Intensive care unit utilization among patients with cancer at the end of life

Over the last 2 decades, survival rates in critically ill cancer patients have improved. Despite the increase in survival, the intensive care unit (ICU) continues to be a location where end-of-life care takes place. More than 20% of deaths in the United States occur after admission to an ICU, and as baby boomers reach the seventh and eighth decades of their lives, the volume of patients in the ICU is predicted to rise. The aim of this study was to evaluate intensive care unit utilization among patients with cancer who were at the end of life. End of life was defined using decedent and high-risk cohort study designs. The decedent study evaluated characteristics and ICU utilization during the terminal hospital stay among patients who died at The University of Texas MD Anderson Cancer Center during 2003-2007. The high-risk cohort study evaluated characteristics and ICU utilization during the index hospital stay among patients admitted to MD Anderson during 2003-2007 with a high risk of in-hospital mortality. Factors associated with higher ICU utilization in the decedent study included non-local residence, hematologic and non-metastatic solid tumor malignancies, malignancy diagnosed within 2 months, and elective admission to surgical or pediatric services. Having a palliative care consultation on admission was associated with dying in the hospital without ICU services. In the cohort of patients with high risk of in-hospital mortality, patients who went to the ICU were more likely to be younger, male, with newly diagnosed non-metastatic solid tumor or hematologic malignancy, and admitted from the emergency center to one of the surgical services. A palliative care consultation on admission was associated with a decreased likelihood of having an ICU stay. There were no differences in ethnicity, marital status, comorbidities, or insurance status between patients who did and did not utilize ICU services. Inpatient mortality probability models developed for the general population are inadequate in predicting in-hospital mortality for patients with cancer. The following characteristics that differed between the decedent study and high-risk cohort study can be considered in future research to predict risk of in-hospital mortality for patients with cancer: ethnicity, type and stage of malignancy, time since diagnosis, and having advance directives. Identifying those at risk can precipitate discussions in advance to ensure care remains appropriate and in accordance with the wishes of the patient and family.^

Trends in utilization of computer tomography (CT) scans for victims of motor vehicle collision (MVCs) in a level I trauma center from 1996 to 2006

Purpose. To evaluate trends in the utilization of head, abdominal, thoracic and other body regions CTs in the management of victims of MVC at a level I trauma center from 1996 to 2006.^ Method. From the trauma registry, I identified patients involved in MVC's in a level I trauma center and categorized them into three age groups of 13-18, 19-55 and ≥56. I used International Classification of Disease (ICD-9-CM) codes to find the type and number of CTs examinations performed for each patient. I plotted the mean number of CTs per patient against year of admission to find the crude estimate of change in utilization pattern for each type of CT. I used logistic regression to assess whether repetitive CTs (≥ 2) for head, abdomen, thorax and other body regions were associated with age group and year of admission for MVC patients. I adjusted the estimates for gender, ethnicity, insurance status, mechanism and severity of injury, intensive care unit admission status, patient disposition (dead or alive) and year of admission.^ Results. Utilization of head, abdominal, thoracic and other body regions CTs significantly increased over 11-year period. Utilization of head CT was greatest in the 13-18 age group, and increased from 0.58 CT/patient in 1996 to 1.37 CT/patient in 2006. Abdominal CTs were more common in the ≥56+ age group, and increased from 0.33 CT/patient in 1996 to 0.72 CT/patient in 2006. Utilization of thoracic CTs was higher in the 56+ age group, and increased from 0.01 CT/patient in 1996 to 0.42 CT/patient in 2006. Utilization of other CTs did not change materially during the study period for adolescents, adults or older adults. In the multivariable analysis, after adjustment for potential confounders, repetitive head CTs significantly increased in the 13-18 age group (95% CI: 1.29-1.87, p=<0.001) relative to the 19-55 age group. Repetitive thoracic CT use was lower in adolescents (95% CI: 0.22-0.70, p=<0.001) relative to the 19-55 age group.^ Conclusion. There has been a substantial increase in the utilization of head, abdominal, thoracic and other CTs in the management of MVC patients. Future studies need to identify if increased utilization of CTs have resulted in better health outcome for these patients. ^

A Time-Motion Study of Registered Nurses’ Workflow in Intensive Care Unit Remote Monitoring

Utilizing advanced information technology, Intensive Care Unit (ICU) remote monitoring allows highly trained specialists to oversee a large number of patients at multiple sites on a continuous basis. In the current research, we conducted a time-motion study of registered nurses’ work in an ICU remote monitoring facility. Data were collected on seven nurses through 40 hours of observation. The results showed that nurses’ essential tasks were centered on three themes: monitoring patients, maintaining patients’ health records, and managing technology use. In monitoring patients, nurses spent 52% of the time assimilating information embedded in a clinical information system and 15% on monitoring live vitals. System-generated alerts frequently interrupted nurses in their task performance and redirected them to manage suddenly appearing events. These findings provide insight into nurses’ workflow in a new, technology-driven critical care setting and have important implications for system design, work engineering, and personnel selection and training.

