Year in review 2006: Critical Care – resource management
Critical Care volume 11, Article number: 223 (2007)
As health care resources become increasingly constrained, it is imperative that intensive care unit resources be optimized. In the years to come, a number of challenges to intensive care medicine will need to be addressed as society changes. Last year's Critical Care papers provided us with a number of interesting and highly accessed original papers dealing with health care resources. The information yielded by these studies can help us to deal with issues such as prognostication, early detection and treatment of delirium, prevention of medical errors and use of radiology resources in critically ill patients. Finally, several aspects of scientific research in critically ill patients were investigated, focusing on the possibility of obtaining informed consent and recall of having given informed consent.
During 2006 several original papers were published in Critical Care dealing with resource management. The term 'resource management' means the efficient and effective deployment of an organization's resources when and where they are needed. Intensive care consumes a disproportionate amount of health care resources, and as these resources become increasingly constrained it is imperative that deployment of intensive care unit (ICU) resources be optimized.
With respect to appropriate allocation of ICU resources, it is clear that accurate prognostication in critical illness is of the utmost importance. Also, efforts should continue to reduce length of stay. Over recent years, the number of reports focusing on delirium has risen. Because development of delirium has a strong impact on clinical outcome, delirium influences resource management in the ICU. In the ICU setting, the rate of errors in medication prescribing is high, possibly because of the high numbers of drugs that ICU patients receive, preference for intravenous administration and the high incidence of organ failure. It is clear that such errors also have impact on ICU resource management, and it may be possible to prevent medical errors in the ICU by using computerized physician order entry. Hospital resources should also be taken into account; for instance, a critical evaluation of the use of radiology may be warranted. Finally, optimizing ICU resource management includes not only the immediate clinical resources of the ICU and hospital but also other, less tangible factors, such as difficulties associated with obtaining and recall of having given informed consent.
Accurate prognostication in critical illness is essential for appropriate decision making, patient counselling and resource allocation. In a study comparing prognostic models for morbidity prediction after cardiopulmonary bypass surgery in an Italian hospital, Biagoli and coworkers  found a Bayesian linear model to have greater discriminatory power compared with simple scoring models, even when customized to a local population. Provided that computers and the required software are available in the ICU, the simplicity of scoring models must be balanced against greater discriminatory power and better calibration of more complex linear and nonlinear models.
Researchers and clinicians only recently began to conduct systematic evaluations of critical care outcomes beyond hospital and ICU mortality. A group from Slovenia compared 2-year survival and quality of life (QoL) between patients with sepsis or trauma treated in the surgical ICU . Patients with trauma tended to be younger, male and more likely to be alive in the ICU, hospital and at 2-year follow up. Absolute differences in hospital mortality (62% versus 42%) and 2-year mortality (33% versus 57%) were similar, suggesting that most of the difference in outcomes occurred during the hospital stay. QoL was similar between the two groups. Two years after critical illness, the majority of the patients had pain, symptoms of depression, or problems with usual activities.
Advances made in critical care and organ support have led to the emergence of a distinct clinical entity: 'chronic critical illness' (CCI) . In a prospective observational study conducted in an Argentinean ICU , 12% of patients met criteria for CCI, defined as need for tracheostomy for prolonged mechanical ventilation. CCI patients were more likely to have acute respiratory distress syndrome and greater acuity of illness, but they were less likely to have significant underlying co-morbidity, and there was no difference in mortality in comparison with patients who did not meet criteria for CCI. Although the authors postulated that there was greater reserve in patients without underlying co-morbidities, conferring upon them a survival advantage, alternative explanations include the preferences of patients, families and providers for less aggressive care in the presence of significant co-morbidities. Friedrich and colleagues  studied risk factors for mortality in a Canadian cohort of CCI patients, which in this study was defined as having spent more than 30 days in the ICU. Although this group of patients represented only 8% of ICU admissions, they occupied 48% of ICU beds. At 6 months of follow up, 50% of patients were dead, 40% returned to a previous place of residence, and 10% resided in long-term care facilities. The main predictors of mortality were older age, presence of immunosuppression, need for mechanical ventilation for longer than 90 days, and need for vasopressor or inotropic support for more than 3 days after day 30 of the ICU stay or acute renal failure (requiring dialysis) 30 days after day 30 of the ICU stay.
