Pacemakers, Defibrillators and (Im)mortality.

Pacemakers, Defibrillators and (Im)mortality.

Cardiac Implantable Electronic Devices (CIEDs – a cover-all term for permanent pacemakers and implantable defibrillators) are becoming increasingly common in the population as a whole and therefore are becoming increasingly encountered by health professionals delivering End-of-Life (EoL) care. This can result in ethical dilemmas around switching off or modifying the therapies delivered by these devices.

There’s a very interesting article  with  2 accompanying editorials in this month’s JAMA Internal Medicine (the journal formerly known as Archives of Internal Medicine) looking at the potentially thorny issues around de-activating CIEDs.  All are free, open access.

The article, by Buchhalter et al,  is a retrospective chart review covering a 4 year period from 2008-2012 and looking at all patients who had a CIED deactivated at the Mayo Clinic in Minnesota.

Of note:

  • 159 requests for deactivation
  • 9 requests not carried out
  • 2 of the non deactivations were physician refusals (I found this particularly interesting).  In both cases the patient had a PPM and requested that it be turned off, which is a slightly different issue compared with turning off an ICD.  In one case the physician requested an ethics consult but the patient died before it could be arranged.  In the second case the physician refused to deactivate the device but referred the patient to another physician.  Again the patient died before the consult took place.
  • Of the remaining 150 patients who underwent device deactivation, 99% had a terminal prognosis (the one patient who didn’t was getting inappropriate shocks from an ICD)
  • Most of the patients had an ICD and only had tachycardia therapies stopped.  Some of them also had bradycardia therapies deactivated.  A small number of the patients were pacemaker dependant and had bradycardia therapies deactivated.
  • Half of the requests were from patients and half from surrogate decision makers (SDMs)
  • 57% of the patients had an advanced directive, but only one of them mentioned the CIED!
  • 27% of patients who had tachycardia therapies deactivated died within a day of deactivation, 71% within a week, 87% within a month.
  • Of those who also had bradycardia therapies switched off, 53% died within a day, 88% within a week.

The authors mention in the discussion that most of the requests were for deactivation of tachycardia therapies in order to avoid uncomfortable shocks at the end of life.  From an ethical standpoint, deactivating an ICD to me seems no different to being documented as Not-for-Resuscitation.  Deactivating a PPM, particularly in a pacemaker dependant patient probably requires a bit more discussion with patients and SDMs, but again would seem to me to fall under the umbrella of withdrawing life-sustaining treatment as opposed to actively ending someone’s life.

The first accompanying editorial by Butler and Puri was a better read, and a bit more emotive.  It begins;

As he lay dying in a hospital in San Diego, a 71-year-old retired commercial fisherman was shocked 10 times by his implantable cardioverter-defibrillator (ICD), convulsing in front of his wife, 7 children, siblings, and mother. For 2 days, no medical professional intervened. The device was deactivated only at his wife’s insistence. Afterwards, she wanted to know, “Why wasn’t there a sticker on his chart? Why didn’t someone write that order?”

The editorialists go on to discuss the issue of the increasing number of devices being implanted and how these might impact on EoL care.  They neatly sum up fragmentation of medical care (a problem encountered daily by intensivists, palliative medicine specialists, geriatrician and the few other generalists who happen to be left in the super-specialized hospital of the 21st century) and highlight the important of interprofessional communication.

The authors mention that only in 2010 did the Heart Rhythm Society state in  a guideline that it was “ethically permissible” to deactiviate a device, and they wonder when anyone will state that it should be an “ethical responsibility” to inform patients that deactivation is an option.  The authors conclude by postulating a way forward that involves increased training in communication skills and increased collaboration between cardiology and palliative medicine – a trend that is already occurring in many places.

One of the authors of the editorial, Katy Butler, has previously written on this issue from a very personal perspective in a New York Times Magazine article entitled “What Broke my Father’s Heart.”   This article was quite moving and well worth a read.  It’s always good to look at the health system from the perspective of a non-clinician, and Butler, a writer and teacher, does this eloquently and in a balanced manner.

Finally, in a really quite moving and inspirational editorial,  Matlock and Mandrola highlight the fact that delivering caring end of life care is just good medicine and that early communication with patients is the key to preventing many issues and suffering that may result from conflicts at the end of life.   With a couple of simple, to-the-point quotes they sum up the issue;

  • CIEDs do not confer immortality.
  • Death is not optional.
  • Deactivating a pacemaker in a pacemaker-dependent patient is no different than withdrawing a ventilator from a ventilator-dependent patient.

