What factors predict length of stay in the intensive care unit? Systematic review and meta-analysis

PurposeStudies have shown that a small percentage of ICU patients have prolonged length of stay (LoS) and account for a large proportion of resource use. Therefore, the identification of prolonged stay patients can improve unit efficiency. In this study, we performed a systematic review and meta-analysis to understand the risk factors of ICU LoS.Materials and methodsWe searched MEDLINE, Embase and Scopus databases from inception to November 2018. The searching process focused on papers presenting risk factors of ICU LoS. A meta-analysis was performed for studies reporting appropriate statistics.ResultsFrom 6906 citations, 113 met the eligibility criteria and were reviewed. A meta-analysis was performed for six factors from 28 papers and concluded that patients with mechanical ventilation, hypomagnesemia, delirium, and malnutrition tend to have longer stay, and that age and gender were not significant factors.ConclusionsThis work suggested a list of risk factors that should be considered in prediction models for ICU LoS, as follows: severity scores, mechanical ventilation, hypomagnesemia, delirium, malnutrition, infection, trauma, red blood cells, and PaO2:FiO2. Our findings can be used by prediction models to improve their predictive capacity of prolonged stay patients, assisting in resource allocation, quality improvement actions, and benchmarking analysis.     

What do we know about adherence and self-care?

Despite advances in healthcare, heart failure patients continue to experience complications that could have been prevented or treated. This occurs because the only way that a therapeutic or preventive regimen can be effective, assuming that the patient's condition has been accurately diagnosed and appropriately treated, is if the patient implements self-care behaviors and adheres to the treatment regimen. However, it is widely accepted that this does not occur in many or even most instances. This article provides an overview of the current evidence related to adherence and self-care behaviors among heart failure patients and describes the state of the science on interventions developed and tested to enhance self-care maintenance in this population. Our review of literature shows that effective interventions integrate strategies that motivate, empower, and encourage patients to make informed decisions and assume responsibility for self-care. Gaps in current evidence support the need for additional research on ways to improve adherence and self-care for patients who are at an increased risk of poor adherence, including those with cognitive and functional impairments and low health literacy.     

What do we know about the state of chronic pain?

Chronic pain syndromes are characterized by altered neuronal excitability in the pain matrix. The ability to rapidly acquire and store memory of aversive events is one of the basic principles of nervous systems throughout the animal kingdom. These neuroplastic changes take place e. g. in the spinal cord, in thalamic nuclei and cortical and subcortical (limbic) areas integrating pain threshold, intensity and affective components. Chronic inflammation or injury of peripheral nerves evokes the reorganisation of cortical sensory maps. Neurons conveying nociceptive information are controlled by various sets of inhibitory interneurons. The discharge activity of these interneurons counteracts long-term changes in the pain matrix following nociceptor activation, i. e. it prevents the transition of acute pain signaling to chronic pain states. Our most recent research suggests that pain states may be sensitive to novel families of agents and therapeutic measures not predicted by traditional preclinical pain models as well as human pain states. The endogenous cannabinoid system plays a central role in the extinction of aversive memories. We propose that endocannabinoids facilitate extinction of aversive memories via their selective inhibitory effects on GABAergic networks in the amygdala.     

What do we know about the genetics of aspirin intolerance?

Although acetylsalicylic acid is prescribed for a broad range of diseases, it can induce a wide array of clinically recognized hypersensitivity reactions, including aspirin-intolerant asthma (AIA) with rhinitis and aspirin-intolerant urticaria (AIU) with anaphylaxis. Altered eicosanoid metabolism is the generally accepted mechanism of aspirin intolerance; the overproduction of cysteinyl leucotrienes has been suggested to play a causative role in both AIA and AIU. Genetic markers suggested for AIA include HLA-DPBI*0301, leucotriene C4 synthase (LTC4S), ALOX5, CYSLT, PGE2, TBXA2R and TBX21. Similarly, HLA-DB1*0609, ALOX5, FCER1A and HNMT have been identified as possible genetic markers for AIU. An additional low-risk genetic marker for AIA is MS4A2, which encodes the beta-chain of FCER1. Other single and sets of two or more interacting genetic markers are currently being investigated. Analyses of the genetic backgrounds of patients with AIA and AIU will promote the development of early diagnostic and therapeutic interventions, which may reduce the incidence of AIA and AIU.     

What do we know about patients dying in the emergency department?

