"Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents".

CONTEXT: Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. OBJECTIVES: To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. METHODS: In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. RESULTS: We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). CONCLUSIONS: During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.

Association of socioeconomic deprivation with outcomes in critically ill adult patients: an observational prospective multicenter cohort study.

BACKGROUND: The influence of socioeconomic deprivation on health inequalities is established, but its effect on critically ill patients remains unclear, due to inconsistent definitions in previous studies. METHODS: Prospective multicenter cohort study conducted from March to June 2018 in eight ICUs in the Greater Paris area. All admitted patients aged ≥ 18 years were enrolled. Socioeconomic phenotypes were identified using hierarchical clustering, based on education, health insurance, income, and housing. Association of phenotypes with 180-day mortality was assessed using Cox proportional hazards models. RESULTS: A total of 1,748 patients were included. Median age was 62.9 [47.4-74.5] years, 654 (37.4%) patients were female, and median SOFA score was 3 [1-6]. Study population was clustered in five phenotypes with increasing socioeconomic deprivation. Patients from phenotype A (n = 958/1,748, 54.8%) were without socioeconomic deprivation, patients from phenotype B (n = 273/1,748, 15.6%) had only lower education levels, phenotype C patients (n = 117/1,748, 6.7%) had a cumulative burden of 1[1-2] deprivations and all had housing deprivation, phenotype D patients had 2 [1-2] deprivations, all of them with income deprivation, and phenotype E patients (n = 93/1,748, 5.3%) included patients with 3 [2-4] deprivations and included all patients with health insurance deprivation. Patients from phenotypes D and E were younger, had fewer comorbidities, more alcohol and opiate use, and were more frequently admitted due to self-harm diagnoses. Patients from phenotype C (predominant housing deprivation), were more frequently admitted with diagnoses related to chronic respiratory diseases and received more non-invasive positive pressure ventilation. Following adjustment for age, sex, alcohol and opiate use, socioeconomic phenotypes were not associated with increased 180-day mortality: phenotype A (reference); phenotype B (hazard ratio [HR], 0.85; 95% confidence interval CI 0.65-1.12); phenotype C (HR, 0.56; 95% CI 0.34-0.93); phenotype D (HR, 1.09; 95% CI 0.78-1.51); phenotype E (HR, 1.20; 95% CI 0.73-1.96). CONCLUSIONS: In a universal health care system, the most deprived socioeconomic phenotypes were not associated with increased 180-day mortality. The most disadvantaged populations exhibit distinct characteristics and medical conditions that may be addressed through targeted public health interventions.

An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit.

Aim and background: Optimal feeding strategy for critically ill patients of intensive care unit (ICU) is often a matter of debate as patients admitted to ICU are highly catabolic and reduction in muscle mass is very common. We aimed at early achievement of nutritional goals in preventing skeletal muscle breakdown and improving clinical outcomes among critically ill patients with high risk of malnutrition. Materials and methods: Nutrition risk in the critically ill (mNUTRIC) Score was used to identify the risk of malnutrition within 24 hours of admission. Quadriceps muscle mass index was measured within 24 hours of admission to ICU and repeated on 7th day. Enteral feeding was monitored by the nutrition expert as part of routine patient care and clinical outcomes were monitored. Results: A total of 287 patients admitted in ICU were screened for malnutrition and 60 (20.9%) of them had high score (>5). There was no statistically significant reduction in the quadriceps muscle mass index (p < 0.05) (t = 0.601) measured within 24 hours of admission and on the 7th day of ICU stay, signifying that the nutritional prescription and monitoring may be useful in preserving the muscle mass. This study did not find statistically significant association between the high mNUTRIC score on admission and the clinical outcomes, such as 28 days mortality, incidence of pressure ulcers, length of ICU stay, and hospital-acquired infection (p > 0.05). Conclusion: Early initiation and maintenance of enteral nutrition is essential for meeting target calories and protein requirements. It may help to preserve muscle mass in critically ill patients who are otherwise at high risk of malnutrition. How to cite this article: Sharon T, Nayak SG, Shanbhag V, Hebbar S. An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit. Indian J Crit Care Med 2024;28(4):364-368.

