Effect of infections on 30-day mortality among critically ill patients hospitalized in and out of the intensive care unit.

BACKGROUND: This analysis is part of a multicenter study conducted in Israel to evaluate survival of critically ill patients treated in and out of intensive care units (ICUs). OBJECTIVE: To assess the role of infection on 30-day survival among critically ill patients hospitalized in ICUs and regular wards. DESIGN: All adult inpatients were screened on four rounds for patients meeting ICU admission criteria. Retrospective chart review was used to detect presence and type of infection. Mortality was ascertained from day of meeting study criteria to 30 days thereafter. ANALYSIS: The effect of infection on mortality among patients, treated in and out of the ICU, was compared using Kaplan Meier survival curves. Multivariate Cox models were constructed to adjust interdepartmental comparisons for case-mix differences. RESULTS: Of 641 critically ill patients identified, 36.8% already had an infection on day 0. An additional 40.2% subsequently developed a new infection during the follow-up period, ranging from 64.6% in the ICU to 31.5% in regular wards (p < .001). Resistant infections were more prevalent in ICUs. Infection was independently associated with an increase in mortality, regardless of whether the patient was admitted to the ICU. There was no difference in the adjusted risk of mortality associated with an infection diagnosed on day 0 vs. an infection diagnosed later. Risk of dying was similar in resistant and nonresistant infections. Adjusting for infections, survival of ICU patients was better relative to patients in regular wards (adjusted hazard ratio = 0.7). Among the different types of infection, risk of mortality from pneumonia was significantly lower in ICUs relative to regular wards. There was a protective effect in ICUs among noninfected patients. CONCLUSION: The risk of acquiring a new infection is greater in the ICU. However, risk of mortality among ICU patients was lower for the most serious infections and for those without any infection.

Cardiopulmonary resuscitation surprise drills for assessing, improving and maintaining cardiopulmonary resuscitation skills of hospital personnel.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a sudden emergency procedure that requires a rapid and efficient response, and personnel trained in lifesaving procedures. Regular practice and training are necessary to improve resuscitation skills and reduce anxiety among the staff. Western Galilee Hospital has developed simulator programs for surprise CPR training exercises in all hospital departments and units. This study assessed the efficacy of surprise drills. METHODS: Advanced cardiac life-support instructors performed 131 surprise drills between 2003 and 2005, using a computerized simulation mannequin (SIM 4000). Nine criteria were measured and scored in the drill: reaction time, CPR according to ABC principles, calling for doctor, CPR knowledge, CPR skills, resuscitation management, staff work, resuscitation chart, and defibrillator management. Drills were evaluated, discussed, and compared with previous drills from the same department and from other departments. RESULTS: A gradual improvement was observed in the results of the drills held through 2003-2005, more significantly in the medical departments than in the surgical departments and outpatient clinics. The average score in 2005 was 77.2% (P=0.001), compared with 74% (P=0.012) in 2004 and 59% (P<0.001) in 2003. Major improved criteria were calling for doctor, staff work, CPR knowledge, and defibrillator (P<0.05). CONCLUSION: It is our belief that surprise resuscitation drills constitute an effective tool to improve performance in case of a real emergency resuscitation, both on a departmental and a general hospital level.

[The importance of CPR training for assessing the knowledge and skills of hospital medical and nursing personnel].

BACKGROUND: Saving life demands only two hands and some basic knowledge. A qualified person can open airways, resuscitate, massage a heart and call for help. A person with cardio-pulmonary resuscitation (CPR) training can sustain an ailing person's heart and brain for a short time. However, knowledge of CPR guidelines and skills is not enough; medical and nursing practitioners must practice and train regularly to hone those skills. Western Galilee Hospital has developed simulator programs for surprise CPR training exercises in all hospital departments and units. OBJECTIVE: To use surprise drills in order to improve the quality of resuscitation and CPR methods. MATERIALS AND METHODS: ACLS (Advanced cardiac life support) instructors use a computerized simulation mannequin (SIM 4000). Two to three surprise drills are conducted in the hospital each week. At the end of each drill, a final report is given to the department head and a staff meeting is held to discuss the drill results. Between the years 2003-2005, 131 drills were carried out in 30 different departments of Western Galilee Hospital. Nine criteria are measured and scored in the drill: reaction time, ABC principles, calling the doctor, CPR knowledge, CPR skills, resuscitation management, staff work, resuscitation chart, and defibrillator management. Drills are compared with previous drills performed in the same department, and with drills conducted in other departments. Data is analyzed using Anova, Kruskal-Wallis, independent t-test and Spearman correlation coefficient test. RESULTS: Improvement was found in the results of the drills held from 2003-2005, mainly in the medical departments as compared with the surgical departments and ambulatory clinics. The average score in 2005 was 77.2 (p = 0.001), compared with 74 (p = 0.012) in 2004, and 59 (p < 0.001) in 2003. Improved criteria included: calling the doctor, staff work, CPR knowledge, and defibrillator (p < 0.05). CONCLUSIONS: It is our belief that surprise resuscitation drills are the key to improve functioning during actual emergency resuscitation, both on a departmental and a general hospital level.

Survival of critically ill patients hospitalized in and out of intensive care.

OBJECTIVE: A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit. DESIGN: A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge. SETTING: Five acute care hospitals. PATIENTS: A total of 749 newly deteriorated patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients. CONCLUSIONS: Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.

[Severe hypercapnia in asthmatic attack].

This is an unusual case, of an adult man who was hospitalized with a severe asthmatic attack and severe hypercapnia, refractory to intensive medical treatment, which responded to pressure mechanical ventilation. We advise to consider this mode of treatment in similar cases.

Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds.

OBJECTIVE: The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. DESIGN: Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. SETTING: Five acute care Israeli hospitals. PATIENTS: All patients fitting a priori developed study criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time. CONCLUSIONS: The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.