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.

ANÁLISE DA PASSAGEM DE PLANTÃO EM UMA UNIDADE DE TERAPIA INTENSIVA DE UM HOSPITAL PRIVADO - PROPOSTA DE SISTEMATIZAÇÃO DO PROCESSO.
Referencial Teórico: O processo de comunicação com o paciente, segundo Stefanelli e o manual de enfermagem, de Thora Kron , constituíram-se no referencial teórico do estudo. Objetivo: Sistematizar a passagem de plantão, Identificando as distintas formas de passagem de plantão dentro da Unidade de Terapia Intensiva, Comparar a metodologia atual da passagem de plantão com a proposta de elaborar um instrumento para sistematização da passagem de plantão, visando a melhoria do processo de comunicação. Metodologia: Trata-se de uma pesquisa quali-quantitativa. Os dados foram coletados através da aplicação de questionário e um roteiro de observação estruturada da passagem de plantão. A população pesquisada foi de 5 enfermeiros e 17 técnicos. A pesquisa foi realizada em um hospital privado e de pequeno porte em São José dos Campos - SP. Os dados foram organizados em 2 etapas. 1ª Etapa – Aplicação de questionário com subdivisão das respostas para enfermeiros e técnicos, onde foram utilizadas as respostas das seguintes questões abertas que constavam no questionário: Que fatores interferem na passagem de plantão?; O que pode ser melhorado na passagem de plantão? – aspectos positivos e negativos da realidade atual. 2ª Etapa – Aplicação de roteiro para observação estruturada de passagem de plantão, onde foram consideradas as seguintes atividades: pontualidade, condições do ambiente, participação da equipe, atenção e interesse, objetividade das informações, com intuito de confronto com as respostas obtidas nos questionários, ou seja, esse instrumento teve a intenção de validar as respostas obtidas através do questionário. Resultados: Os profissionais estudados responderam que atrasos, conversas paralelas, dispersão, falta de informações consistentes e ruídos são fatores que interferem no momento da passagem de plantão, e evidenciaram que a consolidação desses fatores demonstraram que a comunicação durante a passagem de plantão é comprometida e fragilizada, e que isso pode gerar falhas durante a passagem de plantão. Sugeriram melhorias referentes especificamente aos fatores que podem gerar falhas de comunicação durante a passagem de plantão. O roteiro de observação estruturada, confirmou que os maiores problemas vivenciados durante a passagem de plantão foram os mesmos levantados através dos questionários aplicados. Conclusão: A qualidade da informação a ser transmitida depende da habilidade de cada um, da modalidade escolhida, do tempo despendido e da preocupação da equipe em registrar informações. Para melhorar a qualidade das informações da metodologia atual de passagem de plantão, concluímos que será necessário implementar e monitorar planos de ação, e elaborar um roteiro sistematizado de passagem de plantão, contemplando todas as informações relevantes para garantir a eficiência da comunicação. O sucesso da passagem de plantão depende de um trabalho de equipe bem articulado, criando formas alternativas de transmissão de informações consistentes e de qualidade.

Clinical predictors and outcomes for patients requiring long-term mechanical ventilation in the ICU
Introduction: Prolonged ventilatory support in the ICU setting has a significant and growing impact on health care economics. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes ≥ 50% of ICU patient days and ICU resources. The aim of this study is to describe clinical predictors and the outcome of this patient population. Setting: An 8-bed medical-surgical adult ICU in a 50-bed private hospital. Methods: We conducted a retrospective cohort study in order to identify independent risk factors. We reviewed data from consecutive patients requiring mechanical ventilation from April 2003 to February 2007. We have defined long term patients those in need of mechanical ventilation for a period greater than seven days (LTMV). Epidemiological data, outcome and ICU resource utilization were recorded. Apache II score was calculated (QuaTI software database, Dixtal, Brazil). Statistical analysis was performed by univariate analysis (Fisher's Exact Test, Chi-Square) followed by multivariate stepwise logistic regression. Results: There were 195 consecutive patients (106 male). The mean age was 60±19. The mean APACHE II score was 18±10. The mean LOS was 9 ± 14. The frequency of LTMV was 23% (n=44). By means of univariable analysis, risk factors for LTMV were male sex, creatinine level ≥ 1.5 mg/dl at admission, presence of organic dysfunction at admission according to APACHE II definitions, hemoglobin level ≤ 7g/dl, APACHE II ≥ 25, use of pulmonary artery catheter, dialysis therapy, enteral and parenteral nutritional support. In the multivariate analysis only use of pulmonary artery catheter (OR 8.3; CI95% 2.3-30.1, p<0.001), dialysis therapy (OR 12.7; CI95% 3.1-52.7, p<0.001) and use of enteral nutritional support (OR 40.7; CI95% 13-127.8, p<0.001) were independent predictors of LTMV. The overall ICU mortality rate was 40 %; it was 60% in patients with LTMV compared with 35% in patients without LTMV (p=0.013). Conclusions: Patients requiring long-term mechanical ventilation have a higher mortality rate and use of pulmonary artery catheter, dialysis therapy and enteral nutritional support are clinical predictors. If we could precisely identify patients at risk we could implement an institutional program to act in advance and improve clinical and financial outcomes in this vulnerable population.

