Erratum: Evaluation of the characteristics of infection prevention and control programs and infection control committees in Brazilian hospitals: A countrywide cross-sectional study - CORRIGENDUM.

[This corrects the article DOI: 10.1017/ash.2023.136.].

Evaluation of the characteristics of infection prevention and control programs and infection control committees in Brazilian hospitals: A countrywide cross-sectional study.

Objective: Data are scarce regarding hospital infection control committees and compliance with infection prevention and control (IPC) recommendations in Brazil, a country of continental dimensions. We assessed the main characteristics of infection control committees (ICCs) on healthcare-associated infections (HAIs) in Brazilian hospitals. Methods: This cross-sectional study was conducted in ICCs of public and private hospitals distributed across all Brazilian regions. Data were collected directly from the ICC staff by completing an online questionnaire and during on-site visits through face-to-face interviews. Results: In total, 53 Brazilian hospitals were evaluated from October 2019 to December 2020. All hospitals had implemented the IPC core components in their programs. All centers had protocols for the prevention and control of ventilator-associated pneumonia as well as bloodstream, surgical site, and catheter-associated urinary tract infections. Most hospitals (80%) had no budget specifically allocated to the IPC program; 34% of the laundry staff had received specific IPC training; and only 7.5% of hospitals reported occupational infections in healthcare workers. Conclusions: In this sample, most ICCs complied with the minimum requirements for IPC programs. The main limitation regarding ICCs was the lack of financial support. The findings of this survey support the development of strategic plans to improve IPCs in Brazilian hospitals.

One-year mortality of hematopoietic stem cell recipients admitted to an intensive care unit in a dedicated Brazilian cancer center: a retrospective cohort study

ABSTRACT BACKGROUND: Hematopoietic stem cell transplantation (HSCT) recipients requiring intensive care unit (ICU) admission early after transplantation have a poor prognosis. However, many studies have only focused on allogeneic HSCT recipients. OBJECTIVES: To describe the characteristics of HSCT recipients admitted to the ICU shortly after transplantation and assess differences in 1-year mortality between autologous and allogeneic HSCT recipients. DESIGN AND SETTING: A single-center retrospective cohort study in a cancer center in Brazil. METHODS: We included all consecutive patients who underwent HSCT less than a year before ICU admission between 2009 and 2018. We collected clinical and demographic data and assessed the 1-year mortality of all patients. The effect of allogeneic HSCT compared with autologous HSCT on 1-year mortality risk was evaluated in an unadjusted model and an adjusted Cox proportional hazard model for age and Sequential Organ Failure Assessment (SOFA) at admission. RESULTS: Of the 942 patients who underwent HSCT during the study period, 83 (8.8%) were included in the study (autologous HSCT = 57 [68.7%], allogeneic HSCT = 26 [31.3%]). At 1 year after ICU admission, 21 (36.8%) and 18 (69.2%) patients who underwent autologous and allogeneic HSCT, respectively, had died. Allogeneic HSCT was associated with increased 1-year mortality (unadjusted hazard ratio, HR = 2.79 [confidence interval, CI, 95%, 1.48-5.26]; adjusted HR = 2.62 [CI 95%, 1.29-5.31]). CONCLUSION: Allogeneic HSCT recipients admitted to the ICU had higher short- and long-term mortality rates than autologous HSCT recipients, even after adjusting for age and severity at ICU admission.

High-value care for critically ill oncohematological patients: what do we know thus far? / Cuidados de alto valor para pacientes oncohematológicos graves: o que sabemos até agora?

ABSTRACT The number of patients with cancer requiring intensive care unit admission is increasing around the world. The improvement in the pathophysiological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, has led to a significant increase in their survival over the past three decades. Within the organizational concepts, it is necessary to know what adds value in the care of critical oncohematological patients. Practices in medicine that do not benefit patients and possibly cause harm are called low-value practices, while high-value practices are defined as high-quality care at relatively low cost. In this article, we discuss ten domains with high-value evidence in the care of cancer patients: (1) intensive care unit admission policies; (2) intensive care unit organization; (3) etiological investigation of hypoxemia; (4) management of acute respiratory failure; (5) management of febrile neutropenia; (6) urgent chemotherapy treatment in critically ill patients; (7) patient and family experience; (8) palliative care; (9) care of intensive care unit staff; and (10) long-term impact of critical disease on the cancer population. The disclosure of such policies is expected to have the potential to change health care standards. We understand that it is a lengthy process, and initiatives such as this paper are one of the first steps in raising awareness and beginning a discussion about high-value care in various health scenarios.

