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David A Harrison - One of the best experts on this subject based on the ideXlab platform.
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development and validation of the new icnarc model for prediction of acute hospital mortality in Adult Critical Care
Journal of Critical Care, 2017Co-Authors: Paloma Ferrandovivas, Andrew J I Jones, Kathryn M Rowan, David A HarrisonAbstract:Abstract Purpose To develop and validate an improved risk model to predict acute hospital mortality for admissions to Adult Critical Care units in the UK. Materials and methods 155,239 admissions to 232 Adult Critical Care units in England, Wales and Northern Ireland between January and December 2012 were used to develop a risk model from a set of 38 candidate predictors. The model was validated using 90,017 admissions between January and September 2013. Results The final model incorporated 15 physiological predictors (modelled with continuous nonlinear models), age, dependency prior to hospital admission, chronic liver disease, metastatic disease, haematological malignancy, CPR prior to admission, location prior to admission/urgency of admission, primary reason for admission and interaction terms. The model was well calibrated and outperformed the current ICNARC model on measures of discrimination (area under the receiver operating characteristic curve 0.885 versus 0.869) and model fit (Brier's score 0.108 versus 0.115). On average, the new model reclassified patients into more appropriate risk categories (net reclassification improvement 19.9; P Conclusions The risk model developed in this study showed excellent discrimination and calibration and when validated on a different period of time and across different types of Critical Care unit. This in turn allows improved accuracy of comparisons between UK Critical Care providers.
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association between day and time of admission to Critical Care and acute hospital outcome for unplanned admissions to Adult general Critical Care units cohort study exploring the weekend effect
BJA: British Journal of Anaesthesia, 2017Co-Authors: Nishkantha Arulkumaran, David A Harrison, Stephen J BrettAbstract:Abstract Background We aimed to identify any association between day and time of admission to Critical Care and acute hospital outcome. Methods We conducted a cohort study using prospectively collected data from the national clinical audit of Adult Critical Care. We included 195 428 unplanned admissions from 212 Adult general Critical Care units in England, Wales and Northern Ireland, between April 1, 2013 and March 31, 2015 in the analysis. Results Hourly admission rates for unplanned admissions varied more than three-fold during the 24 h cycle. Overall acute hospital mortality was 26.8%. Before adjustment, acute hospital mortality was similar between weekends and weekdays but was significantly lower for admissions at night compared with the daytime (−3.4%, −3.8 to −3.0%; P Conclusions The day of week and time of admission have no influence on patient mortality for unplanned admissions to Adult general Critical Care units within the UK. Ways to improve Critical Care and hospital systems to minimize delays in admission and potentially improve outcomes need to be ascertained in future research.
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family reported experiences evaluation free study a mixed methods study to evaluate families satisfaction with Adult Critical Care services in the nhs
Health Services and Delivery Research, 2015Co-Authors: Stephen E Wright, Paloma Ferrandovivas, David A Harrison, Emma Walmsley, Sheila Harvey, Emily J Robinson, Ruth R Canter, Elaine Mccoll, Annette Richardson, Michael RichardsonAbstract:Background To improve Care it is necessary to feed back experiences of those receiving Care. Of patients admitted to intensive Care units (ICUs), approximately one-quarter die, and few survivors recollect their experiences, so family members have a vital role. The most widely validated tool to seek their views is the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU). Objectives To test face and content validity and comprehensibility of the FS-ICU (phase 1). To establish internal consistency, construct validity and reliability of the FS-ICU; to describe family satisfaction and explore how it varies by family member, patient, unit/hospital and other contextual factors and by country; and to model approaches to sampling for future use in quality improvement (phase 2). Design Mixed methods: qualitative study (phase 1) and cohort study (phase 2). Setting NHS ICUs (n = 2, phase 1; n = 20, phase 2). Participants Health-Care professionals, ex-patients, family members of ICU patients (n = 41, phase 1). Family members of ICU patients (n = 12,303, phase 2). Interventions None. Main outcome measures Key themes regarding each item of the 24-item FS-ICU (FS-ICU-24) (phase 1). Overall family satisfaction and domain scores of the FS-ICU-24 (phase 2). Results In phase 1, face validity, content validity and comprehensibility were good. Adaptation to the UK required only minor edits. In phase 2, one to four family members were recruited for 60.6% of 10,530 patients (staying in ICU for 24 hours or more). Of 12,303 family members, 7173 (58.3%) completed the questionnaire. Psychometric assessment of the questionnaire established high internal consistency and criterion validity. Exploratory factor analysis indicated new domains: satisfaction with Care, satisfaction with information and satisfaction with the decision-making process. All scores were high with skewed distributions towards more positive scores. For family members of ICU survivors, factors associated with increased/decreased satisfaction were age, ethnicity, relationship to patient, and visit frequency, and patient factors were acute severity of illness and invasive ventilation. For family members of ICU non-survivors, average satisfaction was higher but no family member factors were associated with increased/decreased satisfaction; patient factors were age, acute severity of illness and duration of stay. Neither ICU/hospital factors nor seasonality were associated. Funnel plots confirmed significant variation in family satisfaction across ICUs. Adjusting for family member and patient characteristics reduced variation, resulting in fewer ICUs identified as potential outliers. Simulations suggested that family satisfaction surveys using short recruitment windows can produce relatively unbiased estimates of average family satisfaction. Conclusions The Family-Reported Experiences Evaluation study has provided a UK-adapted, psychometrically valid questionnaire for overall family satisfaction and three domains. The large sample size allowed for robust multilevel multivariable modelling of factors associated with family satisfaction to inform important adjustment of any future evaluation. Limitations Responses to three free-text questions indicate the questionnaire may not be sensitive to all aspects of family satisfaction. Future work Reservations remain about the current questionnaire. While formal analysis of the free-text questions did not form part of this proposal, brief analysis suggested considerable scope for improvement of the FS-ICU-24. Study registration Current Controlled Trials ISRCTN47363549. Funding details The National Institute for Health Research Health Services and Delivery Research programme.
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effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation the tracman randomized trial
JAMA, 2013Co-Authors: Duncan Young, David A Harrison, Brian H Cuthbertson, Kathy RowanAbstract:Results Of the 455 patients assigned to early tracheostomy, 91.9% (95% CI, 89.0%94.1%) received a tracheostomy and of 454 assigned to late tracheostomy, 44.9% (95% CI, 40.4%-49.5%) received a tracheostomy. All-cause mortality 30 days after randomization was 30.8% (95% CI, 26.7%-35.2%) in the early and 31.5% (95% CI, 27.3%-35.9%) in the late group (absolute risk reduction for early vs late, 0.7%; 95% CI, 5.4% to 6.7%). Two-year mortality was 51.0% (95% CI, 46.4%-55.6%) in the early and 53.7% (95% CI, 49.1%-58.3%) in the late group (P=.74). Median Critical Care unit length of stay in survivors was 13.0 days in the early and 13.1 days in the late group (P=.74). Tracheostomy-related complications were reported for 6.3% (95% CI, 4.6%-8.5%) of patients (5.5% in the early group, 7.8% in the late group). Conclusions and Relevance For patients breathing with the aid of mechanical ventilation treated in Adult Critical Care units in the United Kingdom, tracheostomy within 4 days of Critical Care admission was not associated with an improvement in 30-day mortality or other important secondary outcomes. The ability of clinicians to predict which patients required extended ventilatory support was limited.
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evaluation of modernisation of Adult Critical Care services in england time series and cost effectiveness analysis
BMJ, 2009Co-Authors: Andrew Hutchings, Kathy Rowan, David A Harrison, Mary Alison Durand, Richard Grieve, Judith Green, John Cairns, Nick BlackAbstract:Objective To evaluate the impact and cost effectiveness of a programme to transform Adult Critical Care throughout England initiated in late 2000. Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6. Setting 96 Critical Care units in England. Participants 349 817 admissions to Critical Care units. Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity. Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 ($33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000. Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 ($667, €445) to £1096 ($1810, €1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear. Conclusion Substantial improvements in NHS Critical Care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.
Alison Holmes - One of the best experts on this subject based on the ideXlab platform.
