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1.
JAMA ; 326(11): 1024-1033, 2021 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-34546300

RESUMO

Importance: Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported. Objective: To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU). Design, Setting, and Participants: Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020). Interventions: Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU. Main Outcomes and Measures: The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality. Results: Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001). Conclusions and Relevance: Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02462590.


Assuntos
Antibacterianos/uso terapêutico , Lactobacillus rhamnosus , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Probióticos/uso terapêutico , Respiração Artificial , Idoso , Antibacterianos/efeitos adversos , Infecções Bacterianas/prevenção & controle , Diarreia/prevenção & controle , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Respiração Artificial/efeitos adversos , Falha de Tratamento
3.
BMJ Open ; 11(5): e050380, 2021 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-33972345

RESUMO

OBJECTIVE: To determine the prevalence of physician burnout during the pandemic and differences by gender, ethnicity or sexual orientation. DESIGN, SETTING AND PARTICIPANTS: We conducted a cross-sectional survey (August-October in 2020) of internal medicine physicians at two academic hospitals in Vancouver, Canada. PRIMARY AND SECONDARY OUTCOMES: Physician burnout and its components, emotional exhaustion, depersonalisation and personal accomplishment were measured using the Maslach Burnout Inventory. RESULTS: The response rate was 38% (n=302/803 respondents, 49% women,). The prevalence of burnout was 68% (emotional exhaustion 63%, depersonalisation 39%) and feeling low personal accomplishment 22%. In addition, 21% reported that they were considering quitting the profession or had quit a position. Women were more likely to report emotional exhaustion (OR 2.00, 95% CI: 1.07 to 3.73, p=0.03) and feeling low personal accomplishment (OR 2.26, 95% CI: 1.09 to 4.70, p=0.03) than men. Visible ethnic minority physicians were more likely to report feeling lower personal accomplishment than white physicians (OR 1.81, 95% CI: 1.28 to 2.55, p=0.001). There was no difference in emotional exhaustion or depersonalisation by ethnicity or sexual orientation. Physicians who reported that COVID-19 affected their burnout were more likely to report any burnout (OR: 3.74, 95% CI: 1.99 to 7.01, p<0.001) and consideration of quitting or quit (OR: 3.20, 95% CI: 1.34 to 7.66, p=0.009). CONCLUSION: Burnout affects 2 out of 3 internal medicine physicians during the pandemic. Women, ethnic minority physicians and those who feel that COVID-19 affects burnout were more likely to report components of burnout. Further understanding of factors driving feelings of low personal accomplishment in women and ethnic minority physicians is needed.


Assuntos
Esgotamento Profissional , COVID-19 , Médicos , Esgotamento Profissional/epidemiologia , Esgotamento Psicológico , Canadá/epidemiologia , Estudos Transversais , Grupos Étnicos , Feminino , Humanos , Satisfação no Emprego , Masculino , Grupos Minoritários , Pandemias , SARS-CoV-2 , Comportamento Sexual , Inquéritos e Questionários
4.
Health Qual Life Outcomes ; 19(1): 120, 2021 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-33849571

RESUMO

OBJECTIVES: Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP). METHODS: We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach's alpha. Confirmatory factor analysis was conducted. RESULTS: 308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0-432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p < 0.001). The confirmatory factor analysis and Cronbach's alpha confirmed the validity (chi-square, 661.9; CMIN/df, 2.14; GFI, 0.86; CFI, 0.88; CFI/TLI, 1.02; RMSEA, 0.061 [90%CI, 0.055-0.067]) and reliability (0.91 [95%CI, 0.89-0.92]) of the instrument. CONCLUSIONS: The translated Japanese version of the MMD-HP is a reliable and valid instrument to assess moral distress among physicians and nurses.


Assuntos
Atenção à Saúde/ética , Pessoal de Saúde/ética , Pessoal de Saúde/psicologia , Princípios Morais , Psicometria/normas , Inquéritos e Questionários/normas , Traduções , Adulto , Grupo com Ancestrais do Continente Asiático/psicologia , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , Análise Fatorial , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Psicometria/instrumentação , Reprodutibilidade dos Testes , Estresse Psicológico
5.
JAMA ; 325(12): 1173-1184, 2021 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-33755077

RESUMO

Importance: Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice. Objective: To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs). Design, Setting, and Participants: Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US). Exposures: Receiving IMV. Main Outcomes and Measures: Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes. Results: Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 [81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]). Conclusions and Relevance: In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally. Trial Registration: ClinicalTrials.gov Identifier: NCT03955874.


