Dissemination of clinical and scientific practice through social media: a SIAARTI consensus-based document.

BACKGROUND: Dissemination of medical practice and scientific information through social media (SoMe) by clinicians and researchers is increasing. Broad exposure of information can promote connectivity within the scientific community, overcome barriers to access to sources, increase debate, and reveal layperson perspectives and preferences. On the other hand, practices lacking scientific evidence may also be promoted, laypeople may misunderstand the professional message, and clinician may suffer erosion of professional status. The aim of this project was to enhance awareness and advise the anesthesia community and clinicians at large about the potential risks advocate for responsible use of SoMe to disseminate information related to medical practices and knowledge. METHODS: A modified Delphi process with prespecified consensus criteria was conducted among a multidisciplinary panel of experts, including anesthesiologists-intensivists, clinical psychologists, and forensic medicine specialists. Six items were identified: Ethics and deontological principles, the practice of sharing information via social media, legal aspects, psychological aspects, self-promotion, and criteria for appropriate dissemination. Statements and rationales were produced and subjected to blinded panelists' votes. After reaching consensus, a document was written which then underwent external review by experts uninvolved in the consensus process. The project was promoted by the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI). RESULTS: Twelve statements were produced, and consensus was achieved for all. The panel concluded that the general principles guiding dissemination of professional information via SoMe must remain in line with the general principles of ethics, deontology, and scientific validity that guide the medical profession and science in general. Professional equity must be maintained while communicating via SoMe. Medical practices lacking support by scientific evidence should not be disseminated. Patients' informed consent must be obtained before dissemination of information, images, or data. Self-promotion must not be prioritized over any of these principles. CONCLUSIONS: When sharing medical practices and scientific information on SoMe, healthcare professionals are advised to act conscientiously and ethically. Local regulations should be adhered to. Institutional training on the potential risks and proper of SoMe for such purpose may contribute to preservation of professional integrity.

Moral Distress in the Italian PICUs: The Role of Individual and Organizational Factors.

OBJECTIVES: To assess the interplay between individual and organizational factors on moral distress in PICUs. DESIGN: Cross-sectional, article-based survey administered between June and August 2017. SETTING: Twenty-three Italian PICUs. SUBJECTS: Of 874 eligible clinicians, 635 responded to the survey (75% response rate), and 612 correctly completed the survey. Clinicians were 74% female; 66% nurses and 34% physicians; and 51% had between 6 and 20 years of experience from graduation. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Clinicians completed the "Italian Moral Distress Scale-Revised," the "Connor-Davidson Resilience Scale," and a sociodemographic questionnaire inquiring about sex, profession, years of experience, and spiritual/religious belief. PICU organizational characteristics were also collected (e.g., number of admissions, mortality rate, nurse-patient ratio, presence of parents in PICU, presence of parents during physical examination). To identify individual predictors of moral distress, we used stepwise linear regression. To determine the impact of organizational factors on moral distress, we used analysis of covariance, controlling for those individual factors that emerged as significant in the regression model. Moral distress was associated with being a nurse (B = -0.094; p < 0.05) and not having spiritual/religious belief (B = 0.130; p < 0.01), but not with resilience. Clinicians working in PICUs with a medium number of admissions per year (between 264 and 468), a lower nurse:patient ratio (1:3), and where parents' presence during physical examination were never allowed experienced higher moral distress even controlling for profession and spiritual/religious belief. CONCLUSIONS: Organizational factors (medium number of admissions, lower nurse:patient ratio, and parental exclusion from physical examination) played a stronger role than individual factors in increasing moral distress. To decrease moral distress, attention should be paid also to organizational aspects.

Communication and visiting policies in Italian intensive care units during the first COVID-19 pandemic wave and lockdown: a nationwide survey.

