Care Units In England Research Articles

Medical examiner service in children’s deaths: a survey of current practice in paediatric intensive care units in England and Wales

IntroductionA statutory system of medical examiners (ME) was introduced in England and Wales in September 2024. The next of kin will be given the opportunity to speak to the ME...

Association between protein intake and muscle wasting in critically ill children: A prospective cohort study.

Survival from pediatric critical illness in high-income countries is high, and the focus now must be on optimizing the recovery of survivors. Muscle mass wasting during critical illness is problematic, so identifying factors that may reduce this is important. Therefore, the aim of this study was to examine the relationship between quadricep muscle mass wasting (assessed by ultrasound), with protein and energy intake during and after pediatric critical illness. A prospective cohort study in a mixed cardiac and general pediatric intensive care unit in England, United Kingdom. Serial ultrasound measurements were undertaken at day 1, 3, 5, 7, and 10. Thirty-four children (median age 6.65 [0.47-57.5] months) were included, and all showed a reduction in quadricep muscle thickness during critical care admission, with a mean muscle wasting of 7.75%. The 11 children followed-up had all recovered their baseline muscle thickness by 3 months after intensive care discharge. This muscle mass wasting was not related to protein (P = 0.53, ρ = 0.019) (95% CI: -0.011 to 0.049) or energy intake (P = 0.138, ρ = 0.375 95% CI: -0.144 to 0.732) by 72 h after admission, nor with severity of illness, highest C-reactive protein, or exposure to intravenous steroids. Children exposed to neuromuscular blocking drugs exhibited 7.2% (95% CI: -0.13% to 14.54%) worse muscle mass wasting, but this was not statistically significant (P = 0.063). Our study did not find any association between protein or energy intake at 72 h and quadricep muscle mass wasting.

Ethnic minority fathers’ experiences of the Neonatal Care Unit: barriers to accessing psychological support

ABSTRACT Background The Neonatal Care Unit is a challenging environment for parents. Previous literature documents the need for increased and more specialised understanding of support for fathers. There remains a dearth of literature on the experiences of ethnic minority fathers in particular, who may be less likely to access psychological support available. Method This project aimed to understand the barriers ethnic minority fathers face when accessing psychology support at a Neonatal Care Unit in England. Seven fathers from ethnic minority backgrounds participated in semi-structured interviews after their babies were discharged. Results Data were analysed using a Reflexive Thematic Analysis approach. Three main themes were identified: ‘Psychology is a Threat’, ‘It’s Not Really Talked About in our Culture’, and ‘A Space for Mum, Not Me’. These themes are discussed in reference to the extant literature, and recommendations are provided to improve access to support in this neonatal unit. Conclusions There is a need to recognise interacting influences of gender and cultural norms in supporting these fathers, including understanding the role of psychology, consideration of stigma, and knowing families in relation to their cultural context.

Economic evaluation of a vision-based patient monitoring and management system in addition to standard care for adults admitted to psychiatric intensive care units in England

Background and aims Treating patients in psychiatric intensive care units (PICUs) is costly for the English National Health Service (NHS), requiring significant staff time. Oxevision, a non-contact system, providing vision-based patient monitoring and management (VBPMM) has been introduced in some NHS mental health trusts which aims to help clinicians to deliver safer and more efficient care. The objective of this early economic evaluation was to explore the impact of introducing VBPMM with standard care, versus standard care alone on health and economic outcomes in PICUs across England. Methods The model uses a cost calculator approach to evaluate the potential benefits of introducing VBPMM, capturing differences in observation hours and critical events such as assaults. Effectiveness data were primarily based on a 24-month observational before and after study undertaken in an NHS mental health trust using VBPMM. Outcomes reported in this study are incremental costs and reduction in clinical events presented as per occupied bed days, per patient, per average ward, and for the English NHS overall. Scenario analysis was conducted to test the uncertainty of results using statistical significance of key inputs. Results and conclusions The analysis indicates that introducing VBPMM may be cost saving compared with standard care alone. The biggest driver of estimated cost savings was from the potential reduction in one to one observation hours, which may have significant impact in PICUs. Limitations of the analysis include the single center data underpinning the analysis and assumptions made about transferability of clinical data to different sized wards. Scenario analysis was conducted, and the results were robust to statistically significant changes in input parameters. This study suggests that introducing VBPMM on PICUs has the potential to reduce costs and improve efficiency of resource allocation, but results should be confirmed with additional clinical study evidence.

