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Aim: To determine whether there is added benefit in detecting electrographic abnormalities from 16-24 hours of continuous video-EEG in adult medical/surgical ICU patients, compared to a 30-minute EEG., Methods: This was a prospectively enroled non-randomized study of 130 consecutive ICU patients for whom EEG was requested. For 117 patients, a 30-minute EEG was requested for altered mental state and/or suspected seizures; 83 patients continued with continuous video-EEG for 16-24 hours and 34 patients had only the 30-minute EEG. For 13 patients with prior seizures, continuous video-EEG was requested and was carried out for 16-24 hours. We gathered EEG data prospectively, and reviewed the medical records retrospectively to assess the impact of continuous video-EEG., Results: A total of 83 continuous video-EEG recordings were performed for 16-24 hours beyond 30 minutes of routine EEG. All were slow, and 34% showed epileptiform findings in the first 30 minutes, including 2% with seizures. Over 16-24 hours, 14% developed new or additional epileptiform abnormalities, including 6% with seizures. In 8%, treatment was changed based on continuous video-EEG. Among the 34 EEGs limited to 30 minutes, almost all were slow and 18% showed epileptiform activity, including 3% with seizures. Among the 13 patients with known seizures, continuous video-EEG was slow in all and 69% had epileptiform abnormalities in the first 30 minutes, including 31% with seizures. An additional 8% developed epileptiform abnormalities over 16-24 hours. In 46%, treatment was changed based on continuous video-EEG., Conclusion: This study indicates that if continuous video-EEG is not available, a 30-minute EEG in the ICU has a substantial diagnostic yield and will lead to the detection of the majority of epileptiform abnormalities. In a small percentage of patients, continuous video-EEG will lead to the detection of additional epileptiform abnormalities. In a sub-population, with a history of seizures prior to the initiation of EEG recording, the benefits of continuous video-EEG in monitoring seizure activity and influencing treatment may be greater.

Background: The survival of patients who undergo aortic valve replacement (AVR) for severe aortic stenosis with reduced preoperative ejection fractions (EFs) is not well described in the literature., Methods and Results: Patients undergoing AVR for severe aortic stenosis were analyzed using the Northern New England Cardiovascular Disease Study Group surgical registry. Patients were stratified by preoperative EF (≥50%, 40%-49%, and <40%) and concomitant coronary artery bypass grafting. Crude and adjusted survival across strata of EF was estimated for patients up to 8 years beyond their index admission. A total of 5277 patients underwent AVR for severe aortic stenosis between 1992 and 2008. There were 727 (14%) patients with preoperative EF <40%. Preoperative EF had minimal effect on postoperative morbidity. There was no difference in 30-day mortality across EF strata among the isolated AVR cohort. Preserved EF conferred 30-day survival benefit among the AVR+coronary artery bypass grafting population (EF≥50%, 96%; EF<40%, 91%; P=0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts., Conclusions: Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.