Cost of Hospitalization Associated with Inpatient Goals-of-Care Program Implementation at a Comprehensive Cancer Center: A Propensity Score Analysis.

The impact of goals-of-care programs on acute hospitalization costs is unclear. We compared the hospitalization cost in an 8-month period before implementation of a multimodal interdisciplinary goals-of-care program (1 May 2019 to 31 December 2019) to an 8-month period after program implementation (1 May 2020 to 31 December 2020). Propensity score weighting was used to adjust for differences in potential covariates. The primary outcome was total direct cost during the hospital stay for each index hospitalization. This analysis included 6977 patients in 2019 and 5964 patients in 2020. The total direct cost decreased by 3% in 2020 but was not statistically significant (ratio 0.97, 95% CI 0.92, 1.03). Under individual categories, there was a significant decrease in medical oncology (ratio 0.58, 95% CI 0.50, 0.68) and pharmacy costs (ratio 0.86, 95% CI 0.79, 0.96), and an increase in room and board (ratio 1.06, 95% CI 1.01, 1.10). In subgroup analysis, ICU patients had a significant reduction in total direct cost after program implementation (ratio 0.83, 95% CI 0.72, 0.94). After accounting for the length of ICU admission, we found that the total direct cost per hospital day was no longer different between 2019 and 2020 (ratio 0.986, 95% CI 0.92, 1.05), suggesting that shorter ICU admissions likely explained much of the observed cost savings. This study provides real-world data on how "in-the-moment" GOC conversations may contribute to reduced hospitalization costs among ICU patients.

Nutritional and Morphofunctional Assessment of Post-ICU Patients with COVID-19 at Hospital Discharge: NutriEcoMuscle Study.

This paper presents baseline results from the NutriEcoMuscle study, a multicenter observational study conducted in Spain which focused on changes in nutritional status, body composition, and functionality in post-intensive care unit (ICU) COVID-19 patients following a nutritional intervention. Assessments at hospital discharge included Subjective Global Assessment (SGA), Global Leadership Initiative on Malnutrition (GLIM) criteria, the Barthel index, handgrip strength (HGS) and the Timed Up-and-Go test, bioelectrical impedance analysis (BIA), and nutritional ultrasound (US). The study involved 96 patients (71.9% male, mean age 58.8 years, mean BMI 28.8 kg/m2, 36.5% obese). All patients were malnourished at discharge according to GLIM and SGA. Functional status declined from admission up to hospital discharge. A total of 33.3% of patients had a low fat-free mass index (FFMI) and 29.5% had a low phase angle (PhA). Myosteatosis was observed in 83.7% of the population. There was a positive correlation between rectus femoris cross-sectional area, PhA, FFMI, and HGS. In conclusion, post-critically ill COVID-19 patients commonly suffer from malnutrition and reduced muscle mass, causing a loss of independence at hospital discharge. BIA and US could be valuable tools for assessing body composition in these patients. The NutriEcoMuscle study highlights the need for a thorough nutritional and morphofunctional status assessment of post-ICU patients.

Assessment of adherence to the 2020 Surviving Sepsis Campaign guidelines for fluid resuscitation in children with suspected septic shock in paediatric emergency departments: a prospective multicentre study.

