Decision-making in intensive care medicine - A review

A novel score for predicting 1-year mortality of intensive care patients

BACKGROUND

We aimed to develop a simple scoring table for predicting probability of death within 1-year after admission to an intensive care unit. We analysed data on emergency admissions from the nationwide Finnish intensive care quality registry.

METHODS

We included first admissions of adult patients with data available on 1-year vital status (dead or alive) and all five variables included in a premorbid functional status score, which is the number of activities the person can manage independently of the following five: get out of bed, move indoors, dress, climb stairs and walk 400 m. We analysed data on patient characteristics and admission-associated factors from 2012 to 2014 to find predictors of 1-year mortality and to develop a score for predicting probability of death. We tested the performance of this score in data from 2015. We assessed the 1-year functional status score of survivors with data available.

RESULTS

Out of 25,261 patients, 20,628 (81.7%) patients were able to perform all five functional activities independently prior to the intensive care unit admission. At 1-year post admission, 19,625 (77.7%) patients were alive. 1-year functional status score was known for 11,011 patients and 8970 (81.5%) patients achieved functional status score 5, managing all five activities independently. The score based on age, sex, preceding functional status, type of intensive care unit admission, severity of acute illness and the most significant diagnoses predicted 1-year mortality with an area under the receiver operating characteristic curve 0.78 (95% CI, 0.76-0.79). The calibration of our prediction model was good, with calibration intercept -0.01 (-0.07 to 0.05) and calibration slope 0.96 (0.90 to 1.02).

CONCLUSION

Our score based on data available at intensive care unit admission predicted 1-year mortality with fairly good discrimination. Most survivors achieved good functional recovery.

Diagnostic momentum in physical therapy clinical reasoning

RATIONALE AND OBJECTIVES

Diagnostic momentum refers to ruling in a particular diagnosis without adequate evidence. As the field of physical therapy continues to transition more towards autonomous practitioners with direct access, there is a need to identify the effect of a physician diagnosis on a therapist's examination and treatment. The purpose of this study was to identify if diagnostic momentum exists in physical therapy and whether this phenomenon could affect the ability of the therapist to identify clinical red flags.

METHODS

An online survey with randomized case scenarios was completed by 75 licensed practicing physical therapists. Participants received one of two scenarios: a case vignette where the patient was referred to physical therapy for left shoulder pain and presented with 'red flags' indicative of myocardial infarction, or a similar vignette with additional results from an exercise stress test that ruled out myocardial infarction. The subjects were asked if they would 'treat' or 'refer' to another healthcare provider and the reason behind their decision. Independent t-tests and χ2 analyses were conducted to understand the differences between the groups. A thematic analysis was used to explore the therapists' responses regarding the reasoning for their decision.

RESULTS

There was no significant difference in clinical decision making based on age, gender, years of experience, advanced certification, primary caseload or primary practice setting. Among those who received the case without the stress test, 31.4% of participants indicated that they would refer, compared to 12.5% of the participants that had the additional stress test result included within their case. The presence of the negative stress test was indicated as the main reason for choosing to treat without referral by 65.7% of the subjects that received the additional stress test result.

CONCLUSION

This study suggests that practicing physical therapists may be influenced by diagnostic decisions made by other clinicians, causing them to overlook signs and symptoms of possible myocardial infarction.

Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings

Introduction

Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD.

Methods

Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (-1) (palliative) to 3 (aggressive), the sum of which is the "Treatment Approach Score;" and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases.

Results

The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness-agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability-perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring-perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia.

Conclusion

Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.

Association Between Mental Health Disorders and Mortality Among Patients With COVID-19 in 7 Countries: A Systematic Review and Meta-analysis

IMPORTANCE

Heterogeneous evidence exists for the association between COVID-19 and the clinical outcomes of patients with mental health disorders. It remains unknown whether patients with COVID-19 and mental health disorders are at increased risk of mortality and should thus be targeted as a high-risk population for severe forms of COVID-19.

OBJECTIVE

To determine whether patients with mental health disorders were at increased risk of COVID-19 mortality compared with patients without mental health disorders.

