Limitations of life-sustaining treatments in intensive care units in Croatia: a multicenter retrospective study.

AIM: In order to gain insight into the current prevailing practices regarding the limitation of life-sustaining treatment in intensive care units (ICUs) in Croatia, we assessed the frequency of limitation and provision of certain treatment modalities, as well as the associated patient and ICU-related factors. METHODS: A multicenter retrospective cross-sectional study was conducted in 17 ICUs in Croatia. We reviewed the medical records of patients deceased in 2017 and extracted data on demographic, clinical, and health care variables. A logistic regression analysis was conducted to determine the associations between these variables and treatment modalities. RESULTS: The study enrolled 1095 patients (55% male; mean age 69.9±13.7). Analgesia and sedation were discontinued before the patient's death in 23% and 34% of the cases, respectively. Patients older than 71 years were less often mechanically ventilated (P<0.001), and less frequently received inotropes and vasoactive therapy (P=0.002) than younger patients. Patients hospitalized in the ICU for less than 7 days less frequently had discontinuation of mechanical ventilation and inotropes and vasoactive therapy than patients hospitalized for 8 days and longer (P<0.001). Logistic regression analysis showed that ICU type was a crucial determinant, with multidisciplinary and surgical ICUs being associated with higher odds of intubation, mechanical ventilation, vasoactive and inotropic therapy, analgesia, and sedation. CONCLUSION: Older patients and those diagnosed with stroke and intracranial hemorrhage received fewer therapeutic modalities. All the observed treatment modalities were more frequently discontinued in patients who were hospitalized in the ICU for a prolonged time.

EFFECT OF THE INTRODUCTION OF EMERGENCY MEDICINE SPECIALISTS ON THE EMERGENCY DEPARTMENT PERFORMANCE INDICATORS: A RETROSPECTIVE DATA ANALYSIS.

Patient management in the emergency department (ED) is evaluated by performance indicators, such as wait times (time to be seen by a physician), length of stay (LOS) and the number of diagnostic tests per patient. To improve the quality of care, dedicated emergency medicine (EM) specialists are employed to work in the ED. The aim of this study is to evaluate three performance indicators of patient management in the ED compared by specialty, internal medicine (IM) versus EM. Research was conducted in the ED of a large tertiary teaching hospital. A retrospective data analysis of the hospital information system was conducted for the period when only IM specialists were working as attendants, versus a period when two EM specialists joined the ED team. We calculated the percentage of patients seen within the recommended time per Australasian Triage system (AST) category and compared the average LOS and the average number of tests per patient, using data from June 2017 to January 2020. Means, standard deviation, standard error, 95% confidence interval were calculated, and the independent t-test was used to compare means. With the introduction of the EM specialists, the percentage of patients examined within the recommended time frame per AST category was higher. There was a significant reduction in LOS in the ED when comparing only IM specialists to IM specialists with two EM specialists (p<0.001). The IM physicians on average do more tests than EM specialists, which was statistically significant (p<0.05). There was a significant improvement in efficiency in the ED with the introduction of EM specialists which was manifested by shorter patient wait times and shorter length of stay in the Emergency Department and fewer diagnostic test orders.

Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study.

BACKGROUND: Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS: A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann-Whitney U test was used to analyse the differences between two groups and Kruskal-Wallis tests were used to analyse the differences between more than two groups. RESULTS: Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that 'do-not-attempt cardiopulmonary resuscitations' orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient's wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS: DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia's geographical location in Southern Europe.