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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024; 37:805-817. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Pallarès N, Inouzhe H, Straw S, Safdar N, Fernández D, Cortés J, Rodríguez L, Videla S, Barrio I, Witte KK, Carratalà J, Tebé C. Development and validation of a model to predict ceiling of care in COVID-19 hospitalized patients. BMC Palliat Care 2024; 23:173. [PMID: 39010044 PMCID: PMC11250965 DOI: 10.1186/s12904-024-01490-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 06/17/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Therapeutic ceiling of care is the maximum level of care deemed appropiate to offer to a patient based on their clinical profile and therefore their potential to derive benefit, within the context of the availability of resources. To our knowledge, there are no models to predict ceiling of care decisions in COVID-19 patients or other acute illnesses. We aimed to develop and validate a clinical prediction model to predict ceiling of care decisions using information readily available at the point of hospital admission. METHODS We studied a cohort of adult COVID-19 patients who were hospitalized in 5 centres of Catalonia between 2020 and 2021. All patients had microbiologically proven SARS-CoV-2 infection at the time of hospitalization. Their therapeutic ceiling of care was assessed at hospital admission. Comorbidities collected at hospital admission, age and sex were considered as potential factors for predicting ceiling of care. A logistic regression model was used to predict the ceiling of care. The final model was validated internally and externally using a cohort obtained from the Leeds Teaching Hospitals NHS Trust. The TRIPOD Checklist for Prediction Model Development and Validation from the EQUATOR Network has been followed to report the model. RESULTS A total of 5813 patients were included in the development cohort, of whom 31.5% were assigned a ceiling of care at the point of hospital admission. A model including age, COVID-19 wave, chronic kidney disease, dementia, dyslipidaemia, heart failure, metastasis, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke or transient ischaemic attack had excellent discrimination and calibration. Subgroup analysis by sex, age group, and relevant comorbidities showed excellent figures for calibration and discrimination. External validation on the Leeds Teaching Hospitals cohort also showed good performance. CONCLUSIONS Ceiling of care can be predicted with great accuracy from a patient's clinical information available at the point of hospital admission. Cohorts without information on ceiling of care could use our model to estimate the probability of ceiling of care. In future pandemics, during emergency situations or when dealing with frail patients, where time-sensitive decisions about the use of life-prolonging treatments are required, this model, combined with clinical expertise, could be valuable. However, future work is needed to evaluate the use of this prediction tool outside COVID-19.
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Affiliation(s)
- N Pallarès
- Biostatistics Support and Research Unit, Germans Trias I Pujol Research Institute and Hospital (IGTP), Campus Can RutiCarretera de Can RutiCamí de Les Escoles S/N, Barcelona, Badalona, 08916, Spain
- Department of Basic Clinical Practice, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - H Inouzhe
- Basque Center for Applied Mathematics, BCAM, Bilbao, Spain
| | - S Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - N Safdar
- Department of Internal Medicine, St James's University Hospitals, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
- Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, USA
| | - D Fernández
- Department of Statistics and Operations Research, Universitat Politècnica de, Catalunya/BarcelonaTech, Barcelona, Spain
- Institute of Mathematics of UPC - BarcelonaTech (IMTech), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III (CIBERSAM), Madrid, Spain
| | - J Cortés
- Department of Statistics and Operations Research, Universitat Politècnica de, Catalunya/BarcelonaTech, Barcelona, Spain
| | - L Rodríguez
- Basque Center for Applied Mathematics, BCAM, Bilbao, Spain
| | - S Videla
- Department of Clinical Pharmacology, Bellvitge University Hospital, Barcelona, Spain
- Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - I Barrio
- Basque Center for Applied Mathematics, BCAM, Bilbao, Spain
- Department of Mathematics, University of the Basque Country UPV/EHU, Leioa, Spain
| | - K K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - J Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - C Tebé
- Biostatistics Support and Research Unit, Germans Trias I Pujol Research Institute and Hospital (IGTP), Campus Can RutiCarretera de Can RutiCamí de Les Escoles S/N, Barcelona, Badalona, 08916, Spain.
- Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain.