Extension of physiotherapy coverage in ICU: effects on clinical outcomes
Background: Although physiotherapists are members of the interdisciplinary healthcare team for the management of critically ill patients, the availability and coverage in ICUs vary greatly from one setting to another. The lack of systematic reviews and RCTs to support or reject physiotherapy interventions in association with restrictive reimbursement practices may contribute to these variations. The aim of this study was to identify the effects of an extension in the coverage on clinical outcomes. Methods: In December 2007 we extended the physiotherapy coverage from “on-call” service to “on-site” service including weekends. In this retrospective cohort study we considered two different periods, the first one (from April 2007 to November 2007) as pre-intervention period (PI) and the second one (from December 2007 to July 2008) as intervention period (I). We obtained demographic data, APACHE II score, ICU LOS, length of mechanical ventilation, ICU-mortality rate, ventilator-associated pneumonia rate, unplanned extubation rate, pulmonary barotrauma rate and cardiac arrest while on noninvasive mechanical ventilation. We compared these variables between PI and I periods and a p value < 0.05 was considered for statistical significance. Results: We included 340 patients in the study: 166 in the PI and 174 in the I period. As shown in table 1 the APACHE II score and VAP rate were higher in PI patients. TABLE 1 Period Mean or Frequency SD Median p Age (y) PI 55.7 17.4 57 0.17 I 53.1 17.4 52 APACHE II PI 11.7 7.9 11 0.03 I 10.0 8.1 8.0 ICU LOS (days) PI 6.3 15.1 1.58 0.48 I 3.6 6.7 1.43 Use of MV (%) PI 24.1 - - 0.79 I 25.3 - - Length of MV (days) PI 17.9 23.6 5.0 0.15 I 8.5 9.6 3.5 ICU mortality rate (%) PI 9,6 - - 0.50 I 7,6 - - Unplanned extubation (%) PI zero - - 0.12 I 2.3 - - Pulmonary barotrauma (%) PI zero - - - I zero - - VAP rate (%) PI 5.4 - - 0.009 I 0.6 - - Cardiac arrest on NIMV PI zero - - - I zero - - Conclusions: Based on these preliminary data we have shown that the extension of physiotherapy coverage in ICU may be associated with a decrease in VAP rates. The role of physiotherapy in ICU is an ideal field for undertaking future clinical research.

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.

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.

OUTCOME OF BARIATRIC SURGICAL PATIENTS ADMITTED TO ICU
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  10.9 years. The mean BMI was 44.10  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  9.2. The mean LOS was 7.8  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.

Predictive factors of dialytic acute kidney injury in patients admitted in ICU after non-traumatic emergency abdominal surgery
Introduction: Although postoperative risk factors for dialytic acute kidney injury (DAKI) are well described in a wide range of clinical settings we have few data regarding non-traumatic emergency abdominal surgery. The aim of this study was to describe these factors in this subgroup of patients. Methods: We conducted a retrospective cohort study in order to identify independent risk factors. We reviewed data from patients admitted to ICU after non-traumatic emergency abdominal surgery from April 2003 to October 2006. Epidemiological data, outcome and ICU resource utilization were recorded. Apache II score was calculated (QuaTI software database, Dixtal, Brazil). Statistical analysis was performed by univariate analysis (Fisher's Exact Test, Chi-Square) followed by multivariate stepwise logistic regression. Results: There were 168 consecutive patients (86male). The mean age was 55±19. The mean APACHE II score was 11±8. Main reasons for ICU admission according to APACHE II classification were gastrointestinal perforation/obstruction n=100, gastrointestinal surgery due to neoplasia n=21, vascular surgery n=18, gastrointestinal bleeding n=6, hemorrhagic shock=5, sepsis=5, chronic cardiovascular disease n = 4, , respiratory failure n=3, cardiovascular n=3, , metabolic disturbance n=2 and renal surgery due to neoplasia n=1. The mean LOS was 5 ± 13 (days). DAKI frequency was 6.5% (n=11). By means of univariable analysis, risk factors for DAKI were male sex, creatinine level ≥ 1.5 mg/dl at admission, APACHE II ≥ 25, use of pulmonary artery catheter, need of mechanical ventilation ≥ 48 hs, hemoglobin level ≤ 7 g/dl, enteral and parenteral nutritional support. In the multivariate analysis only APACHE II ≥ 25 (OR, 14.9; CI 95% 1.9-111.6, p=0.008), use of enteral support (OR 20.3; CI95% 3.5-117.7, p<0.001) and use of pulmonary artery catheter (OR 10.7; CI95% 1.3-88.5, p=0.028) were independent predictors of DAKI. The overall postoperative mortality rate was 10.7%; it was 54% in patients with DAKI compared with 7.6% in patients without DAKI. Conclusions: Dialytic acute kidney injury following non-traumatic emergency abdominal surgery have a high mortality rate and APACHE II ≥ 25, use of enteral support and use of pulmonary artery catheter are its postoperative predictive factors.

Prognostic factors in cirrhotic patients admitted to ICU
Introduction: The incidence of cirrhosis is increasing exponentially and many of these patients have had historically poor or late access to ICU. The prognosis of critically ill cirrhotic patients is determined by the extent of hepatic and extra hepatic organ dysfunction The aim of this study is to analyze mortality-related factors in this group of patients. Setting: An 8-bed surgical ICU in a 50-bed private hospital. Methods: We conducted a retrospective cohort study in order to identify independent risk factors. We reviewed data from cirrhotic patients admitted to ICU April 2003 to August 2008. Epidemiological data, outcome and ICU resource utilization were recorded. Apache II score was calculated (QuaTI software database, Dixtal, Brazil). Statistical analysis was performed by univariate analysis followed by multivariate stepwise logistic regression. In the analysis we considered age, sex, organic dysfunction at admission, use of pulmonary artery catheter, dialysis therapy, time on mechanical ventilation and nutritional support. Results: There were 36 consecutive patients (32 male). The mean age was 58 ± 12 and 39 % had alcoholic liver disease. The mean APACHE II score was 20 ± 11. Main reasons for ICU admission according to APACHE II classification were gastrointestinal n=9, acute variceal bleeding n=9, metabolic disturbance n=7, pulmonary infection n=3, sepsis n=3, neurological n=2, gastrointestinal perforation/obstruction n= 1, respiratory failure n=1 and thoracic aorthic aneurysm n=1 . The mean LOS was 3.4 ± 3.1 (days). The overall ICU mortality was 39%. In the statistical analysis only an APACHE II ≥ 20 (OR 16, CI95% 2.73-93.62, p= 0.02) and creatinine level ≥ 1.5 mg/dl at admission (OR 6.12, CI 95% 1.4-26.9, p=0.01) were predictive of death. Conclusions: Cirrhotic patients admitted to ICU have a high mortality rate and an APACHE II ≥ 20 and acute renal failure are independent mortality predictors.

