Intensive Care Unit death and factors influencing family satisfaction of Intensive Care Unit care

Introduction:

Family satisfaction of Intensive Care Unit (FS-ICU) care is believed to be associated with ICU survival and ICU outcomes. A review of literature was done to determine factors influencing FS-ICU care in ICU deaths.

Results:

Factors that positively influenced FS-ICU care were (a) communication: Honesty, accuracy, active listening, emphatic statements, consistency, and clarity; (b) family support: Respect, compassion, courtesy, considering family needs and wishes, and emotional and spiritual support; (c) family meetings: Meaningful explanation and frequency of meetings; (d) decision-making: Shared decision-making; (e) end of life care support: Support during foregoing life-sustaining interventions and staggered withdrawal of life support; (f) ICU environment: Flexibility of visiting hours and safe hospital environment; and (g) other factors: Control of pain and physical symptoms, palliative care consultation, and family-centered care. Factors that negatively influenced FS-ICU care were (a) communication: Incomplete information and unable to interpret information provided; (b) family support: Lack of emotional and spiritual support; (c) family meetings: Conflicts and short family meetings; (d) end of life care support: Resuscitation at end of life, mechanical ventilation on day of death, ICU death of an elderly, prolonged use of life-sustaining treatment, and unfamiliar technology; and (e) ICU environment: Restrictive visitation policies and families denied access to see the dying loved ones.

Conclusion:

Families of the patients admitted to ICU value respect, compassion, empathy, communication, involvement in decision-making, pain and symptom relief, avoiding futile medical interventions, and dignified end of life care.     

Impact of infection on admission and of the process of care on mortality of patients admitted to the Intensive Care Unit: the INFAUCI study

A prospective, cohort, clinical, observational study was performed in 14 Intensive Care Units (ICUs) to evaluate the contemporary epidemiology, morbi-mortality and determinants of outcome of the population with an infection on admission. All 3766 patients admitted during a consecutive 12-month period were screened. Their median age was 63 [26–83], 61.1% were male and 69.8% had significant comorbidities. On admission to the ICU 1652 patients (43.9%) had an infection, which was community acquired in 68.2% (one-fifth with healthcare-associated criteria) and ward-acquired in the others. Roughly half presented to the ICU with septic shock. As much as 488 patients with community-acquired infections were deemed stable enough to be first admitted to the ward, but had similar mortality to unstable patients directly admitted to the ICU (35.9% vs. 35.1%, p 0.78). Only 48.3% of this infected population had microbiological documentation and almost one-quarter received inappropriate initial antibiotic therapy. This, along with comorbidities, was a main determinant of mortality. Overall, infected patients on admission had higher mortality both in the ICU (28.0% vs. 19.9%, p <0.001) and in the hospital (38.2% vs. 27.5%, p <0.001) and even after being discharged to the ward (14.2% vs. 9.6%, p <0.001). Also, patients not infected on admission who acquired an infection in the ICU, had an increased risk of dying in the hospital (odds ratio 1.41 [1.12–1.83]). Consequently, infection, regardless of its place of acquisition, was associated with increased mortality. Improving the process of care, especially first-line antibiotic appropriateness, and preventing ICU-acquired infections, may lead to better outcomes.     

Controlling an Outbreak of Multidrug-resistant Acinetobacter baumannii in a Pediatric Intensive Care Unit: a Retrospective Analysis

