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The impact of SSC 2012 on the planning and evaluation of my hospital's performance  The impact of SSC 2012 on the planning and evaluation of my hospital's performance
 

The impact of SSC 2012 on the planning and evaluation of my hospital's performance The impact of SSC 2012 on the planning and evaluation of my hospital's performance

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Seminar led by Rui Moreno, MD, PhD, from the Hospital de Santo António dos Capuchos Unidad de Cuidados Intensivos Polivalente Centro Hospitalar de Lisboa Central- Portugal. ...

Seminar led by Rui Moreno, MD, PhD, from the Hospital de Santo António dos Capuchos Unidad de Cuidados Intensivos Polivalente Centro Hospitalar de Lisboa Central- Portugal.

Abstract: The impact of SSC 2012 on the planning and evaluation of my hospital's performance  The 2012 revision of the Surviving Sepsis Guidelines, together with the new sepsis bundles, will, have a profound impact on the evaluation of the performance of health care systems dealing with the recognition and early treatment of the patient with severe sepsis and septic shock.  With the application and evaluation of the new bundles (now at 3 hours and 6 hours after triage), most of the evaluation will focus in the very early stages of the process of care, when in a significant number of patients will be still in the Emergency Department (ED). This constitutes a major change when compared to the 2008 revision of the SSC, since at that time part of the evaluation was done after 24 hours of diagnosis, when most of the patients was already on the ICU.  An immediate consequence of this will be a major pressure on the ED and in the early connection of the ED with the ICU. This will can be done by creating dedicated admission pathways to patients with suspected severe sepsis and septic shock, to the presence of intensivists on the ED or even to the direct admission (by-passing the ED) to the ICU of theses patients. More than focusing in new therapies, the 2012 revision of the SSC will put the emphasis on the planning and creation of systems able to work fast and flexibly, delivering fast care where it is needed more. Only systems of care able to control and deal with these timing problems will be in condition to offer first quality care to the patient with severe sepsis and septic shock and consequently to have a good evaluation of their performance.

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    The impact of SSC 2012 on the planning and evaluation of my hospital's performance  The impact of SSC 2012 on the planning and evaluation of my hospital's performance  The impact of SSC 2012 on the planning and evaluation of my hospital's performance The impact of SSC 2012 on the planning and evaluation of my hospital's performance Presentation Transcript

    • The impact of SSC 2012 on the panning and evaluation of my hospital's performance Critical Care Department - Hospital Vall d'Hebron Barcelona, June, 10, 2013 Rui Moreno UCINC, Hospital de São José Centro Hospitalar de Lisboa Central, E.P.E.
    • DECLARATION OF POTENTIAL (REAL) CONFLICT OF INTEREST
    • DECLARATION OF POTENTIAL CONFLICT OF INTEREST • I am not an Anaesthesiologist • I am not and Internist • I am not a surgeon • I am not a GP
    • DECLARATION OF POTENTIAL CONFLICT OF INTEREST • I am not an Anaesthesiologist • I am not and Internist • I am not a surgeon • I am not a GP I AM AN INTENSIVIST!
    • THE PATIENT WITH SEPSIS NEED TEAMS, NOT TRIBES!
