Intensive Care Unit Consultants Research Articles

Family satisfaction with care provided to patients deceased in intensive care unit

Background & Objective: Patient’s family satisfaction is a crucial but often overlooked indicator of the quality of the intensive care unit (ICU). The goal was to assess how satisfied patients’ families were with the treatment they received for terminally ill patients, where we worked with them to create a care plan. Methods: The study was conducted in ICU at Pakistan Kidney and Liver Institute and Research Center (PKLI & RC), Lahore, Pakistan which is a quaternary care center between December 1st 2022 and April 30th 2023. We used the Family Satisfaction in the Intensive Care Unit 24 (FS-ICU 24) questionnaire to interview the next of kin of patients who passed away in our ICU. Results: Of the 330 patients admitted to the intensive care unit (ICU) between December 1, 2022, and April 30, 2023, 42 patients (12.7%) passed away. Mean age was 46.8 ± 14.5 years, with 28 men (66.7%) and 14 females (33.3%). Mean length of ICU stay was 5.57 ± 5.84 day. On a scale of 1-5 (1 = very Dissatisfied; 5 = fully satisfied) the overall family’s satisfaction score was 4.21 ± 0.52 with ICU consultants received a high satisfaction rating for informing families about their patients’ conditions and involving them in the decision-making process. Conclusion: The study showed involving family members in the care plan and helping them prepare for death not only helps them deal better but also makes them feel satisfied with the treatment they received in the intensive care unit, It makes them appreciate that they were able to participate in the decision-making process. doi: https://doi.org/10.12669/pjms.40.10.8697 How to cite this: Sharieff S, Sajjal A, Idrees A, Rafai WA. Family satisfaction with care provided to patients deceased in intensive care unit. Pak J Med Sci. 2024;40(10):2441-2446. doi: https://doi.org/10.12669/pjms.40.10.8697 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Mental health status among COVID-19 patients survivors of critical illness in Saudi Arabia: A 6-month follow-up questionnaire study.

Psychological assessment after intensive care unit (ICU) discharge is increasingly used to assess patients' cognitive and psychological well-being. However, few studies have examined those who recovered from coronavirus disease 2019 (COVID-19). There is a paucity of data from the Middle East assessing the post-ICU discharge mental health status of patients who had COVID-19. To evaluate anxiety and depression among patients who had severe COVID-19. This is a prospective single-center follow-up questionnaire-based study of adults who were admitted to the ICU or under ICU consultation for > 24 h for COVID-19. Eligible patients were contacted via telephone. The patient's anxiety and depression six months after ICU discharge were assessed using the Hospital Anxiety and Depression Scale (HADS). The primary outcome was the mean HADS score. The secondary outcomes were risk factors of anxiety and/or depression. Patients who were admitted to the ICU because of COVID-19 were screened (n = 518). Of these, 48 completed the questionnaires. The mean age was 56.3 ± 17.2 years. Thirty patients (62.5%) were male. The main comorbidities were endocrine (n = 24, 50%) and cardiovascular (n = 21, 43.8%) diseases. The mean overall HADS score for anxiety and depression at 6 months post-ICU discharge was 11.4 (SD ± 8.5). A HADS score of > 7 for anxiety and depression was detected in 15 patients (30%) and 18 patients (36%), respectively. Results from the multivariable ordered logistic regression demonstrated that vasopressor use was associated with the development of anxiety and depression [odds ratio (OR) 39.06, 95% confidence interval: 1.309-1165.8; P < 0.05]. Six months after ICU discharge, 30% of patients who had COVID-19 demonstrated a HADS score that confirmed anxiety and depression. To compare the psychological status of patients following an ICU admission (with vs without COVID-19), further studies are warranted.

