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1.  The effect of multidisciplinary care teams on intensive care unit mortality 
Archives of internal medicine  2010;170(4):369-376.
Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care.
We conducted a population-based retrospective cohort study of medical patients admitted to Pennsylvania acute hospitals (N=169) from July 1, 2004 to June 30, 2006, linking a statewide hospital organizational survey to hospital discharge data. Multivariate logistic regression was used to determine the independent relationship between daily multidisciplinary rounds and 30-day mortality.
112 hospitals and 107,324 patients were included in the final analysis. Overall 30-day mortality was 18.3%. After adjusting for patient and hospital characteristics, multidisciplinary care was associated with significant reductions in the odds of death (OR=0.84, 95% CI: 0.76–0.93, p=0.001). When stratifying by intensivist physician staffing, the lowest odds of death were in ICUs with high-intensity physician staffing and multidisciplinary care teams (OR=0.78, 95% CI: 0.68–0.89, p<0.0001), followed by ICUs with low intensity physician staffing and multidisciplinary care teams (OR=0.88, 95%CI: 0.79–0.97, p=0.014), compared to hospitals with low intensity physician staffing but without multidisciplinary care teams. The effects of multidisciplinary care were consistent across key subgroups including patients with sepsis, patients requiring invasive mechanical ventilation, and patients in the highest quartile of severity of illness
Daily rounds by a multidisciplinary team are associated with lower mortality among medical ICU patients. The survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary teams in high-intensity staffed ICUs.
PMCID: PMC4151479  PMID: 20177041
2.  Intensivist physician staffing and the process of care in academic medical centres 
Quality & Safety in Health Care  2007;16(5):329-333.
Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation.
To determine the relationship between intensivist staffing and select process‐based quality indicators in the intensive care unit.
Research design
Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project.
861 adult patients receiving prolonged mechanical ventilation in an intensive care unit.
Patient‐level information on physician staffing and process‐of‐care quality indicators were collected on day 4 of mechanical ventilation. By day 4, 668 patients received care under a high intensity staffing model (primary intensivist care or mandatory consult) and 193 patients received care under a low intensity staffing model (optional consultation or no intensivist). Among eligible patients, those receiving care under a high intensity staffing model were more likely to receive prophylaxis for deep vein thrombosis (risk ratio 1.08, 95% CI 1.00 to 1.17), stress ulcer prophylaxis (risk ratio 1.10, 95% CI 1.03 to 1.18), a spontaneous breathing trial (risk ratio 1.37, 95% CI 0.97 to 1.94), interruption of sedation (risk ratio 1.64, 95% CI 1.13 to 2.38) and intensive insulin treatment (risk ratio 1.40, 95% CI 1.18 to 1.79) on day 4 of mechanical ventilation. Models accounting for clustering by hospital produced similar estimates of the staffing effect, except for prophylaxis against thrombosis and stress ulcers.
High intensity physician staffing is associated with increased use of evidence‐based quality indictors in patients receiving mechanical ventilation.
PMCID: PMC2464974  PMID: 17913772
3.  Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness 
Medical care  2013;51(1):4-10.
For patients recovering from severe acute illness, admission to a long-term acute care hospital (LTAC) is an increasingly common alternative to continued management in an intensive care unit.
To examine the effectiveness of LTAC transfer in patients with chronic critical illness.
Research Design
Retrospective cohort study in United States hospitals from 2002 to 2006.
Medicare beneficiaries with chronic critical illness, defined as mechanical ventilation and at least 14 days of intensive care.
Survival, costs and hospital readmissions. We used multivariate analyses and instrumental variables to account for differences in patient characteristics, the timing of LTAC transfer and selection bias.
A total of 234,799 patients met our definition of chronic critical illness. Of these, 48,416 (20.6%) were transferred to an LTAC. In the instrumental variable analysis, patients transferred to an LTAC experienced similar survival compared to patients who remained in an intensive care unit (adjusted hazard ratio = 0.99, 95% CI: 0.96 to 1.01, p=0.27). Total hospital-related costs in the 180 days following admission were lower among patients transferred to LTACs (adjusted cost difference = -$13,422, 95% CI: -26,662 to -223, p=0.046). This difference was attributable to a reduction in skilled nursing facility admissions (adjusted admission rate difference = -0.591 (95% CI: -0.728 to -0.454, p <0.001). Total Medicare payments were higher (adjusted cost difference = $15,592, 95% CI: 6,343 to 24,842, p=0.001).
