medicine, and Dana Center for Preventive Ophthalmology Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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.
PMID: 15640634 [PubMed - indexed for MEDLINE]
Comment in:
The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit.
Varelas PN, Conti MM, Spanaki MV, Potts E, Bradford D, Sunstrom C, Fedder W, Bey LH, Jaradeh S, Gennarelli TA.
Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.
OBJECTIVE: To evaluate the impact of a newly appointed neurointensivist on neurosciences intensive care unit (NICU) patient outcomes and quality of care variables. DESIGN: Observational cohort with historical controls. SETTING: Ten-bed neurointensive care unit in tertiary university hospital. PATIENTS: Mortality, length of stay (LOS), and discharge disposition of all patients admitted to the NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University Hospitals Consortium database. Individual patient medical records were reviewed for major complications and important prognostic variable documentation. INTERVENTIONS: Appointment of a neurointensivist. MEASUREMENTS AND MAIN RESULTS: We analyzed 1,087 patients before and 1,279 after the neurointensivist's appointment. The unadjusted in-hospital mortality decreased from 10.1% in the before to 9.1% in the after period (95% confidence interval, -1.3 to 3%, relative mortality reduction of 9.9%), but this decrease was significantly different than the expected increase of 1.4% in University Hospitals Consortium mortality during the same period (p = .048). The unadjusted mortality in the NICU decreased from 8% to 6.3% (95% confidence interval, -0.5 to 4, relative mortality reduction 21%) and mean NICU LOS from 3.5 to 2.9 days (95% confidence interval, 0.2 to 0.9, relative NICU LOS reduction 17%). A significant 42% reduction of the risk of death during the first 3 days of NICU admission (p = .003) and a 12% greater risk for NICU discharge (p = .02) were found in the after period in multivariate proportional hazard models. Discharge home increased from 51.7% in the before to 59.7% in the after period (95% confidence interval, 4 to 12, relative increase of 15%) and discharge to a nursing home decreased from 8.1% to 6.8% (95% confidence interval, -1 to 4, relative decrease of 16%). Although a higher total number of complications occurred in the after period, fewer of them occurred in the NICU (odds ratio, 0.2; 95% confidence interval, 0.08 to 0.54, p = .001); this may possibly be due to the better documentation by the NICU team in the after period. CONCLUSIONS: The institution of a neurointensivist-led team model was associated with an independent positive impact on patient outcomes, including a lower intensive care unit mortality, LOS, and discharge to a skilled nursing facility and a higher discharge home.
Publication Types:
PMID: 15640630 [PubMed - indexed for MEDLINE]
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A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care.
Badger JM.
Objective The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses' coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort-oriented care. Methods The use of a descriptive qualitative research design with brief selective participant observation and focus group interviews was used to explore the coping experiences of MICU nurses. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States. Nineteen female and 5 male nurses participated in the study. Results MICU nurses used a variety of coping strategies including cognitive, affective, and behavioral techniques to cope with end-of-life care transitions. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as professionals. Providing futile care, the perception of "torturing the patient," and conflict with families caused the greatest distress to staff. Conclusions MICU nurses are dynamic and resourceful when responding to challenging end-of-life patient care situations.
PMID: 15647735 [PubMed - in process]
A 12-month clinical survey of incidence and outcome of acute respiratory distress syndrome in Shanghai intensive care units.
Lu Y, Song Z, Zhou X, Huang S, Zhu D, Yang C Bai X, Sun B, Spragg R; Shanghai ARDS Study Group.
Laboratory of Respiratory and Intensive Care Medicine, Children's Hospital of Fudan University, 183 Feng Lin Road, 200032 Shanghai, China.
OBJECTIVE: To investigate incidence, causes, and outcome of acute respiratory distress syndrome (ARDS) in adult patients admitted to intensive care units (ICU) in Shanghai. DESIGN: A prospective 12-month survey during 2001-2002 of the predispositions, clinical management strategies, complications, and 90-day survival rates of patients with ARDS. PATIENTS AND SETTING: Fifteen ICU in 12 university hospitals in Shanghai. All ICU admissions >/=15 years of age in the 12-month period were assessed. Patients fulfilling diagnostic criteria of ARDS, as defined by the American-European Consensus Conference, and having a continuous treatment period >/=24 h, were recruited. MEASUREMENTS AND RESULTS: Of 5320 adult patients admitted to ICUs, there were 108 (2%) with ARDS. At inclusion, ARDS patients had a mean PaO(2)/FiO(2) value of 111.3+/-40.3 mmHg and a mean acute physiology and chronic health evaluation score (APACHE II) of 17.3+/-8.0; 33 patients had a lung injury score >2.5. Forty-one and 67 patients had ARDS associated with diseases of pulmonary and extrapulmonary origin, respectively. The most common predisposing factors for ARDS were pneumonia (34.3%) and nonpulmonary sepsis (30.6%). The overall ICU mortality was 10.3%. In-hospital and 90-day mortalities of ARDS patients were 68.5 and 70.4%, respectively, and accounted for 13.5% of the overall ICU mortality. For ARDS patients, multiple organ dysfunction syndrome was a major risk factor associated with death (59.5%). CONCLUSION: The high morbidity and mortality of ARDS in the ICUs in Shanghai require reassessment of respiratory and intensive care management and implementation of effective therapeutic interventions.
PMID: 15650866 [PubMed - in process]
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