Impact of vaccination on COVID-19-associated admissions to critical care in England: a study of population linked data with quantitative bias analysis for linkage error.

ObjectivesTo explore associations between COVID-19 vaccination and admission to critical care with COVID-19 in England, by age group, dose, and over time. ApproachWe conducted a population cohort study by linking the Case Mix Programme national clinical audit of adult intensive care to the National Immunisation Management System, combined with population denominators from the Office for National Statistics. We compared patient characteristics and estimated rates of critical care admission by vaccination status and age group and explored variation in admission rates and relative protection over time. Finally, we used quantitative bias analysis to explore sensitivity to potential linkage error. ResultsBetween 1 May and 15 December 2021 (England’s Delta wave), 11,431 patients were admitted to adult critical care units in England with COVID-19, of whom 10,141 were included in the cohort. Vaccinated patients were older, with higher levels of severe comorbidity and immunocompromise. Unvaccinated patients were greatly overrepresented, with people who had received two or more doses being at least 92% less likely to be admitted compared with those who were unvaccinated, for all ages, once the second dose had been rolled out. Those aged 50 years or older who had received a booster/third dose were 98-99% less likely to be admitted compared with unvaccinated. Our analysis was robust to linkage error, but closely related analyses could have been exquisitely sensitive to missed links. ConclusionOur findings are consistent with a high degree of vaccine-acquired protection against critical care admission, with little waning in the first 6-9 months for those aged under 70. While our analysis was robust to linkage error, significant care is warranted with related analyses of linked vaccination and outcome databases.

Psychological needs of critical care staff and barriers to accessing support: A qualitative study.

Worldwide, critical care staff are vulnerable to mental health difficulties. Support is varied and uptake is minimal.Therefore, barriers need to be understood in order to be addressed; doing so may improve staff's mental health, resulting in positive consequences. This qualitative research took place between September 2020–November 2020 at a National Health Service critical care unit in England. Participants were critical care staff (n = 9). Data were collected through semistructured interviews and analyzed using thematic analysis. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) was used to report the findings, with analysis resulting in six themes: support is the team together in the moment, keeping work‐related difficulties from the forefront of the mind, it's just part of the job, stigma makes it hard to speak up about psychological difficulties, normalizing psychological support, and desire for psychological support within critical care. Psychologist presence in critical care, as well as further options for support, may help to reduce barriers and improve staff mental health. Further research is needed to evaluate staff outcomes across multiple sites to refine understanding and interventional approach.

Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study.

