Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit.

OBJECTIVE: In this study, clinical practice guidelines were developed by a multidisciplinary team for patients with infections admitted to a surgical intensive care unit (ICU). DESIGN: A 51-day baseline audit period (Phase I) in a 20-bed (private rooms) surgical ICU was compared with a 34-day period in the same unit after implementation of the guidelines (Phase II). PATIENTS: Phase I included 182 patients (670 patient days), and Phase II included 139 patients (427 patient days). RESULTS: There was no significant difference between patients in the Phase I and Phase II groups regarding age (65.4/19-95 vs. 64.8/18-90 yrs), gender (56% male vs. 55% male), severity of illness (mean Acute Physiology and Chronic Health Evaluation III, 38 vs. 39.1), total infections (respiratory, 8% vs. 4%; urinary tract, 15% vs. 4%; wound, 4% vs. 3%; skin/soft tissue, 3% vs. 7%; sepsis, 5% vs. 3%; intra-abdominal, 9% vs. 17%), and no infection (64% vs. 67%). Clinical outcomes of patients with infections in the Phase I group compared with those in the Phase II group were as follows: clinical improvement or cure, 64% vs. 76%; persistent infection, 17% vs. 11%; clinical failure, 0 vs. 2%; and death, 18% vs. 7% (p = NS). When patients with infections were compared, death rates were 20% in the Phase I group and 5.6% in the Phase II group (p = .02). After implementation of the clinical pathways, antibiotic costs were reduced from $676.54 per patient to $157.88 per patient (p = .001). Length of stay in the ICU was 3.7 days in the Phase I trial and a mean of 3 days in the Phase II trial (p = NS). Specimens of Escherichia coli demonstrated a trend toward a decreased resistance to all antibiotics and Pseudomonas aeruginosa to ciprofloxacin and aminoglycosides (p = NS). CONCLUSIONS: In this study, the use of clinical practice guidelines for patients who were admitted to the surgical ICU was shown to reduce costs, without adversely affecting patients' outcomes. This study has important implications for the use of clinical practice guidelines for the management of patients with infections who are admitted to surgical ICUs.

An exploratory analysis of medication utilization in a medical intensive care unit.

OBJECTIVES: To evaluate patterns of medication use in a medical intensive care unit (ICU) and to explore relationships between drug use, patient age, admitting diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) scores, length of stay, and survival. DESIGN: Combination prospective and retrospective study. SETTING: Medical ICU in a large teaching institution. PATIENTS: Patient admissions (n = 191) to a medical ICU during a 4-month study period. INTERVENTIONS: The following data were collected: age, length of stay, diagnosis, physiologic variables necessary for APACHE II scores, medications administered, and survival. MEASUREMENTS AND MAIN RESULTS: The mean length of stay of the study patients was 5.2 +/- 9.8 days. Overall mortality rate was 33%. The mean age of survivors, 62.7 yrs, was significantly (p < .05) lower than that value for nonsurvivors (68.6 yrs). Postcardiopulmonary resuscitation (CPR) or -stroke patients had a mortality rate that was higher than the overall mortality rate (p < .05). APACHE II scores of > 19 were associated with a reduced survival rate when compared with the overall mortality rate. The mean daily and mean total number of medications administered per patient were 7.5 +/- 3.4 and 12.1 +/- 7.6, respectively. Antihypertensives/vasodilators and gastrointestinal prophylaxis medications were administered most commonly in 69% and 65% of patients, respectively. The median total drug use per patient was significantly greater in nonsurvivors vs. survivors (13 and 10, respectively, p < .02). There was a positive linear relationship between total medication use and log length of stay (r2 = .62). Patients admitted post-CPR or with seizures received the highest number of medications (p < .05). CONCLUSIONS: Patients admitted to the medical ICU receive multiple medications from a variety of pharmacologic classes. Prolonged length of stay, certain admitting diagnoses, and death are associated with increased medication administration. Age, certain admitting diagnoses, and APACHE II scores are significantly related to survival.