Search

The appropriate justification for using a diagnostic or therapeutic intervention is that it provides benefit to patients, society, or both. For decades, indwelling arterial catheters have been used very commonly in patients in the ICU, despite a complete absence of data addressing whether they confer any such benefits. Both of the main uses of arterial catheters, BP monitoring and blood sampling for laboratory testing, can be done without these invasive devices. Prominent among complications of arterial catheters are bloodstream infections and arterial thrombosis. To my knowledge, only a single observational study has assessed a patient-centered outcome related to arterial catheter use, and it found no evidence that they reduce hospital mortality in any patient subgroup. Given the potential dangers, widespread use, and uncertainty about consequences of arterial catheter use in ICUs, equipoise exists and randomized trials are needed. Multiple studies in different, well-characterized, patient subgroups are needed to clarify whether arterial catheters influence outcomes. These studies should assess the range of relevant outcomes, including mortality, medical resource use, patient comfort, complications, and costs. [ABSTRACT FROM AUTHOR]

The article discusses the evolution of physician staffing in intensive care units (ICUs). The different staffing models for ICUs are described including around-the-clock intensivist staffing, staffing with nonintensivist physicians and staffing with house officers. The difference between open and closed ICU structures is explained. The relationship between staffing and workload is tackled. The role of telemedicine and other technologies in the evolution of ICU staffing is also tackled.

The evidence regarding physician staffing of ICUs does not yet provide a consistent view of the best model to use. Most studies have significant limitations, and this subject is complicated by the fact that optimal ICU staffing may depend on ICU characteristics. The topic with the most data regarding patient outcomes is the intensity of intensivist involvement in care, particularly the value of closed- vs open-model ICUs; however, the evidence is inconsistent here as well. Even if closed-model ICUs produce better outcomes, we do not know which specific elements of that multifaceted organizational paradigm are responsible for improvement. Also, studies of around-the-clock intensivist presence have not consistently shown that it is associated with superior outcomes. Increasingly, nonphysician providers are playing innovative roles in the ICU, and care provided by teams including nurse practitioners or physician assistants appears to be safe and comparable to that provided by other staffing models. Although we do not know the best way to staff ICUs, the conditions of ICU physician coverage will continue to change under the stresses of shortages of intensivists and increasing duty hour limitations for trainees. Nonphysician providers, innovative physician staffing models, telemedicine, and other technologies will be increasingly used to cope with these realities. This evolution makes it more important than ever to study how staffing affects outcomes. Only quantitative evaluation can tell us whether one staffing model is better than another. Accordingly, we need more research from multiple sites to develop a consistent and integrated understanding of this complex topic. [ABSTRACT FROM AUTHOR]

The article studies the effects of decisions to withhold life-supporting therapies (LST) on long-term mortality for patients in a critical care setting. The authors hypothesize that in the context of otherwise providing all indicated care, the decision to withhold the use of LST does not affect mortality in critically-ill patients 60 days after their admission to the intensive care unit.

Discusses problems with intensive care unit (ICU) care. Importance of ICU in modern health care; Measures of ICU performance; Need to improve ICU systems and processes.

Part II. Discusses a practical framework for performance improvement in the intensive care unit (ICU). Importance of ICU in modern health care; Strategies to improve ICU performance; Use of information system to improve ICU performance

Study objective: To use an existing database from a large cohort study with follow-up as long as 5.5 years to assess the extended prognosis of patients who survived their hospitalizations for severe acute respiratory failure (ARF). Design, setting, and patients: Secondary analysis of an inception cohort of 1,722 patients with ARF requiring mechanical ventilation from five major medical centers who were entered into the prospective Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. The 1,075 patients (62.4%) who survived hospitalization had systematic follow-up of vital status for a median time of 662 days (interquartile range, 327 to 1,049 days; range, 2 to 2,014 days). Interviews performed a median of 5 months after hospital discharge assessed functional capacity and quality of life (QOL). The main outcome measure was survival after hospital discharge. Secondary measures were functional status and QOL. Cox proportional hazard regression identified factors influencing posthospital survival. Results: The median survival time after hospital discharge for ARF was > 5.3 years. The posthospital survival lime was shorter for those with older age, male gender, several preexisting comorbid conditions, worse prehospital functional status, greater acute physiologic derangement, and a do-not-resuscitate order while in the hospital, and for those discharged to a location other than home. Five months after hospital discharge, 48% of survivors needed help with at least one activity of daily living, and 27% rated their QOL as poor or fair. However, most of these impairments were present before respiratory failure occurred. Conclusions: Extended survival is common among patients with ARF who require mechanical ventilation and who survive hospitalization. Among these patients, only a small fraction of the impairment in activity and QOL can be considered to be a sequela of the respiratory failure or its therapy. These findings are relevant to the care decisions for such critically ill patients. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about the differences between cuff and arterial catheterization (AC) in measuring blood pressure (BP) in critically ill patients.