In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness. The aim of the Renal Replacement Anticoagulant Management study was to evaluate the clinical and health economic impacts of intensive care units moving from systemic heparin anticoagulation to regional citrate anticoagulation for continuous renal replacement therapy. This was an observational comparative effectiveness study. The setting was NHS adult general intensive care units in England and Wales. Participants were adults receiving continuous renal replacement therapy in an intensive care unit participating in the Intensive Care National Audit & Research Centre Case Mix Programme national clinical audit between 1 April 2009 and 31 March 2017. Exposure - continuous renal replacement therapy in an intensive care unit after completion of transition to regional citrate anticoagulation. Comparator - continuous renal replacement therapy in an intensive care unit before starting transition to regional citrate anticoagulation or had not transitioned. Primary effectiveness - all-cause mortality at 90 days. Primary economic - incremental net monetary benefit at 1 year. Secondary outcomes - mortality at hospital discharge, 30 days and 1 year; days of renal, cardiovascular and advanced respiratory support in intensive care unit; length of stay in intensive care unit and hospital; bleeding and thromboembolic events; prevalence of end-stage renal disease at 1 year; and estimated lifetime incremental net monetary benefit. Individual patient data from the Intensive Care National Audit & Research Centre Case Mix Programme were linked with the UK Renal Registry, Hospital Episode Statistics (for England), Patient Episodes Data for Wales and Civil Registrations (Deaths) data sets, and combined with identified periods of systemic heparin anticoagulation and regional citrate anticoagulation (survey of intensive care units). Staff time and consumables were obtained from micro-costing. Continuous renal replacement therapy system failures were estimated from the Post-Intensive Care Risk-adjusted Alerting and Monitoring data set. EuroQol-3 Dimensions, three-level version, health-related quality of life was obtained from the Intensive Care Outcomes Network study. Out of the 188 (94.9%) units that responded to the survey, 182 (96.8%) use continuous renal replacement therapy. After linkage, data were available from 69,001 patients across 181 intensive care units (60,416 during periods of systemic heparin anticoagulation use and 8585 during regional citrate anticoagulation use). The change to regional citrate anticoagulation was not associated with a step change in 90-day mortality (odds ratio 0.98, 95% confidence interval 0.89 to 1.08). Secondary outcomes showed step increases in days of renal support (difference in means 0.53 days, 95% confidence interval 0.28 to 0.79 days), advanced cardiovascular support (difference in means 0.23 days, 95% confidence interval 0.09 to 0.38 days) and advanced respiratory support (difference in means, 0.53 days, 95% CI 0.03 to 1.03 days) with a trend toward fewer bleeding episodes (odds ratio 0.90, 95% confidence interval 0.76 to 1.06) with transition to regional citrate anticoagulation. The micro-costing study indicated that regional citrate anticoagulation was more expensive and was associated with an estimated incremental net monetary loss (step change) of -£2376 (95% confidence interval -£3841 to -£911). The estimated likelihood of cost-effectiveness at 1 year was less than 0.1%. Lack of patient-level treatment data means that the results represent average effects of changing to regional citrate anticoagulation in intensive care units. Administrative data are subject to variation in data quality over time, which may contribute to observed trends. The introduction of regional citrate anticoagulation has not improved outcomes for patients and is likely to have substantially increased costs. This study demonstrates the feasibility of evaluating effects of changes in practice using routinely collected data. (1) Prioritise other changes in clinical practice for evaluation and (2) methodological research to understand potential implications of trends in data quality. This trial is registered as ClinicalTrials.gov NCT03545750. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 13. See the NIHR Journals Library website for further project information.

Associations between ethnicity and admission to intensive care among women giving birth: a cohort study.

To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period. Cohort study. Maternity and intensive care units in England and Wales. A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit. Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data. Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth. In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups. Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission. Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.

Caring for critically ill adults in paediatric intensive care units in England during the COVID-19 pandemic: planning, implementation and lessons for the future

ObjectiveTo describe the experience of paediatric intensive care units (PICUs) in England that repurposed their units, equipment and staff to care for critically ill adults during the first wave of...

The effect of care provided by paediatric critical care transport teams on mortality of children transported to paediatric intensive care units in England and Wales: a retrospective cohort study

BackgroundCentralisation of paediatric intensive care units (PICUs) has the increased the need for specialist paediatric critical care transport teams (PCCT) to transport critically ill children to PICU. We investigated the impact of care provided by PCCTs for children on mortality and other clinically important outcomes.MethodsWe analysed linked national data from the Paediatric Intensive Care Audit Network (PICANet) from children admitted to PICUs in England and Wales (2014–2016) to assess the impact of who led the child’s transport, whether prolonged stabilisation by the PCCT was detrimental and the impact of critical incidents during transport on patient outcome. We used logistic regression models to estimate the adjusted odds and probability of mortality within 30 days of admission to PICU (primary outcome) and negative binomial models to investigate length of stay (LOS) and length of invasive ventilation (LOV).ResultsThe study included 9112 children transported to PICU. The most common diagnosis was respiratory problems; junior doctors led the PCCT in just over half of all transports; and the 30-day mortality was 7.1%. Transports led by Advanced Nurse Practitioners and Junior Doctors had similar outcomes (adjusted mortality ANP: 0.035 versus Junior Doctor: 0.038). Prolonged stabilisation by the PCCT was possibly associated with increased mortality (0.059, 95% CI: 0.040 to 0.079 versus short stabilisation 0.044, 95% CI: 0.039 to 0.048). Critical incidents involving the child increased the adjusted odds of mortality within 30 days (odds ratio: 3.07).ConclusionsVariations in team composition between PCCTs appear to have little effect on patient outcomes. We believe differences in stabilisation approaches are due to residual confounding. Our finding that critical incidents were associated with worse outcomes indicates that safety during critical care transport is an important area for future quality improvement work.