BackgroundMultidrug-resistant Acinetobacter baumannii (MDRAB) is widespread among intensive care units worldwide, posing a threat to patients and the health system. We describe the successful management of a MDRAB outbreak by implementing an infection-control strategy in a pediatric intensive care unit (PICU).MethodsThis retrospective study investigated the patients admitted to the PICU in periods 1 (8 months) and 2 (7 months), from the index MDRAB case to intervention implementation, and from intervention implementation to cessation of MDRAB spread. An infection-control strategy was designed following six concepts: 1) cohort isolation of colonized patients, 2) enforcement of hand hygiene, 3) universal contact precautions, 4) environmental management, 5) periodic surveillance culture study, and 6) monitoring and feedback.ResultsOf the 427 patients, 29 were confirmed to have MDRAB colonization, of which 18 had MDRAB infections. Overall incidence per 1,000 patient days decreased from 7.8 (period 1) to 5.8 (period 2). The MDRAB outbreak was declared terminated after the 6-month follow-up following period 2. MDRAB was detected on the computer keyboard and in condensed water inside the ventilator circuits. The rate of hand hygiene performance was the lowest in the three months before and after index case admission and increased from 84% (period 1) to 95% (period 2). Patients with higher severity, indicated by a higher Pediatric Risk of Mortality III score, were more likely to develop colonization (P = 0.030), because they had invasive devices and required more contact with healthcare workers. MDRAB colonization contributed to an increase in the duration of mechanical ventilation and PICU stay (P < 0.001), but did not affect mortality (P = 0.273).ConclusionThe MDRAB outbreak was successfully terminated by the implementation of a comprehensive infection-control strategy focused on the promotion of hand hygiene, universal contact precautions, and environmental management through multidisciplinary teamwork.     

Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country

Background and Aim:

Advances in biomedical technology have made medical treatment to be continued beyond a point, at which it does not confer an advantage but may increase the suffering of patients. In such cases, continuation of care may not always be useful, and this has given rise to the concept of limitation of life-sustaining treatment. Our aim was to study mortality patterns over a 6-year period in a Pediatric Intensive Care Unit (PICU) in a developing country and to compare the results with published data from other countries.

Materials and Methods:

Retrospective cohort study was conducted in a PICU of a tertiary care hospital in Pakistan. Data were drawn from the medical records of children aged 1-month – 16 years of age who died in PICU, from January 2007 to December 2012.

Results:

A total of 248 (from an admitted number of 1919) patients died over a period of 6 years with a mortality rate 12.9%. The median age of children who died was 2.8 years, of which 60.5% (n = 150) were males. The most common source of admission was from the emergency room (57.5%, n = 143). The most common cause of death was limitation of life-sustaining treatment (63.7%, n = 158) followed by failed cardiopulmonary resuscitation (28.2%, n = 70) and brain death (8.1%, n = 20). We also found an increasing trend of limitation of life-sustaining treatment do-not-resuscitate (DNR) over the 6-year reporting period.

Conclusion:

We found limitation of life support treatment (DNR + Withdrawal of Life support Treatment) to be the most common cause of death, and parents were always involved in the end-of-life care decision-making.     

The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: A review of the literature

Purpose

The introduction of a Critical Care Information System (CCIS) into an intensive care unit (ICU) is purported to reduce the time health care providers (HCP) spend on documentation and increase the time available for direct patient care. However, there is a paucity of rigorous empirical research that has investigated these assertions. Moreover, those studies that have sought to elucidate the relationship between the introduction of a CCIS and the time spent by staff on in/direct patient care activities have published contradictory findings. The objective of this literature review is to establish the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU.

Methods

Five electronic databases were searched including PubMed Central, EMBASE, CINAHL, IEEE Xplore, and the Cochrane Database of Systematic Reviews. Reference lists of all published papers were hand searched, and citations reviewed to identify extra papers. We included studies that were empirical articles, published in English, and provided original data on the impact of a CCIS on time spent documenting and in direct patient care by staff in the ICU.

Results

In total, 12 articles met the inclusion criteria. Workflow analysis (66%) and time-and-motion analysis (25%) were the most common forms of data collection. Three (25%) studies found an increase in time spent charting, five (42%) found no difference, and four (33%) studies reported a decrease. Results on the impact of a CCIS on direct patient care were similarly inconclusive.

Conclusions

Due to the discrepant findings and several key methodological issues, the impact of a CCIS on time spent charting and in direct patient care remains unclear. This review highlights the need for an increase in rigorous empirical research in this area and provides recommendations for the design and implementation of future studies.     

