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Purpose: The purpose of this study was to determine the attributable intensive care unit (ICU) and hospital length of stay and mortality of ICU-acquired Clostridium difficile infection (CDI). Materials and methods: In this retrospective cohort study of 3 tertiary and 3 community ICUs, we screened all patients admitted between April 2006 and December 2011 for ICU-acquired CDI. Using both complete and matched cohort designs and Cox proportional hazards analysis, we determined the association between CDI and ICU and hospital length of stay and mortality. Adjustment or matching variables were site, age, sex, severity of illness, and year of admission; any infection as an ICU admitting or acquired diagnosis before the diagnosis of CDI and diagnosis of CDI were time-dependent exposures. Results: Of 15314 patients admitted to the ICUs during the study period, 236 developed CDI in the ICU. In the complete cohort analysis, the hazard ratios (95% confidence interval) for CDI related to ICU and hospital discharge were 0.82 (0.72, 0.94) and 0.83 (0.73, 0.95), respectively (0.5 additional ICU days and 3.4 hospital days), and related to death in ICU and hospital, they were 1.00 (0.73, 1.38) and 1.19 (0.93, 1.52), respectively. In the matched analysis, the hazard ratios for CDI related to ICU and hospital discharge were 0.91 (0.81, 1.03) and 0.98 (0.85, 1.13), respectively, and related to death in ICU and hospital, they were 1.18 (0.85, 1.63) and 1.08 (0.82, 1.43), respectively. Conclusions: C difficile infection acquired in ICU is associated with an increase in length of ICU and hospital stay but not with any difference in ICU or hospital mortality. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. Materials and Methods: In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. Results: Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = −0.46; P = .03), and teamwork across hospital units (r = −0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture. Conclusion: Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs. [Copyright &y& Elsevier]

Abstract: Purpose: The aims of this study were to determine if there is seasonal variation in the number of intensive care unit (ICU) admissions for community-acquired pneumonia (CAP) and if there is a relationship between these admissions and weather or reports of influenza-like illness in the community. Materials and Methods: In this time series analysis in 3 medical-surgical ICUs (8, 13, and 20 beds) in the Vancouver region, we included patients admitted to adult ICUs for CAP between January 2002 and March 2006. We used Poisson regression to analyze the association between weekly number of ICU admissions for CAP, and average temperature, range in temperature, total precipitation, and cases of influenza-like illness/100 physician visits reported by sentinel physicians in the community. Results: In 740 patients admitted to ICUs for CAP, admissions peaked each year in the winter-spring months. In multivariate models, a sine function with a single annual peak was independently associated with number of patients admitted to ICU for CAP (rate ratio [95% confidence interval], 1.12 [1.00, 1.26]), but neither the weather measurements nor the weekly rate of reported influenza-like illness was significantly associated. Conclusion: Intensive care unit admissions for CAP are seasonal, but neither weather measurements nor weekly rate of reported influenza-like illness in the community is associated with these admissions. [Copyright &y& Elsevier]

Abstract: Background: Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied. Methods: Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlain''s percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A κ statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality. Results: Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by κ statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71). Conclusion: Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study was to determine the association between transport intervals (including time from call to arrival of transport team at the sending hospital, time spent by the transport team in the sending hospital, and transport time between the sending and receiving hospital) and intensive care unit (ICU) and hospital length of stay and hospital mortality at the receiving hospital. Materials and Methods: This was a retrospective, stratified cohort study involving all patients 15 years and older who were transferred from one hospital to another of equal or larger size in British Columbia, Canada, and who spent at least 1 day in an ICU or coronary care unit (CCU) at the receiving hospital during 1999 (n = 1930). Data were obtained from 6 administrative databases and linked using generalized software. Results: After adjustment for age, sex, comorbidity, and diagnostic group, longer time from call to arrival of paramedics at the sending hospital was associated with a shorter length of ICU/CCU stay (rate ratio [RR], 0.91; 95% confidence interval [CI], 0.86-0.97) for survivors and a longer length of hospital (RR, 1.12; 95% CI, 1.05-1.21) and ICU/CCU (RR, 1.14; 95% CI, 1.04-1.25) stay for nonsurvivors in the higher-priority air transport group, and with a slightly shorter length of hospital stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the lower-priority air transport group. Longer time spent by paramedics at the sending hospital was associated with a shorter length of hospital stay (RR, 0.79; 95% CI, 0.65-0.96) for survivors in the higher-priority air transport group. Longer time for transport between the sending and receiving hospitals was associated with a longer length of ICU/CCU stay (RR, 1.69; 95% CI, 1.26-2.27) for survivors in the higher-priority air transport group but a slightly shorter length of ICU/CCU stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the ground transport group. There were no associations between transport times and hospital mortality. Conclusions: Transport intervals are independently associated with ICU/CCU and hospital lengths of stay at the receiving hospital for critically ill adults transferred to referral centers. [Copyright &y& Elsevier]

