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Objective: To evaluate the association between consecutive days worked by intensivists and ICU patient outcomes., Design: Retrospective cohort study linked with survey data., Setting: Australia and New Zealand ICUs., Patients: Adults (16+ yr old) admitted to ICU in the Australia New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Registries (July 1, 2016, to June 30, 2018)., Interventions: None., Measurements and Main Results: We linked data on staffing schedules for each unit from the Critical Care Resources Registry 2016-2017 annual survey with patient-level data from the Adult Patient Database. The a priori chosen primary outcome was ICU length of stay. Secondary outcomes included hospital length of stay, ICU readmissions, and mortality (ICU and hospital). We used multilevel multivariable regression modeling to assess the association between days of consecutive intensivist service and patient outcomes; the predicted probability of death was included as a covariate and individual ICU as a random effect. The cohort included 225,034 patients in 109 ICUs. Intensivists were scheduled for seven or more consecutive days in 43 (39.4%) ICUs; 27 (24.7%) scheduled intensivists for 5 days, 22 (20.1%) for 4 days, seven (6.4%) for 3 days, four (3.7%) for 2 days, and six (5.5%) for less than or equal to 1 day. Compared with care by intensivists working 7+ consecutive days (adjusted ICU length of stay = 2.85 d), care by an intensivist working 3 or fewer consecutive days was associated with shorter ICU length of stay (3 consecutive days: 0.46 d fewer, p = 0.010; 2 consecutive days: 0.77 d fewer, p < 0.001; ≤ 1 consecutive days: 0.68 d fewer, p < 0.001). Shorter schedules of consecutive intensivist days worked were also associated with trends toward shorter hospital length of stay without increases in ICU readmissions or hospital mortality., Conclusions: Care by intensivists working fewer consecutive days is associated with reduced ICU length of stay without negatively impacting mortality.

Purpose: To evaluate the associations between strained ICU capacity and patient outcomes., Methods: Multi-center population-based cohort study of nine integrated ICUs in Alberta, Canada. Path-analysis modeling was adopted to investigate direct and indirect associations between strain (available beds ≤1; occupancy ≥95%) and outcomes. Mixed-effects multivariate regression was used to measure the association between strain and acuity (APACHE II score), and both acuity and strain measures on ICU mortality and length of stay., Results: 12,265 admissions comprise the study cohort. Available beds ≤1 and occupancy ≥95% occurred for 22.3% and 17.0% of admissions. Lower bed availability was associated with higher APACHE II score (p<0.0001). The direct effect of ≤1 available beds at ICU admission on ICU mortality was 11.6% (OR 1.116; 95% CI, 0.995-1.252). Integrating direct and indirect effects resulted in a 16.5% increased risk of ICU mortality (OR 1.165; 95% CI, 1.036-1.310), which exceeded the direct effect by 4.9%. Findings were similar with strain defined as occupancy ≥95%. Strain was associated with shorter ICU stay, primarily mediated by greater acuity., Conclusions: Strained capacity was associated with increased ICU mortality, partly mediated through greater illness acuity. Future work should consider both the direct and indirect relationships of strain on outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Importance: The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care., Objective: To test the hypotheses that: (1) there is significant variation in the PIR across ICUs and (2) higher PIRs are associated with higher hospital mortality for ICU patients., Design, Setting, and Participants: Retrospective cohort analysis of patients (≥16 years) admitted to ICUs staffed by a single intensivist during daytime hours in the United Kingdom from 2010 to 2013., Exposures: Patient-to-intensivist ratios, which we defined for each patient as the number of patients cared for by the intensivist each day averaged over the patient's stay., Main Outcomes and Measures: Using standard summary statistics, we evaluated PIR variation across ICUs. We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge., Finding: Among 49 686 adults in 94 ICUs, median age was 66 (interquartile range [IQR], 52-76) years, and 45.1% were women. The ultimate hospital mortality was 25.7%. The median PIR for patients was 8.5 (IQR, 6.9-10.8; full range, 1.0-23.5), and varied substantially among individual ICUs. The association between PIR and ultimate hospital mortality was U-shaped; there was a reduction in the odds of mortality associated with an increasing PIR up to 7.5 after which the odds of mortality increased again significantly (average patient mortality for lowest PIR, 22%; PIR of 7.5, 15%; highest PIR, 19%; P = .003). A similar U-shaped association was seen for PIR and mortality in the ICU (nadir of mortality at a PIR of 7.8, P < .001)., Conclusions and Relevance: PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivist may impact patient outcomes.

