correctly draws attention to the relevance of eternal marriage to the question of polygamy, his t... more correctly draws attention to the relevance of eternal marriage to the question of polygamy, his treatment is limited and dated.
Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sough... more Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sought to characterize the organizational structure, processes of care, use of protocols, and standardized outcomes in a large sample of U.S. ICUs. We surveyed 69 ICUs about organization, size, volume, staffing, processes of care, use of protocols, and annual ICU mortality. ICUs participating in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Sixty-nine intensivists completed the survey. We characterized structure and process variables across ICUs, investigated relationships between these variables and annual ICU mortality, and adjusted for illness severity using Acute Physiology and Chronic Health Evaluation II. Ninety-four ICU directors were invited to participate in the study and 69 ICUs (73%) were enrolled, of which 25 (36%) were medical, 24 (35%) were surgical, and 20 (29%) were of mixed type, and 64 (93%) were located in teaching hospitals with a median number of five trainees per ICU. Average annual ICU mortality was 10.8%, average Acute Physiology and Chronic Health Evaluation II score was 19.3, 58% were closed units, and 41% had a 24-hour in-house intensivist. In multivariable linear regression adjusted for Acute Physiology and Chronic Health Evaluation II and multiple ICU structure and process factors, annual ICU mortality was lower in surgical ICUs than in medical ICUs (5.6% lower [95% CI, 2.4-8.8%]) or mixed ICUs (4.5% lower [95% CI, 0.4-8.7%]). We also found a lower annual ICU mortality among ICUs that had a daily plan of care review (5.8% lower [95% CI, 1.6-10.0%]) and a lower bed-to-nurse ratio (1.8% lower when the ratio decreased from 2:1 to 1.5:1 [95% CI, 0.25-3.4%]). In contrast, 24-hour intensivist coverage (p = 0.89) and closed ICU status (p = 0.16) were not associated with a lower annual ICU mortality. In a sample of 69 ICUs, a daily plan of care review and a lower bed-to-nurse ratio were both associated with a lower annual ICU mortality. In contrast to 24-hour intensivist staffing, improvement in team communication is a low-cost, process-targeted intervention strategy that may improve clinical outcomes in ICU patients.
Clinical protocols may decrease unnecessary variation in care and improve compliance with desirab... more Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized ICUs have superior patient outcomes compared with less highly protocolized ICUs. Observational study in which participating ICUs completed a general assessment and enrolled new patients 1 day each week. A total of 6,179 critically ill patients. Fifty-nine ICUs in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. None. The primary exposure was the number of ICU protocols; the primary outcome was hospital mortality. A total of 5,809 participants were followed prospectively, and 5,454 patients in 57 ICUs had complete outcome data. The median number of protocols per ICU was 19 (interquartile range, 15-21.5). In single-variable analyses, there were no differences in ICU and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in ICUs with a high versus low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between ICUs with high versus low numbers of protocols for lung protective ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and for spontaneous breathing trials (55% vs 51%; p = 0.27). Clinical protocols are highly prevalent in U.S. ICUs. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality.
THE IM PRES SIVE CON TIN UED GROWTH of the Church of Je sus Christ of Lat ter-day Saints has oc c... more THE IM PRES SIVE CON TIN UED GROWTH of the Church of Je sus Christ of Lat ter-day Saints has oc ca sioned sig nif i cant de bate about the course of its his tor i cal de vel op ment. In ter ested schol ars, crit ics, and dev o tees have com mented re peat edly on the changes (or lack thereof) in LDS the ol ogy and prac tice oc ca sioned by the Church's ex pan sion in a vari ably hos tile en vi ron ment. Schol ars have described the pass ing of the po lit i cal king dom of God 1* and the demise of the Church's of fi cial po lyg amy, 2** em pha siz ing the rad i cal changes rep re sented by such de par tures. Other au thors have noted the loss of Mor mon de vo tion to phys i cal sym bols or the 173 * SAMUEL BROWN {[email protected]} is an ac a demic phy si cian in Boston who stud ies life-threat en ing in fec tions pro fes sion ally and early Mormon ism, par tic u larly its death cul ture, avocationally. He lives with his family in Cam bridge, Mas sa chu setts. He thanks Brett Rushforth, An drew Brown, Kate Holbrook, and the Jour nal's anon y mous re view ers for their care ful read ing of this manu script and help ful sug ges tions.