MULTIPLE POSTTRANSCRIPTIONAL REGULATORY FEATURES CONTROL EXPRESSION OF ETHANOLAMINE UTILIZATION GENES IN ENTEROCOCCUS FAECALIS

Enterococcus faecalis is a Gram-positive bacterium that lives as a commensal organism in the mammalian gastrointestinal tract, but can behave as an opportunistic pathogen. Our lab discovered that mutation of the eutK gene attenuates virulence of E. faecalis in the C. elegans model host. eutK is part of the ethanolamine metabolic pathway which was previously unknown in E. faecalis. I discovered the presence of two unique posttranscriptional regulatory features that control expression of eut locus genes. The first feature I found is an AdoCBL riboswitch, a cis-acting RNA regulatory element that acts as a positive regulator of gene expression. The second feature I discovered is a unique two-component system, EutVW. The EutV response regulator contains an ANTAR family domain, which binds RNA to trigger transcriptional antitermination. I determined that induction of expression of several genes in the eut locus is dependent on ethanolamine, AdoCBL and the two-component system. AdoCBL and ethanolamine are both required for induction of eut locus gene expression. Additionally, I discovered eutG is regulated by a unique mechanism of antitermination. Both the AdoCBL riboswitch and EutV response regulator control the expression of the downstream gene eutG. EutV potentially acts through a novel antitermination mechanism in which a dimer of EutV binds to a pair of mRNA stem loops forming an antitermination complex. My data show a unique mechanism by which two environmental signals are integrated by two different posttranscriptional regulators to regulate a single locus.

Intensive care for extreme prematurity--moving beyond gestational age.

BACKGROUND: Decisions regarding whether to administer intensive care to extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients. METHODS: We prospectively studied a cohort of 4446 infants born at 22 to 25 weeks' gestation (determined on the basis of the best obstetrical estimate) in the Neonatal Research Network of the National Institute of Child Health and Human Development to relate risk factors assessable at or before birth to the likelihood of survival, survival without profound neurodevelopmental impairment, and survival without neurodevelopmental impairment at a corrected age of 18 to 22 months. RESULTS: Among study infants, 3702 (83%) received intensive care in the form of mechanical ventilation. Among the 4192 study infants (94%) for whom outcomes were determined at 18 to 22 months, 49% died, 61% died or had profound impairment, and 73% died or had impairment. In multivariable analyses of infants who received intensive care, exposure to antenatal corticosteroids, female sex, singleton birth, and higher birth weight (per each 100-g increment) were each associated with reductions in the risk of death and the risk of death or profound or any neurodevelopmental impairment; these reductions were similar to those associated with a 1-week increase in gestational age. At the same estimated likelihood of a favorable outcome, girls were less likely than boys to receive intensive care. The outcomes for infants who underwent ventilation were better predicted with the use of the above factors than with use of gestational age alone. CONCLUSIONS: The likelihood of a favorable outcome with intensive care can be better estimated by consideration of four factors in addition to gestational age: sex, exposure or nonexposure to antenatal corticosteroids, whether single or multiple birth, and birth weight. (ClinicalTrials.gov numbers, NCT00063063 [ClinicalTrials.gov] and NCT00009633 [ClinicalTrials.gov].).

The Family Partners Credit Card: A Token Economy System Adapted for Intensive Family Preservation Services to Enable Families to Manage Difficult Behavior of Adolescents

Increasingly, families referred for Intensive Family Preservation Services have not experienced a crisis of maltreatment, focused on the parent; rather these families have children with chronic behavioral difficulties for which their parents lack the skills to cope. These are the same families whose children were formerly placed in residential programs. This paper presents The Family Partners Credit Card System, incorporating behavioral techniques developed to treat children in out-of-home placements into a family preservation model. Two case examples illustrate how the system has been modified to train biological or adoptive parents in parenting skills, enable them to teach their children pro-family behaviors, and reinforce new behaviors through a credit card that monitors an ongoing balance of credits and fines.

