Background. Guidelines for sedation, ventilator weaning, and delirium screening are helpful to avoid too deep sedation and to identify signs of delirium in the intensive care unit (ICU). Methods. National ICU registry members (<svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-0.1560001pt" id="M1" height="8.41101pt" version="1.1" viewBox="0 -8.25501 34.2872 8.41101" width="34.2872pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-111" d="M504 89L488 119C453 85 428 69 416 69C408 69 405 75 412 102L462 304C492 438 460 451 436 451S388 441 356 423C311 397 229 336 170 256H168L189 340C208 418 200 451 177 451C144 451 82 413 24 352L40 322C65 345 98 369 108 369C114 369 119 363 112 335L28 -3L36 -12C54 -3 83 4 112 10C125 73 138 122 153 174C205 258 328 382 376 382C395 382 399 369 384 305L330 93C312 25 323 -12 351 -12C378 -12 439 21 504 89Z"/></g><g transform="matrix(.013,0,0,-0.013,10.332,0)"><path id="g54-34" d="M556 331V384H55V331H556ZM556 140V193H55V140H556Z"/></g><g transform="matrix(.013,0,0,-0.013,21.95,0)"><path id="g50-52" d="M290 377C321 398 342 415 358 430C378 450 389 473 389 502C389 578 329 635 238 635H237C184 635 137 610 109 578L64 515L88 493C112 529 154 573 208 573S303 542 303 482C303 409 233 370 141 341L149 308C165 313 190 319 215 319C272 319 341 283 341 193C342 98 292 43 222 43C163 43 122 72 96 94C88 101 79 100 70 94C61 87 47 73 46 60C44 47 48 37 62 23C76 10 118 -12 165 -12C238 -12 430 62 430 223C430 297 379 359 290 375V377Z"/></g><g transform="matrix(.013,0,0,-0.013,28.281,0)"><path id="g50-56" d="M453 623H65C60 580 56 530 46 472H80C103 538 110 548 175 548H389C310 380 195 168 90 0L98 -12L175 -2C273 206 366 408 462 610L453 623Z"/></g></svg>) were surveyed regarding use of scoring instruments and guidelines for sedation and ventilator weaning, choice of drugs, and daily sedation interruption practices. Results were merged with registry data on ventilator time and length of stay for ICU patients ventilated &#x3e;24 hours (7.075 ICU stays). Results. Eighty-five percent of the 33 responding ICUs used sedation scales and 39&#x25; and 55&#x25; had sedation and weaning protocols, respectively. An association was found between using protocols and longer mean ventilator time and mean length of ICU stay. Thirty three percent (11/33) practiced daily sedation interruption. Regular delirium assessment was associated with significantly shorter mean ventilator time and mean length of ICU stay but used by few. Conclusion. More ICUs had guidelines for weaning than for sedation. The ventilator time and length of ICU stay compared well with other studies. Although having guidelines was associated with longer ventilator time and ICU stay, the differences were rather small. Daily sedation interruption was seldom used. Few units used delirium scoring instruments.

Marit Bekkevold

Reidar Kv&#xe5;le

Guttorm Bratteb&#xf8;

Relation of Reported Sedation and Ventilator Weaning Practices to Ventilator Time in Norwegian Intensive Care Units