RESUMO O número de pacientes oncológicos com necessidade de internação em unidades de terapia intensiva está aumentando em todo o mundo. A maior compreensão fisiopatológica desse grupo de pacientes, bem como opções de tratamento cada vez melhores e mais direcionadas à doença subjacente, tem levado a um aumento significativo da sobrevida nas últimas três décadas. Dentro dos conceitos organizacionais é necessário saber o que agrega valor ao cuidado de pacientes onco-hematológicos graves. As práticas terapêuticas não benéficas aos pacientes e possivelmente causadoras de danos são chamadas práticas de baixo valor, enquanto as práticas de alto valor são definidas como cuidados de alta qualidade a um custo relativamente baixo. Neste artigo discutimos dez domínios com evidências de alto valor no cuidado de pacientes com câncer: (1) políticas de internação na unidade de terapia intensiva; (2) organização da unidade de terapia intensiva; (3) investigação etiológica da hipoxemia; (4) manejo da insuficiência respiratória aguda; (5) manejo da neutropenia febril; (6) tratamento quimioterápico de urgência em pacientes graves; (7) experiência do paciente e da família; (8) cuidados paliativos; (9) cuidados com a equipe da unidade de terapia intensiva; e (10) impacto a longo prazo da doença grave na população oncológica. Esperase que a divulgação dessas políticas traga mudanças aos padrões atuais do cuidado em saúde. Entendemos que é um processo longo, e iniciativas como o presente artigo são um dos primeiros passos para aumentar a conscientização e possibilitar discussão sobre cuidados de alto valor em vários cenários de saúde.

One-year mortality of hematopoietic stem cell recipients admitted to an intensive care unit in a dedicated Brazilian cancer center: a retrospective cohort study.

BACKGROUND: Hematopoietic stem cell transplantation (HSCT) recipients requiring intensive care unit (ICU) admission early after transplantation have a poor prognosis. However, many studies have only focused on allogeneic HSCT recipients. OBJECTIVES: To describe the characteristics of HSCT recipients admitted to the ICU shortly after transplantation and assess differences in 1-year mortality between autologous and allogeneic HSCT recipients. DESIGN AND SETTING: A single-center retrospective cohort study in a cancer center in Brazil. METHODS: We included all consecutive patients who underwent HSCT less than a year before ICU admission between 2009 and 2018. We collected clinical and demographic data and assessed the 1-year mortality of all patients. The effect of allogeneic HSCT compared with autologous HSCT on 1-year mortality risk was evaluated in an unadjusted model and an adjusted Cox proportional hazard model for age and Sequential Organ Failure Assessment (SOFA) at admission. RESULTS: Of the 942 patients who underwent HSCT during the study period, 83 (8.8%) were included in the study (autologous HSCT = 57 [68.7%], allogeneic HSCT = 26 [31.3%]). At 1 year after ICU admission, 21 (36.8%) and 18 (69.2%) patients who underwent autologous and allogeneic HSCT, respectively, had died. Allogeneic HSCT was associated with increased 1-year mortality (unadjusted hazard ratio, HR = 2.79 [confidence interval, CI, 95%, 1.48-5.26]; adjusted HR = 2.62 [CI 95%, 1.29-5.31]). CONCLUSION: Allogeneic HSCT recipients admitted to the ICU had higher short- and long-term mortality rates than autologous HSCT recipients, even after adjusting for age and severity at ICU admission.

Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients. / Comparação da acurácia de residentes, médicos seniores e decisores substitutos na previsão da mortalidade hospitalar de pacientes críticos.

OBJECTIVE: To compare the predictive performance of residents, senior intensive care unit physicians and surrogates early during intensive care unit stays and to evaluate whether different presentations of prognostic data (probability of survival versus probability of death) influenced their performance. METHODS: We questioned surrogates and physicians in charge of critically ill patients during the first 48 hours of intensive care unit admission on the patient's probability of hospital outcome. The question framing (i.e., probability of survival versus probability of death during hospitalization) was randomized. To evaluate the predictive performance, we compared the areas under the ROC curves (AUCs) for hospital outcome between surrogates and physicians' categories. We also stratified the results according to randomized question framing. RESULTS: We interviewed surrogates and physicians on the hospital outcomes of 118 patients. The predictive performance of surrogate decisionmakers was significantly lower than that of physicians (AUC of 0.63 for surrogates, 0.82 for residents, 0.80 for intensive care unit fellows and 0.81 for intensive care unit senior physicians). There was no increase in predictive performance related to physicians' experience (i.e., senior physicians did not predict outcomes better than junior physicians). Surrogate decisionmakers worsened their prediction performance when they were asked about probability of death instead of probability of survival, but there was no difference for physicians. CONCLUSION: Different predictive performance was observed when comparing surrogate decision-makers and physicians, with no effect of experience on health care professionals' prediction. Question framing affected the predictive performance of surrogates but not of physicians.

OBJETIVO: Comparar o desempenho preditivo de residentes, médicos seniores de unidades de terapia intensiva e decisores substitutos dos pacientes logo no início da internação na unidade de terapia intensiva e avaliar se diferentes apresentações de prognóstico (probabilidade de sobrevida versus probabilidade de óbito) influenciaram seus desempenhos. MÉTODOS: Os decisores substitutos e os médicos responsáveis pelos pacientes críticos foram questionados durante as primeiras 48 horas de internação na unidade de terapia intensiva sobre a probabilidade do desfecho hospitalar do paciente. O enquadramento da pergunta (isto é, a probabilidade de sobrevida versus a probabilidade de óbito durante a internação) foi randomizado. Para avaliar o desempenho preditivo, comparou-se a área sob a curva ROC para desfecho hospitalar entre as categorias decisores substitutos e médicos. Também estratificaram-se os resultados de acordo com o enquadramento da pergunta randomizado. RESULTADOS: Entrevistaram-se decisores substitutos e médicos sobre os desfechos hospitalares de 118 pacientes. O desempenho preditivo dos decisores substitutos foi significativamente inferior ao dos médicos (área sob a curva de 0,63 para decisores substitutos, 0,82 para residentes, 0,80 para residentes de medicina intensiva e 0,81 para médicos seniores de unidade de terapia intensiva). Não houve aumento no desempenho preditivo quanto à experiência dos médicos (ou seja, médicos seniores não previram desfechos melhor que médicos juniores). Os decisores substitutos pioraram seu desempenho de previsão quando perguntados sobre a probabilidade de óbito ao invés da probabilidade de sobrevida, mas não houve diferença entre os médicos. CONCLUSÃO: Observou-se desempenho preditivo diferente ao comparar decisores substitutos e médicos, sem qualquer efeito da experiência no prognóstico dos profissionais de saúde. O enquadramento da pergunta afetou o desempenho preditivo dos substitutos, mas não o dos médicos.

Comparação da acurácia de residentes, médicos seniores e decisores substitutos na previsão da mortalidade hospitalar de pacientes críticos / Comparison of the accuracy of residents, senior physicians and surrogate decision-makers for predicting hospital mortality of critically ill patients

RESUMO Objetivo: Comparar o desempenho preditivo de residentes, médicos seniores de unidades de terapia intensiva e decisores substitutos dos pacientes logo no início da internação na unidade de terapia intensiva e avaliar se diferentes apresentações de prognóstico (probabilidade de sobrevida versus probabilidade de óbito) influenciaram seus desempenhos. Métodos: Os decisores substitutos e os médicos responsáveis pelos pacientes críticos foram questionados durante as primeiras 48 horas de internação na unidade de terapia intensiva sobre a probabilidade do desfecho hospitalar do paciente. O enquadramento da pergunta (isto é, a probabilidade de sobrevida versus a probabilidade de óbito durante a internação) foi randomizado. Para avaliar o desempenho preditivo, comparou-se a área sob a curva ROC para desfecho hospitalar entre as categorias decisores substitutos e médicos. Também estratificaram-se os resultados de acordo com o enquadramento da pergunta randomizado. Resultados: Entrevistaram-se decisores substitutos e médicos sobre os desfechos hospitalares de 118 pacientes. O desempenho preditivo dos decisores substitutos foi significativamente inferior ao dos médicos (área sob a curva de 0,63 para decisores substitutos, 0,82 para residentes, 0,80 para residentes de medicina intensiva e 0,81 para médicos seniores de unidade de terapia intensiva). Não houve aumento no desempenho preditivo quanto à experiência dos médicos (ou seja, médicos seniores não previram desfechos melhor que médicos juniores). Os decisores substitutos pioraram seu desempenho de previsão quando perguntados sobre a probabilidade de óbito ao invés da probabilidade de sobrevida, mas não houve diferença entre os médicos. Conclusão: Observou-se desempenho preditivo diferente ao comparar decisores substitutos e médicos, sem qualquer efeito da experiência no prognóstico dos profissionais de saúde. O enquadramento da pergunta afetou o desempenho preditivo dos substitutos, mas não o dos médicos.