BACKGROUND: Paediatric sepsis is the leading cause of death in children under 5 years. No studies have evaluated the application of the Surviving Sepsis Campaign 2020 (SSC-2020) guidelines in paediatric emergency departments (PEDs). OBJECTIVE: To assess physician adherence to the SSC-2020 fluid resuscitation guidelines in children with suspected septic shock in PEDs. METHODS: This was a prospective multicentre observational study conducted in 21 French hospitals over 5 sequential weeks, between November 2021 and March 2022. Children with suspected septic shock and who received antimicrobial therapy within 72 hours were included. Primary outcome was SSC-2020 fluid resuscitation guidelines adherence (low 0-24%; moderate 25-74%; high 75-100%) according to: bolus volume of 10-20 mL/kg each, exclusive administration of balanced crystalloids at 1 and 24 hours of management, and initiation of fluid resuscitation within 1 hour of septic shock recognition. RESULTS: 63 children were included. 10 (16%) children had severe sepsis and 2 (3%) met the definition of septic shock. Compared with the SSC-2020 guidelines, 43 (68%) patients received boluses of 10-20 mL/kg; fluid resuscitation was initiated within 1 hour of septic shock recognition in 42 (76%) cases; balanced crystalloids were the only fluids administrated in 35 (56%) and 34 (55%) children at 1 and 24 hours of management, respectively. Main barriers reported by physicians were difficult intravenous access (43%), lack of team training (29%), workload constraints (28%), and absence or out-of-date protocols (24%). CONCLUSIONS: This study found high adherence for fluid resuscitation initiation but moderate adherence for bolus volume and fluid choice. TRIAL REGISTRATION NUMBER: NCT05066464.

Psychosocial Predictors of Ventilator weaning Outcomes among patients in intensive care units.

Background: Ventilator weaning is a process of discontinuing mechanical ventilation and transitioning patients to independent breathing after a period of mechanical support. Weaning outcomes among the critically ill in intensive care units (ICUs) vary significantly among individuals, leading to considerable variation in healthcare costs, length of hospital stay, morbidity and mortality. Addressing psychosocial aspects of care can improve weaning outcomes. Objective: This study aimed to determine the effect of psychosocial factors (social support, family/significant other support, ability to communicate) on weaning outcome within intensive care patients. This research hypothesized that psychological and social factors play a role in determining ventilator weaning outcomes among ICU patients. Methods: This study used a longitudinal, retrospective research design to analyze positive and negative psychosocial predictors of ventilator weaning outcomes. Data collection methods include interviews and questionnaires with patients and their families, as well as clinical data from the patient's medical records. Results: presence of anxiety, depression, and hallucinations, have a negative relationship with weaning outcomes regarding a patient's psychological characteristics (rs = -0.207, -0.163, -0.158), while communication with a patient during mechanical ventilation have a positive relationship with weaning outcomes regarding a patient's psychological characteristics (rs = 0.152; p ≤ 0.05). Moreover patients who have fear during weaning trials, feeling neglected, and feeling insecurity have a negative relationship with weaning outcomes while gaining family support during mechanical ventilation have a positive relationship with weaning outcomes (rs = 0.144; p ≤ 0.05).Significance of results, the findings suggests that psychosocial factors, such as anxiety, depression, patient's perception of their illness, motivation to wean, and family involvement can influence the success of ventilator weaning among patients in ICUs.

Validation of a low-cost continuous renal replacement therapy dialysate fluid controller for experimental purposes.

BACKGROUND: Continuous renal replacement therapy (CRRT) support is crucial for critically ill patients and it is underexplored in specific situations. Experimental CRRT offers a means to gain insights into these scenarios, but the prohibitive cost of CRRT machines limits their accessibility. This study aimed to develop and validate a low-cost and precise dialysate controller for experimental CRRT. RESULTS: Our results demonstrate a commendable level of precision in affluent flow control, with a robust correlation (R2 = 0.99) for continuous flow and a strong correlation (R2 = 0.95) for intermittent flow. Additionally, we observed acceptable agreement with a bias = 3.4 mL (upper limit 95% = 43.9 mL and lower limit 95% = - 37 mL) for continuous flow and bias = - 20.9 mL (upper limit 95% = 54 mL and lower limit 95% = - 95.7 mL) for intermittent flow, in this way, offering a precise CRRT dose for the subjects. Furthermore, we achieved excellent precision in the cumulative ultrafiltration net (UFnet), with a bias = - 2.8 mL (upper limit 95% = 6.5 mL and lower limit 95% = - 12 mL). These results remained consistent even at low affluent flow rates of 8, 12, and 20 mL/min, which are compatible with CRRT doses of 25-30 mL/kg for medium-sized animals. Moreover, the acceptable precision of our findings persisted when the dialysate controller was subjected to high filter dialysate chamber pressure for an extended duration, up to 797 min. CONCLUSIONS: The low-cost dialysate controller developed and tested in this study offers a precise means of regulating CRRT in experimental settings. Its affordability and accuracy render it a valuable instrument for studying CRRT support in unconventional clinical scenarios, particularly in middle-income countries' experimental ICU laboratories.