Assuntos
Estado Terminal/terapia , Desmame do Respirador/métodos , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial , Resultado do Tratamento
6.
J Gen Intern Med ; 36(9): 2593-2600, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33528779

RESUMO

BACKGROUND: Many seriously ill hospitalized patients have cardiopulmonary resuscitation (CPR) as part of their care plan, but CPR is unlikely to achieve the goals of many seriously ill hospitalized patients. OBJECTIVE: To determine if a multicomponent decision support intervention changes documented orders for CPR in the medical record, compared to usual care. DESIGN: Open-label randomized controlled trial. PATIENTS: Patients on internal medicine and neurology wards at two tertiary care teaching hospitals who had a 1-year mortality greater than 10% as predicted with a validated model and whose care plan included CPR, if needed. INTERVENTION: Both the control and intervention groups received usual communication about CPR at the discretion of their care team. The intervention group participated in a values clarification exercise and watched a CPR video decision aid. MAIN MEASURE: The primary outcome was the proportion of patients who had a no-CPR order at 14 days after enrollment. KEY RESULTS: We recruited 200 patients between October 2017 and October 2018. Mean age was 77 years. There was no difference between the groups in no-CPR orders 14 days after enrollment (17/100 (17%) intervention vs 17/99 (17%) control, risk difference, - 0.2%) (95% confidence interval - 11 to 10%; p = 0.98). In addition, there were no differences between groups in decisional conflict summary score or satisfaction with decision-making. Patients in the intervention group had less conflict about understanding treatment options (decisional conflict knowledge subscale score mean (SD), 17.5 (26.5) intervention arm vs 40.4 (38.1) control; scale range 0-100 with lower scores reflecting less conflict). CONCLUSIONS: Among seriously ill hospitalized patients who had CPR as part of their care plan, this decision support intervention did not increase the likelihood of no-CPR orders compared to usual care. PRIMARY FUNDING SOURCE: Canadian Frailty Network, The Ottawa Hospital Academic Medical Organization.

7.
J Crit Care ; 62: 185-189, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33421686

RESUMO

PURPOSE: The purpose is to explore triggers for moral distress, constraints preventing physicians from doing the right thing and ensuing consequences in making decisions for patients approaching end of life in intensive care. MATERIALS AND METHODS: The qualitative study was undertaken in a tertiary referral intensive care unit in Northern Ireland in the United Kingdom. Drawing upon patient case studies of decisions about non escalation and/or withdrawal of life support, we undertook indepth interviews with senior and junior physicians. Interviews were transcribed verbatim and narratively analysed. RESULTS: Eighteen senior and junior physicians involved in 21 patient case studies were interviewed. Analysis determined two predominant themes: key moral distress triggers; and strategies and consequences. Junior residents reported most instances of moral distress, triggered by perceived futility, lack of continuity, protracted decisions and failure to ensure 'good death'. Senior physicians' triggers included constraint of clinical autonomy. Moral distress was far reaching, affecting personal life, working relationships and career choice. CONCLUSION: This study is the first to explore physicians' moral distress in end-of-life decisions in intensive care via a narrative inquiry approach using case studies. Results have implications for the education, recruitment and retention of physicians, relevant in the Covid 19 pandemic.


Assuntos
Tomada de Decisões , Princípios Morais , Médicos/psicologia , Angústia Psicológica , Assistência Terminal/ética , Suspensão de Tratamento , Adulto , Idoso , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Irlanda do Norte , Pesquisa Qualitativa , Reino Unido
8.
Chest ; 159(4): 1484-1492, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33220296

RESUMO

Worldwide, health-care professionals are experiencing unprecedented stress related to the coronavirus disease 2019 pandemic. Responding to a new virus for which there is no effective treatment yet and no vaccine is beyond challenging. Moral distress, which is experienced when clinicians are unable to act in the way that they believe they should, is often experienced when they are dealing with end-of-life care issues and insufficient resources. Both factors have been widespread during this pandemic, particularly when patients are dying alone and there is a lack of personal protection equipment that plagues many overburdened health-care systems. We explore here, guided by evidence, the concept and features of moral distress and individual resilience. Mitigation strategies involve individual and institutional responsibilities; the importance of solidarity, peer support, psychological first aid, and gratitude are highlighted.