Background: We previously reported that transfusion of 1 to 2 units of red blood cells (RBCs) confers a 16% increased hazard of late death after cardiac surgical treatment. We explored whether a similar effect existed among octogenarians., Methods: We enrolled 17,026 consecutive adult patients undergoing cardiac operations from 2001 to 2008 in northern New England. Patients receiving more than 2 units of RBCs or undergoing emergency operations were excluded. Early (to 6 months) and late (to 3 years, among those surviving longer than 6 months) survival was confirmed using the Social Security Death Index. We estimated the relationship between RBCs and survival, and any interaction by age (<80 years versus ≥80 years) or procedure. We calculated the adjusted hazard ratio (HR), and plotted adjusted survival curves., Results: Patients receiving RBCs had more comorbidities irrespective of age. Patients 80 years of age or older underwent transfusion more often than patients younger than 80 years (51% versus 30%; p<0.001). There was no evidence of an interaction by age or procedure (p>0.05). Among patients younger than 80 years, RBCs significantly increased a patient's risk of early death [HR, 2.03; 95% confidence interval [CI], 1.47, 2.80] but not late death 1.21 (95%CI, 0.88, 1.67). RBCs did not increase the risk of early [HR, 1.47; 95% CI, 0.84, 2.56] or late (HR, 0.92 95% CI, 0.50, 1.69) death in patients 80 years or older., Conclusions: Octogenarians receive RBCs more often than do younger patients. Although transfusion of 1 to 2 units of RBCs increases the risk of early death in patients younger than 80 years, this effect was not present among octogenarians. There was no significant effect of RBCs in late death in either age group., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Device-related bloodstream infections are associated with a significant increase in patient morbidity and mortality in multiple health care settings. Recently, intraoperative bacterial contamination of conventional open-lumen 3-way stopcock sets has been shown to be associated with increased patient mortality. Intraoperative use of disinfectable, needleless closed catheter devices (DNCCs) may reduce the risk of bacterial injection as compared to conventional open-lumen devices due to an intrinsic barrier to bacterial entry associated with valve design and/or the capacity for surface disinfection. However, the relative benefit of DNCC valve design (intrinsic barrier capacity) as compared to surface disinfection in attenuation of bacterial injection in the clinical environment is untested and entirely unknown. The primary aim of the current study was to investigate the relative efficacy of a novel disinfectable stopcock, the Ultraport zero, with and without disinfection in attenuating intraoperative injection of potential bacterial pathogens as compared to a conventional open-lumen stopcock intravascular device. The secondary aims were to identify risk factors for bacterial injection and to estimate the quantity of bacterial organisms injected during catheter handling., Methods: Four hundred sixty-eight operating room environments were randomized by a computer generated list to 1 of 3 device-injection schemes: (1) injection of the Ultraport zero stopcock with hub disinfection before injection, (2) injection of the Ultraport zero stopcock without prior hub disinfection, and (3) injection of the conventional open-lumen stopcock closed with sterile caps according to usual practice. After induction of general anesthesia, the primary anesthesia provider caring for patients in each operating room environment was asked to perform a series of 5 injections of sterile saline through the assigned device into an ex vivo catheter system. The primary outcome was the incidence of bacterial contamination of the injected fluid column (effluent). Risk factors for effluent contamination were identified in univariate analysis, and a controlled laboratory experiment was used to generate an estimate of the bacterial load injected for contaminated effluent samples., Results: The incidence of effluent bacterial contamination was 0% (0/152) for the Ultraport zero stopcock with hub disinfection before injection, 4% (7/162) for the Ultraport zero stopcock without hub disinfection before injection, and 3.2% (5/154) for the conventional open-lumen stopcock. The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of bacterial injection as compared to the conventional open-lumen stopcock (RR = 8.15 × 10(-8), 95% CI, 3.39 × 10(-8) to 1.96 × 10(-7), P = <0.001), with an absolute risk reduction of 3.2% (95% CI, 0.5% to 7.4%). Provider glove use was a risk factor for effluent contamination (RR = 10.48, 95% CI, 3.16 to 34.80, P < 0.001). The estimated quantity of bacteria injected reached a clinically significant threshold of 50,000 colony-forming units per each injection series., Conclusions: The Ultraport zero stopcock with hub disinfection before injection was associated with a significant reduction in the risk of inadvertent bacterial injection as compared to the conventional open-lumen stopcock. Future studies should examine strategies designed to facilitate health care provider DNCC hub disinfection and proper device handling.