BACKGROUND: During the first coronavirus disease 2019 (COVID-19) pandemic wave, an unprecedented number of patients with respiratory failure due to a new, highly contagious virus needed hospitalization and intensive care unit (ICU) admission. The aim of the present study was to describe the communication and visiting policies of Italian intensive care units (ICUs) during the first COVID-19 pandemic wave and national lockdown and compare these data with prepandemic conditions. METHODS: A national web-based survey was conducted among 290 Italian hospitals. Each ICU (active between February 24 and May 31, 2020) was encouraged to complete an individual questionnaire inquiring the hospital/ICU structure/organization, communication/visiting habits and the role of clinical psychology prior to, and during the first COVID-19 pandemic wave. RESULTS: Two hundred and nine ICUs from 154 hospitals (53% of the contacted hospitals) completed the survey (202 adult and 7 pediatric ICUs). Among adult ICUs, 60% were dedicated to COVID-19 patients, 21% were dedicated to patients without COVID-19 and 19% were dedicated to both categories (Mixed). A total of 11,102 adult patients were admitted to the participating ICUs during the study period and only approximately 6% of patients received at least one visit. Communication with family members was guaranteed daily through an increased use of electronic devices and was preferentially addressed to the same family member. Compared to the prepandemic period, clinical psychologists supported physicians more often regarding communication with family members. Fewer patients received at least one visit from family members in COVID and mixed-ICUs than in non-COVID ICUs, l (0 [0-6]%, 0 [0-4]% and 11 [2-25]%, respectively, p < 0.001). Habits of pediatric ICUs were less affected by the pandemic. CONCLUSIONS: Visiting policies of Italian ICUs dedicated to adult patients were markedly altered during the first COVID-19 wave. Remote communication was widely adopted as a surrogate for family meetings. New strategies to favor a family-centered approach during the current and future pandemics are warranted.

Moral Distress Trajectories of Physicians 1 Year after the COVID-19 Outbreak: A Grounded Theory Study.

The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians' experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 emergency and critical care physicians who worked in six hospitals from the Lombardy region of Italy. Semi-structured interviews about their professional experience of moral distress were conducted from November 2020-February 2021 (1 year after the pandemic outbreak). The transcripts were qualitatively analyzed following open, axial, and selective coding. A model of moral distress was generated around the core category of Being a Good Doctor. Several Pandemic Stressors threatened the sense of Being a Good Doctor, causing moral distress. Pandemic Stressors included limited healthcare resources, intensified patient triage, changeable selection criteria, limited therapeutic/clinical knowledge, and patient isolation. Emotions of Moral Distress included powerlessness, frustration/anger, and sadness. Physicians presented different Individual Responses to cope with moral distress, such as avoidance, acquiescence, reinterpretation, and resistance. These Individual Responses generated different Moral Outcomes, such as moral residue, disengagement, or moral integrity. The Working Environment, especially the team and organizational culture, was instrumental in restoring or disrupting moral integrity. In order for physicians to manage moral distress successfully, it was important to use reinterpretation, that is, to find new ways of enacting their own values by reframing morally distressing situations, and to perceive a cooperative and supportive Working Environment.

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study.

BACKGROUND: End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS: In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS: Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION: Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING: None.

Life-sustaining treatment decisions in pediatric intensive care: an Italian survey on ethical concerns.

OBJECTIVES: To investigate how life-sustaining treatment (LST) decisions are made and identify problematic ethical concerns confronted by physicians and nurses in pediatric intensive care within Italy. METHODS: An 88-question online survey was created, based on a previous qualitative study conducted by this team. The survey was designed to identify how LST decisions were managed; contrasting actual practices with what participants think practices should be. Replies from physicians and nurses were compared, to identify potential inter-professional ethical tensions. The study also identified participants' principal ethical concerns. Moreover, open-ended questions elicited qualitative perspectives on participants' views. The survey was pilot-tested and refined before initiation of the study. RESULTS: 31 physicians and 65 nurses participated in the study. Participants were recruited from pediatric intensive care units across five Italian cities; i.e., Florence, Milan, Padua, Rome, Verona. Statistically significant differences were identified for (a) virtually all questions contrasting actual practices with what participants think practices should be and (b) 14 questions contrasting physician replies with those of nurses. Physicians and nurses identified the absence of legislative standards for LST withdrawal as a highly problematic ethical concern. Physicians also identified bearing responsibility for LST decisions as a major concern. Qualitative descriptions further demonstrated that these Italian pediatric intensive care clinicians encounter significantly distressing ethical problems in their practice. CONCLUSIONS: The results of this study highlight a need for the development of (a) strategies for improving team processes regarding LST decisions, so they can be better aligned with how clinicians think decisions should be made, and (b) Italian LST decision-making standards that can help ensure optimal ethical practices.

