***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To test the hypothesis that implementation of a practice guideline for blood gas measurement would decrease numbers and increase appropriateness of tests ( according to criteria in the guideline ) for up to 1 yr after introduction of the guideline . DESIGN Numbers of tests and appropriateness of each test were measured retrospectively during each of five periods : two baseline periods 2 yrs and 1 yr before introduction of the guideline and three follow-up periods 2 to 3 months , 6 to 7 months , and 12 to 13 months after introduction of the guideline . SETTING A ten-bed multidisciplinary intensive care unit ( ICU ) within a 500-bed tertiary teaching hospital . PATIENTS A r and om sample of 30 patients admitted to the ICU during each of the periods specified above . INTERVENTIONS The nominal group process was used to develop a new guideline and a multipronged educational approach was used to facilitate implementation of the guideline . MEASUREMENTS AND MAIN RESULTS At 2 to 3 months , test numbers decreased from 4.9 + /- 1.6 to 3.1 + /- 1.8 ( SD ) tests/patient/day and to 2.4 + /- 1.2 tests/patient/day at 12 to 13 months . Appropriateness increased from a mean of 44 % at baseline to 78 % at 2 to 3 months and 79 % at 12 to 13 months . There were no differences in Acute Physiology and Chronic Health Evaluation scores or ICU mortality among the patient groups and no differences in number of ventilator days or time to wean from ventilation . Cost-minimization analysis showed that the incremental cost-saving 1 yr after introduction of the guideline was $ 19.18 per patient per day . CONCLUSIONS Implementation of this guideline for arterial blood gas measurement increases efficiency of test utilization without prolonging mechanical ventilation or affecting outcome The objective of this study was to refine the APACHE ( Acute Physiology , Age , Chronic Health Evaluation ) methodology in order to more accurately predict hospital mortality risk for critically ill hospitalized adults . We prospect ively collected data on 17,440 unselected adult medical/surgical intensive care unit ( ICU ) admissions at 40 US hospitals ( 14 volunteer tertiary-care institutions and 26 hospitals r and omly chosen to represent intensive care services nationwide ) . We analyzed the relationship between the patient 's likelihood of surviving to hospital discharge and the following predictive variables : major medical and surgical disease categories , acute physiologic abnormalities , age , preexisting functional limitations , major comorbidities , and treatment location immediately prior to ICU admission . The APACHE III prognostic system consists of two options : ( 1 ) an APACHE III score , which can provide initial risk stratification for severely ill hospitalized patients within independently defined patient groups ; and ( 2 ) an APACHE III predictive equation , which uses APACHE III score and reference data on major disease categories and treatment location immediately prior to ICU admission to provide risk estimates for hospital mortality for individual ICU patients . A five-point increase in APACHE III score ( range , 0 to 299 ) is independently associated with a statistically significant increase in the relative risk of hospital death ( odds ratio , 1.10 to 1.78 ) within each of 78 major medical and surgical disease categories . The overall predictive accuracy of the first-day APACHE III equation was such that , within 24 h of ICU admission , 95 percent of ICU admissions could be given a risk estimate for hospital death that was within 3 percent of that actually observed ( r2 = 0.41 ; receiver operating characteristic = 0.90 ) . Recording changes in the  APACHE III score on each subsequent day of ICU therapy provided daily up date s in these risk estimates . When applied across the individual ICUs , the first-day APACHE III equation accounted for the majority of variation in observed death rates ( r2 = 0.90 , p less than 0.0001 ) To examine organizational practice s associated with higher and lower intensive care unit ( ICU ) outcome performance . Design : Prospect i ve multicenter study . On-site organizational analysis ; prospect i ve inception cohort . Setting : Nine ICUs ( one medical , two surgical , six medical-surgical ) at five teaching and four nonteaching hospitals . Participants : A sample of 3,672 ICU admissions ; 316 nurses and 202 physicians . Material s and Methods : Interviews and direct observations by a team of clinical