Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: Institutional variation and association with hospital mortality.

AIM: Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients' risk-adjusted hospital mortality. METHODS: We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010 and 2017. We identified patient and ICU characteristics associated with early (within 72 h) and late (>72 h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients' hospital mortality. RESULTS: We included 28,438 patients across 204 ICUs. 10,775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients' hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p < 0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p < 0.001). CONCLUSIONS: Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.

The association of a critical care electronic prescribing system with the quality of patient care provided by clinical pharmacists - a prospective, observational cohort study.

BACKGROUND: Despite the strong face validity of electronic prescribing (EP), the empiric data in support of improved patient safety is sparse. The objective of this study was to compare the clinical significance of pharmacist contributions between an established EP and paper-based prescribing (PBP) system in the intensive care unit (ICU) to understand the EP impact on the quality of patient care. MATERIALS AND METHODS: We conducted a prospective longitudinal study in two 18-bed ICUs; one with EP and the other, PBP. Pharmacist contributions were analysed over three months. Demographic, clinical and adjunctive intervention data were also collected. A multilevel ordinal logistic regression model was used and patients were followed up for 28 days. The primary outcome was the distribution of clinical significance levels of pharmacist contributions. RESULTS: There were 303 patients admitted to the ICU between April 1st and June 30th 2018. EP was used in 171 patients and PBP in 132 patients. 1658 contributions were analysed. There were 14.9% highly clinically significant contributions with EP compared to 44.6% with PBP. The EP group had lower odds (OR 0.05, 95% CI 0.02-0.12) for a higher clinical significance contribution compared to the PBP group, but this changed over the admission and differed between groups, with decreasing odds of a higher-level clinical contribution for each additional admission day with PBP (OR 0.57, 95%CI 0.42-0.78). CONCLUSION: This study showed a significant difference in the distribution of pharmacist contributions made over time, with clinical significance levels remaining stable in the EP group at low severity, as opposed to PBP which were initially high and then gradually decreased in severity over time. This contemporaneous controlled study found that the EP system required less significant input both in the severity and frequency of pharmacist contributions to maintain patient safety.

Evaluating the use of the respiratory-rate oxygenation index as a predictor of high-flow nasal cannula oxygen failure in COVID-19.

BACKGROUND: It can be challenging for clinicians to predict which patients with respiratory failure secondary to coronavirus disease 2019 (COVID-19) will fail on high-flow nasal cannula (HFNC) oxygen and require escalation of therapy. This study set out to evaluate the association between the respiratory rate-oxygenation index (ROX) and HFNC failure in such patients and to assess whether ROX trajectory correlates with treatment failure. METHODS: This was a single-centre, retrospective, observational study of patients with COVID-19 requiring HFNC, conducted over a 3-month period. ROX was calculated as "pulse-oximetry oxygen saturation (SpO2) over the fractional inspired oxygen concentration (FiO2)/respiratory rate" for each patient at 2, 4, and 12 hours from starting HFNC. HFNC failure was defined as escalation to continuous positive airway pressure ventilation or invasive mechanical ventilation (IMV). Time-to-event analyses were performed to account for the longitudinal data set and time-dependent variables. RESULTS: We included 146 patients. Ninety-three (63.7%) experienced HFNC failure, with 53 (36.3%) requiring IMV. Higher ROX values were associated with a lower subhazard of HFNC failure on time-to-HFNC failure analysis (subhazard ratio, 0.29; 95% confidence interval [CI], 0.18-0.46; P<0.001). This remained true after controlling for informative censoring. Median ROX values changed differentially over time, increasing in the HFNC success group (0.06 per hour; 95% CI, 0.05-0.08; P<0.001) but not in the HFNC failure group (0.004 per hour; 95% CI, -0.05 to 0.08; P=0.890). CONCLUSIONS: A higher ROX is associated with a lower risk of HFNC failure. Monitoring ROX trajectory over time may help identify patients at risk of treatment failure. This has potential clinical applications; however, future prospective studies are required.

Palliative care interventions in intensive care unit patients.

PURPOSE: The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS: We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS: Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION: Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.