Assuntos
Adaptação Psicológica , COVID-19 , Pessoal de Saúde/psicologia , Angústia Psicológica , Humanos
9.
Ann Am Thorac Soc ; 18(8): 1343-1351, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33356972

RESUMO

Rationale: Understanding the magnitude of moral distress and its associations may point to solutions. Objectives: To understand the magnitude of moral distress and other measures of wellness in Canadian critical care physicians, to determine any associations among these measures, and to identify potentially modifiable factors. Methods: This was an online survey of Canadian critical care physicians whose e-mail addresses were registered with either the Canadian Critical Care Society or the Canadian Critical Care Trials Group. We used validated measures of moral distress, burnout, compassion fatigue, compassion satisfaction, and resilience. We also measured selected individual, practice, and workload characteristics. Results: Of the 499 physicians surveyed, 239 (48%) responded and there were 225 usable surveys. Respondents reported moderate scores of moral distress (107 ± 59; mean ± standard deviation, maximum 432), one-third of respondents had considered leaving or had previously left a position because of moral distress, about one-third met criteria for burnout syndrome, and a similar proportion reported medium-high scores of compassion fatigue. In contrast, about one-half of respondents reported a high score of compassion satisfaction, and overall, respondents reported a moderate score of resilience. Each of the "negative" wellness measures (moral distress, burnout, and compassion fatigue) were associated directly with each of the other "negative" wellness measures, and inversely with each of the "positive" wellness measures (compassion satisfaction and resilience), but moral distress was not associated with resilience. Moral distress was lower in respondents who were married or partnered compared with those who were not, and the prevalence of burnout was lower in respondents who had been in practice for longer. There were no differences in any of the wellness measures between adult and pediatric critical care physicians. Conclusions: Canadian critical care physicians report moderate scores of moral distress, burnout, and compassionate fatigue, and moderate-high scores of compassion satisfaction and resilience. We found no modifiable factors associated with any wellness measures. Further quantitative and qualitative studies are needed to identify interventions to reduce moral distress, burnout, and compassion fatigue.

10.
Indian J Crit Care Med ; 24(10): 946-954, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33281320

RESUMO

Purpose: To examine reliability and validity of a Thai version of the Family Satisfaction with Intensive Care Unit (FS-ICU 24) questionnaire and use this survey in intensive care units (ICUs) in Thailand. Materials and methods: The standard English FS-ICU questionnaire was translated into the Thai language using translation and culture adaptation guidelines. After reliability and validity testing, we consecutively surveyed the satisfaction of family members of ICU patients over 1 year. Adult family members of patients admitted to medical or surgical ICUs for 48 hours or more who had visited the patients at least once during the ICU stay were included. Results: In all, 315 (95%) of 332 surveys were returned from family members. Cronbach's α of the Thai FS-ICU 24 questionnaire was 0.95. Factor analysis demonstrated good construct validity. The mean (±SD) of total satisfaction score, overall ICU care subscale, and decision-making subscale were 81.5 ± 14.3, 81.0 ± 15.6, and 82.0 ± 14.0. Items with the lowest scores were the waiting room atmosphere and the frequency of doctors communicating with family members about the patient's condition. The mean total satisfaction score tended to be higher in family members of survivors than in family members of nonsurvivors (81.9 ± 13.8 vs 77.7 ± 16.2, p value = 0.059). The overall satisfaction scores between medial ICU and surgical ICU were not significantly different. Conclusion: The Thai version of FS-ICU questionnaire was found to have acceptable reliability and validity in a Thai population and can be used to drive improvements in ICU care. Trial registration: www.clinicaltrials.in.th, TCR20160603002. How to cite this article: Tajarernmuang P, Chittawatanarat K, Dodek P, Heyland DK, Chanayat P, Inchai J, et al. Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey. Indian J Crit Care Med 2020;24(10):946-954.