OBJECTIVE: To determine our knowledge in terms of cause of death and quality of death certification about patients who die in the emergency department. To establish the role of autopsy in this matter. METHODS: Retrospective chart review of all patients dying in an academic emergency department (ED) of a tertiary hospital over a period of 1 year. RESULTS: One hundred and ninety-six patients died in the ED in 1998. In 141/196 patients the cause of death could be determined on clinical grounds. In 53/196 patients, the antemortem clinical diagnosis was unknown. Twenty-nine out of 53 patients underwent autopsy. In all but one patient autopsy revealed the cause of death. After retrospective analysis of all patient data (notes, biology, radiology and pathological investigation), the major causes of death were cardiac (19.4%), cerebral (non-traumatic) (16.8%), trauma (15.3%) and unknown (13.3%). In the patient group with sudden cardiac arrest of unclear origin, the postmortem cause of death was identified as cardiac (51.7%), non-traumatic bleeding (10.3%), infectious (10.3%) and pulmonary embolism (3.4%). In the group of patients with a clinically clear cause of death, who underwent autopsy, 14 class II findings according to the Goldman's classification of autopsy diagnoses (i.e. major diagnosis whose detection would not have altered therapy nor outcome) were found in 16 patients. No class I findings (i.e. major diagnosis whose detection would have altered therapy or outcome) were noted. Altogether, major discrepancies between the antemortem presumed cause of death according to the notes and the real cause of death was found in 15.3%. CONCLUSIONS: Autopsy remains a very important tool to establish the cause of death in patients dying in ED. The concordance between the antemortem presumed cause of death recorded in the patient notes and the real cause (all patient data) is poor.     

What do we know about educating Asian ESL nursing students? A literature review

Because of cultural differences and language barriers, some Asian nursing students who speak English as a second language (ESL) have not realized their full potential and career goals. Based on an exhaustive search through existing electronic databases in health sciences, this article synthesizes the published literature between 1980 and 2010 on this subgroup of nursing students in four domains: conceptual frameworks, language and communication, support and infrastructure, and instructional strategies. However, some of the classic works were published before 1980. Findings indicate that a body of literature on ESL nursing students has emerged in the last decades, with several limitations. Based on this review, implications for future educational practice and research are elaborated, with an emphasis on an evidence-based approach.     

Delirium in the intensive care unit: are we helping the patient?

The intensive care unit (ICU) represents a dynamic interaction between patient factors and interventional factors. The complexity of this situation can generate an impaired consciousness in the patients. The critical care provider is faced with deducing the etiology and treatment of delirium in the ICU. Many of the therapeutic agents that are used in the ICU may precipitate delirium. Patients may also experience delirium as part of their underlying medical conditions. Withdrawal syndromes, delirium tremens in particular, are known to cause delirium. By a combination of appropriate selection of medications and an awareness of delirium as a side effect, the patient in the ICU may be treated in a manner to minimize the clouding of consciousness. An understanding of the proposed pathophysiology of various types of delirium will allow appropriate clinical measures to be taken.     

Measurements in the intensive care unit: what do they mean?

Intensivists depend upon a large number of measurements to make daily decisions in the ICU. However, the reliability of these measures may be jeopardized by the effects of therapy. Moreover, in critical illness, what is normal is not necessarily optimal. Procalcitonin, a putative marker of occult infection, is emerging as a valuable diagnostic marker in the ICU. Although questions remain regarding its specificity, an increasing body of work suggests that it is reliably elevated in the setting of infection. As demonstrated by Level and colleagues in this issue of Critical Care, its utility as a diagnostic marker is not affected by concomitant hemodialysis.     

What we know and what we don’t know about perinatal Zika virus infection: a systematic review

Introduction: Zika virus (ZIKV) infection has caused the most challenging worldwide infectious epidemic outbreak in recent months. ZIKV causes microcephaly and other congenital malformations. There is a need to perform updated systematic reviews on ZIKV infection periodically because this epidemic is bringing up new evidence with extraordinary speed.

Areas covered: Evidence related to ZIKV infection in the gestational, perinatal, and early infant periods covering epidemiology, virology, pathogenesis, risk factors, time of infection during pregnancy, newborn symptoms, treatment, and vaccines. To this end, a search was performed using terms [‘Zika’] AND [‘Perinatal Infection’] OR [‘Congenital Infection’] in the PubMed® international electronic database. Out of a total of 1,538 articles published until 30 November 2017, we finally assessed 106 articles articles that were relevant to the research areas included in this study.

Expert commentary: ZIKV is a new teratogenic/neurotropic virus affecting fetuses. Many challenges are still far from being solved regarding the epidemiology, case definition, clinical and laboratory diagnosis, and preventive measures. An approach using ‘omics’ and new biomarkers for diagnosis, and a ZIKV-vaccine for treatment, might finally give us the tools to solve these challenges.     

Nurses’ clinical leadership in the intensive care unit: A scoping review

ObjectiveTo explore the existing knowledge in the literature about nurses' clinical leadership in the intensive care unit.MethodsA scoping review was conducted according to Arksey & O'Malley’s methodology. The search process encompassed five main online databases, PubMed (including MEDLINE), CINAHL, PsycINFO, Scopus and Cochrane, for the period January 2007-September 2022. Data abstraction, quality appraisal and narrative synthesis were conducted in line with the Preferred Reporting Items for Systematic reviews and meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines.ResultsEleven studies were included. The evidence reveals that idealised influence, motivational inspiration, intellectual stimulation and intrinsic individual consideration are the key clinical nurse leader competencies needed in the intensive care unit. The compatible leadership styles in this setting are situational and transformational. Communication skills and professional experience seem to be determinants to consider in the strategies to promote clinical leadership in intensive care units.ConclusionsThis scoping review provides broad and comprehensive knowledge, which helps to understand, in a single study, the key competencies, leadership styles, determinants and strategies needed to promote intensive care unit nurses' clinical leadership.