PROGNOSTIC FACTORS IN PATIENTS ADMITTED TO ICU AFTER NON-TRAUMATIC EMERGENCY ABDOMINAL SURGERY
Introduction: The factors contributing to the high mortality after non-traumatic emergency abdominal surgery are unclear. The aim of this study is to analyze mortality-related factors in this group of patients. Methods: We conducted a retrospective cohort study in order to identify independent risk factors. We reviewed data from patients admitted to ICU after non-traumatic emergency abdominal surgery from April 2003 to July 2005. Epidemiological data, outcome and ICU resource utilization were recorded. Apache II score was calculated (QuaTI software database, Dixtal, Brazil). Statistical analysis was performed by univariate analysis followed by multivariate stepwise logistic regression. In the analysis we considered age, sex, preoperative morbidity, organic dysfunction at admission, use of pulmonary artery catheter, dialysis therapy, time on mechanical ventilation and nutritional support. Results: There were 109 consecutive patients (57 male). The mean age was 57 ± 20. The mean APACHE II score was 12 ± 9. Main reasons for ICU admission according to APACHE II classification were gastrointestinal perforation/obstruction n=72, vascular surgery n=12, gastrointestinal surgery due to neoplasia n=10, chronic cardiovascular disease n = 3, sepsis=3, respiratory failure n=2, cardiovascular n=2, gastrointestinal bleeding n=2, metabolic disturbance n=2 and renal surgery due to neoplasia n=1. The mean LOS was 6 ± 14 (days). The 28-day ICU mortality was 11 % and overall ICU mortality was 13.7%. In the statistical analysis only an APACHE II ≥ 25 (OR 19.8, CI95% 3.6-107.8, p=0.0005) and mechanical ventilation ≥ 48 hs (OR 8.7, CI 95% 1.8-40.4, p=0.0059) were predictive of death. Conclusions: Patients admitted to ICU after non-traumatic emergency abdominal surgery have a high mortality rate and an APACHE II ≥ 25 and time on mechanical ventilation ≥ 48 hs are independent mortality predictors.

QUALIDADE DA ASSISTÊNCIA DE ENFERMAGEM: ANÁLISE DA PERCEPÇÃO DO PACIENTE.
Referencial teórico: Conhecer a percepção do paciente sobre o cuidado recebido tem sido uma preocupação de pesquisadores e de profissionais responsáveis pela assistência , pois os pacientes estão cada vez mais exigentes e conscientes de seus direitos. Além disso, a satisfação do cliente e deve estar diretamente ligada ao plano estratégico institucional para garantira a sustentabilidade do negócio. Os fatores que implicam na sua satisfação tornam-se importantes não apenas pelo fato de que o paciente satisfeito colabora com a assistência prestada e com o seu próprio tratamento, mas também por que a opinião do paciente sobre o cuidado recebido fornece à enfermagem subsídios para planejar a assistência e prestar assistência com qualidade visando o auto cuidado e recuperação do paciente. Objetivo: Levantar a percepção dos pacientes sobre a qualidade da assistência prestada pela equipe de enfermagem de um hospital privado. Procedimentos metodológicos: A pesquisa foi realizada em um hospital privado e pequeno porte. É um estudo quantitativo, com abordagem de dados através de um questionário que foi aplicado aos pacientes de forma aleatória somando uma amostra de quarenta participantes. Análise dos resultados: O presente estudo buscou evidenciar a importância de se desempenhar os cuidados de enfermagem de maneira coerente com as expectativas e necessidades do cliente. A faixa etária predominante da população analisada foi da idade de 34 à 48 anos, representando 22,5% dos pacientes, 52,5% foram pacientes cirúrgicos. As perguntas relacionadas a agilidade / presteza, conhecimento / segurança, acolhimento / simpatia e resolutividade, foram pontuadas na sua totalidade em nível de excelência. Os pacientes estudados avaliaram a equipe de auxiliares de enfermagem do período noturno com as melhores notas, já o contrário ocorreu em relação aos enfermeiros, sendo os do período diurno melhor pontuados. Em resumo, as equipes foram consideradas pela maioria como excelentes em todos os quesitos, porém percebe-se por meio dos comentários escritos a valorização do quesito acolhimento/simpatia que, na maioria das vezes foi mais valorizada do que a questão técnica. Os resultados contribuirão para avaliar se, na percepção dos pacientes, os processos de qualidade implantados no serviço de enfermagem são eficazes para assegurar a satisfação do paciente durante o período de permanência na instituição. Conclusões: Apesar dos resultados positivos, percebe-se que os auxiliares de enfermagem do período noturno foram mais valorizados. Isso pode ser devido ao fato de que a rotina noturna é mais tranqüila, possibilitando maior permanência do colaborador junto ao paciente. Já em relação aos enfermeiros, o contrário é fato, pois durante o período diurno ocorre a grande maioria das internações, onde o enfermeiro realiza a SAE, favorecendo a proximidade com o paciente e familiares. Percebemos que a satisfação do paciente é diferencial estratégico para a instituição, e nisso toda a equipe deve estar focada para que o paciente receba uma assistência de qualidade e que o mesmo fique satisfeito, com todas suas necessidades atendidas, assim sendo, a equipe poderá fidelizar, conservar, cativar e conquistar novos clientes.

