Intensive Care Unit Physicians Research Articles

Clinical impact of physician staffing transition in intensive care units: a retrospective observational study

BackgroundIntensivists play an essential role in improving the outcomes of critically ill patients in intensive care units (ICUs). The transition of ICU physician staffing from low-intensity ICUs (elective intensivist or no intensivist consultation) to high-intensity ICUs (mandatory intensivist consultation or a closed ICU) improves clinical outcomes. However, whether a transition from high-intensity to low-intensity ICU staffing affects ICU outcomes and quality of care remains unknown.MethodsA retrospective observational study was conducted to examine the impact of high- versus low-intensity staffing models on all-cause mortality in a suburban secondary community hospital with 400 general beds and 8 ICU beds. The ICU was switched from a high-intensity staffing model (high-former period) to low-intensity staffing in July 2019 (low-mid period) and then back to high-intensity staffing in March 2020 (high-latter period). Patients admitted from the emergency department, general ward, or operating room after emergency surgery were enrolled in these three periods and compared, balancing the predicted mortality and covariates of the patients. The primary outcome was all-cause mortality analyzed using hazard ratios (HRs) from Cox proportional hazards regression. An interrupted time-series analysis (ITSA) was also conducted to evaluate the effects of events (level change) and time.ResultsThere were 962 eligible admissions, of which 251, 213, and 498 occurred in the high-former, low-mid, and high-latter periods, respectively. In the matched group (n = 600), the all-cause mortality rate comparing the high-former period with the low-mid period showed an HR of 0.88 [95% confidence interval (CI), 0.56, 1.39; p = 0.58] and that comparing the high-latter period with the low-mid period showed an HR of 0.84 [95% CI, 0.54, 1.30; p = 0.43]. The result for comparison between the three periods was p = 0.80. ITSA showed level changes of 4.05% [95% CI, -13.1, 21.2; p = 0.63] when ICU staffing changed from the high-former to the low-mid period and 1.35% [95% CI, -13.8, 16.5; p = 0.86] when ICU staffing changed from the low-mid to the high-latter period.ConclusionThere was no statistically significant difference in all-cause mortality among the three ICU staffing periods. This study suggests that low-intensity ICU staffing might not worsen clinical outcomes in the ICU in a medium-sized community hospital. Multiple factors, including the presence of an intensivist, other medical staff, and practical guidelines, influence the prognosis of critically ill patients.

Nordic survey on assessment and treatment of fluid overload in intensive care.

Fluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU. We developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022. We received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05-0.50 mcg/kg/min) when administering loop diuretics. Self-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.

The Emergence of Travel-related Infections in Critical Care Units.

Several tropical or geographically confined infectious diseases may lead to organ failure requiring management in an intensive care unit (ICU), both in endemic low- and middle-income countries where ICU facilities are increasingly being developed and in (nonendemic) high-income countries through an increase in international travel and migration. The ICU physician must know which of these diseases may be encountered and how to recognize, differentiate, and treat them. The four historically most prevalent "tropical" diseases (malaria, enteric fever, dengue, and rickettsiosis) can present with single or multiple organ failure in a very similar manner, which makes differentiation based solely on clinical signs very difficult. Specific but frequently subtle symptoms should be considered and related to the travel history of the patient, the geographic distribution of these diseases, and the incubation period. In the future, ICU physicians may also be more frequently confronted with rare but frequently lethal diseases, such as Ebola and other viral hemorrhagic fevers, leptospirosis, and yellow fever. No one could have foreseen the worldwide 2019-up to now coronavirus disease 2019 (COVID-19) crisis caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was initially spread by travel too. In addition, the actual pandemic due to SARS-CoV-2 reminds us of the actual and potential threat of (re)-emerging pathogens. If left untreated or when treated with a delay, many travel-related diseases remain an important cause of morbidity and even mortality, even when high-quality critical care is provided. Awareness and a high index of suspicion of these diseases is a key skill for the ICU physicians of today and tomorrow to develop.

Surgical chest complications after liver transplantation.