    • Sepsis = Decomposition, decay Septic = Rotten Σήψις
    • DEFINITIONS Bone et al. Chest. 1992;101:1644; Wheeler and Bernard. N Engl J Med. 1999;340:207. SepsisSIRSInfection/ Trauma Severe Sepsis Sepsis with ≥1 sign of organ failure  Cardiovascular (refractory hypotension)  Renal  Respiratory  Hepatic  Hematologic  CNS  Unexplained metabolic acidosis Shock
    • 800 1,000 1,200 1,400 1,600 1,800 2001 2025 2050 Year 300 400 500 600 SepsisCases(x103) TotalUSPopulation(million) Angus DC, et al. JAMA 2000;284:2762-70. Angus DC, et al. Crit Care Med 2001;29:1303-10. SEVERE SEPSIS IS INCREASING IN INCIDENCE Severe Sepsis Cases US Population
    • EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLY ILL PATIENT 0% 10% 20% 30% 40% 50% 60% 70% 80% 0-1 2-3 4-6 7-10 11-15 16-21 Days in ICU before the study day Infectionrate N = 6010 1608 1857 1248 1176 742 (EPIC II, 2008)
    • INFECTION AND OUTCOME 0,0 5,0 10,0 15,0 20,0 25,0 30,0 35,0 40,0 45,0 Mortality,% ICU mortality 13,9 32,2 Hospital mortality 18,7 41,8 No infection Infection (Moreno et al. 2005 - data from the SAPS 3 study)
    • 0% 25% 50% 75% 100% %ofpatients 0 2 4 6 8 10 12 14 16 18 20 22 24 SOFA score Survivors Non-survivors (R. Moreno, 1997) EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLY ILL PATIENT
    • 1 OSF 2 OSF 3 OSF 0 20 40 60 80 100 1 2 3 4 5 6 7 ICUmortality(%) Number of days in MOF ORGAN FAILURE AND MORTALITY IN PATIENTS WITH SEPSIS AND ORGAN FAILURE (data from Moreno et al.)
    • DECLARATION OF BARCELA 2002
    • Surviving Sepsis Campaign: Timeline Barcelona Declaration SSC Guidelines 2010 ??? Guidelines And bundles Revision 2005 NEJM editorial 2004 2002 Guidelines Revision Phase III starts: IHI partnership 2008 2012 Results published 15,000 pts 20% RRR 2006 2012--
    • Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock 2004
    • Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock 2008
    • Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock 2012
    • Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli Lilly Peter Q. Eichacker, M.D., Charles Natanson, M.D., and Robert L. Danner, M.D
    • New Policy to deal with Potential Conflicts of Interest
    • GRADE PRO: Guideline development process • Prioritize problems (and define specific question(s) • Perform systematic review • Summarize the evidence in evidence profiles (summary of findings tables) • Judge which outcomes are critical • Judge overall quality of evidence • Judge balance of benefits and downsides • Generate recommendation • Judge strength of recommendation
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    • 43
    • 4.5 potentials for a mishap per operation
    • NURSING WORK Gets IV bags, Checks orders in binder 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 Hangs IV IV push Oral meds, topical cream Checks updates in computer Hangs IV Planning for new shift Checks orders in binderHangs IV Hangs IV Hangs IV Oral meds IV push Oral meds Insulin Hangs IV Pain med Checks updates in computer Topical cream Other RN needs binder Nursing home assessment Narcotic keys Staffing IV pump alarm Fingerstick machine calibration Hand off assessment IV pump alarm Narcotic meds too many to put in cart Narcotic keys Other RN leaves floor Signature for narcotics Move patient to new bed Water for patient New nursing assistant arrives MD asks to tape down IV LPN she is covering Children on floor Patient risk of falling Other RN returns Hang IV for her Pain med request BP machine problems Dinner Patient moved up in bed Water for patient Fingerstick machine IV pump alarm Beds Weigh patient Staffing Other RN dinner Hang IV IV pump alarm Cart Wife of patient Emily S. Patterson PhD
    • Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis/Septic Shock Version 2012
    • Direct medical costs
    • van Beeck et al. J Trauma 1997;42:1116 TRAFFIC INJURIES 0 10 20 30 40 50 60 70 80 90 0 10 20 Age in years MillionsofUS$ Male Female
    • van Beeck et al. J Trauma 1997;42:1116 OCCUPATIONAL INJURIES 0 10 20 30 40 50 60 70 80 90 0 1 2 3 4 5 Male Female Age in years MillionsofUS$
    • DOMESTIC INJURIES 0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90 100 Age in years MillionsofUS$ van Beeck et al. J Trauma 1997;42:1116 Male Female
    • 2000 2200 2400 2600 2800 3000 3200 3400 3600 1990 1991 1992 1993 1994 1995 Totalexpenditureinacutecare-MillionEuro Years Denmark TOTAL EXPENDITURE IN HEALTH CARE
    • Direct medical costs
    • IF WE WANT TO AVOID A DISASTER OUR FOCUS SHOULD BE ON THE EVALUATION AND OPTIMIZATION OF THE SERVICES WE PROVIDE
    • HOW (UN)RELIABLE IS MEDICINE? • 10-1 means that 1 to 9 times out of 10 the intended actions fail to produce the desired results or are defective. An example is if I have a 80% compliance with giving appropriate DVT prophylaxis there are 2 defects in our process in every 10 patients • 10-2 means that 1 to 9 times out of 100 the intended action or results fail or are defective. An example is if I have 96% compliance with giving appropriate DVT prophylaxis there will be 4 defects in our process in every 100 patients
    • Average Percent High Income Zip Codes Low Income Zip Codes Expected in One Year Diabetic Eye Exams 47,9 53,2 44,9 100,0 Hgb A1c Monitoring 55,9 59,5 50,9 100,0 Mammography Screening 46,7 50,8 39,8 100,0 Colon Cancer Screening 9.0 (45%) 10,3 8,0 20,0 Influenza Vaccine 46,5 50,8 41,5 100,0 Pneunococcal Vaccine 8 (80%) 8,7 7,3 10,0 Pham HH. Delivery of Preventive Services. JAMA 2005; 294:473-481
    • WHAT ARE OUR EXPECTATIONS OF RELIABILITY IN OTHER INDUSTRIES? 1. How many of you would put up with your automobile not starting two out of ten starts? 2. How many of you would fly commercially, if airplanes crashed or abandoned the trip one out of every ten flights? 3. How many of you would frequent a restaurant that served contaminated food three times out of every ten meals?
    • HEALTH CARE RELIABILITIES (Un)Reliability Outcome/Process 10-1 Beta blockers and ASA in Acute MI HgA1c tested at least 3 times every 2 yrs Mammograms, Immunization Lower Vt in ALI Patients. 10-2 Serious adverse events in hospital Deaths in high risk surgery 10-3 Neonatal mortality General surgery deaths 10-4 Deaths in routine anesthesia 10-5 Blood Banking 10-6 ?
    • 10.3 10.5 10.3 9.6 8 7.7 6.9 2 2 2 2 12 21 31 0 5 10 15 20 25 30 35 1996 1997 1998 1999 2000 2001 2002 Median Vt ml/kg % of ARDS Patients Recieving 6 ml/kg Vt ARDS Network Paper Published NEJM May 2000 Death deceased from 40% to 31% p= 0.007 (Am J. Respir & CCM 2004; 169 supp:A256)
    • 10.3 10.5 10.3 9.6 8 7.7 6.9 2 2 2 2 12 21 31 0 5 10 15 20 25 30 35 1996 1997 1998 1999 2000 2001 2002 Median Vt ml/kg % of ARDS Patients Recieving 6 ml/kg Vt ARDS Network Paper Published NEJM May 2000 Death deceased from 40% to 31% p= 0.007 Two Years after publishing the evidence, ‘7’ of 10 patients are NOT receiving best care (Am J. Respir & CCM 2004; 169 supp:A256)
    • TIDAL VOLUME IN THE ICU’S 0 2 4 6 8 10 12 Luhr 1999 Esteban 2000 Esteban 2002 Esteban 2002 ALIVE 2004 SAPS3 mL/kg (João Gouveia et al. Data from the SAPS 3 study)
    • PEEP IN THE ICU’S 0 2 4 6 8 10 12 14 Luhr 1999 Esteban 2000 Esteban 2002 Esteban 2002 ALIVE 2004 SAPS3 cmH2O (João Gouveia et al. Data from the SAPS 3 study)
    • We demand the right to make bad choices.
