OUTCOME OF BARIATRIC SURGICAL PATIENTS ADMITTED TO ICU
De Marco F.V.C, Guimarães A.L.G, Imanishi W.M, Catania M., Souza N.K.G, Kikko R.K, Bruno P.M.C, Hospital Gastroclinica, São José dos Campos, São Paulo, Brazil. Background: The problem of obesity has reached epidemic proportions and the number of bariatric procedures is increasing. There are few data about the outcome of these patients in the intensive care environment. Objectives: The aim of this study was to evaluate the outcome of bariatric surgical patients admitted to ICU. Setting: An 8-bed surgical ICU in a 50-bed private hospital. Methods: From April 2003 to February 2005 we prospectively followed bariatric surgical patients admitted to ICU. Outcome and ICU resource utilization were recorded. Apache II score was calculated. (QuaTI System software database, Dixtal, SP, Brazil). Results: There were 304 patients (240 were female) in 313 consecutive ICU admissions. The mean age was 36.9 „b 10.9 years. The mean BMI was 44.10 „b 5.2 kg/m2. Of these patients 302 (99.3%) were admitted in the immediate postoperative period for a primary procedure. 252 patients (82.9%) underwent Roux-en-Y gastric bypass and 52 patients (17.1%) underwent biliopancreatic diversion. In 20 (6.4%) of 313 admissions the length of stay was > 24 hs. APACHE II score was 10.0 „b 9.2. The mean LOS was 7.8 „b 16.8 days. The main reasons for unplanned ICU admissions (n=11) were bowel occlusion (n=2), anastomotic leakage (n=2), gastrointestinal bleeding (n=2) wound infection (n=1), pulmonary embolism (n=1), acute pulmonary edema (n=1), massive atelectasis (n=1) and perforated bowel (n=1). There was need for mechanical ventilation in 22 (7.0%) admissions, pulmonary artery catheter in 02 (0.6%), dialysis therapy in 01(0.3%) and parenteral nutrition in 01(0.3%). Only 3 patients have developed complications (anaphylactic reaction, respiratory acidosis, cetoacidosis) during the immediate postoperative period for a primary procedure (< 48 hs) and only 1 has never been discharged from ICU. The 28-day ICU mortality rate was 0.65 % (n=2) and the overall ICU mortality rate was 0.98 % (n=3). Conclusions: Based on these preliminary results, we conclude that bariatric surgical patients in the immediate postoperative period for a primary procedure are very low risk ICU patients.

Drug interactions in a surgical ICU: an incidence and patient safety analysis
Introduction: Drug-drug interactions can cause adverse drug events (ADEs) and affect ICU patient care. A pharmacist on rounds decreases the number of preventable order-writing ADEs and positively impacts patient safety, outcome and drug costs. The aim of this study is to describe the frequency of drug-drug interactions and its implications on patient outcome. Methods: From August 2006 to February 2007 our clinical pharmacist, present on daily rounds, conducted an active screening of all ICU physician orders searching for drug-drug interactions (Epocrates Rx® drug reference).These interactions were classified in seven different groups according to potential adverse effects: neurological, cardiovascular, gastrointestinal, renal / metabolic, pharmacokinetic, hematological and others. Once an interaction was identified the ICU team was warned to detect and report any possible ADE and the pharmacist could make interventions judged necessary like a recommendation of an alternative therapy or dose adjustments. Physicians’ acceptance rate of these interventions and incidence of ADEs were recorded. Results: We analyzed 333 orders with 3118 prescribed items. There were 1661 drug-drug interactions identified (1 interaction per 2 prescribed items) and these interactions were present in 333 orders (100%). Neurological was the leading group with 29.4% (n=489) followed by cardiovascular 24.1% (n=400), gastrointestinal 13.6% (n=226), renal/metabolic 12.2% (n=203), pharmacokinetic 10.8% (n=179), hematological 5.4% (n=90) and others 4.5% (n=74). A great variety of therapies was involved in these interactions. The clinical pharmacist made 27 interventions in order to change the prescribed drug therapy and acceptance rate was 67%. The incidence of order-writing ADEs was 3.3 per 1000 patient days. There was not ADEs-associated mortality rate during the study period. Conclusions: Drug-drug interactions are frequent and involve the majority of routinely prescribed items in ICU environment. Neurological and cardiovascular are the most common affected systems .These interactions can adversely affect patient outcome and a clinical pharmacist integrating the multiprofessional ICU team can help to identify and minimize its effects.