Patients with chronic critical illness transferred to LTACs experience similar survival compared with patients who remain in intensive care units, incur fewer health care costs driven by a reduction in post-acute care utilization, but invoke higher overall Medicare payments.
PMCID: PMC3500575  PMID: 22874500
mechanical ventilation; costs; Medicare; patient readmission; intensive care
4.  Nighttime Intensivist Staffing and Mortality among Critically Ill Patients 
The New England journal of medicine  2012;366(22):2093-2101.
Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.
We conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available.
The analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P = 0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P = 0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P = 0.18), yet the direction of the findings were similar to those in the APACHE cohort.
The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing. (Funded by the National Heart, Lung, and Blood Institute.)
PMCID: PMC3979289  PMID: 22612639
5.  Accuracy of Prehospital Transport Time Estimation 
Estimates of prehospital transport times are an important part of emergency care system research and planning; however the accuracy of these estimates is unknown. We examined the accuracy of three estimation methods against observed transport times in a large cohort of prehospital patient transports.
We performed a validation study using prehospital records in King County, Washington and southwestern Pennsylvania from 2002 to 2006 and 2005 to 2011, respectively. We generated transport time estimates using three methods: linear arc distance, Google Maps and ArcGIS Network Analyst. We assessed estimation error, defined as the absolute difference between observed and estimated transport time, and the proportion of estimated times that were within specified error thresholds. Based on the primary results, we then tested whether a regression estimate that incorporated population density, time-of-day and season could improve accuracy. Finally, we compared hospital catchment areas using each method with a fixed drive time.
We analyzed 29,935 prehospital transports to 44 hospitals. The mean absolute error was 4.8 minutes (± 7.3) using linear arc, 3.5 minutes (± 5.4) using Google Maps and 4.4 minutes (± 5.7) using ArcGIS. All pairwise comparisons were statistically significant (p<0.01). Estimation accuracy was lower for each method among transports more than twenty minutes (mean absolute error was 12.7 minutes (± 11.7) for linear arc, 9.8 minutes (± 10.5) for Google Maps and 11.6 minutes (± 10.9) for ArcGIS). Estimates were within five minutes of observed transport time for 79% of linear arc estimates, 86.6% of Google Maps estimates and 81.3% of ArcGIS estimates. The regression-based approach did not substantially improve estimation. There were large differences in hospital catchment areas estimated by each method.
We showed that route-based transport time estimates demonstrate moderate accuracy. These methods can be valuable for informing a host of decisions related to the system organization and patient access to emergency medical care; however, they should be employed with sensitivity to their limitations.
PMCID: PMC4251659  PMID: 24552519
6.  Improving risk classification of critical illness with biomarkers: a simulation study 
Journal of critical care  2013;28(5):541-548.
Optimal triage of patients at risk of critical illness requires accurate risk prediction, yet little data exists on the performance criteria required of a potential biomarker to be clinically useful.
Materials and Methods
We studied an adult cohort of non-arrest, non-trauma emergency medical services encounters transported to a hospital from 2002–2006. We simulated hypothetical biomarkers increasingly associated with critical illness during hospitalization, and determined the biomarker strength and sample size necessary to improve risk classification beyond a best clinical model.
Of 57,647 encounters, 3,121 (5.4%) were hospitalized with critical illness and 54,526 (94.6%) without critical illness. The addition of a moderate strength biomarker (odds ratio=3.0 for critical illness) to a clinical model improved discrimination (c-statistic 0.85 vs. 0.8, p<0.01), reclassification (net reclassification improvement=0.15, 95%CI: 0.13,0.18), and increased the proportion of cases in the highest risk categoryby+8.6% (95%CI: 7.5,10.8%). Introducing correlation between the biomarker and physiological variables in the clinical risk score did not modify the results. Statistically significant changes in net reclassification required a sample size of at least 1000 subjects.
Clinical models for triage of critical illness could be significantly improved by incorporating biomarkers, yet, substantial sample sizes and biomarker strength may be required.
PMCID: PMC3707977  PMID: 23566734
Biomarker; simulation; sample size; reclassification
7.  The Relationship between Hospital Volume and Mortality in Mechanical Ventilation: An Instrumental Variable Analysis 
Health Services Research  2009;44(3):862-879.
To examine the relationship between hospital volume and mortality for nonsurgical patients receiving mechanical ventilation.
Data Sources
Pennsylvania state discharge records from July 1, 2004, to June 30, 2006, linked to the Pennsylvania Department of Health death records and the 2000 United States Census.