    • Bad choices yield bad results
    • 4.5 potentials for a mishap per operation
    • NURSING WORK Gets IV bags, Checks orders in binder 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 Hangs IV IV push Oral meds, topical cream Checks updates in computer Hangs IV Planning for new shift Checks orders in binderHangs IV Hangs IV Hangs IV Oral meds IV push Oral meds Insulin Hangs IV Pain med Checks updates in computer Topical cream Other RN needs binder Nursing home assessment Narcotic keys Staffing IV pump alarm Fingerstick machine calibration Hand off assessment IV pump alarm Narcotic meds too many to put in cart Narcotic keys Other RN leaves floor Signature for narcotics Move patient to new bed Water for patient New nursing assistant arrives MD asks to tape down IV LPN she is covering Children on floor Patient risk of falling Other RN returns Hang IV for her Pain med request BP machine problems Dinner Patient moved up in bed Water for patient Fingerstick machine IV pump alarm Beds Weigh patient Staffing Other RN dinner Hang IV IV pump alarm Cart Wife of patient Emily S. Patterson PhD
    • Revised SSC Bundles • Based on 2012 SSC guideline Revision • Utilizing analysis of 28,000 pt in the SSC database • New software to be developed • No industry funding utilized in revising guidelines or bundles
    • Revised SSC Bundles • Management bundle dropped • IPP: High compliance at outset of study • No significant change in compliance • Glucose: • Clouded by controversy • Steroids: • OR > 1.0 in SSC analysis • rhAPC: • Significant OR for survival but after the results of PROWESS-SHOCK was withdraw from all markets
    • Sepsis Resuscitation Bundle (To be started immediately and completed within 3 hours) • Serum lactate measured in 3 hours. • Blood cultures obtained prior to antibiotic administration. • Minimize time to administration of broad-spectrum antibiotics with a maximum of 3 hours. • In the event of hypotension and/or lactate > 3mmol/L, deliver a minimum bolus of 30 ml/kg of crystalloid (or colloid equivalent) within 1 hour.
    • Septic Shock Bundle (To be started immediately and completed within 6 hours) • Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. • In the event of persistent arterial hypotension despite volume resuscitation (septic shock) and/or initial lactate > 4 mmol/L (36 mg/dl): • Insert central line • Achieve central venous pressure (CVP) of > 8 mm Hg. • Achieve central venous oxygen saturation (ScvO2) of > 70%.
    • Role of Collaboration ICUED
    • SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH • From the data they obtained, Dr. Vincent and colleagues make a number of observations: • First, sepsis occurs frequently, being reported in almost 40% of patients in the ICU • Second, the frequency of sepsis varies markedly between countries, and countries with higher frequencies of sepsis have higher mortality rates among all patients admitted to the ICU. • Finally, they report that the presence of a positive cumulative fluid balance over the first 72 hrs from the onset of sepsis is, among other variables, independently associated with higher ICU mortality. Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554)
    • SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )
    • SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN THE WASH • Data demonstrate that the mortality rate from organ failure was the same for patients with severe sepsis as it was for those without sepsis, suggesting that organ dysfunction, rather than infection per se, is the key. • What could account for these findings? • ...difference in case-mix and ICU admission threshold • ...the higher mortality rate in the ICUs with higher sepsis prevalence might be a marker of overtaxed resources in the ICU or during pre-ICU care • ... it is tempting to speculate that baseline differences in antibiotic use between ICUs may have contributed both to the differences in the reported frequency of sepsis and to the mortality rates observed. Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )
    • (Crit Care Med 2006; 34:211–218)
    • FINDING OUT WHAT WE DO IN THE ICU Mitchell M. Levy, MD, FCCM • This task force represents a change in focus, not only for SCCM in particular but for the field of critical care in general. • ...for a long time, SCCM, along with other critical care societies, focused on the model of critical care delivery. • Regardless of the model of critical care delivery, the most important aspect of critical care is the quality of care patients receive in a given ICU. • For many years, the assessment of this quality was based on measuring and reporting outcomes of care. • Now, finally, there is a growing understanding that paying attention to the details or process of care is the truly essential aspect of quality measurement in the ICU. (Crit Care Med 2006; 34:227–228)
    • FINDING OUT WHAT WE DO IN THE ICU Mitchell M. Levy, MD, FCCM • Curtis et al., at the direction of SCCM, have provided clinicians in critical care units with a blue-print or mirror for self-examination. The next step is for critical care clinicians to look into that mirror and decide whether or not we like what we see. (Crit Care Med 2006; 34:227–228)
    • NEGOVSKY IBSEN SAFAR WE HAVE STRONG SCIENTIFIC FOUNDATIONS TO OUR SPECIALITY
    • FROM REANIMATION TO INTENSIVE CARE MEDICINE REANIMATION INTENSIVE CARE INTENSIVE CARE MEDICINE
    • 20 years ago Dr Bill Knaus acknowledged: • It ’ s the human resources of the ICU TEAM, their organization and distribution, and how we apply technology consistently, NOT the genius of individuals or the treatment “ magic bullet ” that leads to EFFICIENT and EFFECTIVE ICU. Knaus et al Annals Int Med 1986: 104.410
    • DISEASES THAT MADE THE ICU Polio: Mortality 60% to 20% ??? (but just in 2 or 3 countries) Tetanus: Mortality approaches Zero Guillian-Barré syndrome: Mortality approaches Zero Acute organophosphate poisoning: almost disapeared Most of the mortality relates to co-morbidity and complications of ICU treatment.
