The Effect of ICU Out-of-Hours Admission on Mortality: A Systematic Review and Meta-Analysis

This article by Galloway and others was published in the November 2017 issue of “Critical Care Medicine”

Objectives:  Organizational factors are associated with outcome of critically ill patients and may vary by time of day and day of week. We aimed to identify the association between out-of-hours admission to critical care and mortality.
Data Sources:  MEDLINE (via Ovid) and EMBASE (via Ovid).
Study Selection:  We performed a systematic search of the literature for studies on out-of-hours adult general ICU admission on patient mortality.
Data Extraction:  Meta-analyses were performed and Forest plots drawn using RevMan software. Data are presented as odds ratios ([95% CIs], p values).
Data Synthesis:  A total of 16 studies with 902,551 patients were included in the analysis with a crude mortality of 18.2%. Fourteen studies with 717,331 patients reported mortality rates by time of admission and 11 studies with 835,032 patients by day of admission. Admission to ICU at night was not associated with an increased odds of mortality compared with admissions during the day (odds ratio, 1.04 [0.98-1.11]; p = 0.18). However, admissions during the weekend were associated with an increased odds of death compared with ICU admissions during weekdays (1.05 [1.01-1.09]; p = 0.006). Increased mortality associated with weekend ICU admissions compared with weekday ICU admissions was limited to North American countries (1.08 [1.03-1.12]; p = 0.0004). The absence of a routine overnight on-site intensivist was associated with increased mortality among weekend ICU admissions compared with weekday ICU admissions (1.11 [1.00-1.22]; p = 0.04) and night time admissions compared with daytime ICU admissions (1.11 [1.00-1.23]; p = 0.05).
Conclusions: Adjusted risk of death for ICU admission was greater over the weekends compared with weekdays. The absence of a dedicated intensivist on-site overnight may be associated with increased mortality for acute admissions. These results need to be interpreted in context of the organization of local healthcare resources before changes to healthcare policy are implemented.
The article is available on the internet to those who have a personal subscription via this link to the full text.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.


Critical Care Reviews Newsletter 309 12th November 2017

The Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature from the past week.  “It has been another great week of critical care publications, including the French NUTRIREA-2 trial, comparing early enteral with early parenteral nutrition in ventilated adults with shock (following on from CALORIES and PePANIC), the Canadian/Australian/New Zealand TRICS3 trial, comparing restrictive with liberal transfusion thresholds in the cardiac surgery patients (following on from TITRe2), as well as RCTs looking at contrast-induced nephropathy (PRESERVE) and late thromboectomy after stroke (DAWN). There are also new guidelines on cardiopulmonary resuscitation and emergency cardiovascular care, and European guidelines on perioperative venous thromboembolism prophylaxis in various settings, as well as narrative reviews on the neurological wake-up test, improving CPR performance and chloride in intensive care units.”

The full copy of newsletter 3094 12th November 2017 can be accessed via this link.

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

This article by Beesley and colleagues was published in “Critical Care Medicine” in November 2017.  The full text of the article can be accessed via this link.
Objectives:  The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to curtains-1854110_960_720

determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients.
Design:  This is a prospective, observational study of family members of adult ICU patients.
Setting:  Adult medical and surgical ICU in a tertiary care centre.
Subjects:  Family members of ICU patients.
Interventions:  Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and post-traumatic stress disorder.
Measurement and main Results:  Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported post-traumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02).
Conclusions:  Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and post-traumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.




Admission of tetanus patients to the ICU: a retrospective multicentre study.

This research by Mahieu and colleagues was published in the journal Annals of Intensive Care in November 2017.  The full text of the article can be accessed via this link.
Background:  An extended course of tetanus (up to 6 weeks) requiring ICU admission and protracted mechanical ventilation (MV) may have a significant impact on short- and long-term survival. The subject is noteworthy and deserves to be discussed.
Methods:  Twenty-two ICUs in France performed tetanus screenings on patients admitted between January 2000 and December 2014. Retrospective data were collected from hospital databases and through the registers of the town hall of the patients.
Results:  Seventy patients were included in 15 different ICUs. Sixty-three patients suffered from severe or very severe tetanus according to the Ablett classification. The median age was 80 years [interquartile range 73-84], and 86% of patients were women. Ninety per cent of patients (n = 63) required MV for a median of 36 days [26-46], and 66% required administration of a neuromuscular-blocking agent for 23 days [14-29]. A nosocomial infection occurred in 43 patients (61%). ICU and 1-year mortality rates were 14% (n = 10) and 16% (n = 11), respectively. Forty-five per cent of deaths occurred during the first week. Advanced age, a higher SAPS II, any infection, and the use of vasopressors were significantly associated with a lower number of days alive without ventilator support by day 90. Age was the only factor that significantly differed between deceased and survivors at 1 year (83 [81-85] vs. 79 [73-84] years, respectively; p = 0.03). Sixty-one per cent of survivors suffered no impairment to their functional status.
Conclusion:  In a high-income country, tetanus mainly occurs in healthy elderly women. Despite prolonged MV and extended ICU length of stay, we observed a low 1-year mortality rate and good long-term functional status.