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Rowe M, Brown J, Marsh A, Thompson J. Predicting Mortality Following Traumatic Brain Injury or Subarachnoid Hemorrhage: An Analysis of the Validity of Standardized Mortality Ratios Obtained From the APACHE II and ICNARC H-2018 Models. J Neurosurg Anesthesiol 2023; 35:292-298. [PMID: 35125410 DOI: 10.1097/ana.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/13/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Standardized mortality ratios (SMRs), calculated using the Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) and Intensive Care National Audit and Research Centre H-2018 (ICNARC H-2018 ) risk prediction models, are widely used in UK intensive care units (ICUs) to measure and compare the quality of critical care delivery. Both models incorporate an assumption of Glasgow Coma Score (GCS) if an actual GCS without sedation is not recordable in the first 24 hours after ICU admission. This study assesses the validity of the APACHE II and ICNARC H-2018 models to predict mortality in ICU patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH) in whom GCS is related to outcomes. METHODS In a retrospective analysis, the SMR calculated by the APACHE II and ICNARC H-2018 models for all UK ICU admissions in a 1-year period was compared with calculated SMRs in TBI/aSAH patients and at 3 GCS groups. Data for patients admitted to a single tertiary neurocritical care unit were similarly analyzed. RESULTS Both models predicted mortality well for the overall TBI/aSAH population; SMR (95% confidence interval) was 1.00 (0.96-1.04) and 0.99 (0.95-1.03) for the APACHE II and ICNARC H-2018 models, respectively. When analyzed by GCS grouping, both models underpredicted mortality in TBI/aSAH patients with GCS ≤8 (SMR, 1.1 [1.05-1.15]) and "unrecordable" GCS (SMR, 1.88 [1.77-1.99]). Similar findings were identified in the local data analysis. DISCUSSION The APACHE II and ICNARC H-2018 models predicted mortality well for the overall TBI/aSAH ICU population but underpredicted mortality when GCS was ≤8 or "unrecordable." This raises questions about the accuracy of these risk prediction models in TBI/aSAH patients and their use to evaluate treatments and compare outcomes between centers.
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Affiliation(s)
- Matt Rowe
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients. Sci Rep 2022; 12:3336. [PMID: 35228569 PMCID: PMC8885918 DOI: 10.1038/s41598-022-06787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 02/04/2022] [Indexed: 11/08/2022] Open
Abstract
In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.
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Walzl N, Sammy IA, Taylor PM, Smith JE, Lowe DJ. Systematic review of factors influencing decisions to limit treatment in the emergency department. Emerg Med J 2022; 39:147-156. [PMID: 33658272 DOI: 10.1136/emermed-2019-209398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/28/2021] [Accepted: 02/04/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature. DESIGN Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis. RESULTS 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of 'high quality'. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into 'patient and disease factors' (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), 'hospital factors' (colleague opinion, resource availability) and 'non-patient healthcare factors' (moral, ethical, social and cost factors). CONCLUSIONS Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.
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Affiliation(s)
- Nathan Walzl
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Ian A Sammy
- Emergency Department, Scarborough General Hospital, Lower Scarborough, Trinidad and Tobago
- Tobago Regional Health Authority, Lower Scarborough, Trinidad and Tobago
| | - Paul M Taylor
- The University of Sheffield School of Health and Related Research, Sheffield, UK
- St Luke's Hospice, Sheffield, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
| | - David J Lowe
- Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
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U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment. Crit Care Med 2020; 47:1522-1530. [PMID: 31385883 PMCID: PMC6798748 DOI: 10.1097/ccm.0000000000003903] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Supplemental Digital Content is available in the text. Deciding whether to admit a patient to the ICU requires considering several clinical and nonclinical factors. Studies have investigated factors associated with the decision but have not explored the relative importance of different factors, nor the interaction between factors on decision-making. We examined how ICU consultants prioritize specific factors when deciding whether to admit a patient to ICU.
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Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
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Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
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Walzl N, Jameson J, Kinsella J, Lowe DJ. Ceilings of treatment: a qualitative study in the emergency department. BMC Emerg Med 2019; 19:9. [PMID: 30654741 PMCID: PMC6335704 DOI: 10.1186/s12873-019-0225-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/08/2019] [Indexed: 11/29/2022] Open
Abstract
Background Decision-making concerning the limitation of potentially life-prolonging treatments is often challenging, particularly in the Emergency Department (ED). Current literature in this area of Emergency Medicine is limited and heterogeneous. We seek to determine the factors that influence ceiling of treatment institution in the ED. Methods We conducted a phenomenological qualitative study employing semi-structured interviews. Emergency Medicine Consultants were recruited via a sample of convenience from 5 hospitals in the West of Scotland. Data saturation was achieved after 15 interviews. Interviews were recorded, anonymised, transcribed, coded, and an iterative thematic analysis was carried out. Results A model was created to illustrate the identified themes. Patient wishes are central to decision-making. Acute clinical factors and patient-specific factors lay the foundations of ceiling of treatment decisions. This is heavily contextualised by family input, collateral information, anticipated outcome, and whether the patient is accepted for higher care. This decision-making process flows through a ‘filter’ of cultural and environmental factors. The overarching nature of patient benefit was found to be of key importance, framing all aspects of ceiling of treatment institution. Ultimately, all ceiling of treatment decisions result in one of three common patient pathways: full escalation, limited escalation, and maintenance of current care with the option of palliative care initiation. Conclusions We present a conceptual model composed of 10 major thematic factors that influence Consultant ceiling of treatment decision-making in the ED. Clinicians should be cognizant of influential factors and associated biases when making these important and challenging decisions. Electronic supplementary material The online version of this article (10.1186/s12873-019-0225-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nathan Walzl
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G128QQ, UK.