Study Design
We categorized all general acute care hospitals in Pennsylvania (n=169) by the annual number of nonsurgical, mechanically ventilated discharges according to previous criteria. To estimate the relationship between annual volume and 30-day mortality, we fit linear probability models using administrative risk adjustment, clinical risk adjustment, and an instrumental variable approach.
Principle Findings
Using a clinical measure of risk adjustment, we observed a significant reduction in the probability of 30-day mortality at higher volume hospitals (≥300 admissions per year) compared with lower volume hospitals (<300 patients per year; absolute risk reduction: 3.4%, p=.04). No significant volume–outcome relationship was observed using only administrative risk adjustment. Using the distance from the patient's home to the nearest higher volume hospital as an instrument, the volume–outcome relationship was greater than observed using clinical risk adjustment (absolute risk reduction: 7.0%, p=.01).
Care in higher volume hospitals is independently associated with a reduction in mortality for patients receiving mechanical ventilation. Adequate risk adjustment is essential in order to obtained unbiased estimates of the volume–outcome relationship.
PMCID: PMC2699912  PMID: 19674428
Critical care; intensive care; respiratory failure; risk adjustment; mortality
8.  Long-term acute care hospital utilization after critical illness 
Long-term acute care hospitals have emerged as a novel approach for the care of patients recovering from severe acute illness, but the extent and growth of their activity at the national level is unknown.
To examine temporal trends in long-term acute care hospital utilization after an episode of critical illness among fee-for-service Medicare beneficiaries ≥ 65 years of age.
Design, Setting and Patients
Retrospective cohort study using the Medicare Provider Analysis and Review files from 1997 to 2006. We included all Medicare hospitalizations involving admission to an intensive care unit of an acute-care, non-federal hospital within the continental United States.
Main outcome measures
Overall long-term acute care utilization, associated costs, and survival following transfer.
The number of long-term acute care hospitals in the United States increased at a mean rate of 8.8% per year, from 192 in 1997 to 408 in 2006. During that time, the annual number of long-term acute care admissions after critical illness increased from 13,732 to 40,353, with annual costs increasing from $484 million to $1.325 billion. The age-standardized population incidence of long-term acute care utilization after critical illness increased from 38.1/100,000 in 1997 to 99.7/100,000 in 2006, with greater use among male individuals and black individuals in all time periods. Over time, transferred patients had higher numbers of comorbidities (5.0 in 1997–2000 versus 5.8 in 2004–2006, p<0.001), and were more likely to receive mechanical ventilation at the long-term acute care hospital (16.4% in 1997–2000 versus 29.8% in 2004–2006, p<0.001). One-year mortality after long-term acute care hospital admission was high throughout the study period: 50.7% in 1997–2000 and 52.2% in 2004–2006.
Long-term acute care hospital utilization after critical illness is common and increasing. Survival among Medicare beneficiaries transferred to long-term acute care after critical illness is poor.
PMCID: PMC3094575  PMID: 20530778
9.  Variation in use of intensive care for adults with diabetic ketoacidosis* 
Critical care medicine  2012;40(7):2009-2015.
Intensive care unit (ICU) beds are limited, yet few guidelines exist for triage of patients to the ICU, especially patients at low-risk for mortality. The frequency with which low-risk patients are admitted to ICUs in different hospitals is unknown. Our objective was to assess variation in use of intensive care for patients with diabetic ketoacidosis (DKA), a common condition with a low-risk of mortality.
Observational study using the New York State Inpatient Database (2005-2007).
159 New York State acute care hospitals.
15,994 adult (≥18) hospital admissions with a primary diagnosis of DKA (ICD-9-CM 250.1x).
Measurements and Main Results
We calculated reliability- and risk-adjusted ICU utilization, hospital length of stay (LOS), and mortality. We identified hospital-level factors associated with increased likelihood of ICU admission after controlling for patient characteristics using multilevel mixed-effects logistic regression analyses; we assessed the amount of residual variation in ICU utilization using the intra-class correlation coefficient. Use of intensive care for DKA patients varied widely across hospitals (adjusted range: 2.1% to 87.7%), but was not associated with hospital LOS or mortality. After multilevel adjustment, hospitals with a high volume of DKA admissions admitted DKA patients to the ICU less often (OR 0.40, p=0.002, highest quintile compared to lowest) whereas hospitals with higher rates of ICU utilization for all non-DKA inpatients admitted DKA patients to the ICU more frequently (OR 1.31, p=0.001, for each additional ten percent increase). In the multi-level model, more than half (58%) of the variation in ICU admission practice attributable to hospitals remained unexplained.
