Strategy for intensive care in patients with subarachnoid hemorrhage

Severe medical complications account for 20-30% of all deaths in patients with subarachnoid hemorrhage. High quality of intensive care is needed to prevent and correct pulmonary complications and electrolyte disturbances. Guidelines of intensive medical treatment should be defined to control intracranial hypertension and ischemic secondary cerebral damage in comatose patients. Extensive monitoring is necessary to achieve adequate observation in the perioperative period and safe treatment of vasospasm. A multidisciplinary approach in a critical area with intensive and sub-intensive beds, based on the cooperative role of neurosurgeons and anesthetists/intensivists, could improve the medical care, reducing complications, ICU stay and costs.     

Mental health consultation in the pediatric intensive care unit.

The need for psychosocial intervention to be integrated with medical care on intensive care units is high, but too often mental health professionals are ill-equipped by traditional training programs for such work. Medical crisis counseling provides a conceptual framework useful in developing the skills needed to effectively intervene in such settings. The pediatric intensive care unit ( PICU ) is arguably one of the most emotionally demanding and high-stress areas where mental health clinicians may be asked to consult. This article describes medical crisis consultation in the PICU setting, suggests survival strategies for the mental health consultant to the PICU, and provides illustrative case examples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Toward a medical approach to the evaluation of activity in a physician-staffed mobile intensive care unit

OBJECTIVE: To test the ability of various medical criteria for classifying the patients in a physician-staffed mobile intensive care unit (MICU) by referring to intervention times. STUDY DESIGN: Prospective, open study. PATIENTS AND METHODS: For all the on-scene interventions of the MICUs over a 10-month period, the following data were prospectively collected: pre-hospital diagnosis, initial severity score, medical care score, immediate outcome and three intervention times: on-scene time (OS), time spent with the patient by the MICU team (MT), total duration of intervention (TD). RESULTS: A total of 3,672 MICU interventions were included. Median times were 45 min (32-59) for OS, 66 min (41-91) for MT and 85 min (61-116) for TD. The amount of interventions in a city was correlated with the population (R = 0.95; P < 0.001). The medical care score was greater than one in more than half of the patients. It defined five groups of patients which were different for the three intervention times (P < or = 0.001). A third of the patients were directly transported by the MICU to an ICU. For the median test, immediate outcome groups were different for the three intervention times (P < 0.001). After exclusion of patients with initial cardiac arrest, initial severity score defined five groups of patients which were different for the three intervention times (P < 0.002). Initial severity score and medical care score were correlated (R = 0.37; P < 0.001). CONCLUSION: A classification of the patients based on immediate outcome would be a more accurate indicator of the variability in medical care and consumption of resources in a physician-staffed MICU. In addition, a medical intervention score should be developed to better characterise this medical activity.     

The impact of major congenital malformations on mortality in a neonatal intensive care unit

Neonatal mortality due to congenital malformations or genetic disorders has not decreased despite a decrease in overall neonatal deaths with recent advances in medical technology. As a consequence, an increasing percentage of neonatal deaths is attributable to congenital malformations and genetic disorders. This study retrospectively reviewed neonatal deaths associated with congenital malformations over an 11-year period in the neonatal intensive care unit (NICU) at Kosair Children's Hospital, Louisville, Kentucky. Presently, congenital malformations are responsible for approximately 45% (range 32% to 61%) of deaths in the NICU with congenital heart disease, lethal genetic disorders, and pulmonary hypoplasia being the main contributors. Other major causes of neonatal death included extreme prematurity, respiratory disorders, necrotizing enterocolitis, sepsis, asphyxia, and primary pulmonary hypertension. It is important that clinicians are aware that improved survival is expected for most diseases because of technological advances, but that further significant reductions in neonatal mortality will depend on genetic counseling and prevention of congenital malformations.     