DATA SOURCES

For this systematic review and meta-analysis, MEDLINE, Web of Science, and Google Scholar were searched from inception to February 12, 2021. Bibliographies were also searched, and the corresponding authors were directly contacted. The search paradigm was based on the following combination: (mental, major[MeSH terms]) AND (COVID-19 mortality[MeSH terms]). To ensure exhaustivity, the term mental was replaced by psychiatric, schizophrenia, psychotic, bipolar disorder, mood disorders, major depressive disorder, anxiety disorder, personality disorder, eating disorder, alcohol abuse, alcohol misuse, substance abuse, and substance misuse.

STUDY SELECTION

Eligible studies were population-based cohort studies of all patients with identified COVID-19 exploring the association between mental health disorders and mortality.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. This systematic review is registered with PROSPERO.

MAIN OUTCOMES AND MEASURES

Pooled crude and adjusted odds ratios (ORs) for the association of mental health disorders with mortality were calculated using a 3-level random-effects (study/country) approach with a hierarchical structure to assess effect size dependency.

RESULTS

In total, 16 population-based cohort studies (data from medico-administrative health or electronic/medical records databases) across 7 countries (1 from Denmark, 2 from France, 1 from Israel, 3 from South Korea, 1 from Spain, 1 from the UK, and 7 from the US) and 19 086 patients with mental health disorders were included. The studies covered December 2019 to July 2020, were of good quality, and no publication bias was identified. COVID-19 mortality was associated with an increased risk among patients with mental health disorders compared with patients without mental health disorders according to both pooled crude OR (1.75 [95% CI, 1.40-2.20]; P < .05) and adjusted OR (1.38 [95% CI, 1.15-1.65]; P < .05). The patients with severe mental health disorders had the highest ORs for risk of mortality (crude OR: 2.26 [95% CI, 1.18-4.31]; adjusted OR: 1.67 [95% CI, 1.02-2.73]).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis of 16 observational studies in 7 countries, mental health disorders were associated with increased COVID-19-related mortality. Thus, patients with mental health disorders should have been targeted as a high-risk population for severe forms of COVID-19, requiring enhanced preventive and disease management strategies. Future studies should more accurately evaluate the risk for patients with each mental health disorder. However, the highest risk seemed to be found in studies including individuals with schizophrenia and/or bipolar disorders.

Demand for Intensive Care beds and patient classification according to the priority criterion

OBJECTIVE

to assess the demand for Intensive Care Unit beds as well as the classification of the patients for admission, according to the priority system.

METHOD

a retrospective and cross-sectional study, developed from January2014 to December2018 in two Intensive Care Units for adults of a university hospital. The sample consisted of the requests for vacancies according to the priority system(scale from 1 to 4, where 1 is the highest priority and 4 is no priority), registered in the institution's electronic system.

RESULTS

a total of 8,483 vacancies were requested, of which 4,389(51.7%) were from unitB. The highest percentage in unitA was of Priority2 patients(32.6%); and Priority1 was prevalent in unitB(45.4%). The median lead time between request and admission to unitA presented a lower value for priority1 patients(2h57) and a higher value for priority4 patients(11h24); in unitB, priority4 patients presented shorter time(5h54) and priority3 had longer time(11h54). 40.5% of the requests made to unitA and 48.5% of those made to unitB were fulfilled, with 50.7% and 48.5% of these patients being discharged from the units, respectively.

CONCLUSION

it is concluded that the demand for intensive care beds was greater than their availability. Most of the patients assisted were priorities1 and2, although a considerable percentage of those classified as priorities3 and4 is observed.

Perceived stress and post-traumatic stress disorder symptoms among intensive care unit staff caring for severely ill coronavirus disease 2019 patients during the pandemic: a national study

BACKGROUND

Intensive care unit (ICU) staff have faced unprecedented challenges during the coronavirus disease 2019 (COVID-19) pandemic, which could significantly affect their mental health and well-being. The present study aimed to investigate perceived stress and post-traumatic stress disorder (PTSD) symptoms reported by ICU staff working directly with COVID-19 patients.

METHODS

The Perceived Stress Scale was used to assess perceived stress, the PTSD Diagnostic Scale for the Diagnostic and Statistical Manual of Mental Disorders (5th edition) was used to determine PTSD symptoms, and a sociodemographic questionnaire was used to record different sociodemographic variables.