Background: We examined a recent regional experience to determine the effect of a prior cardiac operation on short-term and midterm outcomes after coronary artery bypass grafting (CABG)., Methods: We identified 20,703 patients who underwent nonemergent CABG at 8 centers in northern New England from 2000 to 2008, of whom 818 (3.8%) had undergone prior cardiac operations. Prior CABG using a minimal or full sternotomy was considered a prior sternotomy. Survival data out to 4 years were obtained from a link with the Social Security Administration Death Index. Hazard ratios were estimated using a Cox proportional hazards regression model, and adjusted survival curves were estimated using inverse probability weighting. In a separate analysis, 1,182 patients were matched 1:1 by a patient's propensity for having undergone prior CABG., Results: Patients with prior sternotomies had a greater burden of comorbid diseases and increased acuity and had a greater likelihood of returning to the operating room for bleeding and low cardiac output failure. Prior sternotomy was associated with an increased risk of death out to 4 years for patients undergoing CABG, with an unmatched hazard ratio of 1.34 (95% confidence interval, 1.10 to 1.64) and a matched hazard ratio of 1.36 (95% confidence interval, 1.01 to 1.81)., Conclusions: Analyses of our recent regional experience with nonemergent CABG showed that a prior cardiac operation was associated with a nearly twofold increased hazard of death at up to 4 years of follow-up., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Healthcare-associated infections (HCAIs) impact 10% of hospitalized patients. Some of these infections result from bacterial cross contamination and poor compliance with guidelines (Pittet D: Compliance with hand disinfection and its impact on hospital-acquired infections. J HospInfect 48 Suppl A:S40-S46, 2001); (Watanakunakorn C, Wang C, Hazy J: An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 19:858-860, 1998). Contamination of provider hands may be a modifiable risk factor. We instituted a novel multimodal system designed to improve hand hygiene by ICU providers., Materials and Methods: A before and after study design was used to evaluate the impact on the incidence of CRBSI and VAP of a multi-modal program incorporating education, performance feedback, and a body worn hand hygiene device. Compliance was communicated quarterly. Primary outcomes were CRBSIs and VAPs per 1,000 line days or per 1,000 ventilator days and compliance rates. Secondary outcomes were hospital length of stay and mortality., Results: A total of 1, 262 and 1,331 patients were evaluated during consecutive 12 month periods. VAP per 1000 vent days were significantly reduced after introduction of the program [3.7 vs. 6.9] P < .01. The reduction in CRBSI per 1000 line days was not significant [1.5 vs. 2.6], P = .09. Observed hand hygiene increased during the study period. There was no significant difference in mortality., Conclusions: A novel multi-modal hand hygiene system resulted in a reduction in VAP. Provider hand contamination during patient care in the ICU is a modifiable risk factor for reducing ventilator associated pneumonias., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: We have recently shown that intraoperative bacterial transmission to patient IV stopcock sets is associated with increased patient mortality. In this study, we hypothesized that bacterial contamination of anesthesia provider hands before patient contact is a risk factor for direct intraoperative bacterial transmission., Methods: Dartmouth-Hitchcock Medical Center is a tertiary care and level 1 trauma center with 400 inpatient beds and 28 operating suites. The first and second operative cases in each of 92 operating rooms were randomly selected for analysis. Eighty-two paired samples were analyzed. Ten pairs of cases were excluded because of broken or missing sampling protocol and lost samples. We identified cases of intraoperative bacterial transmission to the patient IV stopcock set and the anesthesia environment (adjustable pressure-limiting valve and agent dial) in each operating room pair by using a previously validated protocol. We then used biotype analysis to compare these transmitted organisms to those organisms isolated from the hands of anesthesia providers obtained before the start of each case. Provider-origin transmission was defined as potential pathogens isolated in the patient stopcock set or environment that had an identical biotype to the same organism isolated from hands of providers. We also assessed the efficacy of the current intraoperative cleaning protocol by evaluating isolated potential pathogens identified at the start of case 2. Poor intraoperative cleaning was defined as 1 or more potential pathogens found in the anesthesia environment at the start of case 2 that were not there at the beginning of case 1. We collected clinical and epidemiological data on all the cases to identify risk factors for contamination., Results: One hundred sixty-four cases (82 case pairs) were studied. We identified intraoperative bacterial transmission to the IV stopcock set in 11.5 % (19/164) of cases, 47% (9/19) of which were of provider origin. We identified intraoperative bacterial transmission to the anesthesia environment in 89% (146/164) of cases, 12% (17/146) of which were of provider origin. The number of rooms that an attending anesthesiologist supervised simultaneously, the age of the patient, and patient discharge from the operating room to an intensive care unit were independent predictors of bacterial transmission events not directly linked to providers., Conclusion: The contaminated hands of anesthesia providers serve as a significant source of patient environmental and stopcock set contamination in the operating room. Additional sources of intraoperative bacterial transmission, including postoperative environmental cleaning practices, should be further studied.