and organizational research ers . Demographic , physiologic , and outcome data for an average of 408 admissions per ICU ; and question naires on ICU structure and organization . The ratio of actual/predicted hospital death rate was used to measure ICU effectiveness ; the ratio of actual/predicted length of ICU stay was used to assess efficiency . Measurements and Main Results : ICUs with superior risk-adjusted survival could not be distinguished by structural and organizational question naires or by global judgment following on-site analysis . Superior organizational practice s among these ICUs were related to a patient-centered culture , strong medical and nursing leadership , effective communication and coordination , and open , collaborative approaches to solving problems and managing conflict . Conclusions : The best and worst organizational practice s found in this study can be used by ICU leaders as a checklist for improving ICU management . ( Crit Care Med 1993 ; 21:1443–1451 Data from two 3-month time periods before and after the arrival of a pediatric intensivist  were collected prospect ively and compared to determine the intensivist 's impact on ICU mortality , use of monitoring and therapeutic modalities , and efficiency of ICU bed utilization . Severity of illness and care modalities were determined daily for all patients with the Physiologic Stability Index and the Therapeutic Intervention Scoring System . The only major organizational change in the postintensivist period was the organization and implementation of a daytime ICU team . Case mix variables , including sex ; medical/surgical , emergency/elective , and diagnostic distributions ; and nursing hours/patient day , were equivalent in the pre-intensivist and postintensivist sample s. After the intensivist 's arrival , there was a significant decrease in admissions with very low severity of illness ( Physiologic Stability Index less than 4 ; 52 % vs. 34 % ; p less than .05 ) and a significant decrease in bed utilization by patients who received only monitoring services ( 27 % vs. 17 % of bed days ; p less than .001 ) . The severity of the illness-adjusted ICU mortality rate was significantly higher in the pre-intensivist period than in the postintensivist period ( weighted mean mortality difference 5.3 + /- 2.6 % ; p less than .05 ) . The incidence of both therapeutic and monitoring modalities increased in the postintensivist period . These results indicate that a pediatric intensivist can improve mortality rates and efficiency of bed utilization in the pediatric ICU OBJECTIVES --To compare outcome between intensive care units in Britain and Irel and both before and after adjustment for case mix with the American APACHE II method and to vali date the American APACHE II method in Britain and Irel and . DESIGN -- Prospect i ve , cohort study of consecutive admissions to intensive care units . SETTING --26 general intensive care units in Britain and Irel and . SUBJECTS--8796 admissions to the study intensive care units . MAIN OUTCOME MEASURE -- Death or survival at discharge from intensive care unit and hospital . RESULTS --At discharge from both intensive care unit and hospital there was a greater than twofold variation in crude mortality between the 26 units . After adjustment for case mix , variations in mortality were still apparent . For four intensive care units the observed numbers of deaths were significantly different from the number predicted by the American APACHE II equation . The overall goodness of fit , or predictive ability , of the APACHE II equation for the British and Irish data was good , being only slightly inferior to that obtained when the equation was tested on the data from which it had been derived . When patients were grouped by various factors such as age and diagnosis , the equation did not adjust across the subgroups in a uniform manner . CONCLUSIONS --The American APACHE II equation did not fit the British and Irish data . Use of the American equation could be of advantage or disadvantage to individual intensive care units , depending on the mix of patients treated Objective : To examine the effect of high levels of pre-intensive care unit ( ICU ) discharge care , as assessed by the Therapeutic Intervention Scoring System ( TISS ) , on subsequent hospital mortality.¶ Design : A 1-year prospect i ve , observational study .¶ Setting : The ICU and wards of a university teaching hospital with no high dependency facility (HDU).