Prevalence of the Cys282Tyr and His63Asp HFE gene mutations in Spanish patients with hereditary hemochromatosis and in controls

The article outlines a nine-step process adopted at The University of Texas MD Anderson Cancer Center for handling patient requests for medically inappropriate interventions. The main step in the process is review by an Institutional Review Committee composed of the physician-in-chief, ethics committee members, and medical experts. The decision of the Review Committee is binding. The experience with this "futility" policy is discussed including a follow-up pilot project conducted by the Department of Gynaecologic Oncology that introduces a standardized advance care planning medical record progress note in which patient preferences about cardiopulmonary resuscitation, mechanical ventilation, and location of death are documented. The note is to be used at the beginning of non-curative therapy and is intended to help to avoid future requests for futile interventions.     

Outreach education to improve quality of rural ICU care. Results of a randomized trial

This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes.     

Metabolical changes induced by adaptation to circumpolar conditions in Spitsbergen

The Home Hospitalization Programme was initiated in Jerusalem in 1991 to provide intensive medical care at home in order to prevent or shorten hospitalizations. The programme was based upon regular home visits by physicians, and nursing assessment to determine the need for regular nursing care. Primary-care physicians and nurses were renumerated by a global monthly fee, and were on 24-h call in addition to their periodic visits. Patients were recruited by senior geriatric physicians from acute hospital wards, as well as from the community, at the family doctor's request. Ancillary services available to the home hospitalization team included laboratory and electrocardiographic testing, specialty consultations, physical occupational or speech therapy, social work and home help up to 3 h daily. Monthly visits by a senior physician provided oversight and further consultation. Home hospitalization grew out of the continuing care division of the Clalit Sick Fund, a health maintenance organization providing umbrella medical insurance and ambulatory care. The programme grew synergistically with the other facilities of continuing care to encompass a network of comprehensive services to acute, subacute and chronic patients both at home and in institutional settings. In 4 years this network succeeded in establishing the focus of subacute intensive care in the community, achieving high levels of patient and family satisfaction, as well as striking economic advantages. In its first 2 years of operation home hospitalization saved S4 million due to reduced hospital utilization, and preliminary data for the subsequent 2 years indicated that this trend continued. Home hospitalization became the hub of a far-reaching system of supportive, intensive and humane care in the community.     

Responding to trauma—extraordinarily meaningful.

The behavioral and psychological component of trauma is critical. It is noted that the National Highway Traffic Safety Administration seeks to ensure that every citizen in the US is served by an organized and coordinated system of timely and effective emergency medical care. However, the field of emergency medical services is changing and these changes require new players and partners. States are focusing on inclusive systems of emergency medical care that encompass trauma care and injury prevention. Thus, behavioral scientists will play a greater role than ever before. An example is given of training for trauma intervention, in which a school of professional psychology operates the local hospital emergency room crisis service. Staffed by faculty and students, they triage, treat, or refer all mental health emergencies. A case is also made for more research on causation and prevention of accidental deaths and injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Memory function in aging and Parkinson''s disease--an event-related potential study]

PURPOSE: Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs. RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were $89,355 ($484 per intervention patient). CONCLUSION: This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.     

Clinical implications of cyclins, cyclin-dependent kinases, RB and E2F1 in squamous-cell lung carcinoma