Screening for Candida auris in patients admitted to eight intensive care units in England, 2017 to 2018.

Background Candida auris is an emerging multidrug-resistant fungal pathogen associated with bloodstream, wound and other infections, especially in critically ill patients. C. auris carriage is persistent and is difficult to eradicate from the hospital environment.AimWe aimed to pilot admission screening for C. auris in intensive care units (ICUs) in England to estimate prevalence in the ICU population and to inform public health guidance.MethodsBetween May 2017 and April 2018, we screened admissions to eight adult ICUs in hospitals with no previous cases of C. auris, in three major cities. Swabs were taken from the nose, throat, axilla, groin, perineum, rectum and catheter urine, then cultured and identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Patient records were linked to routine ICU data to describe and compare the demographic and health indicators of the screened cohort with a national cohort of ICU patients admitted between 2016 and 2017.ResultsAll C. auris screens for 921 adults from 998 admissions were negative. The upper confidence limit of the pooled prevalence across all sites was 0.4%. Comparison of the screened cohort with the national cohort showed it was broadly similar to the national cohort with respect to demographics and co-morbidities.ConclusionThese findings imply that C. auris colonisation among patients admitted to ICUs in England is currently rare. We would not currently recommend widespread screening for C. auris in ICUs in England. Hospitals should continue to screen high-risk individuals based on local risk assessment.

Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases

BackgroundAdults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care.MethodsA national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors.ResultsThe cohort comprised 76,704 adults with median age 81 years (IQR 70–88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0–28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90–7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78–6.62]), dementia (aHR 5.07 [95% CI 3.80–6.77]) and liver disease (aHR 9.75 [95% CI 6.50–14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04–1.39]) compared with cancer ‘other’. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36–2.79]) and cancer (aHR 2.59 [95% CI 2.13–3.15]) (reference: lowest).ConclusionsOne in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.

Increase in the use of inhaled nitric oxide in neonatal intensive care units in England: a retrospective population study

ObjectiveTo describe temporal changes in inhaled nitric oxide (iNO) use in English neonatal units between 2010 and 2015.DesignRetrospective analysis using data extracted from the National Neonatal Research Database.SettingAll National Health...

Antimicrobial-impregnated central venous catheters for preventing neonatal bloodstream infection: the PREVAIL RCT.