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waterborne elizabethkingia meningoseptica in Adult Critical Care
Emerging Infectious Diseases, 2016Co-Authors: Luke S. P. Moore, Daniel S Owens, Simon Ashworth, Hugo Donaldson, Jane F. Turton, Annette Jepson, Alison HolmesAbstract:Elizabethkingia meningoseptica (formerly Flavobacterium meningosepticum and, during 1994–2005 Chryseobacterium meningosepticum) (1) is a gram-negative nonfermenting obligate aerobe. It is widely distributed in the environment (2), yet also an acknowledged opportunistic human pathogen. Most frequently associated with neonatal meningitis (3,4), the organism also has been described in osteomyelitis (5) and skin structure infections (6,7). In addition, E. meningoseptica has been associated with colonization of the respiratory tract in ventilated Adult patients, but causation of ventilator-associated pneumonia in this cohort is less clear; some studies have attributed pathogenicity (8–10), but others have found no attributable disease from colonization (11,12). Outbreaks have been linked to hospital water sources in Adult Critical Care units (8,13); these outbreaks have been suggested to be attributable to the tolerance exhibited by Elizabethkingia species to such environments. Challenges in the laboratory diagnosis of this organism complicate a true understanding of its role in disease. Difficulties in culture, including variable (strain-dependent) growth on MacConkey agar (1) and misidentification on some automated laboratory platforms (4,7), contribute to diagnostic challenges. Recent changes to clinical laboratory practice, particularly the widespread adoption of matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry, has improved confidence in identification of nonfermenting gram-negative organisms (14) and specifically facilitated rapid identification of E. meningoseptica from patient samples (15). How this advance confounds the reported epidemiology of this organism remains unclear and contributes to the lack of clarity around attributable illness. In the context of recent increased international reporting of E. meningoseptica outbreaks among Adults, including in the United States (10), Brazil (16), South Asia (17), and Southeast Asia (8,18), establishing whether E. meningoseptica is an emerging pathogenic organism is essential. We report a retrospective observational study detailing an outbreak of E. meningoseptica acquisition in a London teaching hospital Adult Critical Care unit in accordance with the ORION protocol (19), analyzing the clinico-physiologic response of patients who acquired E. meningoseptica, and deriving a measure of attributable illness. We analyzed case identification in the context of the wider changes to diagnostic laboratory practice to determine whether E. meningoseptica is an emerging, or pseudo-emerging (i.e., previously present but unidentified or underidentified), organism (20).
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waterborne elizabethkingia meningoseptica in Adult Critical Care
Emerging Infectious Diseases, 2016Co-Authors: Luke S. P. Moore, Daniel S Owens, Simon Ashworth, Hugo Donaldson, Jane F. Turton, Annette Jepson, Alison HolmesAbstract:Elizabethkingia meningoseptica is an infrequent colonizer of the respiratory tract; its pathogenicity is uncertain. In the context of a 22-month outbreak of E. meningoseptica acquisition affecting 30 patients in a London, UK, Critical Care unit (3% attack rate) we derived a measure of attributable morbidity and determined whether E. meningoseptica is an emerging nosocomial pathogen. We found monomicrobial E. meningoseptica acquisition (n = 13) to have an attributable morbidity rate of 54% (systemic inflammatory response syndrome ≥2, rising C-reactive protein, new radiographic changes), suggesting that E. meningoseptica is a pathogen. Epidemiologic and molecular evidence showed acquisition was water-source-associated in Critical Care but identified numerous other E. meningoseptica strains, indicating more widespread distribution than previously considered. Analysis of changes in gram-negative speciation rates across a wider London hospital network suggests this outbreak, and possibly other recently reported outbreaks, might reflect improved diagnostics and that E. meningoseptica thus is a pseudo-emerging pathogen.
Jill Cox - One of the best experts on this subject based on the ideXlab platform.