Resource use in the ICU: comparison between medical and surgical patients
Introduction: Intensive care uses a disproportionate share of medical resources, and little is known about the differences between medical and surgical patients in terms of clinical behavior and resource use in the ICU. The aim of this study is to compare the outcome and resource use between these two groups of patients. Setting: An 8-bed medical-surgical adult ICU in a 50-bed private hospital. Methods: From April 2003 to April 2006 we followed consecutive patients admitted to ICU. Patients were assigned to one of the two groups (medical vs. surgical) at the time of ICU admission. Outcome and ICU resource utilization were recorded. Apache II score was calculated. We compared the resource use between the two groups using Chi-Square and Mann-Whitney tests. We identified mortality predictors using stepwise logistic regression analysis. For statistical significance a p value 0.05 was considered. Results: We admitted 1081 patients. Of these 884 were surgical (group S) and 197 were medical (group M). The group M used more mechanical ventilation (38.5 % vs. 12.3%, p < 0.001), for a longer period (32.5 days vs. 6.33 days, p < 0.001), used more invasive hemodynamic monitoring (8.1% vs. 1.9%, p < 0.001), enteral nutritional support (16.7% vs. 2.94%, p < 0.001), parenteral nutritional support (16.2% vs. 4.19%, p < 0.001), dialysis therapy (8.63 % vs. 1.9 %, p < 0.001) and had a longer LOS (6.1 days vs. 2.3 days, p < 0.001). The mortality predictors for group M were Apache II score > 25 (OR 6.1  2.6 – 14.2,p < 0.001) and time on mechanical ventilation > 48 hs (OR 6.7  3.1 – 14.5, p < 0.001). For group S mortality predictors were Apache II score > 25 (OR 13.2 3.6-48.4, p < 0.001), time on mechanical ventilation > 48 hs (OR 21.7  7.6 - 62.1, p < 0.001), age > 65 years (OR 4.0  1.4-11.3, p = 0.008) and need of parenteral nutrition (OR 6.4 1.9 – 21.6, p = 0.002). ICU mortality rate was higher in group M (34.7 % vs. 3.9 %, p < 0.001 / OR 5.8 3.1 – 10.6, p < 0.001). Conclusions: We conclude that medical patients have a higher mortality rate and consume more resources than surgical ones. Health stakeholders when planning critical care delivery should take this fact into consideration.

Are long term ICU patients associated with decreased profitability in a fee for service reimbursement system?
Introduction: Long term ICU stay has been associated with financial losses for private hospitals operating on capitation, flat fee or prospective payment systems. Hypothesis: The aim of this study is to evaluate the impact of ICU length of stay (LOS) on profitability for hospitals operating under a fee for service system with a cost-plus pricing strategy. Methods: The study was conducted in a 50-bed surgical private hospital in Brazil with no commercial relationship with public health insurance. From January to June 2010 we prospectively followed consecutive patients admitted to our ICU and registered all revenues, fixed and variable costs generated in ICU environment. We used a bottom-up approach (TASY Electronic Healthcare Record- Wheb Sistemas, Brazil) to determine all relevant costs and we have considered taxes and physician fees as variable costs. We calculated the total cost / revenue ratio (%) and related with LOS for each patient. We also calculated the mean revenue and cost (US dollars) per ICU day. We established the mean operating margin (total revenue minus total costs) per ICU day for the following groups of patients according to their LOS: 2 days, 4 days, 6 days and > 6 days. Results: We enrolled 184 consecutive patients. The mean LOS was 5.75 ±11.4 days. The mean APACHE II score was 13.2±8.5. The overall mortality rate was 9 %. We have observed that for all range of ICU LOS (1-88 days) the total cost / revenue ratio was always inferior to 100% (range 42% to 74%) making the ICU stay a profit driver regardless the LOS. The mean revenue and cost per ICU day were respectively $ 1936 and $ 1117. The operating margins per patient per day increased with long term stay: 2 days -$ 663, 4 days-$ 621, 6 days-$ 1,100 and > 6 days-$ 1,245. Conclusions: These preliminary data showed that private hospitals do not lose money with long term ICU patients in a fee for service reimbursement and cost-plus pricing strategy setting (Brazilian private healthcare sector). If this is a misaligned incentive to providers to promote aggressive management of LOS in ICU, early adoption of end of life care best practices and to reduce costs with acute hospital care of critically ill patients requires further investigation.

Drug interactions with potential to cause hematologic effects in critically ill patients : an incidence and patient safety analysis
Introduction : There is a close relationship among infection, inflammation, and coagulation that provides the rationale for increased use of anticoagulant treatments in ICU patients. Drug-drug interactions are very common in ICU setting and they put critically ill patients at risk. In order to assure patient safety, ICU physicians must increase their knowledge about drug interactions that can cause hematologic effects and impact clinical outcomes. There are scarce data about the incidence of these types of drug interactions and the frequency that they cause adverse events. Objectives: The aim of this study is to determine the incidence of drug interactions with potential hematologic effects and the incidence of adverse events caused by these interactions. Methods: Between January 2008 and December 2008 we prospectively analyzed ICU prescriptions with the aim to identify potential drug-drug interactions. The screening was done by the clinical pharmacist, present on daily rounds, with the help from specific software (Epocrates Rx® drug reference).The interactions detected were classified in eight groups according to the affected system (neurological, cardiovascular, gastrointestinal, renal / metabolic, pharmacokinetic, hematological, musculoskeletical, others). We considered the hematologic group and identified the most common potential effects and the involved medications. We also recorded the incidence of adverse drug events and morbidity and mortality associated with these events. Results: The ICU admitted 300 patients in study period. We analyzed 682 physician orders with 8059 prescribed itens. We have identified 3716 drug interactions. The neurological and cardiovascular systems were the most potentially affected accounting for 67 % of tracked interactions. The hematologic group comprised 9 % (n=339). The most common effects were increased risk of bleeding, hemolysis, cytopenias and alterations in coagulation lab tests. The involved medications comprised a wide range of ICU prescribed drugs. We were not able to identify any adverse drug event with hematologic effects but even with our active search procedure sub notification remains an issue to be taken into consideration. Our overall rate of adverse drug events was X per 1231 patient days and no ICU mortality rate could be attributed to these events. Conclusions: Drug interactions leading to hematological effects are common in ICU patients, involve a wide range of medications and although adverse drug events seem to be not so frequent their possibility cannot be neglected when physicians are making diagnostic thinking and therapeutic approach. The clinical pharmacist is essential in keeping the multiprofessional team updated regarding this important aspect of ICU care.