    • DEVELOPMENT AS A CHALENGE • Education and training of new professionals. • Training in Intensive care of other professionals. • Better much between resources and workload. • The flux of patients within the hospital: admission and discharge policies, readmissions. • Patient safety: prevention of adverse events. • Organisative aspects: leadership, communication, team- work.
    • Current and projected workforce requirements for care of the critically ill. Angus D et al. JAMA 2000 : 284; 2762-70
    • RETIRE FROM ICU CARE AT 77 YEARS: (Angus et. Al, JAMA 2002)
    • 0 50 100 150 200 250 300 350 400 2001 2006 2011 2016 2021 2026 2031 Year At 2006 rates Modelling trend ICNARCIntensiveCareNationalAudit&ResearchCentre 160% increase in demand over 10 years. Projected ICU Bed Day Requirements Rowan K et al
    • INTENSIVE CARE IS NOT ABOUT MACHINES IT IS ABOUT PEOPLE IT IS ABOUT ORGANIZATION
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    • 12
    • NUMBER OF INTENSIVE CARE BEDS PER 100.000 INHABITANTS Portugal USA França UK Canadá Bélgica Alemanha HolandaEspanha 0 5 10 15 20 25 30 0 2 4 6 8 10 13 nºdecamasdeMedicinaIntensiva por100.000habitantes Países (Data from Wunsch et all, 2008)
    • NUMBER OF INTENSIVE CARE BEDS PER 100.000 INHABITANTS Portugal USA França UK Canadá Suécia Holanda Espanha Croácia Bélgica Alemanha 0 5 10 15 20 25 0 2 4 6 8 10 12 14 Trinidá e Tobago 13 Países nºdecamasdeMedicinaIntensiva por100.000habitantes (Data from Adhikari et al., 2010)
    • 13
    • • ≈2 millions Total n° Acute Care Beds • ≈ 60.000 Total N° IC Beds • ≈3% IC Beds/AC Beds % Acute and intensive care beds in Europe…….
    • (Andrew Rhodes & Rui Moreno, 2012, ICM)
    • Acute care beds Acute care hospital beds / 100,000 population. Total number of ICU and IMCU care beds Total Adult ICU and IMCU beds / 100,000 population Adult ICU beds as % of all acute care beds %>65 Andorra 188 224 6 7.1 3.2 13 Austria 48446 635 1833 21.8 3.4 18.2 Belgium 50156 456 1900 17.3 3.8 18 Bulgaria 57460 766 2154 28.7 3.7 18.2 Croatia 15629 353 650 14.7 4.2 16.9 Cyprus 2813 350 92 11.4 3.3 10.4 Czech Republic 91068 865 1227 11.6 1.3 16.3 Denmark 17124 308 372 6.7 2.2 17.1 Estonia 5096 380 262 19.5 5.1 17.7 Finland 12442 231 329 6.1 2.6 17.8 France 232821 358 10540 16.2 4.5 16.8 Germany 469791 575 23,890 29.2 5.1 20.6 Greece 44411 392 680 6 1.5 19.6 Hungary 41574 416 1374 13.8 3.3 16.9 Iceland 1169 367 29 9.1 2.5 12.7 Ireland 12202 272 289 6.5 2.4 11.6 Italy 201932 333 7,550 12.5 3.7 20.3 Latvia 11833 531 217 9.7 1.8 16.9 Lithuania 17061 526 502 15.5 2.9 16.5 Luxemberg 2511 491 127 24.8 5.1 14.9 Netherlands 56085 337 1065 6.4 1.9 15.6 Norway 13639 277 395 8 2.9 16 Poland 156662 410 2635 6.9 1.7 13.7 Portugal 31722 298 451 4.2 1.4 18 Romania 108611 507 4574 21.4 4.2 14.8 Slovakia 32560 599 500 9.2 1.5 12.8 Slovenia 7656 373 131 6.4 1.7 16.8 Spain 124194 269 4479 9.7 3.6 17.1 Sweden 26131 278 550 5.8 2.1 19.7 Switzerland 28096 357 866 11 3.1 17 United Kingdom 147809 237 4114 6.6 2.8 16.5