All 4 articles are thought-provoking, well worth a read and eminently relevant to those working in critical care or, indeed, any aspect of acute medicine.

The Daughter from California Syndrome

The Daughter from California Syndrome

What follows is an illustrative case (from my imagination) that everyone who works in intensive care, palliative care or geriatrics will at one time or another have experienced;

A widow in her 80s is admitted with pneumonia. She is moribund. She has a long history of complex medical problems including severe dementia and is looked after at home, full time, by one of her daughters. The daughter is unmarried and has given up work to look after the patient. The treating team discusses treatment options with the daughter and after a long discussion all involved decide that, while the patient never expressed any specific end-of-life wishes, her daughter firmly believes that she would wish to be made comfortable in the event of a life-threatening illness. The team and daughter decide that the patient will be admitted to a medical ward and receive comfort measures only and specifically that she won’t receive antibiotics, IV fluid or any invasive measures.

Then the Daughter from America shows up. This daughter hasn’t seen her mother for many years, doesn’t talk to her sister and isn’t aware of how much is involved in caring for her mother. She demands that her mother receive aggressive life-saving treatment and be transferred to ICU with instructions for full active treatment including CPR. She is verbally abusive to staff and her sister and threatens to sue the hospital and various staff involved in her mother’s care.

Sounds familiar doesn’t it? We’ve all encountered a case (or multiple cases) where there is discord amongst family members about what the most appropriate course of treatment should be for a patient who has impaired capacity to make decisions. Anecdotally it seems that most commonly it is the family member who has come from furthest way, who hasn’t seen the patient for longest, who arrives latest in the patient’s course; who has the most unrealistic demands. I have been calling this “The Daughter from America Syndrome” as America suitably far away from Down Under. Of course the distressed family member can be a son, brother or cousin and can come from France, New Zealand or Singapore. America is used purely as a metaphor. I’ve encountered this phenomenon so often that I even came up with an equation;

Unreasonableness = (Distance travelled x time since last seen x time since onset of current illness) raised to the power 2 if the relative has come from North America.*

Well you can imagine my delight when I saw my prejudices vindicated in a black and white in a serious journal. And I wasn’t far off with the name either, with the authors of a great little paper from the April 1991 Journal of the American Geriatrics Society describing “The Daughter from California Syndrome“. Molloy et al describe the syndrome using a typical vignette (similar to the one above) and then posits why this phenomenon might occur and offers strategies for when it does.

The Authors wonder if denial, guilt and anger makes distressed family members seem irrational. This could be compounded by often longstanding intra-family conflict.

The authors then offer some strategies for dealing with the difficult family, including:

– A family meeting
– Making sure that all health care providers provide consistent information
– Allow the family to deliberate for a fixed period and follow up if there is disagreement.

This is all common sense stuff that we all do anyway, I hope. They hilariously end with the throw away line “Finally, if all of these measures fail, consult the geriatric service. Everyone else does.” Gold.

They also touch on the role of the courts as an absolute last resort in such cases, and remind us that, as health-care providers, we are under no ethical, or legal, obligation to provide care that we believe to be futile or harmful.

All in all a great little article (admittedly it’s a bit hard to find – you might have to actually go to the library) that’s well worth a read.

J Am Geriatr Soc. 1991 Apr;39(4):396-9.
Decision making in the incompetent elderly: “The Daughter from California
Molloy DW, Clarnette RM, Braun EA, Eisemann MR, Sneiderman B.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
PMID: 2010590

*I’m not anti-American. Far from it. I even drink IPA. It’s just that most of the far away family members I encounter are from the USA or Canada. I suspect if I was in the USA I’d be adding an Australian factor.

Transatlantic Intensive Care

When it comes to comparing patient outcomes in sepsis, we antipodeans often smugly sit back and comment that  “we don’t need no surviving sepsis campaign” (apologies to Pink Floyd) because our outcomes are compatible with, or better than those seen in the experimental arm of Rivers’ Early Goal Directed Therapy (EGDT) campaign.  The survival rate in the EGDT study was 30.5%, compared with 35.3% in the comparator arm of the severe sepsis subgroup of the SAFE study and, more recently, 23.7% in the comparator arm of the sepsis subgroup of the CHEST study.