Characteristics and Outcomes of Patients Requiring Repeat Intensive Care Unit Consults

ObjectiveTo better understand the mortality and notable characteristics of patients initially denied intensive care unit (ICU) admission that are later admitted on reconsultation. Patients and MethodsWe collected data regarding all adult inpatients (n=3725) who received one or more ICU consults at an academic tertiary care hospital medical center between January 1, 2018 and October 1, 2021. We compared patients who were initially denied ICU admission and later admitted on reconsultation (C2A1, n=144) with those who were admitted after the first consultation (C1A1, n=2286) and those denied at first consult and never later admitted (C1A0, n=1295). ResultsTen percent of patients initially rejected by the ICU were later admitted on reconsultation. There was no significant difference in the adjusted hospital death odds ratios between C1A1 and C2A1 (0.67; 95% CI 0.43-1.01; P=.11). Assessing subgroups of the C2A1 population, we found that 8.2% (n=100) of full code patients were later admitted to the ICU on reconsultation vs 23.2% (n=40) of do not attempt resuscitation patients (P<.001); 7.6% (n=77) of patients initially consulted from the emergency department were later admitted to the ICU on reconsultation vs 15.1% (n=52) of patients initially consulted from an inpatient setting (P<.001). ConclusionIn this cohort, we demonstrated that patients admitted on repeat ICU consultation have no significant difference in mortality compared with equivalent patients admitted after the first consultation. Understanding and further exploring the consequences of these ICU reconsultations is vital to developing optimal critical care triaging practices.

An analysis of referrals to a level 3 intensive care unit in a resource-limited setting in South Africa.

With a shortage of intensive care unit (ICU) beds and rising healthcare costs in resource-limited settings, clinicians need to appropriately triage admissions into ICU to avoid wasteful expenditure and unnecessary bed utilisation. To assess the nature, appropriateness and outcome of referrals to a tertiary centre ICU. A retrospective review of ICU consults from September 2016 to February 2017 at King Edward VIII Hospital was performed. The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE291/17). Data pertaining to patients' demographics, referring doctor, diagnosis, comorbidities as well as biochemical and haemodynamic parameters were extracted. This information was then cross-referenced to the outcome of the ICU consultation. Data were descriptively analysed. Five hundred consultations were reviewed over a 6-month period; 52.2% of patients were male and the mean age was 44 years. Junior medical officers referred 164 (32.8%) of the consultations. Although specialist supervision was available in 459 cases, it was only utilised in 339 (73.9%) of these cases. Most referrals were from tertiary (46.8%) or regional (30.4%) hospitals; however, direct referrals from district hospitals and clinics accounted for 20.4% and 1.4% of consultations, respectively. The appropriate referral pathway was not followed in 81 (16.2%) consultations. Forty-five percent of consults were accepted; however, 9.3% of these patients died before arrival in ICU. A total of 151 (30.2%) patients were refused ICU admission, with the majority (57%) of these owing to futility. Patients were unstable at the time of consult in 53.2% of referrals and 34.4% of consults had missing data. Critically ill patients are often referred by junior doctors without senior consultation, and directly from low-level healthcare facilities. A large proportion of ICU referrals are deemed futile and, of the patients accepted for admission, almost 1 in 10 dies prior to ICU admission. More emphasis needs to be placed on the training of doctors to appropriately triage and manage critically ill patients and ensure appropriate ICU referral and optimising of patient outcomes. There is a paucity of information related to ICU referrals in South Africa. The nature, appropriateness and outcomes of referrals to a tertiary ICU is discussed in this study.

The impact of inconsistent human annotations on AI driven clinical decision making