Liver transplantation is a major abdominal operation and the intimate anatomic relation of the liver with the right hemidiaphragm predisposes the patient to various manifestations in the chest cavity. Furthermore, chronic liver disease affects pulmonary function before and after liver transplantation resulting in a considerable percentage of patients presenting with morbidity related to chest complications. This review aims to identify the potential chest complications of surgical interest during or after liver transplantation. Complications of surgical interest are defined as those conditions that necessitate an invasive procedure (such as thoracocentesis or a chest tube placement) in the chest or a surgical intervention performed by a thoracic surgeon. These complications will be classified as perioperative and postoperative; the latter will be categorized as early and late. Although thoracocentesis or a chest tube placement is usually sufficient when invasive measures are deemed necessary, in some patients, thoracic surgical interventions are warranted. A high index of suspicion is needed to recognize and treat these conditions promptly. A close collaboration between abdominal surgeons, intensive care unit physicians and thoracic surgeons is of paramount importance.

Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error

BackgroundStrategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisciplinary conferences (MDCs), radiologists and ICU physicians re-evaluate recent examinations. Structured bilateral feedback is provided to identify errors early. This study aims at investigating its impact on the occurrence of QM events (imaging-related errors). Standardised protocols of all MDCs from 1st of June 2018 through 31st of December 2019 were analysed with regard to categories of QM events (i.e. indication, procedure, report) and resulting consequences.ResultsWe analysed 241 MDCs with a total of 973 examinations. 14.0% (n = 136/973) of examinations were affected by QM events. The majority of events were report-related (76.3%, n = 106/139, e.g. misinterpreted finding), followed by procedure-related (18.0%, n = 25/139, e.g. technical issue) and indication-related events (5.8%, n = 8/139, e.g. faulty indication). The median time until identification of a QM event (time to MDC) was 2 days (interquartile range = 2). Comparing the first to the second half of the intervention period, the incidence of QM events decreased significantly from 22.9% (n = 109/476) to 6.0% (n = 30/497) (p < 0.0001). Significance of this effect was confirmed by linear regression (p < 0.0001).ConclusionsEstablishing structured discussion and feedback between radiologists and intensive care physicians in the form of MDCs is associated with a statistically significant reduction in QM events. These results indicate that MDCs may be one suitable approach to timely identify imaging-related error.

Current state and practice variation in the use of Meningitis/Encephalitis (ME) FilmArray panel in children

BackgroundThe Meningitis/Encephalitis FilmArray® Panel (ME panel) was approved by the U.S. Food and Drug Administration in 2015 and provides rapid results when assessing patients with suspected meningitis or encephalitis. These patients are evaluated by various subspecialties including pediatric hospital medicine (PHM), pediatric emergency medicine (PEM), pediatric infectious diseases, and pediatric intensive care unit (PICU) physicians. The objective of this study was to evaluate the current use of the ME panel and describe the provider and subspecialty practice variation.MethodsWe conducted an online cross-sectional survey via the American Academy of Pediatrics Section of Hospital Medicine (AAP-SOHM) ListServe, Brown University PEM ListServe, and PICU Virtual pediatric system (VPS) Listserve.ResultsA total of 335 participants out of an estimated 6998 ListServe subscribers responded to the survey. 68% reported currently using the ME panel at their institutions. Among test users, most reported not having institutional guidelines on test indications (75%) or interpretation (76%). 58% of providers self-reported lack of knowledge of the test’s performance characteristics. Providers from institutions that have established guidelines reported higher knowledge compared to those that did not (51% vs. 38%; p = 0.01). More PHM providers reported awareness of ME panel performance characteristics compared to PEM physicians (48% vs. 27%; p = 0.004); confidence in test interpretation was similar between both groups (72 vs. 69%; p = 0.80).ConclusionDespite the widespread use of the ME panel, few providers report having institutional guidelines on test indications or interpretation. There is an opportunity to provide knowledge and guidance about the ME panel among various pediatric subspecialties.