Abstract: Background: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Despite a large amount of research evidence, the optimal diagnostic and treatment strategies for VAP remain controversial. Purpose: The aim of this study was to develop evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. Data sources include Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials. Study Selection: The authors systematically searched for all relevant randomized controlled trials and systematic reviews on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1, 2006. Data Extraction: Independently and in duplicate, the panel critically appraised each published trial. The effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. The full guideline development panel arrived at a consensus for scores on safety, feasibility, and economic issues. Levels of Evidence: Based on the scores for each topic, the following statements of recommendation were used: recommend, consider, do not recommend, and no recommendation because of insufficient or conflicting evidence. Data Synthesis: For the diagnosis of VAP in immunocompetent patients, we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy. When there is a suspicion of VAP, we recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP. Choice of antibiotics should be based on patient factors and local resistance patterns. We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP. For patients who receive adequate initial antibiotic therapy, we recommend 8 days of antibiotic therapy. We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP. Conclusion: We present evidence-based recommendations for the diagnosis and treatment of VAP. Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP. [Copyright &y& Elsevier]

Abstract: Background: Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Purpose: To develop evidence-based guidelines for the prevention of VAP. Data Sources: MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials. Study Selection: The authors systematically searched for all relevant randomized, controlled trials and systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to October 1, 2006. Data Extraction: Independently and in duplicate, the panel scored the internal validity of each trial. Effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of the guideline panel. Levels of Evidence: The following statements were used: recommend, consider, do not recommend, and no recommendation due to insufficient or conflicting evidence. Data Synthesis: To prevent VAP: [We recommend:] that the orotracheal route of intubation should be used for intubation; a new ventilator circuit for each patient; circuit changes if the circuit becomes soiled or damaged, but no scheduled changes; change of heat and moisture exchangers every 5 to 7 days or as clinically indicated; the use of a closed endotracheal suctioning system changed for each patient and as clinically indicated; subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours; head of bed elevation to 45° (when impossible, as near to 45° as possible should be considered). [Consider:] the use of rotating beds; oral antiseptic rinses. [We do not recommend:] use of bacterial filters; the use of iseganan [We make no recommendations regarding:] the use of a systematic search for sinusitis; type of airway humidification; timing of tracheostomy; prone positioning; aerosolized antibiotics; intranasal mupirocin; topical and/or intravenous antibiotics. Conclusion: There are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection. [Copyright &y& Elsevier]

Abstract: Ventilator-associated pneumonia (VAP) is associated with increased duration of mechanical ventilation and increased risk of death for critically ill patients. Although scientific advances have the potential to improve the outcomes of critically ill patients who are at risk of or who have VAP, the translation of research knowledge on effective strategies to prevent, diagnose, and treat VAP is not uniformly applied in practice in the intensive care unit. Knowledge about VAP may be used more effectively at the bedside by a systematic process of knowledge translation through implementation of clinical practice guidelines. Unfortunately, there remain large gaps in our understanding of guideline implementation in the intensive care unit, specifically as it applies to guidelines for the prevention, diagnosis, and treatment of VAP. [Copyright &y& Elsevier]

