Critical care medicine
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To compare prolonged mechanical ventilation decision-makers' expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon. ⋯ One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.
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Critical care medicine · Nov 2009
Immortal time bias in critical care research: application of time-varying Cox regression for observational cohort studies.
To examine the bias introduced by using time-fixed methodology to analyze the effects of a time-varying exposure incurred in the intensive care unit. ⋯ Studies using a time-fixed analytic approach to understand relationships between exposures and clinical outcomes can result in considerable bias when the variables overlap temporally in occurrence. Those conducting such studies, and clinicians reading them, should ensure that time-varying exposures are correctly analyzed to avoid biased conclusions.
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Critical care medicine · Nov 2009
Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.
To use a handover assessment tool for identifying patient information corruption and objectively evaluating interventions designed to reduce handover errors and improve medical decision making. The continuous monitoring, intervention, and evaluation of the patient in modern intensive care unit practice generates large quantities of information, the platform on which medical decisions are made. Information corruption, defined as errors of distortion/omission compared with the medical record, may result in medical judgment errors. Identifying these errors may lead to quality improvements in intensive care unit care delivery and safety. ⋯ When asked to recall clinical information discussed at handover, medical members of the intensive care unit team provide data that are significantly corrupted compared with the medical record. Low subjective clinical judgment scores are significant associated with low handover scores. The handover/clinical intention scores may, therefore, be useful screening tools for intensive care unit system vulnerability to medical error. Additionally, handover instruments can identify interventions that reduce system vulnerability to error and may be used to guide quality improvements in handover practice.
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Critical care medicine · Nov 2009
Cardiac function index provided by transpulmonary thermodilution behaves as an indicator of left ventricular systolic function.
To test whether cardiac function index could actually behave as an indicator of left ventricular systolic function by testing if 1) it increased with inotropic stimulation; 2) it was not altered by fluid loading; 3) it correlated with the echographic left ventricular ejection fraction, considered as the clinical gold standard for measuring left ventricular systolic function, and it reliably tracked the changes in left ventricular ejection fraction during therapeutic intervention. The transpulmonary thermodilution calculates the cardiac function index, which is the ratio of cardiac output over global end-diastolic volume. ⋯ Cardiac function index fulfilled the criteria required from a clinical indicator of left ventricular global systolic function. Thus, it could serve as an easy bedside detection of the alteration in left ventricular ejection fraction that should alert the physician and incite to perform an echocardiography. Furthermore, cardiac function index tracked accurately the effects of an inotropic therapy.