Our study did not find an association between nighttime ICU discharge and hospital mortality. However, the ICU readmission rate was higher and the hospital length of stay longer in the nighttime transfer group.

Objective Our objective was to assess the cost implications of changing the ICU staffing model from on-demand presence to mandatory 24 hour in-house critical care specialist presence. Design A pre-post comparison was undertaken among the prospectively assessed cohorts of patients admitted to our medical ICU one year before and after the change. Our data was stratified by APACHE III quartile and whether a patient was admitted during the day or at night. Costs were modeled using a generalized linear model with log-link and gamma distributed errors. Setting A large academic center in the Midwest. Patients All patients admitted to the adult medical ICU on or after January 1, 2005 and discharged on or before December 31, 2006. Patients receiving care under both staffing models were excluded. Intervention Changing the ICU staffing model from on-demand presence to mandatory 24 hour in-house critical care specialist presence. Measurements Total cost estimates of hospitalization were calculated for each patient starting from the day of ICU admission to day of hospital discharge. Main Results Adjusted mean total cost estimates were 61% lower in the post-period relative to the pre-period for patients admitted during night hours (7PM to 7AM) who were in the highest APACHE III quartile. No significant differences were seen at other severity levels. Unadjusted ICU length of stay fell in the post-period relative to the pre-period (3.5 vs. 4.8) with no change in non-ICU length of stay. Conclusions We find 24-hour ICU intensivist staffing reduces lengths of stay and cost estimates for the sickest patients admitted at night. The costs of introducing such a staffing model need to be weighed against the potential total savings generated for such patients in smaller ICUs, especially ones that predominantly care for lower acuity patients.

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Population-based rates of ICU admission and utilization in Olmsted County, Minnesota, increased with age and are highest in the very elderly. The presence of chronic illness, particularly cardiovascular conditions, significantly increases ICU utilization and risk of ICU admission.

OBJECTIVES: To formulate new “Choosing Wisely” for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES: Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION: English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION: Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS: Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine’s Next Five “Choosing” Wisely for Critical Care practices. CONCLUSIONS: Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the “Choosing Wisely” campaign.

A multidisciplinary unit specific approach using performance improvement methodologies focusing on human factors can reliably and sustainably reduce the rate of mislabelled laboratory specimens in a large tertiary care hospital.

BackgroundRecently completed clinical trials have shown that certain interventions improve the outcome of the critically ill. To facilitate the implementation of these interventions, professional organizations have developed guidelines. Although the impacts of the individual evidence-based interventions have been well described, the overall impact on outcome of introducing multiple evidence-based protocols has not been well studied. The objective of this study was to determine the impact of introducing multiple evidence-based protocols on patient outcome.MethodsA retrospective, cohort study of 8,386 patients admitted to the medical intensive care unit (MICU) of an academic, tertiary medical center, from January 2000 through June 2005 was performed. Four evidence-based protocols (lung protective strategy for acute lung injury, activated protein C for severe sepsis/septic shock, intravenous insulin for hyperglycemia control and a protocol for sedation/analgesia) were introduced in the MICU between February 2002 and April 2004. We considered the time from January 2000 through January 2002 as the pre-protocol period, from February 2002 through March 2004 as the transition period and from April 2004 through June 2005 as the protocol period. We retrieved data including demographics, severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) III, MICU length of stay and hospital mortality. Student's t, Kruskal-Wallis, Mann-Whitney U, chi square and multiple logistic regression analyses were used to compare differences between groups. P-values < 0.05 were considered significant.ResultsThe predicted mean mortality rates were 20.7%, 21.1% and 21.8%, with the observed mortality rates of 19.3%, 18.0% and 16.9% during the pre-protocol, transition and protocol periods, respectively. Using the pre-protocol period as a reference, the severity-adjusted risk (95% confidence interval) of dying was 0.777 (0.655 – 0.922) during the protocol period (P = 0.0038). The average 28-day MICU free days improved during the protocol period compared to the pre-protocol period. The benefit was limited to sicker patients and those who stayed in the MICU longer.ConclusionThe introduction of multiple evidence-based protocols is associated with improved outcome in critically ill medical patients.

Patients who resided outside of our local community and who had medical admissions to the intensive care unit were more severely ill, had greater mortality rates, and had longer length of stay compared with community patients. Our findings support the existence of referral bias in critically ill medical patients at our tertiary medical center.