We observed variation across hospitals in use of intensive care for DKA patients that was not associated with differences in hospital LOS or mortality. Institutional practice patterns appear to impact admission decisions and represent a potential target for reduction of resource utilization in higher use institutions.
PMCID: PMC3561634  PMID: 22564962
Diabetic Ketoacidosis; Delivery of Health Care; Physician’s Practice Patterns
10.  Potential Value of Regionalized Intensive Care for Mechanically Ventilated Medical Patients 
Rationale: Regionalization has been proposed as a method to improve outcomes for medical patients receiving mechanical ventilation in the intensive care unit.
Objectives: To determine the number of patients who would be affected by regionalization and the potential mortality reduction under a regionalized system of care.
Methods: We performed a retrospective cohort study with Monte Carlo simulation, using 2001 state discharge data from eight states representing 42% of the U.S. population. Adult medical patients undergoing invasive mechanical ventilation were identified. Patient location and hospital mortality rates were obtained from the discharge data; estimates of the relative risk reduction in hospital mortality for high-volume hospitals compared with low-volume hospitals were obtained from the published literature and applied to the cohort.
Measurements and Main Results: Of 180,976 adult medical patients who underwent mechanical ventilation at 1,170 nonfederal hospitals, 83,050 (46%) received mechanical ventilation at 887 (76%) hospitals with low annual volumes (fewer than 275 patients per year). Using published risk estimates, approximately 4,720 lives per year (95% range, 2,522–6,744) could potentially be saved in the 8 states by routinely transferring patients from low- to high-volume hospitals, representing a number needed to treat of 15.7. The median distance that patients would need to travel to reach a high-volume hospital was 8.5 miles (interquartile range, 4.0–21.2 mi).
Conclusions: Regionalization of intensive care could potentially improve survival for patients undergoing mechanical ventilation. Transfer distances are modest for most patients.
PMCID: PMC2218846  PMID: 18006884
mechanical ventilation; triage; transportation of patients; critical care; Monte Carlo method
11.  Does space make waste? The influence of ICU bed capacity on admission decisions 
Critical Care  2013;17(3):315.
Expanded abstract
Stelfox HT, Hemmelgarn BR, Bagshaw SM, Gao S, Doig CJ, Nijssen-Jordan C, Manns B: Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration. Arch Intern Med 2012, 172:467-474.
Intensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few empiric data on whether the availability of ICU beds influences triage and processes of care for hospitalized patients who develop sudden clinical deterioration.
The objective was to evaluate the effect of ICU bed availability on the processes and outcomes of care for hospitalized patients with sudden clinical deterioration on a hospital ward.
We conducted a retrospective cohort study.
The study was conducted in three hospitals in Calgary, Alberta, Canada, with 2,040 beds and a catchment population of 1.5 million individuals.
Hospitalized adults (n = 3,494) with a sudden clinical deterioration triggering medical emergency team (MET) activation between 1 January 2007 and 31 December 2009 participated.
This study compared treatments and outcomes among sudden clinical deterioration patients according to the number of ICU beds available (zero, one, two, or more than two) at the time of the MET activation. The outcomes of interest were ICU admission rates (within 2 hours of MET activation), changes in the goals of care (resuscitative, medical, and comfort), and hospital mortality. All analyses were adjusted for hospital, physician, and patient factors.
The cohort consisted of 3,494 patients. Reduced ICU bed availability was associated with a decreased likelihood of ICU admission within 2 hours of MET activation (P = 0.03) and with an increased likelihood of change in patient goals of care (P <0.01). Patients with sudden clinical deterioration when zero ICU beds were available were 33.0% (95% confidence interval (CI), −5.1% to57.3%) less likely to be admitted to the ICU and were 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than two ICU beds were available. However, hospital mortality did not vary significantly by ICU bed availability (P = 0.82).
For hospitalized patients with sudden clinical deterioration, ICU bed scarcity decreases the probability of ICU admission and increases the probability of initiating comfort measures on the ward but does not influence hospital mortality.
PMCID: PMC3745081  PMID: 23672968
12.  Organizational Characteristics Associated with the Use of Daily Interruption of Sedation in US Hospitals: A National Study 
BMJ quality & safety  2011;21(2):145-151.
Daily interruption of sedation (DIS) has multiple proven benefits, but implementation is erratic. Past research on sedative interruption utilization focused on individual clinicians, ignoring the role of organizations in shaping practice. We test the hypothesis that specific hospital organizational characteristics are associated with routine use of DIS.