BYU Studies 5, no. (6) 121 D espite thoughtful attempts by Douglas Davies to situate death ... more BYU Studies 5, no. (6) 121 D espite thoughtful attempts by Douglas Davies to situate death at the center of the Mormon "culture of salvation," the exploration of death in early Mormonism has been somewhat limited to date, particularly as it relates to the Smith family and the earliest years of Mormonism. Against this relative silence stands the testimony of the Smiths themselves, who were deeply concerned with questions of mortality. Joseph Smith was unequivocal on this point during his 1843 funeral sermon for James Adams: "All men know that all men must die. What is the object of our coming into existence then dying and falling away to be here no more? This is a subject we ought to study more than any other, which we ought to study day and night. If we have any claim on our Heavenly Father for any thing it is for knowledge on this important subject." 1. There are several treatments of the experience of death in Mormonism: Douglas Davies, The Mormon Culture of Salvation (Aldershot, England: Ashgate, 2000); Klaus J. Hansen, Mormonism and the American Experience (Chicago: University of
correctly draws attention to the relevance of eternal marriage to the question of polygamy, his t... more correctly draws attention to the relevance of eternal marriage to the question of polygamy, his treatment is limited and dated.
Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sough... more Hospital-level variations in structure and process may affect clinical outcomes in ICUs. We sought to characterize the organizational structure, processes of care, use of protocols, and standardized outcomes in a large sample of U.S. ICUs. We surveyed 69 ICUs about organization, size, volume, staffing, processes of care, use of protocols, and annual ICU mortality. ICUs participating in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Sixty-nine intensivists completed the survey. We characterized structure and process variables across ICUs, investigated relationships between these variables and annual ICU mortality, and adjusted for illness severity using Acute Physiology and Chronic Health Evaluation II. Ninety-four ICU directors were invited to participate in the study and 69 ICUs (73%) were enrolled, of which 25 (36%) were medical, 24 (35%) were surgical, and 20 (29%) were of mixed type, and 64 (93%) were located in teaching hospitals with a median number of five trainees per ICU. Average annual ICU mortality was 10.8%, average Acute Physiology and Chronic Health Evaluation II score was 19.3, 58% were closed units, and 41% had a 24-hour in-house intensivist. In multivariable linear regression adjusted for Acute Physiology and Chronic Health Evaluation II and multiple ICU structure and process factors, annual ICU mortality was lower in surgical ICUs than in medical ICUs (5.6% lower [95% CI, 2.4-8.8%]) or mixed ICUs (4.5% lower [95% CI, 0.4-8.7%]). We also found a lower annual ICU mortality among ICUs that had a daily plan of care review (5.8% lower [95% CI, 1.6-10.0%]) and a lower bed-to-nurse ratio (1.8% lower when the ratio decreased from 2:1 to 1.5:1 [95% CI, 0.25-3.4%]). In contrast, 24-hour intensivist coverage (p = 0.89) and closed ICU status (p = 0.16) were not associated with a lower annual ICU mortality. In a sample of 69 ICUs, a daily plan of care review and a lower bed-to-nurse ratio were both associated with a lower annual ICU mortality. In contrast to 24-hour intensivist staffing, improvement in team communication is a low-cost, process-targeted intervention strategy that may improve clinical outcomes in ICU patients.
Clinical protocols may decrease unnecessary variation in care and improve compliance with desirab... more Clinical protocols may decrease unnecessary variation in care and improve compliance with desirable therapies. We evaluated whether highly protocolized ICUs have superior patient outcomes compared with less highly protocolized ICUs. Observational study in which participating ICUs completed a general assessment and enrolled new patients 1 day each week. A total of 6,179 critically ill patients. Fifty-nine ICUs in the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. None. The primary exposure was the number of ICU protocols; the primary outcome was hospital mortality. A total of 5,809 participants were followed prospectively, and 5,454 patients in 57 ICUs had complete outcome data. The median number of protocols per ICU was 19 (interquartile range, 15-21.5). In single-variable analyses, there were no differences in ICU and hospital mortality, length of stay, use of mechanical ventilation, vasopressors, or continuous sedation among individuals in ICUs with a high versus low number of protocols. The lack of association was confirmed in adjusted multivariable analysis (p = 0.70). Protocol compliance with two ventilator management protocols was moderate and did not differ between ICUs with high versus low numbers of protocols for lung protective ventilation in acute respiratory distress syndrome (47% vs 52%; p = 0.28) and for spontaneous breathing trials (55% vs 51%; p = 0.27). Clinical protocols are highly prevalent in U.S. ICUs. The presence of a greater number of protocols was not associated with protocol compliance or patient mortality.