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pressure injury risk factors in Adult Critical Care patients a review of the literature
Ostomy Wound Management, 2017Co-Authors: Jill CoxAbstract:Critically ill patients require complex Care in a technologically sophisticated environment where they are highly vulnerable to pressure-related injuries. However, pressure injury (PI) development remains a multifactorial phenomenon in Critically ill persons; true risk is both pervasive and elusive. The purpose of this comprehensive review of the empirical literature was to examine the risk factors associated with PIs among Adult patients admitted to contemporary intensive Care units (ICUs). Inclusion criteria stipulated publications were to be peer-reviewed, quantitative studies with a focus on pressure ulcer (PU) risk factors in Adult Critical Care patients published between 2010 and 2016 in which statistical analysis involved multivariate analysis using PU development as the outcome variable. Studies not available in English, those in which the primary focus was on PU prevention or treatment, and those that focused solely on the use of PU risk assessment scales were excluded. A comprehensive review of the OVID and PubMed computerized databases using the search terms pressure ulcer, Critical Care, intensive Care, and risk factors yielded 540 reports; 358 remained after duplicates were eliminated and 28 after the inclusion/exclusion criteria were applied. Following examination, 16 studies were suitable for inclusion. A total of 43 risk factors emerged. Of those, 7 were identified in 3 or more studies in multivariate regression analysis; these included age, prolonged ICU admission, diabetes mellitus, cardiovascular disease, hypotension, prolonged mechanical ventilation, and vasopressor administration. To facilitate results interpretation, risk factors from multivariate analyses were grouped in 6 broad categories: demographic/patient characteristics, comorbidities, intrinsic factors, iatrogenic/Care factors, PI risk assessment scales, and severity of illness/mortality risk. The shared attribute of the 7 risk factors identified was they are all potentially nonmodifiable. Advancing the science regarding the pathogenesis of PI development is imperative when trying to better understand unavoidable pressure-related injuries. The need for large multisite studies and studies using large datasets capable of validating risk factors unique to this population persists. Additionally, the need for enhanced PI risk quantification for Adult ICU patients remains.
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vasopressors and development of pressure ulcers in Adult Critical Care patients
American Journal of Critical Care, 2015Co-Authors: Jill Cox, Sharon RocheAbstract:Background Vasopressors are lifesaving agents used to raise mean arterial pressure in Critically ill patients in shock states. The pharmacodynamics of these agents suggest vasopressors may play a role in development of pressure ulcers; however, this aspect has been understudied. Objective To examine associations between type, dose, and duration of vasopressors (norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine) and development of pressure ulcers in medical-surgical and cardiothoracic intensive Care unit patients and to examine predictors of the development of pressure ulcers in these patients. Methods A retrospective correlational design was used in a sample of 306 medical-surgical and cardiothoracic intensive Care unit patients who received vasopressor agents during 2012. Results Norepinephrine and vasopressin were significantly associated with development of pressure ulcers; vasopressin was the only significant predictor in multivariate analysis. In addition, mean arterial pressure less than 60 mm Hg in patients receiving vasopressors, cardiac arrest, and mechanical ventilation longer than 72 hours were predictive of development of pressure ulcers. Patients with a cardiac diagnosis at the time of admission to the intensive Care unit were less likely than patients without such a diagnosis to experience pressure ulcers while in the unit. Conclusion The addition of vasopressin administered concomitantly with a first-line agent (often norepinephrine) may represent the point at which the risk for pressure ulcers escalates and may be an early warning to heighten strategies to prevent pressure ulcers. Conversely, because vasopressors cannot be terminated to avert development of pressure ulcers, these findings may add to the body of knowledge on factors that potentially contribute to the development of unavoidable pressure ulcers.