Impact of a pharmacist‐driven antimicrobial stewardship program on the prescription of antibiotics by intensive care physicians in a Latin American hospital: A retrospective study

AbstractBackgroundThe implementation of antimicrobial stewardship programs (AMS) has shown to be an effective tool for the rational use of antimicrobials, but this has been challenging in several Latin American countries, due to limited resources, such as the lack of trained clinical pharmacists in infectious disease. This study aims to determine the impact of a pharmacist‐driven AMS on the prescription of antibiotics by intensive care physicians (ICPs) and the bacterial resistance patterns in a Latin American hospital.MethodsA retrospective observational study was conducted that compared the optimal selection and the consumption (days of therapy/1000 ICP patient‐days) of antibiotics in patients treated by intensive care unit (ICU) physicians, before and after AMS implementation, defined as pre‐AMS (January–December 2014) and post‐AMS (January 2020–March 2021) at Hospital Clínica Bíblica, Costa Rica. Bacterial resistance patterns were also compared.Results333 patients met the inclusion criteria (52% pre‐AMS and 48% post‐AMS). After a five‐year intervention, the optimal antibiotic selection prescribed by ICP was 43.1% (n = 75) in the pre‐AMS period and 86.8% (n = 138) in the post‐AMS period (43.7% absolute improvement, P &lt; 0.001). The prescription trends of some antibiotics showed an improvement, such as ertapenem in 45% (P &lt; 0.001) and levofloxacin in 59% (P &lt; 0.001). Also, there was an improvement in some empiric antibiotic prescriptions with the diagnosis, including an increase of 32% (P &lt; 0.001) in Community‐Acquired Pneumonia. There was a reduction in the consumption of antimicrobials including a decrease of 66.9% (P = 0.017) for vancomycin and 64.7% (P = 0.033) for meropenem. Regarding bacterial resistance, the study found a decrease of 11% (P = 0.048) in Pseudomonas aeruginosa resistant to meropenem and a reduction in the detection of extended‐spectrum beta‐lactamase in Escherichia coli (11% decrease; P = 0.007).ConclusionThe pharmacist‐driven AMS showed a positive impact on antibiotic selection and consumption in ICU patients. In addition, strategies implemented through the AMS could have had a beneficial impact on antibiotic resistance.

Meropenem/Vaborbactam and Cefiderocol as Combination or Monotherapy to Treat Multi-Drug Resistant Gram-Negative Infections: A Regional Cross-Sectional Survey from Piedmont Infectious Disease Unit Network (PIDUN).

Meropenem/vaborbactam (MV) and cefiderocol were recently approved by the Food and Drug Administration and European Medicines Agency and are among the most promising antibacterial in treatment regimens against multi-drug resistant (MDR) gram-negative bacilli. A survey with close-ended questions was proposed to infectious disease (ID) and intensive care unit (ICU) physicians of Piedmont and Valle d'Aosta Region's hospitals. The aim was to collect data about habits and prescriptions of cefiderocol and MV. Twenty-three physicians (11 ID specialists and 12 anesthesiologists) in 13 Italian hospitals took part in the survey. Both cefiderocol and MV were mostly used as target therapy after a previous treatment failure and after ID specialist consult. The most frequent MDR pathogen in hospitals was Klebsiella pneumoniae carbapenemase-producing bacteria (KPC), followed by P. aeruginosa and A. baumannii. MDRs were more frequently isolated in ICU. In conclusion, cefiderocol was used in empiric regimens when A.baumannii was suspected, while MV was more used in suspect of KPC. MV and cefiderocol can be the first option in empiric treatment for critically ill patients in settings with high risk of MDR. The treatment should then be followed by rapid de-escalation when microbiological results are available.

Palliative Care e-Learning for Physicians Caring for Critically Ill and Dying Patients during the COVID-19 Pandemic: An Outcome Evaluation with Self-Assessed Knowledge and Attitude.

During the COVID-19 pandemic, the care of critically ill and dying patients in isolation wards, intensive care units (ICUs), and regular wards was severely impaired. In order to support physicians in communicative and palliative care skills, an e-learning tool was developed as part of the joint project “Palliative Care in Pandemic Times” (PallPan). This study investigates the feasibility of this e-learning tool. Secondly, we aim to analyze changes in knowledge and attitude upon completion of the e-learning tool. A 38-item questionnaire-based evaluation study with assessment of global and specific outcomes including ICU and non-ICU physicians was performed. In total, 24 questionnaires were included in the anonymous analysis. Feasibility was confirmed by a very high rate of overall satisfaction (94% approval), with relevance reaching 99% approval. Overall, we detected high gains in knowledge and noticeably lower gains on the attitude plane, with the highest gain in naming reasons for incorporating palliative care. The lowest learning gain on the attitude plane was observed when the participants were confronted with their own mortality. This study shows that e-learning is a feasible tool for gaining knowledge and even changing the attitudes of physicians caring for critically ill and dying patients in a self-assessment evaluation.