In supervised learning model development, domain experts are often used to provide the class labels (annotations). Annotation inconsistencies commonly occur when even highly experienced clinical experts annotate the same phenomenon (e.g., medical image, diagnostics, or prognostic status), due to inherent expert bias, judgments, and slips, among other factors. While their existence is relatively well-known, the implications of such inconsistencies are largely understudied in real-world settings, when supervised learning is applied on such ‘noisy’ labelled data. To shed light on these issues, we conducted extensive experiments and analyses on three real-world Intensive Care Unit (ICU) datasets. Specifically, individual models were built from a common dataset, annotated independently by 11 Glasgow Queen Elizabeth University Hospital ICU consultants, and model performance estimates were compared through internal validation (Fleiss’ κ = 0.383 i.e., fair agreement). Further, broad external validation (on both static and time series datasets) of these 11 classifiers was carried out on a HiRID external dataset, where the models’ classifications were found to have low pairwise agreements (average Cohen’s κ = 0.255 i.e., minimal agreement). Moreover, they tend to disagree more on making discharge decisions (Fleiss’ κ = 0.174) than predicting mortality (Fleiss’ κ = 0.267). Given these inconsistencies, further analyses were conducted to evaluate the current best practices in obtaining gold-standard models and determining consensus. The results suggest that: (a) there may not always be a “super expert” in acute clinical settings (using internal and external validation model performances as a proxy); and (b) standard consensus seeking (such as majority vote) consistently leads to suboptimal models. Further analysis, however, suggests that assessing annotation learnability and using only ‘learnable’ annotated datasets for determining consensus achieves optimal models in most cases.

Feasibility to estimate mean systemic filling pressure with inspiratory holds at the bedside.

Background: A decade ago, it became possible to derive mean systemic filling pressure (MSFP) at the bedside using the inspiratory hold maneuver. MSFP has the potential to help guide hemodynamic care, but the estimation is not yet implemented in common clinical practice. In this study, we assessed the ability of MSFP, vascular compliance (Csys), and stressed volume (Vs) to track fluid boluses. Second, we assessed the feasibility of implementation of MSFP in the intensive care unit (ICU). Exploratory, a potential difference in MSFP response between colloids and crystalloids was assessed. Methods: This was a prospective cohort study in adult patients admitted to the ICU after cardiac surgery. The MSFP was determined using 3-4 inspiratory holds with incremental pressures (maximum 35cm H2O) to construct a venous return curve. Two fluid boluses were administered: 100 and 500ml, enabling to calculate Vs and Csys. Patients were randomized to crystalloid or colloid fluid administration. Trained ICU consultants acted as study supervisors, and protocol deviations were recorded. Results: A total of 20 patients completed the trial. MSFP was able to track the 500ml bolus (p < 0.001). In 16 patients (80%), Vs and Csys could be determined. Vs had a median of 2029ml (IQR 1605-3164), and Csys had a median of 73mlmmHg-1 (IQR 56-133). A difference in response between crystalloids and colloids was present for the 100ml fluid bolus (p = 0.019) and in a post hoc analysis, also for the 500ml bolus (p = 0.010). Conclusion: MSFP can be measured at the bedside and provides insights into the hemodynamic status of a patient that are currently missing. The clinical feasibility of Vs and Csys was judged ambiguously based on the lack of required hemodynamic stability. Future studies should address the clinical obstacles found in this study, and less-invasive alternatives to determine MSFP should be further explored. Clinical Trial Registration: ClinicalTrials.gov Identifier NCT03139929.

Higher intensive care unit consultations for COVID-19 patients living with HIV compared to those without HIV coinfection in Uganda.

Coronavirus disease‐2019 (COVID‐19) is the leading cause of death worldwide from a single infectious agent. Whether or not HIV infection affects clinical outcomes in patients with COVID‐19 remains inconclusive. This study aimed to compare the clinical outcomes of people living with HIV (PLWH) and non‐HIV‐infected patients hospitalized during the second wave of the COVID‐19 pandemic in Uganda. We retrospectively retrieved data on patients with COVID‐19 who were admitted to the Mulago National Referral Hospital in Uganda between April 2021 and mid‐July 2021. We performed propensity‐score‐matching of 1:5 to compare outcomes in COVID‐19 patients living with and those without HIV coinfection (controls). We included 31 PLWH and 155 non‐HIV controls. The baseline characteristics were similar across groups (all p values > 0.05). PLWH had close to threefold higher odds of having ICU consultation compared to controls (odds ratio [OR]: 2.9, 95% CI: 1.2–6.9, p = 0.015). There was a trend toward having a severe or critical COVID‐19 illness among PLWHIH compared to controls (OR: 1.9, 95% CI: 0.8–4.7, p = 0.164). Length of hospitalization was not significantly different between PLWH and non‐HIV controls (6 days vs. 7 days, p = 0.184). Seven‐day survival was 63% (95% CI: 42%–78%) among PLWH and 72% (95% CI: 61%–82%) among controls while 14‐day survival was 50% (95% CI: 28%–69%) among PLWH and 65% (95% CI: 55%–73%) among controls (p = 0.280). There was another trend toward having 1.7‐fold higher odds of mortality among PLWH compared to controls (OR: 1.7, 95% CI: 0.8–3.8, p = 0.181). Our data suggest that PLWH may be at an increased risk of severe or critical COVID‐19 illness requiring ICU consultation. Further studies with larger sample sizes are recommended.