OBJECTIVE: To develop, implement, and assess the outcomes of a system for providing pharmaceutical care to medical progressive care patients. METHODS: A system for providing pharmaceutical care was developed and implemented for an 8-week period beginning in June 1995. Both patient care outcomes and drug therapy cost change from the intervention period were compared with those of an 8-week baseline period. Variables compared included unit length of stay, hospital length of stay, transfers to the intensive care unit, readmissions, and adverse drug reactions requiring treatment. Differences between periods for these variables were assessed by using chi 2 tests and t-tests with alpha set at p less than 0.05. The clinical significance of the interventions were assessed independently by four physicians: two intensivists and two internists. The total drug therapy cost change from the intervention period was calculated as follows: total cost avoidance from individual recommendations subtracted from the total cost incurred from individual recommendations. RESULTS: The pharmacist evaluated 152 patients during the intervention period. A total of 235 pharmacotherapy recommendations were made on 103 patients, of whom 86.4% were accepted. Significantly fewer adverse drug reactions (ADRs) received treatment during the intervention period (p = 0.027). The mean unit length of stay was lower during the intervention period (4.8 +/- 3.7 d) than during the baseline period (6.0 +/- 5.6 d); however, this difference was not significant (p = 0.053). Individual physician assessment of the pharmacists' recommendations revealed that 75.8% were considered somewhat significant, significant, or very significant. The total drug therapy cost change from the intervention period was -$6534.53. The projected annual drug therapy cost reduction from this study is $42,474.45. CONCLUSIONS: The provision of pharmaceutical care to medical progressive care patients was associated with a substantial decrease in drug therapy cost and a decrease in the number of ADRs that required treatment.     

APACHE II, data accuracy and outcome prediction

From review of 122 intensive care charts, Acute Physiology and Chronic Health Evaluation (APACHE) II points were determined for eight physiological values. Using a strict interpretation of APACHE II criteria, an average of 20.6% of these points were higher and 6.7% lower than the points entered originally into an intensive care database. The resulting 1.73 points mean increase in APACHE II score increased predicted mortality from 24.8% to 27.8% and decreased the mortality ratio (observed hospital deaths devided by predicted deaths) from 1.52 (95% confidence interval: 1.11-2.03) to 1.35 (95% confidence interval: 0.99-1.81). There were few errors entering the data recorded on the audit form into the intensive care unit database with an optical mark reader and keyboard. Inaccuracy and inconsistency in data collection must be excluded before differences in mortality ratios are ascribed to intensive care unit performance.     

A discussion of futility and chronic wound care

Although futility is commonly referred to when discussing end-of-life issues, theories of futile care are applied to issues of chronic care, particularly chronic wound care, herein. A case study will be used within the context of defining futility, understanding beneficence in healthcare, and discussing the obligation of the clinician to deliver therapeutic intervention that balances burden with benefit. Open and honest communication will be highlighted as one method to facilitate resolution when dilemmas of futility occur.     

Computer based nursing documentation means to achieve the goal

New functions have been integrated in the Giessen Hospital Information System WING to support the classification of all intensive care patients into the Therapeutic Intervention Scoring System (TISS). The use of those functions has been pushed when health insurance bodies demanded evidence for the correct classification of ICU beds. This article presents an overview on this development from the start in just one intensive care unit to the complete coverage of six intensive care units and three intensive monitoring units with a total of 109 beds. For those units complete TISS data has been documented for more than a year now at a detailed level. On average 14 interventions have been recorded per patient and day, accumulating to a database with more than a million entries. We describe the experiences made during introduction and the different front-end applications we used to achieve the goal. Results gained from the huge database and their implications for our future work are discussed. TISS documentation is now an established routine on every intensive care unit of our University hospital. It has been implemented without major financial or manpower investments and no specific intensive care information system has been needed. Establishing this type of basic care documentation made nurses aware of their activities, so that now they consider electronic care documentation to be in their very own interest. The next goal has been set by nurses themselves, they want to establish intervention based care documentation on normal wards as well. We think that step by step we will thus be able to achieve a more complete electronic patient record.     