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differentiating a pressure ulcer from acute skin failure in the Adult Critical Care patient
Advances in Skin & Wound Care, 2015Co-Authors: Barbara Delmore, Jill Cox, Linda Rolnitzky, Andy S Chu, Angela StolfiAbstract:PURPOSE:The purpose of this learning activity is to provide information regarding the differentiation between pressure ulcers and acute skin failure (ASF) in Critically ill patients.TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in skin and
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enteral nutrition in the prevention and treatment of pressure ulcers in Adult Critical Care patients
Critical Care Nurse, 2014Co-Authors: Jill Cox, Louisa RasmussenAbstract:Prevention and healing of pressure ulcers in Critically ill patients can be especially challenging because of the patients' burden of illness and degree of physiological compromise. Providing adequate nutrition may help halt the development or worsening of pressure ulcers. Optimization of nutrition can be considered an essential ingredient in prevention and healing of pressure ulcers. Understanding malnutrition in Critical Care patients, the effect of nutrition on wound healing, and the application of evidence-based nutritional guidelines are important aspects for patients at high risk for pressure ulcers. Appropriate screenings for nutritional status and risk for pressure ulcers, early collaboration with a registered dietician, and administration of appropriate feeding formulations and micronutrient and macronutrient supplementation to promote wound healing are practical solutions to improve the nutritional status of Critical Care patients. Use of nutritional management and enteral feeding protocols may provide vital elements to augment nutrition and ultimately result in improved clinical outcomes.
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pressure ulcer development and vasopressor agents in Adult Critical Care patients a literature review
Ostomy Wound Management, 2013Co-Authors: Jill CoxAbstract:Critical Care units provide technologically sophisticated Care to the sickest patients in the healthCare system. The contribution of iatrogenic factors, including administration of pharmacologic agents such as vasopressors, to pressure ulcer (PU) development in Adult Critical Care patients is understudied, thus less understood, but may be an important PU risk factor to consider in the Critical Care population. Vasopressor agents are potent vasoconstrictors commonly administered to Critical Care patients to elevate mean arterial pressure to counteract the effects of inadequate tissue perfusion and hypoxia; they have reemerged over the past decade in contemporary intensive Care units as important first-line drugs in the treatment of shock states. A comprehensive review of the literature was undertaken in order to determine the level of evidence regarding the relationship between vasopressor agents (norepinephrine, epinephrine, phenylephrine, vasopressin, and dopamine) and PU development in Adult Critical Care patients. Computerized databases of EBSCOCINAHL and OVID MEDLINE were searched for English-language publications from 2000 to the present using the following terms: pressure ulcer, vasopressor, norepinephrine, epinephrine, vasopressin, dopamine, phenylephrine, Critical Care and pressure ulcers; intensive Care and pressure ulcers; and pressure ulcer risk factors. Ten studies were identified that met the inclusion/exclusion criteria. Statistically significant associations were reported between the broad category of vasopressor agents and PU development in seven studies. Of those, two identified a specific vasopressor agent (norepinephrine) as a significant predictor of PU development in this population. Empirical support for the broad category of vasopressors as a PU risk factor is increasing, and a small body of evidence is emerging to support the role of one specific vasopressor (norepinephrine) in PU development. Increased vigilance regarding PU risk in Critical Care patients receiving vasopressor agents may be warranted. However, studies are needed to examine the effects of individual vasopressor agents and dosage and duration thresholds, as well as empirical investigation regarding the synergistic effect of multiple vasopressor agents administered simultaneously, on PU development in this population. Finally, research is needed to further elucidate vasopressor use as an independent risk factor for PU development in this population.
Derek C Angus - One of the best experts on this subject based on the ideXlab platform.
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reorganizing Adult Critical Care delivery the role of regionalization telemedicine and community outreach
American Journal of Respiratory and Critical Care Medicine, 2010Co-Authors: Yenlan Nguyen, Jeremy M Kahn, Derek C AngusAbstract:Variation in the quality of Critical Care services across hospitals coupled with an emerging workforce crisis necessitates system-level change in the organization of intensive Care. In this review, we evaluate three alternative organizational models that may expand access to high-quality Critical Care: tiered regionalization, intensive Care unit telemedicine, and quality improvement through regional outreach. These models share a potential to increase survival and reduce costs. Yet there are also major barriers to implementation, including the lack of a strong evidence base and the need for significant upfront financial investment. Reorganization of intensive Care will also require the support of all involved stakeholders: patients and their families, Critical Care practitioners, administrative and public health professionals, and policy makers. To varying degrees these models require a central authority to implement and regulate the system, as well as specific legislation, investment in information techn...