| | | | - John Kinsella
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G128QQ, UK.,Academic Unit of Anaesthesia, Pain and Critical Care Medicine, School of Medicine, University of Glasgow, Glasgow, UK
| | - David J Lowe
- School of Medicine, University of Glasgow, Wolfson Medical School Building, University Avenue, Glasgow, G128QQ, UK.,Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
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Conroy M, O'Flynn J, Marsh B. Mortality and long-term dialysis requirement among elderly continuous renal replacement therapy patients in a tertiary referral intensive care unit. J Intensive Care Soc 2018; 20:138-143. [PMID: 31037106 DOI: 10.1177/1751143718784868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Elderly patients are frequently considered poor candidates for continuous renal replacement therapy in intensive care units, but with little evidence base. Methods We gathered data regarding patients requiring continuous renal replacement therapy at our institution's intensive care unit during 2012-2014, and compared outcomes between patients of 75 years or older, and younger patients. Results Older patients had similar intensive care unit mortality to younger patients (41.5% vs. 36.1%, p = 0.21), but higher hospital mortality (54.2% vs. 44.0%, p = 0.02), and one-year mortality (63.6% vs. 50.6%, p = 0.005). There were no significant differences in dialysis-dependence rates between older and younger patients at intensive care unit discharge (31.9% vs. 35.8%, p = 0.50), and hospital discharge (18.5% vs. 24.2%, 0.32). Rates of new dialysis-dependence between older and younger patients at time of hospital discharge were similar (10.2% vs. 6.0%, p = 0.20). Conclusions Intensivists should not withhold continuous renal replacement therapy based on age alone. Other factors should be considered in triage of patients for intensive care unit and continuous renal replacement therapy.
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Affiliation(s)
- Michael Conroy
- Department of Critical Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John O'Flynn
- Department of Critical Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian Marsh
- Department of Critical Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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García-Peña C, Pérez-Zepeda MU, Robles-Jiménez LV, Sánchez-García S, Ramírez-Aldana R, Tella-Vega P. Mortality and associated risk factors for older adults admitted to the emergency department: a hospital cohort. BMC Geriatr 2018; 18:144. [PMID: 29914394 PMCID: PMC6006959 DOI: 10.1186/s12877-018-0833-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 06/10/2018] [Indexed: 11/18/2022] Open
Abstract
Background Older emergency department patients are more vulnerable than younger patients, yet many risk factors that contribute to the mortality of older patients remain unclear and under investigation. This study endeavored to determine mortality and factors associated with mortality in patients over 60 years of age who were admitted to the emergency departments of two general hospitals in Mexico City. Methods This is a hospital cohort study involving adults over 60 years of age admitted to the emergency department and who are beneficiaries of the Mexican Institute of Social Security and residents of Mexico City. All causes of mortality from the time of emergency department admission until a follow-up home visit after discharge were measured. Included risk factors were: socio-demographic, health-care related, mental and physical variables, and in-hospital care-related. Survival functions were estimated using Kaplan-Meier curves. Hazard ratios (HR) were derived from Cox regression models in a multivariate analysis. Results From the 1406 older adults who participated in this study, 306 (21.8%) did not survive. Independent mortality risk factors found in the last Cox model were age (HR = 1.02, 95% CI, 1.005–1.04; p = 0.01), length of stay in the ED (HR = 1.003, 95% CI = 0.99, 1.04; p = 0.006), geriatric care trained residents model in Hospital A (protective factor) (HR = 0.66, 95% CI = 0.46, 0.96; p = 0.031), and the FRAIL scale (HR of 1.34 95% CI, 1.02–1.76; p = 0.033). Conclusions Risk factors for mortality in patients treated at Mexican emergency departments are length of stay and variables related to frailty status.
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Affiliation(s)
- Carmen García-Peña
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico.
