Outcomes of Patient- and Family-Centered Care Interventions in the ICU

The aim of this systematic review was to determine whether patient- and family-centered care interventions in the ICU improve outcomes | Critical Care Medicine

Data Synthesis: There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I2 = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I2 = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.

Conclusions: Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

Full reference: Goldfarb, M,J. et al. (2017) Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine: Published online: July 26 2017

A Multifaceted Intervention to Improve Outcomes in Intensive Care

This study examines the effectiveness of a patient-centered care and engagement program in the medical ICU | Critical Care Medicine

Interventions: Structured patient-centered care and engagement training program and web-based technology including ICU safety checklist, tools to develop shared care plan, and messaging platform. Patient and care partner access to online portal to view health information, participate in the care plan, and communicate with providers.

Measurements and Main Results: Primary outcome was aggregate adverse event rate. Secondary outcomes included patient and care partner satisfaction, care plan concordance, and resource utilization. We included 2,105 patient admissions, (1,030 baseline and 1,075 during intervention periods). The aggregate rate of adverse events fell 29%, from 59.0 per 1,000 patient days (95% CI, 51.8-67.2) to 41.9 per 1,000 patient days (95% CI, 36.3-48.3; p < 0.001), during the intervention period. Satisfaction improved markedly from an overall hospital rating of 71.8 (95% CI, 61.1-82.6) to 93.3 (95% CI, 88.2-98.4; p < 0.001) for patients and from 84.3 (95% CI, 81.3-87.3) to 90.0 (95% CI, 88.1-91.9; p < 0.001) for care partners. No change in care plan concordance or resource utilization.

Conclusions: Implementation of a structured team communication and patient engagement program in the ICU was associated with a reduction in adverse events and improved patient and care partner satisfaction.

Full reference: Dykes, P. et al. (2017) Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study. Critical Care Medicine. Published online: 3rd May 2017

Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information.  This study aimed to determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs).

It was published by White et al in the JAMA 17th May 2016.  The issue is available in the Health Care Library on D Level of Rotherham Hospital or for those with a personal subscription to JAMA can be accessed via this link

This mixed-methods study comprising quantitative surveys and qualitative interviews was conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009.

Discordance about prognosis, defined as a difference between a physician’s and a surrogate’s prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician’s prognostic estimate and a surrogate’s best guess of that estimate); differences in belief (any difference between a surrogate’s actual estimate and their best guess of the physician’s estimate). Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient’s prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates’ prognostic estimates were much more accurate than chance alone, but physicians’ prognostic estimates were statistically significantly more accurate than surrogates’ (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19).

Among critically ill patients, discordant expectations about prognosis were common between patients’ physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians’ assessments of patients’ prognoses and differences in beliefs about patients’ prognoses.

Therapeutic hypothermia in patients following traumatic brain injury: a systematic review

Dunkley, S. et al. Nursing in Critical Care. Published online: 6 May 2016

Background: The efficacy of therapeutic hypothermia in adult patients with traumatic brain injury is not fully understood. The historical use of therapeutic hypothermia at extreme temperatures was associated with severe complications and led to it being discredited. Positive results from animal studies using milder temperatures led to renewed interest. However, recent studies have not convincingly demonstrated the beneficial effects of therapeutic hypothermia in practice.

Aim: This review aims to answer the question: in adults with a severe traumatic brain injury (TBI), does the use of therapeutic hypothermia compared with normothermia affect neurological outcome?

Design: Systematic review.

Method: Four major electronic databases were searched, and a hand search was undertaken using selected key search terms. Inclusion and exclusion criteria were applied. The studies were appraised using a systematic approach, and four themes addressing the research question were identified and critically evaluated.

Results: A total of eight peer-reviewed studies were found, and the results show there is some evidence that therapeutic hypothermia may be effective in improving neurological outcome in adult patients with traumatic brain injury. However, the majority of the trials report conflicting results. Therapeutic hypothermia is reported to be effective at lowering intracranial pressure; however, its efficacy in improving neurological outcome is not fully demonstrated. This review suggests that therapeutic hypothermia had increased benefits in patients with haematoma-type injuries as opposed to those with diffuse injury and contusions. It also suggests that cooling should recommence if rebound intracranial hypertension is observed.