Assessment of frequency and types of drug interactions in intensive care units: a cross-sectional study.

Background: Drug interactions can cause adverse reactions, from treatment inefficiency to serious treatment complications in the patient. Due to the complexity of drug therapy and the simultaneous use of several drugs and different drug groups, patients hospitalized in intensive care units are exposed to more drug interactions. Therefore, this study was conducted to investigate the frequency of drug interactions in patients hospitalized in the ICU. Methods: In this cross-sectional study, the files of 300 patients hospitalized in the ICU were examined. Drug interactions were determined using Lexicomp software and the book drug iteration facts. Data analysis was done using SPSS 21 software. Findings: The findings showed that there were a total of 1121 cases of interference. Two hundred thirty-one (77%) patients had moderate interference, 94 (31.3%) patients had mild interference, and 67 patients (22.3%) had severe interference. One hundred eight patients had B-type interference, 223 C-type interference, 116 D-type interference, and 6 X-type interference, so most of the interactions are C-type interference. One hundred eighty-six patients had pharmacokinetic interference and 201 patients had pharmacodynamics interference. The highest interaction was between two drugs, heparin and aspirin with 58 cases. Conclusion: This study highlights the alarming frequency and types of drug interactions observed in ICU. The high prevalence of drug interactions emphasizes the need for improved medication management and vigilance in these critical care settings. Polypharmacy and certain drug combinations were identified as major contributing factors to the occurrence of drug interactions, which calls for regular medication reviews and cautious prescribing practices.

Haemodynamic assessment and management of hypotension in the preterm.

The management of low blood flow states in premature neonates is fraught with many challenges. We remain over-reliant on regimented stepwise protocols that use mean blood pressure as a threshold for intervention to guide treatment, without giving due consideration to the underlying pathophysiology. The current available evidence does not reflect the need to concentrate on the unique pathophysiology of the preterm infant and thus leads to widespread misuse of vasoactive agents that often do not provide the desired clinical effect. Therefore, understanding the underlying pathophysiological underpinnings of haemodynamic compromise may better guide choice of agent and assess physiological response to the selected intervention.

Investigation of morbidity, length of stay, and healthcare costs of inpatient paediatric burns.

Burn injuries are the third most common cause of death in children due to trauma. Hospitalizations related to burn injuries are common. Prolonged hospitalization associated with burn treatment can result in increased resource utilization, leading to higher costs. Thus, it is essential to investigate these areas to reduce costs. The study investigated the morbidity and length of hospital stay of paediatric burn patients, as well as calculated the social security costs of hospitalization and treatment. The retrospective observational descriptive study examined the medical records of 774 paediatric patients treated in a burn intensive care unit at a tertiary medical faculty hospital between 01 March 2019 and 31 March 2022. The invoice records of payments made by the Social Security Institution to the hospital in return for health services provided to patients were examined. The healthcare costs were calculated. A total of 57.6% of the participants were boys and 79.2% were between the ages of 1-4. About 90% of the cases involved burns with a total body surface area (TBSA) of less than 20% and a 2nd-degree burn depth. Scalding was the most common cause of burns (88.2%). Among all patients, the mortality rate was 2.1% (n = 16). The mean length of hospital stay was 10.29 ± 9.59 days. The mean cost per day was 212.02 ± 190.94 US dollars ($US), and the cost per 1% TBSA was 241.70 ± 301.32 $US. According to the causes of burn injury, the mean cost of electricity was 5000.77 ± 8101.85 $US, fire 4818.02 ± 5852.22 $US, and chemical 3285.49 ± 4503.2 $US were observed in the first 3 ranks respectively. According to this study, paediatric burn cases occur due to preventable causes, and even though the mortality rate was low, the severity of burns, TBSA%, and presence of complications caused prolonged lengths of hospital stays, which caused social security costs to rise.

