Māori health outcomes in an intensive care unit in Aotearoa New Zealand

Ageism and lookism as stereotypes of health disparity in intensive care units in Iran: a critical ethnography

BACKGROUND

The intensive care unit presents structural complexities, and the prevailing power imbalance between patients and staff can lead to health disparities. Hence, unveiling the underlying factors that give rise to and reinforce these disparities can contribute to their prevention. This study aims to shed light on the stereotypes linked to ageism and lookism, which perpetuate health disparities within the intensive care unit setting in Iran.

METHODS

This critical ethnographic study employed Carsepkan's approach and was carried out in intensive care units in the west of Iran from 2022 to 2023. The data collection and analysis were conducted through three interconnected stages. In the initial stage, more than 300 h of observations were made at the research site. In the subsequent stage, a horizon analysis was performed. Conversations with 14 informants were conducted in the final stage to enrich the dataset further. Then the analysis process was carried out as in the previous step to uncover an implicit culture of health disparity. To verify the validity and reliability of the study, credibility, conformability, dependability, and transferability were all taken into account.

FINDINGS

The ageism and lookism stereotypes emerged from seven main themes; youth-centric; negative ageism; age-friendliness; age-related priority; centered care for pediatric patients and families; appearance-centeredness; and a contradiction between belief and behavior.

CONCLUSION

This critical study showed that ageism and lookism stereotypes permeated the intensive care unit's culture. These stereotypes have the potential to influence equality dynamics, as well as to foster and support health disparity in the intensive care unit.

Māori end-of-life care in the intensive care unit: A qualitative exploration of nursing perspectives

BACKGROUND

Although goals of care for intensive care patients are typically focussed on restoration of health, 8-15% of patients will die in the intensive care unit (ICU), or soon after transfer to a ward. Early recognition of the need for end-of-life care is vital to identify and support the wishes of the patient and needs of their family. In Aotearoa, New Zealand, Māori are over-represented in admissions to ICUs. Enabling nursing staff to provide culturally safe care to Māori patients and whānau (family, including extended family, kin) at the end of life is critical to upholding Te Tiriti o Waitangi requirements and providing equitable care. This qualitative study explores the experiences of both Māori and non-Māori intensive care nurses, in providing end-of-life care for Māori patients and their whānau.

OBJECTIVES

The objective of this study was to characterise nursing experiences of end-of-life care for Māori in the ICU, identify barriers to and facilitators of confident, competent culturally responsive care, and highlight opportunities to improve preparation and support.

METHODS

Qualitative semistructured interviews were undertaken with nine intensive care nurses (four Māori and five non-Māori) with experience ranging from novice to expert. Data collection and analysis was underpinned by reflexive thematic analysis strengthened by Kaupapa Māori Research values and tikanga best practice.

FINDINGS

Participants described positive and negative experiences in caring for Māori at the end of life. Culturally responsive end-of-life care for Māori in intensive care appears dependent on the acknowledgement and inclusion of whānau as members of the multidisciplinary team. Participants identified a need for high-quality education, supportive unit end-of-life care guidelines and hospital policies, and cultural resources to confidently provide quality end-of-life care.

CONCLUSION

Improved understanding of Māori culture, critical awareness of systems of power and privilege, and the availability of cultural liaisons may increase the confidence and competence of ICU nurses providing care to Māori whānau.

Māori Health Outcomes in Intensive Care Following Cardiac Surgery in Aotearoa New Zealand

BACKGROUND

Māori, the indigenous peoples of Aotearoa New Zealand (NZ) experience disproportionately worse outcomes in cardiovascular health compared to non-Māori. Waikato Hospital provides tertiary cardiothoracic services to the Midland region of NZ, and has instituted an official policy to eliminate ethnic inequity in health. We aimed to audit the outcomes of our cardiothoracic intensive care unit (ICU) against this standard.

