Little is known about the amount of cross-transmission, the risk factors for infection, and the relative effectiveness of infection control procedures when methicillin-resistant Staphylococcus aureus (MRSA) infection occurs at highly endemic levels in intensive care units. A cohort study was done to identify exposures associated with cases that likely were the result of cross-transmission (i.e., occurring in clusters and with indistinguishable MRSA macrorestriction profiles). Fitting a simple stochastic model to the ascertained data allowed prediction of the effectiveness of infection control measures. Exposure to relative staff deficit (adjusted rate ratio, 1.05 independent; 95% confidence interval, 1.02-1.09) was the only factor significantly associated with potential transmission (P =.001). It was predicted that a 12% improvement in adherence to hand-hygiene policies might have compensated for staff shortage and prevented transmission during periods of overcrowding, shared care, and high workload but that this would be hard to achieve.

Reimbursement schemes in intensive care are more complex than in other areas of healthcare, due to special procedures and high care needs. Knowledge regarding the principles of functioning in other countries can lead to increased understanding and awareness of potential for improvement. This can be achieved through mutual exchange of solutions found in other countries. In this review, experts from eight European countries explain their respective intensive care unit reimbursement schemes. Important conclusions include the apparent differences in the countries’ reimbursement schemes-despite all of them originating from a DRG system-, the high degree of complexity found, and the difficulties faced in several countries when collecting the data for this collaborative work. This review has been designed to assist the intensivist clinician and researcher in understanding neighbouring countries’ approaches and in putting research into the context of a European perspective. In addition, steering committees and decision makers might find this a valuable source to compare different reimbursement schemes.

No abstract

Early enteral feeding is now recognized as one of the fundamentals of critical care practice [1][2][3][4]. Enteral nutrition (EN) increases gut blood flow, thereby protecting the gastric mucosa [5,6]. Early feeding results in fewer septic complications, decreased catabolic response to injury, decreased stress ulceration in the ventilated patient, improved gut immune function and improved wound healing [3,4,7,8]. Successful enteral feeding relies on intact gastrointestinal motility, which is frequently impaired in the critically ill.Prokinetic agents have a valuable role to play in this situation. A recent review by Booth and coworkers [9] with an accompanying editorial [10] in Critical Care Medicine systematically reviewed the evidence for the use of gastrointestinal promotility drugs in critical care. The context of the review was that promotility agents may improve tolerance to EN, and reduce gastroesophageal reflux and pulmonary aspiration; they therefore have the potential to improve outcomes of critically ill patients. The authors appear to have conducted a comprehensive search of the available literature over the preceding two decades. The studies were then methodologically assessed for their quality using a previously described scoring system, with attempts made to contact the primary investigators for further information where this was thought necessary.The review scrutinized 18 studies involving a total of 908 individuals. A significant proportion of the review examined the role of prokinetics in aiding tube placement, whereas the remainder looked at the effects of cisapride, erythromycin and metoclopramide on gut transit/feeding tolerance. (For a summary of the actions of those agents, see Table 1.) Cisapride is currently unavailable in many countries because of cardiac toxicity [11].A breakdown of the reviewed studies is shown in Table 2. If we exclude the studies on tube placement, those with endpoints that involved patient outcomes and those gastrointestinal transit studies that involved cisapride alone, then we are left with only six studies (highlighted in Table 2 with asterisks), involving 80 patients, that examined agents that are available as prokinetics in contemporary practice. The review justified the inclusion of cisapride because there are currently new generation agents undergoing trials; however, it failed to mention that the studies on the new motilin receptor agonists (macrolide derivatives), such as ABT-229, have yielded disappointing results [12,13]. The authors suggested that we should be more cautious with our use of erythromycin, given the increasing incidence of antibiotic resistance, and suggested 20 mg metoclopramide as first-line treatment. This dose appears to have little scientific basis because only one of the tube placement studies [14] used it; the review stated that a dose of 20 mg was used in the gastrointestinal transit study conducted by Jooste and coworkers [15], but it actually employed a 10 mg dose. The value of the review is that it highlights the lack of any larg...

National registries are needed to reduce variations in care and improve patient safety