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We observed significant reductions in mortality and hospital LOS for patients initially admitted to a closed ICU versus an open unit. We did not observe a significant difference in ICU LOS or total cost after adjustment for severity.

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Streptococcal toxic shock syndrome (STSS) is a severe invasive disease with a 40-80% mortality rate. Inflammatory cytokines induced by streptococcal pyrogenic exotoxins (SPEs) produce the clinical manifestations of a flu-like syndrome, followed by high fevers and multiorgan failure. Previously published reports have described the use of intravenous immunoglobulin (IVIg) as adjunctive treatment for STSS. However, concerns have been raised about the thromboembolic complications of this therapy. We report a severe case of STSS treated with two adjunctive courses of IVIg complicated by severe bilateral pulmonary thromboemboli. To our knowledge, this is the only reported case of thromboemboli associated with IVIg for STSS. The results of this case support the cautious use of IVIg for STSS and demonstrate the need for controlled trials to determine the appropriate timing, dosage, and course of treatment.

Clinical Vignette A 58 year-old postmenopausal woman, previously healthy, visited the emergency department (ED) with complaints of lower abdominal discomfort, fevers and burning with urination. She denied vaginal discharge or bleeding. In the ED, temperature was 39°C, heart rate 99 beats/min, blood pressure 100/58 mm Hg, and respiratory rate 16/min. Her SpO 2 was 98% on room air. Her physical examination was unremarkable except for mild suprapubic tenderness without rebound or guarding. Initial laboratory work included a urine analysis showing 50 white blood cells (WBC)/ hpf, 10 epithelial cells/hpf, 4+ bacteria, and 2+ hyaline casts. Her peripheral blood revealed a WBC 12 000 × 10 6 /mL, blood urea nitrogen 12 mg/dL, creatinine 1.0 mg/dL, bicarbonate 18 mmol/L, and lactic acid 1.5 mg/dL. After an hour in the ED, the nurse noted the patient started to perspire heavily, and the patient reported chills and dizziness. The skin felt warm and appeared "flushed" with normal capillary refill and she had bounding pulses. Her heart rate had increased to 108 and blood pressure dropped to 82/46. She received 500 mL of 0.9% saline bolus and cefotaxime IV, after 2 sets of blood cultures. After the fluid bolus, her repeat blood pressure was 86/52. She received 2 additional challenges of 500 mL 0.9% saline, with only a slight improvement in her blood pressure. The physician decided to admit to a medical ICU with diagnosis of sepsis/urinary source.

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In response to the changes in the delivery of health care, the concept of using hospitalists to care for inpatients has been steadily gaining popularity. Theoretically, hospitalists could deliver cost-effective quality health care to hospitalized patients. Because the currently available literature provides insufficient data on the impact of hospitalists on patient care and because many of the currently practicing hospitalists are trained in pulmonary and critical care medicine, we will review some of the available information on hospitalists and intensivists in an effort to provide an overview of their potential impact on patient care. Various studies of hospitalist programs demonstrate that there might be a significant reduction in length of stay as well as the cost of inpatient care. In addition, some of the intensivist studies suggest potential reduction in length of stay and mortality. Most of the data available, however, are methodologically weak and are anecdotal. Thus, there is an urgent need for well-designed, prospective, controlled studies to evaluate the effect of hospitalist care on outcome measures such as length of stay, cost, patient satisfaction, and quality of care. In addition, studies examining the indirect effects of hospitalists on outpatient resource use are also needed.