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Understanding changes in established practice: pulmonary artery catheter use in critically ill patients.

ABSTRACT: Multiple studies suggest that routine use of pulmonary artery catheters is not beneficial in critically ill patients. Little is known about the patterns of "uptake" of practice change that involves removal of a device previously considered standard of care, rather than adoption of a new technique or technology. Our objective was to assess recent pulmonary artery catheter use across ICUs and identify factors associated with high use.Cohort study.U.S. ICUs in Project IMPACT.Adult ICU admissions from 2001 to 2008.None.Trends in pulmonary artery catheter use from 2001 to 2008 were assessed. For 2006-2008, we compared pulmonary artery catheter use across ICUs. We assessed characteristics of ICUs and hospitals in the top quartile for in-ICU pulmonary artery catheter placement (vs the bottom quartile) using chi-square and t tests and factors associated with in-ICU pulmonary artery catheter insertion using multilevel mixed effects logistic regression. Total pulmonary artery catheter use decreased from 10.8% of patients (2001-2003) to 6.2% (2006-2008; p < 0.001); insertion of pulmonary artery catheters in ICU decreased from 4.2% to 2.2% (p < 0.001). In 2006-2008, ICUs in the top quartile for in-ICU pulmonary artery catheter insertion (3.4-25.0% of patients) were more often surgical (54.2% vs 21.7% in the lowest quartile, p = 0.070), teaching hospitals (54.2% vs 4.3%, p = 0.001), and had surgeon leadership (40.9% vs 13.0%, p = 0.067). After multivariable regression, surgical patients (p < 0.001) and all patients in surgical ICUs (p = 0.057) were more likely to have pulmonary artery catheters placed in ICU.Use of pulmonary artery catheters in ICU patients has declined but with significant variation across units. Removal of this technology has occurred most in nonsurgical ICUs and patients.

SUBMITTER: Gershengorn HB

PROVIDER: S-EPMC4047564 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Understanding changes in established practice: pulmonary artery catheter use in critically ill patients.

Gershengorn Hayley B HB Wunsch Hannah H

Critical care medicine 20131201 12

<h4>Objective</h4>Multiple studies suggest that routine use of pulmonary artery catheters is not beneficial in critically ill patients. Little is known about the patterns of "uptake" of practice change that involves removal of a device previously considered standard of care, rather than adoption of a new technique or technology. Our objective was to assess recent pulmonary artery catheter use across ICUs and identify factors associated with high use.<h4>Design</h4>Cohort study.<h4>Setting</h4>U. ...[more]

PMID: 23978814

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Project description:Sleep is a biological mandate with an integral role in optimizing functions that maintain psychological and physical health. During critical illness, however, sleep may be disrupted at best and elusive at worst. Sleep improvement efforts and research endeavors evaluating interventions to improve sleep in critically ill adults are hampered by limited methods available to measure sleep in this setting. This narrative review summarizes available modalities for sleep assessment in the ICU, describes new ICU sleep assessment methods under development, and highlights features of the ideal ICU sleep measurement tool.Data sourcesThe most relevant literature and author experiences were assessed for inclusion from PubMed and textbooks.Study selectionThe authors selected studies for inclusion by consensus.Data extractionThe authors reviewed each study and selected appropriate data for inclusion by consensus.Data synthesisCurrently available tools to measure sleep in critically ill adults have important flaws. Subjective measurements are limited by recall bias, the inability of many patients to communicate, and poorly correlate with objective measures when completed by surrogates. Actigraphy does not consider the effects of sedating medications or myopathy leading to an over estimation of sleep time. Polysomnography, the gold standard for sleep assessment, is limited by interpretation issues and practical application concerns. Single and multiple channel electroencephalogram devices offer real-time physiologic data and are more practical to use than polysomnography but are limited by the scope of sleep-specific information they can measure and poorly characterize the circadian system.ConclusionsA measurement tool that offers real-time sleep and circadian assessment and is practical for broad application in the ICU does not exist. Newer sleep assessment devices have shown promise in measuring physiologic data in real time; when used in combination with other assessment modalities, and analyzed by computational techniques, they may revolutionize sleep monitoring in the ICU.

Project description:BackgroundThe utility of pulmonary artery catheters (PACs) and their measurements depend on a variety of factors including data interpretation and personnel training. This US multi-center, retrospective electronic health record (EHR) database analysis was performed to identify associations between PAC use in adult cardiac surgeries and effects on subsequent clinical outcomes.MethodsThis cohort analysis utilized the Cerner Health Facts database to examine patients undergoing isolated coronary artery bypass graft (CABG), isolated valve surgery, aortic surgery, other complex non-valvular and multi-cardiac procedures, and/or heart transplant from January 1, 2011, to June 30, 2015. A total of 6844 adults in two cohorts, each with 3422 patients who underwent a qualifying cardiac procedure with or without the use of a PAC for monitoring purposes, were included. Patients were matched 1:1 using a propensity score based upon the date and type of surgery, hospital demographics, modified European System for Cardiac Operative Risk Evaluation (EuroSCORE II), and patient characteristics. Primary outcomes of 30-day in-hospital mortality, length of stay, cardiopulmonary morbidity, and infectious morbidity were analyzed after risk adjustment for acute physiology score.ResultsThere was no difference in the 30-day in-hospital mortality rate between treatment groups (OR, 1.17; 95% CI, 0.65-2.10; p = 0.516). PAC use was associated with a decreased length of stay (9.39 days without a PAC vs. 8.56 days with PAC; p < 0.001), a decreased cardiopulmonary morbidity (OR, 0.87; 95% CI, 0.79-0.96; p < 0.001), and an increased infectious morbidity (OR, 1.28; 95% CI, 1.10-1.49; p < 0.001).ConclusionsUse of a PAC during adult cardiac surgery is associated with decreased length of stay, reduced cardiopulmonary morbidity, and increased infectious morbidity but no increase in the 30-day in-hospital mortality. This suggests an overall potential benefit associated with PAC-based monitoring in this population.Trial registrationThe study was registered at clinicaltrials.gov (NCT02964026) on November 15, 2016.

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Understanding changes in established practice: pulmonary artery catheter use in critically ill patients.

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Understanding changes in established practice: pulmonary artery catheter use in critically ill patients.

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