Critical Care in the United States of America

To describe the extent and variation of critical care services in Sri Lanka as a first step towards the development of a nationwide critical care unit (CCU) registry.

A cross-sectional survey was conducted in all state CCUs by telephone or by visits to determine administration, infrastructure, equipment, staffing, and overall patient outcomes.

There were 99 CCUs with 2.5 CCU beds per 100 000 population and 13 CCU beds per 1 000 hospital beds. The median number of beds per CCU was 5. The overall admissions were 194 per 100 000 population per year. The overall bed turnover was 76.5 per unit per year, with CCU mortality being 17%.

Most CCUs were headed by an anesthetist. There were a total of 790 doctors (1.6 per bed), 1 989 nurses (3.9 per bed), and 626 health care assistants (1.2 per bed). Majority (87.9%) had 1:1 nurse-to-patient ratio, although few (11.4%) nurses had received formal intensive care unit training. All CCUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (such as electronic monitoring and infusion pumps).

Sri Lanka, a lower middle-income country has an extensive network of critical care facilities but with inequalities in its distribution and facilities.

Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.

La formación en medicina intensiva, ya sea como especialidad primaria o a partir de una troncalidad común para después convertirse en supra-especialidad, debería incluir competencias clave que garanticen un cuidado estándar y homogéneo del paciente crítico, así como proveer al sistema sanitario del número de especialistas en medicina intensiva (intensivistas) de forma ajustada y anticipada al ritmo de crecimiento de la necesidad asistencial.

La organización de los cuidados intensivos desde la visión de las distintas especialidades o en unidades centralizadas y jerarquizadas, es heterogénea y está en constante evolución. No obstante el acceso y tratamiento precoz del enfermo crítico por parte de un intensivista, debería estar siempre garantizado, no únicamente en los servicios de medicina intensiva, sino en todos los departamentos de un hospital, actuando el intensivista como elemento central en la comunicación y coordinación entre los diferentes servicios y especialistas, a fin de lograr la más alta calidad y eficacia en la asistencia.

La investigación clínica en medicina intensiva está sustentada por la excelencia de conocimiento de sus profesionales, pero son necesarias estructuras de apoyo: la integración de la investigación e innovación en la rutina diaria y un incremento de la investigación traslacional, a fin de identificar áreas que muestren elementos potenciales de avance en el aspecto clínico y la aplicación de los principios de la investigación básica y fisiológica en el entorno de la medicina intensiva. Las tecnologías de la comunicación y la información ofrecen un marco idóneo para compartir y poner en común el conocimiento y apoyar la formación, la investigación y la innovación en medicina intensiva.

Ciudadanía, profesionales de la salud y responsables políticos deben apoyar que aquellos profesionales con el mejor conocimiento científico tomen las decisiones sobre las prioridades en la gestión del cuidado del enfermo crítico, dentro de un modelo económico sostenible. Las sociedades científicas tienen un papel crucial en la definición de los niveles mínimos de atención médica intensiva y también en asegurar estándares de capacitación, formación de intensivistas y acreditación, promoviendo la interacción entre especialidades, familias, sociedad y responsables políticos. La percepción del valour de la medicina intensiva entre la ciudadanía y la Administración debe ser constantemente mejorada mediante esfuerzos coordinados y dirigidos a incrementar el conocimiento que la medicina intensiva pone a su disposición y de los éxitos alcanzados por esta especialidad.

Objective: To identify factors associated with the triage decision for patients classified as Society of Critical Care Medicine (SCCM) Triage Priority 3, and their outcomes.

Design: Single-centre, prospective, observational cohort study.

Setting: General intensive care unit in a tertiary regional hospital, over the 9 months January to September 2007.

Patients: SCCM Triage Priority 3 patients.

Results: All patients were followed up for at least 6 months. Among the 1346 triaged patients, 250 were classified as SCCM Triage Priority 3. Fewer than a third of these (76, 30.4%) were admitted to the ICU. Medical patients were more likely to be rejected than surgical or neurosurgical patients. Those with a poorer physicianpredicted chance of long-term survival were more likely to be rejected than those with a better predicted prognosis. The MPMII₀-predicted mortality was higher for those denied ICU admission. Non-postoperative status (odds ratio [OR], 26.3) and physician-predicted risk > 50% of death within 1 month (OR, 11.8) were independently correlated with denial of ICU admission in a multiple logistic regression analysis. Cox regression analysis showed that independent risk factors for mortality were denial of ICU admission (hazard ratio [HR], 2.80), higher MPMII₀-predicted mortality (HR, 1.12 for every 10% increment) and the presence of renal disease as an admission diagnosis (HR, 2.28).

Conclusions: For SCCM Triage Priority 3 patients, postoperative status and better physician-predicted prognosis correlated with ICU admission. Patients had lower medium-term survival if they were denied ICU admission, or had higher MPMII0-predicted mortality, or renal disease as Crit Care Resusc 2010; 12: 42–49 the admission diagnosis.

To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center.

Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score.

The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality.

The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.

To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICUs) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality.

Multicentered retrospective cohort study.

Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the eastern half of the United States.

31,301 patients discharged with acute ischemic stroke in 2000.

None.

Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Of all patients with acute ischemic stroke, 26% required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-yr follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared with non-ICU patients. MV was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval [CI] 4.93–6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-yr follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01, 95% CI 0.93–1.09). MV still had a higher risk of death (hazard ratio 1.88, 95% CI 1.57–2.25), and PEG patients had a 2.59-fold greater mortality hazard (95% CI 2.38–2.82).

Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the identification of clinical factors that lead to increased mortality in long-term survivors and efforts to reduce those risks.