RESULTS

Altogether, 124 participants (57.2% of whom were men) were included in the analysis. The majority of participants perceived working in the ICU with COVID-19 patients as moderately to severely stressful. Moreover, 71.4% of doctors and 74.4% of nurses experienced moderate-to-severe perceived stress. The staff with previous ICU experience were less likely to have a probable diagnosis of PTSD than those without previous ICU experience.

CONCLUSIONS

Assessing perceived stress levels and PTSD among ICU staff may enhance our understanding of COVID-19-induced mental health challenges. Specific strategies to enhance ICU staff's mental well-being during the COVID-19 pandemic should be employed and monitored regularly. Interventions aimed at alleviating sources of anxiety in a high-stress environment may reduce the likelihood of developing PTSD.

Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

OBJECTIVE

The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care.

DESIGN

This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis.

SETTING

Data were collected in a Swiss tertiary care centre between March and June 2013.

PARTICIPANTS

12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.

RESULTS

Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need.

CONCLUSIONS

In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.

Cognitive biases, environmental, patient and personal factors associated with critical care decision making: A scoping review

PURPOSE

Cognitive biases and factors affecting decision making in critical care can potentially lead to life-threatening errors. We aimed to examine the existing evidence on the influence of cognitive biases and factors on decision making in critical care.

MATERIALS AND METHODS

We conducted a scoping review by searching MEDLINE for articles from 2004 to November 2020. We included studies conducted in physicians that described cognitive biases or factors associated with decision making. During the study process we decided on the method to summarize the evidence, and based on the obtained studies a descriptive summary of findings was the best fit.

RESULTS

Thirty heterogenous studies were included. Four main biases or factors were observed, e.g. cognitive biases, personal factors, environmental factors, and patient factors. Six (20%) studies reported biases associated with decision making comprising omission-, status quo-, implicit-, explicit-, outcome-, and overconfidence bias. Nineteen (63%) studies described personal factors, twenty-two (73%) studies described environmental factors, and sixteen (53%) studies described patient factors.

CONCLUSIONS

The current evidence on cognitive biases and factors is heterogenous, but shows they influence clinical decision. Future studies should investigate the prevalence of cognitive biases and factors in clinical practice and their impact on clinical outcomes.

Use of intensive care unit priority model in directing intensive care unit admission in Sudan: A prospective cross-sectional study

Background:

The shortage of specialized intensive care beds is one of the principal factors that limit intensive care unit (ICU) admissions. This study explores the utilization of priority criteria in directing ICU admission and predicting outcomes.

Methods:

This was a prospective cross-sectional study conducted in two ICUs in Sudan from April to December 2018. Patients were assessed for ICU admission and were ranked by priority into Groups 1, 2, 3, and 4 (1 highest priority and 4 lowest priority), and these groups were compared using independent t-test, Chi-square, and ANOVA.

Results:

A total of 180 ICU admitted patients were enrolled, 53% were male. The prioritization categories showed that 86 (47.8%), 50 (27.8%), 13 (7.2%), and 31 (17.2%) were categorized as priority 1, 2, 3, and 4, respectively. Patients in priority groups 3 and 4had significantly higher ICU mortality rates compared to those in groups 1 and 2 (P < 0.001), were likely to be older (P < 0.001), had significantly more comorbidities (P = 0.001), were more likely to be dependent (P < 0.001), and had longer ICU length of stay (P = 0.028).

Conclusion:

Patients classified as priority 3 and 4 were predominantly older and had many comorbidities. They were likely to be dependent, stay longer in ICU, and exhibit mortality.

UK consultants' experiences of the decision-making process around referral to intensive care: an interview study

OBJECTIVE

The decision whether to initiate intensive care for the critically ill patient involves ethical questions regarding what is good and right for the patient. It is not clear how referring doctors negotiate these issues in practice. The aim of this study was to describe and understand consultants' experiences of the decision-making process around referral to intensive care.

DESIGN

Qualitative interviews were analysed according to a phenomenological hermeneutical method.

SETTING AND PARTICIPANTS

Consultant doctors (n=27) from departments regularly referring patients to intensive care in six UK hospitals.