METHOD

We analysed data from the prospectively-entered Australia and NZ Intensive Care Society database for all planned cardiothoracic ICU admissions from 2014 to 2018 at Waikato Hospital for patients aged 15-years and older (n=2,736). Outcomes measured were in-ICU, in-hospital, and 1-year mortality.

RESULTS

Māori were under-represented in this cohort (17.9%) compared to the general Midland population. Māori patients were younger (median 60 vs 68-years old, p<0.001), were more commonly female (34.8% vs 23.6%, p<0.001), domiciled in more deprived areas (2018 NZ Index of Deprivation of 9 vs 6, p<0.001), and more likely to have rheumatic heart disease (35.6% vs 16.6%, p<0.001). More non-Māori required coronary vessel only surgery (57.4% vs 45.2%), whilst more Māori required valvular only surgery (41.1% vs 31.2%) (p<0.001 overall). Baseline Acute Physiology and Chronic Health Evaluation (APACHE) III risk of death score was higher for Māori (1.53% vs 0.89%, p<0.001), as was the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (2.04% vs 1.55%, p<0.001). Unadjusted mortality was higher for Māori in-ICU (3.1% vs 1.3%, p=0.005) and at 1-year (7.1% vs 3.8%, p=0.002). Adjusted in-ICU mortality, however, was predicted by combined coronary-valvular surgery (adjusted odds ratio, AOR 25.5 [95% confidence interval (CI) 3.30-348.46], p=0.005), Australia and New Zealand Risk of Death (ANZROD) score (AOR 1.11 [CI 1.05-1.19] p<0.001), and renal replacement therapy requirement (AOR 154.56 [CI 30.86-1,107.17] p<0.001), but not by Māori ethnicity (AOR 0.27 [CI 0.03-1.43] p=0.156).

CONCLUSION

Our audit has identified significant inequity for Māori at our cardiothoracic ICU. Māori are sicker on presentation for planned cardiac surgery, as evidenced by higher admission severity scores, and experience higher unadjusted mortality up to 1-year compared to non-Māori. Māori also appear under-represented despite a greater burden of cardiovascular disease in the community. Further study is required to identify if upstream risk factors, including failure of early detection and referral for disease, contribute to these findings.

Clinical outcomes of Indigenous Australians and New Zealand Māori with metabolic acidosis and acidaemia

Objective: To assess the incidence and impact of metabolic acidosis in Indigenous and non-Indigenous patients Design: Retrospective study. Setting: Adult intensive care units (ICUs) from Australia and New Zealand. Participants: Patients aged 16 years or older admitted to an Australian or New Zealand ICU in one of 195 contributing ICUs between January 2019 and December 2020 who had metabolic acidosis, defined as pH < 7.30, base excess (BE) < -4 mEq/L and PaCO2 ≤ 45 mmHg. Main outcome measures: The primary outcome was the prevalence of metabolic acidosis. Secondary outcomes included ICU length of stay, hospital length of stay, receipt of renal replacement therapy (RRT), major adverse kidney events at 30 days (MAKE30), and hospital mortality. Results: Overall, 248 563 patients underwent analysis, with 11 537 (4.6%) in the Indigenous group and 237 026 (95.4%) in the non-Indigenous group. The prevalence of metabolic acidosis was higher in Indigenous patients (9.3% v 6.1%; P < 0.001). Indigenous patients with metabolic acidosis received RRT more often (28.2% v 22.0%; P < 0.001), but hospital mortality was similar between the groups (25.8% in Indigenous v 25.8% in non-Indigenous; P = 0.971). Conclusions: Critically ill Indigenous ICU patients are more likely to have a metabolic acidosis in the first 24 hours of their ICU admission, and more often received RRT during their ICU admission compared with non-Indigenous patients. However, hospital mortality was similar between the groups.

SPLIT ENZ: Survivorship of Patients post Long Intensive care stay, Exploration/Experience in a New Zealand cohort (A mixed methods study protocol) (Preprint)

Background

Post Intensive Care Syndrome (PICS) was defined by the Society of Critical Care Medicine in 2012 with subsequent international research highlighting poor long-term outcomes; reduced quality of life; and impairments, for survivors of critical illness. To date, there has been no published research on the long-term outcomes of survivors of critical illness in New Zealand.