Implementing early rehabilitation and mobilisation for children in UK paediatric intensive care units: the PERMIT feasibility study.

Background: Early rehabilitation and mobilisation encompass patient-tailored interventions, delivered within intensive care, but there are few studies in children and young people within paediatric intensive care units. Objectives: To explore how healthcare professionals currently practise early rehabilitation and mobilisation using qualitative and quantitative approaches; co-design the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual of early rehabilitation and mobilisation interventions, with primary and secondary patient-centred outcomes; explore feasibility and acceptability of implementing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual within three paediatric intensive care units. Design: Mixed-methods feasibility with five interlinked studies (scoping review, survey, observational study, codesign workshops, feasibility study) in three phases. Setting: United Kingdom paediatric intensive care units. Participants: Children and young people aged 0-16 years remaining within paediatric intensive care on day 3, their parents/guardians and healthcare professionals. Interventions: In Phase 3, unit-wide implementation of manualised early rehabilitation and mobilisation. Main outcome measures: Phase 1 observational study: prevalence of any early rehabilitation and mobilisation on day 3. Phase 3 feasibility study: acceptability of early rehabilitation and mobilisation intervention; adverse events; acceptability of study design; acceptability of outcome measures. Data sources: Searched Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PEDro, Open grey and Cochrane CENTRAL databases. Review methods: Narrative synthesis. Results: In the scoping review we identified 36 full-text reports evaluating rehabilitation initiated within 7 days of paediatric intensive care unit admission, outlining non-mobility and mobility early rehabilitation and mobilisation interventions from 24 to 72 hours and delivered twice daily. With the survey, 124/191 (65%) responded from 26/29 (90%) United Kingdom paediatric intensive care units; the majority considered early rehabilitation and mobilisation a priority. The observational study followed 169 patients from 15 units; prevalence of any early rehabilitation and mobilisation on day 3 was 95.3%. We then developed a manualised early rehabilitation and mobilisation intervention informed by current evidence, experience and theory. All three sites implemented the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual successfully, recruited to target (30 patients recruited) and followed up the patients until day 30 or discharge; 21/30 parents consented to complete additional outcome measures. Limitations: The findings represent the views of National Health Service staff but may not be generalisable. We were unable to conduct workshops and interviews with children, young people and parents to support the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual development due to pandemic restrictions. Conclusions: A randomised controlled trial is recommended to assess the effectiveness of the manualised early rehabilitation and mobilisation intervention. Future work: A definitive cluster randomised trial of early rehabilitation and mobilisation in paediatric intensive care requires selection of outcome measure and health economic evaluation. Study registration: The study is registered as PROSPERO CRD42019151050. The Phase 1 observational study is registered Clinicaltrials.gov NCT04110938 (Phase 1) (registered 1 October 2019) and the Phase 3 feasibility study is registered NCT04909762 (Phase 3) (registered 2 June 2021). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/21/06) and is published in full in Health Technology Assessment; Vol. 27, No. 27. See the NIHR Funding and Awards website for further award information.

