Triage of Critically Ill Patients: Characteristics and Outcomes of Patients Refused as Too Well for Intensive Care.

BACKGROUND: The appropriate selection of patients for the intensive care unit (ICU) is a concern in acute care settings. However, the description of patients deemed too well for the ICU has been rarely reported. METHODS: We conducted a single-centre retrospective observational study of all patients either deemed "too well" for or admitted to the ICU during one year. Refused patients were screened for unexpected events within 7 days, defined as either ICU admission without another indication, or death without treatment limitations. Patients' characteristics and organisational factors were analysed according to refusal status, outcome and delay in ICU admission. RESULTS: Among 2219 enrolled patients, the refusal rate was 10.4%. Refusal was associated with diagnostic groups, treatment limitations, patients' location on a ward, night time and ICU occupancy. Unexpected events occurred in 16 (6.9%) refused patients. A worse outcome was associated with time spent in hospital before refusal, patients' location on a ward, SOFA score and physician's expertise. Delayed ICU admissions were associated with ICU and hospital length of stay. CONCLUSIONS: ICU triage selected safely most patients who would have probably not benefited from the ICU. We identified individual and organisational factors associated with ICU refusal, subsequent ICU admission or death.

Characteristics, comorbidities, 30-day outcome and in-hospital mortality of patients hospitalised with COVID-19 in a Swiss area - a retrospective cohort study.

BACKGROUND: Since its first description in December 2019, coronavirus disease 19 (COVID-19) has spread worldwide. There is limited information about presenting characteristics and outcomes of Swiss patients requiring hospitalisation. Furthermore, outcomes 30 days after onset of symptoms and after hospital discharge have not been described. AIMS: To describe the clinical characteristics, outcomes 30 days after onset of symptoms and in-hospital mortality of a cohort of patients hospitalised for COVID-19 in a Swiss area. METHODS: In this retrospective cohort study, we included all inpatients hospitalised with microbiologically confirmed COVID-19 between 1 March and 12 April 2020 in the public hospital network of a Swiss area (Fribourg). Demographic data, comorbidities and outcomes were recorded. Rate of potential hospital-acquired infection, outcomes 30 days after onset of symptoms and in-hospital mortality are reported. RESULTS: One hundred ninety-six patients were included in the study. In our population, 119 (61%) were male and the median age was 70 years. Forty-nine patients (25%) were admitted to the intensive care unit (ICU). The rate of potential hospital-acquired infection was 7%. Overall, 30 days after onset of symptoms 117 patients (60%) had returned home, 23 patients (12%) were in a rehabilitation facility, 18 patients (9%) in a medical ward, 6 patients (3%) in ICU and 32 (16%) patients had died. Among patients who returned home within 30 days, 73 patients (63%) reported persistent symptoms. The overall in-hospital mortality was 17%. CONCLUSION: We report the first cohort of Swiss patients hospitalised with COVID-19. Thirty days after onset of the symptoms, 60% had returned home. Among them, 63% still presented symptoms. Studies with longer follow-up are needed to document long-term outcomes in patients hospitalised with COVID-19.

[Admission or non admission of patients with cancer to the ICU]. / Admission ou non-admission du patient oncologique aux soins intensifs.

Determining if a critically ill patient with cancer will benefit from medical care in an intensive care unit can be a real challenge. Studies show that anticipating critical situations in oncology and collaboration between oncologists and intensivists diminish mortality and enhance resource use. This article covers some of the facts to consider in order to improve the management of these patients.

La question du projet thérapeutique et de l'admission ou non aux soins intensifs (SI) d'un patient souffrant d'un cancer et se trouvant en situation critique peut être complexe à appréhender. La décision d'un tel transfert est lourde de conséquences pour les patients et leurs familles, ainsi que pour son coût humain et économique. Il est donc primordial d'avoir une réflexion en amont sur le bien-fondé de chaque transfert. Une concertation régulière impliquant le médecin traitant/l'oncologue et le malade/sa famille tout au long de l'évolution de la maladie permet de clarifier les situations susceptibles de conduire à un transfert en SI.

[The culture of "useful error" in health care establishments: impact of morbidity and mortality conferences (MMCs)]. / Culture de l'erreur dans les etablissements de soins: place des colloques de morbidité-mortalité.

Since the publication of the Institute of Medicine's report, "To Err is Human", in 1999, patient safety has become an economic and political objective. The notion of safety involves willingness and initiation of measures to reduce or eliminate errors leading to preventable adverse events. Morbidity and mortality conferences are useful tool to improve local care management through the discussion of adverse events and medical errors and the conception of alternative approaches. In addition, MMCs have an educational value for the entire medical and nursing staff. The involvement of the head of the department is crucial to achieve a cultural change within the caregivers by developing the concept of "useful error" during MMCs.

[Anesthetic gases for the treatment of acute severe asthma]. / Emploi de mélanges d'agents volatils dans l'asthme aigu grave.

Halogenated gases have sometimes been used for treating acute severe asthma when this disorder is refractory to any drug. Presently, we only can rely on some sparsed observations, or to small retrospective series. Isoflurane seems to be the most studied gas: it has clearly a bronchodilating action, and its side-effects seem to be minor. However, to administer such medications, precise knowledge and technical skills are mandatory. In addition, the intensive care personnel must be protected from an accidental exposure. Therefore, intensive care physicians should be helped by an experienced anesthesiologist when using these gases.

[Heliox in acute severe asthma]. / Emploi de mélanges hélium-oxygène (héliox) dans l'asthme aigu grave.

In acute severe asthma, the use of heliox can reduce dyspnea, when the patient is spontaneously breathing as well as in mechanical ventilation. This effect is due to a decrease in airway resistance. A better penetration of aerosolized bronchodilators has also been observed. However, the clinical benefit of these physiological measurable effects remains undetermined. Heliox could nevertheless be interesting in emergency situations in order to avoid endotracheal intubation, and in very difficult cases when mechanical ventilation is almost impossible to perform. This gas mixture could also be used with non-invasive mechanical ventilation, but this indication is presently investigated.