Tag Archives: quality improvement

Comparing length of stay between adult patients admitted to the intensive care unit with alcohol withdrawal syndrome treated with phenobarbital versus lorazepam

Mary C Hoye1, Sorin Danciu1, Marc A Jacobs2, Brad J Glavan2

1 Providence Portland Medical Center, Portland, OR, USA
2 The Oregon Clinic, Portland, OR, USA

DOI: 10.2478/jccm-2026-0018

Objective: Review the use of phenobarbital and lorazepam to treat alcohol withdrawal syndrome (AWS) in the ICU, compare length of stay, examine medication use trends, implement provider training, and evaluate outcomes post-training.
Methods: Design – Retrospective observational study, Quality improvement. Setting – Tertiary care hospital with 36 ICU beds. Patients – Adults admitted to the ICU and placed on clinical institute withdrawal assessment (CIWA) protocol. Patients with epilepsy were excluded.
Results: During the 34-month baseline period, 713 patients were admitted to the ICU with alcohol use disorder (AUD) on CIWA, without epilepsy. 189 patients were treated with phenobarbital, 460 patients received only lorazepam, 64 patients received neither medication. All but 2 of the patients who received phenobarbital also received lorazepam. Compared to phenobarbital, lorazepam-only patients had shorter ICU LOS (p<0.001, 95% CI -2.36, -1.32) but higher mortality 13.91% vs. 4.76% (p=0.0008). We then developed and provided a training (which we refer to as an “intervention”) to all ICU providers encouraging consistent use of phenobarbital in the ICU when appropriate. During the 3-month post-intervention period 44 patients were admitted to the ICU with AUD on CIWA protocol. Of the 44 patients: 26 received phenobarbital, 12 received only lorazepam, 6 received neither medication. Significantly more patients were treated with only phenobarbital (57.69%)) compared to baseline (1.06%). Compared to patients treated with phenobarbital, patients treated with only lorazepam had a significantly higher mortality rate (33.33% vs. 7.69%, p=0.04).
Conclusions: We found significant variability in the use of phenobarbital and lorazepam for treatment of AWS in the ICU. After a quality improvement training for ICU physicians, there was less frequent concurrent use of benzodiazepines and barbiturates, no difference in ICU or hospital LOS, and significantly lower mortality rate for those treated with phenobarbital.

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Evaluation of the Efficiency of the Newly Developed Needle in Emergency Room: A Single-Center Observational Study

Yuki Kishihara, Hideto Yasuda, Masahiro Kashiura, Takatoshi Oishi, Yutaro Shinzato, Takashi Moriya

Jichi Ika University Saitama Medical Center, Saitama-shi, Saitama Japan

DOI: 10.2478/jccm-2024-0025

Aim of the study: Peripheral intravascular catheter (PIVC) insertion is frequently performed in the emergency room (ER) and many failures of initial PIVC insertion occur. To reduce the failures, new needles were developed. This study aimed to investigate whether the use of the newly developed needle reduced the failure of initial PIVC insertion in the ER compared with the use of the existing needle.
Material and methods: This single-centre, prospective observational study was conducted in Japan between April 1, 2022, and February 2, 2023. We included consecutive patients who visited our hospital by ambulance as a secondary emergency on a weekday during the day shift (from 8:00 AM to 5:00 PM). The practitioners for PIVC insertion and assessors were independent. The primary and secondary outcomes were the failure of initial PIVC insertion and number of procedures, respectively. We defined the difficulty of titrating, leakage, and hematoma within 30 s after insertion as failures. To evaluate the association between the outcomes and the use of newly developed needles, we performed multivariate logistic regression and multiple regression analyses by adjusting for covariates.
Results: In total, 522 patients without missing data were analysed, and 81 (15.5%) patients showed failure of initial PIVC insertion. The median number of procedures (interquartile range) was 1 (1–1). Multivariate logistic regression analysis revealed no significant association between the use of newly developed PIVCs and the failure of initial PIVC insertion (odds ratio, 0.79; 95% confidence interval, [0.48–1.31]; p = 0.36). Moreover, multiple regression analysis revealed no significant association between the use of newly developed PIVCs and the number of procedures (regression coefficient, -0.0042; 95% confidence interval, [-0.065–0.056]; p = 0.89).
Conclusions: Our study did not show a difference between the two types of needles with respect to the failure of initial PIVC insertion and the number of procedures.

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Impact of Palliative Care on Interhospital Transfers to the Intensive Care Unit

Safanah Tabassum Siddiqui1, Emily Xiao2, Sonika Patel3, Kiran Motwani1, Keneil Shah1, Xinyuan Ning4, Kathryn S. Robinett1

1 University of Maryland School of Medicine, Baltimore, MD, USA
2 University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
4 The University of Chicago Pritzker School of Medicine, Chicago, IL, USA

DOI: 10.2478/jccm-2022-0009

Community hospitals will often transfer their most complex, critically ill patients to intensive care units (ICUs) of tertiary care centers for specialized, comprehensive care. This population of patients has high rates of morbidity and mortality. Palliative care involvement in critically ill patients has been demonstrated to reduce over-utilization of resources and hospital length of stays. We hypothesized that transfers from community hospitals had low rates of palliative care involvement and high utilization of ICU resources. In this single-center retrospective cohort study, 848 patients transferred from local community hospitals to the medical ICU (MICU) and cardiac care unit (CCU) at a tertiary care center between 2016-2018 were analyzed for patient disposition, length of stay, hospitalization cost, and time to palliative care consultation. Of the 848 patients, 484 (57.1%) expired, with 117 (13.8%) having expired within 48 hours of transfer. Palliative care consult was placed for 201 (23.7%) patients. Patients with palliative care consult were statistically more likely to be referred to hospice (p<0.001). Over two-thirds of palliative care consults were placed later than 5 days after transfer. Time to palliative care consult was positively correlated with length of hospitalization among MICU patients (r=0.79) and CCU patients (r=0.90). Time to palliative consult was also positively correlated with hospitalization cost among MICU patients (r=0.75) and CCU patients (r=0.86). These results indicate early palliative care consultation in this population may result in timely goals of care discussions and optimization of resources.

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