| | - Mario Ulises Pérez-Zepeda
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico
| | | | - Sergio Sánchez-García
- Unidad de Investigación en Epidemiología y Servicios de Salud, Área Envejecimiento, Mexico City, Mexico
| | | | - Pamela Tella-Vega
- Dirección de Investigación, Instituto Nacional de Geriatría, Periférico Sur No. 2767, Mexico City, Mexico
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Pugh RJ, Ellison A, Pye K, Subbe CP, Thorpe CM, Lone NI, Clegg A. Feasibility and reliability of frailty assessment in the critically ill: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:49. [PMID: 29478414 PMCID: PMC6389132 DOI: 10.1186/s13054-018-1953-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/12/2018] [Indexed: 12/22/2022]
Abstract
Background For healthcare systems, an ageing population poses challenges in the delivery of equitable and effective care. Frailty assessment has the potential to improve care in the intensive care setting, but applying assessment tools in critical illness may be problematic. The aim of this systematic review was to evaluate evidence for the feasibility and reliability of frailty assessment in critical care. Methods Our primary search was conducted in Medline, Medline In-process, EMBASE, CINAHL, PsycINFO, AMED, Cochrane Database of Systematic Reviews, and Web of Science (January 2001 to October 2017). We included observational studies reporting data on feasibility and reliability of frailty assessment in the critical care setting in patients 16 years and older. Feasibility was assessed in terms of timing of evaluation, the background, training and expertise required for assessors, and reliance upon proxy input. Reliability was assessed in terms of inter-rater reliability. Results Data from 11 study publications are included, representing 8 study cohorts and 7761 patients. Proxy involvement in frailty assessment ranged from 58 to 100%. Feasibility data were not well-reported overall, but the exclusion rate due to lack of proxy availability ranged from 0 to 45%, the highest rate observed where family involvement was mandatory and the assessment tool relatively complex (frailty index, FI). Conventional elements of frailty phenotype (FP) assessment required modification prior to use in two studies. Clinical staff tended to use a simple judgement-based tool, the clinical frailty scale (CFS). Inter-rater reliability was reported in one study using the CFS and although a good level of agreement was observed between clinician assessments, this was a small and single-centre study. Conclusion Though of unproven reliability in the critically ill, CFS was the tool used most widely by critical care clinical staff. Conventional FP assessment required modification for general application in critical care, and an FI-based assessment may be difficult to deliver by the critical care team on a routine basis. There is a high reliance on proxies for frailty assessment, and the reliability of frailty assessment tools in critical care needs further evaluation. Prospero registration number CRD42016052073.
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Affiliation(s)
- Richard J Pugh
- Department of Anaesthetics, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
| | - Amy Ellison
- Department of Anaesthetics, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK
| | - Kate Pye
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | | | - Nazir I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Andrew Clegg
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
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Tavares V, Carron PN, Yersin B, Taffé P, Burnand B, Pittet V. The probability of having advanced medical interventions is associated with age in out-of-hospital life-threatening situations. Scand J Trauma Resusc Emerg Med 2016; 24:103. [PMID: 27554262 PMCID: PMC4995648 DOI: 10.1186/s13049-016-0294-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 08/17/2016] [Indexed: 01/11/2023] Open
Abstract
Background The use of out-of-hospital emergency medical services by old and very old individuals is increasing. These patients frequently require complex evaluation and decision-making processes to determine a strategy of care, therapeutic choices or withdrawal of care in life-threatening situations. During out-of-hospital missions, thorough decision-making is difficult because of the limited amount of time and lack of direct access to medical charts or to pre-existing advance directives. In this setting, age may be used as a proxy to determine strategy of care, therapeutic choices or withdrawal of care, particularly in relation to advanced medical interventions. We aimed to determine how an emergency physician’s initiation of out-of-hospital advanced medical interventions varies with the patient’s age. Methods We performed a retrospective analysis of the missions conducted by the emergency physicians-staffed emergency medical services in a Swiss region. We used logistic regression analysis to determine whether the probability of receiving an advanced medical intervention was associated with the patient’s age. Results Among 21,922 out-of-hospital emergency adult missions requiring an emergency physician, the probability of receiving an advanced medical intervention decreased with age. It was highest among those aged 18 – 58 years and significantly lower among those aged ≥ 89 years (OR = 0.66; 95 % CI: 0.53 – 0.82). The probability of cardiopulmonary resuscitation attempts progressively decreased with age and was significantly lower for the three oldest age deciles (80 – 83, 84 – 88 and ≥ 89 years). Conclusion The number of out-of-hospital advanced medical interventions significantly decreased for patients aged ≥ 89 years. It is unknown whether this lower rate of interventions was related only to age or to other medical characteristics of these patients, such as the number or severity of comorbidities. Thus, further studies are needed to confirm whether this observation corresponds to underuse of advanced medical interventions in very old patients.