Why and how to open intensive care units to family visits during the pandemic.

Since the lockdown because of the pandemic, family members have been prohibited from visiting their loved ones in hospital. While it is clearly complicated to implement protocols for the admission of family members, we believe precise strategic goals are essential and operational guidance is needed on how to achieve them. Even during the pandemic, we consider it a priority to share strategies adapted to every local setting to allow family members to enter intensive care units and all the other hospital wards.

[The handover in clinical practice of anesthesiologists and intensivists.] / Il passaggio delle consegne nella pratica clinica degli anestesisti rianimatori.

The handover among healthcare professionals has been a topic of increasing interest over recent years. Many studies have shown that ineffective communication during handover can be critical, particularly for anaesthesiologists and intensivists because of the highly complex needs of patients under their care. Numerous studies have identified the information transfer process as the greatest risk of errors and adverse events (AEs), which results in harm to patients, increases legal issues and damages relations between health professionals. The adoption of effective communication methods determines a significant improvement of the handover and a reduction in the frequency of errors and AEs. The purpose of this document is to focus attention on the problem in order to promote heightened safety procedures within health facilities. Among the numerous methods validated in clinical practice, the authors have chosen the I-PASS method (Illness, Patient, Action, Situation, Synthesis) for its effectiveness on a clinical level, to prevent AEs, and because it is easily tailored to the various work environments in which Italian Anaesthesiologists and Intensivists operate.

Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy.

With 63,098 confirmed cases on 17 April 2020 and 11,384 deaths, Lombardy has been the most affected region in Italy by coronavirus disease 2019 (COVID-19). To cope with this emergency, the COVID-19 Lombardy intensive care units (ICU) network was created. The network identified the need of defining a list of clinical recommendations to standardize treatment of patients with COVID-19 admitted to Intensive Care Unit (ICU). Three core topics were identified: 1) rational use of intensive care resources; 2) ventilation strategies; 3) non-ventilatory interventions. Identification of patients who may benefit from ICU treatment is challenging. Clinicians should consider baseline performance and frailty status and they should adopt disease-specific staging tools. Continuous positive airway pressure, mainly delivered through a helmet as elective method, should be considered as initial treatment for all patients with respiratory failure associated with COVID-19. In case of persisting dyspnea and/or desaturation despite 4-6 hours of noninvasive ventilation, endotracheal intubation and invasive mechanical ventilation should be considered. In the early phase, muscle relaxant use and volume-controlled ventilation is recommended. Prone position should be performed in patients with PaO2/FiO2≤100 mmHg. For patients admitted to ICU with COVID-19 interstitial pneumonia, we do not recommend empiric antibiotic therapy for community-acquired pneumonia. Consultation of an infectious disease specialist is suggested before start of any antiviral therapy. In conclusion, the COVID-19 Lombardy ICU Network identified a list of best practice statements supported by the available evidence and clinical experience or identified as panel members expert opinions for the management of critically ill patients with COVID-19.

How to communicate with families living in complete isolation.

IMPORTANCE: During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals. OBJECTIVE: This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation. EVIDENCE REVIEW: PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure. FINDINGS: Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation. CONCLUSIONS AND RELEVANCE: The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Correction to: A year in review in Minerva Anestesiologica 2019. Critical care.

This corrects the article DOI:10.23736/S0375-9393.20.14384-0.

[Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances.] / Raccomandazioni di etica clinica per l'ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili.

On February 21st, 2020 the first case of severe acute respiratory syndrome due to the coronavirus 2 (SARS-CoV-2) causing the CoViD-19 disease, was identified in Italy. In the following days, despite the restrictive public health measures aimed to avoid the infection's spread, the number of cases increased. As of March 8th, 2020, Italy is the 2nd most affected country in the world. As of March 6th, 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published operational recommendations and ethical considerations to support the clinicians involved in the care of critically-ill CoViD-19 patients, in regard a probable scenario where an imbalance between supply and demand of ICU beds, is put in place by a steadily rising number of these patients.