    • Total size of Population Gross Domestic Product (GDP) ($millions) Gross Domestic Product (GDP) per inhabitant ($) Total expenditure on health as a % of GDP Andorra 84082 2893 34,407 7.7 Austria 8404252 377,382 44,904 8.6 Belgium 11007020 467,779 42,498 8.2 Bulgaria 7504868 47,702 6,356 4.4 Croatia 4425747 60,834 13,745 7.8 Cyprus 804435 23,174 28,808 6.0 Czech Republic 10532770 192,030 18,232 6.9 Denmark 5560628 309,866 55,725 9.8 Estonia 1340194 19,253 14,366 5.3 Finland 5375276 239,177 44,496 6.8 France 65075310 2,562,742 39,381 9.2 Germany 81748892 3,286,451 40,202 8.9 Greece 11329618 305,415 26,957 5.8 Hungary 9986000 130,421 13,060 5.2 Iceland 318452 12,594 39,548 7.9 Ireland 4480176 206,985 46,200 7.2 Italy 60626508 2,055,114 33,898 7.4 Latvia 2229641 24,013 10,770 8.1 Lithuania 3244601 36,370 11,209 7.8 Luxemberg 511840 54,950 107,358 4.1 Netherlands 16654979 780,668 46,873 5.5 Norway 4920305 412,990 83,936 8.1 Poland 38200037 469,401 12,288 5.3 Portugal 10636979 229,154 21,543 5.7 Romania 21413815 161,629 7,548 5.4 Slovakia 5435273 87,450 16,089 6.0 Slovenia 2050189 47,733 23,282 6.8 Spain 46152926 1,409,946 30,549 7.0 Sweden 9415570 458,725 48,720 8.2 Switzerland 7866500 527920 67,110 6.8 United Kingdom 62435709 2,250,209 36,040 8.2
    • (Andrew Rhodes & Rui Moreno, 2012, ICM)
    • (Andrew Rhodes & Rui Moreno, 2012, ICM)
    • (Andrew Rhodes & Rui Moreno, 2012, ICM
    • (Andrew Rhodes & Rui Moreno, 2012, ICM)
    • (Andrew Rhodes & Rui Moreno, 2012, ICM
    • WE HAVE ARRIVED
    • DEVELOPMENT AS AN OPPORTUNITY
    • • Intensivist model (closed) reduced mortality. (OR: 0.71 95%CI 0.62-0.82) • Intensivist model (closed) reduced length of stay Pronovost et al. JAMA; 2002-2151 Physician staffing patterns and clinical outcomes in critically ill patients.
    • Most Positive Factors Most Negative factors Intellectual stimulation Lack of leisure time Treating acutely ill patients Stress among faculty Application of complex physiology Treating chronically ill patients Procedure orientated Inconsistent with my personality Dealing with end-of-life issues Dealing with complex ethical issues. Attitudes and Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training. Lorin S et al. Chest 2005 : 127; 630-6.
    • “Beauty comes first. Victory is secondary. What matters is joy.” Sócrates Brasileiro Sampaio de Souza Vieira de Oliveira
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    • STRESSED INTENSIVISTS ?
    • “The physician must be able to tell the antecedents, know the present, and foretell the future- must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm. The art consists in three things- the disease, the patient, and the physician. The physician is the servant of the art, and the patient must combat the disease along with the physician.” Hippocrates, in Epidemics, Book 1, section 11
    • Gràcies