International perspectives on ethics in critical care

Factors Affecting the Mortality Rate in Non-COVID-19 Intensive Care Unit Patients During the COVID-19 Pandemic in Cyprus: A Retrospective Cohort Study

INTRODUCTION

Mortality statistics constitute a pivotal element in informing public health policymaking in critical care settings. Mortality rates exhibit temporal variability, and their quantification is susceptible to well-established biases that have been exacerbated in the backdrop of the COVID-19 pandemic. A multitude of factors contribute to the process of patients' outcomes within the intensive care unit (ICU) setting. The primary aim of this study is to compare the mortality rate observed during the initial and subsequent phases of the COVID-19 pandemic in non-COVID-19 patient cohorts. Secondary objectives encompass evaluating the demographic and clinical factors and admission times to the ICU as an independent predictor affecting mortality.

METHODS AND MATERIALS

 A retrospective investigation of the data gathered from 1127 non-COVID-19 patients admitted to an ICU situated in Nicosia, Cyprus between March 2020 and December 2022 was performed. We divided the study period into two distinct timeframes. The first period spanned from the onset of the COVID-19 pandemic up until January 2021, coinciding with the relaxation of COVID-related restrictions. The second period was defined as the period when restrictions were not applied. The time of admission to the ICU is categorized as either off-hours or business hours. We recorded various patient characteristics, including age, gender, Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment (SOFA) scores, hospitalization duration, discharge details, mortality events with precise timestamps and primary diagnosis for admission. Multivariate logistic regression analysis was performed with these characteristics to predict the likelihood of mortality.

RESULTS

 This study included 632 males (56.1%) and 495 females (43.9%). Within the patient cohort, 653 patients (57.9%) were discharged from the ICU, while 474 patients (42.1%) experienced mortality during their ICU stay. No significant correlation was found whether patients were admitted to ICU during the first or second period of the COVID-19 pandemic. There was a significant difference in the comparison of outcomes within the ICU between the off-hours and business hours (p=0.001). A total of 329 of 618 (53.2%) patients admitted in off-hours and 145 of 509 (28.4%) patients admitted in business hours died. Moreover, the mean GCS, APACHE II and SOFA scores were higher in patients admitted during off-hours. APACHE II score (OR: 1.11, 95% CI: 1.06 to 1.15, p<0.01), SOFA (OR: 1.21, 95% CI: 1.10 to 1.31, p<0.01) and GCS (OR: 0.88, 95% CI: 0.84 to 0.92, p<0.01) scores and admission to the ICU in off-hours 2.63 (1.91-3.67) were significantly associated with mortality.

CONCLUSION

 The results of this retrospective cohort analysis have shown that the mortality rate was higher in non-COVID-19 patients admitted to ICU during off-hours compared to those admitted during business hours. However, no significant difference was found in the mortality rate between the admissions during the first and second periods of the COVID-19 pandemic.

Providing Neurocritical Care in Resource-Limited Settings: Challenges and Opportunities

Acute neurologic illnesses (ANI) contribute significantly to the global burden of disease and cause disproportionate death and disability in low-income and middle-income countries (LMICs) where neurocritical care resources and expertise are limited. Shifting epidemiologic trends in recent decades have increased the worldwide burden of noncommunicable diseases, including cerebrovascular disease and traumatic brain injury, which coexist in many LMICs with a persistently high burden of central nervous system infections such as tuberculosis, neurocysticercosis, and HIV-related opportunistic infections and complications. In the face of this heavy disease burden, many resource-limited countries lack the infrastructure to provide adequate care for patients with ANI. Major gaps exist between wealthy and poor countries in access to essential resources such as intensive care unit beds, neuroimaging, clinical laboratories, neurosurgical capacity, and medications for managing complex neurologic emergencies. Moreover, many resource-limited countries face critical shortages in health care workers trained to manage neurologic emergencies, with subspecialized neurocritical care expertise largely absent outside of high-income countries. Numerous opportunities exist to overcome these challenges through capacity-building efforts that improve outcomes for patients with ANI in resource-limited countries. These include research on needs and best practices for ANI management in LMICs, developing systems for effective triage, education and training to expand the neurology workforce, and supporting increased collaboration and data sharing among LMIC health care workers and systems. The success of these efforts in curbing the disproportionate and rising impact of ANI in LMICs will depend on the coordinated engagement of the global neurocritical care community.

Critical care research and pre-emptive informed consent: a practical approach used in Chris Hani Baragwanath ICU

OBJECTIVES

1) To establish a protocol within international and local ethical guidelines to obtain informed consent for critical care research, overcoming constraints previously described and 2) To evaluate eventual recruitment using this protocol.

DESIGN

Prospective descriptive study.

SETTING

Multidisciplinary ICU in a community-based university teaching hospital.

PATIENTS AND PARTICIPANTS

Following approval by the University Ethics Committee and Hospital Review Board, patients admitted between January and May 1996 were assessed on weekdays for potential enrollment into existing clinical trials. Discussion with potential candidates and/or next-of-kin occurred at the earliest opportunity and informed consent was obtained preemptively. Next-of-kin was notified if enrollment subsequently occurred. We evaluated the number of patients screened, the number of potential study candidates, the number for whom consent was obtained or refused and the number subsequently enrolled.

INTERVENTIONS

None

RESULTS

Of 249 patients screened, 149 (60%) did not meet the inclusion criteria. Of 100 potential study candidates (40% of all patients screened), we failed to make contact with the next-of-kin in 29 cases (12% of all patients screened). Thus 71 patients or next-of-kin were counselled (28% of all patients screened). In all, 30 patients (12% of all patients screened) were subsequently enrolled into a study.

CONCLUSIONS

A policy of pre-emptive informed consent enabled us to overcome some of the problems previously experienced in our unit with regards to patient enrollment in critical care research. Although overall recruitment remained low, predictions for future enrollment can be made from this study.