Perceptions and attitudes of ICU physicians toward antibiotics prescribing and resistance: A cross-sectional study.

Background and aimAntibiotic resistance is a major emphasis in intensive care units (ICUs). Better understanding of ICU physicians’ perceptions, attitudes, and knowledge about antimicrobial prescribing practices could facilitate more effective interventions in fighting antimicrobial resistance in Egyptian ICUs and establishing a proper Antimicrobial Stewardship Program.MethodsA cross-sectional questionnaire study was conducted including 92 physicians distributed across the different types of Egyptian healthcare institutions in two cities of Egypt; Cairo and El Monufia. Over a period of three months, started in December 2019 and ended in February 2020.ResultsA total of 92 Egyptian physicians were included in the study. Seventy (76.1%) of the surveyed physician strongly agreed and 22 (23.9%) agreed that antibiotic resistance is a worldwide problem. Moreover, 50 (54.3%) strongly agreed and 40 (43.4%) agreed that it is a problem in their hospitals while only 2 (2.1%) disagreed. Poor hand hygiene (67.5%), poor infection control practices by healthcare professionals (63.9%) as well as wrong practices in the management of invasive devices (68.7%), and poor environmental cleaning practices (63.4%) were considered very important causes of AMR by the majority of the surveyed ICU physicians. Almost all of the physicians (95%) rated an advice from a clinical pharmacist as very or moderately helpful intervention, while (52%) declared an advice from a microbiologist or an infectious disease specialist as very helpful.ConclusionThe results of the present study showed that the Egyptian ICU physicians have remarkable knowledge regarding antibiotic resistance as a worldwide problem and a high sensibility toward the problem in their hospitals. The study also showed that implementation of proper AMS is an urgent need as physicians answers for the different questions in the survey showed that their attitudes and perceptions regarding antibiotic resistance and their way in prescription could be modified and improved if AMS programs with suitable training programs and local guidelines are provided among different types of Egyptian hospitals.

"A Delicate balance"-Perceptions and Experiences of ICU Physicians and Nurses Regarding Controlled Donation After Circulatory Death. A Qualitative Study.

Controlled donation after circulatory death (cDCD) is considered by many as a potential response to the scarcity of donor organs. However, healthcare professionals may feel uncomfortable as end-of-life care and organ donation overlap in cDCD, creating a potential barrier to its development. The aim of this qualitative study was to gain insight on the perceptions and experiences of intensive care units (ICU) physicians and nurses regarding cDCD. We used thematic analysis of in-depth semi-structured interviews and 6-month field observation in a large teaching hospital. 17 staff members (8 physicians and 9 nurses) participated in the study. Analysis showed a gap between ethical principles and routine clinical practice, with a delicate balance between end-of-life care and organ donation. This tension arises at three critical moments: during the decision-making process leading to the withdrawal of life-sustaining treatments (LST), during the period between the decision to withdraw LST and its actual implementation, and during the dying and death process. Our findings shed light on the strategies developed by healthcare professionals to solve these ethical tensions and to cope with the emotional ambiguities. cDCD implementation in routine practice requires a shared understanding of the tradeoff between end-of-life care and organ donation within ICU.

Intensive Care Residents' Views Regarding Ethical Issues and Practices.

BackgroundThis study sought to understand the ethical issues encountered by medical residents during their residencies, evaluate the solutions proffered by them, and present their suggestions.Material/MethodsA survey consisting of 32 questions, including demographic information, was developed and distributed to Intensive Care Unit (ICU) residents from December 2020 to January 2021. A total of 53 completed questionnaires were submitted to the researchers. The data were analyzed using SPSS software version 26.0.ResultsOf the participating residents who returned completed forms, 50.9% were male and 49.1% were female, with an overall mean age of 30.5±4.4 years. Most residents’ views on ethical issues concerned themselves, the clinic, and patients/patient relatives. Responses showed a number of commonalities with the views of ICU physicians in other countries. Suggestions for resolving ethical issues solutions included instruction in medical ethics for all staff, increasing and strengthening pathways of communication both inside and outside of the clinics, regular inventory of medical supplies and assessment of equipment to prevent a shortage of resources, and the establishment of a hospital ethics committee.ConclusionsAs numerous and varied ethical issues were encountered in the participating ICUs, we propose the following: preparation of an ICU-specific guide for resolving ethical problems, clarification of rules based on legal regulations, determining a hierarchy of responsibilities, and ethics courses for all ICU staff. In addition, hospital managers should support ICU services from both a legal and ethical standpoint.