The Effect of Human Supervision on an Electronic Implementation of the Canadian Triage Acuity Scale (CTAS)

BackgroundMost electronic emergency department (ED) triage systems allow nurses to modify computer-generated triage scores. It is currently unclear how this affects triage validity. ObjectiveAre nurse-generated triage scores more strongly associated with rates of admission, intensive care unit (ICU) consultation, and mortality than computer-generated scores? MethodsRetrospective observational cohort study of all adult visits to a tertiary ED. An electronic implementation of the Canadian Triage Acuity Scale (CTAS) generated a CTAS score for each visit. In some cases, the triage nurse overwrote the computer-generated CTAS score with a score they felt was more appropriate. Among visits with nurse-modified triage scores, we compared the rate of acuity-related outcomes (mortality, ICU consultation, hospital admission) in each CTAS level as categorized by nurse-generated vs. computer-generated scores. ResultsIn a cohort of 229,744 patients, 19,566 (8.51%) had nurse-modified triage scores. Most modifications consisted of assigning a higher acuity triage score than recommended by the computer. Visits with triage scores 1–2 according to the nurse-generated scores had the same or higher rates of the acuity outcomes than visits that were CTAS 1–2 according to the computer-generated CTAS scores. Conversely, visits with triage scores 4–5 according to the nurse-generated scores had lower rates of the outcomes than visits that were CTAS 4–5 according to the computer-generated CTAS scores. ConclusionsNursing supervision of the computer-automated CTAS triage system was associated with fewer hospital admissions, ICU consultations, and deaths in the triage score 4–5 categories, suggesting a safer triage process than the automated CTAS algorithm alone.

Diagnosing ventilator-associated pneumonia (VAP) in UK NHS ICUs: the perceived value and role of a novel optical technology

BackgroundDiagnosing ventilator-associated pneumonia (VAP) in an intensive care unit (ICU) is a complex process. Our aim was to collect, evaluate and represent the information relating to current clinical practice for the diagnosis of VAP in UK NHS ICUs, and to explore the potential value and role of a novel diagnostic for VAP, which uses optical molecular alveoscopy to visualise the alveolar space.MethodsQualitative study performing semi-structured interviews with clinical experts. Interviews were recorded, transcribed, and thematically analysed. A flow diagram of the VAP patient pathway was elicited and validated with the expert interviewees. Fourteen clinicians were interviewed from a range of UK NHS hospitals: 12 ICU consultants, 1 professor of respiratory medicine and 1 professor of critical care.ResultsFive themes were identified, relating to [1] current practice for the diagnosis of VAP, [2] current clinical need in VAP diagnostics, [3] the potential value and role of the technology, [4] the barriers to adoption and [5] the evidence requirements for the technology, to help facilitate a successful adoption. These themes indicated that diagnosis of VAP is extremely difficult, as is the decision to stop antibiotic treatment. The analysis revealed that there is a clinical need for a diagnostic that provides an accurate and timely diagnosis of the causative pathogen, without the long delays associated with return of culture results, and which is not dangerous to the patient. It was determined that the technology would satisfy important aspects of this clinical need for diagnosing VAP (and pneumonia, more generally), but would require further evidence on safety and efficacy in the patient population to facilitate adoption.ConclusionsCare pathway analysis performed in this study was deemed accurate and representative of current practice for diagnosing VAP in a UK ICU as determined by relevant clinical experts, and explored the value and role of a novel diagnostic, which uses optical technology, and could streamline the diagnostic pathway for VAP and other pneumonias.

