Rapid Availability: Do Disposable Bronchoscopes Drive Increased Use?

Unplanned Extubation in Adult Critical Care

Tourniquet use for extremity fractures has no adverse effect on number of ventilator days for patients who are treated with reamed femoral or tibial shaft nails

Variation in Risk-Adjusted Ventilator-Associated Pneumonia Days Within a Quality Collaborative

To determine if reamed femoral intramedullary nailing increases the pulmonary complications seen in chest-injured patients. Retrospective review of prospectively collected trauma database data from January 1991 to October 1994. Methodist Hospital, Indianapolis, Indiana, Level I Trauma Center. Group I: Chest-injured patients [chest Abbreviated Injury Score (AIS) > or = 2] without femur or tibia fractures. Group II: Chest-injured patients (chest AIS > or = 2) with femoral reamed intramedullary fixation. Group III: Chest-injured patients (chest AIS > or = 2) with femoral shaft fixation using nonreamed fixation (rush rods, plating, or external fixation). Group IV: Non-chest-injured patients (chest AIS < 2) with femoral reamed intramedullary fixation. MAIN OUTCOME MEASUREMENT/HYPOTHESIS: Reamed femoral intramedullary nailing does not alter pulmonary outcomes, even in chest-injured patients. Groups I and II had a very similar incidence of adult respiratory distress syndrome (ARDS), pneumonia, and number of ventilator days. Group III had a significantly higher incidence of ARDS and number of ventilator days than did Group I or II. Group III did not have a chest AIS score significantly different than Groups I and II. Group II had significantly higher ARDS and more ventilator days than did Group IV when only analyzing raw data. When injury severity was adjusted, there were no significant differences in pulmonary outcomes. Reamed intramedullary femoral fixation did not increase pulmonary morbidity in chest-injured patients.

BackgroundLower respiratory tract infections (LRTI) are the most common hospital-acquired infections on ICUs. They have not only an impact on each patient’s individual health but also result in a considerable financial burden for the healthcare system. Our aim was to determine the costs and the length of stay of patients with ICU-acquired LRTI.MethodsWe used a retrospectively matched cohort design, comparing patients with ICU-acquired LRTI and ICU patients without LRTI. LRTI was diagnosed using the definitions of the Centers for Disease Control and Prevention (CDC). Study period was from January to December 2010 analyzing patients from 10 different ICUs (medical, surgical, interdisciplinary). The device utilization ratio was defined as number of ventilator days divided by number of patient days and the device-associated LRTI rate was defined as number of ventilator associated LRTI divided by number of ventilator days. Patients were matched by age, sex, and prospectively obtained Simplified Acute Physiology Score II (SAPS II). The length of ICU stay of control patients needed to be at least as long as that of LRTI-patients before onset of LRTI. We used the Wilcoxon signed-rank test for continuous variables and the McNemar’s test for categorical variables.ResultsThe analyzed ICUs had 40,772 patient days in the study period with a median ventilation utilization ratio of 56 (IQR 42–65). The median device-associated LRTI rate was 3.35 (IQR 0.96-5.36) per 1,000 ventilation days. We analyzed 49 patients with ICU-acquired LRTI and 49 respective controls without LRTI. The median hospital costs for LRTI patients were significantly higher than for patients without LRTI (45,041 € vs. 26,467 €; p < .001). The attributable costs per LRTI patient were 17,015 € (p < .001). Patients with ICU acquired LRTI stayed longer in the hospital than patients without (36 days vs. 24 days; p = 0.011). An LRTI lead to an attributable increase in length of stay by 9 days (p = 0.011).ConclusionsICU-acquired LRTI is associated with increased hospital costs and prolonged hospital stay. Hospital management should therefore implement control measurements to keep the incidence of ICU-acquired LRTI as low as possible.