Conclusion: Although the data indicates a trend towards better neurological outcome and reduced mortality rates, higher quality multi-centred randomized controlled trials are required before therapeutic hypothermia is implemented as a standard adjuvant therapy for treating traumatic brain injury.

Relevance to clinical practice: Therapeutic hypothermia can have a positive impact on patient outcome, but more research is required.

Read the abstract here

The association between prior statin usage and long-term outcomes after critical care admission

Beed, M. et al. Journal of Critical Care. Published online: 4 May 2016

Image source: Fuse809 // CC BY-SA 3.0

Image shows Rosuvastatin’s 3D molecular structure

Background: Statins may have immunomodulatory effects that benefit critically ill patients. Therefore we retrospectively examined the association between survival and the prescription of statins prior to admission to an intensive care unit (ICU), or high dependency unit (HDU), as a result of major elective surgery, or as an emergency with a presumed diagnosis of sepsis.

Methods: We retrospectively studied critical care patients (ICU or HDU) from a tertiary referral UK teaching hospital. Nottingham University Hospital has over 2200 beds with 39 critical care beds. Over five-years period (2000–2005) 414 patients with a presumed diagnosis of sepsis were identified and 672 patients who had planned critical care admission following elective major surgery. Patients prescribed statins prior to hospital admission were compared with those who were not. Demographics, past medical history, drug history, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were examined. Univariate and multivariate analyses were applied using the primary endpoint of survival at five years after admission.

Results: Patients prescribed statins prior to critical care admission were, on average, older, with higher initial APACHE II scores and more pre-existing comorbidities. Statins were almost invariably stopped following admission to critical care. Statin usage was not associated with altered survival during hospital admission, or at five years, for either patients with sepsis (9% v 15%, P = .121; 73% v 84%, P = .503 respectively), or post-operative patients (55% v 58%, P = .762; 57% v 63%, P = .390).

Conclusions: Prior statin usage was not associated with improved outcomes in patients admitted to critical care after elective surgical cases or with a presumed diagnosis of sepsis.

Quality of patient care in the critical care unit in relation to nurse patient ratio: A descriptive study

Falk, A.C. & Wallin, E.M. Intensive and Critical Care Nursing. Published online: 23 April 2016

11679-2Background: Intensive care is one of the most resource-intensive forms of medical care due to severely ill patients that are cared for in units with high staffing levels. Nursing’s impact on the health of patients has shown that the number of nurses per patient and nurse education effects patient outcome. However, there are a lack of studies investigating highly specialised nurses in intensive care and their relation to patient outcome.

Method: This is a retrospective study of critical care registry data (all patients >15 years) in general critical care units at seven university hospitals.

Results: Patient care and complications in relation to nurse/patient ratio showed that unplanned extubations occurred in 3–5.7% of cases. A difference between hospital patients’ length of time on ventilation was found with the hospitals with the least amount of patients and with 0.5–0.6 specialist-nurse/patient a longer time on ventilation was noted. The length of ICU stay showed differences between the hospitals and nurse/patient ratios, with higher nurse/patient ratio with the longer length of ICU stay.

Conclusion: Despite similarities between hospitals in relation to SAPS III on admission to critical care, there was a difference in nurse/patient ratios ranging from 1:1 to 0.5:1 and mean time on both invasive and noninvasive ventilation.

Read the article here


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300 candles

May 27, 2003|By Edited by Lara Weber (lweber@tribune.com) and Chris Courtney (cdcourtney@tribune.com)

For three centuries, St. Petersburg has shone like a jewel in the bleak Russian north, inspiring poets and revolutionaries, surviving communism and a world war. Now it's aglitter with 10 days of festivities for its 300th birthday. The party began Friday and continues through the weekend.


Wednesday, October 28, 2009

Gone but not forgotten. (Evaluation of seven interactive dinosaur educational applications) (Software Review) (Evaluation).