ABSTRACT Objective: To compare the predictive performance of residents, senior intensive care unit physicians and surrogates early during intensive care unit stays and to evaluate whether different presentations of prognostic data (probability of survival versus probability of death) influenced their performance. Methods: We questioned surrogates and physicians in charge of critically ill patients during the first 48 hours of intensive care unit admission on the patient's probability of hospital outcome. The question framing (i.e., probability of survival versus probability of death during hospitalization) was randomized. To evaluate the predictive performance, we compared the areas under the ROC curves (AUCs) for hospital outcome between surrogates and physicians' categories. We also stratified the results according to randomized question framing. Results: We interviewed surrogates and physicians on the hospital outcomes of 118 patients. The predictive performance of surrogate decisionmakers was significantly lower than that of physicians (AUC of 0.63 for surrogates, 0.82 for residents, 0.80 for intensive care unit fellows and 0.81 for intensive care unit senior physicians). There was no increase in predictive performance related to physicians' experience (i.e., senior physicians did not predict outcomes better than junior physicians). Surrogate decisionmakers worsened their prediction performance when they were asked about probability of death instead of probability of survival, but there was no difference for physicians. Conclusion: Different predictive performance was observed when comparing surrogate decision-makers and physicians, with no effect of experience on health care professionals' prediction. Question framing affected the predictive performance of surrogates but not of physicians.

Palliative sedation in patients with advanced cancer in a specialized unit in a middle-income country: A retrospective cohort study.

OBJECTIVE: To describe the 5-year practice on palliative sedation in a specialized palliative care unit in a deprived region in Brazil, and to compare survival of patients with advanced cancer who were and were not sedated during their end-of-life care. METHOD: Retrospective cohort study in a tertiary teaching hospital. We described the practice of palliative sedation and compared the survival time between patients who were and were not sedated in their last days of life. RESULTS: We included 906 patients who were admitted to the palliative care unit during the study period, of whom, 92 (10.2%) received palliative sedation. Patients who were sedated were younger, presented with higher rates of delirium, and reported more pain, suffering, and dyspnea than those who were not sedated. Median hospital survival of patients who received palliative sedation was 9.30 (CI 95%, 7.51-11.81) days and of patients who were not sedated was 8.2 (CI 95%, 7.3-9.0) days (P = 0.31). Adjusted for age and sex, palliative sedation was not significantly associated with hospital survival (hazard ratio = 0.93; CI 95%, 0.74-1.15). SIGNIFICANCE OF RESULTS: Palliative sedation can be accomplished even in a deprived area. Delirium, dyspnea, and pain were more common in patients who were sedated. Median survival was not reduced in patients who were sedated.

Performance status and acute organ dysfunction influence hospital mortality in critically ill patients with cancer and suspected infection: a retrospective cohort analysis. / Funcionalidade e disfunções orgânicas agudas influenciam a mortalidade hospitalar de pacientes críticos com câncer e suspeita de infecção: análise retrospectiva de uma coorte.

