Deep Blue Collection: Pulmonary & Critical Care Medicine, Division of

Seduction and Insight from Cross-National Comparisons

Sun, 01 Nov 2009 00:00:00 GMT

Title: Seduction and Insight from Cross-National Comparisons

Authors: Iwashyna, Theodore J.; Lynch, Julia

Abstract: Editorial discussing the stregnths and limitations of crossnational comparisons of critical care, with particular reference to Use of Intensive Care Services during Terminal Hospitalizations in England and the United StatesHannah Wunsch, Walter T. Linde-Zwirble, David A. Harrison, Amber E. Barnato, Kathryn M. Rowan, and Derek C. AngusAJRCCM 2009 180: 875-880.

The effect of an intensive care unit staffing model on tidal volume in patients with acute lung injury

Mon, 03 Nov 2008 00:00:00 GMT

Title: The effect of an intensive care unit staffing model on tidal volume in patients with acute lung injury

Authors: Cooke, Colin; Watkins, Timothy; Kahn, Jeremy; Treggiari, Miriam; Caldwell, Ellen; Hudson, Leonard; Rubenfeld, Gordon

Abstract: IntroductionLittle is known about the mechanisms through which intensivist physician staffing influences patient outcomes. We aimed to assess the effect of closed-model intensive care on evidence-based ventilatory practice in patients with acute lung injury (ALI).MethodsWe conducted a secondary analysis of a prospective population-based cohort of 759 patients with ALI who were alive and ventilated on day three of ALI, and were cared for in 23 intensive care units (ICUs) in King County, Washington.ResultsWe compared day three tidal volume (VT) in open versus closed ICUs adjusting for potential patient and ICU confounders. In 13 closed model ICUs, 429 (63%) patients were cared for. Adjusted mean VT (mL/Kg predicted body weight (PBW) or measured body weight if height not recorded) for patients in closed ICUs was 1.40 mL/Kg PBW (95% confidence interval (CI) = 0.57 to 2.24 mL/Kg PBW) lower than patients in open model ICUs. Patients in closed ICUs were more likely (odds ratio (OR) = 2.23, 95% CI = 1.09 to 4.56) to receive lower VT (≤ 6.5 mL/Kg PBW) and were less likely (OR = 0.30, 95% CI = 0.17 to 0.55) to receive a potentially injurious VT (≥ 12 mL/Kg PBW) compared with patients cared for in open ICUs, independent of other covariates. The effect of closed ICUs on hospital mortality was not changed after accounting for delivered VT.ConclusionsPatients with ALI cared for in closed model ICUs are more likely to receive lower VT and less likely to receive higher VT, but there were no other differences in measured processes of care. Moreover, the difference in delivered VT did not completely account for the improved mortality observed in closed model ICUs.

The Structure of Critical Care Transfer Networks

Wed, 01 Jul 2009 00:00:00 GMT

Title: The Structure of Critical Care Transfer Networks

Authors: Iwashyna, Theodore J.; Christie, Jason D.; Moody, James; Kahn, Jeremy M.; Asch, David A.

Abstract: Rationale: Moving patients from low-performing hospitals to high-performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival.Objective: To characterize the existing critical care network in terms of the pattern of transfers.Methods: In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations.Measurements: We measured the characteristics of the interhospital transfer network and the extent to which intensive care unit patients are referred to each hospital in that network--a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical, and radiologic capabilities.Results: There were 47,820 transfers of critically ill patients among 3308 hospitals. 4.5% of all critical care stays of any length involved an interhospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital positions were associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality.Conclusions: Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.

Intensive care unit occupancy and patient outcomes

Fri, 01 May 2009 00:00:00 GMT

Title: Intensive care unit occupancy and patient outcomes

Authors: Iwashyna, Theodore J.; Kramer, Andrew A.; Kahn, Jeremy M.

Abstract: Principle: Although intensive care units (ICUs) with higher overall patient volume may achieve better outcomes than lower volume ICUs, there are few data on the effects of increasing patient loads on patients within the ICU.Objectives: To examine the association of ICU occupancy with the patient outcomes within the same ICU.Methods: We examined 200,499 patients in 108 ICUs using the Acute Physiology and Chronic Health Evaluation IV database in 2002-2005. Daily census on the day of admission was determined for each patient and defined in relation to the mean census. We used conditional logistic regression to compare inpatient outcomes of patients admitted on high census days to those admitted in the same ICU on low census days. We controlled for severity of illness at the patient level using data on clinical, demographic, and physiologic variables on admission to the ICU.Measurements and Main Results: Patients admitted on high census days had the same odds of inpatient mortality or transfer to another hospital as patients admitted on average or on low census days. These findings were robust to multiple alternative definitions of day of admission census and were confirmed in several subgroup analyses.Conclusions: The ICUs in this data are able to function as high reliability organizations. They are able to scale up their operations to meet the needs of a wide range of operating conditions while maintaining consistent patient mortality outcomes.