Holiday 2008

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Seven applications designed to introduce children to dinosaurs including DinoPark Tycoon, Dinosaur Discovery and World of Dinosaurs can teach scientific concepts and expand vocabulary. MECC's $59.95 DinoPark Tycoon enables children to run a simulated dinosaur amusement park, while learning about different types of dinosaurs as well as free enterprise. Applied Optical Media's $39.95 Dinosaur Discovery is filled with detailed profiles of over 150 dinosaurs. It is divided into four research methods: name search, custom search, topics and an activities section. It does not include any video clips, nor can it be saved to disk. It does offer a large detailed encyclopedia of dinosaur facts. Steck-Vaughn Co's $130 World of Dinosaurs features 10 vividly illustrated non-fiction books about dinosaurs. The application ships with a teacher's guide and print editions of the books. Children can build vocabulary and reading skills as they read along with the software.

Full Text :COPYRIGHT 1994 All rights reserved. No part of this information may be reproduced, republished or redistributed without the prior written consent of CMP Media, Inc.
Dinosaurs extinct? No way--they're big business! Here are seven programs that put the prehistoric facts in the hands of your students.

To a child, dinosaurs represent action and adventure, a direct link to the distant past when skyscraper-size animals dominated the earth's lush volcanic landscapes. Today, we have dinosaur lunch boxes, erasers, pencils, and much more. Parents and teachers often call on dinosaurs to show youngsters that learning is fun. Studying these prehistoric reptiles can stimulate an interest in paleontology and science, while promoting vocabulary, reading, writing, and research skills. Teachers even draw on dinosaur images when teaching math concepts such as "bigger than" and "smaller than" or arithmetic operations like adding and subtracting. Capitalizing on kids' insatiable quest for knowledge about these primeval beasts, software companies are offering an amazing assortment of programs that take young learners on fascinating scientific journeys back in time. This month, we look at seven of the best interactive dinosaur titles currently available.

DinoPark Tycoon (MECC)

DinoPark Tycoon (the only non-CD-ROM program reviewed here) is an engrossing and entertaining simulation that gives players a chance to establish and run a Dino Zoo. In the process of managing park business, youngsters can access an online database to uncover a variety of facts about 19 different dinosaurs, from the meat-eating 65-pound Coelophysis that lived during the late Triassic Period to the seven-ton carnivorous T-Rex that dominated the later Cretaceous Period. In addition to distinguishing among dinosaurs in terms of diet, climate, length, weight, and time period, entrepreneurs develop problem-solving strategies and practice math skills such as estimating, reading graphs, and forecasting.

Players are neophyte tycoons who receive bank-approved business loans to start a Dino Park. With this money, they must buy land, fences, dinosaurs, and food, and hire employees. They must also deal successfully with a number of business variables (such as park maintenance problems and unhappy employees) in order to keep the enterprise afloat. Players who are good financial managers can borrow more money to enlarge their business, while poor managers must sell off property to get back on their feet. A ledger keeps detailed records of business dealings (including ticket prices, animal inventory, employees, etc.) which kids can review regularly in order to set up a new business plan. If you want a computer program that develops an appreciation for science and the economic facts of life, DinoPark Tycoon is a great place to set up shop.

Dinosaur Discovery (Applied Optical Media)

This data-packed program takes a serious look at more than 150 dinosaurs and prehistoric animals, with detailed color illustrations, pronunciations, information screens, articles, and games. The main menu provides access to four research paths. Visitors can choose Dinosaurs to find a specific dinosaur by name; view its color illustration; and read about the animal's habitat, range, classification, diet, and size. The Bookshelf section lets users perform custom searches, locating dinosaurs by continent or site, size range, period, classification, or multiple data fields.

A third section, Topics, consists of five information options featuring an introductory essay on dinosaurs; a glossary; 24 narrated "chronicles" or slide shows on a variety of dinosaur subjects (such as extinction theories, habitat, physical characteristics, behavior, and plate tectonics); descriptions for 13 "associates" or dinosaur-related animals; and a "museum" with information on dinosaurs selected by previous visitors. An activities section contains three engaging dino-related puzzles and games.