In addition to structure and processes of care, monitoring of risk-adjusted outcomes represents an essential component of quality assurance in the ICU. Cockings and coworkers  demonstrated the feasibility of continuous monitoring of observed versus predicted mortality in a regional hospital in the UK, using an APACHE (Acute Physiology and Chronic Health Evaluation) II risk adjustment model. A risk-adjusted P chart allowed near real-time detection of trends in adjusted outcomes beyond two standard deviations that could represent real changes resulting from nonplanned events or planned interventions in any of the components of the health care system. Continuous monitoring of both processes of care and risk-adjusted outcomes is imperative for quality control in a modern ICU and health care system in general.
Although a large body of critical care literature focuses on treatment of acute deterioration in vital signs, the number of reports focusing on other aspects, including cognitive dysfunction, delirium and post-traumatic stress disorder, is rising . The recognition and treatment of these frequently occurring psychiatric disorders is important not only to improve quality of patient care but also to improve outcome . ICU physicians should view delirium, or acute central nervous system dysfunction, as the brain's form of 'organ dysfunction'. However, ICU physicians and nurses frequently only recognize the presence of a psychiatric disturbance in agitated patients, whereas the presence of a hypoactive delirium is missed .
The development of delirium has a strong impact on clinical outcome. Thomason and coworkers  demonstrated that patients who develop delirium in the ICU have a longer stay in the ICU and duration of mechanical ventilation than those who do not. These data were recently corroborated by Ouimet and colleagues , who showed that delirium was associated with 6 more days in the ICU and 5 more days in the hospital compared with patients who did not develop delirium during their ICU stay. This increase in consumption of hospital and ICU resources is associated with greater costs. In addition, current research indicates that long-term neurocognitive sequelae following delirium occur commonly, are underestimated and may be permanent. This impairment is associated with decreased QoL and disturbances in normal daily activities . Many factors are involved in the pathogenesis of these disorders (Figure 1) .
Development of delirium is related to several risk factors, which can be arbitrarily grouped into patient factors, the acute illness itself and environmental factors, including drugs. Older age and male gender are well known risk factors for delirium, whereas genetic factors may prove to be important as well. Ely and coworkers  recently suggested that the apolipoprotein E4 allele is a genetic factor that predisposes to longer duration of delirium. Also, delirium occurs more frequently in sicker patients and is associated with administration of lorazepam .
Recognition of delirium remains difficult. One of the reasons for this is the poor definition of this entity specifically in the ICU setting. Hence, a screening tool, based on established psychiatric DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria, was developed that takes into account factors such as altered level of consciousness, inattention, disorientation, hallucination or delusion, psychomotor agitation or retardation, inappropriate mood or speech, sleep/wake cycle disturbance, and symptom fluctuation . Later, Ely and colleagues  introduced and validated the Confusion Assessment Method (CAM) for ICU patients, which was simpler to use than the original CAM by taking into account problems with communication in intubated patients. This so-called CAM-ICU exhibited good inter-rater reliability and was useful in establishing the occurrence of delirium, but also in the follow-up of delirium during repeated measurements . However, in nonintubated verbally communicative patients, the original CAM may be superior in detecting subtle cases of delirium .
The most important factor responsible for under-recognition of delirium may be that most studies have measured delirium at one point in time over a 24-hour period. Given the fluctuating nature of delirium, this approach severely limits the sensitivity of detecting delirium, because symptoms indicative of delirium occurring before or after the delirium assessment may go undetected. Incorporating chart review in the evaluation of delirium resulted in an overall incidence exceeding 80% in an ICU population older than 60 years .
Can the occurrence of delirium be predicted or even prevented in ICU patients? Marcantonio and coworkers  conducted a prospective cohort study in elderly noncardiac surgery patients and were able to develop a simple predictive rule using seven preoperative factors, including physical and cognitive function. Among elderly patients undergoing hip surgery who were at risk for delirium, prophylactic haloperidol was compared with placebo . Although there was no difference in the incidence of postoperative delirium between the two groups, those in the haloperidol group exhibited significantly reduced severity and duration of delirium. We await studies aiming to achieve targeted prevention and multi-factorial treatment of delirium in general critically ill patients.