Abstract: Background: Although noninvasive positive pressure ventilation (NPPV) improves outcomes in patients who have acute respiratory failure due to chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), it may be underutilized outside the controlled trial setting. Purpose: The purpose of this study is to determine the proportion of patients who met criteria for a trial of NPPV but were emergently intubated and mechanically ventilated without receiving a trial of NPPV. Methods: We retrospectively reviewed charts of patients who were intubated and ventilated or who received NPPV on admission to one intensive care unit and who had an intensive care unit admitting diagnosis of either exacerbation of COPD or CHF during the period from November 1998 to July 2003. Results: Of the 243 patients who had an admitting diagnosis of COPD or CHF, 59 (24.3%) met explicit criteria for a trial of NPPV. Only 20 (33.9%) of 59 had a trial of NPPV. The remaining 39 (66%) of 59 did not receive a trial of NPPV and were intubated. Interpretation: Nearly two thirds of patients who appeared to meet criteria for NPPV did not receive a trial of this intervention. There is an opportunity to improve the use of NPPV in these patients. Systematic knowledge translation strategies such as guideline implementation and interactive educational interventions may optimize the appropriate use of NPPV. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of the study was to assess the utility of pretest probability and modified clinical pulmonary infection score CPIS in the diagnosis of late-onset ventilator-associated pneumonia (VAP). Materials and Methods: In 740 adults enrolled in a multicenter randomized trial, intensivists prospectively rated the pretest probability of VAP as low, moderate, or high based on their clinical judgment. The modified CPIS was calculated without considering culture results. Ventilator-associated pneumonia diagnosis was determined by 2 adjudicators using standardized definitions. We analyzed the relationship between pretest likelihood, CPIS, and VAP diagnosis. Results: Among the 739 patients analyzed, 14.5%, 39.6%, and 45.9% had low, moderate, and high pretest probability of VAP. Patients with high pretest probability had a lower PaO2/FiO2 ratio and a larger volume of secretions. High or moderate vs low pretest probability had high sensitivity (0.88; 95% confidence interval [CI], 0.87-0.89) and positive predictive value (0.87; 95% CI, 0.86-0.88) but low specificity (0.27; 95% CI, 0.21-0.35) and negative predictive value (0.29; 95% C,: 0.22-0.37) for the diagnosis of VAP. Therefore, 71% of patients who had a low pretest probability were actually infected (1 − negative predictive value). The area under the receiver operating characteristic curve for the modified CPIS was not significant (0.47; 95% CI, 0.42-0.53), meaning that no score threshold was clinically useful. Conclusions: Pretest probability and a modified CPIS, which excludes culture results, are of limited utility in the diagnosis of late-onset VAP. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study was to clarify the prevalence and incidence of, risk factors for, and outcomes from suspected ventilator-associated pneumonia (VAP) associated with the isolation of either Pseudomonas or multidrug-resistant (MDR) bacteria (“high risk” pathogens) from respiratory secretions. Materials and Methods: Data were collected as part of a large, multicentered trial of diagnostic and therapeutic strategies for patients (n = 739) with suspected VAP. Results: At enrollment, 6.4% of patients had Pseudomonas species, and 5.1% of patients had at least 1 MDR organism isolated from respiratory secretions. Over the study period, the incidence of Pseudomonas and MDR organisms was 13.4% and 9.2%, respectively. Independent risk factors for the presence of these pathogens at enrollment were duration of hospital stay ≥48 hours before intensive care unit (ICU) admission (odds ratio, 2.37 [95% CI, 1.40-4.02]; P = .001] and prolonged duration of ICU stay before enrollment (odds ratio, 1.50 [95% CI, 1.17-1.93]; P = .002] per week. Fewer patients whose specimens grew either Pseudomonas or MDR organisms received appropriate empirical antibiotic therapy compared to those without these pathogens (68.5% vs 93.9%, P < .001). The isolation of high risk pathogens from respiratory secretions was associated with higher 28-day (relative risk, 1.59 [95% CI, 1.07-2.37]; P = .04] and hospital mortality (relative risk, 1.48 [95% CI, 1.05-2.07]; P = .05), and longer median duration of mechanical ventilation (12.6 vs 8.7 days, P = .05), ICU length of stay (16.2 vs 12.0 days, P = .05), and hospital length of stay (55.0 vs 41.8 days, P = .05). Conclusions: In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low. However, the presence of high risk pathogens is associated with worse clinical outcomes. [Copyright &y& Elsevier]