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reorganizing Adult Critical Care delivery the role of regionalization telemedicine and community outreach
American Journal of Respiratory and Critical Care Medicine, 2010Co-Authors: Yenlan Nguyen, Jeremy M Kahn, Derek C AngusAbstract:Variation in the quality of Critical Care services across hospitals coupled with an emerging workforce crisis necessitates system-level change in the organization of intensive Care. In this review, we evaluate three alternative organizational models that may expand access to high-quality Critical Care: tiered regionalization, intensive Care unit telemedicine, and quality improvement through regional outreach. These models share a potential to increase survival and reduce costs. Yet there are also major barriers to implementation, including the lack of a strong evidence base and the need for significant upfront financial investment. Reorganization of intensive Care will also require the support of all involved stakeholders: patients and their families, Critical Care practitioners, administrative and public health professionals, and policy makers. To varying degrees these models require a central authority to implement and regulate the system, as well as specific legislation, investment in information technology, and financial incentives for providers. The existing evidence does not strongly support exclusive use of a particular model, and creation of a hybrid model that integrates the three complementary approaches is a practical option. A potential framework for implementation involves triage guidelines developed by professional societies leading to demonstration projects and national legislation in support of optimal systems. Additional research is needed to determine the comparative effectiveness and cost implications of these approaches, with a goal of best matching high-quality Critical Care to patients' needs and professional preferences at the hospital, regional, and national level.
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physician attitudes toward regionalization of Adult Critical Care a national survey
Critical Care Medicine, 2009Co-Authors: Jeremy M Kahn, Rebecca J Asch, Kevin Haynes, Theodore J Iwashyna, Derek C Angus, Gordon D Rubenfeld, David A AschAbstract:Objective: Regionalization has been proposed as a method to improve outcomes for patients with Critical illness. We sought to determine intensivist physician attitudes and potential barriers to the regionalization of Adult Critical Care. Design: Mail survey. Setting: United States. Subjects: Actively practicing physicians specializing in Adult Critical Care, emergency medicine, or internal medicine listed in the 2008 American Medical Association Physician Masterfile (n = 1200). Interventions: None. Measurements and Main Results: There were 569 eligible respondents (effective response rate = 53.0%). Respondents were similar to nonrespondents. Fifty-nine percent of respondents thought their hospital would mainly receive patients under a regionalized system, and 30% thought their hospital would mainly send patients. Opinions were split about whether regionalization would improve overall patient survival (52% agreed) and healthCare efficiency (66% agreed). Specialists in anesthesiology and surgery-Critical Care, academic physicians, and physicians who perceived that they would mainly receive patients were more likely to believe that regionalization would improve outcomes and efficiency (p < 0.001). The most commonly endorsed barriers to regionalization were personal strain on patient's families (66% agreed), current lack of a strong central authority (64% agreed), and the potential to overwhelm capacity at large hospitals (55% agreed). Commonly endorsed strategies to implement regionalization included using objective criteria to determine eligibility for transfer (87% agreed), developing common information technology platforms across hospitals (86% agreed), and demonstrating in a clinical trial that regionalization is beneficial (81 % agreed). Conclusions: Intensivist physicians have mixed opinions about regionalization, with little consensus about whether regionalization will improve outcomes. Most felt that regionalization will improve patient outcomes, but many expressed concerns about unintended adverse consequences. Respondents identified several barriers and potential implementation strategies that can help policymakers design a regionalized system of Critical Care in the United States.