OBJECTIVE: To evaluate how performance status impairment and acute organ dysfunction influence hospital mortality in critically ill patients with cancer who were admitted with suspected sepsis. METHODS: Data were obtained from a retrospective cohort of patients, admitted to an intensive care unit, with cancer and with a suspected infection who received parenteral antibiotics and underwent the collection of bodily fluid samples. We used logistic regression with hospital mortality as the outcome and the Sequential Organ Failure Assessment score, Eastern Cooperative Oncology Group status, and their interactions as predictors. RESULTS: Of 450 patients included, 265 (58.9%) died in the hospital. For patients admitted to the intensive care unit with lower Sequential Organ Failure Assessment (≤ 6), performance status impairment influenced the in-hospital mortality, which was 32% among those with no and minor performance status impairment and 52% among those with moderate and severe performance status impairment, p < 0.01. However, for those with higher Sequential Organ Failure Assessment (> 6), performance status impairment did not influence the in-hospital mortality (73% among those with no and minor impairment and 84% among those with moderate and severe impairment; p = 0.1). CONCLUSION: Performance status impairment seems to influence hospital mortality in critically ill cancer patients with suspected sepsis when they have less severe acute organ dysfunction at the time of intensive care unit admission.

OBJETIVO: Avaliar como a funcionalidade e a disfunção orgânica aguda influenciam a mortalidade hospitalar de pacientes oncológicos admitidos com suspeita de sepse. MÉTODOS: Os dados foram obtidos de uma coorte retrospectiva de pacientes oncológicos com suspeita de infecção admitidos em uma unidade de terapia intensiva. Estes receberam antibióticos por via parenteral e tiveram suas culturas coletadas. Utilizamos uma regressão logística, para avaliar a mortalidade hospitalar como desfecho, Sequential Organ Failure Assessment e Eastern Cooperative Oncology Group como preditores, além de suas interações. RESULTADOS: Dentre os 450 pacientes incluídos, 265 (58,9%) morreram no hospital. Para os pacientes admitidos na unidade de terapia intensiva com Sequential Organ Failure Assessment baixo (≤ 6), o comprometimento da funcionalidade influenciou a mortalidade hospitalar, que foi de 32% entre os pacientes sem comprometimento ou com comprometimento mínimo da funcionalidade e 52% entre os pacientes com comprometimento moderado e grave (p < 0,01). Nos pacientes com Sequential Organ Failure Assessment elevado (> 6), a funcionalidade não influenciou a mortalidade hospitalar (73% entre os pacientes sem comprometimento ou com comprometimento mínimo, e 84% entre os pacientes com comprometimento moderado e grave; p = 0,1). CONCLUSÃO: O comprometimento da funcionalidade parece influenciar a mortalidade hospitalar de pacientes oncológicos com suspeita de sepse sem disfunções orgânicas agudas ou que apresentem disfunções leves no momento da admissão na unidade de terapia intensiva.

Mortality and Life-Sustaining Therapy Decisions in Patients With Cancer and Acute Respiratory Failure Due to COVID-19 or Other Causes: An Observational Study.

It is unknown if patients with cancer and acute respiratory failure due to COVID-19 have different clinical or cancer-related characteristics, decisions to forgo life-sustaining therapies (LST), and mortality compared to patients with cancer and acute respiratory failure due to other causes. In a cohort study, we tested the hypothesis that COVID-19 was associated with increased in-hospital mortality and decreased decisions to forgo LST in patients with cancer and acute respiratory failure. We employed two multivariate logistic regression models. Propensity score matching was employed as sensitivity analysis. We compared 382 patients without COVID-19 with 65 with COVID-19. Patients with COVID-19 had better performance status, less metastatic tumors, and progressive cancer. In-hospital mortality of patients with COVID-19 was lower compared with patients without COVID-19 (46.2 vs. 74.6%; p < 0.01). However, the cause of acute respiratory failure (COVID-19 or other causes) was not associated with increased in-hospital mortality [adjusted odds ratio (OR) 1.27 (0.55-2.93; 95% confidence interval, CI)] in the adjusted model. The percentage of patients with a decision to forgo LST was lower in patients with COVID-19 (15.4 vs. 36.1%; p = 0.01). However, COVID-19 was not associated with decisions to forgo LST [adjusted OR 1.21 (0.44-3.28; 95% CI)] in the adjusted model. The sensitivity analysis confirmed the primary analysis. In conclusion, COVID-19 was not associated with increased in-hospital mortality or decreased decisions to forgo LST in patients with cancer and acute respiratory failure. These patients had better performance status, less progressive cancer, less metastatic tumors, and less organ dysfunctions upon intensive care unit (ICU) admission than patients with acute respiratory failure due to other causes.