Hospital Mortality and Resource Implications of Hospitalisation with COVID-19 in London, UK: A Prospective Cohort Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) had a significant impact on the National Health Service in the United Kingdom (UK), with over 35 000 cases reported in London by July 30, 2020. Detailed hospital-level information on patient characteristics, outcomes, and capacity strain is currently scarce but would guide clinical decision-making and inform prioritisation and planning. METHODS: We aimed to determine factors associated with hospital mortality and describe hospital and ICU strain by conducting a prospective cohort study at a tertiary academic centre in London, UK. We included adult patients admitted to the hospital with laboratory-confirmed COVID-19 and followed them up until hospital discharge or 30 days. Baseline factors that are associated with hospital mortality were identified via semiparametric and parametric survival analyses. RESULTS: Our study included 429 patients: 18% of them were admitted to the ICU, 52% met criteria for ICU outreach team activation, and 61% had treatment limitations placed during their admission. Hospital mortality was 26% and ICU mortality was 34%. Hospital mortality was independently associated with increasing age, male sex, history of chronic kidney disease, increasing baseline C-reactive protein level, and dyspnoea at presentation. COVID-19 resulted in substantial ICU and hospital strain, with up to 9 daily ICU admissions and 41 daily hospital admissions, to a peak census of 80 infected patients admitted in the ICU and 250 in the hospital. Management of such a surge required extensive reorganisation of critical care services with expansion of ICU capacity from 69 to 129 beds, redeployment of staff from other hospital areas, and coordinated hospital-level effort. CONCLUSIONS: COVID-19 is associated with a high burden of mortality for patients treated on the ward and the ICU and required substantial reconfiguration of critical care services. This has significant implications for planning and resource utilisation.

Palliative care interventions in intensive care unit patients - a systematic review protocol.

BACKGROUND: Even though data suggest that palliative care (PC) improves patient quality of life, caregiver burden, cost, and intensive care unit (ICU) length of stay, integration of PC in the ICU is far from being universally accepted. Poor understanding of what PC provides is one of the barriers to the widespread implementation of their services in ICU. Evidence suggests that the availability of specialist PC is lacking in most European countries and provided differently depending on geographical location. The aim of this systematic review is to compare the numbers and types of PC interventions and gauge their impact on stakeholder outcomes and ICU resource utilisation. METHODS: We will undertake a systematic review of the published peer-reviewed journal articles; our search will be carried out MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO. The search strategy will include variations in the term 'palliative care' and 'intensive care'. All studies with patient populations undergoing palliative care interventions will be selected. Only full-text articles will be considered, and conference abstracts excluded. There will be no date restrictions on the year of publications or on language. The primary aim of the present study is to compare the numbers and types of PC interventions in ICU and their impact on stakeholder (patient, family, clinician, other) outcomes. Reporting of findings will follow the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. DISCUSSION: This review will provide insight into the implementation of palliative care in ICU, elucidate differences between countries and health systems, reveal most effective models, and contribute to identifying research priorities to improve outcomes. SYSTEMATIC REVIEW REGISTRATION: International Prospective Register of Systematic reviews PROSPERO ( CRD42018094315 ).

Recurrent sampling and ventriculostomy-associated infections: a case-control study.

BACKGROUND: External ventricular drain (EVD) insertion is a common neurosurgical procedure with a significant risk of ventriculostomy-associated infections (VAIs), other morbidities and mortality. Several risk factors have been identified but their effect is unclear. OBJECTIVE: Our primary objective was to assess whether recurrent EVD sampling increased the risk of VAIs. The secondary objective was to explore the effect of sampling frequency, duration of EVD stay, presence of cerebrospinal fluid leak and concurrent infections. METHODS: Ours was a retrospective, single-centre, age-matched, case control study of 83 patients and 249 controls who underwent EVD insertion between 1 January 2010 - 31 December 2016. Patients with primary CNS infections, age under 1 year and death within 5 days of EVD insertion were excluded. Blinded abstractors collected all patient data through the electronic patient record system and regression analysis was used to compare the two groups. RESULTS: Sampling the EVD more than once did not increase the risk of infection (OR 0.47, 95% CI 0.27-0.83, p = 0.01). Risk factors significantly associated with VAI included CSF leak (OR 2.06, 95% CI 1.16-3.67, p = 0.01), concurrent infection (OR 1.85, 95% CI 1.09-3.16, p = 0.02), and an EVD duration of >10 days (OR 2.28, 95% CI 1.24-4.18, p = 0.01). CONCLUSION: Our findings do not support the notion that increased sampling of EVDs is associated with a higher risk of VAI. CSF leaks, concurrent infection and long-term EVDs are also statistically significant risk factors for infection.

The Utility of ICU Readmission as a Quality Indicator and the Effect of Selection.