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perceived barriers to the regionalization of Adult Critical Care in the united states a qualitative preliminary study
BMC Health Services Research, 2008Co-Authors: Rebecca J Asch, Jeremy M Kahn, Theodore J Iwashyna, Derek C Angus, Gordon D Rubenfeld, David A AschAbstract:Regionalization of Adult Critical Care services may improve outcomes for Critically ill patients. We sought to develop a framework for understanding clinician attitudes toward regionalization and potential barriers to developing a tiered, regionalized system of Care in the United States. We performed a qualitative study using semi-structured interviews of Critical Care stakeholders in the United States, including physicians, nurses and hospital administrators. Stakeholders were identified from a stratified-random sample of United States general medical and surgical hospitals. Key barriers and potential solutions were identified by performing content analysis of the interview transcriptions. We interviewed 30 stakeholders from 24 different hospitals, representing a broad range of hospital locations and sizes. Key barriers to regionalization included personal and economic strain on families, loss of autonomy on the part of referring physicians and hospitals, loss of revenue on the part of referring physicians and hospitals, the potential to worsen outcomes at small hospitals by limiting services, and the potential to overwhelm large hospitals. Improving communication between destination and source hospitals, provider education, instituting voluntary objective criteria to become a designated referral center, and mechanisms to feed back patients and revenue to source hospitals were identified as potential solutions to some of these barriers. Regionalization efforts will be met with significant conceptual and structural barriers. These data provide a foundation for future research and can be used to inform policy decisions regarding the design and implementation of a regionalized system of Critical Care.
Kathy Rowan - One of the best experts on this subject based on the ideXlab platform.
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effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation the tracman randomized trial
JAMA, 2013Co-Authors: Duncan Young, David A Harrison, Brian H Cuthbertson, Kathy RowanAbstract:Results Of the 455 patients assigned to early tracheostomy, 91.9% (95% CI, 89.0%94.1%) received a tracheostomy and of 454 assigned to late tracheostomy, 44.9% (95% CI, 40.4%-49.5%) received a tracheostomy. All-cause mortality 30 days after randomization was 30.8% (95% CI, 26.7%-35.2%) in the early and 31.5% (95% CI, 27.3%-35.9%) in the late group (absolute risk reduction for early vs late, 0.7%; 95% CI, 5.4% to 6.7%). Two-year mortality was 51.0% (95% CI, 46.4%-55.6%) in the early and 53.7% (95% CI, 49.1%-58.3%) in the late group (P=.74). Median Critical Care unit length of stay in survivors was 13.0 days in the early and 13.1 days in the late group (P=.74). Tracheostomy-related complications were reported for 6.3% (95% CI, 4.6%-8.5%) of patients (5.5% in the early group, 7.8% in the late group). Conclusions and Relevance For patients breathing with the aid of mechanical ventilation treated in Adult Critical Care units in the United Kingdom, tracheostomy within 4 days of Critical Care admission was not associated with an improvement in 30-day mortality or other important secondary outcomes. The ability of clinicians to predict which patients required extended ventilatory support was limited.
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evaluation of modernisation of Adult Critical Care services in england time series and cost effectiveness analysis
BMJ, 2009Co-Authors: Andrew Hutchings, Kathy Rowan, David A Harrison, Mary Alison Durand, Richard Grieve, Judith Green, John Cairns, Nick BlackAbstract:Objective To evaluate the impact and cost effectiveness of a programme to transform Adult Critical Care throughout England initiated in late 2000. Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6. Setting 96 Critical Care units in England. Participants 349 817 admissions to Critical Care units. Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity. Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 ($33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000. Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 ($667, €445) to £1096 ($1810, €1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear. Conclusion Substantial improvements in NHS Critical Care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.
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a new risk prediction model for Critical Care the intensive Care national audit research centre icnarc model
Critical Care Medicine, 2007Co-Authors: David A Harrison, Gareth Parry, James R Carpenter, Alasdair Short, Kathy RowanAbstract:Objective:To develop a new model to improve risk prediction for admissions to Adult Critical Care units in the UK.Design:Prospective cohort study.Setting:The setting was 163 Adult, general Critical Care units in England, Wales, and Northern Ireland, December 1995 to August 2003.Patients:Patients wer
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recalibration of risk prediction models in a large multicenter cohort of admissions to Adult general Critical Care units in the united kingdom
Critical Care Medicine, 2006Co-Authors: David A Harrison, Gareth Parry, James R Carpenter, Anthony R Brady, Kathy RowanAbstract:OBJECTIVE: To assess the performance of published risk prediction models in common use in Adult Critical Care in the United Kingdom and to recalibrate these models in a large representative database of Critical Care admissions. DESIGN: Prospective cohort study. SETTING: A total of 163 Adult general Critical Care units in England, Wales, and Northern Ireland, during the period of December 1995 to August 2003. PATIENTS: A total of 231,930 admissions, of which 141,106 met inclusion criteria and had sufficient data recorded for all risk prediction models. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The published versions of the Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE II UK, APACHE III, Simplified Acute Physiology Score (SAPS) II, and Mortality Probability Models (MPM) II were evaluated for discrimination and calibration by means of a combination of appropriate statistical measures recommended by an expert steering committee. All models showed good discrimination (the c index varied from 0.803 to 0.832) but imperfect calibration. Recalibration of the models, which was performed by both the Cox method and re-estimating coefficients, led to improved discrimination and calibration, although all models still showed significant departures from perfect calibration. CONCLUSIONS: Risk prediction models developed in another country require validation and recalibration before being used to provide risk-adjusted outcomes within a new country setting. Periodic reassessment is beneficial to ensure calibration is maintained.