Early rehabilitation and mobilisation, within the first week of intensive care admission, can improve the speed of recovery from illness or injury in adults. However, there is a lack of evidence about whether critically unwell children benefit from early rehabilitation and mobilisation. We aimed to identify which patients may benefit from early rehabilitation and mobilisation. Also, to develop and test a manual of early rehabilitation and mobilisation using the best evidence and expertise ­ called the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual. Then evaluate whether the manual could be implemented safely in paediatric intensive care units and was acceptable to staff and families. We undertook in respect of early rehabilitation and mobilisation: review of existing research; national survey of practice (124 staff); gathered information about current conduct (15 paediatric intensive care units, 169 patients); spoke to experts (18 people); developed the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual to guide paediatric intensive care unit staff; Tested the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual in three paediatric intensive care units with 30 patients; gathered feedback from healthcare professionals via weekly 'debriefs' (47), interviews (13) and surveys (118), and from parents via parent-completed questionnaires (21) and interviews (14). Despite being regarded as important, currently early rehabilitation and mobilisation practice is inconsistent, not considered 'early' enough and often focuses on low-risk activities conducted on the bed. Introducing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual as part of a trial was acceptable and feasible and helps standardise delivery to unwell children. Measuring child and parent reported outcomes was acceptable but follow-up at 30 days was incomplete. A larger trial of early rehabilitation and mobilisation, involving more paediatric intensive care units, is feasible and required to demonstrate benefit to children.

Early detection and assessment of intensive care unit-acquired weakness: a comprehensive review.

Intensive care unit-acquired weakness (ICU-AW) is a serious complication in critically ill patients. Therefore, timely and accurate diagnosis and monitoring of ICU-AW are crucial for effectively preventing its associated morbidity and mortality. This article provides a comprehensive review of ICU-AW, focusing on the different methods used for its diagnosis and monitoring. Additionally, it highlights the role of bedside ultrasound in muscle assessment and early detection of ICU-AW. Furthermore, the article explores potential strategies for preventing ICU-AW. Healthcare providers who manage critically ill patients utilize diagnostic approaches such as physical exams, imaging, and assessment tools to identify ICU-AW. However, each method has its own limitations. The diagnosis of ICU-AW needs improvement due to the lack of a consensus on the appropriate approach for its detection. Nevertheless, bedside ultrasound has proven to be the most reliable and cost-effective tool for muscle assessment in the ICU. Combining the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score assessment, and ultrasound can be a convenient approach for the early detection of ICU-AW. This approach can facilitate timely intervention and prevent catastrophic consequences. However, further studies are needed to strengthen the evidence.

Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study.

BACKGROUND: There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. METHODS: A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice. RESULTS: At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept. CONCLUSIONS: This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Instrumentos para la evaluación del riesgo de lesiones por presión en adultos en estado crítico: scoping review / Risk assessment instruments for pressure ulcer in adults in critical situation: a scoping review / Instrumentos para a avaliação do risco de lesões por pressão para adultos em situação crítica: scoping review*

Objetivo: mapear los instrumentos para la evaluación del riesgo de lesiones por presión en adultos en situación crítica en una unidad de terapia intensiva; identificar los indicadores de desempeño de los instrumentos y la apreciación de los usuarios con respecto al uso/limitaciones de los instrumentos. Método: scoping review. Para redactar el estudio se utilizó la extensión Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. La investigación se realizó mediante la herramienta de búsqueda EBSCOhost en 8 bases de datos, resultando 1846 estudios, de los cuales 22 conforman la muestra. Resultados: se identificaron dos grandes grupos de instrumentos: los generalistas [Braden, Braden (ALB), Emina, Norton-MI, RAPS y Waterlow]; y los específicos (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi y Sanada y el índice COMHON). En cuanto al valor predictivo, EVARUCI y CALCULATE mostraron los mejores resultados de indicadores de desempeño. En cuanto a las apreciaciones/limitaciones señaladas por los usuarios, destaca la escala CALCULATE, seguida de la EVARUCI y la RAPS-ICU, aunque aún necesitan ajustes futuros. Conclusión: el mapeo mostró que las evidencias son suficientes para indicar uno o más instrumentos para la evaluación del riesgo de lesiones por presión en adultos críticos en una unidad de cuidados intensivos.