In December 2012, a multidisciplinary task force was implemented to address the elevated number of central line associated boodstream infections (CLABSIs) at Newark Beth Israel Medical Center from January 2012 to December 2012. Sixty-eight CLABSIs were documented within the adult inpatient population, resulting in a rate of 14.7&#x2009;CLABSIs/1,000 central line days in the adult inpatient population. This was well above the national average of 1.87 infections per 1,000 central line days. Most of these infections were noted to be within the critical care units where the rate was at 2.86 CLABSIs/1,000 central line days. However, in 2013, the annual rate was decreased to 0.709&#x2009;CLABSIs/1000 line days <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-2.3616pt" id="M1" height="12.0395pt" version="1.1" viewBox="-0.0498162 -9.6779 62.6639 12.0395" width="62.6639pt"><g transform="matrix(.0135,0,0,-0.0135,0,0)"><path id="g113-41" d="M300 -147C201 -63 143 98 143 270S200 602 300 686L282 710C136 610 70 450 70 271V270C70 89 136 -72 282 -170L300 -147Z"/></g><g transform="matrix(.0135,0,0,-0.0135,4.688,0)"><path id="g113-81" d="M600 480C600 590 528 650 384 650H143L137 622C222 614 225 607 210 531L130 127C113 41 106 36 23 28L17 0H294L300 28C204 36 195 42 212 127L243 284L314 263C327 263 339 263 352 264C465 271 600 337 600 480ZM508 481C508 351 402 304 329 304C289 304 265 311 250 317L295 559C302 594 310 606 323 611C335 616 350 619 367 619C455 619 508 573 508 481Z"/></g><g transform="matrix(.0135,0,0,-0.0135,16.837,0)"><path id="g117-91" d="M512 -3V55L134 254V256L512 456V514L75 281V230L512 -3Z"/></g><g transform="matrix(.0135,0,0,-0.0135,28.575,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.0135,0,0,-0.0135,35.078,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.0135,0,0,-0.0135,38.167,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,44.67,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,51.173,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g><g transform="matrix(.0135,0,0,-0.0135,57.676,0)"><path id="g113-42" d="M275 270C275 450 212 609 64 710L45 686C145 604 203 442 203 270S147 -63 45 -147L64 -170C213 -68 275 89 275 270Z"/></g></svg> with similar trends observed across the critical care units. Analysis of CLASBI data indicates that the implementation of a multidisciplinary task force dedicated to appropriate central line insertion, maintenance, and the removal of unnecessary central venous catheters can have an impact on reducing rates of CLASBIs throughout the adult inpatient population, including those within critical care units.

Kristen Scatliffe

Adebanke Davis

Carla Wang-Kocik

Nelson Medina Villanueva

Maria Espiritu-fuller

Renita Larang

Patricia Dimitriou

Amy Doran

Anne Repayo

Jeremias Murillo

Christian A. Engell

Morris Cohen

Jennifer A. LaRosa

The Reduction of Catheter-Related Blood Stream Infections through the Implementation of an Interdisciplinary Healthcare Team

Objectives. Extended time in the emergency department (ED) has been related to adverse outcomes among stroke patients. We examined the associations of ED nursing shift change (SC) and length of stay in the ED with outcomes in patients with intracerebral hemorrhage (ICH). Methods. Data were collected on all spontaneous ICH patients admitted to our stroke center from 7/1/08&#x2013;6/30/12. Outcomes (frequency of pneumonia, modified Rankin Scale (mRS) score at discharge, NIHSS score at discharge, and mortality rate) were compared based on shift change experience and length of stay (LOS) dichotomized at 5 hours after arrival. Results. Of the 162 patients included, 60 (37.0&#x25;) were present in the ED during a SC. The frequency of pneumonia was similar in the two groups. Exposure to an ED SC was not a significant independent predictor of any outcome. LOS in the ED &#x2265;5 hours was a significant independent predictor of discharge mRS 4&#x2013;6 (OR 3.638, 95&#x25; CI 1.531&#x2013;8.645, and P = 0.0034) and discharge NIHSS (OR 3.049, 95&#x25; CI 1.491&#x2013;6.236, and P = 0.0023) but not death. Conclusions. Our study found no association between nursing SC and adverse outcome in patients with ICH but confirms the prior finding of worsened outcome after prolonged length of stay in the ED.

Erica M. Jones

Amelia K. Boehme

Aimee Aysenne

Tiffany Chang

Karen C. Albright

Christopher Burns

T. Mark Beasley

Sheryl Martin-Schild

Prolonged Emergency Department Length of Stay as a Predictor of Adverse Outcomes in Patients with Intracranial Hemorrhage

Background. Recent studies of risks in cardiopulmonary arrest (CPA) have been performed using large databases from a broad mix of hospital settings. However, these risks might be different in a large, urban, academic medical center. We attempted to validate factors influencing outcomes from CPA at the University of Maryland Medical Center (UMMC). Methods. Retrospective chart review of all adult patients who underwent CPA between 2000 and 2005 at UMMC. Risk factors and outcomes were analyzed with appropriate statistical analysis and compared with published results. Results. 729 episodes of CPA were examined during the study period. Surgical patients had better survival than medical or cardiac patients. Intensive care unit' (ICU) patients had poor survival, but there was no difference on monitored or unmonitored floors. Respiratory etiologies survived better than cardiac etiologies. CPR duration and obesity were negatively correlated with outcome, while neurologic disease, trauma, and electrolyte imbalances improved survival. Age, gender, race, presence of a witness, presence of a monitor, comorbidities, or time of day of CPA did not influence survival, although age was associated with differences in comorbidities. Conclusions. UMMC risk factors for CPA survival differed from those in more broad-based studies. Care should be used when applying the results of database studies to specific medical institutions.