Objective: We sought to develop and internally validate a clinical prediction model to estimate the outcome of very elderly patients 12 months after being admitted to the ICU., Design: Prospective, longitudinal cohort study., Setting: Twenty-two Canadian ICUs., Patients: We recruited 527 patients 80 years or older who had a medical or urgent surgical diagnosis and were admitted to an ICU for at least 24 hours., Measurements and Main Results: At baseline, we completed a comprehensive geriatric assessment of enrolled patients; survival and functional status was determined 12 months later. We defined recovery from critical illness as Palliative Performance Scale score of greater than or equal to 60. We used logistic regression analysis to examine factors associated with this outcome. Of the 434 patients (82%) whose Palliative Performance Scale was known at 12 months, 50% had died and 29% (126/434) had a score of greater than or equal to 60. In the multivariable model, we found that being married, having a primary diagnosis of emergency coronary artery bypass grafting or valve replacement, and higher baseline Palliative Performance Scale were independently predictive of a 12-month Palliative Performance Scale score of greater than or equal to 60. Male sex, primary diagnosis of stroke, and higher Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, or clinical frailty scale were independently predictive of Palliative Performance Scale score of less than 60., Conclusion: Approximately one-quarter of very old ICU patients achieve a reasonable level of function 1 year after admission. This prediction model applied to individual patients may be helpful in decision making about the utility of life support for very elderly patients who are admitted to the ICU.

Critical illness does not keep to regular, daytime business hours; we must provide high-quality care and support for intensive care unit (ICU) patients 24 hours per day, 7 days per week. Whether this mandates the presence of similar numbers and types of personnel throughout all hours of the day, however, has been the subject of much debate and substantial research. In this article, we review the available literature on the consequences of having three groups of care providers at a patient's bedside overnight: physicians, visitors, and nurses. Though few of the studies on this topic are randomized and prospective, several themes have emerged from the existing data. First, there is dramatic variation in practice between and within countries. Second, the weight of evidence does not indicate that patient outcomes are improved by having an intensivist present overnight in ICUs that are staffed by intensivists during the daytime hours. Third, although visitation is highly restricted in many ICUs-out of concerns for disruption of care and a negative physiological or psychological impact on patients-the available data suggest that patients and their families generally benefit from open visitation policies. And finally, although there is little debate that nurses are (and should be) available in the ICU 24/7, existing data do not provide much of a consensus about the details. Uncertainties include whether outcomes are better when each nurse is assigned only one patient (or, more generally, the optimal patient:nurse ratio), who these nurses should be (e.g., registered nurses vs. other personnel), and what their roles should entail (e.g., managing ventilators). As such, we cannot yet identify the optimal overnight nurse staffing strategy. What is clear is that the critical care community needs more and better data to further define these aspects of the relationship between ICU structure and ICU outcomes., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Rationale: Published studies suggest hospital costs on Day 1 in the intensive care unit (ICU) far exceed those of subsequent days, when costs are relatively stable. Yet, no study stratified patients by ICU type., Objectives: To determine whether daily cost patterns differ by ICU type., Methods: We performed a retrospective study of adults admitted to five ICUs (two surgical: quaternary surgical ICU [SICU quat] and quaternary cardiac surgical ICU [CSICU quat]; two medical: tertiary medical ICU [MICU tertiary] and quaternary medical ICU [MICU quat]; one general: community medical surgical ICU [MSICU comm]) at Montefiore Medical Center in the Bronx, New York during 2013. After excluding costs clearly accrued outside the ICU, daily hospital costs were merged with clinical data. Patterns of daily unadjusted costs were evaluated in each ICU using median regression. Generalized estimating equations with first-order autocorrelation were used to identify factors independently associated with daily costs., Measurements and Main Results: Unadjusted daily costs were higher on Day 1 than on subsequent days only for surgical ICUs-SICU quat (median [interquartile range], $2,636 [$1,834-$4,282] on Day 1 vs. $1,840 [$1,501-$2,332] on Day 2; P < 0.001) and CSICU quat ($5,166 [$3,136-$9,493] on Day 1 vs. $2,060 [$1,336-$2,528] on Day 2; P < 0.001). In nonsurgical ICUs, there was no change (MICU tertiary P = 0.12) or a small increase (MSICU comm P = 0.03; MICU quat P = 0.01) in cost from Days 1 to 2. After multivariate adjustment, there remained a significant decrease in cost from ICU Day 1 to 2 in surgical units with statistically similar Day 1 and 2 costs for other ICUs., Conclusions: Higher Day 1 costs are not seen in patients admitted to medical/nonsurgical ICUs.