Idiographic Self-Monitoring Instruments to Empower Client Participation and Evaluate Outcome in Intensive Family Preservation Services

Intensive Family Preservation Services seek to reflect the values of focusing on client strengths and viewing clients as colleagues. To promote those values, Intensive Family Preservation Programs should include a systematic form of client self monitoring in their packages of outcome measures. This paper presents a model of idiographic self-monitoring used in time series, single system research design developed for Family Partners, a family preservation program of the School for Contemporary Education in Annandale, Virginia. The evaluation model provides a means of empowering client families to utilize their strengths and promote their status as colleague in determining their own goals, participating in the change process, and measuring their own progress.

Institutionalizing Intensive Family Preservation Services: A Strategy for Creating Staffing Standards Based on Projections of At-Risk Children from Referral Sources

In spite of new legislation and much public and professional interest, intensive family preservation service (IFPS) remains in a vulnerable position as compared to other child welfare services. This article details a method to project ideal IFPS caseloads as a function of children who are at-risk for placement by various referral sources. Using this approach, resource allocation for IFPS can be more nearly on equal ground with the traditional child welfare functions and help IFPS to assume its needed place as a core service in the child welfare continuum.

Intensive Family Preservation Services: Do They Have Any Impact on Family Functioning?

Tills article presents a review of the intensive family preservation evaluation literature, the prepost test rnethology employed to evaluate three models in one state and the findings which have informed policymakers and program designers as the service expands. After intensive family preservation services, significant changes were found in parent-centered risk, parental disposition, and child-centered and child performance. No changes were found in economic risk and household adequacy.

Intensive Family Reunification Services: A Conceptual Framework and Case Example

Recent federal mandates require child welfare agencies to make reasonable efforts to reunify families after out-of-home placement. Consistent with those mandates, agencies are increasingly employing techniques from family preservation services intended initially to prevent out-of-home placement. The purpose of this article is to articulate a conceptual framework and practice guidelines for family reunification services and to describe an experimental reunification program based on a family preservation model. A case example illustrates the way in which the services affected one family that participated in the experiment.

A Multi- Faceted, Intensive Family Preservation Program Evaluation

This evaluation of a county intensive family preservation services (ifps) program makes several important methodological contributions to assessing post-treatment placement patterns of ifps clients. It is the first published ifps evaluation that utilizes an interval-level, overall measure of restrictiveness of placement, and one of the few that has followed placement patterns for a full two-years after treatment. The study is also a good example of complementing placement data with measures of family health and stability, and with qualitative feedback from former ifps clients. Finally, this study demonstrates the potential for doing methodologically sound evaluations of local ifps programs.

Targeting Families to Receive Intensive Family Preservation Services: Assessing the Use of Imminent Risk of Placement as a Service Criterion

The process for targeting families to receive intensive family preservation services was examined for 71 child welfare agencies in the United States. The focus of this exploratory/descriptive study was the concept of imminent risk of placement as a criterion for providing services. Findings indicated that agencies had difficulty defining imminent risk and were unable to successfully restrict services to imminent risk cases. Several factors besides imminent risk were identified in relation to the targeting process.

Intensive Family Preservation Services: A Short History but a Long Past

Intensive family preservation services (IFPS) is a program model that has been disseminated widely throughout the country, and has received federal recognition and monetary support since the early 1980s. Recently, IFPS has been criticized for seemingly being unable to prevent out-of-home placements. The authors contend that many evaluators and policy analysts have lost sight of the historical roots of IFPS, and are focusing only on recent fiscal and policy contexts when assessing IFPS program effectiveness. This article reviews the therapeutic and programmatic origins of IFPS including desired treatment outcomes, and suggests that evaluators and policy analysts redirect their focus accordingly.

Intensive In-Home Family-Based Services: Reactions from Consumers and Providers

An intensive family preservation program was examined through interviews with 31 families who received the services and four caseworkers who provided the services. The primary finding from interviews with both care givers and caseworkers was that a positive therapeutic relationship between the worker and the client family contributes most to the success of the program. Workers who provided the services stressed the need for making concrete services available as well as clinical intervention and skills training, and they were adamant about screening families for appropriateness before including them in an intensive, inhome program.

An Examination of Treatment Fidelity in an Intensive Family Preservation Program

Most models of intensive family preservation services are based on providing flexible services to reduce risk and keep families together. This study examined 40 cases served by a public agency Family Preservation Unit in 1992-1993, in order to assess the provision of hard, soft and enabling services in the program and whether their provision matched the program model. The relationships of these services to program outcomes, in terms of child removal, new reports of abuse or neglect, and family gains in resources and strengths, are also assessed.