We report the process implemented in our institution by a task force focused on the reduction of ventilator-associated pneumonia (VAP). Retrospective cohort study of all adults admitted to one of our 4 adult ICUs, intubated on invasive mechanical ventilation. We implemented a ventilator bundle in April of 2007; we report the incidence of VAP in 2008, and, after adjustment in the process (oral care performed by respiratory therapists), the incidence in 2009. The primary outcome was reduction of the microbiologically confirmed VAP rate over a 2 year period. Other outcomes were duration of mechanical ventilation, antibiotic days, ICU and hospital stay, and mortality. During the study period, 2,588 patients received invasive mechanical ventilation in the adult ICUs. The VAP rate during 2008 was 4.3/1,000 ventilator days, and the 2009 rate was 1.2/1,000 ventilator days. The 2008 to 2009 VAP rate ratio was significantly greater than 1 (rate ratio 3.6, 95% CI 1.8-8.0, P < .001). Antibiotic days were less in 2009 versus 2008 (Hodges-Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0-1.0, P = .002). The median stay in the ICU was unchanged, and in the hospital was decreased in 2009 (Hodges-Lehmann estimate of difference between 2008 and 2009, 1.0, 95% CI 0.0-1.0, P < .001). The hospital mortality was 26.1%, and there was no difference between the 2 years. Adherence with the ventilator bundle was above 92% during the study period, but the oral care adherence improved from 33% to 97% after respiratory therapists assumed oral care. Reduction of the incidence of VAP occurred with an intervention that included respiratory therapists doing oral care in patients receiving invasive mechanical ventilation. Oral care done by respiratory therapists may be associated with reduction of VAP.

Background:Unplanned extubation (UE) is a preventable adverse event and may lead to additional complications such as cardiovascular resuscitation or respiratory compromise in a critically ill neonate during an emergent reintubation. A quality improvement project to reduce unplanned endotracheal tube dislodgement would reduce these morbidities. Aim: To reduce unplanned extubations in the NICU to 1 UE/100 ventilator days by October 2018. Setting: A level 4 NICU with 950 annual admissions and a baseline rate of 9.9 unplanned extubations/100 ventilator days Culturally, our NICU clinical team accepted unplanned extubation as a normal risk factor in the patient population and did little to challenge this status –quo. We felt we could decrease our UE rate through the use of standardized securement equipment, standardized care delivery models and a re-education program for all NICU staff. Methods:We formed an inter-professional task force consisting of a Neonatologist, two Respiratory Therapists and the NICU Nurse Educator. We tracked all of our unplanned extubations as well as required the staff involved to file an electronic safety report. PDSA cycles consisted of: staff attitude survey, development of data collection tool, protocol of 2 staff members for all transfers of intubated patient, staff education around securement device and daily retaping of ETT to securement device. UE and ventilator days were extracted from a respiratory database and electronic medical record. Control charts (u-chart) were created using QI Macrosã and IHI-Healthcare control chart rules used to determine special cause variations. The Maine Medical Center Institutional Review Board determined that this was quality improvement and did not qualify as research. Results:A special cause variation was noted via control chart rules for the mean UE rate from baseline of 9.9 UE/100 ventilator days (8/2017-11/2017) compared to post-intervention mean of 1.6 UE/100 ventilator days (8/2018-3/2019). In addition, during the intervention phase of the project (12/2018-7-2018), a special cause variation was noted with an UE rate of 5 UE/100 ventilator days (Figure 1). Conclusions:Development of a QI project by a multidisciplinary taskforce, along with several PDSA cycles including education and staff awareness, reduced UE rate by 84% in a level 4 NICU. Ongoing surveillance, education and review of UE cases will be key to maintaining UE at a goal of 1 UE/100 ventilator days.