Background: Transfusion of red blood cells, while often used for treating blood loss or haemodilution, is also associated with higher infection rates and mortality. The authors implemented an initiative to reduce variation in the number of perioperative transfusions associated with cardiac surgery., Methods: The authors examined patients undergoing non-emergent cardiac surgery at a single centre from the third quarter 2004 to the second quarter 2007. Phase I focused on understanding the current process of managing and treating perioperative anaemia. Phase II focused on (1) quality-improvement project dissemination to staff, (2) developing and implementing new protocols, and (3) assessing the effect of subsequent interventions. Data reports were updated monthly and posted in the clinical units. Phase III determined whether reductions in transfusion rates persisted., Results: Indications for transfusions were investigated during Phase II. More than half (59%) of intraoperative transfusions were for low haematocrit (Hct), and 31% for predicted low Hct during cardiopulmonary bypass. 43% of postoperative transfusions were for low Hct, with an additional 16% for failure to diurese. The last Hct value prior to transfusion was noted (Hct 25-23, p=0.14), suggestive of a higher tolerance for a lower Hct by staff surgeons. Intraoperative transfusions diminished across phases: 33% in Phase I, 25.8% in Phase II and 23.4% in Phase III (p<0.001). Relative to Phase I, postoperative transfusions diminished significantly over Phase II and III., Conclusions: We report results from a focused quality-improvement initiative to rationalise treatment of perioperative anaemia. Transfusion rates declined significantly across each phase of the project.

Background: Exposure to red blood cell (RBC) transfusions has been associated with increased mortality after cardiac surgery. We examined long-term survival for cardiac surgical patients who received one or two RBC units during index hospitalization., Methods: Nine thousand seventy-nine consecutive patients undergoing coronary artery bypass graft, valve, or coronary artery bypass graft/valve surgery at eight centers in northern New England during 2001-2004 were examined after exclusions. A probabilistic match between the regional registry and the Social Security Administration's Death Master File determined mortality through June 30, 2006. Cox Proportional Hazard and propensity methods were used to calculate adjusted hazard ratios., Results: Thirty-six percent of patients (n = 3254) were exposed to one or two RBC units. Forty-three percent of RBCs were given intraoperatively, 56% in the postoperative period and 1% were preoperative. Patients transfused were more likely to be anemic, older, smaller, female and with more comorbid illness. Survival was significantly decreased for all patients exposed to 1 or 2 U of RBCs during hospitalization for cardiac surgery compared with those who received none (P < 0.001). After adjustment for patient and disease characteristics, patients exposed to 1 or 2 U of RBCs had a 16% higher long-term mortality risk (adjusted hazard ratios = 1.16, 95% CI: 1.01-1.34, P = 0.035)., Conclusions: Exposure to 1 or 2 U of RBCs was associated with a 16% increased hazard of decreased survival after cardiac surgery.