My personal smugness continued when I read the title of this early release article by Mitchell Levy et al from Lancet Infectious Diseases a few days ago; “Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study.”  So you can imagine my surprise when I got to the punchline and found out that the (unadjusted) hospital mortality (a secondary outcome of the study) was 41.1% in the European group 28.3% in the US group.  Surely not?  Maybe the sample size was too small.  Nope, 25,375 patients.  That’s pretty impressive.  So what on earth was going on?  Are European intensivists so busy rioting and watching Eurovision that they’re neglecting their patients?  Let’s have a look.

The study was a large retrospective analysis of the surviving sepsis database across 107 ICUs in The USA and Europe.  As mentioned, 25,375 patients with severe sepsis or septic shock were included, 74% from the US and 26% from Europe.  The primary outcome was compliance with surviving sepsis guidelines in the first 6 hours and the first 24 hours.  Secondary outcomes included hospital mortality and ICU length of stay.  Interesting differences between the cohorts included the fact that 65% of US patients came to ICU via the ED, compared with only 32% of Europeans.  Therefore 51% of European patients came to ICU via the ward, compared with only 25% of Americans.  Regardless of origin, European patients had a longer hospital stay before arriving in the ICU (3.4 compared with 1.5 days for ward).  This difference in patient origin has no doubt contributed to the difference seen in outcome data.  Although no cause is apparent from the data, it seems appropriate to hypothesize that the lower number of ICU beds per capita in Europe (in general, with exceptions such as Germany and Belgium) means that patients who would go directly to ICU in the US end up going to the ward until they get sicker, making ICU admission more likely.

As a result of this, the European patients were a sicker group, with a higher SOFA score, a higher incidence of nosocomial sepsis, a longer ICU stay and a higher incidence of mechanical ventilation.  This of course explains the higher unadjusted mortality.  The US patients seemed to be a less sick cohort, with a much higher incidence of single organ dysfunction, particularly urosepsis, for example.  Despite the striking difference in unadjusted mortality (OR 1.8) mentioned in the preamble, once the mortality is adjusted for severity this difference disappears (OR 1.05 but no longer significant).  So it appears that the quality of intensive care is no different on either side of the Atlantic.  What does appear to be different is that the inevitable triaging that must occur when ICU beds are in short supply seems to have an impact on mortality.

So where does this leave us.  Particularly down under?  I think it highlights the fact that sick patients need to be looked after in ICU, and shouldn’t have to wait for the privilege.   I’ll be filing this study under politics rather than clinical medicine.  I think it helps to show that, despite being an expensive resource, intensive care saves lives and it can’t be carried out ad-hoc by overworked doctors and nurses on medical wards.  Critically ill patients with sepsis need to be in an ICU being looked after by intensivists and intensive care nurses.  I suspect that a cost analysis of the cost of ICU care for the patients who died versus the cost society of them dying will show quite a saving.

Here’s the study if you want to have a look for yourself;

Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study

Prof Mitchell M Levy MD,Prof Antonio Artigas MD,Gary S Phillips MAS,Andrew Rhodes MBBS,Richard Beale MBBS,Tiffany Osborn MD,Prof Jean-Louis Vincent MD,Sean Townsend MD,Prof Stanley Lemeshow PhD,Prof R Phillip Dellinger MD

The Lancet Infectious Diseases – 26 October 2012

DOI: 10.1016/S1473-3099(12)70239-6

Is it the destination or the journey?

I want to discuss 3 slightly related studies today.  All are early release article from Critical Care, but that’s not all they have in common.  They all have to do with location.  Any good real-estate agent will tell you that it’s all about location, and it would appear it’s the same for intensive care too.  Where you go, and how you get there, appear to make a difference.  While this shouldn’t come as much of a surprise, it’s a politically tricky issue.

The first study is a large retrospective case-control registry study from England and Wales.  They looked a patients who were transferred from one ICU to another for “non-clinical” reasons (i.e. not for neurosurgery or liver transplant or some other regional specialist service) or  within 48 hours of admission to ICU.  The reasons for transfer weren’t available from the registry data, but one would have to presume that lack of beds or staff was high up the list.

The authors identified 308,323 patients admitted to 198 ICUs between January 2008 and September 2011.  About 4000 patients were excluded for various reasons, and 759 were identified  as having been transferred within 48 hours for non-clinical reasons.  Each of these was then matched with 2 controls.

