Articles: intensive-care-units.
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The American Association of Critical-Care Nurses developed a Demonstration Project to document fiscal costs and patient care effectiveness of critical care nursing in a unit characterized by valued organizational attributes. Data were collected by interview, observation, and written surveys from 42 nurses, 68 physicians, and 192 patient admissions. ⋯ The proportion of charges for nursing-controlled factors was low compared with proportion of total stay spent in the unit. Aspects of structure, process, and outcome can be measured simultaneously in critical care; these measurements indicate that positive organizational and clinical outcomes coexist with valued aspects of the organizational environment.
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Critical care resources in the United States are being rationed, that is, not all critical care expected to be beneficial is being provided to all patients who desire it. Although the extent of rationing is uncertain, it is an everyday occurrence in some hospitals and is likely to occur at least some of the time in many hospitals. ⋯ Since this type of care is being inequitably denied to some patients, hospitals should either adopt formal rationing guidelines or, alternatively, they should take clear steps to avoid rationing by altering the supply of or the demand for critical care. Reasonable arguments are presented in support of both approaches, as are suggestions for their implementation.
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The clinical value of routine chest radiographs was prospectively evaluated in a pediatric intensive care unit. Physicians were asked to predict findings of clinical impact in 353 routine morning chest radiographs performed in 101 patients after examining the patients. In 81 instances (23%), the clinical impact of the chest radiographs was incorrectly predicted and significant alterations in management would have potentially been missed had the chest radiographs not been available. ⋯ Level of training of the predicting physicians did not affect prediction accuracy. In analysis of 43 routine postintubation chest radiographs and 39 routine postcentral venous catheter placement chest radiographs, appliance malpositions were disclosed in 34.9% and 43.6%, respectively. Routine daily and post-appliance placement chest radiographs have significant clinical value in the pediatric intensive care unit.