Dosage and clinical outcomes of medical emergency team and conventional referral mediated unplanned intensive care admissions.

Background: Unplanned intensive care unit (ICU) admission occurs via activation of medical emergency team (MET) and conventional ICU referral (CIR), i.e., ICU consultation. We aimed to compare the dosage, association with unplanned ICU admissions and hospital mortality between MET and CIR systems. Methods: We performed a retrospective, single centre observational study on unplanned ICU admissions from hospital wards between July 2017 and June 2018. We evaluated the dosage (expressed per 1000 admissions) and association of CIR and MET system with unplanned ICU admission using Chi-square test. The relationship (unadjusted and adjusted to Australia and New Zealand risk of death (ANZROD) and lead time) between unplanned ICU admission pathway (MET vs CIR) and hospital mortality was tested by binary logistic regression analysis [Odds ratio (OR) with 95% confidence interval (CI)]. Results: Out of 38,628 patients hospitalised, 679 had unplanned ICU admission (2%) with an ICU admission rate of 18 per 1000 ward admissions. There were 2153 MET and 453 CIR activations, producing a dosage of 56 and 12 per 1000 admissions, respectively. Higher unplanned ICU admission was significantly associated with CIR compared to MET activation (324/453 (71.5%) vs 355/2153 (16.5%) p < 0.001). On binary logistic regression, MET system was significantly associated with higher hospital mortality on unadjusted analysis (OR 1.65 (95% CI: 1.09-2.48) p = 0.02) but not after adjustment with ANZROD and lead time (OR 1.15 (95% CI: 0.71-1.86), p = 0.58). Conclusions: Compared to CIR, MET system had higher dosage but lower frequency of unplanned ICU admissions and lacked independent association with hospital mortality.

Factors Affecting Neurosurgeons' Decisions to Forgo Life-Sustaining Treatments After Traumatic Brain Injury

Traumatic brain injury (TBI) is a multifaceted condition that causes mortality and disability worldwide. Limited data are available on the factors associated with the decision for the withdrawal of life-sustaining treatment (WLST) for patients with TBI. In the present study, we aimed to determine the risk factors and attitudes affecting neurosurgeons when deciding on WLST for patients with TBI using a multicenter survey. An online questionnaire was applied worldwide and shared using social media platforms and electronic mail to ∼5000 neurosurgeons. The social media group "Neurosurgery Cocktail" was used to post a link to the questionnaire. In addition, randomly chosen neurosurgery clinics around the world were sent the survey via electronic mail. Of the participants, 17.22% had decided on WLST after TBI for >26 patients. Neurosurgeons with more WLST decisions were older, had had more clinical experience and intensive care unit (ICU) training, and were better prepared to involve the family members of TBI patients in their decision-making compared with those with fewer WLST decisions. The respondents stated that the patient's family, ICU consultants, and themselves played the most influential role in the WLST decisions, with the hospital administration, social workers, spiritual caregivers, and nurses having lesser roles. The current and presenting Glasgow coma scale scores, pupillary response, advanced patient age, candidates for a vegetative state, and impaired neurological function were significant factors associated with the WLST decision. To the best of our knowledge, the present study is the first to evaluate neurosurgeons concerning their opinions and behaviors regarding WLST decisions after TBI. Increased patient age, Glasgow coma scale score, pupillary response, the presence of comorbidities, candidacy for a vegetative state, and impaired neurological function were the main factors contributing to the decision for WLST. We also found that the family, ICU consultants, and the attending neurosurgeon had the most effective roles in the decisions regarding WLST.

Survival of mechanically ventilated ward patients and association with organisational factors: a multicentre prospective study

ObjectivesDetermine 90-day mortality of mechanically ventilated ward patients outside the intensive care unit (ICU) and its association with organisational factors.DesignMulticentre prospective observational study of mechanically ventilated ward patients. Modified Poisson...