Clinical trials show that antimicrobial-impregnated central venous catheters reduce catheter-related bloodstream infection in adults and children receiving intensive care, but there is insufficient evidence for use in newborn babies. The objectives were (1) to determine clinical effectiveness by conducting a randomised controlled trial comparing antimicrobial-impregnated peripherally inserted central venous catheters with standard peripherally inserted central venous catheters for reducing bloodstream or cerebrospinal fluid infections (referred to as bloodstream infections); (2) to conduct an economic evaluation of the costs, cost-effectiveness and value of conducting additional research; and (3) to conduct a generalisability analysis of trial findings to neonatal care in the NHS. Three separate studies were undertaken, each addressing one of the three objectives. (1) This was a multicentre, open-label, pragmatic randomised controlled trial; (2) an analysis was undertaken of hospital care costs, lifetime cost-effectiveness and value of information from an NHS perspective; and (3) this was a retrospective cohort study of bloodstream infection rates in neonatal units in England. The randomised controlled trial was conducted in 18 neonatal intensive care units in England. Participants were babies who required a peripherally inserted central venous catheter (of 1 French gauge in size). The interventions were an antimicrobial-impregnated peripherally inserted central venous catheter (coated with rifampicin-miconazole) or a standard peripherally inserted central venous catheter, allocated randomly (1 : 1) using web randomisation. Study 1 - time to first bloodstream infection, sampled between 24 hours after randomisation and 48 hours after peripherally inserted central venous catheter removal. Study 2 - cost-effectiveness of the antimicrobial-impregnated peripherally inserted central venous catheter compared with the standard peripherally inserted central venous catheters. Study 3 - risk-adjusted bloodstream rates in the trial compared with those in neonatal units in England. For study 3, the data used were as follows: (1) case report forms and linked death registrations; (2) case report forms and linked death registrations linked to administrative health records with 6-month follow-up; and (3) neonatal health records linked to infection surveillance data. Study 1, clinical effectiveness - 861 babies were randomised (antimicrobial-impregnated peripherally inserted central venous catheter, n = 430; standard peripherally inserted central venous catheter, n = 431). Bloodstream infections occurred in 46 babies (10.7%) randomised to antimicrobial-impregnated peripherally inserted central venous catheters and in 44 (10.2%) babies randomised to standard peripherally inserted central venous catheters. No difference in time to bloodstream infection was detected (hazard ratio 1.11, 95% confidence interval 0.73 to 1.67; p = 0.63). Secondary outcomes of rifampicin resistance in positive blood/cerebrospinal fluid cultures, mortality, clinical outcomes at neonatal unit discharge and time to peripherally inserted central venous catheter removal were similar in both groups. Rifampicin resistance in positive peripherally inserted central venous catheter tip cultures was higher in the antimicrobial-impregnated peripherally inserted central venous catheter group (relative risk 3.51, 95% confidence interval 1.16 to 10.57; p = 0.02) than in the standard peripherally inserted central venous catheter group. Adverse events were similar in both groups. Study 2, economic evaluation - the mean cost of babies' hospital care was £83,473. Antimicrobial-impregnated peripherally inserted central venous catheters were not cost-effective. Given the increased price, compared with standard peripherally inserted central venous catheters, the minimum reduction in risk of bloodstream infection for antimicrobial-impregnated peripherally inserted central venous catheters to be cost-effective was 3% and 15% for babies born at 23-27 and 28-32 weeks' gestation, respectively. Study 3, generalisability analysis - risk-adjusted bloodstream infection rates per 1000 peripherally inserted central venous catheter days were similar among babies in the trial and in all neonatal units. Of all bloodstream infections in babies receiving intensive or high-dependency care in neonatal units, 46% occurred during peripherally inserted central venous catheter days. The trial was open label as antimicrobial-impregnated and standard peripherally inserted central venous catheters are different colours. There was insufficient power to determine differences in rifampicin resistance. No evidence of benefit or harm was found of peripherally inserted central venous catheters impregnated with rifampicin-miconazole during neonatal care. Interventions with small effects on bloodstream infections could be cost-effective over a child's life course. Findings were generalisable to neonatal units in England. Future research should focus on other types of antimicrobial impregnation of peripherally inserted central venous catheters and alternative approaches for preventing bloodstream infections in neonatal care. Current Controlled Trials ISRCTN81931394. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 57. See the NIHR Journals Library website for further project information.

A workforce survey of critical care nurses in the National Health Service.

To measure key aspects of the critical care nursing workforce across the National Health Service (NHS) and compare these with recommended standards where they exist. The provision of high-quality and safe critical care services is dependent on adequate numbers of highly skilled nurses. Understanding the issues and challenges within critical care services across the NHS is key to future planning and policy in this area. A stakeholder-driven consensus development approach was adopted to design a workforce survey by members of the Critical Care National Network Nurse Leads (CC3N) Forum. The survey was conducted across all the critical care units in England, Northern Ireland, Wales, and Scotland. Data were collated to enable presentation of descriptive statistics. Data returns were received from 240 of the 272 units in England and Northern Ireland. Scotland and Wales data were excluded from analysis and reporting. Differences in the sample and data returns limited comparison with the previous survey in some aspects. Stability was seen in vacancy and sickness rates. Improvements were seen in safe nurse: patient ratios, supernumerary "nurse in charge," critical care outreach service cover, use of national competency framework, and agency use. Dependency on overseas nurses in some units remains high. Specialist critical care training levels in many units do not meet current required standards. Clear improvements have been made. There is significant stability. Some challenges remain. Continued review of resource allocation is important in the coming years, as is policy and strategy to ensure recruitment, appropriate training, and support for staff well-being. The reader will gain insight into the critical care nursing workforce in the NHS in England and Northern Ireland. The results are useful for nurses, nurse managers, and policymakers.

