RESUMO
OBJECTIVES: Studies evaluating telemedicine critical care (TCC) have shown mixed results. We prospectively evaluated the impact of TCC implementation on risk-adjusted mortality among patients stratified by pre-TCC performance. DESIGN: Prospective, observational, before and after study. SETTING: Three adult ICUs at an academic medical center. PATIENTS: A total of 2,429 patients in the pre-TCC (January to June 2016) and 12,479 patients in the post-TCC (January 2017 to June 2019) periods. INTERVENTIONS: TCC implementation which included an acuity-driven workflow targeting an identified "lower-performing" patient group, defined by ICU admission in an Acute Physiology and Chronic Health Evaluation diagnoses category with a pre-TCC standardized mortality ratio (SMR) of greater than 1.5. MEASUREMENTS AND MAIN RESULTS: The primary outcome was risk-adjusted hospital mortality. Risk-adjusted hospital length of stay (HLOS) was also studied. The SMR for the overall ICU population was 0.83 pre-TCC and 0.75 post-TCC, with risk-adjusted mortalities of 10.7% and 9.5% (p = 0.09). In the identified lower-performing patient group, which accounted for 12.6% (n = 307) of pre-TCC and 13.3% (n = 1671) of post-TCC ICU patients, SMR decreased from 1.61 (95% CI, 1.21-2.01) pre-TCC to 1.03 (95% CI, 0.91-1.15) post-TCC, and risk-adjusted mortality decreased from 26.4% to 16.9% (p < 0.001). In the remaining ("higher-performing") patient group, there was no change in pre- versus post-TCC SMR (0.70 [0.59-0.81] vs 0.69 [0.64-0.73]) or risk-adjusted mortality (8.5% vs 8.4%, p = 0.86). There were no pre- to post-TCC differences in standardized HLOS ratio or risk-adjusted HLOS in the overall cohort or either performance group. CONCLUSIONS: In well-staffed and overall higher-performing ICUs in an academic medical center, Acute Physiology and Chronic Health Evaluation granularity allowed identification of a historically lower-performing patient group that experienced a striking TCC-associated reduction in SMR and risk-adjusted mortality. This study provides additional evidence for the relationship between pre-TCC performance and post-TCC improvement.
RESUMO
BACKGROUND: Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown. OBJECTIVES: To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning. METHODS: A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals. RESULTS: Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05). CONCLUSIONS: A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.