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Affiliation(s)
- Vania Tavares
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Bertrand Yersin
- Emergency Department, Lausanne University Hospital, CH-1011, Lausanne, Switzerland
| | - Patrick Taffé
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Bernard Burnand
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Valérie Pittet
- Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
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Akroute AR, Bondas T. Critical care nurses and relatives of elderly patients in intensive care unit–Ambivalent interaction. Intensive Crit Care Nurs 2016; 34:59-72. [DOI: 10.1016/j.iccn.2015.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/19/2015] [Accepted: 08/07/2015] [Indexed: 12/31/2022]
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Fassier T, Valour E, Colin C, Danet F. Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study. Ann Emerg Med 2015; 68:28-39.e3. [PMID: 26619758 DOI: 10.1016/j.annemergmed.2015.09.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/19/2015] [Accepted: 09/29/2015] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE We explored physicians' perceptions of and attitudes toward triage and end-of-life decisions for elderly critically ill patients at the emergency department (ED)-ICU interface. METHODS This was a qualitative study with thematic analysis of data collected through semistructured interviews (15 emergency physicians and 9 ICU physicians) and nonparticipant observations (324 hours, 8 units, in 2 hospitals in France). RESULTS Six themes emerged: (1) Physicians revealed a representation of elderly patients that comprised both negative and positive stereotypes, and expressed the concept of physiologic age. (2) These age-related factors influenced physicians' decisionmaking in resuscitate/not resuscitate situations. (3) Three main communication patterns framed the decisions: interdisciplinary decisions, decisions by 2 physicians on their own, and unilateral decisions by 1 physician; however, some physicians avoided decisions, facing uncertainty and conflicts. (4) Conflicts and communication gaps occurred at the ED-ICU interface and upstream of the ED-ICU interface. (5) End-of-life decisions were perceived as more complex in the ED, in the absence of family or of information about elderly patients' end-of-life preferences, and when there was conflict with relatives, time pressure, and a lack of training in end-of-life decisionmaking. (6) During decisionmaking, patients' safety and quality of care were potentially compromised by delayed or denied intensive care and lack of palliative care. CONCLUSION These qualitative findings highlight the cognitive heuristics and biases, interphysician conflicts, and communication gaps influencing physicians' triage and end-of-life decisions for elderly critically ill patients at the ED-ICU interface and suggest strategies to improve these decisions.
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Affiliation(s)
- Thomas Fassier
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France.
| | - Elizabeth Valour
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France
| | - Cyrille Colin
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France; Medical Information, Evaluation and Research Unit, Hospices Civils de Lyon, Lyon, France
| | - François Danet
- Research Unit EAM 4129 Health, Individual, Society, Lyon University, Lyon, France
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The Palliative Treatment Plan as a Bone of Contention between Attending Physicians and Nurses. Healthcare (Basel) 2015; 3:987-94. [PMID: 27417808 PMCID: PMC4934626 DOI: 10.3390/healthcare3040987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/12/2015] [Indexed: 11/30/2022] Open
Abstract
Acute vital crisis in end-of-life situations may result in hospitalization and intensive care without recognizable benefit in many cases. Advance directives regarding indications for resuscitation, hospitalization, and symptomatic treatment help ensure that acute complications can be managed quickly and satisfactorily in the patient’s customary surroundings. A plan was designed and implemented in Austrian nursing homes to provide emergency physicians with rapidly obtainable information on the patient’s current situation, and whether resuscitation attempts and hospitalization are advised or not. This palliative treatment plan is arranged by a physician together with caregivers, close relatives, and the patient or his court-appointed health care guardian or holder of power of attorney. Four years after implementation of the plan, a user satisfaction survey was carried out. The majority of participating nurses, emergency physicians and family doctors judged application and design of the palliative treatment plan positively. However, the low response rate of family doctors indicates nonconformity. In particular, the delegation of symptomatic treatment to nurses proved to be controversial. There is still a need to provide up-to-date information and training for health professionals in order for them to understand advance directives as extended autonomy for patients who have lost their ability to make their own decisions.
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Payne TH, Corley S, Cullen TA, Gandhi TK, Harrington L, Kuperman GJ, Mattison JE, McCallie DP, McDonald CJ, Tang PC, Tierney WM, Weaver C, Weir CR, Zaroukian MH. Report of the AMIA EHR-2020 Task Force on the status and future direction of EHRs. J Am Med Inform Assoc 2015; 22:1102-10. [PMID: 26024883 PMCID: PMC5009932 DOI: 10.1093/jamia/ocv066] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 01/17/2023] Open
Affiliation(s)
- Thomas H Payne
- UW Medicine Information Technology Services, Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Clement J McDonald
- National Institutes of Health, National Library of Medicine, Bethesda, MD, USA
| | - Paul C Tang
- Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - William M Tierney
- Regenstrief Institute, Inc., Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Charlene R Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Michael H Zaroukian
- Sparrow Health System, Lansing, MI and Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA
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Arendts G, Etherton-Beer C, Jones R, Bullow K, MacDonald E, Dumas S, Parker D, Hutton M, Burrows S, Brown SGA, Almeida OP. Use of a risk nomogram to predict emergency department reattendance in older people after discharge: a validation study. Intern Emerg Med 2015; 10:481-7. [PMID: 25757530 DOI: 10.1007/s11739-015-1219-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 02/15/2015] [Indexed: 01/19/2023]
Abstract
In older people, revisit to the emergency department (ED) in the short period after discharge is not entirely avoidable, but in a proportion of cases is preventable, and should ideally be minimised. We have previously derived a risk probability nomogram to predict the likelihood of revisit. In this study, we sought to validate the nomogram for use as a general risk stratification tool for use in older people being discharged from ED. We conducted a prospective cohort study, applying the nomogram to consecutive community dwelling discharged patients aged 65 and over. Patients were followed up at 28 days post-discharge to determine whether there had been any unplanned ED revisit in that period. We cross tabulated predicted risk versus revisit rates. In 1143 study subjects, we find the odds of revisit increases progressively with increasing strata of predicted risk, culminating in an OR of 9.7 (95% CI 4.7-19.9) in the highest risk group. The 28-day revisit rates across strata range from 16% through 65%, with the difference between strata being statistically highly significant (p < 0.001). The area under the ROC curve is 0.65. We conclude that the risk nomogram can classify older people discharged from ED into risk strata, and has modest overall predictive value.