Deciding about cardiopulmonary resuscitation. The contributions of decision analysis

BACKGROUND: Patients have the right to decide whether to authorize cardiopulmonary resuscitation (CPR). Physicians should provide adequate information and help clarify preferences. METHODS: The usefulness of decision analysis was investigated in two convenience samples: 20 healthy outpatient volunteers and 35 audience members at medical ethics grand rounds. Subjects quantified their relative preferences (utilities) for the outcomes of cardiac arrest. First, they rated them on a linear scale. Second, they participated in hypothetical gambles in which they indicated how much they would risk to avoid each outcome. The investigator then calculated the overall expected utilities of the CPR and no-CPR strategies. RESULTS: Subjects were able to complete both the gambles and the rating scale. Utilities derived by the two methods differed greatly. Subjects had strong aversions to an outcome of severe long-term brain damage and widely varying ratings of an outcome of a short period of intensive care followed by death (intensive care unit death). Because intensive care unit death is far more likely than long-term brain damage, its utility was the prime determinant of whether CPR or no-CPR had the higher calculated expected utility. CONCLUSIONS: The methods of decision analysis showed promise as a means not only of informing patients about CPR but of helping them make rational choices. They also revealed the inadequacy of current data on the key outcome of intensive care unit death.     

The intermediate care unit as a cost-effective option for the treatment of medical patients in critical condition

Since the limited accessibility of general intensive care units creates a situation in which medical patients in critical condition continue to be cared for in the regular wards, we conducted a retrospective cohort study to assess the treatment outcomes in such patients referred to the medical intermediate care unit (MICU). At the Soroka Medical Center, a facility with 810 beds, of which 170 beds are in medical wards, including an 8-bed intensive cardiac care unit and a 5-bed general intensive care unit, 119 patients were referred to the MICU, directly from the emergency room or from medical wards, during the first half of 1994. Eighty percent of the patients were admitted to the MICU directly from the emergency room. The mean disease severity, as measured by the APACHE II score, was 12.9, and the mean intensity of care for these patients, as measured by the TISS scale, was 12.6. Twenty-one of the 119 patients died during hospitalization (17.6%). This mortality rate conformed to the mortality risk of 15.5%, which was calculated using prognostic formulae. The ratio of nursing staff to patient in the MICU was approximately 1:3, compared to 2:3 in the general intensive care unit and 1:12 in the wards. The mean cost of one day of hospitalization in the MICU was one-third that in the general intensive care unit and double the cost in a ward. Medical patients in critical condition can be treated in an MICU, with a savings in expenses and without impairing the patient's chances for survival.     

Managing time for greater effectiveness: designing doctor''s ideal day

We cannot rely on geriatricians, internists, and family practitioners alone in the medical community to provide all of the geriatric care. Even though there are alternatives to the use of specialists, we cannot afford to ignore the largest group of current physician trainees who will provide a great deal of geriatric medical care in the future. We need to help make the basic principles of geriatric care part of every training program for every resident, whether in general or specialty programs.     

Four different ways of philanthropic aid to the blind in medieval eastern Christendom

The care of the blind, either as medical treatment or as divine therapy, has probably been the most ancient form of help for ill people. However, it was during the Byzantine Empire (325-1453 AD) that the state organized a 'blindness relief' plan as part of a widespread public health system. Our sources for the subject include medical writings, state decrees, Saint's 'vitae' and representations of relevant works of art. Based on the above data we classify the health care for the blind in Byzantium as: (a) support of ophthalmological education as evidenced by an abundance of medical writings on the subject; (b) establishment of charitable institutions exclusively or partially for the blind, where there was not only medical care but also provision for a wide range of social aid - the most advanced being specially trained escorts for each blind person; and (c) support by the state of an extended chain of religious institutions where miraculous help for the blind was promised. We conclude that the public health policy in Byzantium made adequate and very early provision for the blind.     

Intensive care, old age, and the problem of death in America

This article, part of a larger anthropological investigation of how death occurs in the hospital, explores the relationship of elderly deaths in the intensive care unit to the cultural conversation about the desire for "death with dignity." Based on participant observation, it provides three case studies that focus on the unfolding of events surrounding patient treatment, decision making, and family involvement. The cases are interpreted in the context of four sources of the culturally defined "problem" of death: (a) how medicine operates as the dominant conceptual framework for understanding both old age and death; (b) the power of the technological imperative to determine events; (c) ambivalence regarding end-of-life goals; and (d) the incommensurability of lay and medical knowledge.