INTRODUCTION: The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties.
METHODS AND ANALYSIS: One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome.
ETHICS AND DISSEMINATION: The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences.
OBJECTIVES: To determine the relative contributions of patient risk profile, local and individual clinical practice on length of hospital stay after cardiac surgery.
DESIGN: Ten-year audit of prospectively collected consecutive cardiac surgical cases. Case-mix adjusted outcomes were analysed in models that included random effects for centre, surgeon and anaesthetist.
SETTING: UK centres providing adult cardiac surgery.
PARTICIPANTS: 10 of 36 UK specialist centres agreed to provide outcomes for all major cardiac operations over 10 years. After exclusions (duplicates, cases operated by more than one consultant, deaths and procedures for which the EuroSCORE risk score for cardiac surgery is not appropriate), there were 107 038 cardiac surgical procedures between April 2002 and March 2012, conducted by 127 consultant surgeons and 190 consultant anaesthetists.
MAIN OUTCOME MEASURE: Length of stay (LOS) up to 3 months postoperatively.
RESULTS: The principal component of variation in outcomes was patient risk (represented by the EuroSCORE and remaining patient heterogeneity), accounting for 95.43% of the variation for postoperative LOS. The impact of the surgeon and centre was moderate (intra-class correlation coefficients ICC=2.79% and 1.59%, respectively), whereas the impact of the anaesthetist was negligible (ICC=0.19%). Similarly, 96.05% of the variation for prolonged LOS (>11 days) was attributable to the patient, with surgeon and centre less but still influential components (ICC=2.12% and 1.66%, respectively, 0.17% only for anaesthetists). Adjustment for year of operation resulted in minor reductions in variation attributable to surgeons (ICC=2.52% for LOS and 2.23% for prolonged LOS).
CONCLUSIONS: Patient risk profile is the primary determinant of variation in LOS, and as a result, current initiatives to reduce hospital stay by modifying consultant performance are unlikely to have a substantial impact. Therefore, substantially reducing hospital stay requires shifting away from a one-size-fits-all approach to cardiac surgery, and seeking alternative treatment options personalised to high-risk patients.
National data were obtained from interviews with KATH personnel, correspondence with Ghana's anesthesia society, and review of public records.The practice of anesthesia at KATH incorporated preanesthesia clinics, intraoperative management, and criticalcare. However, there were not enough physicians to consistently supervise care, especially in postanesthesia care units (PACUs) and the critical care unit (CCU.
Deep sedation during stay in the Intensive Care Unit (ICU) may have deleterious effects upon the clinical and cognitive outcomes of critically ill patients undergoing mechanical ventilation. Over the last decade a vast body of literature has been generated regarding different sedation strategies, with the aim of reducing the levels of sedation in critically ill patients. There has also been a growing interest in acute brain dysfunction, or delirium, in the ICU. However, the effect of sedation during ICU stay upon long-term cognitive deficits in ICU survivors remains unclear. Strategies for reducing sedation levels in the ICU do not seem to be associated with worse cognitive and psychological status among ICU survivors. Sedation strategy and management efforts therefore should seek to secure the best possible state in the mechanically ventilated patient and lower the prevalence of delirium, in order to prevent long-term cognitive alterations.
INTRODUCTION: This single-centre retrospective case-control study aimed to assess the effectiveness of a multidisciplinary clinical pathway for blunt chest trauma patients admitted in emergency department (ED).
PATIENTS AND METHODS: All consecutive blunt chest trauma patients with more than 3 rib fractures and no indication of mechanical ventilation were compared to a retrospective cohort over two 24-month periods, before and after the introduction of the bundle of care. Improvement of analgesia was the main outcome investigated in this study. The secondary outcomes were the occurrence of secondary respiratory complications (pneumonia, indication for mechanical ventilation, secondary ICU admission for respiratory failure or death), the intensive care unit (ICU) and hospital length of stay (LOS).
RESULTS: 69 pairs of patients were matched using a 1:1 nearest neighbour algorithm adjusted on age and indices of severity. Between the two periods, there was a significant reduction of the rate of uncontrolled analgesia (55 vs. 17%, p < 0.001). A significant increase in the rate of primary ICU transfer during the post-protocol period (23 vs. 52%, p < 0.001) was not associated with a reduction of secondary respiratory complications or a reduction of ICU or hospital LOS. Only the use of non-steroidal anti-inflammatory drugs appeared to be associated with a significant reduction of secondary respiratory complications (OR = 0.3 [0.1 - 0.9], p = 0.03).
CONCLUSION: Implementation of a multidisciplinary clinical pathway significantly improves pain control after ED management, but increases the rate of primary ICU admission without significant reduction of secondary respiratory complications.
Men's Health (2) Respiratory Failure (1), Pneumonia (1), more mentions
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In the 48 patients with a prospectively documented risk of ≥10%, both a consultant surgeon and anaesthetist were present for 68.8%, 62.8% were admitted to criticalcare and 45.8% commenced surgery within 2 h. The mortality in those retrospectively (62; 31%) and prospectively risk-assessed was 9.5% and 5.2%, respectively.This prospective EL audit demonstrated low 30-day mortality with ...
Among the European countries, the most popular ones were Sweden, Germany, United Kingdom, Switzerland and Norway. The five most popular clinical specialties were general practice, internal medicine, anesthesiology/intensivecare, laboratory/pathology and surgery. With respect to the planned duration of working abroad, at the time of emigration one-fourth of our colleagues planned very short (<2 years) stay.