Background: Few published data exist with respect to current implementation of interventions that increase patient safety in intensive care units (ICUs) Furthermore, even less published data exist that address implementation of outcome-related methodologies of patient safety interventions in ICUs., Objective: The purpose of this study was threefold: (1) to increase implementation rates of known, evidence-based interventions in the Dartmouth Hitchcock Medical Center (DHMC) ICU that have been demonstrated to reduce morbidity and mortality in critically ill patients; (2) to develop a durable and reproducible intervention model that can be applied not only to various aspects of ICU medicine but to any healthcare microsystem that is process oriented; and (3) to design an "ICU-specific" value compass., Design: Using a before/after study design, the interventions involved: (1) establishing a systematic approach to integrate the delivery of proven ICU safety measures; (2) using the design of the various tools to develop a method for team communication and team building; (3) incorporating prompts into a ICU progress note for the healthcare team to address three evidence-based measures on a daily basis; and (4) using a data wall to demonstrate progress and to provide "real-time" feedback for error correction., Setting and Participants: In the before and after study, two groups of 40 consecutive patients admitted to DHMC's Intensive Care Unit were evaluated. The first group of patients was admitted between April and May of 2003. The second group of 40 patients was admitted between May and June of 2004. To ensure process stability, control data were also collected on patients at an interval time point between these two groups., Main Outcome Measures: Three evidence-based interventions were identified that reduce the likelihood of adverse events resulting simply from an ICU stay: (1) prophylaxis against venous thrombo-embolic disease (venous thromboembolism or deep vein thrombosis); (2) prophylaxis against ventilator-associated pneumonia (VAP); and (3) prophylaxis against stress-ulcers (SU). Two data points were obtained per patient per day corresponding to the work shift schedule in the ICU. The unit of measure was patient-shift observation. A limited data set was collected before implementing the change package to ensure system stability., Results: Both traditional statistical analysis and statistical process control (SPC) were used to evaluate the results. For each metric, it was possible to demonstrate an increase in the measure of the mean, reduced point-to-point variation as well as a substantial narrowing of the control limits indicating improved process control., Limitations: By virtue of the involvement of the researcher in the data collection for the control group, the potential existed for methodological bias by acting on the information collected. There was also the lack of a cohesive data structure from which to collect information (ie, the hospital computer speaks one language, the ventilator a second and the monitoring systems a third)., Conclusions: A model for changing the ICU microsystem at DHMC was created that enabled successful implementation of evidence-based measures by maximising the natural flow of work and fostering a team-based culture to improve patient safety. Unique to this method and unlike currently available methods that define only the delivery of the appropriate intervention as success, system success was defined in terms of both true positives, namely delivering care when it is indicated, as well as true negatives, not delivering care when there is none indicated, to offer a more comprehensive system review. Additionally, the method of data collection allowed simplified defect analysis, thereby eliminating a resource-consuming audit of data after the fact. This approach, therefore, provides a basis for adapting and redesigning the PDSA cycle so as to specifically apply this type of "disciplinary" work.

Studies of pediatric sedation practice have suffered from the lack of an objective scale that would allow for a comparison of the effectiveness and safety of sedation provided by various providers and techniques. We present the Dartmouth Operative Conditions Scale (DOCS), which is designed as a research tool to codify the appropriateness of the procedural conditions provided by various sedation interventions. To begin, human factors methodology was used to develop a model of the pediatric sedation process and to define the criteria for measuring a patient's condition during a procedure (DOCS). To accomplish validation, 70 video clips (30-s duration) were then selected from more than 300 h of procedural video tape for testing/grading purposes. Inter-rater reliability was tested by comparing the score for each video clip among 10 different raters. Intra-rater reliability was evaluated by retesting all of the raters 1 yr after their initial rating. Construct validity was confirmed by analyzing the change in DOCS score relative to the time that sedation intervention was undertaken. Criterion validity was tested by comparing the DOCS to a modified COMFORT score. The DOCS was completed with excellent inter-rater (kappa = 0.84) and intra-rater (kappa = 0.91) agreement by 10 health care providers with various backgrounds during the 1-yr study period. Criterion validity was supported by the close correlation between the DOCS and the modified COMFORT scores for 20 distinct video clips (Spearman correlation coefficient = 0.98; P <0.001). The distribution of DOCS scores 20 min after the anesthetic induction was significantly lower than the scores before initiation of sedation, and scores after emergence were consistently higher than those 20 min after sedation (P <0.001), thus confirming construct validity of the scale. The DOCS is a validated research tool when used with video data for comparing the effectiveness and safety of pediatric sedation service, regardless of technique used for decreasing anxiety or pain during a procedure.

Background: Anemia in the critically ill patient population is common. This anemia of critical illness is a distinct clinical entity characterized by blunted erythropoietin production and abnormalities in iron metabolism identical to what is commonly referred to as the anemia of chronic disease., Findings: As a result of this anemia, critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units receive at least one red blood cell unit, and the average is close to five red blood cell units during their intensive care unit stay. There is little evidence that "routine" transfusion of stored allogeneic red blood cells is beneficial for critically ill patients. Most critically ill patients can tolerate hemoglobin levels as low as 7 mg/dL, so a more conservative approach to red blood cell transfusion is warranted., Conclusion: Practice strategies should be directed toward a reduction of blood loss (phlebotomy) and a decrease in the transfusion threshold in critically ill patients.