Design & Setting
National, mailed survey to stratified random sample of United States (US) hospitals in 2009. Respondents were the lead infection control professionals at each institution.
Survey items inquired about DIS use, institutional structure, and organizational culture. Multivariable analysis was used to evaluate the independent association of these factors with DIS use.
A total of 386 hospitals formed our final analytic sample; the response rate was 69.4%. Hospitals ranged in size from 25 to 1359 beds. 26% of hospitals were associated with a medical school. Almost 80% reported regular use of DIS for ventilated patients. While 75.4% of hospitals reported having leadership focus on safety culture, only 42.7% reported that their staff were receptive to changes in practice. In a multivariable logistic regression model, structural characteristics such as size and academic affiliation were not associated with use of DIS. However, leadership emphasis on safety culture (p=0.04), staff receptivity to change (p=0.02) and involvement in an infection prevention collaborative (p=0.04) were significantly associated with regular DIS use.
Several elements of hospital organizational culture were associated with regular use of DIS in US hospitals. Our findings emphasize the importance of combining specific administrative approaches with strategies to encourage receptivity to change among bedside clinicians in order to successfully implement complex evidence-based practices in the intensive care setting.
PMCID: PMC4005254  PMID: 21949434
Organizational Culture; Conscious Sedation; Intensive Care; Mechanical Ventilators
13.  Geographic Access to High Capability Severe Acute Respiratory Failure Centers in the United States 
PLoS ONE  2014;9(4):e94057.
Optimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States.
Cross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008–2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims.
Nonfederal acute care hospitals in the United States.
Measurements and Main Results
We defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air.
Geographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.
PMCID: PMC3976413  PMID: 24705417
14.  Reasons underlying interhospital transfers to an academic medical intensive care unit 
Journal of critical care  2012;28(2):202-208.
Interhospital critical care transfers are common, yet few studies address the underlying reasons for transfers. We examined clinician and patient/surrogateperceptions about interhospital transfers and assessed their agreement on these transfers.
Materials and Methods
A mixed-mode survey of three major stakeholders in interhospital transfers to an academic medical intensive care unit (MICU) from August 2007 to April 2008.
62 hospitals transferred 138 patients during the study period. Response rates varied among stakeholders (accepting physician: 90%, referring physicians: 20%, patients/surrogates: 33%). All three groups frequently endorsed quality of care and need for a specific test/procedure as important. Referring hospital reputation and quality were rarely endorsed. Accepting physicians and patients/surrogates substantially agreed on the need for a specific test (kappa=0.70) and increased survival (kappa=0.78), but otherwise had fair to poor agreement. Referring physicians and patients/surrogates rarely agreed and sometimes disagreed greater than expected by chance (kappa <0). Physician pairs strongly agreed on the importance of accepting hospital experience (kappa=0.96), but agreed less on patient satisfaction at the referring hospital (kappa=0.37) and referring hospital reputation (kappa=0.35).
Stakeholders do not always agree on the reasons for critical care transfers. Efforts to improve communication are warranted to insure informed patient choices.
PMCID: PMC3554843  PMID: 23084130
intensive care; critical care; interhospital transfer; survey
15.  Prediction of Critical Illness During Out-of-Hospital Emergency Care 
Early identification of nontrauma patients in need of critical care services in the emergency setting may improve triage decisions and facilitate regionalization of critical care.
To determine the out-of-hospital clinical predictors of critical illness and to characterize the performance of a simple score for out-of-hospital prediction of development of critical illness during hospitalization.
Design and Setting
Population-based cohort study of an emergency medical services (EMS) system in greater King County, Washington (excluding metropolitan Seattle), that transports to 16 receiving facilities.
Nontrauma, non–cardiac arrest adult patients transported to a hospital by King County EMS from 2002 through 2006. Eligible records with complete data (N=144 913) were linked to hospital discharge data and randomly split into development (n=87 266 [60%]) and validation (n=57 647 [40%]) cohorts.
Main Outcome Measure
Development of critical illness, defined as severe sepsis, delivery of mechanical ventilation, or death during hospitalization.