While unable to identify an effect of transfer on mortality, the authors noted a statistically significant increase in ICU stay of 3.2 days (95%CI 2.1-4.3, p<0.001) in those who were transferred for non-clinical reasons.

How odd.  Surely a trip down the road in an ambulance can’t add 3 days to your ICU stay?  Did they not have transport ventilators?  Was the poor SHO doing mouth-to-tube resuscitation the whole way?  The authors postulate that “physiological upset from transport” or something to that effect could have had an effect.  But 3 days?  Odd.  I work in a region that transfers patients between ICUs very frequently, so I’d be interested to see if the results were transferrable, and whether an organised, well trained retrieval medicine service would make a difference.

The next 2 studies are from continental Europe.  First from Germany where the authors again used registry data to look at the outcome of out-of-hospital-cardiac-arrest (OOHCA) patients based on what hospital they got taken to.  Specifically whether they were taken to a centre capable of percutaneous coronary intervention (PCI) or not.  Now in Germany critically ill patients are looked after by doctor-paramedic teams prehospital, so the doctors were able to use their clinical judgement to decide where to take the patient.  There were no protocols, as there are for trauma and stroke, for example.

The authors identified 889 patients who had a cardiac arrest in Dortmund (city population 580,000; but metro population 5.2 million) in 2008.  Children and patients with traumatic cardiac arrest were excluded, as were those with incomplete data.  The numbers all seem pretty standard; 63% male, median age 69, 26% in VF or VT, 52% witnessed, 82% at home, 13% bystander CPR, 40% ROSC, 10.9% survival to hospital discharge (I had to calculate that myself, always makes me suspicious.)  The outcome they were interested in was the effect of destination hospital on survival to discharge and neurological status at one year.

They found that patients taken directly to a PCI centre were younger, more likely to have a presumed cardiac aetiology, more likely to have ROSC in the field and more likely to have had a GCS of 15 before collapsing.  Once they got the PCI centre, patients were more likely to get a PCI (obviously – but only 50% did) but also more likely to get an echo within 2 hours of arrival and to get therapeutic hypothermia.  They were had a longer ICU stay, more days of mechanical ventilation and were more likely to have an ICD inserted.

The odds ratio for survival to discharge for those taken to PCI centre was 4.5 (!) (40% vs 16% discharged alive).  There was a similar difference in 1 year survival but  no significant difference in neurological outcome.

This sounds pretty amazing.  Even if you don’t get a PCI you do better if taken to a PCI capable hospital after your OOHCA.  But actually, what I think this study shows is exactly the opposite – you get taken to a PCI centre if you’re more likely to survive.  Patients taken to the PCI centres were younger, had likely cardiac aetiology for their arrests, got ROSC prehospital and were less likely to be disabled premorbidly.  There was a big selection bias here.  The young guys who got ROSC after one shock went to the PCI centre sitting up in the back of the ambulance chatting about how lucky they were, while the 90 year olds from the nursing home went to the community hospital in asystole with CPR in progress.  Actually, thats a bit mean.  I have just said that more of the patients in the PCI centre group were ventilated in ICU for longer.  I’m just not sure that this study says anything earth shattering, however I”m happy to be proved wrong if someone thinks I’ve misread it.

I do think it was an interesting and well thought out study though.  It would have been nice to have a bit more data on the patients, like how many of those taken to the non-PCI centre died in the ED (i.e. were dead when they arrived).  But what this study does say to me is that EMS providers (be they docs or paramedics) should be able to take a patient to the hospital that they believe is best, not the closest one.  In a large city with lots of hospitals, it just makes sense for the most critically ill patients to be taken to large tertiary centres with large ICUs staffed by specialist intensivists, senior trainees and very experienced nurses.  We’ve known this for a long time for trauma, and it amazes me that it’s taking so long for us to catch up with cardiac arrest, which is far more common.

Finally, a study (again retrospective) from France looking at the effect of the mode of transport, rather than the destination, on mortality.    Now this one was pretty interesting. They looked at 1,958 patients admitted to French university hospital ICUs with severe trauma (ISS >15) over a 3 year period.  They compared mortality at 30 days or hospital discharge between those brought to hospital by ambulance and those brought in by helicopter.  Now in France the crewing of both modalities is the same (doctor/nurse/driver or pilot) so you’d expect there to be no difference in the care received.  And you’d be wrong.

