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01-12-2015 | Original

Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study

Authors: Marcio Soares, Fernando A. Bozza, Derek C. Angus, André M. Japiassú, William N. Viana, Roberto Costa, Leonardo Brauer, Bruno F. Mazza, Thiago D. Corrêa, André L. B. Nunes, Thiago Lisboa, Fernando Colombari, Alexandre T. Maciel, Luciano C. P. Azevedo, Moyzés Damasceno, Haggeas S. Fernandes, Alexandre B. Cavalcanti, Pedro E. A. A. do Brasil, Jeremy M. Kahn, Jorge I. F. Salluh

Published in: Intensive Care Medicine | Issue 12/2015

Abstract

Purpose

Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs.

Methods

Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients’ data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score.

Results

ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15–0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904–0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased.

Conclusions

In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.

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Weled BJ, Adzhigirey LA, Hodgman TM et al (2015) Critical care delivery: the importance of process of care and ICU structure to improved outcomes: an update from the American College of Critical Care Medicine Task Force on Models of Critical Care. Crit Care Med 43:1520–1525. doi:10.1097/CCM.0000000000000978 CrossRefPubMed

Sakr Y, Moreira CL, Rhodes A et al (2015) The impact of hospital and ICU organizational factors on outcome in critically ill patients: results from the extended prevalence of infection in intensive care study. Crit Care Med 43:519–526. doi:10.1097/CCM.0000000000000754 CrossRefPubMed

Checkley W, Martin GS, Brown SM et al (2014) Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med 42:344–356. doi:10.1097/CCM.0b013e3182a275d7 PubMedCentralCrossRefPubMed

Vincent J-L, Marshall JC, Namendys-Silva SA et al (2014) Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med 2:380–386. doi:10.1016/S2213-2600(14)70061-X CrossRefPubMed

Nguyen Y-L, Wunsch H, Angus DC (2010) Critical care: the impact of organization and management on outcomes. Curr Opin Crit Care 16:487–492. doi:10.1097/MCC.0b013e32833d9180 CrossRefPubMed

Rothen HU, Stricker K, Einfalt J et al (2007) Variability in outcome and resource use in intensive care units. Intensive Care Med 33:1329–1336. doi:10.1007/s00134-007-0690-3 CrossRefPubMed

Kahn JM, Goss CH, Heagerty PJ et al (2006) Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 355:41–50. doi:10.1056/NEJMsa053993 CrossRefPubMed

Wunsch H, Harrison DA, Jones A, Rowan K (2015) The impact of the organization of high-dependency care on acute hospital mortality and patient flow for critically ill patients. Am J Respir Crit Care Med 191:186–193. doi:10.1164/rccm.201408-1525OC CrossRefPubMed

Kim MM, Barnato AE, Angus DC et al (2010) The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med 170:369–376. doi:10.1001/archinternmed.2009.521 PubMedCentralCrossRefPubMed

10.

Wallace DJ, Angus DC, Barnato AE et al (2012) Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 366:2093–2101. doi:10.1056/NEJMsa1201918 PubMedCentralCrossRefPubMed

11.

Pronovost PJ, Angus DC, Dorman T et al (2002) Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 288:2151–2162CrossRefPubMed

12.

Costa DK, Wallace DJ, Kahn JM (2015) The association between daytime intensivist physician staffing and mortality in the context of other ICU organizational practices: a multicenter cohort study. Crit Care Med. doi:10.1097/CCM.0000000000001259

13.

Austin S, Murthy S, Wunsch H et al (2014) Access to urban acute care services in high- vs. middle-income countries: an analysis of seven cities. Intensive Care Med 40:342–352. doi:10.1007/s00134-013-3174-7 PubMedCentralCrossRefPubMed

14.

Adhikari NKJ, Fowler RA, Bhagwanjee S, Rubenfeld GD (2010) Critical care and the global burden of critical illness in adults. Lancet 376:1339–1346. doi:10.1016/S0140-6736(10)60446-1 CrossRefPubMed

15.

Mills A (2014) Health care systems in low- and middle-income countries. N Engl J Med 370:552–557. doi:10.1056/NEJMra1110897 CrossRefPubMed

16.

United Nations Population Division, Department of Economic and Social Affairs. http://www.un.org/en/development/desa/population/publications/trends/wpp2012.shtml. Accessed 25 Aug 2015

17.

Beale R, Reinhart K, Brunkhorst FM et al (2009) Promoting Global Research Excellence in Severe Sepsis (PROGRESS): lessons from an international sepsis registry. Infection 37:222–232. doi:10.1007/s15010-008-8203-z CrossRefPubMed

18.