Critical illness occurred during hospitalization in 5% of the development (n=4835) and validation (n=3121) cohorts. Multivariable predictors of critical illness included older age, lower systolic blood pressure, abnormal respiratory rate, lower Glasgow Coma Scale score, lower pulse oximetry, and nursing home residence during out-of-hospital care (P<.01 for all). When applying a summary critical illness prediction score to the validation cohort (range, 0-8), the area under the receiver operating characteristic curve was 0.77 (95% confidence interval [CI], 0.76-0.78), with satisfactory calibration slope (1.0). Using a score threshold of 4 or higher, sensitivity was 0.22 (95% CI, 0.20-0.23), specificity was 0.98 (95% CI, 0.98-0.98), positive likelihood ratio was 9.8 (95% CI, 8.9-10.6), and negative likelihood ratio was 0.80 (95% CI, 0.79-0.82). A threshold of 1 or greater for critical illness improved sensitivity (0.98; 95% CI, 0.97-0.98) but reduced specificity (0.17; 95% CI, 0.17-0.17).
In a population-based cohort, the score on a prediction rule using out-of-hospital factors was significantly associated with the development of critical illness during hospitalization. This score requires external validation in an independent population.
PMCID: PMC3949007  PMID: 20716737
16.  Race and timeliness of transfer for revascularization in patients with acute myocardial infarction 
Medical care  2011;49(7):662-667.
Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability. We sought to determine if the timeliness of hospital transfer and quality of destination hospitals differed between black and white patients.
We evaluated all white and black Medicare beneficiaries admitted with AMI at non-revascularization hospitals in 2006 who were transferred to a revascularization hospital. We compared hospital length of stay prior to transfer and the transfer destination's 30-day risk-standardized mortality rate (RSMR) for AMI between black and white patients. We used hierarchical regression to adjust for patient characteristics and examine within- and across-hospital effects of race on 30-day mortality and length of stay prior to transfer.
A total of 25,947 (42%) white and 2,345 (37%) black patients with AMI were transferred from 857 urban and 774 rural non-revascularization hospitals to 928 revascularization hospitals. Median (IQR) length of stay prior to transfer was 1 day (1-3) for white patients and 2 days (1-4) for black patients (p<0.001). In adjusted models, black patients tended to be transferred more slowly than white patients, a finding due to both across-hospital and within-hospital effects. For example, within an given urban hospital black patients were transferred an additional 0.24 days (95% CI 0.03-0.44) later than white patients. Additionally, the lengths of stay prior to transfer for all patients at urban hospitals increased by 0.37 days (95% CI 0.28-0.47) for every 20% increase in the proportion of AMI patients who were black. These results were attenuated in rural hospitals. The RSMR of the revascularization hospital to which patients were ultimately sent did not differ between black and white patients
Black patients are transferred more slowly to revascularization hospitals after AMI than white patients, resulting from both less timely transfers within hospitals as well as admission to hospitals with greater delays in transfer; however, 30-day mortality of the revascularization hospital to which both groups were sent to appeared similar. Race-based delays in transfer may contribute to known racial disparities in outcomes of AMI.
PMCID: PMC3905793  PMID: 21677592
Healthcare Disparities; Patient Transfer; Critical Care; Cardiovascular Diseases; Quality Indicators
17.  Severe Sepsis in Pre-Hospital Emergency Care 
Rationale: Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system—pre-hospital emergency care—is unknown.
Objectives: We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke.
Methods: Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital.
Measurements and Main Results: Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%).
Conclusions: EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.
PMCID: PMC3622444  PMID: 23087028
sepsis; emergency medical services; epidemiology
18.  Interhospital Transfers among Medicare Beneficiaries Admitted for Acute Myocardial Infarction at Non-Revascularization Hospitals 
Patients with acute myocardial infarctions (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability, yet we know little about the basis for how such revascularization hospitals are selected.
Methods and Results
We examined interhospital transfer patterns in 71,336 AMI patients admitted to hospitals without revascularization capabilities in the 2006 Medicare claims using network analysis and regression models. A total of 31,607 (44.3%) AMI patients were transferred from 1,684 non-revascularization hospitals to 1,104 revascularization hospitals. Median time to transfer was 2 days. Median transfer distance was 26.7 miles, with 96.1% within 100 miles. In 45.8% of cases, patients bypassed a closer hospital to go to farther hospital that had a better 30-day risk standardized mortality rates. However, in 36.8% of cases, another revascularization hospital with lower 30-day risk-standardized mortality was actually closer to the original admitting non-revascularization hospital than the observed transfer destination. Adjusted regression models demonstrated that shorter transfer distances were more common than transfers to the hospitals with lowest 30-day mortality rates. Simulations suggest that an optimized system that prioritized the transfer of AMI patients to a nearby hospital with the lowest 30-day mortality rate might produce clinically meaningful reduction in mortality.