11.
Am J Crit Care ; 29(3): 214-220, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32355969

RESUMO

BACKGROUND: Identifying critically ill patients who have unmet needs for palliative care is the first step in integrating the palliative approach for patients and their families into intensive care units. OBJECTIVE: To explore how palliative care is addressed in an intensive care unit and to develop and test a screening tool for unmet needs that may be met through the palliative approach. METHODS: A mixed-methods study was conducted in the intensive care unit of a tertiary care hospital to explore the palliative approach. Focus groups and a survey were used to identify items for the screening tool. After pilot testing of the tool, interviews were conducted to refine the content. RESULTS: The first focus group (14 participants) revealed participants' frustration with unclear communication and a desire for better collaboration among health care team members regarding patients with serious life-limiting illnesses and their families. The survey (response rate: 20%; 30 of 150) showed clinicians' preference for items that identify specific needs rather than diagnoses. The second focus group (8 participants) yielded strategies to operationalize the tool for all patients in the intensive care unit. After 2 separate pilot testing cycles, bedside nurses noted that use of the screening tool prompted earlier discussions and broader assessments of what is meaningful to patients and their families. CONCLUSION: Development of a screening tool for unmet palliative care needs among intensive care unit patients is feasible and acceptable and may help to systematically integrate the palliative approach into routine care for critically ill patients.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva/organização & administração , Cuidados Paliativos/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Comunicação , Comportamento Cooperativo , Estudos de Viabilidade , Grupos Focais , Humanos
12.
Crit Care Med ; 48(7): 946-953, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32317594

RESUMO

OBJECTIVES: To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN: Multicenter cohort study. SETTING: Ten adult medical-surgical Canadian ICUs. PATIENTS: Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS: Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.


Assuntos
Erros Médicos/estatística & dados numéricos , Transferência de Pacientes , Adulto , Canadá/epidemiologia , Continuidade da Assistência ao Paciente , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco
14.
Am J Crit Care ; 29(2): 122-129, 2020 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32114614

RESUMO

BACKGROUND: Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES: To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS: A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS: All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION: Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.


Assuntos
Cuidados Críticos/métodos , Delírio/terapia , Unidades de Terapia Intensiva , Manejo da Dor/métodos , Agitação Psicomotora , Algoritmos , Colúmbia Britânica , Sedação Consciente/métodos , Sedação Consciente/estatística & dados numéricos , Delírio/diagnóstico , Humanos , Medição da Dor , Padrões de Prática em Enfermagem/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Inquéritos e Questionários
15.
J Clin Sleep Med ; 16(6): 949-953, 2020 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-32065114

RESUMO

STUDY OBJECTIVES: Intensive care unit nurses commonly work multiple consecutive 12-hour shifts that leave little time for sleep between work shifts. Working multiple consecutive shifts could compromise vigilance and patient care, especially with respect to managing high-risk medications such as insulin infusions. We hypothesized that as the number of consecutive shifts worked by nurses increases, the rate of hypoglycemia in patients who are receiving an insulin infusion would also increase. METHODS: We identified patients who had hypoglycemia (glucose ≤ 3.5 mmol/L, 63 mg/dL) between December 2008 and December 2009 in 3 intensive care units in Vancouver, British Columbia, Canada. For each hypoglycemic event, we counted the number of shifts worked on consecutive days during the previous 72 hours by the bedside nurse who was caring for the patient at the time of hypoglycemia (case shift). For each case shift, we identified up to 3 control shifts (24, 48, and 72 hours before the hypoglycemic event in the same patient when there were no hypoglycemic events) and counted the number of consecutive shifts worked by those nurses in the previous 72 hours. This analysis allowed us to control for patient-associated confounders. Conditional logistic regression was used to determine the association between number of consecutive shifts worked and occurrence of hypoglycemic events. RESULTS: A total of 282 hypoglycemic events were identified in 259 patients. For 191 events, we were able to identify 1 or more control shifts. Compared with nurses who had not worked a shift in the preceding day, the odds ratio of a hypoglycemic event was 1.68 (95% confidence interval: 1.12-2.52), 2.16 (95% confidence interval:1.25-3.73), and 2.54 (95% confidence interval: 1.28-5.06) for nurses who were working their second, third, or fourth consecutive shift, respectively. CONCLUSIONS: Working multiple consecutive nursing shifts is associated with increased risk of hypoglycemic events in patients in an intensive care unit.


