Publications

RATIONALE: Inpatient consultation by specialists is one of the most common medical interventions in the modern intensive care unit (ICU), but few data exist on components of high-quality consultation.

OBJECTIVES: Our objective was to use qualitative methods to develop a conceptual framework of consultative quality in critically ill patients.

METHODS: We conducted a qualitative study of medical ICU physicians at a single institution using a novel, semistructured interview guide. We elicited physicians' attitudes toward processes of obtaining specialty consultation, identified perceived elements of high-quality consults, and identified barriers to obtaining high-quality consults. We used grounded theory to identify themes.

MEASUREMENTS AND MAIN RESULTS: ICU physicians described four common reasons for involving a consulting physician: the need for clinical or procedural expertise, an explicit or implicit protocol of the institution mandating the consult, an opportunity to provide education to the primary or consulting team, and/or at the family's request. Participants identified seven components of a high-quality consult, including the consulting teams' (1) decisiveness, (2) thoroughness, (3) level of interest, (4) professionalism, (5) expertise, (6) timeliness, and (7) involvement with the family of the patient. The intensive care team, the consult team, the health system, and the temporal context in which the consultation takes place may influence the quality of the consultation.

CONCLUSIONS: Several key factors are necessary for a consult to be judged high quality. An opportunity exists to develop an instrument to assess and to improve specialty consultations in the ICU based on these findings.

BACKGROUND: Despite many patients undergoing coronary artery bypass grafting (CABG) to improve their functional status, literature in this area is limited. The purpose of this study is to determine the effect of CABG on the functional health of an elective population and to identify preoperative patient characteristics associated with improved functional health after surgery.

METHODS: Physical and mental functional health was assessed before and 6 months after surgery with the Short-Form Health Survey (SF-36) in 1,061 consecutive patients undergoing elective, isolated CABG. Survey data were complete in 529 patients (49.9%). Preoperative information on patient demographics, severity of cardiovascular illness, and disease comorbidities was also prospectively collected.

RESULTS: Six months post-CABG the mean summary score for physical function improved by 31.9% over baseline (45.1 versus 34.2, p < 0.0001). The mean summary score for mental function improved by 7.3% over baseline (51.3 versus 47.8, p < 0.0001). Overall 73.2% of patients showed improvement in physical function and 41.6% showed improvement in mental function. Multivariate logistic regression identified certain preoperative characteristics as negative correlates of a significant improvement in physical functioning: body mass index 35 kg/m2 or greater, diabetes with sequelae, chronic obstructive pulmonary disease, peripheral vascular disease, and baseline physical function. Baseline mental function and chronic obstructive pulmonary disease were identified as negative correlates and older age as a positive correlate of significant improvement in mental functioning.

CONCLUSIONS: Patient characteristics exist that impact functional health after elective CABG. Knowledge of these characteristics may be helpful when counseling patients about expected improvement in functional health with CABG.