¶ Patients : A total of 283 patients were discharged to hospital wards between July 1997 and June 1998.¶ Results : 11 % of all ICU discharges subsequently died in hospital . Patients discharged with a TISS of 20 or greater had a 21.4 % mortality compared to 3.7 % for those with a TISS of less than 10 . Increasing age , Acute Physiology Score ( APS ) on admission and male sex were also significantly associated with post-discharge death.¶ Conclusions : In a hospital without HDU facilities , patients who are receiving HDU levels of care on discharge from the ICU have a high in-hospital mortality CONTEXT Morbidity and mortality rates in intensive care units ( ICUs ) vary widely among institutions , but whether ICU structure and care processes affect these outcomes is unknown . OBJECTIVE To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU . DESIGN Observational study , with patient data collected retrospectively and ICU data collected prospect ively . SETTING All Maryl and hospitals that performed abdominal aortic surgery from 1994 to 1996 . PATIENTS AND PARTICIPANTS We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryl and who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 ( n = 2987 ) . We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryl and hospitals that performed abdominal aortic surgery . Thirty-nine ( 85 % ) of the ICU directors completed this survey . MAIN OUTCOME MEASURES In-hospital mortality and hospital and ICU length of stay . RESULTS For patients undergoing abdominal aortic surgery , in-hospital mortality varied among hospitals from 0 % to 66 % . In multivariate analysis adjusted for patient demographics , comorbid disease , severity of illness , hospital and surgeon volume , and hospital characteristics , not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality ( odds ratio [ OR ] , 3.0 ; 95 % confidence interval [ CI ] , 1.9 - 4.9 ) . Furthermore , not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest ( OR , 2.9 ; 95 % CI , 1.2 - 7.0 ) , acute renal failure ( OR , 2.2 ; 95 % CI , 1.3 - 3.9 ) , septicemia ( OR , 1.8 ; 95 % CI , 1.2 - 2.6 ) , platelet transfusion ( OR , 6.4 ; 95 % CI , 3.2 - 12.4 ) , and reintubation ( OR , 2.0 ; 95 % CI , 1.0 - 4.1 ) . Not having daily rounds by an ICU physician , having an ICU nurse-patient ratio of less than 1:2 , not having monthly review of morbidity and mortality , and extubating patients in the operating room were associated with increased re source use . CONCLUSIONS Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery . Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations Objective To test the hypothesis that technology availability , staffing , and diagnostic diversity in an intensive care unit ( ICU ) are associated with the ability to decrease hospital mortality . Design Prospect i ve multicenter descriptive cohort study . Setting Ten Brazilian medical-surgical ICUs . Patients 1734 consecutive adult ICU admissions . Measurements and results We recorded t the  amount of technology , number of diagnoses , and availability of nurses  at each ICU . We also used demographic , clinical and physiologic information for an average of 173 admissions to each ICU to calculate st and ardized mortality ratios ( SMRs ) for each ICU . The mean SMR for the ten ICUs was 1.67 ( range 1.01–2.30 ) . A greater availability of ICU equipment and services was significantly ( p<0.001 ) associated with a lower SMR . Conclusion The ability of Brazilian ICUs to reduce hospital mortality is associated with the amount of technology available in these units OBJECTIVE To determine the importance of the following care factors previously associated with hospital quality on survival from pediatric intensive care : size of the intensive care unit ( ICU ) , medical school teaching status of the hospital housing the ICU , specialist status ( pediatric intensivist ) , and unit coordination . DESIGN After a national survey , consecutive case series were collected at 16 sites r and omly selected to represent unique combinations of quality -of-care factors . SETTING Pediatric ICUs . PATIENTS Consecutive admissions to each site . MAIN OUTCOME MEASURE Patient mortality adjusted for physiologic status , diagnosis , and other mortality risk factors . RESULTS There were 5415 pediatric ICU admissions and 248 ICU 
    Output:
    
Results indicate that  organizational factors  may have an impact on mortality after case mix adjustment .
This study has shown that emerging data will help us underst and mortality differences and deliver better outcomes for patients