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Affiliation(s)
- Glenn Arendts
- University of Western Australia, Crawley, Australia,
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19
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Comparison of intensive-care-unit-acquired infections and their outcomes among patients over and under 80 years of age. J Hosp Infect 2014; 87:152-8. [DOI: 10.1016/j.jhin.2014.03.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 03/27/2014] [Indexed: 11/21/2022]
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Thomas P, Lynch K, Mason A, Matthews T, Snelson C. In-Hospital and Post-Discharge Mortality in the Extreme Elderly Admitted to Intensive Care. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
As our population ages, there will be an increasing number of extreme elderly patients (aged 85 years and older) admitted to intensive care units (ICUs). Relatively few studies are published about clinical outcomes in this population. We analysed three years of admissions data to the ICU of a teaching hospital in the West Midlands for patients who were aged 85 years or older at time of admission to ICU. Data from 185 patient episodes were included in the analysis. Six-month mortality in medical and surgical emergency patients was 62.5% and 55.1% respectively. Mortality was low in elective surgical patients at 18.6%. For those who survived the acute hospital admission, 68% of patients were discharged home, with a further 17% moving to a rehabilitation facility. A significant proportion of extreme elderly patients admitted to the ICU are surviving critical illness despite advanced age. The majority of survivors returned home, indicating that they were making a positive functional recovery from their illness.
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Affiliation(s)
- Philip Thomas
- Specialist Registrar, Elderly Care Medicine, Queens Hospital, Burton
| | - Katherine Lynch
- Specialist Registrar, Elderly Care Medicine, Russell's Hall Hospital, Dudley
| | - Aaron Mason
- Senior House Officer, Critical Care, Queen Elizabeth Hospital, Birmingham
| | - Tracie Matthews
- Critical Care Data Officer, Queen Elizabeth Hospital, Birmingham
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22
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BRANDBERG C, BLOMQVIST H, JIRWE M. What is the importance of age on treatment of the elderly in the intensive care unit? Acta Anaesthesiol Scand 2013; 57:698-703. [PMID: 23373851 DOI: 10.1111/aas.12073] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND By 2050, the percentage of the population older than 80 years will double, and some data suggest that elderly patients receive less advanced treatment. Information of outcome in elderly (≥ 65 year), representing roughly half the intensive care unit (ICU) admissions, in Sweden is scarce. METHODS Retrospective cohort study. We included all critically ill patients aged 65 or older (n = 605), admitted to the ICU during the years 2010-2011. Patients were categorized into two age groups: 65-79 (64%) and above 80 (36%). Demographic and epidemiology data were registered, as well as primary diagnosis, Simplified Acute Physiology Score III (SAPS III) mortality (ICU and hospital), withhold/withdraw life-sustaining treatment, the ICU workload, length of stay (ICU and hospital) and discharge location. RESULTS Hospital mortality was significantly higher in patients above 80 years compared with patients 65-79 years of age (33.7% vs. 22.8%). These patients received less treatment and obtained more limitations in care (withhold/withdraw life-sustaining treatments). Patients above 80 years received less invasive ventilatory support (28.3% vs. 37.8%) and shorter length of invasive ventilatory support (1.1 ± 3.9 vs. 2.9 ± 7.4) compared with patients aged 65-79. In multivariate analysis, patients ≥ 80 years received less mechanical ventilation and more limitations in care even after adjustment for SAPS III and comorbidity. CONCLUSIONS Patients above 80 years received less treatment and obtained more limitations in life-sustaining treatments compared with patients aged 65-79, even after adjustment for severity of illness and comorbidity.