THE IM PRES SIVE CON TIN UED GROWTH of the Church of Je sus Christ of Lat ter-day Saints has oc c... more THE IM PRES SIVE CON TIN UED GROWTH of the Church of Je sus Christ of Lat ter-day Saints has oc ca sioned sig nif i cant de bate about the course of its his tor i cal de vel op ment. In ter ested schol ars, crit ics, and dev o tees have com mented re peat edly on the changes (or lack thereof) in LDS the ol ogy and prac tice oc ca sioned by the Church's ex pan sion in a vari ably hos tile en vi ron ment. Schol ars have described the pass ing of the po lit i cal king dom of God 1* and the demise of the Church's of fi cial po lyg amy, 2** em pha siz ing the rad i cal changes rep re sented by such de par tures. Other au thors have noted the loss of Mor mon de vo tion to phys i cal sym bols or the 173 * SAMUEL BROWN {[email protected]} is an ac a demic phy si cian in Boston who stud ies life-threat en ing in fec tions pro fes sion ally and early Mormon ism, par tic u larly its death cul ture, avocationally. He lives with his family in Cam bridge, Mas sa chu setts. He thanks Brett Rushforth, An drew Brown, Kate Holbrook, and the Jour nal's anon y mous re view ers for their care ful read ing of this manu script and help ful sug ges tions.
BYU Studies 5, no. (6) 121 D espite thoughtful attempts by Douglas Davies to situate death ... more BYU Studies 5, no. (6) 121 D espite thoughtful attempts by Douglas Davies to situate death at the center of the Mormon "culture of salvation," the exploration of death in early Mormonism has been somewhat limited to date, particularly as it relates to the Smith family and the earliest years of Mormonism. Against this relative silence stands the testimony of the Smiths themselves, who were deeply concerned with questions of mortality. Joseph Smith was unequivocal on this point during his 1843 funeral sermon for James Adams: "All men know that all men must die. What is the object of our coming into existence then dying and falling away to be here no more? This is a subject we ought to study more than any other, which we ought to study day and night. If we have any claim on our Heavenly Father for any thing it is for knowledge on this important subject." 1. There are several treatments of the experience of death in Mormonism: Douglas Davies, The Mormon Culture of Salvation (Aldershot, England: Ashgate, 2000); Klaus J. Hansen, Mormonism and the American Experience (Chicago: University of
On December 11, 1802, the Reverend Charles Buck noted in his journal, ''This evening, a... more On December 11, 1802, the Reverend Charles Buck noted in his journal, ''This evening, after nearly four years, I finished the last article in my Theological Dictionary.'' This first edition was published in Buck's native England, but the Dictionary soon reached the shores of the ...
Clusters of nosocomial infection often occur undetected, at substantial cost to the medical syste... more Clusters of nosocomial infection often occur undetected, at substantial cost to the medical system and individual patients. We evaluated binary cumulative sum (CUSUM) and moving average (MA) control charts for automated detection of nosocomial clusters. We selected two outbreaks with genotyped strains and used resistance as inputs to the control charts. We identified design parameters for the CUSUM and MA (window size, k, a, b, p 0 , p 1 ) that detected both outbreaks, then calculated an associated positive predictive value (PPV) and time until detection (TUD) for sensitive charts. For CUSUM, optimal performance (high PPV, low TUD, fully sensitive) was for 0.1 < α <0.25 and 0.2 < β <0.25, with p 0 = 0.05, with a mean TUD of 20 (range 8-43) isolates. Mean PPV was 96.5% (relaxed criteria) to 82.6% (strict criteria). MAs had a mean PPV of 88.5% (relaxed criteria) to 46.1% (strict criteria). CUSUM and MA may be useful techniques for automated surveillance of resistant infections.
Chase Westfall makes me want to cry, at least a little. He presents the clarity of ideals in attr... more Chase Westfall makes me want to cry, at least a little. He presents the clarity of ideals in attractive, compelling geometric forms, and he makes those clear ideals indivisible from the ravaged bodies of human beings destroyed by violence.
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