Abstract: Purpose: Comparison of outcomes among intensive care units (ICUs) requires adjustment for patient variables. Severity of illness scores are associated with hospital mortality, but administrative databases rarely include the elements of these scores. However, these databases include the elements of comorbidity scores. The purpose of this study was to compare the value of these scores as adjustment variables in statistical models of hospital mortality and hospital and ICU length of stay after adjustment for other covariates. Materials and Methods: We used multivariable regression to study 1808 patients admitted to a 13-bed medical-surgical ICU in a 400-bed tertiary hospital between December 1998 and August 2003. Results: For all patients, after adjusting for age, sex, major clinical category, source of admission, and socioeconomic determinants of health, we found that Acute Physiology and Chronic Health Evaluation (APACHE) II and comorbidity scores were significantly associated with hospital mortality and that comorbidity but not APACHE II was significantly associated with hospital length of stay. Separate analysis of hospital survivors and nonsurvivors showed that both APACHE II and comorbidity scores were significantly associated with hospital length of stay and APACHE II score was associated with ICU length of stay. Conclusion: The value of APACHE II and comorbidity scores as adjustment variables depends on the outcome and population of interest. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of the study was to determine whether the use of specialist transport personnel improves patient outcome at the receiving hospital for critically ill patients transferred to higher centers. Materials and Methods: A search of 6 electronic databases, 15 relevant journals, and the reference lists of all retrieved articles was conducted for studies comparing outcome at the receiving hospital for critically ill adult or pediatric patients transported by dedicated transport crews or tertiary-based specialists with other forms of transport personnel including referring house staff. All potentially relevant articles were retrieved in full and reviewed independently by 2 reviewers to determine eligibility for inclusion. Data were tabulated and results were summarized. Results: Six cohort studies (n = 4534) were included. When patients of equal severity were assessed, only 1 study demonstrated an improvement in outcome at the receiving hospital (survival to 6 hours) when specialist personnel transported the patients. Methodological limitations and interstudy differences in participants and transport personnel precluded pooling of results. Conclusions: Current data are insufficient. The study designs used create opportunity for significant bias, preventing any useful inferences to be drawn. Further study is warranted. [Copyright &y& Elsevier]

Abstract: Purpose: To describe perspectives of nurses (RNs) and respiratory therapists (RTs) related to end-of-life care for critically ill patients. Methods: For patients who had life support withdrawn in 4 Canadian university-affiliated ICUs, RNs and RTs reported their comfort level with decision making and process for 14 aspects of end-of-life care. Results: Ninety-eight patients had life support withdrawn. Responses were received from 96 (98.0%) bedside RNs and 73 (74.5%) RTs. Most RNs (85/94, 90.4%) and RTs (50/73, 68.5%) were very comfortable with decisions to withhold cardiopulmonary resuscitation or to withdraw life support (83/94, 88.3% of RNs and 56/73, 76.7% of RTs). Most RNs (range 71.3%-80.65%) and RTs (60.0%-70.8%) were very comfortable with ventilation/oxygen withdrawal and sedation. Among paired responses for 72 (73.5%) of 98 patients, RTs rated less favorably than RNs (P < .05): the quality of the physician explanation of the life support withdrawal process, the availability of the physician, the peacefulness of the dying process, and the amount of privacy for families. Suggested improvements included earlier and more inclusive discussions, clearer plans, and better preparation of families and the ICU team for patients'' deaths. Conclusions: Most RNs and RTs were comfortable with decision making and the process of life support withdrawal, but they suggested several ways to improve end-of-life care. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study is to determine if more males than females are admitted to adult intensive care units (ICUs). Materials and methods: In 9 tertiary and community hospitals in British Columbia, Canada, we expressed the number of patients admitted to hospital and to ICU from 1998 to 2008 as a proportion of the population of the main regions served by these hospitals, and for ICU patients in 1 tertiary hospital, as a proportion of the hospital population. Patients not residing in the region of this tertiary hospital or whose addresses were unknown and admissions for sex-specific diagnoses were excluded from the main analyses. Male proportion was divided by female proportion for age groups by decade. Multivariate regression was used to determine the association between sex and admission to ICU after adjustment for confounders. Results: Normalized male-to-female ratio of ICU admissions to the 9 hospitals was greater than 1. In the tertiary hospital analyzed in more detail, the male-to-female ratio for admissions to hospital or to ICU, normalized to the population in the community or hospital, respectively, was greater than 1 for all age groups, and this ratio increased with age. After adjustment for covariates, males and females less than 80 years of age were roughly equally likely to be admitted to ICU from hospital, but in patients aged 80 or older, men were much more likely than women to be admitted (odds ratio, 2.14; 95% confidence interval, 1.56-2.94). Conclusion: More men than women are admitted to ICUs; this difference is especially prominent in elderly patients. [Copyright &y& Elsevier]