Association between serum calcium and in-hospital mortality in critical patients with multiple myeloma: a cohort study

ABSTRACT Background Elevated serum calcium levels may serve as a useful clinical biomarker of mortality in patients with multiple myeloma(MM). However, the clinical significance of the relationship between serum calcium levels and in-hospital mortality in MM patients admitted to the Intensive Care Unit (ICU) remains unclear. Objectives This study aimed to explore the association between serum calcium levels and in-hospital mortality in patients with MM in the ICU. Methods Patients with MM were identified from the Medical Information Mart for Intensive Care IV(MIMIC-IV) database. The outcome was in-hospital mortality. Multivariable-adjusted Cox regression analysis, curve fitting, and threshold effects analysis were used to assess the relationship between serum calcium levels and in-hospital mortality in patients with MM in the ICU. Results Our study included 262 patients with MM with a mean age of 72.3 ± 11.0 years, 63.4% of whom were male. The in-hospital mortality was 19.5% (51/262). The relationship between serum calcium levels and in-hospital mortality was nonlinear. The effect size on the left and right sides of the inflection point, were 0.270 (HR: 0.270, 95% CI 0.106-0.687, P < 0.05) and 2.104 (HR: 2.104, 95% CI 1.069-4.142, P < 0.05), respectively. The results of the sensitivity analysis remained stable. Conclusion Our findings show that a nonlinear relationship exists between serum calcium levels and in-hospital mortality in critically ill patients with MM. A serum calcium level of approximately 8.40 mg/dL was associated with the lowest risk of in-hospital mortality, which increases with rising serum calcium levels, and should be of concern to ICU physicians.

Care providers' experiences regarding barriers to maternal participation in neonatal pain management.

Mothers' involvement in the pain management of infants admitted to the intensive care unit can alleviate the infants' pain. Despite International guidelines, maternal involvement in neonatal pain management is low. Hence, investigating the perspectives of care providers (CPs) on barriers to maternal participation can be helpful in developing practice guidelines. The purpose of this study was to investigate the experiences of CPs on barriers to maternal involvement in neonatal pain management in the intensive care unit. In this study, a qualitative design based on the content analysis approach was used. We included 24 nurses and physicians in the neonatal intensive care unit from February to September 2020. Data were collected through conducting 11 individual interviews and two focus group discussions with eight and five participants, respectively. Three main categories and seven sub-categories were found, including maternal barriers (inadequate emotional readiness and unfamiliarity with role), CPs' barriers (time pressure, fear of family-care provider tension, and insufficient knowledge), and organizational barriers (neglected joint decision-making and restricted organizational participative policies). The identified barriers could be classified into those related to mothers, care providers, and organizations. The lack of appropriate interaction and cooperation between parents and care-providers can affect the emergence of barriers related to the mothers and staff. There is a lack of knowledge regarding neonatal pain management in the health care team and mothers. Educating mothers and CPs about the benefits and ways of mothers' participation can increase readiness and capabilities. Providing clear guidelines about family-centred care and promoting parent-CPs' interactions can increase the mothers' participation.

Factors Associated With Deep Sedation Practice in Mechanically Ventilated Patients: A Post hoc Analysis of a Cross-Sectional Survey Combined With a Questionnaire for Physicians on Sedation Practices.