RESULTS

In the precarious and uncertain situation of critical illness, trust in the decision-making process is needed and can be enhanced through the way in which the process unfolds. When there are no obvious right or wrong answers as to what ought to be done, how the decision is made and how the process unfolds is morally important. Through acknowledging the burdensome doubts in the process, contributing to an emerging, joint understanding of the patient's situation, and responding to mutual moral duties of the doctors involved, trust in the decision-making process can be enhanced and a shared moral responsibility between the stake holding doctors can be assumed.

CONCLUSION

The findings highlight the importance of trust in the decision-making process and how the relationships between the stakeholding doctors are crucial to support their moral responsibility for the patient. Poor interpersonal relationships can damage trust and negatively impact decisions made on behalf of a critically ill patient. For this reason, active attempts must be made to foster good relationships between doctors. This is not only important to create a positive working environment, but a mechanism to improve patient outcomes.

Rapid Development of a Tool for Prioritizing Patients with Coronavirus Disease 2019 for Intensive Care

Supplemental Digital Content is available in the text.

Objectives:

To explain and demonstrate a new approach for rapidly developing a decision-support tool for prioritizing patients with coronovirus 2019 disease for admission to ICUs.

Design:

An expert group used multi-criteria decision analysis methods to specify criteria and weights, representing their relative importance, for prioritizing patients with coronovirus 2019 disease with respect to likely clinical benefit. Specialized multi-criteria decision analysis software, implementing the “Potentially All Pairwise RanKings of all possible Alternatives” method to determine the weights, was used. Social equity considerations for prioritizing patients were also identified as important.

Setting:

The prioritization tool was developed in New Zealand.

Subjects:

An expert group comprising specialists from intensive care medicine and nursing, Māori (New Zealand’s indigenous population) health, infectious diseases, and neonatology was formed. The group’s work was supported by health economists and decision analysts and overseen by an ethicist and a senior representative from the New Zealand Ministry of Health.

Interventions:

Multi-criteria decision analysis to create a prioritization tool.

Measurements and Main Results:

The prioritization tool comprised eight criteria with respect to likely clinical benefit. In decreasing order of importance (weights in parentheses): Sequential Organ Failure Assessment score (15.7%), preexisting cardiovascular conditions (15.7%), functional capacity (15.7%), age (12.4%), preexisting respiratory conditions (11.1%), immunocompromised (11.1%), body mass index (9.2%), and other relevant medical conditions (9.2%). Two social equity considerations were also included in the overarching decision framework to be used alongside the clinical criteria: prioritizing Māori and Pacific people (and, potentially, other at-risk groups), and healthcare and other frontline workers.

Conclusions:

The criteria and weights in the prioritization tool can be easily revised as new evidence emerges. The approach for developing the tool could be used in other countries whose ICUs are at risk of being overwhelmed by the coronavirus disease 2019 pandemic to rapidly develop their own prioritization tools. In the event that future crises threaten to overload ICUs, other prioritization tools could also be rapidly developed.

[Mortality in schizophrenia: Towards a new health scandal? COVID-19 and schizophrenia]