Objective: to map the instruments for risk assessment of pressure ulcers in adults in critical situation in intensive care units; identify performance indicators of the instrument, and the appreciation of users regarding the instruments' use/limitations. Method: a scoping review. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews in the writing of the study. We carried out the searches in the EBSCOhost search tool for 8 databases, resulting in 1846 studies, of which 22 studies compose the sample. Results: we identified two big instrument groups: generalist [Braden, Braden (ALB), Emina, Norton-MI, RAPS, and Waterlow]; and specific (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi and Sanada, and COMHON index). Regarding the predictive value, EVARUCI and CALCULATE presented better results for performance indicators. Concerning appreciation/limitations indicated by users, we highlight the CALCULATE scale, followed by EVARUCI and RAPS-ICU, although they still need future adjustments. Conclusion: the mapping of the literature showed that the evidence is sufficient to indicate one or more instruments for the risk assessment of pressure ulcers for adults in critical situation in intensive care units.

Objetivo: mapear os instrumentos para avaliação do risco de lesões por pressão nos adultos em situação crítica em unidade de cuidados intensivos; identificar os indicadores de desempenho dos instrumentos e a apreciação dos utilizadores quanto ao uso/às limitações dos instrumentos. Método: scoping review. O Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews foi utilizado para a redação do estudo. A pesquisa foi realizada na ferramenta de busca EBSCOhost em oito bases de dados, resultando em 1846 estudos, dos quais 22 compõem a amostra. Resultados: identificaram-se dois grandes grupos de instrumentos: os genéricos [Braden, Braden (ALB), Emina, Norton-MI, RAPS e Waterlow]; e os específicos (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi e Sanada e o índice de COMHON). Quanto ao valor preditivo, a EVARUCI e a CALCULATE apresentaram os melhores resultados de indicadores de desempenho. Em relação à apreciação/às limitações apontadas pelos utilizadores, destacam-se a escala CALCULATE, seguindo-se da EVARUCI e da RAPS-ICU, embora ainda necessitem de ajustes futuros. Conclusão: o mapeamento mostrou que as evidências são suficientes para indicar um ou mais instrumentos para avaliação do risco de lesões por pressão nos adultos em situação crítica em unidade de cuidados intensivos.

Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit.

Medication administration is a complex process, and nurses play a central role in this process. Errors during administration are associated with severe patient harm and significant economic burden. However, the prevalence of under-reporting makes it challenging when analysing the current landscape of medication administration error (MAE) and hinders the implementation of improvements to the existing system. The aim of this study is to describe the reasons for the occurrence of MAEs and the reasons behind the under-reporting of MAEs, to determine the estimated percentage of MAE reporting and to identify factors associated with them from the nurses' perspective. This cross-sectional study was conducted using a validated self-administered questionnaire. The questionnaire contained 65 questions which were divided into three sections: (i) reasons for the occurrence of MAEs, which consisted of 29 items; (ii) reasons for not reporting MAEs, which consisted of 16 items; and (iii) percentage of MAEs actually reported, which consisted of 20 items. It was distributed to 143 nurses in the neonatal intensive care units of five public hospitals in Malaysia. Multivariable logistic regression was used to identify the factors associated with MAE reporting. The estimated percentage of MAE reporting was 30.6%. The most common reasons for MAEs were inadequate nursing staff (5.14 [SD 1.25]), followed by drugs which look alike (4.65 [SD 1.06]) and similar drug packaging (4.41 [SD 1.18]). The most common reasons for not reporting MAEs were that nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error (4.56 [SD 1.32]) and that too much emphasis is placed on MAEs as a measure of the quality of nursing care (4.31 [SD 1.23]). Factors statistically significant with MAE reporting were administration response (adjusted odds ratio [AOR] = 6.90; 95% confidence interval (CI) = 2.01-23.67; P = 0.002), reporting effort (AOR = 3.67; 95% CI = 1.68-8.01; P = 0.001), and nurses with advanced diploma (AOR = 0.29; 95% CI = 0.13-0.65; P = 0.003). Our findings show that under-reporting of MAEs is still common and less than a third of the respondents reported MAEs. Therefore, to encourage error reporting, emphasis should be placed on the benefits of reporting, adopting a non-punitive approach, and creating a blame-free culture.