Universal or targeted approach to prevent the transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae in intensive care units: a cost-effectiveness analysis

This article by Kardas-Sloma and colleagues was published in the journal BMJ Open in November 2017.  The full text of the article can be accessed via this link.
Objective:  Several control strategies have been used to limit the transmission of multidrug-resiarrows-2023445_960_720stant organisms in hospitals. However, their implementation is expensive and effectiveness of interventions for the control of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) spread is controversial. Here, we aim to assess the cost-effectiveness of hospital-based strategies to prevent ESBL-PE transmission and infections.
Design:  Cost-effectiveness analysis based on dynamic, stochastic transmission model over a 1-year time horizon.
Patients and setting:  Patients hospitalised in a hypothetical 10-bed intensive care unit (ICU) in a high-income country.
Interventions:  Base case scenario compared with (1) universal strategies (eg, improvement of hand hygiene (HH) among healthcare workers, antibiotic stewardship), (2) targeted strategies (eg, screening of patient for ESBL-PE at ICU admission and contact precautions or cohorting of carriers) and (3) mixed strategies (eg, targeted approaches combined with antibiotic stewardship).
Main outcomes and measures:  Cases of ESBL-PE transmission, infections, cost of intervention, cost of infections, incremental cost per infection avoided.
Results:  In the base case scenario, 15 transmissions and five infections due to ESBL-PE occurred per 100 ICU admissions, representing a mean cost of €94 792. All control strategies improved health outcomes and reduced costs associated with ESBL-PE infections. The overall costs (cost of intervention and infections) were the lowest for HH compliance improvement from 55%/60% before/after contact with a patient to 80%/80%.

Conclusions:  Improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE. Antibiotic stewardship was not cost-effective. However, adding antibiotic restriction strategy to HH or screening and cohorting strategies slightly improved their effectiveness and may be worthy of consideration by decision-makers.

European guidelines on perioperative venous thromboembolism prophylaxis: Intensive care

This article by Duranteau et al was published in the European journal of Anaesthesiology in November 2017.  It is one of a number of guidelines on this topic.  The full text of the article can be accessed via this link.

Venous thromboembolism is a common and potentially life-threatening complication that occurs in 4 to 15% of patients admitted to ICUs despite the routine use of pharmacological prophylaxis. We therefore recommend an institution-wide protocol for the prevention of venous thromboembolism (Grade 1B). The routine use of ultrasonographic screening for deep vein thrombosis is not recommended when thromboprophylactic measures are in place (Grade 1B), as the detection of asymptomatic deep vein thrombosis may prompt therapeutic anticoagulation that may increase bleeding risk but has no proven reduction of clinically significant thrombotic events. In critically ill patients, we recommend pharmacological prophylaxis with low molecular weight heparin over low-dose heparin (Grade 1B). For critically ill patients with severe renal insufficiency, we suggest the use of low-dose heparin (Grade 2C), dalteparin (Grade 2B) or reduced doses of enoxaparin (Grade 2C). Monitoring of anti-Xa activity may be considered when low molecular weight heparin is used in these patients (Grade 2C). No study has prospectively evaluated the efficacy and safety of deep vein thrombosis prophylaxis in critically ill patients with severe liver dysfunction. Thus, the use of pharmacological prophylaxis in these patients should be carefully balanced against the risk of bleeding. For critically ill patients, we recommend against the routine use of inferior vena cava filters for the primary prevention of venous thromboembolism (Grade 1C). When the diagnosis of heparin-induced thrombocytopaenia is suspected or confirmed, all forms of heparin must be discontinued (Grade 1B). In these patients, immediate anticoagulation with a nonheparin anticoagulant rather than discontinuation of heparin alone is recommended (Grade 1C).

Critical Care Reviews Newsletter Issue 308 5th November 2017

Critical Care Reviews Newsletter, bringing you the best critical care research and open access articles from across the medical literature over the past seven days.
Issue is 308 is “packed with great randomised controlled trials, investigating infected necrotising pancreatitis, PCI in stable angina, as well as the CULPRIT-SHOCK Trial, comparing culprit vessel with multi-vessel PCI in acute MI-related cardiogenic shock, and the presently unpublished SMART trial, comparing saline with balanced crystalloids in a single centre, cluster-randomized multiple crossover trial including 15,802 critically ill adults. There is also the second part of the critical illness-related corticosteroid insufficiency guideline from both ESICM & SCCM; and numerous fantastic reviews, on topics such as cardiovascular oncologic emergencies, adverse effects of crystalloid and colloid fluids and environmental bacterial contamination in the ICU.”
The full newsletter can be accessed via this link.