Dafna Koldobskiy

Soleyah Groves

Steven M. Scharf

Mark J. Cowan

Validation of Factors Affecting the Outcome of Cardiopulmonary Arrest in a Large, Urban, Academic Medical Center

Purpose. To describe the structure, staffing resources, equipment, academic activities, and characteristics of pediatric population of pediatric intensive care units across the country. Material &#x26; Method. This was a prospective, descriptive, and observational survey of pediatric intensive care units from January to December 2009 across Pakistan. A questionnaire survey was emailed to director of each unit. Results. 16 PICUs were participated in this survey (100&#x25; response rate). A total of units with 155 beds were identified (1.1 bed /500,000 children). Regarding the categories, 12 (75&#x25;) were medical, 3 (19&#x25;) were pure cardiac intensive care units, and one unit (6&#x25;) was combined multidisciplinary cardiothoracic unit. 13 (81&#x25;) units were in public sector as compared to 3 (19&#x25;) were in private sector. The mean unit size was 9.7 (range 4&#x2013;28) beds. Twelve (75&#x25;) units were located in three large cities. Only 3 (19&#x25;) units have trained intensivist. 37&#x25; (6/16) had nurse to patient ratio of 1&#x2009;:&#x2009;1-1&#x2009;:&#x2009;2 while others had ratios of 1&#x2009;:&#x2009;3&#x2013;1&#x2009;:&#x2009;5 with all nurses specialized trained for pediatric intensive care units with bachelor degree or diploma in nursing. Only 50&#x25; had capacity for invasive monitoring. Conclusion. We found inadequacies in several aspects of PICUs in Pakistan including fewer PICUs, inadequate PICU beds, and lack of trained personal to look after critically ill pediatric population.

Anwarul Haque

Laila A. Ladak

Muhammad H. Hamid

Sadiq Mirza

Naveed R. Siddiqui

Zulfiqar A. Bhutta

A National Survey of Pediatric Intensive Care Units in Pakistan

Introduction. Refractory status epilepticus (RSE) has significant morbidity and mortality, and its management requires an accurate diagnosis and aggressive treatment. Objectives. To describe the experience of management of RSE in a neurological intensive care unit (NeuroICU) and determine predictors of short-term clinical outcome. Methods. We reviewed cases of RSE from September 2007 to December 2008. Management was titrated to findings on continuous video EEG (cVEEG). We collected patients&#x2019; demographics, RSE etiology, characteristics of seizures, cVEEG findings, treatments, and short-term outcome. Control of RSE was to achieve burst suppression pattern or electrographic cessation of ictal activity. Results. We included 80 patients; 63.8&#x25; were in coma, 25&#x25; had subclinical seizures, and 11.3&#x25; had focal activity. 51.3&#x25; were male and mean age was 45 years. Etiology was neurological lesion in 75.1&#x25;, uncontrolled epilepsy in 20&#x25;, and systemic derangements in 4.9&#x25;. 78.8&#x25; were treated with general anesthesia and concomitant anticonvulsant drugs. The control of RSE was 87.5&#x25; of patients. In-hospital mortality was 22.5&#x25;. The factors associated with unfavorable short-term outcome were coma and age over 60 years. Conclusions. RSE management guided by cVEEG is associated with a good seizure control. A multidisciplinary approach can help achieve a better short-term functional outcome in noncomatose patients.

O. H. Hernandez

J. F. Zapata

M. Jimenez

M. Massaro

A. Guerra

J. C. Arango

J. D. Ciro

H. Delgado

J. I. Suarez

Refractory Status Epilepticus: Experience in a Neurological Intensive Care Unit

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Journal of Critical Care Medicine