Approximately 40,000 to 100,000 people die each year in hospitals in the USA as a result of medical errors . Medication errors are estimated to account for at least 7,000 deaths each year . These errors can occur at all stages of the medication process. Although most of these errors are harmless, some do result in an adverse drug event ; one in 100 in-hospital medication errors result in an adverse drug event, and seven in 100 have the potential to do so [23, 24]. In the ICU setting the rate of preventable and potential adverse drug events is even greater, being almost twice as high as outside the ICU setting . This is possibly because of the high number of drugs that ICU patients receive, the preference for intravenous administration and the high incidence of organ failure. Such adverse events may have considerable impact on use of ICU resources.
Computerized entry of physician orders has been recommended as a major step toward improving patient safety. This is because computerized entry could eliminate many of the problems associated with manual writing of drug orders by decreasing the occurrence of illegible orders, inappropriate doses and incomplete orders.
Colpaert and colleagues  conducted a prospective, controlled, cross-sectional trial in two paper-based units versus one computerized unit in order to evaluate and compare the incidence and severity of medication prescribing errors between these two systems. A total of 2,510 medication prescriptions were evaluated, and 375 medication prescribing errors were identified. The incidence of medication prescribing errors was significantly lower in the computerized unit than in the paper-based unit (3.4% versus 27.0%), with fewer minor medication prescribing errors in the computerized unit than in the paper-based unit. The incidence of intercepted medication prescribing errors was four times lower in the computerized unit than in the paper-based unit. There was also a reduction in adverse drug events (two in the in the computerized unit versus 12 in the paper-based unit).
Computerized physician order entry created new problems, such as inconsistent or duplicate orders. Causes were related to deficiencies in the computerized physician order entry system itself and to human error. Several examples emphasize that it is important to evaluate a newly installed system objectively and correct the problems encountered. One frequent error was the unnoticed changing of an already activated prescription of a continuous infusion medication. Another problem related to requests for assessment of drug plasma concentration levels; they were often being forgotten or, on the other hand, continued to be requested after the medication had been stopped.
Future research is needed to address the cost-benefit ratio of the installation of computerized order systems. At present, information regarding the cost-benefit of such systems is lacking.
Chest radiographs are frequently obtained as a complement to physical examination of critically ill patients [27, 28]. There are two different schools of thought regarding the utility of chest radiographs in the ICU: chest radiographs should be requested based on indication only, specifically when there is a sound reason to obtain a film (a so-called 'on demand' strategy); alternatively, chest radiographs should be obtained routinely every day, without any specific reason to do so (a so-called 'daily routine' strategy). In favour of the latter strategy is the high prevalence of pathological findings on chest radiographs in ICU patients . Presently, the consensus opinion of the American College of Radiology expert panel is that daily routine chest radiographs are indicated in patients with acute cardiopulmonary problems and those receiving mechanical ventilation .
However, interpretation of studies on the usefulness of daily routine chest radiographs is hampered because of major differences in methodology . Also, most studies did not attempt to discriminate between clinically relevant and irrelevant findings. Graat and coworkers  demonstrated that daily routine chest radiographs hardly ever reveal potentially important abnormalities and seldom result in a change in therapy in a mixed medical-surgical ICU. Over a 5-month period, 2,457 daily routine chest radiographs were obtained in 745 consecutive ICU patients. The majority of these chest radiographs did not reveal any new predefined major finding; on only 6% of daily routine chest radiographs (14% of patients) was one or more new and unexpected abnormality encountered, including large atelectases, large infiltrates, severe pulmonary congestion, severe pleural effusion, pneumothorax/pneumomediastinum, and malposition of the orotracheal tube. Interestingly, fewer than half of chest radiographs with a new and unexpected finding turned out to be clinically relevant; in only 2% of all daily routine chest radiographs (6% of patients) did these abnormalities result in a change to therapy.