Features and perceptions of a critical care outreach physician role

Objective: To describe the tasks completed by the critical care outreach physician (CCOP) and staff perceptions of the CCOP role.Design: Prospective observational study and survey of intensive care unit (ICU) staff.Setting: University-affiliated teaching hospital in Australia.Participants: ICU consultants, registrars and nurses.Interventions: Implementing a dedicated ICU consultant to review deteriorating patients outside the ICU.Main outcome measures: Prospective collection of CCOP tasks and survey of ICU staff.Results: During 101 clinical shifts, the CCOP had 1524 encounters (mean, 15.1 [standard deviation, 6.1]; median, 14 [interquartile range, 10–19] per day). The three commonest interventions were emergency department visits, direct consultant communication, and coordinating ICU admissions. Involvement in Medical Emergency Team (MET) calls, expediting patient care, and goals of care discussions were also relatively common. Survey responses were obtained from 55/84 (66%) eligible participants. Most respondents thought the CCOP would improve the predefined processes of care and patient-centred outcomes. The areas of greatest perceived benefit included supporting the MET registrar and coordinating simultaneous emergencies outside the ICU. Areas where the role was perceived to be less beneficial included improving handover, identifying patients at clinical risk outside the ICU, and reducing repeat MET calls.Conclusions: The tasks of a CCOP involved high level communication, coordination of care, and supervision of ICU staff. The effect of this role on patient-centred outcomes requires further research.

Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions

BackgroundVery few studies assessed the association between Intensive Care Unit (ICU) triage decisions and mortality. The aim of this study was to assess whether an association could be found between 30-day mortality, and ICU admission consultation conditions and triage decisions.MethodsWe conducted a retrospective cohort study in two large referral university hospitals in the Netherlands. We identified all adult cancer patients for whom ICU admission was requested from 2016 to 2019. Via a multivariable logistic regression analysis, we assessed the association between 30-day mortality, and ICU admission consultation conditions and triage decisions.ResultsOf the 780 cancer patients for whom ICU admission was requested, 332 patients (42.6%) were considered ‘too well to benefit’ from ICU admission, 382 (49%) patients were immediately admitted to the ICU and 66 patients (8.4%) were considered ‘too sick to benefit’ according to the consulting intensivist(s). The 30-day mortality in these subgroups was 30.1%, 36.9% and 81.8%, respectively. In the patient group considered ‘too well to benefit’, 258 patients were never admitted to the ICU and 74 patients (9.5% of the overall study population, 22.3% of the patients ‘too well to benefit’) were admitted to the ICU after a second ICU admission request (delayed ICU admission). Thirty-day mortality in these groups was 25.6% and 45.9%. After adjustment for confounders, ICU consultations during off-hours (OR 1.61, 95% CI 1.09–2.38, p-value 0.02) and delayed ICU admission (OR 1.83, 95% CI 1.00–3.33, p-value 0.048 compared to “ICU admission”) were independently associated with 30-day mortality.ConclusionThe ICU denial rate in our study was high (51%). Sixty percent of the ICU triage decisions in cancer patients were made during off-hours, and 22.3% of the patients initially considered “too well to benefit” from ICU admission were subsequently admitted to the ICU. Both decisions during off-hours and a delayed ICU admission were associated with an increased risk of death at 30 days. Our study suggests that in cancer patients, ICU triage decisions should be discussed during on-hours, and ICU admission policy should be broadened, with a lower admission threshold for critically ill cancer patients.

Access to Palliative Care for Critically Ill Cancer Patients in Mexico.