Unlabelled: Avoidance of tachycardia is a commonly described goal for anesthetic management during coronary artery bypass graft (CABG) surgery. However, an association between increased intraoperative heart rate and mortality has not been described. We conducted an observational study to evaluate the association between preinduction heart rate (heart rate upon arrival to the operating room) and in-hospital mortality during CABG surgery. Data were collected on 5934 CABG patients. Fifteen percent of patients had an increased preinduction heart rate > or =80 bpm. Crude mortality was significantly more frequent among patients with increased preinduction heart rate (P(trend) = 0.002). After adjustment for baseline differences among patients, preinduction heart rate > or =80 bpm remained associated with increased mortality (P(trend) < 0.001). The increased heart rate may be a cause of the observed mortality. Alternatively, faster heart rate may be either a marker of patients with irreversible myocardial damage, or a marker of patients with limited cardiac reserve at risk for further injury. Lastly, faster heart rate may be a marker for under-use of beta-adrenergic blockade. Because the use of preoperative beta-adrenergic blockade in CABG patients is associated with improved in-hospital survival, further investigation concerning the effect of intraoperative treatment of increased heart rate with beta-adrenergic blockers on mortality after CABG surgery is warranted., Implications: We conducted an observational study to evaluate the association between heart rate upon arrival to the operating room (preinduction heart rate) and in-hospital mortality during coronary artery bypass graft surgery. After adjustment for baseline differences among patients, preinduction heart rate > or =80 bpm was associated with an increased in-hospital mortality after coronary artery bypass graft surgery.

Unlabelled: Heart failure is the most common cause of death among coronary artery bypass graft (CABG) patients. In addition, most variation in observed mortality rates for CABG surgery is explained by fatal heart failure. The purpose of this study was to develop a clinical risk assessment tool so that clinicians can rapidly and easily assess the risk of fatal heart failure while caring for individual patients. Using prospective data for 8,641 CABG patients, we used logistic regression analysis to predict the risk of fatal heart failure. In multivariate analysis, female sex, prior CABG surgery, ejection fraction <40%, urgent or emergency surgery, advanced age (70-79 yr and >80 yr), peripheral vascular disease, diabetes, dialysis-dependent renal failure and three-vessel coronary disease were significant predictors of fatal postoperative heart failure. A clinical risk assessment tool was developed from this logistic regression model, which had good discriminating characteristics (receiver operating characteristic clinical source = 0.75, 95% confidence interval: 0.71, 0.78)., Implications: In contrast to previous cardiac surgical scoring systems that predicted total mortality, we developed a clinical risk assessment tool that evaluates risk of fatal heart failure. This distinction is relevant for quality improvement initiatives, because most of the variation in CABG mortality rates is explained by postoperative heart failure.

Background: Cardiac surgery patients' hematocrits frequently fall to low levels during cardiopulmonary bypass., Methods: We investigated the association between nadir hematocrit and in-hospital mortality and other adverse outcomes in a consecutive series of 6,980 patients undergoing isolated coronary artery bypass graft surgery. The lowest hematocrit during cardiopulmonary bypass was recorded for each patient. Patients were divided into categories based on their lowest hematocrit. Women had a lower hematocrit during bypass than men but both sexes are represented in each category., Results: After adjustment for preoperative differences in patient and disease characteristics, the lowest hematocrit during cardiopulmonary bypass was significantly associated with increased risk of in-hospital mortality, intra- or postoperative placement of an intraaortic balloon pump and return to cardiopulmonary bypass after attempted separation. Smaller patients and those with a lower preoperative hematocrit are at higher risk of having a low hematocrit during cardiopulmonary bypass., Conclusions: Female patients and patients with smaller body surface area may be more hemodiluted than larger patients. Minimizing intraoperative anemia may result in improved outcomes for this subgroup of patients.