Nursing workload associated with the frequency of multidisciplinary rounds: a cross-sectional study. / Carga de trabalho da enfermagem associada com frequência de visitas multidisciplinares: um estudo transversal.

OBJECTIVE: To assess the frequency of multidisciplinary rounds during ICU days, to evaluate the participation of diverse healthcare professionals, to identify the reasons why rounds were not performed on specific days, and whether bed occupancy rate and nurse workload were associated with the conduction of multidisciplinary rounds. METHODS: We performed a cross-sectional study to assess the frequency of multidisciplinary rounds in four intensive care units in a cancer center. We also collected data on rates of professional participation, reasons for not performing rounds when they did not occur, and daily bed occupancy rates and assessed nurse workload by measuring the Nursing Activity Score. RESULTS: Rounds were conducted on 595 (65.8%) of 889 surveyed intensive care unit days. Nurses, physicians, respiratory therapists, pharmacists, and infection control practitioners participated most often. Rounds did not occur due to admission of new patients at the scheduled time (136; 44.7%) and involvement of nurses in activities unrelated to patients' care (97; 31.9%). In multivariate analysis, higher Nursing Activity Scores were associated with greater odds of conducting multidisciplinary rounds (OR = 1.06; 95%CI 1.04 - 1.10; p < 0.01), whereas bed occupancy rates were not (OR = 0.99; 95%CI 0.97 - 1.00; p = 0.18). CONCLUSION: Multidisciplinary rounds were conducted on less than two-thirds of surveyed intensive care unit days. Many rounds were cancelled due to activities unrelated to patient care. Unexpectedly, increased workload was associated with higher odds of conducting rounds. Workload is a possible trigger to discuss daily goals to improve patient outcomes and to enhance the effectiveness of multidisciplinary teams.

OBJETIVO: Avaliar a frequência de visitas multidisciplinares durante a estadia na unidade de terapia intensiva e a participação dos diferentes profissionais da unidade, identificar as razões pelas quais as visitas não foram realizadas em dias específicos e se a taxa de ocupação e a carga de trabalho da enfermagem estavam associadas com a realização de visitas multidisciplinares. MÉTODOS: Realizamos um estudo transversal para avaliar a frequência de visitas multidisciplinares em quatro unidades de terapia intensiva localizadas em um centro para tratamento de câncer. Colhemos também dados referentes à participação de profissionais, a razões para não realização das visitas nos casos em que elas não ocorriam e a taxas diárias de ocupação de leitos, assim como avaliamos a carga de trabalho da enfermagem por meio do Nursing Activity Score. RESULTADOS: Foram conduzidas visitas multidisciplinares em 595 (65,8%) dos 889 dias de unidade de terapia intensiva avaliados. Mais frequentemente tomaram parte dessas visitas enfermeiros, médicos, fisioterapeutas respiratórios e profissionais ligados ao controle de infecções. As visitas não ocorreram em razão da admissão de novos pacientes no horário programado para a visita (136; 44,7%) e do envolvimento dos enfermeiros em atividades não relacionadas ao cuidado de pacientes (97; 31,9%). Na análise multivariada, níveis mais elevados do Nursing Activity Score se associaram com maior tendência à realização de visitas multidisciplinares (RC = 1,06; IC95% 1,04 - 1,10; p < 0,01), enquanto as taxas de ocupação não tiveram essa associação (RC = 0,99; IC95% 0,97 - 1,00; p = 0,18). CONCLUSÃO: Realizaram-se visitas multidisciplinares em menos de dois terços dos dias de unidade de terapia intensiva pesquisados. Muitas das visitas foram canceladas em razão de atividades não relacionadas aos cuidados com o paciente. A carga de trabalho é um possível gatilho para discussão dos alvos do dia para melhorar os desfechos dos pacientes e incrementar a efetividade das equipes multidisciplinares.

