Oral decontamination techniques and ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) is one of the major nosocomial infections in the intensive care unit (ICU), contributing to increased mortality and morbidity. Studies have shown that oral decontamination through the use of mechanical and pharmacological agents significantly reduces the incidence of VAP, but oral care practices in ICUs are not consistent. A double-blind randomised controlled trial was undertaken in the medical ICU of a tertiary care centre in India, to assess the efficacy of a toothbrush-based oral care technique in reducing incidence of VAP. Tooth-brushing with concurrent suctioning technique was not proved to be superior to mouth-swabbing. The greatest risk factor for developing VAP was the number of ventilator days (length of time on a ventilator). There was a statistical association between gender and presence of antibiotics with VAP.

Cost-utility in medical intensive care patients. Rationalizing ongoing care and timing of discharge from intensive care.

RATIONALE: Intensive care unit (ICU) treatment costs pose special challenges in developing countries. OBJECTIVES: To determine the prognostic value of the "utility" score and evaluate the relationship of willingness to pay assessment to utility score during ICU admission. METHODS: We performed a prospective study spanning 12 months in a 24-bed medical ICU in India. Treatment cost was estimated by direct measurement. Global utility score was assessed daily by healthcare providers on a Likert scale (0-1 in increments of 0.1, with 0 indicating death/severe disability and 1 indicating cure/perfect health). The sensitivity, specificity, and likelihood ratios of utility in predicting ICU mortality was calculated. Receiver operating characteristic curves were generated to compare Day 2 utility with APACHE II. The caregiver's willingness to pay for treatment was assessed on alternate days using the bidding method by presenting a cost bid. Based on the response ("yes" or "no"), bids were increased or decreased in a prespecified manner until a final bid value was reached. Simultaneously, treating doctors were asked how much institutional funds they would be willing to spend for treatment. MEASUREMENTS AND MAIN RESULTS: Primary diagnosis in 499 patients included infection (26%) and poisoning (21%). The mean (SD) APACHE II score was 13.9 (5.8); 86% were ventilated. ICU stay was 7.8 (5.5) days. ICU mortality was 23.9% (95% confidence interval, 20.3-27.8). Survival without disability was 8.3% (2/24) for Day 2 utility score ≤0.3 and 95.8% (53/56) for Day 5 score >0.8 (P < 0.001). The likelihood ratio to predict mortality increased as utility values decreased and was highest (5.85) for utility 0.2. Area under the receiver operating characteristic curves for utility and APACHE II were similar. Willingness to pay by the caregiver was 53% of treatment cost and was not influenced by utility. Willingness to pay by ICU doctors showed an inverted U-shaped relationship with utility. CONCLUSIONS: Utility scores help prognosticate, with Day 2 score ≤0.3 associated with poor outcome and ≥0.8 Day 5 score with survival. The caregiver's willingness to pay was inadequate to meet treatment cost. ICU doctors were willing to spend more for moderate utility scores than for very high or low utility values. Further prospective studies are needed to optimize the utilization of scarce ICU resources by identifying patients for appropriate step-down care using utility and willingness to pay.

End-of-life care perspectives of patients and health professionals in an Indian health-care setting.

AIM: This descriptive study set out to explore the end-of-life care perspectives both of patients with advanced carcinoma and of health-care professionals in a tertiary health-care setting in India. METHOD: A descriptive approach was undertaken to assess the end-of-life care perspectives from a sample of 140 patients and 40 health-care professionals. Data was collected through structured interviews with the patients and by self-administered questionnaire from the health-care professionals. RESULTS: There was a significant association in attitudes to artificial prolongation of life with age and religion. Patients placed a higher degree of importance on emotional, social, physical and spiritual dimensions of care compared to the health-care professionals. CONCLUSION: There is an urgent call for formulating an end-of-life care policy and advance directives for patients with terminal illness in India. Nurses and physicians should be proactive in offering key supportive services to ensure patient autonomy and facilitate good death.