ICU Business : Effects of TV advertising as a strategy to increase admissions and occupancy rate
Introduction: ICU is a high fixed costs business and private hospitals are facing a highly competitive commercial environment. In this setting, volume of new admissions and occupancy rate are directly related to revenue generation, investment capacity and attractivity to strategic clients. In order to achieve financial viability and sustainability in the long term, hospitals have to develop a successful marketing mix and choose the appropriate channels of communication. Since critical care typically has been viewed as a service provided by a hospital, and not a product line, business plans have not historically been developed to expand and promote critical care. There are scarce data about the effects of marketing actions on ICU productivity. Objectives: The aim of this study is to determine the effects of hospital-directed TV advertising campaign on ICU admissions and occupancy rate. Methods: Our 8-bed ICU operates on overcapacity considering Brazilian standards and the size of our hospital (50-bed). To our size and number of procedures our ICU was expected to offer only 4 beds. Between January 2005 and December 2008 we collected data on admissions and occupancy rate considering that in 2006 and 2007 the hospital engaged on TV advertising. The themes of the campaigns were hospital-directed and not ICU-focused .For data analysis we considered three periods: period 1 (January/2005 to March/2006) as pre-intervention period, period 2 (April /2006 to December / 2007) as intervention period (insertions on TV) and period 3 (January 2008 to December 2008) as post-intervention period (with no insertions on TV). We also collected data on origin of new admissions. Results: Data on occupancy rate (mean/SD) and its temporal relationship with TV insertions are shown in graph 1. We admitted 1044 patients during the study period. To our surprise we observed a decreased mean number of admissions per month in the intervention period when we compared period 1 and period 2 (24 vs. 18, p= 0.04) and period 2 with period 3 (18 vs. 23, p= 0.03). We have found an increased occupation rate in the intervention period (36% vs. 40% vs. 38%, NS) and an increased occupancy peak/mean ratio (2.03 vs. 2.16 vs. 1.55, NS) but it did not reach statistical significance. We also observed a progressive increase in participation of emergency room as origin of new ICU admissions (6% vs. 22% vs. 26%, NS) Conclusions: We were unable to demonstrate any incremental benefit of TV advertising on ICU admissions and occupancy rate. As our study considered only a campaign with sporadical TV insertions and a not ICU-focused strategy, further work is necessary to determine the effects of regular insertions with ICU-focused themes. With tremendous potential for revenue generation, developing an appropriate marketing plan designed to promote and expand critical care as a service line is in the best interest of private hospitals.

ICU Management : The effect of hiring a nursing director on staff turnover rate
Introduction: ICU is a complex and stressful environment. High staff turnover is a major problem that can impact clinical and financial performance. Hospitals leaders have to set best managerial practices when running this high cost unit in order to assure good talent management. Leadership is an important issue that can affect job fulfillment and retention of skilled health professionals. There are controversial data on literature about the best model of leadership delivery in ICU. Objective: The aim of this study was to evaluate the effect of hiring a nursing director on staff turnover rate (TR). Methods: We retrospectively collected data on TR between November 2006 and September 2008 in our 8-bed ICU (300 admissions per year). We considered two different periods of observation, the first one (October/06-september/07) as pre-intervention (PI) with the ICU coordinated only by a certified ICU physician and the second one as intervention (I) period (October/07-September/08) with the coordination being shared between a physician and an intensive care trained nurse. In the I period there was a co-management responsibility over the multiprofessional team and human resources policy. Results: TR data are shown in graphic 1. The mean TR decreased in the I period (53 % vs. 34 %; p= 0.09) but it did not reach statistical significance. There were no differences in ICU occupancy rate (42% vs. 40%; p=0.82), APACHE II score (11 vs. 12; p=0.47) and ICU mortality (8.4% vs. 9.2%; p=0.72). We observed a difference in ICU staff head count (25 vs. 27; p=0,009) that could have contributed to decrease workload and TR. Even with observed trend toward decreased rates in the I period our unit was underperforming in comparison with other Brazilian units with TR ranging from 25 % to 30 %.

Incidência de hiperglicemia em pacientes críticos: iatrogenia ou doença?
Objetivos: A hiperglicemia é fator de risco para a morbimortalidade de pacientes graves e freqüentemente é identificada como uma complicação da terapia nutricional. O objetivo desse trabalho é comparar a incidência da hiperglicemia iatrogênica com a hiperglicemia associada à doença em pacientes de UTI recebendo terapia nutricional. Métodos: De janeiro a junho de 2010 nós acompanhamos prospectivamente todos os pacientes admitidos na UTI de um hospital cirúrgico privado de 50 leitos. Coletamos dados epidemiológicos, o escore APACHE II, a utilização de terapia nutricional e a incidência de hiperglicemia (duas ou mais medidas de glicemia > 170 mg/dl em um período de 24 hs). Consideramos a hiperglicemia iatrogênica quando a glicose ofertada pela terapia nutricional e pela infusão de fluidos fosse superior a 5 mg/kg/min. Resultados: Foram admitidos 184 pacientes . A média de idade foi 55,3 anos e do score APACHE II 11,9. Houve a necessidade de ventilação mecânica em 16,6 %, diálise em 1,7%, média de permanência 4,5 dias e mortalidade hospitalar 8,1%. Em 11% dos pacientes houve a prescrição de terapia nutricional enteral (8,8%) ou parenteral (2,2%). A hiperglicemia foi observada em 22,8% do total de dias de terapia nutricional, porém não observamos a ocorrência de hiperglicemia iatrogênica. Conclusões: No nosso estudo a hiperglicemia em ambiente de UTI esteve relacionada à doença e não à complicação de terapia nutricional.