Objective: Very elderly persons admitted to ICUs are at high risk of death. To document life-sustaining interventions (mechanical ventilation, vasopressors, renal replacement therapy) provided in the ICU and outcomes of care., Design: Multicenter, prospective cohort study., Setting: ICUs of 24 Canadian hospitals., Participants/setting: Patients 80 years old or older admitted to the ICU., Interventions: None., Measurements and Main Results: One thousand six hundred seventy-one patients were included. The average age of the cohort was 85 years (range, 80-100 yr). Median total length of stay in ICU was 4 days (interquartile range, 2-8 d) and in hospital was 17 days (interquartile range, 8-33 d). Of all patients included, 502 (30%) stayed in ICU for 7 days or more and 344 (21%) received some form of life-sustaining treatment for at least 7 days. ICU and hospital mortality were 22% and 35%, respectively. For nonsurvivors, the median time from ICU admission to death was 10 days (interquartile range, 3-20 d). Of those who died (n = 5 85), 289 (49%) died while receiving mechanical ventilation, vasopressors, or dialysis. The presence of frailty or advance directives had little impact on limiting use of life-sustaining treatments or shortening the time from admission to death., Conclusions: In this multicenter study, one third of very elderly ICU patients died in hospital, many after a prolonged ICU stay while continuing to receive aggressive life-sustaining interventions. These findings raise questions about the use of critical care at the end of life for the very elderly.

Background: Little is known about the perspectives and experiences of family members of very elderly patients who are admitted to the intensive care unit., Aim: To describe family members' perspectives about care provided to very elderly critically ill patients., Design: Multicenter, prospective, cohort study., Participants and Setting: In total, 535 family members of patients aged 80 years or older admitted to 22 intensive care units for more than 24 h., Results: Family members reported that the "patient be comfortable and suffer as little as possible" was their most important value and "the belief that life should be preserved at all costs" was their least important value considered in making treatment decisions. Most family members (57.9%) preferred that life support be used for their family member, whereas 24.1% preferred comfort measures only, and 14.4% were unsure of their treatment preferences. Only 57.3% reported that a doctor had talked to them about treatment options for the patient. Overall, 29.7% of patients received life-sustaining treatments for more than 7 days and 50.3% of these died in hospital. Families were most satisfied with the skill and competency of nurses and least satisfied with being included and supported in the decision-making process and with their sense of control over the patient's care., Conclusion: There is incongruity between family values and preferences for end-of-life care and actual care received for very elderly patients who are admitted to the intensive care unit. Deficiencies in communication and decision-making may be associated with prolonged use of life-sustaining treatments in very elderly critically ill patients, many of whom ultimately die., (© The Author(s) 2015.)

Background: Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients., Methods: One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment., Results: Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place., Conclusions: The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs., Trial Registry: ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Rationale: Variation in practice and outcomes, not explained by patient or illness characteristics, is common in health care, including in intensive care units (ICUs)., Objective: To quantify within-ICU, between-physician variation in resource use in a single medical ICU., Methods: This was a prospective, noninterventional study in a medical ICU where nine intensivists provide care in 14-d rotations. Consecutive sample consisted of 1,184 initial patient admissions whose care was provided by a single intensivist. Multivariate models were constructed for average daily discretionary costs, ICU length of stay, and hospital mortality, adjusting for patient and illness characteristics, and workload., Measurements and Main Results: The identity of the intensivist was a significant predictor for average daily discretionary costs (p < 0.0001), but not ICU length of stay (p = 0.33) or hospital mortality (p = 0.83). The intensivists had more influence on costs than all other variables except the severity and type of acute illness. Average daily discretionary costs varied by 43% across the different intensivists, equating to a mean difference of 1,003 dollars per admission between the highest and lowest terciles of intensivists., Conclusions: There are large differences among intensivists in the amount of resources they use to manage critically ill patients. Higher resource use was not associated with lower length of stay or mortality.

ICUs are a vital but troubled component of modern health-care systems. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance, to a systems-oriented approach that emphasizes the need to assess and improve the ICU systems and processes that hinder the ability of individuals to perform their jobs well. This second part of a two-part treatise establishes a practical framework for performance improvement and examines specific strategies to improve ICU performance, including the use of information systems.

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.