Can Bispectral Index be a Point-of-care Monitor for Sleep Quality Assessment in Critically Ill Patients?

How to cite this article: Kapoor I, Prabhakar H. Can Bispectral Index be a Point-of-care Monitor for Sleep Quality Assessment in Critically Ill Patients? Indian J Crit Care Med 2023;27(11):782-783.

Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs.

Introduction: Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence. Aim of the study: To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU. Material and Methods: We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions. Results: NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001). Conclusions: Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

Comparison of Morbidity, Mortality, and Costs of VAP Patients with Non-VAP Patients in the Tertiary Referral Hospital of Kerman, Iran.

Background: Ventilator-associated pneumonia is the most common type of nosocomial infection in ICUs. Hence, this study shall focus on the morbidity, mortality, and costs associated with this infection among ICU patients. Materials and Methods: The current research is a prospective descriptive-analytical study. The study population included patients admitted to the Tertiary Referral Hospital of Kerman University of Medical Sciences who were enrolled in the study according to inclusion criteria and demographic characteristics data, length of stay in ICU and general wards, and direct and indirect medical expenses such as unemployment and rehabilitation cost, etc. Results: Nine of the 144 patients studied died. (4 in the Ventilator-Associated Pneumonia (VAP) group and 5 in the non-VAP group). Among them, the prevalence of Acinetobacter Baumannii was significantly higher than other bacteria (P-Value=0.001). The duration of hospitalization in the ICU (18±9 vs. 9.5±6 days) and recovery time (21.6±9 9.6 vs. 13.2±7 days) were higher in the VAP group (P-Value<0.05). Moreover, the duration of hospitalization in the general ward was 15.4±8 days in the VAP group and 10.6±6 days in the non-VAP group (P-Value<0.05). The cost of treatment in the VAP group ($7952.28) was significantly higher than in the non-infected group ($4400.98). The average rehabilitation cost in the VAP group was $2571.42 and in the non-affected group was $1530.88. The financial loss due to the delay in work starting was $482 in the non-VAP group which was significantly less than the VAP group ($792). Conclusion: Having VAP can significantly increase mortality, length of stay in the ICU as well as increase direct and indirect costs for patients.

Ultrasound assessment of muscle mass and correlation with clinical outcomes in critically ill patients: a prospective observational study.

PURPOSE: Muscular atrophy implies structural and functional alterations related to muscular force production and movement. This condition has been reported to be the main reason for generalized muscle weakness; it reflects the severity of the disease and can have a profound impact on short- and long-term clinical outcomes. The purpose of this study was to determine whether muscle atrophy ultrasound parameters early predict muscle weakness, morbidity, or 28-days mortality. METHODS: This was a prospective, observational single center cohort study. Ultrasound was used to determine the cross-sectional area and muscle thickness of the rectus femoris on the first and third day of ICU stay. The main outcome was the incidence of significant muscle atrophy (≥ 10%). RESULTS: Ultrasound measurements were made in 31 patients, 58% (18/31) of which showed significant muscle atrophy. The relative loss of muscle mass per day was 1.78 at 5% per day. The presence of muscle atrophy presents increased risk for limb muscle weakness and handgrip weakness. The 28-days mortality rate was similar in both subgroups. CONCLUSION: The presence of muscle atrophy presents an increased clinical risk for the development of limb ICUAW and handgrip, although these observations were not statistically significant. The results could be used to plan future studies on this topic.