Les patients atteints de schizophrénie représentent une population vulnérable qui a été sous-étudiée dans le cadre de la recherche COVID-19. Nous avons cherché à établir si les résultats et les soins de santé différaient entre les patients atteints de schizophrénie et les patients sans diagnostic de maladie mentale. Nous avons mené une étude basée sur la population de tous les patients présentant des symptômes respiratoires et une infection à COVID-19 identifiés qui ont été hospitalisés en France entre février et juin 2020. Au total, 50 750 patients ont été inclus, dont 823 étaient des patients avec schizophrénie (1,6 %). Ces derniers ont connu une augmentation de la mortalité hospitalière (25,6 % contre 21,7 % pour les autres patients) et une diminution du taux d’admission en unité de soins intensifs-réanimation (23,7 % contre 28,4 %) par rapport aux témoins. Les patients schizophrènes âgés de 65 à 80 ans présentaient un risque de mortalité significativement plus élevé que les témoins du même âge (+7,89 %) alors qu’ils ont été moins admis en USI que les témoins du même âge (−15,44 %). Cette étude montre l’existence de disparités en matière de santé et d’accès aux soins entre les patients schizophrènes et les patients sans diagnostic de maladie mentale. Ces disparités diffèrent en fonction de l’âge et du profil clinique des patients, ce qui suggère l’importance d’une gestion clinique personnalisée du COVID-19 et de stratégies de soins de santé avant, pendant et après l’hospitalisation pour réduire les disparités de santé dans cette population vulnérable. Les patients schizophrènes âgés de 65 à 80 ans étaient plus souvent envoyés par les hôpitaux ou les institutions que les patients sans diagnostic de maladie mentale grave, ce qui peut expliquer les mauvais résultats de santé des patients schizophrènes. Une étude française a rapporté que la plupart des patients psychiatriques hospitalisés avec un diagnostic COVID-19 étaient gardés dans des services psychiatriques spécialisés et non dans des hôpitaux généraux. La division entre médecine physique et psychiatrique entraîne une confusion quant au secteur du service de santé (c’est-à-dire les niveaux de soins primaires, de santé mentale ou de soins aigus) qui devrait assumer la responsabilité de la gestion des patients ayant des besoins de santé complexes. Nous manquons de données nationales sur le taux de patients âgés schizophrènes qui sont institutionnalisés, mais nous pouvons raisonnablement supposer que l’institutionnalisation est un facteur de risque d’infection grave par COVID-19 chez les patients âgés avec schizophrénie. Nos résultats soutiennent une stratégie de détection systématique chez les patients avec schizophrénie institutionnalisés et d’intervention précoce dans cette population. Cela a déjà été fait dans un refuge pour sans-abri à Boston où 36 % des résidents ont été testés positifs. Le taux d’admission en réanimation était plus faible chez les patients schizophrènes que chez les patients sans diagnostic de maladie mentale grave, ce qui illustre parfaitement le débat entre les arguments fondés sur l’utilité et ceux fondés sur l’équité. Les patients schizophrènes présentaient l’un des plus mauvais indicateurs de pronostic justifiant le triage en réanimation. Cependant, ce triage basé uniquement sur le pronostic exacerbe les inégalités existantes en matière de santé, laissant les patients défavorisés dans une situation plus difficile.

Facilitating supportive care in cardiac intensive care units

PURPOSE OF REVIEW

The number of patients who die in the hospital in the Western world is high, and 20-30% of them are admitted to an ICU in the last month of life, including those in cardiac ICUs (CICUs) where invasive procedures are performed and mortality is high. Palliative consultation is provided in only a few cases. The ethical and decisional aspects associated with the advanced stages of illness are very rarely discussed.

RECENT FINDINGS

The epidemiological and clinical landscape of CICUs has changed in the last decade; the incidence of acute coronary syndromes has decreased, whereas noncardiovascular diseases, comorbidities, the patients' age and clinical and therapeutic complexity have increased. The use of advanced and invasive treatments, such as mechanical ventilation, mechanical circulatory support and renal replacement therapies, has increased. This evolution increases the possibility of developing a life-threatening clinical event.

SUMMARY

This review aimed to analyze the main epidemiological, clinical, ethical and training aspects that can facilitate the introduction of supportive/palliative care programs in the CICU to improve symptom management during the advanced/terminal stages of illness, and address such issues as advance care planning, withdrawing/withholding life-sustaining treatments, deactivation of implantable defibrillators and palliative sedation.

Disparities in Intensive Care Unit Admission and Mortality Among Patients With Schizophrenia and COVID-19: A National Cohort Study

Patients with schizophrenia (SCZ) represent a vulnerable population who have been understudied in COVID-19 research. We aimed to establish whether health outcomes and care differed between patients with SCZ and patients without a diagnosis of severe mental illness. We conducted a population-based cohort study of all patients with identified COVID-19 and respiratory symptoms who were hospitalized in France between February and June 2020. Cases were patients who had a diagnosis of SCZ. Controls were patients who did not have a diagnosis of severe mental illness. The outcomes were in-hospital mortality and intensive care unit (ICU) admission. A total of 50 750 patients were included, of whom 823 were SCZ patients (1.6%). The SCZ patients had an increased in-hospital mortality (25.6% vs 21.7%; adjusted OR 1.30 [95% CI, 1.08-1.56], P = .0093) and a decreased ICU admission rate (23.7% vs 28.4%; adjusted OR, 0.75 [95% CI, 0.62-0.91], P = .0062) compared with controls. Significant interactions between SCZ and age for mortality and ICU admission were observed (P = .0006 and P < .0001). SCZ patients between 65 and 80 years had a significantly higher risk of death than controls of the same age (+7.89%). SCZ patients younger than 55 years had more ICU admissions (+13.93%) and SCZ patients between 65 and 80 years and older than 80 years had less ICU admissions than controls of the same age (-15.44% and -5.93%, respectively). Our findings report the existence of disparities in health and health care between SCZ patients and patients without a diagnosis of severe mental illness. These disparities differed according to the age and clinical profile of SCZ patients, suggesting the importance of personalized COVID-19 clinical management and health care strategies before, during, and after hospitalization for reducing health disparities in this vulnerable population.