Impact of accreditation process in a surgical intensive care unit
Background: Accreditation has been generally viewed as a desirable process to establish standards and work toward achieving higher quality medical care.The worldwide emphasis on accountability has stimulated dramatic growth in internal quality management programs ,external benchmarking with comparative data and accreditation for healthcare facilities.There are few published data about the effects of accreditation process on ICU performance.Objective : The aim of this study was to describe the effects of accreditation process in a surgical ICU.Setting: 8-bed surgical ICU in a 50-bed private hospital.Methods : In this retrospective cohort study we considered two different periods, the first one (from October 2003 to September 2004) as pre-accreditation (PA) period and the second one (from October 2004 to September 2005) as accreditation period (A). We obtained demographic data, APACHE II score, ICU-mortality rate, standardized mortality ratio, LOS, ICU-acquired infection rate, invasive procedure-related complication rate, pressure ulcer frequency and number of training hours per satff member. We compared these variables between pre-accreditation and accreditation periods using the Wilcoxon´s test for statistical analysis. A p value < 0.05 was considered for statistical significance. Results: We included 784 patients in the study: 426 in the pre-accreditation and 358 in the accreditation period. As shown in table 1 although we observed a statistical significant increase in age, APACHE II score, ICU occupation rate and LOS we were unable to demonstrate any difference in the other variables between the periods. Also we could observe a trend toward increasing training hours per staff member as a possible benefit from accreditation process. TABLE 1 Period Mean SD Median p* Age (y) PA 48.43 2.53 49.00 0.012 A 51.82 3.00 51.75 APACHE II PA 7.09 1.48 6.85 0.017 A 8.29 1.18 8.35 Occupation rate (%) PA 36.00 5.00 34.00 0.041 A 47.00 16.00 47.00 ICU-mortality rate (%) PA 6 5 5 0.158 A 11 7 10 SMR PA 0.66 0.41 0.60 0.146 A 1.00 0.63 1.00 LOS (days) PA 2.51 0.43 2.45 0.002 A 3.89 1.09 3.60 ICU-acquired infection PA 2.00 2.00 1.00 0.091 rate (%) A 4.00 3.00 4.00 Procedure-related PA 1.00 1.00 0.00 0.161 complication rate (%) A 2.00 2.00 1.00 Pressure ulcer frequency (%) PA 1.00 1.00 0.00 0.223 A 2.00 2.00 0.00 Training hours per PA 0.46 0.25 0.42 0.086 staff member (h) A 2.22 1.92 1.98 Conclusions: Based on these preliminary data we were unable to demonstrate any benefit from the implementation of accreditation standards in ICU routine daily pratice. A trend toward increasing training hours could be observed. Whether accreditation process has a positive impact on ICU performance is a question that remains to be answered.

HOSPITAL ACCREDITATION PROCESS: THE ROLE OF CRITICAL CARE UNIT MEDICAL DIRECTOR

INTRODUCTION: Accreditation is an internationally recognized process through which healthcare organizations are able to improve the safety and quality of services delivered to patients. The focus of accreditation is to help organizations understand what they are doing well and what opportunities are available for improvement. In a hospital accreditation there is emphasis on structure, documentation, the clinical process and outcomes of care. Although patients in ICUs occupy between 5% and 10% of inpatient beds in hospitals and the expense associated with these beds is 20% to 35% of the total hospital costs there are few published data about the role of critical care unit director in a hospital accreditation process. METHODS: In June 2004 our 50-bed surgical private hospital started its accreditation process comprised of the establishment of an effective quality assurance/accreditation committee, a self-assessment against a set of standards, an initial on site survey by an accrediting organization and follow-up action on recommendations that have arisen from the survey. A list of actions to be taken in order to achieve compliance with accreditation standards was made and those actions were divided into two groups named as healthcare provider-related (HPR) and non-healthcare provider-related (NHPR). We analyzed those HPR actions and subdivided this group as critical care-specific (CCS); critical care-related (CCR) and non-critical care (NCC) actions. RESULTS: In 16 of 34 hospital areas there was total compliance with accreditation standards. There were 124 actions to be taken in order to achieve total hospital compliance. Of these, 68 (54.8%) actions were classified as HPR. There were 03 (2.4%) CCS, 45 (36.3%) CCR and 20 (16.1%) NCC actions. The ICU was involved in 38.7% of the overall process. The ICU medical director was appointed by the accreditation committee to coordinate the development of 21 (17%) actions (03 CCS, 13 CCR and 05 NCC). CONCLUSIONS: ICU medical director may play a critical role in a hospital accreditation process and the hospital stakeholders should take his or her inclusion in the accreditation committee in consideration.