Looking at the data first.  74% were transported by road, 24% by helicopter.  Mean ISS was the same (25) but there was more hypotension (SBP <90) in the helicopter group.  Prehospital time was significantly longer in the helicopter group (surprise, surprise) at 2.3 vs 1.8 hours.  Yes, you read that right, around 2 hours in both groups.  And here was I thinking that 20 minutes on scene with a trauma patient was a long time.  It isn’t clear what effect entrapment had on these times.  Oh, and the helicopter group had more procedures prehospital (intubation, chest decompression, transfusion).  Although crude mortality was the same between the 2 groups, An adjusted analysis (for male gender, time of day, seriousness of accident) showed a decreased risk of death in the helicopter group (0.68, p=0.035)

So despite spending longer playing with their toys in the field, the helicopter crews were able to improve survival.   But how? The authors of the study don’t know, but postulate that the helicopters tend to be crewed by doctors and nurses from larger, regional hospitals whereas the road ambulances tend to be crewed by docs and nurses from smaller community hospitals.  So it may be the experience and decision making ability of the more experienced helicopter crews that makes the difference.  Food for thought anyway.

Beta test

I love it when a controversy pops up in the intensive care literature.  Especially when it doesn’t involve steroids.  My favourite paper of last year was definitely FEAST because I think it took a topic that we thought we knew so much about and turned it on it’s head.  There’s a few months left in 2012 but a big contender for my favourite paper of this year would have to be this little gem from Macchia et al in Italy.  They performed a large retrospective analysis of 9465 patients admitted to ICU with sepsis in 22 regions of Italy over a 5 year period between 2003 and 2008.  They found that 1061 patients had been taking beta blockers before their ICU admission and 8404 patients had not.

Surprisingly, despite their overall poorer baseline status, those who were taking beta blockers prior to ICU admission had a 28 day mortality rate 20% less than those who weren’t!  Overall 28 day mortality was 17.7% in the beta-blocker group and 22.1% in the control group.  So an absolute risk reduction of 4.4% and a relative risk reduction of 19%.  This gives an NNT of 23 patients to save one life with beta blockers.

Now obviously this was a retrospective analysis with all of the inherent risks and biases, but there is a plausible physiological mechanism underlying the observed effect.  Animal data has shown for some years that administering beta blockers to rats and pigs with septic shock induced myocardial dysfunction results in improved survival and, somewhat counter-intuitively seems to reduce myocardial dysfunction.  There are various theories as to why this may be, but the one that seems predominant is that there is an adrenergic storm associated with septic shock, resulting in increased cardiac workload at a time of limited oxygen supply.  This results in the myocardial dysfunction seen in 60% of patients with septic shock.  It is thought that beta blockers prevent this catecholamine storm from having a detrimental effect on the heart.

It’s food for thought anyway, and there’s a small trial underway at the moment that’s randomising patients with septic shock to either esmolol or placebo.  But they’re only recruiting 100 patients and many more will be required to give us the answer.  This sounds like a job for ANZICS….

1. Crit Care Med. 2012 Oct;40(10):2768-72.

Previous prescription of β-blockers is associated with reduced mortality among
patients hospitalized in intensive care units for sepsis*.

Macchia A, Romero M, Comignani PD, Mariani J, D'Ettorre A, Prini N, Santopinto M,
Tognoni G.

From the Laboratory of Pharmacoepidemiology (MA, RM, D'EA, TG), Consorzio Mario
Negri Sud, Santa Maria Imbaro (CH), Italy; Fundación GESICA (MA, MJ), Buenos
Aires, Argentina; and Critical Care Unit (MA, CPD, PN, SM), Hospital Alemán,
Buenos Aires, Argentina.