Clinical pathways have been proven to be valuable tools in improving outcomes in patients with neurological diagnoses. However, their use with trauma populations has been limited. The unpredictable nature of trauma makes it difficult to develop a day-by-day plan of care that would be applicable to all patients with the same trauma diagnosis. Nevertheless, a severe traumatic brain injury (TBI) clinical pathway was developed and implemented at a Level 1 Trauma Center with significant reductions in length of stay and number of ventilator days. With the publication of the Guidelines for the Management of Severe Head Injury, this pathway was refashioned into a severe TBI phased-outcome pathway. Rather than a day-by-day plan of care, this clinical pathway consists of four phases of care: (a) admission to the intensive care unit, (b) acute critical care, (c) mobility and weaning, and (d) pre-rehabilitation. After 12 months, the improvements accomplished by the original pathway have been maintained or exceeded.

Introduction: Long-term immobility has detrimental effects for critically ill patients admitted to the intensive care unit (ICU) including ICU-acquired weakness. Early mobilization of patients admitted to ICU has been demonstrated to be a safe, feasible and effective strategy to improve patient outcomes. The optimal mobilization of trauma ICU patients has not been extensively studied. Our objective was to determine the impact of an early mobilization protocol on outcomes among trauma patients admitted to the ICU. Methods: We analyzed all adult trauma patients ( &amp;gt; 18 years old) admitted to ICU over a 2-year period prior to and following implementation of an early mobilization protocol, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared patient characteristics and outcomes (mortality, length of stay [LOS], ventilator days) between the pre- and post-implementation groups. Associations between early mobilization and clinical outcomes were estimated using binary and linear regression models. Results: Overall, there were 526 patients included in the analysis (292 pre-implementation, 234 post-implementation). The study population ranged in age from 18 to 92 years (mean age 49.0 ± 20.4 years) and 74.3% of all patients were male. The pre- and post-implementation groups were similar in age, sex, and injury severity. In-hospital mortality was reduced in the post-implementation group (25.3% vs. 17.5%; p = 0.031). In addition, there was a reduction in ICU mortality in the post-implementation group (21.6% vs. 12.8%; p = 0.009). We did not observe any difference in overall hospital LOS, ICU LOS, or ventilator days between the two groups. Compared to the pre-implementation period, trauma patients admitted to the ICU following protocol implementation were less likely to die in-hospital (OR = 0.52, 95% CI 0.30-0.91; p = 0.021) or in the ICU (OR = 0.40, 95% CI 0.21- 0.76, p = 0.005). Results were similar following a sensitivity analysis limited to patients with blunt or penetrating injuries. There was no difference between the pre- and post-implementation groups with respect to in-hospital LOS, ICU LOS, or the number of ventilator days. Conclusion: We found that trauma patients admitted to ICU during the post-implementation period had decreased odds of in-hospital mortality and ICU mortality. Ours is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.

Health Care–Associated Infection in Elderly Patients With Cerebrovascular Disease in Intensive Care Units: A Retrospective Cohort Study in Taizhou, China

Early Versus Late Enteral Nutrition in the Pediatric Critically-Ill Trauma Patient: A Retrospective Cohort Study.

A multidisciplinary group was formed to develop strategies to reduce ventilator-associated lower respiratory tract infections (LRI) in an intensive care unit (ICU) of a 540-bed acute care teaching medical center. The group process was facilitated by the Infection Director and the quality management specialist. The group was made of medical, nursing, and respiratory therapy staff. Quality improvement techniques were used to define the process of care for ventilated patients in the ICU. "State of the art" care was defined after a literature review and brainstorming sessions. Current practice and new concepts were then forged into a realistic protocol for the ICU. The resulting protocol was introduced into the ICU in May 1992. The information was communicated to Respiratory Therapy and ICU staff in writing and at department meetings. After a 4-month introductory period and learning curve process, a decrease in the endemic rate of ventilator-associated LRI was reduced in the fourth quarter of 1992. The mean 1993 LRI rate was 21 LRI/1000 ventilator days versus 26 LRI/1000 ventilator days in 1992 before protocol implementation. This equates to 18 LRI prevented in 1993. This represents a savings of $126,000. There was a significant decrease in the process variation of the monthly mean LRI/1000 ventilator days in 1993 from 1992. To date, there continues to be improvement with a mean of 16 LRI/1000 ventilator days reported in 1994. The ICU staff developed a multidisciplinary process evaluation and monitored staff implementation of the protocol over time. The results of the evaluation were used as feedback to measure protocol implementation. This was found to improve compliance with the protocol. Both the process (care of ventilated patients) and the outcome (number of LRI) have been improved through use of continuous quality improvement concepts and transdisciplinary interventions.