Introduction: Clostridioides difficile infection (CDI) is a serious complication of critical illness. The objective of the study was to determine its incidence, prevalence, timing, severity, predictors, and outcomes., Methods: We performed a prospective nested cohort study of CDI within a randomized trial comparing Lactobacillus rhamnosus GG to placebo. We adjudicated cases of CDI using standardized definitions, assessed timing (pre-ICU, in ICU, post-ICU) and severity. We analyzed risk factors and outcomes., Results: Of 2650 patients, 86 were diagnosed with CDI during 90,833 hospital-days (0.95/1000 hospital-days); CDI prevalence was 3.2%. CDI incidence varied in timing; 0.3% patients had CDI pre-ICU, 2.2% in the ICU; an 0.8% developed CDI post-ICU. Relapse or recurrence of CDI was documented in 9.3% patients. Infections were mild/moderate in severity. Complications included septic shock (26.7%), organ failure (16.3%), and toxic megacolon requiring colectomy (1.2%). No risk factors for CDI were identified. CDI was not associated with hospital mortality. The duration of hospital stay was longer for those who had CDI compared those who did not, CONCLUSION: CDI was uncommon, severity was mild to moderate and not associated with mortality however CDI was associated with a longer hospital stay., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Background: Perceptions about functional and employment status before admission to the intensive care unit (ICU) may influence how patients and clinicians make decisions about cardiopulmonary resuscitation., Objective: To examine the relationship between cardiopulmonary resuscitation directives established within 24 hours of admission to the ICU and clinical perceptions of premorbid functional and employment status., Design: Prospective observational study in 15 university-affiliated centers in Canada, the United States, Australia, and Sweden., Patients: A total of 1,008 ICU patients aged 18 years or older expected to stay in the ICU at least 72 hours., Measurements: By using multinomial logistic regression, we examined the relationship between functional status and employment status perceived by the ICU team 1 month before ICU admission (the independent variables) and resuscitation status (the dependent variable). Each patient had either an explicit resuscitation directive (to resuscitate or not to resuscitate), or an implicit resuscitation directive to resuscitate., Results: On average, patients were 61.7 years (+/-17.4 y) old with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.5 (+/-8.7); 846 (83.9%) were ventilated mechanically within 48 hours and 345 (34.2%) died in the ICU. Most patients (793, 78.7%) had no explicit resuscitation directive; 98 (9.7%) had an explicit plan to resuscitate, whereas 117 (11.6%) had an explicit plan of do-not-resuscitate. Of 1,008 patients, 98 (9.7%) were severely functionally limited, 217 (21.5%) were somewhat limited, 628 (62.3%) were totally independent, and 65 (6.4%) had unknown functional status 1 month before ICU admission. Severe functional status impairment was associated moderately with an explicit plan to resuscitate (odds ratio, 2.2 relative to no explicit directive) and associated strongly with an explicit do-not-resuscitate plan (odds ratio, 6.2 relative to no explicit directive, P value on the difference =.011). This relationship was not influenced by age, sex, APACHE II score, medical or surgical status, admission diagnosis, employment status, or city. However, severe functional status was associated strongly and significantly with an explicit do-not-resuscitate directive among those who could not participate in decision making (odds ratio, 8.2; 95% confidence interval, 4.5-15.0), and more weakly associated in those who could participate (odds ratio, 1.7; 95% confidence interval, 0.3-8.6). Being unemployed was associated with an increased odds of an explicit resuscitation directive versus no explicit directive (odds ratio, 5.5; 95% confidence interval, 2.2-13.4)., Conclusions: Functional status impairment perceived by the ICU team is associated clearly with do-not-resuscitate directives in patients unable to participate in decision making. However, the association appears much weaker in patients able to participate in decision making. PATIENTS' perceived employment status also may influence resuscitation decisions. Our results emphasize the challenges of ensuring that crucial resuscitation decisions are not affected adversely by patients' inability to participate in decisions, and by their functional and employment status.

Purpose: Labor costs are the largest fraction of operating costs in an intensive care unit (ICU). Estimation of appropriate nursing supply is frequently based on the midnight census of patients, which is a "snapshot" view of the ICU. We postulated that the midnight census would not correlate as well as time-weighted nursing demand (a calculation of need for nursing staff) with the actual number of nurses who were required to staff the ICU (nursing supply). The purpose of this study was to compare the correlation between midnight census and actual nursing supply with the correlation between time-weighted nursing demand and nursing supply., Materials and Methods: We measured nursing activity, midnight census, and actual nursing supply for each of 77 consecutive days in a 14-bed medical-surgical ICU within a 450-bed tertiary care teaching hospital. We calculated time-weighted nursing demand based on 1:1 nursing for ICU patients, 1:2 nursing for step-down patients, 0.5 additional nurse hours for each cardiac arrest, and 0.5 additional nurse hours for each new admission to the ICU., Results: There was a correlation between midnight census and nursing supply (r2 = .42, P<.0001) and between nursing demand and nursing supply (r2 = .83, P<.0001). The correlation coefficient for the relationship between nursing demand and nursing supply was significantly greater than that for the relationship between midnight census and nursing supply (P<.01)., Conclusions: Time-weighted nursing demand is a better predictor than midnight census of nursing supply in an ICU.