Integrated modelling of built environment and functional requirements: Implications for resilience

The built environment is a core part of most healthcare systems, involving a number of requirements such as those related to space and patients' well-being. However, these are usually addressed separately from other functional requirements, resulting in designs that do not support resilient performance. This study proposes a framework for the integrated modelling of built environment and other functional requirements, relying on two approaches: Functional Resonance Analysis Method (FRAM), and Building Information Modelling (BIM). Requirements are defined as equivalent to the precondition aspect of FRAM functions. BIM allows the creation of a database of requirements and functions, linked to an object-oriented model of the built environment. The proposed framework was devised and tested in an intensive care unit. Findings shed light on the necessary resilience to cope with the gap between built environment-as-imagined in design and built environment-as-done due to performance adjustments. This type of resilience may have a long-lasting nature, as many built environment attributes cannot be easily changed.

Increased in-hospital mortality from COVID-19 in patients with schizophrenia

Background

There is limited information describing the presenting characteristics and outcomes of patients with schizophrenia (SCZ) requiring hospitalization for coronavirus disease 2019 (COVID-19).

Aims

We aimed to compare the clinical characteristics and outcomes of COVID-19 SCZ patients with those of non-SCZ patients.

Method

This was a case-control study of COVID-19 patients admitted to 4 AP–HM/AMU acute care hospitals in Marseille, southern France. COVID-19 infection was confirmed by a positive result on polymerase chain reaction testing of a nasopharyngeal sample and/or on chest computed scan among patients requiring hospital admission. The primary outcome was in-hospital mortality. The secondary outcome was intensive care unit (ICU) admission.

Results

A total of 1092 patients were included. The overall in-hospital mortality rate was 9.0%. The SCZ patients had an increased mortality compared to the non-SCZ patients (26.7% vs. 8.7%, P = 0.039), which was confirmed by the multivariable analysis after adjustment for age, sex, smoking status, obesity and comorbidity (adjusted odds ratio 4.36 [95% CI: 1.09–17.44]; P = 0.038). In contrast, the SCZ patients were not more frequently admitted to the ICU than the non-SCZ patients. Importantly, the SCZ patients were mostly institutionalized (63.6%, 100% of those who died), and they were more likely to have cancers and respiratory comorbidities.

Conclusions

This study suggests that SCZ is not overrepresented among COVID-19 hospitalized patients, but SCZ is associated with excess COVID-19 mortality, confirming the existence of health disparities described in other somatic diseases.

Swedish intensivists' experiences and attitudes regarding end-of-life decisions

BACKGROUND

To make end-of-life (EOL) decisions is a complex and challenging task for intensive care physicians and a substantial variability in this process has been previously reported. However, a deeper understanding of intensivists' experiences and attitudes regarding the decision-making process is still, to a large extent, lacking. The primary aim of this study was to address Swedish intensivists' experiences, beliefs and attitudes regarding decision-making pertaining to EOL decisions. Second, we aimed to identify underlying factors that may contribute to variability in the decision-making process.

METHOD

This is a descriptive, qualitative study. Semi-structured interviews with nineteen intensivists from five different Swedish hospitals, with different ICU levels, were performed from 1 February 2017 to 31 May 2017.

