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

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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.

 

Quality of patient care in the critical care unit in relation to nurse patient ratio: A descriptive study

Falk, A.C. & Wallin, E.M. Intensive and Critical Care Nursing. Published online: 23 April 2016

11679-2Background: Intensive care is one of the most resource-intensive forms of medical care due to severely ill patients that are cared for in units with high staffing levels. Nursing’s impact on the health of patients has shown that the number of nurses per patient and nurse education effects patient outcome. However, there are a lack of studies investigating highly specialised nurses in intensive care and their relation to patient outcome.

Method: This is a retrospective study of critical care registry data (all patients >15 years) in general critical care units at seven university hospitals.

Results: Patient care and complications in relation to nurse/patient ratio showed that unplanned extubations occurred in 3–5.7% of cases. A difference between hospital patients’ length of time on ventilation was found with the hospitals with the least amount of patients and with 0.5–0.6 specialist-nurse/patient a longer time on ventilation was noted. The length of ICU stay showed differences between the hospitals and nurse/patient ratios, with higher nurse/patient ratio with the longer length of ICU stay.

Conclusion: Despite similarities between hospitals in relation to SAPS III on admission to critical care, there was a difference in nurse/patient ratios ranging from 1:1 to 0.5:1 and mean time on both invasive and noninvasive ventilation.

Read the article here