Objective To compare methods of characterizing intensive care unit (ICU) bed use and estimate the number of beds needed. Study Setting Three geographic regions in the Canadian province of Manitoba. Study Design Retrospective analysis of population-based data from April 1, 2000, to March 31, 2007. Methods We compared three methods to estimate ICU bed requirements. Method 1 analyzed yearly patient-days. Methods 2 and 3 analyzed day-to-day fluctuations in patient census; these differed by whether each hospital needed to independently fulfill its own demand or this resource was shared across hospitals. Principal Findings Three main findings were as follows: (1) estimates based on yearly average usage generally underestimated the number of beds needed compared to analysis of fluctuations in census, especially in the smaller regions where underestimation ranged 25-58 percent; (2) 4-29 percent fewer beds were needed if it was acceptable for demand to exceed supply 18 days/year, versus 4 days/year; and (3) 13-36 percent fewer beds were needed if hospitals within a region could effectively share ICU beds. Conclusions Compared to using yearly averages, analyzing day-to-day fluctuations in patient census gives a more accurate picture of ICU bed use. Failing to provide adequate 'surge capacity' can lead to demand that frequently and severely exceeds supply. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effect of esophageal stimulation on nutritional adequacy in critically ill patients at risk for enteral feeding intolerance.Design: A multicenter randomized sham-controlled clinical trial.Setting: Twelve ICUs in Canada.Patients: We included mechanically ventilated ICU patients who were given moderate-to-high doses of opioids and expected to remain alive and ventilated for an additional 48 hours and who were receiving enteral nutrition or expected to start imminently.Interventions: Patients were randomly assigned 1:1 to esophageal stimulation via an esophageal stimulating catheter (E-Motion Tube; E-Motion Medical, Tel Aviv, Israel) or sham treatment. All patients were fed via these catheters using a standardized feeding protocol.Measurements and Main Results: The co-primary outcomes were proportion of caloric and protein prescription received enterally over the initial 7 days following randomization. Among 159 patients randomized, the modified intention-to-treat analysis included 155 patients: 73 patients in the active treatment group and 82 in the sham treatment group. Over the 7-day study period, the percent of prescribed caloric intake (± SE) received by the enteral route was 64% ± 2 in the active group and 65% ± 2 in sham patients for calories (difference, -1; 95% CI, -8 to 6; p = 0.74). For protein, it was 57% ± 3 in the active group and 60% ± 3 in the sham group (difference, -3; 95% CI, -10 to 3; p = 0.30). Compared to the sham group, there were more serious adverse events reported in the active treatment group (13 vs 6; p = 0.053). Clinically important arrhythmias were detected by Holter monitoring in 36 out of 70 (51%) in the active group versus 22 out of 76 (29%) in the sham group (p = 0.006).Conclusions: Esophageal stimulation via a special feeding catheter did not improve nutritional adequacy and was associated with increase risk of harm in critically ill patients. [ABSTRACT FROM AUTHOR]

Objectives: The distinction between overuse and appropriate use of the ICU hinges on whether a patient would benefit from ICU care. We sought to test 1) whether physicians agree about which types of patients benefit from ICU care and 2) whether estimates of ICU benefit are influenced by factors unrelated to severity of illness.Design: Randomized study.Setting: Online vignettes.Subjects: U.S. critical care physicians.Interventions: Physicians were provided with eight vignettes of hypothetical patients. Each vignette had a single patient or hospital factor randomized across participants (four factors related and four unrelated to severity of illness).Measurements and Main Results: The primary outcome was the estimate of ICU benefit, assessed with a 4-point Likert-type scale. In total, 1,223 of 8,792 physicians volunteered to participate (14% recruitment rate). Physician agreement of ICU benefit was poor (mean intraclass correlation coefficient for each vignette: 0.06; range: 0-0.18). There were no vignettes in which more than two thirds of physicians agreed about the extent to which a patient would benefit from ICU care. Increasing severity of illness resulted in greater estimated benefit of ICU care. Among factors unrelated to severity of illness, physicians felt ICU care was more beneficial when told one ICU bed was available than if ICU bed availability was unmentioned. Physicians felt ICU care was less beneficial when family was present than when family presence was unmentioned. The patient's age, but not race/ethnicity, also impacted estimates of ICU benefit.Conclusions: Estimates of ICU benefit are widely dissimilar and influenced by factors unrelated to severity of illness, potentially resulting in inconsistent allocation of ICU care. [ABSTRACT FROM AUTHOR]