Because this was a retrospective analysis, it is not possible to state there was a causal relationship between care by a critical care physician and worse outcome. Other unmeasured clinical differences between the patients receiving CCM and those that did not may have existed that resulted in the higher mortality. Additionally, although the database identified management by a critical care physician, it did not differentiate whether the management was by a full-time intensivist. Therefore, conclusions cannot be made regarding the value of full-time, on-site intensivist management.
Bottom line: Additional analysis is required to determine the value of intensivists in the management of critically ill patients.
Citation: Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med 2008; 148: 801-809.
Background: The Institute of Medicine Report, “To Err is Human” suggested 7,000 deaths occur annually because of medication errors. Renal insufficiency is relatively common in hospitalized patients. Previous studies have suggested overdose of medications is frequent in patients with renal insufficiency. There is a lack of large-scale studies identifying the most commonly overdosed medications and the predictive physician factors for these errors.
Study design: Retrospective observational study.
Setting: A single 1,080-bed tertiary teaching hospital
Synopsis: A clinical data mart was constructed that contained 48 months of prescription data, serum creatinine levels, along with physician characteristics. 28,954 patients with renal insufficiency had 431,119 prescription orders to analyze. 3.5% of drug doses were found excessive. The overdose rate in patients with moderate to severe renal insufficiency was 28.2%. 10 drugs accounted for 85.4% of the overdoses. There was a negative correlation between physician clinical experience and overdose rate.
Study results are limited by the study’s retrospective nature. Further, the prescribed dose was presumed to be the dose actually administered, and there were no data on the actual doses given to patients. The study was limited to a single institution and may not be generalizable.
Bottom line: Iatrogenic drug overdose is quite common among inpatients with renal insufficiency. Only a few drugs are commonly responsible. The physicians’ clinical experience, workload of prescriptions, and patients’ renal function correlated with overdose.
Citation: Sheen SS, Choi JE, Park RW, Kim EY, Lee YH, Kang UG. Overdoser rate of drugs requiring renal dose adjustment: data analysis of 4 years prescriptions at a tertiary teaching hospital. J Gen Intern Med 2007;23(4):423-8
Will a national education program based on the “Surviving Sepsis Campaign” guidelines improve survival and processes of care?
Background: Sepsis is one of the most prevalent diseases and one of the main causes of death among hospitalized patients. Several single-center studies have suggested quality improvement efforts based on the Surviving Sepsis Guidelines were associated with better outcomes.
Study design: Prospective multicenter before-and-after study design.
Setting: 59 medical and surgical ICUs throughout Spain.
Synopsis: 854 patients with severe sepsis were enrolled in the pre–intervention group. The intervention consisted of education on the use of bundles of care. The treatment was organized into two bundles: a resuscitation bundle (six tasks to be performed within six hours) and a management bundle (four tasks to be completed within 24 hours). 1,465 patients were enrolled in the post-training period. Hospital mortality, adherence to the bundles, ICU mortality, 28-day mortality, hospital and ICU length of stay were measured.
Patients in the post-intervention group had lower mortality (44.0% vs. 39.5% P=0.04) and better compliance with the bundles improved. No other outcomes improved. One year later, mortality gains persisted but compliance with the resuscitation bundle had lapsed.