Change in Ratio of Observed-to-Expected Deaths in Pediatric Patients after Implementing a Closed Policy in an Adult ICU That Admits Children

Ueno, Yoshitoyo; Imanaka, Hideaki; Oto, Jun; Nishimura, Masaji

doi:10.1155/2012/674262

Cited by 5 publications

(3 citation statements)

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“…Decreased surgical morbidity was also observed in a closed format where better care could be provided by the intensivist and team. [19] Short hospital stay and well as longer duration of stay at home prior to re-admission were also observed with the closed format ICU as compared to an open one. [20] However, when adjusted for severity of disease, no significant difference in cost was observed between the open and closed format ICU.…”

Section: Discussionmentioning

confidence: 99%

Mortality rate and other clinical features observed in Open vs closed format intensive care units

Yang

Feng

2019

Medicine

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Background: Nowadays most of the intensive care units (ICUs) operate as a closed format in comparison to an open format. The new concept of a closed ICU is where patients are admitted under the full responsibility of a trained intensivist, whereas an open ICU is where patients are admitted under the care of another attending physician and intensivists are just available for consultation. In this analysis, we aimed to systematically compare mortality rate and other clinical features observed in open vs closed ICU formats. Methods: Biomedical and pharmacological bibliographic database Excerpta Medica database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cochrane Central and www.ClinicalTrials.gov were searched for required English publications. Mortality, the frequency of patients requiring mechanical ventilation, central line, arterial line and pulmonary arterial catheter were assessed respectively. Statistical analysis was carried out by the RevMan software. Odds ratios (OR) with 95% confidence intervals (CIs) were used to represent the data following analysis. Results: Five studies with a total number of 6160 participants enrolled between years 1992 to 2007 were included. Results of this analysis showed that mortality rate was significantly higher in the open format ICU (OR: 1.31, 95% CI: 1.17–1.48; P = .00001) (using a fixed effect model) and (OR: 1.31, 95% CI: 1.09–1.59; P = .005) (using a random effect model). Closed format ICUs were associated with significantly higher number of patients that required central line (OR: 0.56, 95% CI: 0.34–0.92; P = .02). Patients requiring mechanical ventilation (OR: 1.08, 95% CI: 0.65–1.78; P = .77), patients requiring arterial line (OR: 1.05, 95% CI: 0.49–2.29; P = .89) and patients requiring pulmonary arterial catheter (OR: 0.86, 95% CI: 0.40–1.87; P = .71) were similar in the open vs the closed setting. Conclusion: This analysis showed that mortality rate was significantly higher in an open as compared to a closed format ICU. However, the frequency of patients requiring mechanical ventilation, arterial line and pulmonary arterial catheter was similarly observed. Larger trials are expected to further confirm those hypotheses.

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Section: Discussionmentioning

confidence: 99%

Mortality rate and other clinical features observed in Open vs closed format intensive care units

Yang

Feng

2019

Medicine

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“…In contrast to the prehospital setting, a large proportion of pediatric in-hospital cardiac arrests occur in an intensive care unit, emergency department, or interventional setting (eg, catheterization laboratory or operating room), 9 where the hospital-based personnel are presumably highly trained for invasive airway management and ventilatory support.…”