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outcome measures for Adult Critical Care a systematic review
Health Technology Assessment, 2000Co-Authors: J A Hayes, Nick Black, Crispin Jenkinson, J D Young, Kathy Rowan, K Daly, S RidleyAbstract:Objectives 1. To identify generic and disease specific measures of impairment, functional status and health-related quality of life that have been used in Adult Critical Care (intensive and high-dependency Care) survivors. 2. To review the validity, reliability and responsiveness of the measures in Adult Critical Care survivors. 3. To consider the implications for future policy and to make recommendations for further methodological research. 4. To review what is currently known of the outcome of Adult Critical Care. Data sources Searches of electronic databases (MEDLINE, EMBASE, CINAHL, PsycLIT, The Cochrane Library and SIGLE) from 1970 to August 1998. Manual searches of five journals (1985-98) not indexed in electronic databases and relevant conference proceedings (1993-98). Reference lists of six existing reviews, plus snowballing from reference lists of all relevant articles identified. Study selection Randomised trials, non-randomised trials (cohort studies) and case series that included data on outcomes after discharge from Adult (16 years and over) Critical Care. Data extraction and synthesis If reported, the following data were extracted from each paper: patient characteristics (age, gender, severity of illness, diagnostic category) number of patients eligible for study, follow-up period, number of deaths before follow-up, number and proportion of survivors included in follow-up method of presentation of outcome data - proportion normal as defined by reference values, or aggregate value (e.g. mean or median), or aggregate values plus an indication of variance (e.g. standard deviation or inter-quartile range). Evidence for three measurement properties was sought for each outcome measure that had been used in at least two studies - their validity, reliability and responsiveness in Adult Critical Care. If the authors did not report these aspects explicitly, an attempt was made to use the data provided to provide these measurement properties. For measures that were used in at least ten studies, information on actual reported outcomes were also extracted. Results MEASURES USED IN Critical Care: Measures of impairment were largely confined to the respiratory system so are almost certainly not appropriate for many Critical Care survivors. They can be categorised as respiratory volumes (e.g. vital capacity), gas flow within the respiratory system (e.g. forced expiratory volume in 1 second (FEV1)), pulmonary diffusing capacity (e.g. carbon monoxide diffusing capacity) and visualisation of the upper airway (e.g. bronchoscopy). Multiple tests are often performed. Eight measures of physical functional status were used, five generic and three disease-specific. The most frequently used generic measures were multi-item scales. Two single-item global measures attempted to capture a person's overall activity level or functional status. Five multi-item measures of mental functional status were used, four generic and one specific to trauma patients. The generic measures were either confined to assessing depressive symptoms or also encompassed a measure of anxiety. Measures of neuropsychological functioning relate to a person's cognition, attention, ability to process information and memory. Apart from one single-item measure, which focused on communication level, six multi-item measures were used with Critical Care survivors. Such measures are particularly appropriate for use with survivors of head injury or other neurological insult and, in that sense, they are disease-specific rather than generic measures. Single item measures of recovery were frequently used but researchers often invented their own, so there was little consistency in the wording. These measures had five principal foci - return to work, return to own home, degree of recovery, productivity and chronic health status. One multi-item scale was also used. (ABSTRACT TRUNCATED)