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Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for the expected range of patient ...
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Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for the expected range of patient illness and injury and throughput are determined. Simultaneously, non-ICU clinical responsibilities and other expectations, such as education of trainees and participation in hospital operations, must be understood. To meet these responsibilities, physicians must be recruited, mentored, and retained. The physician leader may have similar responsibilities for nonphysician practitioners. In concert with other critical care leaders, the service adopts a model of care and assembles an ICU team of physicians, nurses, nonphysician providers, respiratory therapists, and others to provide clinical services. Besides clinician resources, leaders must assure that services such as radiology, pharmacy, the laboratory, and information services are positioned to support the complexities of ICU care. Metrics are developed to report success in meeting process and outcomes goals. Leaders evolve the system of care by reassessing and modifying practice patterns to continually improve safety, efficacy, and efficiency. Major emphasis is placed on the importance of continuity, consistency, and communication by expecting practitioners to adopt similar practices and patterns. Services anticipate and adapt to evolving expectations and resource availability. Effective services will result when skilled practitioners support one another and ascribe to a service philosophy of care.
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Leaders of critical care services require knowledge and skills not typically acquired during their medical education and training. Leaders possess personality characteristics and evolve and adopt behaviors and knowledge in additio...
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Leaders of critical care services require knowledge and skills not typically acquired during their medical education and training. Leaders possess personality characteristics and evolve and adopt behaviors and knowledge in addition to those useful in the care of patients and rounding with an ICU team. Successful leaders have impeccable integrity, possess a service mentality, are decisive, and speak the truth consistently and accurately. Effective leaders are thoughtful listeners, introspective, develop a range of relationships, and nurture others. They understand group psychology, observe, analyze assumptions, decide, and improve the system of care and the performance of their team members. A leader learns to facilely adapt to circumstance, generate new ideas, and be a catalyst of change. Those most successful further their education as a leader and learn when and where to seek mentorship. Leaders understand their organization and its operational complexities. Leaders learn to participate and knowledgeably contribute to the fiscal aspects of income, expense, budget, and contracts from an institutional and department perspective. Clinician compensation must be commensurate with expectations and be written to motivate and make clear duties that are clinical and nonclinical. A leader understands and plans to address the evolving challenges facing healthcare, especially resource constraints, the emotions and requirements of managing the end of life, the complexities of competing demands and motivations, the bureaucracy of healthcare practice, and reimbursement. Responsibilities to manage and evolve must be met with intelligence, sensitivity, and equanimity.
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Patients admitted to internal medicine may be moved to more advanced-care settings when their condition deteriorates. In these advanced care settings, there may be higher levels of monitoring and greater ability to deliver Intensi...
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Patients admitted to internal medicine may be moved to more advanced-care settings when their condition deteriorates. In these advanced care settings, there may be higher levels of monitoring and greater ability to deliver Intensive Medical Treatments (IMTs). To the best of our knowledge, no previous study has examined the proportion of patients at different levels of care who receive different types of IMTs.In this retrospective observational cohort study, we examined data from 56,002 internal medicine hospitalizations at Shaare Zedek Medical Center, between 01.01.2016 and 31.12.2019. Patients were divided according to where they received care: general-ward, Intermediate-Care Unit, Intensive Care Unit (ICU), or both (Intermediate-Care and ICU). We examined the rates at which these different groups of patients received one or more of the following IMTs: mechanical ventilation, daytime bi-level positive airway pressure (BiPAP), or vasopressor therapy.Most IMTs were delivered in a general-ward setting – ranging from 45.9% of IMT-treated hospitalizations involving combined mechanical ventilation and vasopressor therapy to as high as 87.4% of IMT-treated hospitalizations involving daytime BiPAP. Compared to ICU patients, Intermediate-Care Unit patients were older (mean age 75.1 vs 69.1, p < 0.001 for this and all other comparisons presented here), had longer hospitalizations (21.3 vs 14.5 days), and were more likely to die in-hospital (22% vs 12%). They were also more likely to receive most of the IMTs compared to ICU patients. For example, 9.7% of Intermediate-Care Unit patients received vasopressors, compared to 5.5% of ICU patients.In this study, most of the patients who received IMTs actually received them in a general-bed and not in a dedicated unit. These results imply that IMTs are predominantly delivered in unmonitored settings, and suggest an opportunity to re-examine where and how IMTs are given. In terms of health policy, these findings suggest a need to further examine the setting and patterns of intensive interventions, as well as a need to increase the number of beds dedicated to delivering intensive interventions.
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Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306-11, 2014; Roberts and Scott, Med Care 48(11):1026-35...