Phua J, Koh Y, Du B et al (2011) Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study. BMJ 342:d3245PubMedCentralCrossRefPubMed

19.

Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383CrossRefPubMed

20.

Vesin A, Azoulay E, Ruckly S et al (2013) Reporting and handling missing values in clinical studies in intensive care units. Intensive Care Med 39:1396–1404. doi:10.1007/s00134-013-2949-1 CrossRefPubMed

21.

Noritomi DT, Ranzani OT, Monteiro MB et al (2014) Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 40:182–191. doi:10.1007/s00134-013-3131-5 CrossRefPubMed

22.

Du B, An Y, Kang Y et al (2013) Characteristics of critically ill patients in ICUs in mainland China. Crit Care Med 41:84–92. doi:10.1097/CCM.0b013e31826a4082 CrossRefPubMed

23.

Chittawatanarat K, Sataworn D, Thongchai C, Thai Society of Critical Care Medicine Study Group (2014) Effects of ICU characters, human resources and workload to outcome indicators in Thai ICUs: the results of ICU-RESOURCE I study. J Med Assoc Thai 97(Suppl 1):S22–S30

24.

Vukoja M, Riviello E, Gavrilovic S et al (2014) A survey on critical care resources and practices in low- and middle-income countries. Glob Heart 9:337–342. doi:10.1016/j.gheart.2014.08.002 CrossRefPubMed

25.

Bozza FA, Salluh JI (2010) An urban perspective on sepsis in developing countries. Lancet Infect Dis 10:290–291. doi:10.1016/S1473-3099(10)70074-8 CrossRefPubMed

26.

Sevransky JE, Checkley W, Herrera P et al (2015) Protocols and hospital mortality in critically ill patients: the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med. doi:10.1097/CCM.0000000000001157

27.

Ranzani OT, Simpson ES, Augusto TB et al (2014) Evaluation of a minimal sedation protocol using ICU sedative consumption as a monitoring tool: a quality improvement multicenter project. Crit Care 18:580. doi:10.1186/s13054-014-0580-3 PubMedCentralCrossRefPubMed

28.

Neuraz A, Guérin C, Payet C et al (2015) Patient mortality is associated with staff resources and workload in the ICU: a multicenter observational study. Crit Care Med 43:1587–1594. doi:10.1097/CCM.0000000000001015 CrossRefPubMed

29.

Nguyen Y-L, Milbrandt EB, Weissfeld LA et al (2011) Intensive care unit renal support therapy volume is not associated with patient outcome. Crit Care Med 39:2470–2477. doi:10.1097/CCM.0b013e3182257631 CrossRefPubMed

30.

Cooke CR, Kennedy EH, Wiitala WL et al (2012) Despite variation in volume, veterans affairs hospitals show consistent outcomes among patients with non-postoperative mechanical ventilation. Crit Care Med 40:2569–2575. doi:10.1097/CCM.0b013e3182591eee CrossRefPubMed

31.

Kahn JM (2013) What’s new in ICU volume-outcome relationships? Intensive Care Med 39:1635–1637. doi:10.1007/s00134-013-2992-y CrossRefPubMed

32.

Rhodes A, Moreno RP (2012) Intensive care provision: a global problem. Rev Bras Ter Intensiv 24:322–325CrossRef

33.

Rhodes A, Ferdinande P, Flaatten H et al (2012) The variability of critical care bed numbers in Europe. Intensive Care Med 38:1647–1653. doi:10.1007/s00134-012-2627-8 CrossRefPubMed

34.

Reineck LA, Pike F, Le TQ et al (2014) Hospital factors associated with discharge bias in ICU performance measurement. Crit Care Med 42:1055–1064. doi:10.1097/CCM.0000000000000132 CrossRefPubMed

Title: Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study
Authors: Marcio Soares
Fernando A. Bozza
Derek C. Angus
André M. Japiassú
William N. Viana
Roberto Costa
Leonardo Brauer
Bruno F. Mazza
Thiago D. Corrêa
André L. B. Nunes
Thiago Lisboa
Fernando Colombari
Alexandre T. Maciel
Luciano C. P. Azevedo
Moyzés Damasceno
Haggeas S. Fernandes
Alexandre B. Cavalcanti
Pedro E. A. A. do Brasil
Jeremy M. Kahn
Jorge I. F. Salluh
Publication date: 01-12-2015
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 12/2015
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-015-4076-7

At a glance: The STEP trials

Springer Medicine

Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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