PurposeThe study aimed to explore factors associated with deep sedation practice in intensive care units (ICUs).Materials and MethodsA post hoc analysis was conducted for a cross–sectional survey on sedation practices in mechanically ventilated (MV) patients, combined with a questionnaire for physicians regarding their preferences for light sedation (P–pls Score) in 92 Chinese ICUs.ResultsThere were 457 and 127 eligible MV patients in the light and deep sedation groups respectively. A multivariable logistic regression analysis demonstrated that the control mode of mechanical ventilation, plasma lactate level, and the Sequential Organ Failure Assessment (SOFA) score were independent risk factors for deep sedation practice (p <0.01). Notably, the adjusted odds ratio (95% CI) of the average P–pls score in the ICU ≤ 2 for deep sedation practice was 1.861 (1.163, 2.978, p = 0.01). In addition, the areas under curves of receiver operating characteristics (AUC–ROC) of the model to predict the probability of deep sedation practice were 0.753 (0.699, 0.806) and 0.772 (0.64, 0.905) in the training set and the validation set, respectively. The 28–day mortality was increased in patients with exposure to deep sedation practice but not significantly.ConclusionBoth factors related to stressful stimuli and the ICU physicians' perception of patient tolerability in mechanical ventilation were likely associated with deep sedation practice in MV patients.

Symptoms of Anxiety, Depression, and Post-Traumatic Stress Disorder in Health Care Personnel in Norwegian ICUs during the First Wave of the COVID-19 Pandemic, a Prospective, Observational Cross-Sectional Study.

Background: The COVID-19 pandemic has induced demanding work situations in intensive care units (ICU). The objective of our study was to survey psychological reactions, the disturbance of social life, work effort, and support in ICU nurses, physicians, and leaders. Methods: From May to July 2020, this cross-sectional study included 484 ICU professionals from 27 hospitals throughout Norway. Symptoms of anxiety and depression were measured on Hopkins Symptom Checklist-10 (HSCL-10). Symptoms of post-traumatic stress disorder (PTSD) were measured on the PCL-5. Results: The study population were highly educated and experienced professionals, well prepared for working with COVID-ICU patients. However, 53% felt socially isolated and 67% reported a fear of infecting others. Probable cases of anxiety and depression were found in 12.5% of the registered nurses, 11.6% of the physicians, and 4.1% of the leaders. Younger age and <5 years previous work experiences were predictors for high HSCL-10 scores. Reported symptom-defined PTSD for nurses 7.1%; the leaders, 4.1%; and 2.3% of physicians. Conclusions: ICU health care professionals experienced talking with colleagues as the most helpful source of support. The COVID-ICU leaders reported a significantly higher mean score than physicians and nurses in terms of pushing themselves toward producing high work effort.

Birth asphyxia is under‐rated as a cause of preterm neonatal mortality in low‐ and middle‐income countries: A prospective, observational study from PURPOSe

To assess respiratory distress syndrome (RDS) compared with birth asphyxia as the cause of death in preterm newborns, assigned by the neonatal intensive care unit (NICU) physician at the time of death and assigned by a panel with complete obstetric history, placental evaluation, tissue histology and microbiology. Prospective, observational study. Study NICUs in India and Pakistan. Preterm infants delivered in study facility. A total of 410 preterm infants who died in the NICU with cause of death ascertained by the NICU physicians and independently by expert panels. We compared the percentage of cases assigned RDS versus birth asphyxia as cause of death by the physician and the panel. RDS and birth asphyxia. Of 410 preterm neonatal deaths, the discharging NICU physicians found RDS as a cause of death among 83.2% of the cases, compared with the panel finding RDS in only 51.0%. In the same neonatal deaths, the NICU physicians found birth asphyxia as a cause of death in 14.9% of the deaths, whereas the panels found birth asphyxia in 57.6% of the deaths. The difference was greater in Pakistan were the physicians attributed 89.7% of the deaths to RDS and less than 1% to birth asphyxia whereas the panel attributed 35.6% of the deaths to RDS and 62.7% to birth asphyxia. NICU physicians who reported cause of death in deceased preterm infants less often attributed the death to birth asphyxia, and instead more often chose RDS, whereas expert panels with more extensive data attributed a greater proportion of deaths to birth asphyxia than did the physicians.

REDUCE - Indication catalogue based ordering of chest radiographs in intensive care units.