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Affiliation(s)
- C. BRANDBERG
- Department of Anaesthesiology; Intensive Care Unit; Capio S:t Gorans Hospital AB; Stockholm; Sweden
| | - H. BLOMQVIST
- Department of Anaesthesiology; Intensive Care Unit; Capio S:t Gorans Hospital AB; Stockholm; Sweden
| | - M. JIRWE
- Department of Neurobiology, Care Sciences and Society; Karolinska Institute; Stockholm; Sweden
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Andersen FH, Kvåle R. Do elderly intensive care unit patients receive less intensive care treatment and have higher mortality? Acta Anaesthesiol Scand 2012; 56:1298-305. [PMID: 23016991 DOI: 10.1111/j.1399-6576.2012.02782.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND The number of elderly (≥ 80 years) will increase markedly in Norway over the next 20 years, increasing the demand for health-care services, including intensive care. The aims of this study were to see if intensive care unit (ICU) resource use and survival are different for elderly ICU patients than for younger adult ICU patients. MATERIALS AND METHODS A retrospective cohort study comparing ICU patients between 50 and 79.9 years (Group I) with patients over 80 years (Group II) registered in the Norwegian Intensive Care Registry from 2006 to 2009. A subgroup analysis of 5-year age groups was performed. RESULTS A total of 27,921 patients were analysed. The ICU/hospital mortalities were 14.3%/21.4% (Group I) and 19.8%/32.4% (Group II). Overall mortality increased with increasing age, and hospital mortality rate increased more than ICU mortality. The observed difference in admission categories could not explain the significant difference in median length of stay (LOS), 2.3 days (Group I) vs. 2.0 days (Group II). The elderly received less mechanical ventilatory support (40.6% vs. 56.1%) and had shorter median ventilatory support time, 0.8 days vs. 1.9 days. Median LOS dropped from around 80 years on, ventilator support time from around 65-70 years. CONCLUSION Octogenarians had shorter ICU stays, had higher overall mortality, had a shift of dying at the ward rather than in the ICU, and received less and shorter mechanical ventilatory support.
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Affiliation(s)
- F H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway.
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24
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de Decker L, Beauchet O, Gouraud-Tanguy A, Berrut G, Annweiler C, Le Conte P. Treatment-limiting decisions, comorbidities, and mortality in the emergency departments: a cross-sectional elderly population-based study. J Nutr Health Aging 2012; 16:914-8. [PMID: 23208032 DOI: 10.1007/s12603-012-0414-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Older adults experience a higher risk of death in the emergency departments (EDs), in part, as a result of their comorbidities. A treatment-limiting decision is often reported for older adults who die in the EDs. The Charlson Comorbidity Index (CCI) is a validated method for the scoring of comorbidities. Whether an association between the CCI and treatment-limiting decisions exists remains unknown. OBJECTIVE To determine whether the CCI was associated with the treatment-limiting decisions made for older patients who die in the EDs. METHODS A total of 2,095 patients ≥65 years old who died in the EDs in France and Belgium were prospectively included between 2004 and 2005. The recorded data included: 1) the CCI score; 2) patient age; 3) gender; 4) living in senior housing facilities; 5) hospitalizations occurring in the previous year; 6) presence of functional limitations (according to the Knaus classification); 7) chronic diseases; and 8) presence of organ failure(s). A treatment-limiting decision was defined as a predetermined choice not to implement therapies that would otherwise be required to sustain life. RESULTS A treatment-limiting decision was identified in 993 (47%) patients. Fully-adjusted logistic regression model showed that a CCI ≥ 5 (OR=25.56 with P=0.037), age ≥85years (OR=20.33 with P<0.001), living in an institution (OR=0.15 with P=0.017), hematologic (OR=6.92 with P=0.020) and respiratory disease (OR=0.17 with P=0.046), and neurologic causes (OR=0.20 with P=0.010) of organ failure were significantly associated with treatment-limiting decisions. CONCLUSION An elevated CCI score (≥5) was associated with a treatment-limiting decision in elderly patients evaluated in the EDs. Further research is needed to corroborate this finding.
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Affiliation(s)
- L de Decker
- Department of Geriatrics, Nantes University Hospital, Nantes, France.
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25
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Boumendil A, Angus DC, Guitonneau AL, Menn AM, Ginsburg C, Takun K, Davido A, Masmoudi R, Doumenc B, Pateron D, Garrouste-Orgeas M, Somme D, Simon T, Aegerter P, Guidet B. Variability of intensive care admission decisions for the very elderly. PLoS One 2012; 7:e34387. [PMID: 22509296 PMCID: PMC3324496 DOI: 10.1371/journal.pone.0034387] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 03/02/2012] [Indexed: 11/18/2022] Open
Abstract
Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients' outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n = 2495). 12.4% (n = 329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n = 717) and 50.7% (n = 1264). At six months, 57.5% (n = 1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients' characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients' outcome remains unclear.
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Affiliation(s)
- Ariane Boumendil
- Unité de Recherche en Épidémiologie Systèmes d'Information et Modélisation U707, Institut national de la santé et de la recherche médicale, Paris, France.
