RESUMEN
PURPOSE OF THE STUDY: The purpose of the study is to determine if teleintensive care unit (ICU)-directed daily ventilator rounds improved adherence to lung protective ventilation (LPV), reduced ventilator duration ratio (VDR), and ICU mortality ratios. METHOD USED: A retrospective observational longitudinal quarterly analysis of adherence to low tidal volume LPV (<7.5 mL/kg predicted body weight; Pao2/fraction of inspired oxygen<300), ventilator duration, and ICU mortality ratios (Acute Physiology and Chronic Health Evaluation IV-adjusted). The teleICU practice used Philips (Andover, MA) VISICU eCareManagerTM (Andover, MA) platform, providing ICU care and process improvement. RESULTS: Before ventilator rounds implementation, there was wide variation in hospital adherence to low tidal volume (29.5±18.2; range 10%-69%). Longitudinal improvement was seen across hospitals in the 3 Qs after implementation, reaching statistical significance by Q3 postimplementation (44.9±15.7; P<.002 by 2-tailed Fisher exact test), maintained at 2 subsequent Qs (48% and 52%; P<.001). Ventilator duration ratio also showed preimplementation variability (1.08±.34; range 0.71-1.90). After implementation, absolute and significant mean VDR reduction was observed (0.92±.28; -15.8%, P<.05). Intensive care unit mortality ratio demonstrated longitudinal improvement, reaching significance after the Q3 postimplementation (0.94 vs 0.67; P<.04), and this was sustained in the most recent Q analyzed (0.65; P<.03). CONCLUSIONS: Implementation of teleICU-directed ventilator rounds was associated with improved and durable adherence to LPV and significant reductions in both VDR and ICU mortality.
Asunto(s)
Cuidados Críticos/métodos , Mortalidad Hospitalaria , Respiración Artificial/métodos , Síndrome de Dificultad Respiratoria/terapia , Telemedicina/métodos , APACHE , Peso Corporal , Estudios Transversales , Adhesión a Directriz , Humanos , Unidades de Cuidados Intensivos , Respiración Artificial/mortalidad , Respiración Artificial/estadística & datos numéricos , Síndrome de Dificultad Respiratoria/mortalidad , Estudios Retrospectivos , Volumen de Ventilación Pulmonar , Resultado del TratamientoRESUMEN
BACKGROUND: When patients are discharged from the hospital, they are assumed to be stable until follow-up as outpatients. OBJECTIVE: To study the frequency of new or worsening symptoms within 2-5 days of hospital discharge. DESIGN: Retrospective analysis of data from telephone calls to patients by centralized call center. SETTING: Patients discharged by hospitalists employed by IPC-The Hospitalist Company. PATIENTS: 15,767 patients surveyed between May 1, 2003, and October 31, 2003. INTERVENTION: Patients discharged home were contacted by a central call center in the first several days after discharge. MEASUREMENTS: Patient demographics, self-rated health status, prevalence of new or worsening symptoms, medication issues, home health services issues, and status of scheduled follow-up appointments. RESULTS: Of the patients surveyed, 11.9% reported new or worsening symptoms since leaving the hospital. There were no differences by age. Women were more likely than men to be symptomatic. Patients with worse health status were more likely to have new or worse symptoms (P < .0001). Symptomatic patients were minimally more likely to have made a follow-up appointment (61.0% vs. 58.4%, P < .05) and were more likely to have medication issues (22.2% vs. 6.8%, P < .0001) and problems with receiving home health care services (5.8% vs. 3.6%, P < .05). CONCLUSIONS: A significant percentage of patients had new or worsening symptoms in the first several days after discharge. These patients were only minimally more likely to have made follow-up appointments. A system to manage the postdischarge transition period is essential to improving posthospitalization outcomes.