OBJECTIVES: : Results from basic science and narrative reviews suggest a
potential role of β-blockers in patients with sepsis. Although the hypothesis is 
physiologically appealing, it could be seen as clinically counterintuitive. We
sought to assess whether patients previously prescribed chronic β-blocker therapy
had a different mortality rate than those who did not receive treatment.
SETTING: : Record linkage of administrative databases of Italian patients
hospitalized for sepsis during years 2003-2008 were identified and followed up
for all-cause mortality at 28 days.
MEASUREMENTS AND MAIN RESULTS: : We identified 9,465 patients aged ≥40 yrs who
were hospitalized in critical care units for sepsis. Of these, 1,061 patients
were on chronic prescription with β-blockers and 8404 were not previously
treated. Despite a higher risk profile, patients previously prescribed with
β-blockers had lower mortality at 28 days (188/1061 [17.7%]) than those
previously untreated (1857/8404 [22.1%]) (odds ratio 0.78; 95% confidence
interval 0.66-0.93; p = .005 for unadjusted analysis, and odds ratio 0.81; 95%
confidence interval 0.68-0.97; p = .025 for adjusted analyses). Sensitivity and
pair-matched results confirm the primary findings.
CONCLUSIONS: : As far as we are aware, this pharmacoepidemiologic assessment is
the largest to examine the potential association of previous β-blocker
prescription and mortality in patients with sepsis. Chronic prescription of
β-blockers may confer a survival advantage to patients who subsequently develop
sepsis with organ dysfunction and who are admitted to an intensive care unit.
Prospective randomized clinical trials should formally test this hypothesis.

PMID: 22824934  [PubMed - in process]

EEG is better then SSEP for prognostication at 24 hours in patients cooled post cardiac arrest

Interesting study from the Netherlands in this months CCM.  Patients treated with therapeutic hypothermia for cardiac arrest (regardless of etiology or location) had continuous electroencephalogram (EEG) and daily somatosensory evoked potentials (SSEP) to see if EEG shows any benefit compared with SSEP with regards to early prognostication.  It has become difficult to clinically prognosticate as it seems likely that hypothermia delays the time to neurological recovery.  A method that reliable allowed early prognostication would allow us to provide better care to patients and families by appropriately palliating those with no chance of meaningful neurological recovery and also by carrying on with aggressive treatment for those with a good chance of recovery.
Both isoelectric EEG and absent SSEP had sensitivity of 100% for poor outcome at 24 hours.  Specificity of SSEP for 24%, while specificity of EEG was 68%.  So it appears that EEG can identify more non-survivors earlier.  Important notes of caution were that this was a relatively small (60 patient), single center study.  Also, the study wasn’t completely blinded.  Clinicians were allowed access to both EEG and SSEP data. The authors state that access was needed to EEG data so that epileptiform discharges could be treated, but obviously a flat EEG at 24 hours could have become a self-fulfilling prophecy.

Anyway, here’s the study

1. Crit Care Med. 2012 Oct;40(10):2867-75.

Continuous electroencephalography monitoring for early prediction of neurological
outcome in postanoxic patients after cardiac arrest: A prospective cohort study*.

Cloostermans MC, van Meulen FB, Eertman CJ, Hom HW, van Putten MJ.

From the Chair of Clinical Neurophysiology (MCC, FBvM, MJAMvP), MIRA institute
for Biomedical Engineering and Technical Medicine, University of Twente,
Enschede, The Netherlands; Department of Clinical Neurophysiology and Neurology
(MCC, CJE, MJAMvP), and Department of Intensive Care Medicine (HWH), Medisch
Spectrum Twente, Enschede, The Netherlands.

OBJECTIVE: : To evaluate the value of continuous electroencephalography in early 
prognostication in patients treated with hypothermia after cardiac arrest.
DESIGN: : Prospective cohort study.
SETTING: : Medical intensive care unit.
PATIENTS: : Sixty patients admitted to the intensive care unit for therapeutic
hypothermia after cardiac arrest.
MEASUREMENTS AND MAIN RESULTS: : In all patients, continuous electroencephalogram
and daily somatosensory evoked potentials were recorded during the first 5 days
of admission or until intensive care unit discharge. Neurological outcomes were
based on each patient's best achieved Cerebral Performance Category score within 
6 months. Twenty-seven of 56 patients (48%) achieved good neurological outcome
(Cerebral Performance Category score 1-2).At 12 hrs after resuscitation, 43% of
the patients with good neurological outcome showed continuous, diffuse slow
electroencephalogram rhythms, whereas this was never observed in patients with
poor outcome.The sensitivity for predicting poor neurological outcome of
low-voltage and isoelectric electroencephalogram patterns 24 hrs after
resuscitation was 40% (95% confidence interval 19%-64%) with a 100% specificity
(confidence interval 86%-100%), whereas the sensitivity and specificity of absent
somatosensory evoked potential responses during the first 24 hrs were 24%
(confidence interval 10%-44%) and 100% (confidence interval: 87%-100%),
respectively. The negative predictive value for poor outcome of low-voltage and
isoelectric electroencephalogram patterns was 68% (confidence interval 50%-81%)
compared to 55% (confidence interval 40%-60%) for bilateral somatosensory evoked 
potential absence, both with a positive predictive value of 100% (confidence
interval 63%-100% and 59%-100% respectively). Burst-suppression patterns after 24
hrs were also associated with poor neurological outcome, but not inevitably so.
CONCLUSIONS: : In patients treated with hypothermia, electroencephalogram
monitoring during the first 24 hrs after resuscitation can contribute to the
prediction of both good and poor neurological outcome. Continuous patterns within
12 hrs predicted good outcome. Isoelectric or low-voltage electroencephalograms
after 24 hrs predicted poor outcome with a sensitivity almost two times larger
than bilateral absent somatosensory evoked potential responses.