Over 40% of AMI patients admitted to non-revascularization hospitals are transferred to revascularization hospitals. Many patients are not directed to nearby hospitals with the lowest 30-day risk-standardized mortality, and this may represent an opportunity for improvement.
PMCID: PMC3103265  PMID: 20682917
patient transfers; revascularization; networks; Medicare; mortality
19.  Making the GRADE: how useful are the new Surviving Sepsis Campaign guidelines? 
Critical Care  2013;17(6):328.
PMCID: PMC4056029  PMID: 24229440
20.  Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation 
Critical care medicine  2012;40(8):10.1097/CCM.0b013e3182536a63.
Shared decision making is inadequate in intensive care units (ICUs). Decision aids can improve decision making quality, though their role in an ICU setting is unclear. We aimed to develop and pilot test a decision aid for shared decision makers of patients undergoing prolonged mechanical ventilation.
ICUs at three medical centers.
53 surrogate decision makers and 58 physicians.
Design and interventions
We developed the decision aid using defined methodological guidelines. After an iterative revision process, formative cognitive testing was performed among surrogate-physician dyads. Next, we compared the decision aid to usual care control in a prospective, before/after design study.
Measurements and main results
Primary outcomes were physician-surrogate discordance for expected patient survival, comprehension of relevant medical information, and the quality of communication. Compared to control, the intervention group had lower surrogate-physician discordance (7 [10] vs 43 [21]), greater comprehension (11.4 [0.7] vs 6.1 [3.7]), and improved quality of communication (8.7 [1.3] vs 8.4 [1.3]) (all p<0.05) post-intervention. Hospital costs were lower in the intervention group ($110,609 vs $178,618; p=0.044); mortality did not differ by group (38% vs 50%, p=0.95). 94% of surrogates and 100% of physicians reported that the decision aid was useful in decision making.
We developed a prolonged mechanical ventilation decision aid that is feasible, acceptable, and associated with both improved decision making quality and less resource utilization. Further evaluation using a randomized controlled trial design is needed to evaluate the decision aid's effect on long-term patient and surrogate outcomes.
PMCID: PMC3826165  PMID: 22635048
decision aid; decision making; respiration; artificial; critical illness; prolonged mechanical ventilation
21.  Resolving conflicting comparative effectiveness research in critical care 
Critical care medicine  2012;40(11):3090-3092.
PMCID: PMC3655079  PMID: 23080443
Randomized trials; observational studies; comparative effectiveness research; drotrecogin alfa; propensity score
22.  Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study 
Critical Care  2013;17(5):R216.
Intensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing. Although nighttime intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care.
We conducted a retrospective cohort study of ICU decedents using the 2009–2010 Acute Physiology and Chronic Health Evaluation clinical information system linked to a survey of ICU staffing practices. We restricted the analysis to ICUs with high-intensity daytime staffing, in which the addition of nighttime staffing does not influence mortality. We used multivariable regression to assess the relationship between nighttime intensivist staffing and two separate outcomes potentially related to the quality of end-of-life care: time from ICU admission to death and death at night.
Of 30,456 patients admitted to 27 high-intensity daytime staffed ICUs, 3,553 died in the hospital within 30 days. After adjustment for potential confounders, admission to an ICU with nighttime intensivist staffing was associated with a shorter duration between ICU admission and death (adjusted difference: –2.5 days, 95% CI -3.5 to -1.5, p-value < 0.001) and a decreased odds of nighttime death (adjusted odds ratio: 0.75, 95% CI 0.60 to 0.94, p-value 0.011) compared to admission to an ICU without nighttime intensivist staffing.
Among ICU decedents, nighttime intensivist staffing is associated with reduced time between ICU admission and death and reduced odds of nighttime death.
PMCID: PMC4057319  PMID: 24090194
23.  The risks and rewards of expanding ICU capacity 
Critical Care  2012;16(5):156.
ICU capacity strain is associated with increased morbidity and lost hospital revenue, leading many hospitals to increase the number of ICU beds. However, this approach can lead to inefficiency and waste. A recent report in Critical Care highlights a different approach: creating new service lines for low-risk patients. In this case, the authors started a post-anesthesia care unit with an intensivist-led care team, resulting in lower hospital costs with no changes in ICU mortality. Although this type of change carries some risks, and will not work for every hospital, it is an example of the creative solutions hospitals must sometimes undertake to maintain the supply of critical care in response to a rising demand.
PMCID: PMC3682253  PMID: 23025825
24.  First do no harm: surrogate endpoints and the lesson of β-agonists in acute lung injury 
Critical Care  2012;16(3):314.