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Chen CF, Ho WH, Chou HY, Yang SM, Chen IT, Shi HY. Long-term prediction of emergency department revenue and visitor volume using autoregressive integrated moving average model. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2011; 2011:395690. [PMID: 22203886 PMCID: PMC3235663 DOI: 10.1155/2011/395690] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Revised: 10/07/2011] [Accepted: 10/07/2011] [Indexed: 11/21/2022]
Abstract
This study analyzed meteorological, clinical and economic factors in terms of their effects on monthly ED revenue and visitor volume. Monthly data from January 1, 2005 to September 30, 2009 were analyzed. Spearman correlation and cross-correlation analyses were performed to identify the correlation between each independent variable, ED revenue, and visitor volume. Autoregressive integrated moving average (ARIMA) model was used to quantify the relationship between each independent variable, ED revenue, and visitor volume. The accuracies were evaluated by comparing model forecasts to actual values with mean absolute percentage of error. Sensitivity of prediction errors to model training time was also evaluated. The ARIMA models indicated that mean maximum temperature, relative humidity, rainfall, non-trauma, and trauma visits may correlate positively with ED revenue, but mean minimum temperature may correlate negatively with ED revenue. Moreover, mean minimum temperature and stock market index fluctuation may correlate positively with trauma visitor volume. Mean maximum temperature, relative humidity and stock market index fluctuation may correlate positively with non-trauma visitor volume. Mean maximum temperature and relative humidity may correlate positively with pediatric visitor volume, but mean minimum temperature may correlate negatively with pediatric visitor volume. The model also performed well in forecasting revenue and visitor volume.
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Affiliation(s)
- Chieh-Fan Chen
- Emergency Department, Kaohsiung Municipal United Hospital, Kaohsiung 80457, Taiwan
- Department of Health Business Administration, Meiho University, Pingtung 91202, Taiwan
| | - Wen-Hsien Ho
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Huei-Yin Chou
- Department of Health Business Administration, Meiho University, Pingtung 91202, Taiwan
| | - Shu-Mei Yang
- Emergency Department, Kaohsiung Municipal United Hospital, Kaohsiung 80457, Taiwan
| | - I-Te Chen
- Center for General Education, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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Lederer W, Feichtner A, Medicus E. [The palliative treatment plan as basis for informed decisions in palliative or emergency care]. Wien Med Wochenschr 2011; 161:543-7. [PMID: 21956549 DOI: 10.1007/s10354-011-0031-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 07/29/2011] [Indexed: 11/30/2022]
Abstract
Acute vital crisis in end-of-life situations may result in a person being hospitalized and thus, expelled from his intimate environment, which aggravates the continuity of care. This entails a heavy burden for patients and necessitates an emergency medical services (EMS) call without recognizable benefit in many cases. Crisis episodes frequently mark the beginning of the dying process. Advance care planning or end-of-life care in elderly patients can help prevent such situations and ensure high contentment of patients, families and caregivers. Frequently, the question arises whether the burden arising from further hospitalization or from certain medical treatment options is reasonably balanced by the potential benefits of the steps taken. In such comprehensive care settings a custom-tailored palliative treatment plan may serve as an instrument for advance care planning. A palliative treatment plan set up by a physician together with a caregiver helps ensure that acute problems can be solved quickly and satisfactorily in the patient's customary surroundings. If EMS assistance is still needed, the emergency physician has written information on the patient's situation and can act quickly to meet the patient's immediate needs. This also means that EMS personnel must be properly trained in providing palliative care. In this way the palliative treatment plan can help caregivers continue to care for patients in their intimate surroundings.
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Affiliation(s)
- Wolfgang Lederer
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Innsbruck, Austria.
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Nguyen YL, Angus DC, Boumendil A, Guidet B. The challenge of admitting the very elderly to intensive care. Ann Intensive Care 2011; 1:29. [PMID: 21906383 PMCID: PMC3224497 DOI: 10.1186/2110-5820-1-29] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 08/01/2011] [Indexed: 12/01/2022] Open
Abstract
The aging of the population has increased the demand for healthcare resources. The number of patients aged 80 years and older admitted to the intensive care unit (ICU) increased during the past decade, as has the intensity of care for such patients. Yet, many physicians remain reluctant to admit the oldest, arguing a "squandering" of societal resources, that ICU care could be deleterious, or that ICU care may not actually be what the patient or family wants in this instance. Other ICU physicians are strong advocates for admission of a selected elderly population. These discrepant opinions may partly be explained by the current lack of validated criteria to select accurately the patients (of any age) who will benefit most from ICU hospitalization. This review describes the epidemiology of the elderly aged 80 years and older admitted in the ICU, their long-term outcomes, and to discuss some of the solutions to cope with the burden of an aging population receiving acute care hospitalization.
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Affiliation(s)
- Yên-Lan Nguyen
- Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France.
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