Ambulation of patients with acute respiratory failure may be unnecessarily limited in the acute intensive care setting. We hypothesized that ambulation of patients with acute respiratory failure would increase with transfer to an intensive care unit where activity is a key component of patient care. Pre-post cohort study of respiratory failure patients. Adult intensive care units at LDS Hospital. Respiratory failure patients requiring >4 days of mechanical ventilation who were transferred from other LDS Hospital intensive care units to the respiratory intensive care unit. We prospectively applied an early activity protocol to all consecutive respiratory failure patients transferred to the respiratory intensive care unit. We studied 104 respiratory failure patients who required mechanical ventilation for >4 days. Transferring a patient to the respiratory intensive care unit substantially increased the probability of ambulation (p < .0001). After 2 days in the respiratory intensive care unit, the number of patients ambulating had increased three-fold compared with pretransfer rates. Female gender (p = .019), the absence of sedatives (p = .009), and lower Acute Physiology and Chronic Health Evaluation II scores (p = .017) also predicted an increased probability of ambulation. Improvements in ambulation with transfer to the respiratory intensive care unit remained significant after adjustment for Acute Physiology and Chronic Health Evaluation II scores and other covariates. Transfer of acute respiratory failure patients to the respiratory intensive care unit substantially improved ambulation, independent of the underlying pathophysiology. The intensive care environment may contribute unnecessary immobilization throughout the course of acute respiratory failure. Sedatives, even given intermittently, substantially reduce the likelihood of ambulation. Controlled studies are needed to determine whether intensive care unit immobilization contributes to long-term neuromuscular dysfunction or whether early intensive care unit activity improves outcomes.

Adult code cart redesign: Clinical implications.

Unplanned extubations (UE) are directly associated with morbidity, mortality, and increased health care costs among critically-ill children. Multi-center implementation of the Solutions for Patient Safety Network prevention bundle has been successful, but UE rates remain a common cause of preventable health care harm. This was a longitudinal (2020-2025), multi-intervention quality improvement (QI) project in a single quaternary care pediatric intensive care unit (PICU) driven largely by a new QI respiratory therapist. Interventions built upon the initial implementation of the UE prevention bundle. The smart aim of this project was to sustainably decrease UE/100 invasive ventilationdays in the PICU at Children's of Alabama by 50% through multiple Plan-Do-Study-Act (PDSA) cycles. The baseline event rate was 0.58 UE/100 invasive ventilation days. Criteria for a center line shift to 0.16 UE/100 invasive mechanical ventilation days (72.5% decrease) were met in the first quarter of 2023 following four PDSA cycles and sustained through the end of the project. There was no change in invasive ventilation days/patient/quarter, but the percentage of PICU patients exposed to invasive ventilation by quarter starting dropped from 42% to 33% beginning in the first quarter of 2021. There were no center line shifts in post-UE outcomes over the project period including re-intubation within 1 h, re-intubation with cardiopulmonary resuscitation, or no re-intubation. Through multiple interventions, UE/100 invasive ventilation days decreased by 72.5% and has been sustained from the first quarter of 2023 through the second quarter of 2025 without impacting balancing measures such as invasive ventilation duration. These results support the importance of building upon the Solutions for Patient Safety Network UE prevention bundle and havinga dedicated champion to drive improvement and sustainability.