OBJECTIVES: Intensive care readmission rates are used to signal quality, yet it is unclear whether they represent poor quality in the transition of care from the ICU to the ward, patient factors, or differences in survival of the initial admission. This study aims to measure the selection effect of surviving the initial ICU admission on readmission rates. DESIGN: Retrospective cohort study of adult patients admitted to ICUs participating in the Case Mix Program database from the Intensive Care National Audit Research Centre. SETTINGS: The study includes 262 ICUs in the United Kingdom. PATIENTS: The study includes 682,975 patients admitted to ICUs between 2010 and 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study includes 682,975 patients admitted to ICUs in the United Kingdom. There were 591,710 patients discharged alive, of which 9,093 (1.53%) were readmitted within the first 2 days of ICU discharge. Post-ICU admission hospital mortality and ICU readmission were poorly correlated (r = 0.130). The addition of a selection model resulted in a weaker correlation (r = 0.082). CONCLUSIONS: ICU readmission performed poorly as a performance metric. The selection process by which only patients who survive their index admission are eligible for readmission has a significant effect on ICU readmission rankings, particularly the higher ranked ICUs. Failure to consider this selection bias gives misleading signals about ICU performance and leads to faulty design of incentive schemes.

Current use of live tissue training in trauma: a descriptive systematic review.

BACKGROUND: Growing public concern for animal welfare, advances in computerized simulation and economic barriers have drawn a critical eye to the use of live tissue training (LTT) in trauma skills acquisition. As a consequence, other simulation methods have replaced LTT, for example, in the Advanced Trauma Life Support (ATLS) course. Owing to the lack of clear conclusions in the literature, we conducted a systematic review to determine the value of LTT alone and in comparison to other simulation methods in trauma. METHODS: We performed a systematic review of the literature considering observational studies and randomized controlled trials (RCTs) that examined LTT in trauma exclusively or compared with other simulation methods. Independently and in duplicate, we adjudicated studies for inclusion and data abstraction. We assessed the quality and risk of bias. RESULTS: Twelve studies met our inclusion criteria: 2 RCTs and 10 prospective cohort studies. Eight and 4 studies were performed in the military and in the civilian settings, respectively. Anesthetized swine were used in 8 studies and goats in 1. The cohort studies involved LTT alone. Different adjunctive training modalities were included: mannequins in 6 studies, cadavers in 2, computer simulation in 1, video presentations in 2 and wound moulage scenarios in 1. The overall methodological quality was moderate as per the Newcastle-Ottawa score (mean 6.0 ± 0, possible range 1-9). The 2 RCTs did not demonstrate adequate random sequence generation and allocation concealment. CONCLUSION: There is limited evidence that other types of simulation are better than LTT. Data on training effects of LTT versus other simulations on outcomes are lacking.

CONTEXTE: Les préoccupations croissantes du public envers le bien-être des animaux, le perfectionnement des dispositifs de simulation informatisés et les contraintes budgétaires ont remis en question la formation sur tissus vivant (FTV) pour l'acquisition des compétences en traumatologie. Par conséquent, d'autres méthodes de simulation ont remplacé la FTV, par exemple, le cours ATLS (Advanced Trauma Life Support ­ Cours avancé de réanimation des polytraumatisés). Étant donné l'absence de conclusions claires dans la littérature, nous avons procédé à une revue systématique afin de comparer la valeur de la FTV seule à celle d'autres méthodes de simulation en traumatologie. MÉTHODES: Nous avons procédé à une revue systématique de la littérature, plus particulièrement des études d'observation et des essais randomisés et contrôlés (ERC) portant exclusivement sur la FTV en traumatologie ou en comparaison avec d'autres méthodes de simulation. De manière indépendante et dupliquée, nous avons sélectionné les études à inclure et nous en avons extrait les données. Nous avons évalué la qualité et le risque de biais. RÉSULTANTS: Douze études répondaient aux critères d'inclusion : 2 ERC et 10 études de cohorte prospectives. Huit et 4 études ont été effectuées dans des contextes militaires et civils, respectivement. Des porcs anesthésiés ont été utilisés pour 8 études et des chèvres pour une étude. Les études de cohorte ne concernaient que la FTV. Les différentes modalités de formation complémentaires incluaient : mannequins dans 6 études, cadavres dans 2 études, simulation par ordinateur dans 1 étude, présentations vidéo dans 2 études et scénarios de moulage de plaies dans 1 étude. La qualité méthodologique globale s'est révélée modérée selon le score Newcastle­Ottawa (moyenne 6,0 ± 0, éventail de valeurs possibles 1­9). Les 2 ERC ne disposaient pas de séquences aléatoires adéquates et l'attribution des traitement n'y était pas effectuée à l'insu. CONCLUSION: Les preuves dont on dispose pour déterminer si d'autres types de simulation sont préférables à la FTV sont limitées. On manque de données comparatives concernant les effets de la FTV sur l'issue des interventions par rapport à d'autres types de simulations.