Mortality comparison between ICU patients admitted during daytime and night shifts
Introduction: There is a growing concern among ICU clinicians and hospital managers with patient safety. In this context, issues like budget restraints ,shortage of skilled professionals and excessive workload in ICU may put patients admitted on night shifts at risk of worse outcomes. These issues could gain special importance in small private hospitals with low volume of patients and squeezed operating margins. There are controversial data on literature about this topic. Objectives: This study is aimed at determining whether mortality rates among ICU patients differ according to the time of ICU admission. Methods: We have collected prospectively data on consecutive ICU admissions between April 2003 and July 2007 in our 8-bed unit of a 50-bed private hospital. Patients were grouped according to their time of admission and compared using univariable and multivariable analyses. We have considered nigh shift the period between 18:00 pm to 7:00 am. Results: There were 1641 consecutive patients. Of these patients, 677 (41.7%) were admitted at night shifts. The group admitted at nigh shifts were more critically ill according the APACHE II score (9.6 vs 8.0, p < 0.001), stayed at ICU for longer periods ( 4.3 vs 3.0, p < 0.001), used more supportive procedures like mechanical ventilation ( 24.2% vs 15.7 %, p= 0.001), CVC insertion (29.7% vs 22.3 %, p=0.001), parenteral nutrition (8.9% vs 5.8 %, p=0.018), developed more nosocomial infections like surgical site infections (1.9% vs 0.5 %,p= 0.007) and had a higher in-hospital mortality (10.2% vs 7.4%, p=0.043). The unadjusted odds ratio for night shift admission and in-hospital mortality was 1.43 ( 95% CI 1.01-2.02) but when we have adjusted for initial disease severity the effect of the time of ICU admission on mortality disappeared. Conclusions: In our ICU, night shift admissions were not associated with higher mortality.

Risk management in ICU: the role of physician in the incident reporting system
Introduction: It has been estimated that average patient in the ICU has 1.7 errors in his or her care daily. Most units rely on voluntary, anonymous and confidential incident reporting systems (IRS) to detect those errors. A reporting culture from frontline ICU physicians is critical in this process. There are scarce data about this issue in literature and they suggest a gap between physicians and other members of the multiprofessional team in reporting safety problems. Objective: The aim of this study is to describe incident reports from frontline staff in a surgical ICU and evaluate physician pattern of reporting. Methods: From August 2010 and January 2011 we have retrospectively reviewed all incident reports related to ICU (from and directed to ICU). Our 50-bed private hospital adopts an IRS that is paper-based, relying on willingness to report (anyone can do it) and the identification of the reporter is not mandatory. Confidentiality is fully assured but the reporter professional category is registered. The Institute of Healthcare Improvement (IHI) classification of incident severity (usual, acceptable, moderate, important and unacceptable) is used and all relevant events are deeply investigated through root cause analysis (RCA) tools. We have evaluated reports coming from physicians in number (% of the total) and quality of the report (clearness and relevance). Results: There were 354 incidents reports on the hospital and 59 (16.6%) were ICU related. Of those 34 (57.6 %) were generated by the ICU staff and 25 (42.4%) by the outside personnel. There were 42 (71.1%) reports directed to the ICU and 17 (28.9%) reports from the ICU to other departments. According to IHI criteria, reported ICU related incidents were classified as usual 6.8% (n=4), acceptable 72.9% (n=43), moderate 18.6% (n=11), important 1.7% (n=1) and unacceptable zero. Nurses were major reporters with 47.5% (n=28) followed by others 27.1% (n=16), dietitians 13.6% (n=8), clinical pharmacists 6.8% (n=4), respiratory therapists 3.4% (n=2) and physicians 1.7% (n=1). The single incident report from physicians was due to a breach in institutional code assistance protocol and failure in calling rapid response team and was considered of good quality. Conclusions: In our hospital incident reporting system is supported by the multiprofessional team but physicians were outnumbered by all other healthcare professionals in terms of quantity of reports. Our data suggest that ICU physicians lack reporting culture despite their leadership role in the care of critically ill patients.

Understanding safety issues in ICU: an incident reporting system analysis
Introduction: It has been estimated that average patient in the ICU has 1.7 errors in his or her care daily. To detect those errors and mitigate the risks the creation of an incident reporting system (IRS) is critical. Objectives: To evaluate the characteristics of incidents reported after the implementation of a voluntary incident reporting system (IRS) in a surgical ICU in a 50-bed private hospital. Methods: From August 2010 to March 2011 we have retrospectively reviewed all incident reports related to ICU (from and directed to ICU). Our hospital adopts an IRS that is paper-based, relying on willingness to report and the identification of the reporter is not mandatory. The Institute of Healthcare Improvement (IHI) classification of incident severity (usual, acceptable, moderate, important and unacceptable) is used and all relevant events are deeply investigated through root cause analysis (RCA). When opportunities for improvement or preventative actions to be taken are identified a PDCA (Plan-Do-Check-Act) cycle is conducted. We have classified all the reports in the following groups: breach in a standardized operating procedure or clinical care protocols (group 1), drug administration-related (group 2), supplies and logistic (group 3), medical equipment (group 4), poor communication between multiprofessional team (group 5), poor interdepartmental communication (group 6) and others (group 7). We have also collected epidemiologic and clinical outcome data. Results: The ICU admitted 242 patients, mean age was 60 years, mean APACHE II score was 13, LOS was 5 days and overall hospital mortality was 12 %. There were 539 incidents on the hospital and 81 (15%) were ICU related. According to the IHI criteria incidents were classified as usual 4.9% (n=4), acceptable 64.2% (n=52), moderate 28.4% (n=23), important 2, 5% (n=2) and unacceptable zero. We have considered that there was moderate or severe harm in 12 % (n=10) of reported ICU events. Group 1 was most frequently reported (54.3%), followed by group 2 (24.7%), group 7 (7.4%), group 3 (4.9%), group 6 (4.9%), group 4 (2.5%) and group 5 (1.2%). We have conducted 12 full PDCA cycles in the study period. Conclusions: These preliminary data show that incidents are common in ICU and IRS is critical to risk and process improvement management in this environment.

