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These findings suggest that determination of the number and the type of organ dysfunctions and infection offers a clear and reliable method for characterizing ICU patients. Before a widespread use, this model requires to be validated in other institutions.

In a population of patients >or=75 years old, very old age is not directly associated with ICU mortality. After ICU discharge, deaths occurred predominantly during the first 3 months: age and prior limitation of activity were associated with the risk of dying.

Intensive-care-unit (ICU) patients are at risk for both acquiring nosocomial infection and dying, and require a high level of therapy whether infection occurs or not. The objective of the present study was to precisely define the interrelationships between underlying disease, severity of illness, therapeutic activity, and nosocomial infections in ICU patients, and their respective influences on these patients' outcome. In a 10-bed medical ICU, we conducted a case-control study with matching for initial severity of illness, with daily monitoring of severity of illness and therapeutic activity scores, and with analysis of the contribution of nosocomial infections to patients' outcomes. Forty-one cases of patients who developed nosocomial infections during a 1-yr period were paired with 41 controls without nosocomial infection according to three criteria: age (+/- 5 yr), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (+/- 5 points), and duration of exposure to risk. Successful matching was achieved for 118 of 123 (96%) variables. Neurologic failure on the third day after ICU admission was the sole independent risk factor for nosocomial infection (adjusted odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.09 to 1.64; p = 0.007). Unlike control patients, case patients showed no clinical improvement and required a high level of therapeutic activity between ICU admission and the day of infection. Mortality attributable to nosocomial infection was 44%. Excess length of stay and duration of antibiotic treatment attributable to nosocomial infection were 14 d and 10 d, respectively. Attributable therapeutic activity as measured with the Therapeutic Intervention Scoring System (TISS) and Omega score was 368 and 233 points, respectively. Such consequences were observed in patients who developed multiple infections. These findings suggest that a persistent high level of therapeutic activity and persistent impaired consciousness are risk factors for nosocomial infections in ICU patients. These infections are responsible for excess mortality, prolongation of stay, and excess therapeutic activity resulting in important cost overruns for health-care systems.

Ultrasound guidance improved the success rate of jugular vein cannulation in ICU patients. Our results suggest that ultrasound guidance should be used when the internal jugular vein has not been successfully cannulated within 3 min by the external landmark-guided technique.

Background Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units. Objectives To evaluate the feasibility and usefulness of regular morbidity and mortality conferences specific to intensive care units for improving quality of care and patient safety. Methods For 1 year, a prospective study was conducted in an 18-bed intensive care unit. Events analyzed included deaths in the unit and 4 adverse events (unexpected cardiac arrest, unplanned extubation, reintubation within 24–48 hours after planned extubation, and readmission to the unit within 48 hours after discharge) considered potentially preventable in optimal intensive care practice. During conferences, events were collectively analyzed with the help of an external auditor to determine their severity, causality, and preventability. Results During the study period, 260 deaths and 100 adverse events involving 300 patients were analyzed. The adverse events rate was 16.6 per 1000 patient-days. Adverse events occurred more often between noon and 4 pm (P = .001).The conference consensus was that 6.1% of deaths and 36% of adverse events were preventable. Preventable deaths were associated with iatrogenesis (P = .008), human errors (P < .001), and failure of unit management factors or communication (P = .003). Three major recommendations were made concerning standardization of care or prescription and organizational management, and no similar incidents have recurred. Conclusion In addition to their educational value, regular morbidity and mortality conferences formatted for intensive care units are useful for assessing quality of care and patient safety.