Expanded abstract
Matthay MA, Brower RG, Carson S, Douglas IS, Eisner M, Hite D, Holets S, Kallet RH, Liu KD, MacIntyre N, Moss M, Schoenfeld D, Steingrub J, Thompson BT: Randomized, placebo-controlled clinical trial of an aerosolized β-agonist for treatment of acute lung injury. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Am J Respir Crit Care Med 2011, 184:561-568.
β2-Adrenergic receptor agonists accelerate resolution of pulmonary edema in experimental and clinical studies of acute lung injury (ALI).
Objective: To determine whether an aerosolized β2-agonist would improve clinical outcomes in patients with ALI.
Design: Multi-center, phase III randomized, placebo-controlled clinical trial.
Setting: 33 hospitals participating National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network.
Subjects: Patients who were intubated and receiving mechanical ventilation, had bilateral infiltrates consistent with edema on frontal chest radiograph, had a ratio of PaO2 to FIO2 (fraction of inspired oxygen) of 300 or less, and not had clinical evidence of left atrial hypertension. A maximum enrolment of 1,000 patients was planned.
Intervention: Patients were randomized to receive aerosolized albuterol (5 mg) or saline placebo every 4 hours for up to 10 days.
Outcomes: The primary outcome variable was ventilator-free days (VFD). Secondary outcome measures included mortality before hospital discharge on day 60 and day 90, the number of intensive care unit (ICU)-free days and the number of organ failure-free days.
There were 282 patients enrolled before the trial was stopped for futility after the second interim analysis. The VFDs difference with albuterol treatment was unfavourable by -2.2 days, well past the futility boundary of -0.4 VFDs. VFDs were not significantly different between the albuterol and placebo groups (means of 14.4 and 16.6 days, respectively; 95% confidence interval for the difference, -4.7 to 0.3 days; P = 0.087). Rates of death before hospital discharge and the number of organ failure-free days were also not significantly different between the two groups. The number of ICU-free days was lower in the albuterol group in comparison with the placebo group (means of 13.5 and 16.2 days respectively; 95% confidence intervals for the mean difference, -4.9 to -0.4 days; P = 0.023). Overall, heart rates were significantly higher in the albuterol group by approximately 5 beats/minute in the first 2 days after randomization (P < 0.05), but rates of new onset atrial fibrillation (10% in both groups) and other cardiac dysrhythmias were not significantly different.
These results suggest that aerosolized albuterol does not improve clinical outcomes in ALI patients. Routine use of β2 agonist therapy in mechanically ventilated ALI patients cannot be recommended.
PMCID: PMC3580665  PMID: 22731873
25.  The Population Burden of Long-Term Survivorship after Severe Sepsis Among Older Americans 
Severe sepsis is associated with persistent high-levels of morbidity among older survivors. But the impact of severe sepsis on population health—particularly population levels of disability—is unknown.
Ascertain the absolute number of patients surviving at least 3 years after severe sepsis in Medicare, and estimate their burden of cognitive dysfunction and disability.
Retrospective cohort analysis of Medicare data.
All short-stay inpatient hospitals in the United States, 1996–2008.
Patients aged 65 and older.
Severe sepsis was detected using a standard administrative definition. Case-fatality, prevalence and incidence rates were calculated.
There were 637,867 Medicare patients alive at the end of 2008 who survived severe sepsis 3 or more years earlier. An estimated 476,862 (95% CI: 455,026, 498,698) had functional disability, with 106,311 (95% CI: 79,692, 133,930) survivors having moderate-to-severe cognitive impairment. The annual number of new 3-year survivors following severe sepsis rose 119% during 1998–2008. The increase in survivorship resulted from more new diagnoses of severe sepsis rather than a change in case fatality rates; severe sepsis rates rose from 13.0 per 1,000 Medicare beneficiary-years to 25.8 (p<0.001), whereas 3-year case fatality rates changed much less, from 73.5%to 71.3% (p<0.001) for the same cohort. Increasing rates of organ dysfunction among hospitalized patients drove the increase in severe sepsis incidence, with an additional small contribution from population aging.
Sepsis survivorship, which carries with it substantial long-term morbidity, is a common and rapidly growing public health problem for older Americans. There has been little change in long-term case fatality, despite changes in practice. Clinicians should anticipate more frequent sequelae of severe sepsis in their patient populations.
PMCID: PMC3374893  PMID: 22642542
Medicare; severe sepsis; disability; population health

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