A recent study conducted by the same investigators  confirmed the findings of others [34, 35]. Elimination of daily routine chest radiographs reduced markedly the number of chest radiographs (from 1.1 ± 0.3 to 0.6 ± 0.4 chest radiographs/patient per day), while not affecting readmission rates and ICU and hospital mortality rates. The reduction in chest radiographs usage equalled a cost reduction of more than €18,000 per month in this 30-bed ICU.
One time-consuming aspect of ICU practice is obtaining informed consent for medical interventions. Even if informed consent can be obtained, another hurdle must be address if one wishes to conduct clinical research. Researchers – academic as well as non-academic – will have to fulfil all of the new obligations now imposed by the European Union (EU) Directive on Clinical Research. It is not clear yet whether these changes will be a blessing or a curse for clinical research involving critically ill patients .
The EU Directive on Clinical Research (2001/20/EC)  was approved 6 years ago  and implemented in national laws of the EU member states. This has limited the ability of family members to act as legal representatives in terms of granting consent for participation in medical research involving humans where the patient is incapacitated. Specifically, that ability is restricted to the spouse or legal representative. Although the Directive was devised to protect people with chronic incapacity to make their own decisions, it also strongly influenced whether patients undergoing treatment in emergency medicine departments could be included in clinical research protocols. The medical community reacted and lobbied for different rules in relation to these acutely incompetent patients [39, 40]. The same concerns applied to critically ill patients, who are frequently (temporarily) incapable of giving informed consent [41–43].
In The Netherlands, the requirements described in the Directive have been transposed into the revision of the Medical Research in Human Subjects Act and Medical Law . The amended Act changes the rules governing (drug) studies in The Netherlands. However, regarding the legal representative, an amendment was made, so that – in the absence of a legal representative, spouse, or life companion – the law presently also permits parents, children, and siblings to give surrogate informed consent.
Veelo and coworkers  studied the effects of this revision and found that under the original EU Directive, 46% of patients would be without a legal representative; under the new revised version of the Directive this proportion was only 8%. Older age was significantly associated with impossibility of obtaining informed consent using the original EU Directive, leading to possible bias in clinical research in critically ill patients. Only one of 211 patients (0,5%) was represented by a formal legal representative, designated in advance. Legal guardians were not found among the representatives in this series. Representatives felt very confident in how well they were able to represent the patients. In turn, patients were equally confident that their representatives were able to represent them .
Sometimes, ICU patients are able to give informed consent themselves, possibly as a result of lighter sedation. However, recall of participation is poor, in that only 32% of patients could recall the purpose of the clinical trial and its related risks . Factors associated with complete recall were whether a patient had been able to ask at least one question about the trial or had been able to read the information leaflet.
In the years to come, a number of challenges in intensive care medicine will need to be addressed as society changes. The available resources for health care will remain under great pressure, risk management will increasingly require our attention, and new challenges in research will arise as a result of changes in legislation. Last year's Critical Care papers have provided us with a number of interesting and highly accessed original papers dealing with these issues. The information yielded by these studies may help us to deal with some of these issues.
Confusion Assessment Method
chronic critical illness
intensive care unit
quality of life.