To advance a transition towards an indication-based chest radiograph (CXR) ordering in intensive care units (ICUs) without compromising patient safety. Single-center prospective cohort study with a retrospective reference group including 857 ICU patients. The routine group (n = 415) received CXRs at the discretion of the ICU physician, the restrictive group (n = 442) if specified by an indication catalogue. Documented data include number of CXRs per day and CXR radiation dose as primary outcomes, re-intubation and re-admission rates, hours of mechanical ventilation and ICU length of stay. CXR numbers were reduced in the restrictive group (964 CXRs in 2479 days vs. 1281 CXRs in 2318 days) and median radiation attributed to CXR per patient was significantly lowered in the restrictive group (0.068 vs. 0.076 Gy x cm2, P = 0.003). For patients staying ≥24 h, median number of CXRs per day was significantly reduced in the restrictive group (0.41 (IQR 0.21-0.61) vs. 0.55 (IQR 0.34-0.83), P < 0.001). Survival analysis proved non-inferiority. Secondary outcome parameters were not significantly different between the groups. CXR reduction was significant even for patients in most critical conditions. A substantial reduction of the number of CXRs on ICUs was feasible and safe using an indication catalogue thereby improving resource management. DRKS00015621, German Clinical Trials Register.

Communication during covid area: The impact of creating a new communication center

BackgroundSince the breakout of COVID-19 pandemic, many ways have been proposed to improve the quality of communication between the medical staff patient and their familiesIn our department of intensive care unit in tanger Morocco and due to the lack of resources we proposed to create a communication center near the hospital to keep the families updated. ObjectivesExplore the outcomes and the satisfaction of family members and intensive care unit physicians about the quality of communication through reception center during the restrictive measures imposed by COVID-19. Methodswe have conducted a satisfaction survey with sample of 100 families and 35 members of ICU physician during the period between August and December 2021. ResultsWe found that communications allowed families a better understanding of the clinical state of their patient, However it was inferior to the visit near bed visits, they also thought that it helps reduce the stress due to the lack of information. Physicians believedthat the communication center improved the quality of care given to the patient and helped to reduce the tension with family and increased the trust link between then and family members. ConclusionThe creation of reception center improved the relation between physicians and families and improved the quality care however it remains insufficient and other strategies should be considered including telecommunication and near bed visits specially in seriouslyç ill patients

Italian Version of the Cornell Assessment of Pediatric Delirium: Evaluation of the Scale Reliability and Ability to Detect Delirium Compared to Pediatric Intensive Care Unit Physicians Clinical Evaluation

BackgroundDelirium is an acute brain dysfunction associated with increased length of hospitalization, mortality, and high healthcare costs especially in patients admitted to the pediatric intensive care unit (PICU). The Cornell Assessment of Pediatric Delirium (CAPD) is a screening tool for evaluating delirium in pediatric patients. This tool has already been used and validated in other languages but not in Italian.ObjectivesTo test the reliability of the Italian version of the CAPD to screen PICU patients for delirium and to assess the agreement between CAPD score and PICU physician clinical evaluation of delirium.MethodsProspective double-blinded observational cohort study of patients admitted to a tertiary academic center PICU for at least 48 h from January 2020 to August 2021. We evaluated intra- and inter-rater agreement using the Intraclass Correlation Coefficient (ICC). The ability of the scale to detect delirium was evaluated by comparing the nurses’ CAPD assessments with the clinical evaluation of a PICU physician with expertise in analgosedation using the area under the ROC curve (AUC).Measurements and Main ResultsSeventy patients were included in the study. The prevalence of pediatric delirium was 54% (38/70) when reported by a positive CAPD score and 21% (15/70) when diagnosed by the PICU physician. The CAPD showed high agreement levels both for the intra-rater (ICC 1 0.98, 95% CI: 0.97–0.99) and the inter-rater (ICC 2 0.93, 95% CI: 0.89–0.96) assessments. In patients with suspected delirium according to the CAPD scale, the observed sensitivity and specificity of the scale were 0.93 (95% CI: 0.68–1.00) and 0.56 (95% CI: 0.42–0.70), respectively. The AUC observed was 0.75 (95% CI: 0.66–0.8490).ConclusionThe Italian version of the CAPD seems a reliable tool for the identification of patients at high risk of developing delirium in pediatric critical care settings. Compared to the clinical evaluation of the PICU physician, the use of the CAPD scale avoids a possible underestimation of delirium in the pediatric population.