Development, Validation, and Clinical Utility Assessment of a Prognostic Score for 1-Year Unplanned Rehospitalization or Death of Adult Sepsis Survivors

The longer-term risk of rehospitalizations and death of adult sepsis survivors is associated with index sepsis illness characteristics. To derive and validate a parsimonious prognostic score for unplanned rehospitalizations or death in the first year after hospital discharge of adult sepsis survivors. This cohort study used data from the Intensive Care National Audit & Research Centre Case Mix Programme database on adult sepsis survivors identified from consecutive critical care admissions to 192 adult general critical care units in England, United Kingdom, between April 1, 2009, and March 31, 2014 (94 748 patients in the derivation cohort), and between April 1, 2014, and March 31, 2015 (24 669 patients in the validation cohort). Statistical analysis was performed from July 5 to October 31, 2019. Generic characteristics (age, sex, race/ethnicity, 2015 Index of Multiple Deprivation [IMD2015] in England quintiles, preadmission dependence, previous hospitalizations in the year preceding index sepsis admission, comorbidity, admission type, Acute Physiology and Chronic Health Evaluation II physiology score, hospital length of stay, worst blood lactate and blood hemoglobin concentrations, and type of hospital) and sepsis-specific characteristics (site of infection, numbers of organ dysfunctions, and organ support) at the index sepsis admission were used as predictors. Prognostic score derived and validated using multivariable logistic regression for the outcome of unplanned rehospitalization or death in the first year after hospital discharge of adult sepsis survivors, as well as clinical usefulness assessed using decision curve analysis. Prognostic score validation was performed for internal validation with bootstrapping and temporal cohort external validation. This cohort study included 94 748 patients (51 164 men [54.0%]; mean [SD] age, 61.3 [17.0] years) in the derivation cohort and 24 669 patients (13 255 men [53.7%]; mean [SD] age, 62.1 [16.8%]) in the validation cohort. Unplanned rehospitalization or death in the first year after hospital discharge occurred for 48 594 patients (51.3%) in the derivation cohort and 13 129 patients (53.2%) in the validation cohort. Eight independent predictors were identified and weighted to generate a prognostic score for every patient: previous hospitalizations, age in 10-year increments, IMD2015 in England quintiles, preadmission dependence, comorbidities, admission type, blood hemoglobin level, and site of infection. The total prognostic score ranged from 0 to 22 points, with lower scores indicating a lower risk of the outcome. The derivation and validation cohorts had similar rates of prognostic scores of 0 to 4 points (5088 of 16 684 patients [30.5%] and 471 of 1725 patients [27.3%]) and prognostic scores of 11 points or more (15 732 of 21 641 patients [72.7%] and 5753 of 7952 patients [72.3%]). The area under the receiver operating characteristic curve for the prognostic score was 0.675 (95% CI, 0.672-0.679). The decision curve analysis highlighted an optimal score cutoff of 7 points or more. The prognostic score reported in this study uses 8 internationally feasible predictors measured during the index sepsis admission and provides clinically useful information on sepsis survivors' risk of unplanned rehospitalization or death in the first year after hospital discharge.

The interaction between arterial oxygenation and carbon dioxide and hospital mortality following out of hospital cardiac arrest: a cohort study

BackgroundOutcomes following out of hospital cardiac arrest (OHCA) are poor. The optimal arterial oxygen and carbon dioxide (PaCO2) levels for managing patients following OHCA are unknown. We hypothesized that abnormalities in arterial oxygenation (PaO2/FiO2 ratio or PaO2) and PaCO2 would be associated with hospital mortality following OHCA. We hypothesized that PaCO2 would significantly modify the oxygenation–mortality relationship.MethodsThis was an observational cohort study using data from OHCA survivors admitted to adult critical care units in England, Wales and Northern Ireland from 2011 to 2018. Logistic regression analyses were performed to assess the relationship between hospital mortality and oxygenation and PaCO2.ResultsThe analysis included 23,625 patients. In comparison with patients with a PaO2/FiO2 > 300 mmHg, those with a PaO2/FiO2 ≤ 100 mmHg had higher mortality (adjusted OR, 1.79; 95% CI, 1.48 to 2.15; P < 0.001). In comparison to hyperoxemia (PaO2 > 100 mmHg), patients with hypoxemia (PaO2 < 60 mmHg) had higher mortality (adjusted OR, 1.34; 95% CI, 1.10 to 1.65; P = 0.004). In comparison with normocapnia, hypercapnia was associated with lower mortality. Hypocapnia (PaCO2 ≤ 35 mmHg) was associated with higher mortality (adjusted OR, 1.91; 95% CI, 1.63 to 2.24; P < 0.001). PaCO2 modified the PaO2/FiO2–mortality and PaO2–mortality relationships, though these relationships were complex. Patients who were both hyperoxic and hypercapnic had the lowest mortality.ConclusionsLow PaO2/FiO2 ratio, hypoxemia and hypocapnia are associated with higher mortality following OHCA. PaCO2 modifies the relationship between oxygenation and mortality following OHCA; future studies examining this interaction are required.

