Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage.

PURPOSE: To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. MATERIALS AND METHODS: Retrospective, observational study of patients refused MICU admission at an urban university hospital. RESULTS: Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). CONCLUSIONS: Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.

A relação médico-família diante da terminalidade em UTI / The doctor-family relation when facing terminality in ICU

A comunicação entre paciente, família e equipe médica no contexto da terminalidade torna-se complexa em função da multiplicidade de fatores envolvidos. Neste artigo, objetivamos investigar a visão do médico intensivista acerca da participação da família em situação de terminalidade em UTI e da comunicação de más notícias. Realizou-se uma pesquisa qualitativa, na qual foram entrevistados seis membros da equipe médica intensivista de um hospital privado de médio porte. Da análise do conteúdo das entrevistas emergiram seis categorias: percepção sobre o paciente em situação de terminalidade; emoções frente à morte e ao morrer; conflitos éticos; família diante da terminalidade; comunicando más notícias e relação médico-família no processo de tomada de decisões. Neste trabalho, são apresentadas as três últimas categorias. Os resultados mostraram que o processo de comunicação é valorizado, com ênfase na comunicação empática, afetiva e efetiva. Quanto ao processo de tomada de decisão, ora o modelo compartilhado é utilizado, ora o modelo paternalista, dependendo da compreensão da família acerca da terminalidade. Apesar do reconhecimento da importância da família, esta é vista como presença incômoda, pois indaga e questiona. O trabalho interdisciplinar e colaborativo entre os membros da equipe de saúde tem destaque...

Communication between patients, families and medical staff in the context of terminality becomes complex due to the multiplicity of factors involved. In this paper we seek to investigate the intensivist doctor’s point of view regarding the participation of the family in a terminal situation in ICU and the communication of bad news. We performed a qualitative research in which we interviewed six members of the intensivist medical staff of a medium-sized private hospital. Six categories emerged from the content analysis of the interviews: perception of the patient in terminal condition; emotions towards death and dying; ethical conflicts; family facing terminality; communicating bad news; and the doctor-family relation in the decision-making process. In this study we will present the last three categories. The results showed that the communication process is valued, with emphasis on an empathic, affective and effective communication. Concerning the decision-making process, at times the shared model is used, at others the paternalist model, depending upon the family’s understanding of terminality. Despite the acknowledgement of the importance of the family, the latter is seen as an uncomfortable presence since it pries and questions. Special attention is given to interdisciplinary and collaborative work between healthcare staff members...

Problems related to antifungal prescription: a qualitative study of the views of intensivists.

RATIONALE AND OBJECTIVE: The choice of the appropriate antifungal medication is essential for therapeutic success. Although guidelines are available in the literature that regulate the consistent use of antifungal, no previous qualitative studies have addressed the difficulties related to the use of antifungal medication, especially in the intensive care unit (ICU). Our objective was to qualitatively investigate how intensivists consider antifungal prescriptions in an adult ICU. METHODS: The Grounded Theory analytical method was used for the data analysis. Physicians who worked in the adult ICU and prescribed antifungal medications were individually interviewed. A semi-structured interview was used to ask core questions, followed by follow-up questions at the discretion of the interviewer. RESULTS: Our analysis generated eight main emerging themes that were classified into three related groups. The main insights were that various interconnected reasons were given for the lack of conformity with regard to prescription patterns for antifungals. A negative cycle was perceived based on issues related to prescriptions and the search for knowledge. If problems related to individual actions and multidisciplinary team integration are resolved and local protocols are implemented based on local epidemiology, then barriers to proper prescriptions can be overcome when intensivists are faced with the unusual practice of prescribing antifungals. CONCLUSIONS: Our investigation indicates the need for prescription assistance with support from a well-trained multidisciplinary team and consensus among its members and the importance of well-designed protocols.