RESUMO
Background: Data regarding delivery of evidence-based care to critically ill patients in Intensive Care Units (ICU) during the COVID-19 pandemic is crucial but lacking. This study aimed to evaluate the implementation rate of the ABCDEF bundle, which is a collection of six evidence-based ICU care initiatives which are strongly recommended to be incorporated into clinical practice, and ICU diaries for patients with and without COVID-19 infections in ICUs, and to analyze the impact of COVID-19 on implementation of each element of the bundle and independent associated factors. Methods: A world-wide 1-day point prevalence study investigated the delivery of the ABCDEF bundle and ICU diary to patients without or with COVID-19 infections on 27 January 2021 via an online questionnaire. Multivariable logistic regression analysis with adjustment for patient demographics evaluated the impact of COVID-19 and identified factors in ICU administrative structures and policies independently associated with delivery. Results: From 54 countries and 135 ICUs, 1,229 patients were eligible, and 607 (49%) had COVID-19 infections. Implementation rates were: entire bundle (without COVID-19: 0% and with COVID-19: 1%), Element A (regular pain assessment: 64 and 55%), Element B (both spontaneous awakening and breathing trials: 17 and 10%), Element C (regular sedation assessment: 45 and 61%), Element D (regular delirium assessment: 39 and 35%), Element E (exercise: 22 and 25%), Element F (family engagement/empowerment: 16 and 30%), and ICU diary (17 and 21%). The presence of COVID-19 was not associated with failure to implement individual elements. Independently associated factors for each element in common between the two groups included presence of a specific written protocol, application of a target/goal, and tele-ICU management. A lower income status country and a 3:1 nurse-patient ratio were significantly associated with non-implementation of elements A, C, and D, while a lower income status country was also associated with implementation of element F. Conclusions: Regardless of COVID-19 infection status, implementation rates for the ABCDEF bundle, for each element individually and an ICU diary were extremely low for patients without and with COVID-19 infections during the pandemic. Strategies to facilitate implementation of and adherence to the complete ABCDEF bundle should be optimized and addressed based on unit-specific barriers and facilitators.
RESUMO
PURPOSE: This study aims to describe the presence and severity of extracranial concomitant injuries in traumatic brain injury (TBI) patients and to ascertain their effect on long-term functional outcome. METHOD: A retrospective cohort study was performed in a single-center recruiting patients with first episode of TBI. The types and severity of extracranial concomitant injuries were documented for patients who fulfilled the inclusion criteria. Injuries with Abbreviated Injury Scale (AIS) grade 3-6 were considered to be high grade. A cross-sectional functional assessment was conducted at 18 months post-injury using Glasgow Outcome Scale. RESULTS: A total of 100 patients were included in the analysis. Extracranial concomitant injuries were seen in 78% of the patients. Three commonest injuries were facial (44%), lower extremity (20%) and upper extremity (12%) injuries. Among the AIS grade ≥ 3, injury involving the chest was most common (41%). Presence of extracranial concomitant injuries AIS grade ≥ 3 was significantly associated with disability in TBI patients at 18 months (OR 12.74, 95% CI 2.39-67.95, p = 0.003). CONCLUSION: Presence of extracranial concomitant injuries was high. In TBI survivors, extracranial concomitant injuries AIS grade ≥ 3 influenced the long-term functional outcome at 18 months, causing moderate and severe disabilities. IMPLICATIONS FOR REHABILITATION: Concomitant injuries should be suspected in patients with traumatic brain injury, especially in a high-speed trauma mechanisms as the incidence can be as high as 78% as in this study and may interfere with the long term rehabilitation and outcome. This study shows that severe extra cranial concomitant injuries are associated with a poor long term functional outcome even in the mild traumatic brain injury patients and therefore need to be addressed early in the rehabilitation of this group of patients. Early diagnosis and management of severe concomitant injuries is warranted and may improve the functional gains in the long term after traumatic brain injury.