Surveillance of bloodstream infections in intensive care units in England, May 2016–April 2017: epidemiology and ecology

Bloodstream infections (BSIs) in patients in intensive care units (ICUs) are associated with increased morbidity, mortality and economic costs. Many BSIs are associated with central venous catheters (CVCs). The Infection in Critical Care Quality Improvement Programme (ICCQIP) was established to initiate surveillance of BSIs in English ICUs. A web-based data capture system was launched on 1st May 2016 to collect all positive blood cultures (PBCs), patient-days and CVC-days. National Health Service (NHS) trusts in England were invited to participate in the surveillance programme. Data were linked to the antimicrobial resistance dataset maintained by Public Health England and to mortality data. Between 1st May 2016 and 30th April 2017, 84 ICUs (72 adult ICUs, seven paediatric ICUs and five neonatal ICUs) based in 57 of 147 NHS trusts provided data. In total, 1474 PBCs were reported, with coagulase-negative staphylococci, Escherichia coli, Staphylococcus aureus and Enterococcus faecium being the most commonly reported organisms. The rates of BSI and ICU-associated CVC-BSI were 5.7, 1.5 and 1.3 per 1000 bed-days and 2.3, 1.0 and 1.5 per 1000 ICU-CVC-days in adult, paediatric and neonatal ICUs, respectively. There was wide variation in BSI and CVC-BSI rates within ICU types, particularly in adult ICUs (0-44.0 per 1000 bed-days and 0-18.3 per 1000 ICU-CVC-days). While the overall rates of ICU-associated CVC-BSIs were lower than 2.5 per 1000 ICU-CVC-days across all age ranges, large differences were observed between ICUs, highlighting the importance of a national standardized surveillance system to identify opportunities for improvement. Data linkage provided clinically important information on resistance patterns and patient outcomes at no extra cost to participating trusts.

COVID-19 pandemic: changing the way we live and die.

The article looks at a report by the Intensive Care National Audit Research Centre on the impact of the COVID-19 pandemic on Great Britain. Topics mentioned include mortality rate for 165 patients admitted to 285 intensive care units in England, Wales, and Northern Ireland since February 2020, percentage of those admitted with COVID-19 who were clinically obese, and the role of the government to ensure that health experts in all settings have the correct personal protective equipment

A Population-based Observational Study of Childhood Encephalitis in Children Admitted to Pediatric Intensive Care Units in England and Wales.

Encephalitis is a serious neurologic condition that can result in admission to intensive care. Yet, there are no studies on pediatric intensive care unit (PICU) admission rates and usage of intensive care resources by children with encephalitis in England and Wales. The objectives of this study were to (1) define the PICU incidence and mortality rates for childhood encephalitis, (2) describe the usage of intensive care resources by children with encephalitis admitted to PICU and (3) explore the associated cost from PICU encephalitis admissions. Retrospective analysis of anonymized data for 1031 children (0-17 years) with encephalitis admitted (January 2003 to December 2013) to PICU in England and Wales. The PICU encephalitis incidence was 0.79/100,000 population/yr (95% confidence interval [CI]: 0.74-0.84), which gives an annual total of 214 bed days of intensive care occupancy for children admitted with encephalitis and an estimated annual PICU bed cost of £414,230 (interquartile range: 198,111-882,495) for this cohort. PICU encephalitis admissions increased during the study period (annual percentage change = 4.5%, 95% CI: 2.43%-6.50%, P ≤ 0.0001). In total, 808/1024 (78.9%) cases received invasive ventilation while 216/983 (22.0%) and 50/890 (5.6%) cases received vasoactive treatment and renal support, respectively. There were 87 deaths (8.4%), giving a PICU encephalitis mortality rate of 0.07/100,000 population (0-17 years)/yr (95% CI: 0.05-0.08). These data suggest that encephalitis places a significant burden to the healthcare service. More work is needed to improve outcomes for children with encephalitis.