Assuntos
Hipoglicemia , Insulina , Canadá , Estado Terminal , Humanos , Hipoglicemia/induzido quimicamente , Hipoglicemia/epidemiologia , Hipoglicemiantes/efeitos adversos , Insulina/efeitos adversos
16.
Can J Anaesth ; 67(4): 475-484, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31970619

RESUMO

PURPOSE: Collection and analysis of health data are crucial to achieving high-quality clinical care, research, and quality improvement. This review explores existing hospital, regional, provincial and national data platforms in Canada to identify gaps and barriers, and recommend improvements for data science. SOURCE: The Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group undertook an environmental survey using list-identified names and keywords in PubMed and the grey literature, from the Canadian context. Findings were grouped into sections, corresponding to geography, purpose, and patient sub-group initiatives, using a narrative qualitative approach. Emerging themes, impressions, and recommendations towards improving data initiatives were generated. PRINCIPAL FINDINGS: In Canada, the Canadian Institute for Health Information Discharge Abstract Database contains high-level clinical data on every adult and child discharged from acute care facilities; however, it does not contain data from Quebec, critical care-specific severity of illness risk-adjustment scores, physiologic data, or data pertaining to medication use. Provincially mandated critical care platforms in four provinces contain more granular data, and can be used to risk adjust and link to within-province data sets; however, no inter-provincial collaborative mechanism exists. There is very limited infrastructure to collect and link biological samples from critically ill patients nationally. Comprehensive international clinical data sets may inform future Canadian initiatives. CONCLUSION: Clinical and biological data collection among critically ill patients in Canada is not sufficiently coordinated, and lags behind other jurisdictions. An integrated and inclusive critical care data platform is a key clinical and scientific priority in Canada.


Assuntos
Melhoria de Qualidade , Qualidade da Assistência à Saúde , Canadá , Cuidados Críticos , Estado Terminal , Humanos
17.
J Intensive Care Med ; 35(1): 63-67, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28901208

RESUMO

PURPOSE: To determine whether invasive pneumococcal disease (IPD) due to serotype 5, which occurred as a local outbreak in 2006 to 2007, is associated with intensive care unit (ICU) admission, hospital mortality, or organ supports in those who are critically ill. MATERIALS AND METHODS: Retrospective review of patients who presented with IPD to 2 tertiary hospitals in Vancouver, Canada, from July 2004 to June 2007. We compared patient characteristics, interventions, and outcomes between patients who had serotype 5 and other serotypes using bivariate and multivariate analyses. RESULTS: A total of 149 patients had serotype 5 and 106 had nonserotype 5. Patients with serotype 5 were younger, had lower prevalence of comorbid diseases, and had higher rates of substance use than patients with nonserotype 5. There were no differences in chest tube placement for complications of pneumonia or in ICU admission. Frequency of necrotizing pneumonia and hospital mortality were lower in the serotype 5 group. For the 71 patients with IPD who were admitted to ICU, there was no difference in severity of illness, ICU length of stay, or ICU mortality between the groups. There was also no difference in organ supports except that the serotype 5 group was more likely to receive vasopressors. CONCLUSION: Serotype 5 in patients who have IPD is associated with no difference in ICU admission but with increased use of vasopressors and lower hospital mortality.


Assuntos
Infecções Pneumocócicas/microbiologia , Streptococcus pneumoniae/classificação , Adulto , Fatores Etários , Idoso , Estado Terminal , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infecções Pneumocócicas/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores de Risco , Sorogrupo
18.
Health Serv Res ; 55(1): 35-43, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31709536

RESUMO

OBJECTIVE: To evaluate whether the male predominance of older people admitted to intensive care units (ICUs) is due to gender differences in the presence of spouses, partners, or children; rates of gender-specific disease; or triage decisions made by health system personnel. DATA SOURCES AND COLLECTION: Three population-based datasets, 2004-2012, of Canadians ≥65 years: provincial health care data from Manitoba (n = 250 190) and national data of nursing home residents (n = 133 982) and community-based homecare recipients (n = 210 090). STUDY DESIGN: Retrospective observational study, using multivariable Cox proportional hazards and logistic regression. PRINCIPAL FINDINGS: Males predominated in ICU admissions: from Manitoba (hazard ratio [HR] = 1.87, 95% CI = 1.80-1.95), nursing homes (HR = 1.47, 1.35-1.60), and homecare (odds ratio = 1.14, 1.11-1.17). Adjustment for spouses, partners, and children did not attenuate this effect. The HR for gender was lower by 13.5 percent, relative, after excluding ICU care for cardiac causes. Male predominance was not present during a second ICU admission among survivors of a first ICU-containing hospitalization (HR = 1.07, 0.96-1.20). CONCLUSIONS: In three older cohorts, the male predominance of ICU admission was not explained by gender differences in the presence of a spouse, partner, or children, or cardiac disease rates. The third finding suggests that triage bias is unlikely to be responsible for the male predominance.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/normas , Admissão do Paciente/estatística & dados numéricos , Admissão do Paciente/normas , Sexismo/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Manitoba , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores Sexuais
19.
Trials ; 20(1): 587, 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31604480

