A b s t r ac t A total of 108 ICUs agreed to participate in the study, and 103 reported data. The analysis included 1981 ICU-months of data and 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P≤0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval (CI), 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. Conclusions An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

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An intervention to decrease catheter-related bloodstream infections in the ICU

Objective
The Surviving Sepsis Campaign (SSC or “the Campaign”) developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations on process improvement and patient outcomes.

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The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Background Survival of patients with acute lung injury or the acute respiratory distress syndrome (ARDS) has been improved by ventilation with small tidal volumes and the use of positive end-expiratory pressure (PEEP); however, the optimal level of PEEP has been difficult to determine. In this pilot study, we estimated transpulmonary pressure with the use of esophageal balloon catheters. We reasoned that the use of pleuralpressure measurements, despite the technical limitations to the accuracy of such measurements, would enable us to find a PEEP value that could maintain oxygenation while preventing lung injury due to repeated alveolar collapse or overdistention. Methods We randomly assigned patients with acute lung injury or ARDS to undergo mechanical ventilation with PEEP adjusted according to measurements of esophageal pressure (the esophageal-pressure–guided group) or according to the Acute Respiratory Distress Syndrome Network standard-of-care recommendations (the control group). The primary end point was improvement in oxygenation. The secondary end points included respiratory-system compliance and patient outcomes. Results The study reached its stopping criterion and was terminated after 61 patients had been enrolled. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at 72 hours was 88 mm Hg higher in the esophageal-pressure– guided group than in the control group (95% confidence interval, 78.1 to 98.3; P = 0.002). This effect was persistent over the entire follow-up time (at 24, 48, and 72 hours; P = 0.001 by repeated-measures analysis of variance). Respiratory-system compliance was also significantly better at 24, 48, and 72 hours in the esophagealpressure–guided group (P = 0.01 by repeated-measures analysis of variance). Conclusions As compared with the current standard of care, a ventilator strategy using esophageal pressures to estimate the transpulmonary pressure significantly improves oxygenation and compliance. Multicenter clinical trials are needed to determine whether this approach should be widely adopted. (ClinicalTrials.gov number, NCT00127491.)

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Mechanical Ventilation Guided by Esophageal Pressure in Acute Lung Injury

Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. We found that the adverse event detection methods commonly used to track patient safety in the United States today—voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators—fared very poorly compared to other methods and missed 90 percent of the adverse events. The Institute for Healthcare Improvement's Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured

Improving communication in the ICU using daily goals.

Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.

A trigger tool to identify adverse events in the intensive care unit.

Because waits, delays, and cancellations are so common in healthcare, patients and providers assume that waiting is an inevitable, but regrettable, part of the care process For years, hospitals responded to delays by adding resources--more beds and buildings or more staff--as the only way to deal with an increasingly needy population Furthermore, as long as payment for services covered the costs, more construction and more staff allowed for continued inefficiencies in the system Today, few organizations can afford this solution Moreover, recent work on assessing the reasons for delays suggests that adding resources is not the answer In many cases, delays are not a resource problem; they are a flow problem The Institute for Healthcare Improvement has worked with more than 60 hospitals in the United States and the United Kingdom to evaluate what influences the smooth and timely flow of patients through hospital departments and to develop and implement methods for improving flow Specific areas of focus include smoothing the flow of elective surgery, reducing waits for inpatient admission through emergency departments, achieving timely and efficient transfer of patients from the intensive care unit to medical/surgical units, and improving flow from the inpatient setting to long-term-care facilities

Carol Haraden

Papers

Improving communication in the ICU using daily goals.

Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.

A trigger tool to identify adverse events in the intensive care unit.

Patient flow in hospitals: understanding and controlling it better.

Developing and pilot testing quality indicators in the intensive care unit