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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Publish the guidelines!!
- Peter S Kidd, Galway, Ireland (7 June 2002)
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Are we confident of the results?
- George Ntoumenopoulos, Physiotherapy Department, The Alfred, Melbourne, Australia (10 June 2002)
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Distributions and Seasonality
- Jeremy N.V. Miles, Karen E. Bloor (27 July 2002)
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A, answer for the shortage of ICU beds worldwide
- Kate D Hutchings (8 August 2002)
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Peter S Kidd, ICU Pharmacist UCHG, Newcastle Road, Galway, Ireland
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It would be particularly helpful if the locally developed guidelines were published for the critical appraisal of your readers. Obviously local influences may impact on the extent to which these are based on the best evidence available. Nevertheless I am sure many readers would consider the details of the protocol to be very interesting, and valuable in stimulating discussion in other intensive care units. |
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George Ntoumenopoulos, senior Clinician Physiotherapist 3181, Physiotherapy Department, The Alfred, Melbourne, Australia
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I appreciated the article by Brattebø et al but have some concerns about the reporting of results. The authors allude to changes in mortality and ICU length of stay, but do not highlight that the changes were not statistically significant, and in fact do not report p-values. For example the length of stay in ICU is presented as "Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days". The confidence interval crosses zero and as such is not considered a statistically significant change. The clearer reporting of the findings will ensure that readers are not mislead by the findings. |
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Jeremy N.V. Miles, Lecturer in Biostatistics Department of Health Sciences, University of York, York, YO10 5DD, Karen E. Bloor
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We would like to highlight two potential problems with the analysis of the data presented. First, from Figure 1, the data do not seem to follow a normal distribution. When a small number of cases have extreme values, mean scores may be biased. It is common for measures of duration to have extreme scores, because they have a minimum of zero, and can be very short, but have (almost) no limitation on how long they can be. In this case, a very small number of individuals can have a large effect on the results of a study. It is possible that the mean scores, particularly in the pre-intervention case, may be biased by the small number of cases of longer duration, which can be seen in Figure 1. In these circumstances a transformation (such as a logarithmic transformation) can be used to normalise the data prior to analysis, or alternatively a non-parametric approach may be used. Second, the data may show some signs of seasonality, that is, a naturally occurring variation over the year. The two periods are not directly comparable - the pre-intervention period includes the winter month of November, which appears to be a peak. The post-intervention period ends before that time. The lack of direct comparability of the two time periods might suggest that the differences found may be, in part, an artefact of the time periods used, rather than wholly due to the intervention. A modelling approach that can include a seasonal component, such as ARIMA, may be more appropriate in these circumstances. |
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Kate D Hutchings, Nurse Unit Manager Freemasons Hospital Melbourne Victoria Australia
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With a shortage of ICU beds worldwide, fast track extubation resulting in a reduced length of stay in ICU is a great quality initiative. What is quality? Quality is concerned with cost, accessibility, efficiency, safety and acceptability – this study addressed these key issues. Cost was not the precipitating factor for undertaking this study however by reducing ventilation days and thus sedation requirements some cost saving measures may have been achieved. The accessibility of the ICU beds to the community as whole have been improved with shorter lengths of stay, more patients would have access to these beds resulting in an improvement in efficiencies. Safety by removing invasive lines and ET tubes earlier the risk of infection to the patient has been reduced. Finally the rational behind the quality initiative is acceptable to the public as it is reducing time spent in hospital and therefore decreasing recovery time. Having worked in ICU’s for many years the idea of nursing staff lead weaning is not a new initiative however to formalise it and create a quality activity from it is to be commended. The main focus was of clinical risk reduction and this is very well supported in the literature in regard to prolonged ventilation time increasing the risk of nosocomial infection and sepsis in the critically ill patient. With the establishment of a detailed criterion for the weaning process the nursing staff were able to take ownership of the plan and thus fast track time to extubation. It was an easily implemented plan with nursing staff being the most appropriate members of the team to facilitate the process. They were well informed, educated and provided with ongoing feedback. My concerns in this article is the lack of discussion surrounding the limitation or adverse events eg re intubation rate and re admission to ICU with the reduction in length of stay. The overall results of a reduction of 1 day of ventilation and 2 days less in an ICU bed is an efficient use of resources however there needed to be reference to the problems that arose. I can’t imagine no one needed to be reintubated. I would also like to comment on the lack of detail of patient mix – obviously a surgical ICU however was it predominantly cardio thoracic, abdominal or trauma? These factors would greatly influence the numbers and results and also the ability to use this weaning process in other intensive care units to achieve comparable results. |
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