Background: Accessibility to tertiary intensive care resources differs among hospitals within a rural region. Determining whether accessibility is associated with outcome is important for understanding the role of regionalization when providing critical care to a rural population., Methods: In a prospective design, we identified and recorded the mortality ratio, percentage of unanticipated deaths, length of stay in the intensive care unit (ICU), and survival time of 147 patients transferred directly from other hospitals and 178 transferred from the wards within a rural tertiary-care hospital., Results: The two groups did not differ significantly in the characteristics measured. Differences in access to tertiary critical care in this rural region did not affect survival or length of stay after admission to this tertiary ICU. The odds ratio (1.14; 95% confidence interval 0.72-1.83) for mortality associated with transfer from a rural community hospital was not statistically significant., Conclusions: Patients at community hospitals in this area who develop need for tertiary critical care are just as likely to survive as patients who develop ICU needs on the wards of this rural tertiary-care hospital, despite different accessibility to tertiary intensive-care services.

Objective: We tested the hypothesis that a monitoring display proposed by Blike et al. improves the performance of anesthesiologists. We measured the performance of anesthesiologists using the new display and compared it to their performance with a traditional display. We studied three different displays on how they affected recognition and differentiation of five etiologies of shock-anaphylaxis, bradycardia, hypovolemia, ischemia and pulmonary embolus., Methods: The participants monitored heart rate, systemic arterial and pulmonary blood pressure, central venous pressure, and cardiac output during five shock states and five non-shock states. The resulting 10 data sets made up ten decision screens, which we presented randomly on a computer monitor to the subjects in one of three different formats (a Single Sensor Single Indicator (SSSI) Numeric display; an Object display; and an Object Minus Shapes display). Subjects used soft-buttons on a computer touch-screen monitor to: a) advance to the next display; b) differentiate a non-shock state from a shock state; and, c) select the etiology of shock state represented by the display (Figure 4). The internal clock and memory of the computer made the collection of data automatic., Results: The subjects recognized a problem more rapidly with the help of a graphical "pointer on a reference scale" in both Object displays, but their accuracy had not improved in comparison to the SSSI Numeric display. The shape of the Object display improved performance of etiology determination compared to the Object Minus Shapes display and SSSI Numeric display. Testing (10 trials) was completed in less than 45 minutes., Conclusions: The new display with "emergent features" can improve the diagnostic performance of clinicians.

Objective: This study tests the hypothesis that a graphical object display (a data display consisting of meaningful shapes) will affect the ability of anesthesiologists to perform a diagnostic task rapidly and correctly. The diagnostic tasks studied were recognition and differentiation of five etiologies of shock--anaphylaxis, bradycardia, myocardial ischemia, hypovolemia, pulmonary embolus., Methods: Data sets consisting of HR, Systemic Arterial BP, Pulmonary Arterial BP, CVP, and Cardiac Output were generated for five shock states and five non-shock states. The resulting 10 data sets were presented on a computer monitor to study subjects twice (first in an alpha-numeric format and then in the object format) for a total of twenty decision screens. Subjects used soft-buttons on a computer touch-screen monitor to: a) advance to the next display; b) differentiate a non-shock state from a shock state; and, c) select the etiology of shock state represented by the display (Figure 2). Data collection was automatic, using the internal clock and memory of the computer., Results: Eleven anesthesiologists participated in this study. They completed a total of 3060 diagnostic decisions, half with each display format. Performance measures were time to decision and diagnostic accuracy. The object display improved no-shock recognition by 1.0 second and shock etiology determination by 1.4 seconds (p < 0.05). The object display also significantly improved accuracy for shock recognition by 1.4% and etiology determination by 4.1% (p < 0.05). Testing was completed in a time interval of <45 min per 10 trials., Conclusions: The primary finding of this study was that anesthesiologists using the object display format committed significantly fewer diagnostic errors when interpreting physiologic data. In addition, both the recognition of no-shock and the diagnosis of shock etiology were completed more rapidly when the object display was used. The major limitation of this initial trial is the simplicity of the test. Future investigation of the impact of the display on clinical decision making will require more realistic clinical scenarios with partial or full simulation to better understand the potential clinical impact.