Objective

The aim of this study is to explore long-term outcomes after critical illness in New Zealand. The primary objectives are to describe and quantify symptoms and disability, explore possible risk factors, and to identify unmet needs in survivors of critical illness.

Methods

This will be a mixed methods study with 2 components. First, a prospective cohort study of approximately 100 participants with critical illness will be followed up at 1, 6, and 12 months after hospital discharge. The primary outcome will be disability assessed using the World Health Organization Disability Assessment Scale 2.0. Secondary outcomes will focus on mental health using the Hospital Anxiety and Depression Scale and the Impact of Events Scale-revised, cognitive function using the Montreal Cognitive Assessment (Montreal Cognitive Assessment–BLIND), and health-related quality of life using the European Quality of Life-Five Dimension-Five Level. The second element of the study will use qualitative grounded theory methods to explore participants experiences of recovery and highlight unmet needs.

Results

This study was approved by the New Zealand Northern A Health and Disability Ethics Committee on August 16, 2021 (21/NTA/107), and has been registered with the Australian New Zealand Clinical Trials Registry on October 5, 2021. SPLIT ENZ is due to start recruitment in early 2022, aiming to enroll 125 patients over 2 years. Data collection is estimated to be completed by 2024-2025 and will be published once all data are available for reporting.

Conclusions

Although international research has identified the prevalence of PICS and the extent of disability in survivors of critical illness, there is no published research in New Zealand. Research in this field is particularly pressing in the context of COVID-19, an illness that may include PICS in its sequelae.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN1262100133588; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382566&showOriginal=true&isReview=true

International Registered Report Identifier (IRRID)

PRR1-10.2196/35936

Mortality outcomes for MĀori requiring renal replacement therapy during critical illness: A single unit audit in Aotearoa New Zealand

BACKGROUND

MĀori in New Zealand (NZ) are disproportionately affected by chronic kidney disease (CKD), and experience lower life expectancy on community dialysis compared to non-MĀori. We previously identified higher renal replacement therapy (RRT) requirement for MĀori in our intensive care unit (ICU), the tertiary referral centre for NZ's Te Manawa Taki region.

AIM

Describe mortality outcomes by ethnicity in the RRT-requiring population in our ICU.

METHODS

Retrospective audit of the Australia and NZ Intensive Care Society database for adult admissions to our general ICU from Te Manawa Taki between 2014-2018. Patients were stratified by non-RRT requirement (non-RRT), RRT-requiring acute kidney injury (AKI-RRT), and RRT-requiring end-stage renal disease (ESRD).

RESULTS

Relative to the Te Manawa Taki population, MĀori were over-represented across all strata, especially ESRD (61.8%), followed by AKI-RRT (35.0%), and non-RRT (32.4%) (p<0.001). There was no excess mortality by ethnicity in any stratum. Crude in-ICU mortality was similar by ethnicity amongst AKI-RRT (30.8% amongst MĀori, vs 31.5%, p=1.000), and ESRD (16.4% amongst MĀori, vs 20.6%, p=0.826). This trend remained at 1 year. Adjusted for clinically selected variables, neither AKI-RRT nor ESRD mortality was predicted by MĀori ethnicity, both in-ICU and at 1-year. Irrespective of ethnicity, AKI-RRT patients had highest in-ICU mortality (31.2%) (p<0.001), whilst ESRD had highest 1-year mortality (46.1%) (p<0.001).

CONCLUSION

Increased RRT requirement amongst MĀori in our ICU is due to higher representation amongst ESRD. We did not demonstrate excess mortality by ethnicity in any stratum. AKI-RRT had higher in-ICU mortality than ESRD, but this reversed at 1-year. This article is protected by copyright. All rights reserved.