Funcionalidade e disfunções orgânicas agudas influenciam a mortalidade hospitalar de pacientes críticos com câncer e suspeita de infecção: análise retrospectiva de uma coorte / Performance status and acute organ dysfunction influence hospital mortality in critically ill patients with cancer and suspected infection: a retrospective cohort analysis

RESUMO Objetivo: Avaliar como a funcionalidade e a disfunção orgânica aguda influenciam a mortalidade hospitalar de pacientes oncológicos admitidos com suspeita de sepse. Métodos: Os dados foram obtidos de uma coorte retrospectiva de pacientes oncológicos com suspeita de infecção admitidos em uma unidade de terapia intensiva. Estes receberam antibióticos por via parenteral e tiveram suas culturas coletadas. Utilizamos uma regressão logística, para avaliar a mortalidade hospitalar como desfecho, Sequential Organ Failure Assessment e Eastern Cooperative Oncology Group como preditores, além de suas interações. Resultados: Dentre os 450 pacientes incluídos, 265 (58,9%) morreram no hospital. Para os pacientes admitidos na unidade de terapia intensiva com Sequential Organ Failure Assessment baixo (≤ 6), o comprometimento da funcionalidade influenciou a mortalidade hospitalar, que foi de 32% entre os pacientes sem comprometimento ou com comprometimento mínimo da funcionalidade e 52% entre os pacientes com comprometimento moderado e grave (p < 0,01). Nos pacientes com Sequential Organ Failure Assessment elevado (> 6), a funcionalidade não influenciou a mortalidade hospitalar (73% entre os pacientes sem comprometimento ou com comprometimento mínimo, e 84% entre os pacientes com comprometimento moderado e grave; p = 0,1). Conclusão: O comprometimento da funcionalidade parece influenciar a mortalidade hospitalar de pacientes oncológicos com suspeita de sepse sem disfunções orgânicas agudas ou que apresentem disfunções leves no momento da admissão na unidade de terapia intensiva.

ABSTRACT Objective: To evaluate how performance status impairment and acute organ dysfunction influence hospital mortality in critically ill patients with cancer who were admitted with suspected sepsis. Methods: Data were obtained from a retrospective cohort of patients, admitted to an intensive care unit, with cancer and with a suspected infection who received parenteral antibiotics and underwent the collection of bodily fluid samples. We used logistic regression with hospital mortality as the outcome and the Sequential Organ Failure Assessment score, Eastern Cooperative Oncology Group status, and their interactions as predictors. Results: Of 450 patients included, 265 (58.9%) died in the hospital. For patients admitted to the intensive care unit with lower Sequential Organ Failure Assessment (≤ 6), performance status impairment influenced the in-hospital mortality, which was 32% among those with no and minor performance status impairment and 52% among those with moderate and severe performance status impairment, p < 0.01. However, for those with higher Sequential Organ Failure Assessment (> 6), performance status impairment did not influence the in-hospital mortality (73% among those with no and minor impairment and 84% among those with moderate and severe impairment; p = 0.1). Conclusion: Performance status impairment seems to influence hospital mortality in critically ill cancer patients with suspected sepsis when they have less severe acute organ dysfunction at the time of intensive care unit admission.

Carga de trabalho da enfermagem associada com frequência de visitas multidisciplinares: um estudo transversal / Nursing workload associated with the frequency of multidisciplinary rounds: a cross-sectional study

RESUMO Objetivo: Avaliar a frequência de visitas multidisciplinares durante a estadia na unidade de terapia intensiva e a participação dos diferentes profissionais da unidade, identificar as razões pelas quais as visitas não foram realizadas em dias específicos e se a taxa de ocupação e a carga de trabalho da enfermagem estavam associadas com a realização de visitas multidisciplinares. Métodos: Realizamos um estudo transversal para avaliar a frequência de visitas multidisciplinares em quatro unidades de terapia intensiva localizadas em um centro para tratamento de câncer. Colhemos também dados referentes à participação de profissionais, a razões para não realização das visitas nos casos em que elas não ocorriam e a taxas diárias de ocupação de leitos, assim como avaliamos a carga de trabalho da enfermagem por meio do Nursing Activity Score. Resultados: Foram conduzidas visitas multidisciplinares em 595 (65,8%) dos 889 dias de unidade de terapia intensiva avaliados. Mais frequentemente tomaram parte dessas visitas enfermeiros, médicos, fisioterapeutas respiratórios e profissionais ligados ao controle de infecções. As visitas não ocorreram em razão da admissão de novos pacientes no horário programado para a visita (136; 44,7%) e do envolvimento dos enfermeiros em atividades não relacionadas ao cuidado de pacientes (97; 31,9%). Na análise multivariada, níveis mais elevados do Nursing Activity Score se associaram com maior tendência à realização de visitas multidisciplinares (RC = 1,06; IC95% 1,04 - 1,10; p < 0,01), enquanto as taxas de ocupação não tiveram essa associação (RC = 0,99; IC95% 0,97 - 1,00; p = 0,18). Conclusão: Realizaram-se visitas multidisciplinares em menos de dois terços dos dias de unidade de terapia intensiva pesquisados. Muitas das visitas foram canceladas em razão de atividades não relacionadas aos cuidados com o paciente. A carga de trabalho é um possível gatilho para discussão dos alvos do dia para melhorar os desfechos dos pacientes e incrementar a efetividade das equipes multidisciplinares.