Compliance with evidence based nutritional recommendations in a surgical ICU
Introduction: Evidence based medicine (EBM) practice is considered as the most important way by which healthcare professionals could deliver affordable, safe and quality care. Clinical guidelines (CG) are aimed at assisting practitioners about appropriate decisions in specific clinical circumstances. There is wide variability in the acceptance of the CG recommendations by clinical staff. In the high cost and high risk ICU setting the adoption of EBM can impact financial and clinical performance. Nutritional support is crucial to optimize the outcome of critically ill patients. Objectives: Our study is aimed at determining the compliance to SCCM & ASPEN guidelines recommendations in a surgical ICU. Methods: From April 2003 to August 2009 we have retrospectively collected data from consecutive ICU admissions regarding nutritional therapy. We have focused on the following practices: early administration of enteral nutrition (48 hs), head-of- bed elevation, proportion of patient-days receiving enteral or parenteral nutrition support (nutrition-days) with glucose levels above 170 mg/dl, pharmacologic stress ulcer prevention for patients on MV, time (days) to starting parenteral nutrition in patients not in condition to receive enteral nutrition and duration (days) of parenteral support. Results : We admitted 1995 consecutive patients (48% male), the mean age was 55,8 years, the mean APACHE II score was 10,5, ICU LOS was 3,8 days, SMR was 0,7 and overall ICU mortality was 9,5 %. Of those, 323 (16%) patients were assisted by our multiprofessional nutritional team. Compliance data are shown in Table 1: Indicator(for eligible patients) Result Standard Early administration of enteral nutrition 75 % 100% ≥ 30-degree head-of-bed (HOB) elevation 99 % 97% Stress ulcer prevention 98 % 95% Hyperglycemia on nutrition support 32% < 25% Time to parenteral (days) 2.4 > 7 Duration of parenteral support (days) 10 > 7 Conclusions: Our preliminary results show that there are differences in acceptance of nutrition guidelines recommendations by ICU staff. We need further investigation to identify the drivers of this process in order to improve the outcome of critically ill patients.

Compliance with Fast Hug evidence based practices in a general ICU
Introduction : The application of Fast Hug mnemonic (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention and Glucose control) may help improve the quality of care received by ICU patients. It can be used as a checklist and helps the multiprofessional team to deliver evidence based care at the bedside. Objective: The aim of this study was to determine the proportion of critically ill patients meeting Fast Hug evidence based practices.Setting: A 8-bed general ICU in a 50-bed private hospital. Methods : Between january 2006 and december 2008 we collected prospectivelly data from every patient admitted to our ICU. We considered the following indicators to define compliance to Fast Hug : early administration of enteral nutrition (48 hs) , proportion of 12 hours-shifts with pain classified as moderate or intense during nursing assessment, proportion of wake-up call (sedation vacation) practice in mechanically ventilated (MV) patients, pharmacological or mechanical prophylaxis of deep venous thrombosis for at risk patients, proportion of ventilator-days maintaining a ≥ 30-degree head-of-bed (HOB) elevation, pharmacologic stress ulcer prevention for patients on MV and proportion of patient-days receiving enteral or parenteral nutrition support (nutrition-days) with glucose levels above 170 mg/dl. Results : We admitted 737 consecutive patients (417 male), the mean age was 53,8 years, the mean APACHE II score was 10,5, ICU LOS was 4,6 days, SMR was 0,8 and overall ICU mortality was 10,3 %. Compliance data are shown in Table 1: Indicator (for eligible patients) Results Standard Early administration of enteral nutrition 75 % 100% Proportion of 12 hours-shifts with pain 4,5 % Zero Proportion of wake-up call practice 43 % 80% Prophylaxis of deep venous thrombosis 70 % 90 % ≥ 30-degree head-of-bed (HOB) elevation 99 % 97 % Stress ulcer prevention 98 % 95% Hyperglycemia on nutrition support 32% 25% Conclusions : These preliminary data show there is a variation in translating clinical evidence into clinical practice and that some practices gain more acceptance than others among ICU staff. We need to identify the drivers of clinical acceptance in order to deliver quality care for critically ill patients.

Mortality comparison between ICU patients admitted during daytime and night shifts
Introduction: There is a growing concern among ICU clinicians and hospital managers with patient safety. In this context, issues like budget restraints ,shortage of skilled professionals and excessive workload in ICU may put patients admitted on night shifts at risk of worse outcomes. These issues could gain special importance in small private hospitals with low volume of patients and squeezed operating margins. There are controversial data on literature about this topic. Objectives: This study is aimed at determining whether mortality rates among ICU patients differ according to the time of ICU admission. Methods: We have collected prospectively data on consecutive ICU admissions between April 2003 and July 2007 in our 8-bed unit of a 50-bed private hospital. Patients were grouped according to their time of admission and compared using univariable and multivariable analyses. We have considered nigh shift the period between 18:00 pm to 7:00 am. Results: There were 1641 consecutive patients. Of these patients, 677 (41.7%) were admitted at night shifts. The group admitted at nigh shifts were more critically ill according the APACHE II score (9.6 vs 8.0, p < 0.001), stayed at ICU for longer periods ( 4.3 vs 3.0, p < 0.001), used more supportive procedures like mechanical ventilation ( 24.2% vs 15.7 %, p= 0.001), CVC insertion (29.7% vs 22.3 %, p=0.001), parenteral nutrition (8.9% vs 5.8 %, p=0.018), developed more nosocomial infections like surgical site infections (1.9% vs 0.5 %,p= 0.007) and had a higher in-hospital mortality (10.2% vs 7.4%, p=0.043). The unadjusted odds ratio for night shift admission and in-hospital mortality was 1.43 ( 95% CI 1.01-2.02) but when we have adjusted for initial disease severity the effect of the time of ICU admission on mortality disappeared. Conclusions: In our ICU, night shift admissions were not associated with higher mortality.