To determine the outcomes of hospitalized cancer patients requiring intensive care unit (ICU) intervention and receiving palliative care. An observational retrospective study was completed at a single academic critical care unit in Mexico City. All hospitalized cancer patients who were evaluated by the intensive care team to assess need for ICU were included between January and December 2018. During the study period, the ICU group made 408 assessments of critically ill cancer patients in noncritical hospitalized areas. In total, 24.2% (99/408) of the patients in this population were consulted by the palliative care team. Of the patients evaluated, 46.5% (190/408) had advanced stage, but only 28.4% were receiving care by the palliative care team. The only risk factor for hospital mortality in the multivariate analysis was the quick Sequential Organ Failure Assessment (qSOFA) score at the time of the consultation by the ICU group (HR = 2.10, 95% CI = 1.34-3.29, p = 0.001). The median time between palliative care consultation and death was 3 days (IQR = 2-22). A total of 63% (37/58) of patients who were discharged from the hospital died during follow-up. The median follow-up time was 55 days (95% CI = 26.9-83.0). The overall mortality rate for the entire group during hospitalization and after hospital discharge was 80.8% (80/99). Fewer than 3 out of 10 hospitalized cancer patients requiring admission to the ICU were evaluated by the palliative care team despite having incurable cancer. The qSOFA score of patients at the time of the ICU consultation was the only risk factor for mortality during hospitalization. Future research efforts in Mexico should focus on earlier integration of palliation care with usual oncology care in incurable cancer patients.

Physicians’ predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study

Background: Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. Aim: To determine whether physicians’ predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. Design: A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. Setting/participants: ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. Conclusions: ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.

Understanding and improving decision-making around referral and admissions to intensive care: a mixed methods study

Background: Intensive care treatment can be life-saving but is invasive and distressing for patients receiving them, and not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge. Objectives: To explore the decision-making process around referral and admission to ICU and develop an intervention to improve it. Methods: A mixed methods study including: a) Two systematic reviews investigating factors associated with decisions to admit to an intensive care unit (ICU) and experiences of clinicians, patients and families of the process. b) A focused ethnographic study including observation of decisions and interviews with ICU doctors, referring doctors, patients and families in six NHS Trusts in the UK Midlands. 55 decisions regarding 46 patients were observed. 101 doctors were interviewed. c) A Choice Experiment questionnaire survey with paired patient profiles developed using data from the ethnographic study and systematic reviews. UK ICU consultants and Critical Care Outreach Nurses were invited to participate. Participants’ preferences for ICU admission were analysed using a Random Utility Framework and preference heterogeneity using a latent class logit (LCL) model. d) Using the data from systematic reviews, ethnographic study and CE we developed a Decision Support Intervention (DSI) including an ethical framework for decision-making, guidance for referral and supporting referral and decision support forms and patient and family information leaflets. It was tested for implementation feasibility in three NHS Trusts purposively sampled for size of ICU. An eight week implementation period was followed by six weeks data collection. Quantitative and qualitative data were collected to evaluate form usage, intervention acceptability, barriers and facilitators to implementation, and impact on decisionmaking. e) A tool to evaluate the ethical quality of decision-making related to ICU admission was developed, based on assessment of patient records. The tool was tested for inter-rater and inter-site reliability in 120 patient records across the three sites in the implementation feasibility study. Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of DNACPR order, referring specialty, referrer seniority, and ICU bed availability. ICU doctors used a gestalt assessment of the patient in making decisions. The CE showed age was the most important factor in consultant and CCOR nurses preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, the importance of inter-professional relationships, and good communication between teams and with patients and families. Doctors find it difficult to articulate and balance benefits and burdens of ICU treatment for a patient. There was low uptake of the DSI although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients. Several challenges were identified in developing an evaluation tool.

