Apache II score as a predictor of length of stay and outcome in our ICUs

The APACHE II (acute physiology and chronic health evaluation) is used widely for predicting probability of hospital mortality and length of stay in the ICU. APACHE II forms were available to all ICU residents within 24 hours of admission, and a score was assigned to them. Based on our results the APACHE II score has reliably predicted an outcome of the least amount of length of stay (LOS) in the ICU as well as a 100% probability of being shifted out of the ICU for a score of \u3c 10 (according to international benchmarks). This reliable scoring system can be used for predicting mortality and length of stay and therefore, resource allocation, antibiotic use and ethical decisions regarding counseling families about end of life decisions--all within 24 hours of admissions

Impact of antibiotic restriction on broad spectrum antibiotic usage in the ICU of a developing country

Objective: To reduce rates of nosocomial pneumonia and cost of antibiotic therapy. Methods: By means of a policy implementation the following broad spectrum antibiotics were restricted to usage in the ICU for 72 hours: Cefepime, Meropenem, Imipenem, Tazocin, Polymixin B and Vancomycin, after an institutional based pharmacy and therapeutic committee approval. The ICU pharmacist would alert the ICU residents or consultants after 48 hours of the computer based antibiotic entry that the order would expire within hours. Telephone approval was obtained followed by a formal consultation if deemed necessary by the ID specialist or primary team. Antibiotic usage was standardized by defined daily doses (DDDs) per 1000/patient-days. Results: A cumulative 34% reduction was seen in the use of all broad spectrum antibiotics in our ICU after the enforcement of the antibiotic restriction policy. The largest reduction was seen in the use of Tazocin (190 DDDs) and Meropenem (60 DDDs). The policy resulted in a reduction by 40% of overall broad spectrum antibiotic pharmacy costs. The number of multidrug resistant organisms has remained static but the ventilator associated pneumonia rates have declined.Conclusion: Streamlining the formulary to control antibiotic choices and the creation of a restriction program using the expertise of infectious disease physicians resulted in significant reductions in the use of and expenditure for broad spectrum antibiotics (JPMA 57:484:2007)

Therapeutic hypothermia post-cardiac arrest: a clinical nurse specialist initiative in Pakistan

Purpose: The purpose of this project was to assess the feasibility of an evidence-based therapeutic hypothermia protocol in adult post-cardiac arrest (CA) patients in a university hospital in Pakistan.Background: Cardiac arrest has a deleterious effect on neurological function, and survival is associated with significant morbidity. The International Liaison Committee of Cardiopulmonary Resuscitation and the American Heart Association recommend the use of mild hypothermia in post-CA victims to mitigate brain injury caused by anoxia. In Pakistan, the survival rate in CA victims is poor. At present, there are no hospitals in the country that use the evidence-based hypothermia intervention in adult post-CA victims.DESCRIPTION: This pilot project of therapeutic hypothermia in adult post-CA patients was implemented in a university hospital in Pakistan by a clinical nurse specialist in collaboration with the cardiopulmonary resuscitation committee and the nursing leadership of the hospital. Various clinical nurse specialist competencies and roles were used to address the 3 spheres of influence: patient, nurses, and system, while executing an evidence-based hypothermia protocol. Process and outcome indicators were monitored to evaluate the effectiveness and feasibility of hypothermia intervention in this setting.OUTCOME: The hypothermia protocol was successfully implemented in 3 adult post-CA patients using cost-effective measures. All 3 patients were extubated within 72 hours after CA, and 2 patients were discharged home with good neurological outcome.CONCLUSION: Adoption of an evidence-based hypothermia protocol for adult CA patients is feasible in the intensive care setting of a university hospital in Pakistan.IMPLICATIONS: The process used in the project can serve as a road map to other hospitals in resource-limited countries such as Pakistan that are motivated to improve post-CA outcomes. This experience reveals that advanced practice nurses can be instrumental in translation of evidence into practice in a healthcare system in Pakistan

End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan

Background:With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit. Methods: This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way anova were used to compare differences in response between the groups. Results:One hundred and thirty-seven physicians and critical care nurses completed the survey. ‘Brain death’ was defined as an ‘irreversible cessation of brainstem function’ by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P-value \u3c 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P-value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to ‘sustain life at all costs’ and only 8% gave religious beliefs as a reason. Conclusions:There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians’ and nurses’ perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula