Prevalence and Outcomes of Infection Among Patients in Intensive Care Units in 2017

This article by Vincent and other EPIC III Investigators was published in JAMA during March 2020.
Importance:  Infection is frequent among patients in the intensive care unit (ICU). Contemporary information about the types of infections, causative pathogens, and outcomes can aid the development of policies for prevention, diagnosis, treatment, and resource allocation and may assist in the design of interventional studies.
Objective:  To provide information about the prevalence and outcomes of infection and the available resources in ICUs worldwide.
Design, Setting, and Participants:  Observational 24-hour point prevalence study with longitudinal follow-up at 1150 centers in 88 countries. All adult patients (aged ≥18 years) treated at a participating ICU during a 24-hour period commencing at 08:00 on September 13, 2017, were included. The final follow-up date was November 13, 2017.
Exposures: Infection diagnosis and receipt of antibiotics.
Main Outcomes and Measures:  Prevalence of infection and antibiotic exposure (cross-sectional design) and all-cause in-hospital mortality (longitudinal design).
Results:  Among 15 202 included patients (mean age, 61.1 years [SD, 17.3 years]; 9181 were men [60.4%]), infection data were available for 15 165 (99.8%); 8135 (54%) had suspected or proven infection, including 1760 (22%) with ICU-acquired infection. A total of 10 640 patients (70%) received at least 1 antibiotic. The proportion of patients with suspected or proven infection ranged from 43% (141/328) in Australasia to 60% (1892/3150) in Asia and the Middle East. Among the 8135 patients with suspected or proven infection, 5259 (65%) had at least 1 positive microbiological culture; gram-negative microorganisms were identified in 67% of these patients (n = 3540), gram-positive microorganisms in 37% (n = 1946), and fungal microorganisms in 16% (n = 864). The in-hospital mortality rate was 30% (2404/7936) in patients with suspected or proven infection. In a multilevel analysis, ICU-acquired infection was independently associated with higher risk of mortality compared with community-acquired infection (odds ratio [OR], 1.32 [95% CI, 1.10-1.60]; P = .003). Among antibiotic-resistant microorganisms, infection with vancomycin-resistant Enterococcus (OR, 2.41 [95% CI, 1.43-4.06]; P = .001), Klebsiella resistant to β-lactam antibiotics, including third-generation cephalosporins and carbapenems (OR, 1.29 [95% CI, 1.02-1.63]; P = .03), or carbapenem-resistant Acinetobacter species (OR, 1.40 [95% CI, 1.08-1.81]; P = .01) was independently associated with a higher risk of death vs infection with another microorganism.
Conclusions and Relevance:  In a worldwide sample of patients admitted to ICUs in September 2017, the prevalence of suspected or proven infection was high, with a substantial risk of in-hospital mortality.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.

Would you like to be admitted to the ICU? The preferences of intensivists and general public according to different outcomes

This research by Furnis and collaborators was first published on line in late June 2019 in the Journal of Critical Care.
Background:  Discussions about invasiveness of care (advanced directives) and end-of-life issues have become frequent among intensivists and patients. Nevertheless, there are considerable divergences in the attitudes between intensivists and patients toward end-of-life care in the intensive care units (ICU).
Methods:  The goal was to compare the preferences between intensivists and general public regarding ICU admission of a hypothetical patient with six different clinical outcomes. For that, intensivists and the general public (university graduate professionals outside the area of health) were invited to participate in this study. A survey was conducted with a hypothetical patient with six different clinical outcomes ranging from ICU discharge without any neurological sequelae, nor dependence for daily activities, to death. The WHOQOL-BREF was applied. Comparisons were made between the answers provided by intensivists regarding what they would choose for themselves and their patients, and the preferences of general public.
Results:  Between July 2013 and July 2016, 300 participants in 5 hospitals in São Paulo, Brazil were invited to participate in this study, of whom 257 (85.7%) responded the survey. Eighty-two intensivists responded what they would choose for themselves, 81 intensivists responded what they would choose for their patients, and 94 people from general public responded what they would choose for themselves. Quality of life did not differ among the groups. In all scenarios, except when the outcome was severe disability or death, intensivists were more likely to choose ICU admission for their patients than for themselves (p < .05 for all). Compared with general public, intensivists were more likely to choose ICU admission for themselves only when the best clinical scenario outcome is considered (p < .001). General public was significantly less prone to choosing ICU admission than intensivists when choosing for their patients, in three out of six scenarios (p < .001 for all).
Conclusions:  Considerable divergences exist between intensivists’ and patients’ preferences toward end-of-life care. Advanced care planning and effective ongoing communication among intensivists, patients and relatives are essential to improve end-of-life decisions and the quality of care.
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Impact of triage-to-admission time on patient outcome in European intensive care units: A prospective, multi-national study

This article by Sheldon and colleagues was first published in the Journal of Critical Care during May 2019.
Purpose:  Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwide. Assessing the impact of delayed admission must account for illness severity. This study examined both the relationship between triage-to-admission time and 28-day mortality and the impact of controlling for Simplified Acute Physiology Score (SAPS) II scores on that relationship.
Methods:  Prospective cross-sectional analysis of referrals to eleven ICUs in seven European countries between 2003 and 2005. Outcomes among patients admitted within versus after 4 h were compared using a Chi-square test. Triage-to-admission time was also analyzed as a continuous variable; outcomes were assessed using a non-parametric Kruskal-Wallis test.
Results:  Among 3175 patients analyzed, triage-to-admission time was 2.1 ± 3.9 h. Patients admitted within 4 h had higher SAPS II scores (33.6 versus 30.6, Pearson correlation coefficient −0.07, p < 0.0001). 28-day mortality was surprisingly higher among patients admitted earlier (29.6 vs 25.2%, OR 1.25, 95% CI 0.99–1.58, p = 0.06). Even after adjusting for SAPS II scores, delayed admission was not associated with higher mortality (OR 1.08, CI 0.83–1.41, p = 0.58).
Conclusions:  Even after accounting for quantifiable parameters of illness severity, delayed admission did not negatively impact outcome. Triage practices likely influence outcomes. Severity scores may not fully reflect illness acuity or trajectory.
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The Effect of ICU Diaries on Psychological Outcomes and Quality of Life of Survivors of Critical Illness and Their Relatives: A Systematic Review and Meta-Analysis

This review by McIlroy and colleagues was published in the November 2018 issue of Critical Care Medicine.
Objectives:  To evaluate the effect of ICU diaries on post traumatic stress disorder symptoms in ICU survivors and their relatives.Secondary objectives were to determine the effect on anxiety, depression, and health-related quality of life in patients and their relatives.
Data Sources:  We searched online databases,trial registries, and references of relevant articles.
Study Selection:  Studies were included if there was an ICU diary intervention group which was compared with a group without a diary.
Data Extraction:  Titles, abstracts, and full-text articles were reviewed independently by two authors. Data was abstracted using a structured template.
Data Synthesis:  Our search identified 1,790 articles and retained eight studies for inclusion in the analysis. Pooled results found no significant reduction in patients’ post traumatic stress disorder symptoms with ICU diaries (risk ratio, 0.75 [0.3-1.73]; p = 0.5; n = 3 studies); however, there was a significant improvement in patients’ anxiety(risk ratio, 0.32 [0.12, 0.86]; p = 0.02; n = 2 studies) and depression (risk ratio, 0.39 [0.17-0.87]; p = 0.02; n = 2 studies) symptoms. Two studies reported significant improvement in post traumatic stress disorder symptoms of relatives of ICU survivors; however, these results could not be pooled due to reporting differences. One study reported no significant improvement in either anxiety (risk ratio, 0.94; 95% [0.66-1.33]; p = 0.72) or depression (risk ratio, 0.98; 95% [0.5-1.9]; p = 0.95) in relatives. There was a significant improvement in health-related quality of life of patients with a mean increase in the Short Form-36 general health score by 11.46 (95% CI, 5.87-17.05; p ≤0.0001; n = 2 studies). No studies addressed health-related quality of life of relatives.  
Conclusions:  ICU diaries decrease anxiety and depression and improve health-related quality of life, but not post traumatic stress disorder among ICU survivors and may result in less post traumatic stress disorder among relatives of ICU patients. Multicenter trials with larger sample sizes are necessary to confirm these findings.
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Can a Novel ICU Data Display Positively Affect Patient Outcomes and Save Lives?

This article by Olchanski et al was published in the September issue of Journal of Medical Systems.

The aim of this study was to quantify the impact of ProCCESs AWARE, Ambient Clinical Analytics, Rochester, MN, a novel acute care electronic medical record interface, on a range of care process and patient health outcome metrics in intensive care units (ICUs).  ProCCESs AWARE is a novel acute care EMR interface that contains built-in tools for error prevention, practice surveillance, decision support and reporting. We compared outcomes before and after AWARE implementation using a prospective cohort and a historical control. The study population included all critically ill adult patients (over 18 years old) admitted to four ICUs at Mayo Clinic, Rochester, MN, who stayed in hospital at least 24 h. The pre-AWARE cohort included 983 patients from 2010, and the post-AWARE cohort included 856 patients from 2014. We analyzed patient health outcomes, care process quality, and hospital charges. After adjusting for patient acuity and baseline demographics, overall in-hospital and ICU mortality odds ratios associated with AWARE intervention were 0.45 (95% confidence interval 0.30 to 0.70) and 0.38 (0.22, 0.66). ICU length of stay decreased by about 50%, hospital length of stay by 37%, and total charges for hospital stay by 30% in post AWARE cohort (by $43,745 after adjusting for patient acuity and demographics). Better organization of information in the ICU with systems like AWARE has the potential to improve important patient outcomes, such as mortality and length of stay, resulting in reductions in costs of care.


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Outcomes of Patient- and Family-Centered Care Interventions in the ICU

The aim of this systematic review was to determine whether patient- and family-centered care interventions in the ICU improve outcomes | Critical Care Medicine



Data Synthesis: There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I2 = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I2 = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.

Conclusions: Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.

Full reference: Goldfarb, M,J. et al. (2017) Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis. Critical Care Medicine: Published online: July 26 2017


A Multifaceted Intervention to Improve Outcomes in Intensive Care

This study examines the effectiveness of a patient-centered care and engagement program in the medical ICU | Critical Care Medicine



Interventions: Structured patient-centered care and engagement training program and web-based technology including ICU safety checklist, tools to develop shared care plan, and messaging platform. Patient and care partner access to online portal to view health information, participate in the care plan, and communicate with providers.

Measurements and Main Results: Primary outcome was aggregate adverse event rate. Secondary outcomes included patient and care partner satisfaction, care plan concordance, and resource utilization. We included 2,105 patient admissions, (1,030 baseline and 1,075 during intervention periods). The aggregate rate of adverse events fell 29%, from 59.0 per 1,000 patient days (95% CI, 51.8-67.2) to 41.9 per 1,000 patient days (95% CI, 36.3-48.3; p < 0.001), during the intervention period. Satisfaction improved markedly from an overall hospital rating of 71.8 (95% CI, 61.1-82.6) to 93.3 (95% CI, 88.2-98.4; p < 0.001) for patients and from 84.3 (95% CI, 81.3-87.3) to 90.0 (95% CI, 88.1-91.9; p < 0.001) for care partners. No change in care plan concordance or resource utilization.

Conclusions: Implementation of a structured team communication and patient engagement program in the ICU was associated with a reduction in adverse events and improved patient and care partner satisfaction.

Full reference: Dykes, P. et al. (2017) Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study. Critical Care Medicine. Published online: 3rd May 2017

Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients.

Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information.  This study aimed to determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs).

It was published by White et al in the JAMA 17th May 2016.  The issue is available in the Health Care Library on D Level of Rotherham Hospital or for those with a personal subscription to JAMA can be accessed via this link

This mixed-methods study comprising quantitative surveys and qualitative interviews was conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009.

Discordance about prognosis, defined as a difference between a physician’s and a surrogate’s prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician’s prognostic estimate and a surrogate’s best guess of that estimate); differences in belief (any difference between a surrogate’s actual estimate and their best guess of the physician’s estimate). Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient’s prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates’ prognostic estimates were much more accurate than chance alone, but physicians’ prognostic estimates were statistically significantly more accurate than surrogates’ (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19).

Among critically ill patients, discordant expectations about prognosis were common between patients’ physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians’ assessments of patients’ prognoses and differences in beliefs about patients’ prognoses.

Therapeutic hypothermia in patients following traumatic brain injury: a systematic review

Dunkley, S. et al. Nursing in Critical Care. Published online: 6 May 2016

Background: The efficacy of therapeutic hypothermia in adult patients with traumatic brain injury is not fully understood. The historical use of therapeutic hypothermia at extreme temperatures was associated with severe complications and led to it being discredited. Positive results from animal studies using milder temperatures led to renewed interest. However, recent studies have not convincingly demonstrated the beneficial effects of therapeutic hypothermia in practice.

Aim: This review aims to answer the question: in adults with a severe traumatic brain injury (TBI), does the use of therapeutic hypothermia compared with normothermia affect neurological outcome?

Design: Systematic review.

Method: Four major electronic databases were searched, and a hand search was undertaken using selected key search terms. Inclusion and exclusion criteria were applied. The studies were appraised using a systematic approach, and four themes addressing the research question were identified and critically evaluated.

Results: A total of eight peer-reviewed studies were found, and the results show there is some evidence that therapeutic hypothermia may be effective in improving neurological outcome in adult patients with traumatic brain injury. However, the majority of the trials report conflicting results. Therapeutic hypothermia is reported to be effective at lowering intracranial pressure; however, its efficacy in improving neurological outcome is not fully demonstrated. This review suggests that therapeutic hypothermia had increased benefits in patients with haematoma-type injuries as opposed to those with diffuse injury and contusions. It also suggests that cooling should recommence if rebound intracranial hypertension is observed.

Conclusion: Although the data indicates a trend towards better neurological outcome and reduced mortality rates, higher quality multi-centred randomized controlled trials are required before therapeutic hypothermia is implemented as a standard adjuvant therapy for treating traumatic brain injury.

Relevance to clinical practice: Therapeutic hypothermia can have a positive impact on patient outcome, but more research is required.

Read the abstract here

The association between prior statin usage and long-term outcomes after critical care admission

Beed, M. et al. Journal of Critical Care. Published online: 4 May 2016
Image source: Fuse809 // CC BY-SA 3.0

Image shows Rosuvastatin’s 3D molecular structure

Background: Statins may have immunomodulatory effects that benefit critically ill patients. Therefore we retrospectively examined the association between survival and the prescription of statins prior to admission to an intensive care unit (ICU), or high dependency unit (HDU), as a result of major elective surgery, or as an emergency with a presumed diagnosis of sepsis.

Methods: We retrospectively studied critical care patients (ICU or HDU) from a tertiary referral UK teaching hospital. Nottingham University Hospital has over 2200 beds with 39 critical care beds. Over five-years period (2000–2005) 414 patients with a presumed diagnosis of sepsis were identified and 672 patients who had planned critical care admission following elective major surgery. Patients prescribed statins prior to hospital admission were compared with those who were not. Demographics, past medical history, drug history, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were examined. Univariate and multivariate analyses were applied using the primary endpoint of survival at five years after admission.

Results: Patients prescribed statins prior to critical care admission were, on average, older, with higher initial APACHE II scores and more pre-existing comorbidities. Statins were almost invariably stopped following admission to critical care. Statin usage was not associated with altered survival during hospital admission, or at five years, for either patients with sepsis (9% v 15%, P = .121; 73% v 84%, P = .503 respectively), or post-operative patients (55% v 58%, P = .762; 57% v 63%, P = .390).

Conclusions: Prior statin usage was not associated with improved outcomes in patients admitted to critical care after elective surgical cases or with a presumed diagnosis of sepsis.