The effect of cancer treatment summaries on patient-centered communication and quality of care for cancer survivors: A pooled cross-sectional HINTS analysis

ObjectiveProvision of cancer treatment summaries to patients is recommended to improve patient-centered communication (PCC). The objective of this study is to assess relationships between cancer treatment summary receipt, PCC, and quality of care (QOC).MethodsLinear and logistic regression of cross-sectional data from the Health Information National Trends Survey (HINTS) was conducted using data from years 2012, 2014, and 2017. The independent variable was receipt of treatment summary; the dependent variables were overall PCC score, six domains of PCC, and QOC.ResultsIn the pooled sample, 36.9% of patients with cancer treatment history reported receiving a treatment summary. There was a significant positive association between overall PCC score and treatment summary receipt, and higher odds of high scores for the PCC domains “responding to emotions” and “managing uncertainty.” We did not observe significant associations between treatment summary receipt and other PCC domains or QOC.ConclusionProviding patients cancer treatment summaries may improve PCC, but fewer than half of patients reported receiving one of these summaries.Practice ImplicationsProviding cancer treatment summaries is important, however, providing them without engaging in additional communication may be insufficient to improve all patient-centered care domains or quality of care.     

Involving the patient: a prospective study on use, appreciation and effectiveness of an information system in head and neck cancer care

OBJECTIVE: To determine use, appreciation and effectiveness of an electronic health information support system in head and neck (H&N) cancer care. DESIGN: A prospective evaluation study. The evaluated system has four different functions: (1) communication amongst health care providers and between health care providers and patients, (2) information for health care providers and patients, (3) contact with fellow sufferers and (4) monitoring of discharged patients by means of electronic questionnaires. Evaluation of the system was done both objectively using automatically created log files and stored messages, and subjectively by using paper questionnaires from patients and general practitioners (GPs). SETTING: Department of Otorhinolaryngology and Head and Neck Surgery of a tertiary health care centre in the Netherlands. The system was put at patients' disposal for a period of 6 weeks following discharge from the hospital after surgery for H&N cancer, and was additional to standard care. PARTICIPANTS: Head and neck cancer patients, hospital physicians, members of a hospital-based support team, GPs, district nurses and speech therapists. MAIN OUTCOME MEASURES: Actual use of the system by patients and health care providers. Patients' appreciation for each of the system's four different functions. GPs' appreciation for the system. Capability to detect potential patient problems with the system. RESULTS: The system was used by 36 H&N cancer patients, 10 hospital physicians, 2 members of the support team, 8 GPs, 2 district nurses and 2 speech therapists. The total number of patient-sessions was 982: an average of 27.3 sessions per patient during the 6 weeks study period. In total, 456 monitoring questionnaires were completed. The support team in hospital responded with 231 actions. In 16 cases, an extra appointment was made for a patient with the hospital physician. Out of these cases, immediate action was considered necessary eight times. Patients appreciated the system highly, rating it with an average score of 8.0 on a 10-point scale. All patients used the monitoring function, and rated 'monitoring' with a mean score of 8.0 on a 10-point scale. Least used and appreciated was the 'contact with fellow sufferers' function. Only 8 out of possible 36 GPs used the system, rating it with an average of 5.6 on a 10-point scale. CONCLUSIONS: The electronic health information support system was used intensively and highly appreciated by H&N cancer patients. The system enabled the early detection of occurring health problems that required direct intervention. ICT can play an additional role in the management of patients, also in a relatively elderly and computer illiterate patient population.     

Effect of the new contract on GPs' working lives and perceptions of quality of care: a longitudinal survey.

BACKGROUND: An ambitious pay-for-performance system was implemented in UK general practice in 2004 amid doubts that it could improve both the working lives of doctors and quality of care. AIM: To evaluate doctors' perceptions of their working lives and quality of care before and after the new contract. DESIGN OF STUDY: Longitudinal questionnaire survey. SETTING: England, UK. METHOD: A longitudinal postal survey of English GPs in February 2004 and September 2005. Measures included reported job satisfaction (7-point scale), hours worked, income, and impact of the contract. RESULTS: Responses were available from 2105 doctors in 2004 and 1349 in 2005. Mean overall job satisfaction increased from 4.58 out of 7 in 2004 to 5.17 in 2005. The greatest improvements in satisfaction were with remuneration and hours of work. Mean reported hours worked fell from 44.5 to 40.8. Mean income increased from an estimated 73,400 pounds in 2004 to 92,600 pounds in 2005. Most GPs reported that the new contract had increased their income (88%), but decreased their professional autonomy (71%), and increased their administrative (94%) and clinical (86%) workloads. After the introduction of the contract doctors were more positive than they had anticipated about its impact on quality of care. CONCLUSION: GPs' job satisfaction increased after the introduction of the new contract, despite perceptions of negative consequences for workload and autonomy. GPs reported working fewer hours with a higher income, and their expectations regarding the impact of the contract on quality of care had been exceeded.     

