High prevalence of corrected QT interval prolongation in acutely ill patients is associated with mortality: results of the QT in Practice (QTIP) Study.

Crit Care Med. 2012 Feb;40(2):394-9

Authors: Pickham D, Helfenbein E, Shinn JA, Chan G, Funk M, Weinacker A, Liu JN, Drew BJ

Abstract
OBJECTIVE: To test the potential value of more frequent QT interval measurement in hospitalized patients.
DESIGN: We performed a prospective, observational study.
SETTING: All adult intensive care unit and progressive care unit beds of a university medical center.
PATIENTS: All patients admitted to one of six critical care units over a 2-month period were included in analyses.
INTERVENTIONS: All critical care beds (n = 154) were upgraded to a continuous QT monitoring system (Philips Healthcare).
MEASUREMENTS AND MAIN RESULTS: QT data were extracted from the bedside monitors for offline analysis. A corrected QT interval >500 msecs was considered prolonged. Episodes of QT prolongation were manually over-read. Electrocardiogram data (67,648 hrs, mean 65 hrs/patient) were obtained. QT prolongation was present in 24%. There were 16 cardiac arrests, with one resulting from Torsade de Pointes (6%). Predictors of QT prolongation were female sex, QT-prolonging drugs, hypokalemia, hypocalcemia, hyperglycemia, high creatinine, history of stroke, and hypothyroidism. Patients with QT prolongation had longer hospitalization (276 hrs vs. 132 hrs, p < .0005) and had three times the odds for all-cause in-hospital mortality compared to patients without QT prolongation (odds ratio 2.99 95% confidence interval 1.1-8.1).
CONCLUSIONS: We find QT prolongation to be common (24%), with Torsade de Pointes representing 6% of in-hospital cardiac arrests. Predictors of QT prolongation in the acutely ill population are similar to those previously identified in ambulatory populations. Acutely ill patients with QT prolongation have longer lengths of hospitalization and nearly three times the odds for mortality then those without QT prolongation.

PMID: 22001585 [PubMed - indexed for MEDLINE]

Zero risk for central line-associated bloodstream infection: are we there yet?.

Crit Care Med. 2012 Feb;40(2):388-93

Authors: McLaws ML, Burrell AR

Abstract
OBJECTIVE: Identify the longest period a central line remains free from central line-associated bloodstream infection during an 18-month insertion-bundle project.
DESIGN: Prospective cohort.
SETTING: New South Wales adult intensive care units at university teaching hospitals between July 2007 and December 2008.
PATIENTS: Intensive care unit adult patients whose central line was inserted in the intensive care unit.
INTERVENTION: Compliance with the insertion bundle for central lines during the first 12-month roll-out period and the last 6 months.
MAIN OUTCOMES: The cumulative line days that remained close to infection-free before the lowest probability of central line-associated bloodstream infection, 1 in 100 chances, was identified using conditional probability modeling. An adjusted central line-associated bloodstream infection rate was calculated for these cumulated line days and thereafter where the probability for infection increased with additional dwell time.
RESULTS: The lowest probability identified for central line-associated bloodstream infection was 1 in 100 chances regardless of the phase of the project or central line type. During the first 12 months of the project, the close to infection-free period finished by the end of day 7 giving an adjusted central line-associated bloodstream infection rate of 1.8 (95% confidence interval 0.9-3.3)/1000 line days. By the last 6 months of the project the close to infection-free period was extended by 2 additional line days to the end of day 9, giving an adjusted central line-associated bloodstream infection rate of 0.9 (95% confidence interval 0.5-1.5)/1,000 line days. For dialysis and unspecified central line types, the close to infection-free period was extended by 5 additional line days, from day 2 with a rate of 4.3 (95% confidence interval 0.9-12.5)/1,000 line days to day 7, giving a rate of 0.6 (95% confidence interval 0.2-2.4)/1,000 line days.
CONCLUSION: The success of the insertion bundle was identified by improved analysis that identified that the safest dwell time was extended to the first 9 days for centrally inserted lines and up to day 7 for dialysis, peripherally inserted central catheters, and unspecified central line types. Given that three quarters of intensive care unit patients have their central line removed by day 7, zero risk for central line-associated bloodstream infection should be achievable in the majority of patients where clinicians comply with the clinician and patient insertion bundles.

PMID: 22020239 [PubMed - indexed for MEDLINE]

Clinical outcomes after telemedicine intensive care unit implementation.

Crit Care Med. 2012 Feb;40(2):450-4

Authors: Willmitch B, Golembeski S, Kim SS, Nelson LD, Gidel L

Abstract
OBJECTIVE: To examine clinical outcomes before and after implementation of a telemedicine program in the intensive care units of a five-hospital healthcare system.
DESIGN: Observational study with the baseline period of 1 yr before the start of a telemedicine intensive care unit program implementation at each of 5 hospitals. The post periods are 1, 2, and 3 yrs after telemedicine intensive care unit program implementation at each hospital.
SETTING: Ten adult intensive care units (114 beds) in five community hospitals in south Florida. A telemedicine intensive care unit program with remote 24/7 intensivist and critical care nurse electronic monitoring was implemented by a phased approach between December 2005 and July 2007.
MEASUREMENTS AND MAIN RESULTS: Records from 24,656 adult intensive care unit patients were analyzed. Hospital length of stay, intensive care unit length of stay, hospital mortality, and Case Mix Index were measured. Severity of illness using All Patient Refined-Diagnosis Related Groups scores was used as a covariate. From the baseline year to year 3 postimplementation, the severity-adjusted hospital length of stay was lowered from 11.86 days (95% confidence interval [CI] 11.55-12.21) to 10.16 days (95% CI 9.80-10.53; p < .001), severity-adjusted intensive care unit length of stay was lowered from 4.35 days (95% CI 4.22-4.49) to 3.80 days (95% CI 3.65-3.94; p < .001), and the relative risk of hospital mortality decreased to 0.77 (95% CI 0.69-0.87; p < .001).
CONCLUSIONS: After 3 yrs of deployment of a telemedicine intensive care unit program, this retrospective observational study of mortality and length of stay outcomes included all cases admitted to an adult intensive care unit and found statistically significant decreases in severity-adjusted hospital length of stay of 14.2%, intensive care unit length of stay of 12.6%, and relative risk of hospital mortality of 23%, respectively, in a multihospital healthcare system.

PMID: 22020235 [PubMed - indexed for MEDLINE]