Biagioli B, Scolletta S, Cevenini G, Barbini E, Giomarelli P, Barbini P: A multivariate Bayesian model for assessing morbidity after coronary artery surgery. Crit Care 2006, 10: R94. 10.1186/cc4441
Korosec Jagodic H, Jagodic K, Podbregar M: Long-term outcome and quality of life of patients treated in surgical intensive care: a comparison between sepsis and trauma. Crit Care 2006, 10: R134. 10.1186/cc5047
Estenssoro E, Reina R, Canales HS, Saenz MG, Gonzalez FE, Aprea MM, Laffaire E, Gola V, Dubin A: The distinct clinical profile of chronically critically ill patients: a cohort study. Crit Care 2006, 10: R89. 10.1186/cc4941
Friedrich JO, Wilson G, Chant C: Long-term outcomes and clinical predictors of hospital mortality in very long stay intensive care unit patients: a cohort study. Crit Care 2006, 10: R59. 10.1186/cc4888
Cockings JG, Cook DA, Iqbal RK: Process monitoring in intensive care with the use of cumulative expected minus observed mortality and risk-adjusted P charts. Crit Care 2006, 10: R28. 10.1186/cc3996
Meyer NJ, Hall JB: Brain dysfunction in critically ill patients – the intensive care unit and beyond. Crit Care 2006, 10: 223. 10.1186/cc4980
Eisendrath SJ, Shim JJ: Management of psychiatric problems in critically ill patients. Am J Med 2006, 119: 22-29. 10.1016/j.amjmed.2005.05.033
Ely EW, Siegel MD, Inouye SK: Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. Semin Respir Crit Care Med 2001, 22: 115-126. 10.1055/s-2001-13826
Thomason JW, Shintani A, Peterson JF, Pun BT, Jackson JC, Ely EW: Intensive care unit delirium is an independent predictor of longer hospital stay: a prospective analysis of 261 non-ventilated patients. Crit Care 2005, 9: R375-R381. 10.1186/cc3729
Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y: Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007, 33: 66-73. 10.1007/s00134-006-0399-8
Hopkins RO, Jackson JC: Long-term neurocognitive function after critical illness. Chest 2006, 130: 869-878. 10.1378/chest.130.3.869
Milbrandt EB, Angus DC: Bench-to-bedside review: critical illness-associated cognitive dysfunction – mechanisms, markers, and emerging therapeutics. Crit Care 2006, 10: 238. 10.1186/cc5078
Ely EW, Girard TD, Shintani AK, Jackson JC, Gordon SM, Thomason JW, Pun BT, Canonico AE, Light RW, Pandharipande P, et al.: Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients. Crit Care Med 2007, 35: 112-117. 10.1097/01.CCM.0000251925.18961.CA
Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus RS, Bernard GR, Ely EW: Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006, 104: 21-26. 10.1097/00000542-200601000-00005
Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y: Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001, 27: 859-864. 10.1007/s001340100909
Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK: Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001, 29: 1370-1379. 10.1097/00003246-200107000-00012
Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, Harding SD, Bernard GR, Dittus RS, Ely EW: Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers. Crit Care Med 2005, 33: 1199-1205. 10.1097/01.CCM.0000166867.78320.AC
McNicoll L, Pisani MA, Ely EW, Gifford D, Inouye SK: Detection of delirium in the intensive care unit: comparison of confusion assessment method for the intensive care unit with confusion assessment method ratings. J Am Geriatr Soc 2005, 53: 495-500. 10.1111/j.1532-5415.2005.53171.x
Pisani MA, Araujo KL, Van Ness PH, Zhang Y, Ely EW, Inouye SK: A research algorithm to improve detection of delirium in the intensive care unit. Crit Care 2006, 10: R121. 10.1186/cc5027
Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R, et al.: A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994, 271: 134-139. 10.1001/jama.271.2.134
Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC, Burger BJ, Eikelenboom P, van Gool WA: Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005, 53: 1658-1666.
Kohn L, Corrigan J, Donaldson M: To Err is Human: Building A Safer Health System. Washington, DC: National Academy Press; 1999.
Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, et al.: Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995, 274: 29-34. 10.1001/jama.274.1.29
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L: The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999, 6: 313-321.
Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL: Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997, 25: 1289-1297. 10.1097/00003246-199708000-00014
Colpaert K, Claus B, Somers A, Vandewoude K, Robays H, Decruyenaere J: Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. Crit Care 2006, 10: R21. 10.1186/cc3983
Trotman-Dickenson B: Radiology in the intensive care unit (part I). J Intensive Care Med 2003, 18: 198-210. 10.1177/0885066603251897
Graat ME, Hendrikse KA, Spronk PE, Korevaar JC, Stoker J, Schultz MJ: Chest radiography practice in critically ill patients: a postal survey in the Netherlands. BMC Med Imaging 2006, 6: 8. 10.1186/1471-2342-6-8
Hall JB, White SR, Karrison T: Efficacy of daily routine chest radiographs in intubated, mechanically ventilated patients. Crit Care Med 1991, 19: 689-693. 10.1097/00003246-199105000-00015
American College of Radiology: Routine daily portable X-ray.[http://www.acr.org/]
Graat ME, Stoker J, Vroom MB, Schultz MJ: Can we abandon daily routine chest radiography in intensive care patients? J Intensive Care Med 2005, 20: 238-246. 10.1177/0885066605277212
Graat ME, Choi G, Wolthuis EK, Korevaar JC, Spronk PE, Stoker J, Vroom MB, Schultz MJ: The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Crit Care 2006, 10: R11. 10.1186/cc3955
Graat ME, Kroner A, Spronk PE, Korevaar JC, Stoker J, Vroom MB, Schultz MJ: Elimination of daily routine chest radiographs in a mixed medical-surgical intensive care unit. Intensive Care Med 2007, 33: 639-644. 10.1007/s00134-007-0542-1
Price MB, Grant MJ, Welkie K: Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit. Crit Care Med 1999, 27: 1588-1593. 10.1097/00003246-199908000-00033
Krivopal M, Shlobin OA, Schwartzstein RM: Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU. Chest 2003, 123: 1607-1614. 10.1378/chest.123.5.1607
van der Voort PH, van Dijk Y, Kesecioglu J: Changes in the Dutch law on medical research. Intensive Care Med 2006, 32: 1906-1907. 10.1007/s00134-006-0385-1
European Parliament and European Council: The European Union (EU) Directive on Clinical Research ('2001/20/EC').[http://www.ccmo-online.nl/hipe/uploads/downloads/EU-2001-20_ENG.pdf]
Anonymous: Directive 2001/20/EC of the European Parliament and Council of 4 April 2001 on the approximation of the laws, regulations and administrative provisions of the member states relating to implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use. Official J Eur Commun 2001, L121: 34-44.
Singer EA, Mullner M: Implications of the EU directive on clinical trials for emergency medicine. BMJ 2002, 324: 1169-1170. 10.1136/bmj.324.7347.1169
Kompanje EJ, Maas AI: 'Treat first, ask later?' Emergency research in acute neurology and neurotraumatology in the European Union. Intensive Care Med 2004, 30: 168-169. 10.1007/s00134-003-2044-0
Lemaire F, Bion J, Blanco J, Damas P, Druml C, Falke K, Kesecioglu J, Larsson A, Mancebo J, Matamis D, et al.: The European Union Directive on Clinical Research: present status of implementation in EU member states' legislations with regard to the incompetent patient. Intensive Care Med 2005, 31: 476-479. 10.1007/s00134-005-2574-8
van Dijk Y, van der Voort PH, Kuiper MA, Kesecioglu J: Research on subjects incapable of giving informed consent: the situation in Dutch intensive care departments. Intensive Care Med 2003, 29: 2100-2101. 10.1007/s00134-003-1913-x
Silverman HJ, Druml C, Lemaire F, Nelson R: The European Union Directive and the protection of incapacitated subjects in research: an ethical analysis. Intensive Care Med 2004, 30: 1723-1729. 10.1007/s00134-004-2367-5
Medical Research in Human Subjects Act (WMO) and the Medicine Law http://ccmo-online.nl/hipe/uploads/downloads_catw/Medical%20Research%20involving%20Human%20Subjects%20Act%20March%2001%202006.pdf
Veelo DP, Spronk PE, Kuiper MA, Korevaar JC, van der Voort PH, Schultz MJ: A change in the Dutch Directive on Medical Research Involving Human Subjects strongly increases the number of eligible intensive care patients: an observational study. Intensive Care Med 2006, 32: 1845-1850. 10.1007/s00134-006-0384-2
Chenaud C, Merlani P, Luyasu S, Ricou B: Informed consent for research obtained during the intensive care unit stay. Crit Care 2006, 10: R170. 10.1186/cc5120
The authors declare that they have no competing interests.
Authors’ original submitted files for images
Below are the links to the authors’ original submitted files for images.
About this article
Cite this article
Schultz, M.J., Kuiper, M., Spronk, P.E. et al. Year in review 2006: Critical Care – resource management. Crit Care 11, 223 (2007). https://doi.org/10.1186/cc5961
- Intensive Care Unit
- Intensive Care Unit Patient
- Intensive Care Unit Stay
- Computerize Physician Order Entry
- Legal Representative