Patient safety : Evaluating ICU physicians knowledge about important drug-drug interactions
Introduction: Drug-drug interactions are prevalent in ICU environment and may cause harm to critically ill patients. The ICU multiprofessional team must have a comprehensive understanding about this important issue in order to conduct an appropriate diagnostic and therapeutic approach. There are few data about the knowledge that ICU physicians have about recognizing and handling the most significant of these interactions. Objectives: This study was aimed at evaluating ICU physicians’ knowledge about drug interactions. Methods: We surveyed ICU physicians with a 50-question questionnaire that was elaborated based on the work of our clinical pharmacy department and with a true or false design (T/F). At our unit the clinical pharmacist took part in daily rounds performing a complete analysis of the items prescribed in physician orders. This analysis was done with software (Epocrates Rx® drug reference). The drug interactions were identified and discussed by the ICU team to define the following approach to the patient. We have constructed a database of these interactions (from January 2006 to March 2009) that served as basis for our questionnaire. We have considered the aspects of frequency and potential severity as criteria for an interaction being included. Results: We surveyed 15 full time ICU physicians and we had no refusal to participate in the study. Of the respondents 8 had daily contact with an ICU pharmacist and were frequently exposed to clinical discussions about drug interactions. The general right answer rate was 60 % (range 40 – 98 %). When we considered only the drug interactions classified as moderate or severe by our database the right answer rate dropped to 56 %. Among the most frequent interactions the rate was 57 %. There was no difference when we compared true with false questions regarding the right answer rate. We identified 12 questions with very low scores; the right answer rate ranged from 20% to 46% (7T/5F) and they involved a wide variety of commonly prescribed ICU medications with potential effects over many physiologic systems. Conclusions: Based on these preliminary data we have concluded that there is room for improvement regarding ICU physicians’ knowledge about drug interactions and we have to do it if we want to deliver a safe and quality care to our patients. The clinical pharmacist as a member of the multiprofessional team is essential in support to clinical activities at the bedside, acting as a source of timely information and continuing education to all ICU professionals.

Preventing adverse drug events: potential drug interactions involving antimicrobials in critically ill patients
Introduction : Drug interactions are common, and the effects of these interactions can range from innocuous to deadly. Critically ill patients often receive a variety of potent drugs, including antimicrobials, making this population extremely susceptible to drug–drug interactions. Therefore, physicians must be familiar not only with the antimicrobial drugs capable of producing adverse drug events, but also their potential drug-drug interactions. There are scarce data about the incidence of these types of drug interactions and the how frequently it might cause adverse events. Objectives: The purpose of this study is to evaluate the incidence of potential drug interactions involving antimicrobials and the possibility to cause adverse events. Methods: The clinical pharmacist has prospectively analyzed ICU prescriptions between January 2009 and December 2009 with the purpose to identify potential drug-drug interactions involving antimicrobials. The screening was done with the relief from a software (Epocrates Rx® drug reference). The interactions detected were classified in eight groups according to the affected system (neurological, cardiovascular, gastrointestinal, renal, endocrine, hematological, musculoskeletical and others) and through the type of interaction (pharmacokinetic, pharmacodynamic and others). We have identified the most common potential effects, the medications involved and have observed the incidence of adverse drug events. Results: The ICU admitted 347 patients during the study period. We have analyzed 661 physician orders with 8209 prescribed itens. We have identified 871 antimicrobial drug interactions (71 different interactions) which compound 20% of the total drug interactions (n=4349). The cardiovascular system and the pharmacokinetic interaction were the most potentially affected (38%; 42%). The most common medications involved were: fluconazole (24%), clarithromycin (23%), levofloxacin (12%); linezolid (11%). The clinical pharmacist has made an intervention regarding medication safety in 3% (n=27) and the acceptance rate by the medical ICU staff was 74%. We have not been able to identify any adverse drug event caused by drug interaction even with our active search and the spontaneous reports. However, sub notification must be taken into consideration. Conclusions: Clinicians should be aware of potential drug–drug interactions when making therapy selections for critically ill patients. Antimicrobial drugs are susceptible to interact with other drugs, which may increase the risk of adverse drug events. The clinical pharmacist interventions may improve clinical outcomes by optimizing medication use, monitoring potentially preventable adverse drug events and promoting information about this important issue to the ICU multi-professional team.

Time to meet energy requirements in enteral nutrition and its impact on patient tolerance and clinical outcomes in ICU
Introduction: Delivering early nutrition support therapy, primarily using the enteral route, is seen as a strategy that may reduce disease severity, diminish complications, decrease length of stay in the ICU, and favorably impact patient outcome. SCCM and ASPEN guidelines support that after the initiation of enteral feeding we have 10 days to meet 100 % of predicted energy requirements before we consider supplementation with parenteral nutrition (PN). There are scarce data about the clinical effects of using a more accelerated approach to reach full caloric adequacy with enteral nutrition (EN). Objective: The aim of this observational study is to evaluate if a diminished time to target caloric goal is associated with more patient intolerance and clinical benefits in ICU patients receiving EN. Methods: From January 2010 to June 2010 we prospectively followed all consecutive ICU patients receiving EN. We have collected epidemiological data, APACHE II score, LOS (ICU and hospital), need of mechanical ventilation, incidence of nosocomial infection and hospital mortality. We also have collected data on nutrition therapy as time to target caloric goal (<48hs, <72 hs, <96 hs, <120 hs and > 120 hs), total time on nutrition therapy, incidence of diarrhea and other signs of EN intolerance (vomits, abdominal pain and distension). For statistical analysis we used Kolmogorov-Smirnov test, Student´s t-test and Pearson´s correlation coefficient. Results: We enrolled 32 patients (17 M/ 15 F) in the study. The mean age was 66±18 years, mean APACHE II score 21±9, mean ICU and hospital LOS were 21.3 and 35 days respectively, incidence of nosocomial infection was 21.8%, mean total time in nutrition therapy was 18.3 ± 14 days and hospital mortality was 28 % .There was need of mechanical ventilation in 56%. There was need of PN supplementation in 9.4% (n=3) of patients. Comparing the different groups (<48hs / n= 5, <72 hs / n= 7, <96 hs / n= 3, <120 hs/ n= 1 and > 120 hs / n= 16) we were unable to detect any difference with statistical significance regarding incidence of diarrhea, EN intolerance, need of MV, total time on nutrition therapy, incidence of nosocomial infection, ICU and hospital LOS and hospital mortality. Conclusions: These preliminary data have showed no correlation of a diminished time to meet energy requirements in EN with patient tolerance to nutrition therapy and clinical benefits.