Abstract Objective: To assess the frequency of multidisciplinary rounds during ICU days, to evaluate the participation of diverse healthcare professionals, to identify the reasons why rounds were not performed on specific days, and whether bed occupancy rate and nurse workload were associated with the conduction of multidisciplinary rounds. Methods: We performed a cross-sectional study to assess the frequency of multidisciplinary rounds in four intensive care units in a cancer center. We also collected data on rates of professional participation, reasons for not performing rounds when they did not occur, and daily bed occupancy rates and assessed nurse workload by measuring the Nursing Activity Score. Results: Rounds were conducted on 595 (65.8%) of 889 surveyed intensive care unit days. Nurses, physicians, respiratory therapists, pharmacists, and infection control practitioners participated most often. Rounds did not occur due to admission of new patients at the scheduled time (136; 44.7%) and involvement of nurses in activities unrelated to patients' care (97; 31.9%). In multivariate analysis, higher Nursing Activity Scores were associated with greater odds of conducting multidisciplinary rounds (OR = 1.06; 95%CI 1.04 - 1.10; p < 0.01), whereas bed occupancy rates were not (OR = 0.99; 95%CI 0.97 - 1.00; p = 0.18). Conclusion: Multidisciplinary rounds were conducted on less than two-thirds of surveyed intensive care unit days. Many rounds were cancelled due to activities unrelated to patient care. Unexpectedly, increased workload was associated with higher odds of conducting rounds. Workload is a possible trigger to discuss daily goals to improve patient outcomes and to enhance the effectiveness of multidisciplinary teams.

Long-term mortality in very old patients with cancer admitted to intensive care unit: A retrospective cohort study.

BACKGROUND: Long-term outcomes of older patients referred to intensive care unit (ICU) are of paramount importance for care planning and counseling of patients and relatives. METHODS: We performed a retrospective study with patients aged ≥80 years admitted to ICU from 2011 to 2017 in a cancer center. We performed two Cox proportional hazard regressions. In the first, we tested whether type of cancer (solid locoregional, solid metastatic or hematologic), Eastern Cooperative Oncology Group Performance Status (ECOG PS), and comorbidities [Charlson Comorbidity Index - CCI]) were associated with one-year mortality in all patients. In the second, we assessed whether delirium, use of vasopressors, mechanical ventilation, renal replacement therapy, and forgoing life-sustaining therapies were associated with one-year mortality in survivors to hospital discharge. RESULTS: Of 763 patients included, 482 (62.3%) patients died at one year. Metastatic cancer was significantly associated with one-year mortality (HR = 1.97; CI 95%, 1.16-3.36), but hematologic cancer, CCI and ECOG PS were not. Among patients who survived to hospital discharge, delirium, use of vasopressors, mechanical ventilation, renal replacement therapy and decisions to forgo life-sustaining therapies in ICU were not associated with one-year mortality. CONCLUSIONS: Metastatic disease at ICU admission was associated with one-year mortality in patients aged ≥80 years. Delirium, use of vasopressors, mechanical ventilation and renal replacement therapy and decisions to forgo life-sustaining therapies in ICU were not associated with one-year mortality among the patients discharged from hospital.

Elderly patients with cancer admitted to intensive care unit: A multicenter study in a middle-income country.

BACKGROUND: Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs). METHODS: This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality. RESULTS: Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96). CONCLUSIONS: Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.