Unlike the other titles, Dinosaur Discovery lacks video clips and animations; its many fact screens and articles can be printed, but cannot be saved to disk for use with other applications. Nevertheless, this program does contain a broad, encyclopedic database of information on dinosaurs and related animals and its several games are lots of fun.

Dinosaur Safari (Creative Multimedia)

An exciting, interactive adventure game set in the future, Dinosaur Safari sends players back in time to the Mesozoic Era in search of dinosaurs and other prehistoric animals. As photojournalists on assignment for the National Chronographic Society (NCS), they track down clues to determine the whereabouts of specific dinosaurs and other extinct reptiles. When they encounter a target creature, they photograph it for the society's Datazine (a high-tech electronic publication featuring pictures, movies, and information from the past). Once they have all the shots they need, they return to the future and sell their best pictures to the Society, taking care to make it back to NCS headquarters before fuel runs out.

Players earn points based on the quality of photographs they shoot, and amount of energy remaining in the time travel machine when they return. The more assignments players complete, the harder subsequent missions become. Each assignment teaches valuable information about dinosaurs, as youngsters consult online guides for help with identifying locations, time periods, and plants and animals encountered along the way.

Dinosaur Safari offers colorful screens, realistic sound effects, and especially high-quality animation, including three-dimensional recreations of dinosaur movements, physical features, and eating habits. The program contains information on 70 Mesozoic plants and 60 Mesozoic animals, and a suggested list of offline readings.

DinoSource (Westwind Media)

If you're looking for a rich source of information on dinosaurs, this interactive program supplies it with detailed data on more than 200 prehistoric creatures. Students can read interesting dinosaur facts by browsing an illustrated online database which includes vital statistics on size, diet, geographical location, time period, and more. It also features very impressive music, sound effects, and three-dimensional graphics (some of which are animated).

Program options include a narrated slide show of all dinosaurs in the database, and the ability to search for animals with specific characteristics. (Information displays cannot be printed or saved to disk, and once you generate a list of dinosaurs based on selected fields, you must manually reset the fields to their original defaults to view information screens on other dinosaurs.) In addition to the primary database, DinoSource has information screens about prehistoric time periods; bird-hipped vs. lizard-hipped dinosaurs; diet types; and a glossary of terms. A Fact or Fiction activity presents a broad essay on dinosaurs, with information on the time periods in which they lived, general misconceptions, and theories of extinction.

Two lively games draw on information presented in the database and the Fact or Fiction activities: One, Dinosaur Dilemma, invites up to three players to answer questions in a Jeopardy-like quiz format with question categories for Time & Place, Anatomy, Diet, Classification, and Mystery. And a final absorbing activity sends youngsters on a simulated dinosaur excavation where they work with authentic archeologists' tools to uncover bits of fossilized bone and other clues.

Microsoft Dinosaurs (Microsoft)

This dynamic, user-friendly program is an interactive guide to more than 80 dinosaurs and related prehistoric animals. It features over 200 articles, 1,000 high-resolution photographs, hundreds of narratives, and many special audio effects. All animal pictures can be copied to the clipboard for use with other applications, and fact screens can be printed.

Microsoft Dinosaurs lets you read about "weird" dinosaurs, find out what paleontologists do, discover how to recognize an Ankylosaurus or Triceratops, tag along on a dinosaur expedition to the Gobi desert, read "fact boxes" on dozens of animals, and much more. Screen hot spots take you to related cross-references and pop-up windows with dictionary definitions or spoken pronunciations. An index feature is also available to help you in your research.

Visitors browse by clicking topic icons on the main contents screen. An Atlas button leads to illustrations and fact screens describing how the earth's continents looked millions of years ago; a timeline provides access to Paleozoic, Mesozoic, and Cenozoic eras; and a Families path presents information on lizard-hipped and bird-hipped dinosaurs. Other options include guided tours to 16 topical areas, and six narrated dinosaur movies, with storyboards depicting prehistoric life in the oceans, a Triceratops being stalked by a Tyrannosaurus, and more. Microsoft Dinosaurs is both entertaining and informative, and has a well-designed interface that invites exploration for an interactive journey that even young children will enjoy.