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confidence: 99%

Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival

Andersen

Raymond

Berg

et al. 2016

JAMA

144

101

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IMPORTANCETracheal intubation is common during pediatric in-hospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown.OBJECTIVE To determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes. DESIGN, SETTING, AND PARTICIPANTSObservational study of data from United States hospitals in the Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with index in-hospital cardiac arrest between January 2000 and December 2014 were included. Patients who were receiving assisted ventilation, had an invasive airway in place, or both at the time chest compressions were initiated were excluded. EXPOSURES Tracheal intubation during cardiac arrest. MAIN OUTCOMES AND MEASURESThe primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and neurologic outcome. A favorable neurologic outcome was defined as a score of 1 to 2 on the pediatric cerebral performance category score. Patients being intubated at any given minute were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics. RESULTSThe study included 2294 patients; 1308 (57%) were male, and all age groups were represented (median age, 7 months [25th-75th percentiles, 21 days, 4 years]). Of the 2294 included patients, 1555 (68%) were intubated during the cardiac arrest. In the propensity score-matched cohort (n = 2270), survival was lower in those intubated compared with those not intubated (411/1135 [36%] vs 460/1135 [41%]; risk ratio [RR], 0.89 [95% CI, 0.81-0.99]; P = .03). There was no significant difference in return of spontaneous circulation (770/1135 [68%] vs 771/1135 [68%]; RR, 1.00 [95% CI, 0.95-1.06]; P = .96) or favorable neurologic outcome (185/987 [19%] vs 211/983 [21%]; RR, 0.87 [95% CI, 0.75-1.02]; P = .08) between those intubated and not intubated. The association between intubation and decreased survival was observed in the majority of the sensitivity and subgroup analyses, including when accounting for missing data and in a subgroup of patients with a pulse at the beginning of the event.CONCLUSIONS AND RELEVANCE Among pediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiac arrest compared with no intubation was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding, these findings do not support the current emphasis on early tracheal intubation for pediatric in-hospital cardiac arrest.

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“…When ICU staffing transitions from low intensity to high intensity, there are significant improvements in outcomes [ 1 , 2 ] in medical [ 21 ], surgical [ 10 , 22 ], and specialized (cardiovascular [ 9 , 23 , 24 ], neurological [ 25 – 27 ], and pediatric [ 28 ]) ICUs. The Leapfrog Group's ICU Physician Staffing Safety Standards recommend high-intensity staffing [ 4 ] based on the results of prior studies [ 21 – 23 , 29 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical impact of physician staffing transition in intensive care units: a retrospective observational study

et al. 2022

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Background Intensivists play an essential role in improving the outcomes of critically ill patients in intensive care units (ICUs). The transition of ICU physician staffing from low-intensity ICUs (elective intensivist or no intensivist consultation) to high-intensity ICUs (mandatory intensivist consultation or a closed ICU) improves clinical outcomes. However, whether a transition from high-intensity to low-intensity ICU staffing affects ICU outcomes and quality of care remains unknown. Methods A retrospective observational study was conducted to examine the impact of high- versus low-intensity staffing models on all-cause mortality in a suburban secondary community hospital with 400 general beds and 8 ICU beds. The ICU was switched from a high-intensity staffing model (high-former period) to low-intensity staffing in July 2019 (low-mid period) and then back to high-intensity staffing in March 2020 (high-latter period). Patients admitted from the emergency department, general ward, or operating room after emergency surgery were enrolled in these three periods and compared, balancing the predicted mortality and covariates of the patients. The primary outcome was all-cause mortality analyzed using hazard ratios (HRs) from Cox proportional hazards regression. An interrupted time-series analysis (ITSA) was also conducted to evaluate the effects of events (level change) and time. Results There were 962 eligible admissions, of which 251, 213, and 498 occurred in the high-former, low-mid, and high-latter periods, respectively. In the matched group (n = 600), the all-cause mortality rate comparing the high-former period with the low-mid period showed an HR of 0.88 [95% confidence interval (CI), 0.56, 1.39; p = 0.58] and that comparing the high-latter period with the low-mid period showed an HR of 0.84 [95% CI, 0.54, 1.30; p = 0.43]. The result for comparison between the three periods was p = 0.80. ITSA showed level changes of 4.05% [95% CI, -13.1, 21.2; p = 0.63] when ICU staffing changed from the high-former to the low-mid period and 1.35% [95% CI, -13.8, 16.5; p = 0.86] when ICU staffing changed from the low-mid to the high-latter period. Conclusion There was no statistically significant difference in all-cause mortality among the three ICU staffing periods. This study suggests that low-intensity ICU staffing might not worsen clinical outcomes in the ICU in a medium-sized community hospital. Multiple factors, including the presence of an intensivist, other medical staff, and practical guidelines, influence the prognosis of critically ill patients.

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Change in Ratio of Observed-to-Expected Deaths in Pediatric Patients after Implementing a Closed Policy in an Adult ICU That Admits Children

Cited by 5 publications

References 14 publications

Mortality rate and other clinical features observed in Open vs closed format intensive care units

Mortality rate and other clinical features observed in Open vs closed format intensive care units

Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival

Clinical impact of physician staffing transition in intensive care units: a retrospective observational study

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