PMID: 22824933  [PubMed - in process]

Intensivists achieve better outcomes for less money. Surprise!

I can’t even begin to fathom the health system in the USA. But one thing I do know is that in many hospitals critically ill patients in ICU aren’t looked after by intensivists. So-called “open-unit ICU” is the norm where all specialists can admit their patients to ICU and manage them once there.

This interesting little before and after analysis by Parikh et al in this month’s edition of Critical Care Medicine shows that the introduction of specialist intensivists providing care for patients in a 12 bed mixed ICU in a community hospital is associated with some pretty impressive outcomes. What struck me most was that those patients who weren’t looked after by an intensivist were 6 times more likely to get ventilator associated pneumonia and 8 times more likely to get Central Line Associated Bloodstream Infection (CLABSI). What were the non-intensivists doing? Spitting on their hands before performing procedures?

Also of note was that those cared for by intensivists got out of ICU a day sooner and the hospital ended up with a net saving at the end of the year of about $800,000. This is amusing because apparently one of the most commonly cited reasons for not hiring intensivists is that they cost too much! I suspect the actual reason for intensivists not being ubiquitous in the US is simply territorial behaviour by other specialists.

Unfortunately the study didn’t show that intensivists saved lives, but it wasn’t powered to do so and previous studies have already shown that care provided by intensivists decreases both ICU and hospital mortality by 1/3.

Anyway, check it out for yourself if this kind of stuff floats your boat.

Crit Care Med. 2012 Jul 20. [Epub ahead of print]

Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital.

Parikh A, Huang SA, Murthy P, Dombrovskiy V, Nolledo M, Lefton R, Scardella AT.

From the UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ (AP, SAH, PM, VD, MN, ATS); and University Medical Center at Princeton, Princeton, NJ (MN, RL).


Prior studies have shown that implementation of the Leapfrog intensive care unit physician staffing standard of dedicated intensivists providing 24-hr intensive care unit coverage reduces length of stay and in-hospital mortality. A theoretical model of the cost-effectiveness of intensive care unit physician staffing patterns has also been published, but no study has examined the actual cost vs. cost savings of such a program.

To determine whether improved outcomes in specific quality measures would result in an overall cost savings in patient care

Retrospective, 1 yr before-after cohort study

A 15-bed mixed medical-surgical community intensive care unit

A total of 2,181 patients: 1,113 patients preimplementation and 1,068 patients postimplementation.

Leapfrog intensive care unit physician staffing standard

Intensive care unit and hospital length of stay, rates for ventilator-associated pneumonia and central venous access device infection, and cost of care.

Following institution of the intensive care unit physician staffing, the mean intensive care unit length of stay decreased significantly from 3.5 ± 8.9 days to 2.7 ± 4.7 days, (p < .002). The frequency of ventilator-associated pneumonia fell from 8.1% to 1.3% (p < .0002) after intervention. Ventilator-associated pneumonia rate per 100 ventilator days decreased from 1.03 to 0.38 (p < .0002). After intervention, the frequency of the central venous access device infection events fell from 9.4% to 1.1% (p < .0002). Central venous access device infection rate per 1000 line days decreased from 8.49 to 1.69. The net savings for the hospital were $744,001. The 1-yr institutional return on investment from intensive care unit physician staffing was 105%.

Implementation of the Leapfrog intensive care unit physician staffing standard significantly reduced intensive care unit length of stay and lowered the prevalence of ventilator-associated pneumonia and central venous access device infection. A cost analysis yielded a 1-yr institutional return on investment of 105%. Our study confirms that implementation of the Leapfrog intensive care unit physician staffing model in the community hospital setting improves quality measures and is economically feasible.

PMID: 22824939
[PubMed – as supplied by publisher]