RESULTS

Intensivists strive to make end-of-life decisions that are well-grounded, based on sufficient information. Consensus with the patient, family and other physicians is important. Concurrently, decisions that are made with scarce information or uncertain medical prognosis, decisions made during on-call hours and without support from senior consultants cause concern for many intensivists. Underlying factors that contribute to the variability in decision-making are lack of continuity among senior intensivists, lack of needed support during on-call hours and disagreements with physicians from other specialties. There is also an individual variability primarily depending on the intensivist's personality.

CONCLUSION

Swedish intensivists' wish to make end-of-life decisions based on sufficient information, medically certain prognosis and consensus with the patient, family, staff and other physicians. Swedish intensivists' experience a variability in end-of-life decisions, which is generally accepted and not questioned.

Procedural outcomes of deep brain stimulation (DBS) surgery in rural and urban patient population settings

Presently, disparities exist between race, sex, socioeconomic status, hospitals, income, comorbidities, and insurance profiles of patients undergoing DBS surgery. Here, we aim to highlight several variables and their predictive powers of DBS surgery outcomes as measured by dischargelocation, length of hospital stays, and total hospital charges. A retrospective cohort study using discharge data from NIS and HCUP for analyses and regression model statistics is performed. Comparative analyses demonstrate urban patients were more often non-routinely discharged, possessed private insurance, and accrued greater hospital costs compared to rural patients. Moreover, regression analyses predicts urban patients have 70% lower odds of routine discharge while those with a major loss of function prior to surgery also have 81% lower odds of routine discharge compared to those with minor loss of function. Ultimately, our study found urban patients or patients with major illnesses have higher hospital charges, longer hospitalization, and more often non-routinely discharged.

Intensive Care Role in Disaster Management Critical Care Clinics

The "daily disasters" within the ebb and flow of routine critical care provide a foundation of preparedness for the less-frequent, larger events that affect most health care organizations at some time. Although large disasters can overwhelm, those who strengthen processes and habits through daily practice will be the best prepared to manage them.

Facilitators of and barriers to adopting a restrictive red blood cell transfusion practice: a population-based cross-sectional survey

BACKGROUND

Despite recommendations for restrictive approaches to red blood cell transfusion in the intensive care unit (ICU), variation from best practices persists. The aim of this study was to explore potential facilitators of and barriers to practising a restrictive red blood cell transfusion strategy among intensive care physicians using the theoretical domains framework.

METHODS

We conducted an online population-based cross-sectional survey of all intensive care physicians in 1 health care system (Alberta). Survey questions were based on 6 key theoretical domains of the theoretical domains framework: Knowledge, Social/professional roles and identity, Motivation and goals, Beliefs about consequences, Social influences and Beliefs about capabilities. The survey was administered between July 27 and Oct. 6, 2017. Descriptive statistics (demographic and Likert scale data) and conventional content analysis (open-ended responses) were conducted.

RESULTS

Forty-two intensive care physicians completed the survey (estimated response rate 56%). The respondents identified knowledge of published evidence, use of guidelines, improved outcomes, physician autonomy, and perceived culture of acceptance and collegial support as facilitators of practising a restrictive transfusion strategy. Identified barriers included potential impact on and cost to other clinical goals, conflicting practices and beliefs of physicians in other clinical specialties, deficits in medical trainees' skills and knowledge, and attitudinal barriers related to denial.

INTERPRETATION

Using the theoretical domains framework, we identified 9 key self-reported facilitators of and barriers to intensive care physicians' transfusion behaviour. Understanding these determinants will help inform development and implementation of interventions within ICUs to encourage optimal use of red blood cell transfusion practices for nonbleeding patients whose condition is stable.

The experiences of health care professionals, patients, and families of the process of referral and admission to intensive care: A systematic literature review

Treatment in an intensive care unit can be life-saving but it can be distressing and not every patient can benefit. Decisions to admit a patient to an intensive care unit are complex. We wished to explore how the decision to refer or admit is experienced by those involved, and undertook a systematic review of the literature to answer the research question: What are the experiences of health care professionals, patients, and families, of the process of referral and admission to an intensive care unit? Twelve relevant studies were identified, and a thematic analysis was conducted. Most studies involved health care professionals, with only two considering patients' or families' experiences. Four themes were identified which influenced experiences of intensive care unit referral and review: the professional environment; communication; the allocation of limited resources; and acknowledging uncertainty. Patients' and families' experiences have been under-researched in this area.