RESUMO

RATIONALE: In critically ill patients receiving invasive mechanical ventilation (MV), research supports the use of daily screening to identify patients who are ready to undergo a spontaneous breathing trial (SBT) followed by conduct of an SBT. However, once daily (OD) screening is poorly aligned with the continuous care provided in most intensive care units (ICUs) and the best SBT technique for clinicians to use remains controversial. OBJECTIVES: To identify the optimal screening frequency and SBT technique to wean critically ill adults in the ICU. METHODS: We aim to conduct a multicenter, factorial design randomized controlled trial with concealed allocation, comparing the effect of both screening frequency (once versus at least twice daily [ALTD]) and SBT technique (Pressure Support [PS] + Positive End-Expiratory Pressure [PEEP] vs T-piece) on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American ICUs. In the OD arm, respiratory therapists (RTs) will screen study patients between 06:00 and 08:00 h. In the ALTD arm, patients will be screened at least twice daily between 06:00 and 08:00 h and between 13:00 and 15:00 h with additional screens permitted at the clinician's discretion. When the SBT screen is passed, an SBT will be conducted using the assigned technique (PS + PEEP or T-piece). We will follow patients until successful extubation, death, ICU discharge, or until day 60 after randomization. We will contact patients or their surrogates six months after randomization to assess health-related quality of life and functional status. RELEVANCE: The around-the-clock availability of RTs in North American ICUs presents an important opportunity to identify the optimal SBT screening frequency and SBT technique to minimize patients' exposure to invasive ventilation and ventilator-related complications. TRIAL REGISTRATION: Clinical Trials.gov, NCT02399267 . Registered on Nov 21, 2016 first registered.


Assuntos
Estado Terminal/terapia , Pulmão/fisiopatologia , Respiração Artificial , Respiração , Testes de Função Respiratória , Desmame do Respirador , Extubação , Humanos , Estudos Multicêntricos como Assunto , América do Norte , Valor Preditivo dos Testes , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento
20.
BMJ Open ; 9(9): e031775, 2019 09 08.
Artigo em Inglês | MEDLINE | ID: mdl-31501132

RESUMO

INTRODUCTION: Research supports the use of specific strategies to discontinue mechanical ventilation (MV) in critically ill patients. Little is known about how clinicians actually wean and discontinue MV in practice or the association between different discontinuation strategies and outcomes. The primary objective of this study is to describe international practices in the use of (1) daily screening for readiness to discontinue MV, (2) modes of MV used before initial discontinuation attempts, (3) weaning and spontaneous breathing trial (SBT) protocols, (4) SBT techniques and (5) sedation and mobilisation practices to facilitate weaning and discontinuation. The secondary objectives are to identify patient characteristics and time-dependent factors associated with use of selected strategies, investigate associations between SBT outcome (failure vs success) and outcomes, explore differences between patients who undergo an SBT early versus later in their intensive care unit (ICU) stay, and investigate the associations between different SBT techniques and humidification strategies on outcomes. METHODS AND ANALYSIS: We will conduct an international, prospective, observational study of MV discontinuation practices among critically ill adults who receive invasive MV for at least 24 hours at approximately 150 ICUs in six geographic regions (Canada, USA, UK, Europe, India and Australia/New Zealand). Research personnel at participating ICUs will collect demographic data, data to characterise the initial strategy or event that facilitated discontinuation of MV (direct extubation, direct tracheostomy, initial successful SBT, initial failed SBT or death before any attempt could be made), clinical outcomes and site information. We aim to collect data on at least 10 non-death discontinuation events in each ICU (at least 1500 non-death discontinuation events). ETHICS AND DISSEMINATION: This study received Research Ethics Approval from St. Michael's Hospital (11-024) Research ethics approval will be sought from all participating sites. The results will be disseminated through publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03955874.


Assuntos
Estado Terminal/terapia , Procedimentos Clínicos/normas , Respiração Artificial/métodos , Traqueostomia/métodos , Desmame do Respirador/métodos , Suspensão de Tratamento/normas , Adulto , Cuidados Críticos/métodos , Cuidados Críticos/normas , Feminino , Humanos , Masculino , Monitorização Fisiológica/métodos , Estudos Observacionais como Assunto , Avaliação de Processos e Resultados em Cuidados de Saúde , Padrões de Prática Médica , Fatores de Tempo
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