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Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths (Kaye and Marchaim, J Am Geriatr Soc 62(2):306-11, 2014; Roberts and Scott, Med Care 48(11):1026-35, 2010; Warren and Quadir, Crit Care Med 34(8):2084-9, 2006; Zimlichman and Henderson, JAMA Intern Med 173(22):2039-46, 2013). Importantly, infections acquired during a hospital stay have been shown to be preventable (Loveday and Wilson, J Hosp Infect 86:S1-70, 2014). In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes. This meta-analysis aims to summarise the effectiveness of chlorhexidine (CHG) bathing, in adult intensive care patients, to reduce infection. A systematic literature search was undertaken to identify trials assessing the effectiveness of CHG bathing to reduce risk of infection, among adult intensive care patients. Infections included were: bloodstream infections; central line-associated bloodstream infections (CLABSI); catheter-associated urinary tract infections; ventilator-associated pneumonia; methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus; and Clostridium difficile. Summary estimates were calculated as incidence rate ratios (IRRs) and 95% confidence/credible intervals. Variation in study designs was addressed using hierarchical Bayesian random-effects models. Seventeen trials were included in our final analysis: seven of the studies were cluster-randomised crossover trials, and the remaining studies were before-and-after trials. CHG bathing was estimated to reduce the risk of CLABSI by 56% (Bayesian random effects IRR?=?0.44 (95% credible interval (CrI), 0.26, 0.75)), and MRSA colonisation and bacteraemia in the ICU by 41% and 36%, respectively (IRR?=?0.59 (95% CrI, 0.36, 0.94); and IRR?=?0.64 (95% CrI, 0.43, 0.91)). The numbers needed to treat for these specific ICU infections ranged from 360 (CLABSI) to 2780 (MRSA bacteraemia). This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.
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Delirium is a common occurrence in cardiac and cardiovascular surgical intensive care units. Due to multiple confounding factors, this diagnosis remains challenging for medical professionals. Multiple theories exist regarding the ...
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Delirium is a common occurrence in cardiac and cardiovascular surgical intensive care units. Due to multiple confounding factors, this diagnosis remains challenging for medical professionals. Multiple theories exist regarding the pathophysiology of delirium, which include disruption of neurotransmitters as well as inflammation. Delirium has been associated with prolonged hospitalizations and an increase in mortality. Although there are widely used screening tools for delirium, none have been validated in this particular patient population. Limited treatments exist for delirium, so: both pharmacologic and nonpharmacologic preventative measures should be employed in this patient population.
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Background: Advanced age might limit intensive care unit (ICU) admission or aggressive treatments. Outcome comparisons of elderly patients mortality admitted to the ICU have been made with a much younger population, admitted often...
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Background: Advanced age might limit intensive care unit (ICU) admission or aggressive treatments. Outcome comparisons of elderly patients mortality admitted to the ICU have been made with a much younger population, admitted often times for different reasons and in significantly healthier conditions. This could lead to unreliable conclusions. This study assesses mortality in ICU patients age 65 and older who presumably have a closer health status, and the level of aggressiveness of ICU procedures performed on them.
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The prognosis of cirrhotic patients admitted to the ICU is considered to be poor but has been mainly reported in liver ICU. We aimed to describe the prognosis of cirrhotic patients admitted to a general ICU, to assess the predicto...
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The prognosis of cirrhotic patients admitted to the ICU is considered to be poor but has been mainly reported in liver ICU. We aimed to describe the prognosis of cirrhotic patients admitted to a general ICU, to assess the predictors of mortality in this population, and, finally, to identify a subgroup of patients in whom intensive care escalation might be discussed. We performed a retrospective monocentric study of all cirrhotic patients consecutively admitted between 2002 and 2014 in a general ICU in a regional university hospital. Two hundred and eighteen?cirrhotic patients were admitted to the ICU. The 28-day and 6-month mortality rates were 53 and 74?%, respectively. Among the 115 patients who were discharged from ICU, only eight patients underwent liver transplantation, whereas 48 had no clear contraindication. Multivariable analyses on 28-day mortality identified three independent variables, incorporated into a new three-variable prognostic model as follows: SOFA?≥?12 (OR 4.2 [2.2-8.0]; 2 points), INR?≥?2.6 (OR 2.5 [1.3-4.8]; 1 point), and renal replacement therapy (OR 2.3 [1.1-5.1]; 1 point). For a value of the score at 4 (16?% of patients), 28-day and 3-month mortality rates were 91 and 100?%, respectively. An external validation of the score among 149 critically ill cirrhotic patients showed a good accuracy for predicting in-ICU mortality. Mortality of cirrhotic patients admitted to a general ICU was comparable to that of other studies. A pragmatic score integrating the SOFA score, INR, and the need for extrarenal epuration was strongly associated with mortality. Among the 16?% of patients presenting with score 4 at ICU admission, 100?% died in the 3-month follow-up period. The prognostic evaluation on day 3 remains essential for the majority of patients. However, this score calculable at ICU admission might identify patients in whom the benefit of intensive care escalation should be discussed, in particular when liver transplantation is contraindicated.
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