An Evaluation of Outcome from Intensive Care in Major Medical Centers

Abstract

We prospectively studied treatment and outcome in 5030 patients in intensive care units at 13 tertiary care hospitals. We stratified each hospital's patients by individual risk of death using diagnosis, indication for treatment, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. We then compared actual and predicted death rates using group results as the standard. One hospital had significantly better results with 69 predicted but 41 observed deaths (p less than 0.0001). Another hospital had significantly inferior results with 58% more deaths than expected (p less than 0.0001). These differences occurred within specific diagnostic categories, for medical patients alone and for medical and surgical patients combined, and were related more to the interaction and coordination of each hospital's intensive care unit staff than to the unit's administrative structure, amount of specialized treatment used, or the hospital's teaching status. Our findings support the hypothesis that the degree of coordination of intensive care significantly influences its effectiveness.

A Multidisciplinary Teamwork Training Program: The Triad for Optimal Patient Safety (TOPS) Experience

“…Furthermore, accreditors and educators have emphasized teaching new core competencies (e.g., system-based practice) to promote quality and safety, but have given little guidance on the best educational strategies to employ 17,18 . Multidisciplinary teamwork training has the potential to improve patient safety and can help break down the traditional discipline-based silos that contribute to communication and teamwork failures [19][20][21][22] .…”

Scoring systems for the critically ill:use, misuse and abuse

“…Dans l'étude de référence de Knaus et coll. 4 , ils ont utilisé les scores APACHE pour comparer les taux de décès prédits et réels et se sont servis des résultats de groupes comme norme. Ils ont ensuite construit un palmarès des résultats institutionnels pour démontrer la supériorité de certains centres, et leurs caractéristiques, et, bien sûr, l'infériorité des autres.…”

“…Knaus et al's benchmark study 4 used APACHE scores to compare actual and predicted death rates using group results as the standard. The authors then constructed a ranking of institutional outcomes to demonstrate the superiority of some centres (and their characteristics) and, naturally enough, the inferiority of others.…”

The impact of nurses on patient morbidity and mortality - the need for a policy change in response to the nursing shortage

“…A seminal study conducted two decades ago 4 found that interaction and coordination amongst clinicians (medical and nursing staff) reduced patient deaths in ICU settings, but did not establish a link between nursing activities and patient outcomes. Since then a growing body of research indicates that RNs provide a continuous (24-h per day, 7 days per week) surveillance system for patients enabling the early detection and prompt intervention when their condition deteriorates.…”