Profile of ICU Bed Requests at Helen Joseph Hospital

Abstract Background: Intensive care unit (ICU) beds are a scarce resource at Helen Joseph Hospital (HJH). A limited number of beds serve a population with a large burden of disease. Medical practitioners request ICU beds for patients they deem in need of ICU management. However, the decision to admit patients to the ICU remains the responsibility of the ICU consultant on call. No formal prognostic scoring system (such as Acute Physiological and Chronic Health Evaluation or Simplified Acute Physiology Score) or admission guidelines were in place when performing this study. Aim: To compile a profile of all the ICU admission requests at HJH. Methods: A contextual, prospective, descriptive research design was followed in this study. Data was collected during one winter and one summer month in 2012 using consecutive sampling from ICU consultation forms. Results: A total of 139 patients were included in the study. The median age was 44 years. The majority of patients (79%) were under the age of 60 years. The overall admission rate was 35.25% and the most common reason for admission was mechanical ventilation. Of the patients refused ICU admission, 41% were assessed as being too ill, 30% were assessed as too well and 29% were refused admission due to a lack of resources. Patients admitted to the ICU had a 77.55% survival rate. The relationship between ICU admission and 30-day improved outcome was statistically significant, with those being admitted to ICU having a better outcome. Conclusions: Overall a relatively young population is admitted to ICU at HJH. The allocation of beds between the disciplines is fairly equal, both with good survival benefits. The lack of ICU resources is an important limitation to ICU admission. Admission to ICU demonstrated a survival benefit.

Application of Quality Control Circle in Improving the Correct Implementation Rate of Multiple Drug Resistant Organism Isolation Measures in ICU Medical Personnel

Objective: Effective isolation management of multiple drug resistant organism (MDRO) patients is considered an important measure to prevent cross-infection. To reduce the spread of MDRO, there is a need to improve the correct implementation of isolation measures for intensive care unit (ICU) medical personnel. We will investigate the application of quality control circle (QCC) activities in improving the correct implementation rate of isolation measures for patients with MDRO in ICU medical personnel. Methods: A 10-member QCC activity group was established. All of the ICU medical personnel were taken as the research objects, including doctors, nurses, assistant nurses, rotation training personnel, external ICU consultants and cleaning personnel. The correct implementation of isolation measures for patients with MDRO infection were investigated and studied, which identified the problem areas and analyzed the main reasons. The quality improvement countermeasures were formulated and implemented in ICU medical personnel, while the results were compared with before and after the QCC activities. Results: After QCC activities, the correct implementation rate of isolation measures by ICU medical personnel for patients with MDRO infection increased from 57.7% to 82.4%. The incidence of MDRO infection in ICU patients decreased from 9.64% to 3.77%, with statistically significant differences (P < 0.05). Conclusion: The QCC activities improved the correct implementation rate of MDRO isolation measures by ICU medical personnel, standardizing the isolation management of MDRO patients, while the incidence of MDRO in ICU patients was also effectively reduced.

Assessment of a Hospital-Wide CIWA-Ar Protocol for Management of Alcohol Withdrawal Syndrome.

ObjectiveTo determine if a hospital-wide symptom-based alcohol withdrawal protocol may result in significant clinical improvements to patient outcomes, safety, and hospital efficiency.MethodsRetrospective/prospective cohort study between January 1, 2016 and December 31, 2016 (pre-protocol), and between March 1, 2017 and August 7, July 2017 (post-protocol). Pre-protocol patients were identified retrospectively using International Classification of Diseases, 10th revision codes (F10.1, F10.2, and Z71.4). Post-protocol patients were identified by the use of a unique alcohol withdrawal order set in their electronic medical record. The primary endpoint was average length of stay. Secondary outcomes included death, escalation of care as defined as requiring intensive care unit (ICU) consultation or the rapid response team, average ICU length of stay, respiratory failure, average benzodiazepine usage, and incidence of seizures.ResultsThe study included 276 patients in the pre-protocol group and 145 patients in the post-protocol group. There was a significant reduction found in the primary endpoint of average length of stay (7.15 ± 6.5 days vs 5.7 ± 5.6 days; P=.02). There was a significant reduction in the average benzodiazepine use, use of adjunctive medications, need for ICU consultation or rapid response team, respiratory failure, average ICU length of stay, use of neurologic imaging, and the need for lumbar puncture.ConclusionImplementation of a Clinical Institute Withdrawal Assessment for Alcohol, Revised–based alcohol withdrawal protocol may significantly improve quality of care, patient safety, and treatment effectiveness in a large, mixed medical/surgical, urban community-based academic medical center.