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

BackgroundInter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea.MethodsThis nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups.ResultsWe found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient''s request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054).ConclusionThe incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient''s request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.     

The HIV Care Cascade and sub-analysis of those linked to but not retained in care: the experience from a tertiary HIV referral service in Dublin Ireland

Background: The HIV Care Cascade model can be used to measure how clinical services align with United Nations’ (UN) HIV treatment targets. Previous models have highlighted sequential losses at each step of the Cascade with a significant proportion being not retained in care (NRIC).

Objective: We aimed to assess the feasibility of meeting the UN targets and assess factors associated with, and calculate the true proportion of those, NRIC.

Methods: All people living with HIV who were linked to our service, one of three specialist HIV care providers in Dublin Ireland, from its establishment in 1993 to 1 December 2014, were included in the cohort and were categorized as linked to care, retained in care (RIC), on antiretroviral therapy (on ART), virally suppressed (HIV RNA <40copies/ml), and NRIC. An analysis of those NRIC was performed to categorize their current status through direct/indirect contact.

Results: Of 1000 patients linked to care, 78.7% (n = 787) were RIC, of whom 91.5% (n = 720) were on ART, with 89.9% (n = 644) virally suppressed. Those RIC were more likely older (p = 0.006) and non-IVDU (p < 0.001). Of 213 (21.3%) NRIC, 56 (26.3%) emigrated, 27 (12.7%) transferred care, 15 (7.0%) stopped attending but were contactable, 38 (17.8%) died, and 77 (36.1%) were lost to follow-up. After revision, 10.5% of the cohort was confirmed as NRIC, with 6 of 15 defined as “stopped attending” re-linked to care following direct contact.

Conclusions: Our HIV Care Cascade model demonstrates that the true numbers of patients NRIC may be significantly lower than previously estimated and once RIC, treatment goals approaching the United Nations Programme on HIV and AIDS targets are possible with 91.5% on treatment and almost 90% of those on treatment virally suppressed. That 40% reengaged following direct contact suggests benefit through regular monitoring and direct contact based on the HIV Care Cascade model.     

Effects of the economic crisis and social support on health-related quality of life: first wave of a longitudinal study in Spain

Background

Economic recession affects quality of life by increasing rates of mental disorders in particular. Social support can be an important protective factor.

Aim

To estimate the impact of being personally affected by an economic crisis on health-related quality of life (HRQoL), taking into account the possible buffering effect of perceived social support.

Design and setting

Data from the first wave (March 2012 to November 2012) of the ‘Social Support and Quality of Life Study’, a longitudinal study carried out in a primary health care centre in a deprived neighbourhood of Barcelona, Spain.

Method

A total of 143 participants were assessed using the 12-item Short-Form Health Survey, the List of Threatening Experiences and the Duke Social Support scales. The effect of economic crisis on mental and physical HRQoL was assessed using ordinary least squares regression models to test the interaction between social support and having experienced an economic crisis.

Results

There was no statistical association between having suffered an economic crisis and physical HRQoL. The interaction between social support and economic crisis was also tested without finding any statistical association. An interaction was detected between social support and economic crisis in relation to mental HRQoL; those who had low levels of social support and had also experienced an economic crisis had the lowest levels of mental HRQoL.

Conclusion

Social support constitutes a safety net that offers protection against the adverse effect of economic recessions on mental health. Primary care professionals are in a key position to promote social activities and to strengthen social networks in the community.