Prehistoria (Grolier Electronic Publishing)

Here's a multimedia guide to more than 500 prehistoric creatures living on earth millions of years ago. The disc, which is based on the print edition of Macmillan's Encyclopedia of Dinosaurs and Prehistoric Animals, examines seven animal types, including fish, amphibians, reptiles, and mammals, and explores several dinosaur species in depth.

Prehistoria provides six paths, each of which allows visitors to customize their research through a series of selections. The software will group animals by similarities; show a timeline for 11 featured geological eras; display video clips, slide shows, and audiovisual essays on a variety of topics (including evolution, extinction, dinosaurs, and fossil excavation); let you search using key words or phrases; and more.

Prehistoria is an amazing multimedia reference with voiced animal name pronunciations, colorful illustrations, and narrated QuickTime movies. It would benefit from stronger cross-referencing and information access abilities. (The time period chart is accessible only from within files on particular animals; the search command can be activated only through the main menu; there are no link buttons to allow users to jump easily from essays to illustrated data cards, and so forth.)

Navigation glitches aside, Prehistoria's graphically oriented database (with its drawings, photographs, video clips, articles, and audio-visual essays) is a great tool for anyone interested in learning more about dinosaurs and other prehistoric animals.

World of Dinosaurs (Steck-Vaughn)

This beautifully illustrated program introduces beginning readers to the topic of dinosaurs through ten interactive, non-fiction books with titles such as What Is a Dinosaur?, Putting a Dinosaur Together, and Were Dinosaurs Good Parents? The software is well-supported with printed materials, including a teacher's guide and 16-page editions of all books found on the disk.

Each electronic story is introduced by Dino, a personable, animated green dinosaur who invites viewers to answer questions, and discusses in a humorous way the scientific concepts they will encounter in the text. (Though, even after hearing each introduction once, there's no way to proceed directly to a selection without going through Dino. Once inside a book, children can listen to stories read aloud, following the text on the computer or in the printed reader. Words highlight onscreen as they are read, and dictionary definitions are available for each word. Screen hot spots lead to fact displays of statistics, page illustrations animate with realistic sound effects, and videos are available to enhance the concepts presented on some pages. At the end of each story, Dino reappears with post-reading activities to reinforce main ideas.

World of Dinosaurs also includes an activity component where kids can write their own stories and color and print dinosaur art clips. A preferences menu lets teachers customize books and track student progress. This program is a delightful reading resource for young children, and the high-interest books provide a great scientific supplement to any K-2 science (dinosaur) unit.

* Evaluator: Carol S. Holzberg, Ph.D., Shutesbury, MA, anthropologist and computer journalist, writer for several publications, computer consultant, and computer resource person at the Shutesbury Elementary School.

Source Citation
Holzberg, Carol S. "Gone but not forgotten." Technology & Learning 15.1 (1994): 12+. General OneFile. Web. 28 Oct. 2009. .

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All you need to know about bridges...

A dental bridge is a fixed prosthesis used for replacing missing teeth in the oral cavity. It can either replace a single missing tooth, or multiple teeth in the arch by using teeth adjacent to the socket as anchors. The prosthesis only replaces the crown portion of the missing tooth, and effectively restores functionality, as well as aesthetics.

Depending upon the location of the empty sockets in the oral cavity, bridges can be fabricated using a number of different materials such as porcelain, metal or porcelain fused to metal (PFM). Anterior teeth may be replaced using porcelain and PFM bridges, whereas posterior teeth can be replaced with the help of metal and PFM bridges.

The procedure involves slight cutting down of the tooth on either side of the empty socket; which will then act as a supporting shoulder for the fabricated artificial crown. Once the ideal height has been achieved, an impression is taken on the basis of which a bridge is fabricated in the dental laboratory. Following a trial session, the bridge is then carefully cemented on to the teeth with the help of a strong dental cement or bonding agent.

Because they use the support of natural teeth in the oral cavity, bridges are generally strong and can easily withstand the forces of mastication without fracturing. It is however important to maintain good oral hygiene to prevent accumulation of calculus under and around the hollow crown that replaces the missing tooth. Call today for a free Consultation.