What Happens to Patients Discharged Against Medical Advice?

Acute Stroke in the Emergency Department: Profiles of Patients and Obstacles to Acute Intervention

AIMS

To build a demographic profile of patients presenting to the emergency department (ED) with stroke, determine the proportion who successfully undergo thrombolysis and active interventions, and study their outcomes up to discharge or death in the hospital.

METHODS AND MATERIALS

A sample size of 215 was calculated and patients were recruited consecutively on presentation to the ED after obtaining consent. Data was collected and they were followed up till the outcome. Data was tabulated and analyzed both as a whole and after further categorization into infarction, hemorrhagic stroke, and cerebral venous thrombosis (CVT). Mean and standard deviation were used for continuous variables and chi-square for categorical variables.

RESULTS

A total of 216 patients were recruited, 156 (72%) male and 60 (28%) female. There were 135 (63%) ischemic strokes, 67 (31%) hemorrhagic, and 14 (6%) CVT. The mean age was 56.57 years (SD 14.22 years). A total of 12 patients (5.5%) presented within the 'golden hour' and 28 ischemic strokes presented within the thrombolysis window, of which nine were thrombolyzed. In total, 39 patients were intubated in the ED, of which 10 (7.41%) had ischemic strokes, 27 (40.3%) had hemorrhagic strokes and two (14.29%) had CVTs. There were 192 patients admitted to in-patient care, while 24 (11%) were discharged against medical advice. A further 14 patients were intubated during admission. Nine patients (13.43%) with hemorrhagic strokes underwent surgical decompression, five (7.46%) had an external ventricular drain (EVD) placed, six (8.96%) underwent aneurysm clipping, and two (2.99%) underwent aneurysm coiling. One case of CVT underwent surgical decompression.

CONCLUSIONS

Stroke is a highly heterogeneous clinical entity with nuanced differences between the different subtypes. There appear to be significant obstacles regarding the early presentation of strokes to hospitals and the initiation of thrombolysis in the case of acute interventions.

Prevalence of frailty and association with patient centered outcomes: A prospective registry-embedded cohort study from India

PURPOSE

We aimed to study the prevalence of frailty, evaluate risk factors, and understand impact on outcomes in India.

METHODS

This was a prospective registry-embedded cohort study across 7 intensive care units (ICUs) and included adult patients anticipated to stay for at least 48 h. Primary exposure was frailty, as defined by a score ≥ 5 on the Clinical Frailty Scale and primary outcome was ICU mortality. Secondary outcomes included in-hospital mortality and resource utilization. We used generalized linear models to evaluate risk factors and model association between frailty and outcomes.

RESULTS

838 patients were included, with median (IQR) age 57 (42,68) yrs.; 64.8% were male. Prevalence of frailty was 19.8%. Charlson comorbidity index (OR:1.73 (95%CI:1.39,2.15)), Subjective Global Assessment categories mild/moderate malnourishment (OR:1.90 (95%CI:1.29, 2.80)) and severe malnourishment (OR:4.76 (95% CI:2.10,10.77)) were associated with frailty. Frailty was associated with higher odds of ICU mortality (adjusted OR:2.04 (95% CI:1.25,3.33)), hospital mortality (adjusted OR:2.36 (95%CI:1.45,3.84)), development of stage2/3 AKI (unadjusted OR:2.35 (95%CI:1.60, 3.43)), receipt of non-invasive ventilation (unadjusted OR:2.68 (95%CI:1.77, 4.03)), receipt of vasopressors (unadjusted OR:1.47 (95%CI:1.04, 2.07)), and receipt of kidney replacement therapy (unadjusted OR:3.15 (95%CI:1.90, 5.17)).

CONCLUSIONS

Frailty is common among critically ill patients in India and is associated with worse outcomes.

STUDY REGISTRATION

CTRI/2021/02/031503.

Traumatic Brain Injury in Cameroon: A Prospective Observational Study in a Level I Trauma Centre

Background and Objective: About 14 million people will likely suffer a traumatic brain injury (TBI) per year by 2050 in sub-Saharan Africa. Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma centre in Cameroon. Materials and Methods: Data on demographics, causes, clinical aspects, and discharge status were collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality-of-Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes six months after TBI. Comparisons between two categorical variables were done using Pearson's chi-square test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years was most represented (78%). Males were more affected (90%). A low educational level was seen in 122 (76%) cases. Road traffic incidents (RTI) (85%), assaults (7.5%), and falls (2.5%) were the main causes of TBI, with professional bike riders being frequently involved (27%). Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% of cases, and intracranial traumatic abnormalities were identified in 64% of cases. Financial constraints (93%) was the main reason for not performing a CT scan. Forty-six (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) and high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only four patients received post-injury physical therapy services. Conclusions: TBI in Cameroon mainly results from RTIs and commonly affects young adult males. Lack of pre-hospital care, financial constraints limiting both CT scanning and medical care, and a lack of acute physiotherapy services likely influenced care and outcomes adversely.

Stakeholder engagement as a strategy to enhance palliative care involvement in intensive care units: A theory of change approach

BACKGROUND

Adult patients admitted to intensive care units in the terminal phase experience high symptom burden, increased costs, and diminished quality of dying. There is limited literature on palliative care engagement in ICU, especially in lower-middle-income countries. This study explores a strategy to enhance palliative care engagement in ICU through a stakeholder participatory approach.

METHODS

Theory of Change approach was used to develop a hypothetical causal pathway for palliative care integration into ICUs in India. Four facilitated workshops and fifteen research team meetings were conducted virtually over three months. Thirteen stakeholders were purposively chosen, and three facilitators conducted the workshops. Data included workshop discussion transcripts, online chat box comments, and team meeting minutes. These were collected, analysed and represented as theory of change map.

RESULTS

The desired impact of palliative care integration was good death. Potential long-term outcomes identified were fewer deaths in ICUs, discharge against medical advice, and inappropriate admissions; increased referrals to palliative care; and improved patient and family satisfaction. Twelve preconditions were identified, and eleven key interventions were developed. Five overarching assumptions related to contextual factors influencing the outcomes of interventions.

CONCLUSION

Theory of change framework facilitated the identification of proposed mechanisms and interventions underpinning palliative care integration in ICUs.

Epidemiology, Management, and Outcomes of Sepsis in ICUs among Countries of Differing National Wealth across Asia

Rationale: Directly comparative data on sepsis epidemiology and sepsis bundle implementation in countries of differing national wealth remain sparse. Objectives: To evaluate across countries/regions of differing income status in Asia 1) the prevalence, causes, and outcomes of sepsis as a reason for ICU admission and 2) sepsis bundle (antibiotic administration, blood culture, and lactate measurement) compliance and its association with hospital mortality. Methods: A prospective point prevalence study was conducted among 386 adult ICUs from 22 Asian countries/regions. Adult ICU participants admitted for sepsis on four separate days (representing the seasons of 2019) were recruited. Measurements and Main Results: The overall prevalence of sepsis in ICUs was 22.4% (20.9%, 24.5%, and 21.3% in low-income countries/regions [LICs]/lower middle-income countries/regions [LMICs], upper middle-income countries/regions, and high-income countries/regions [HICs], respectively; P < 0.001). Patients were younger and had lower severity of illness in LICs/LMICs. Hospital mortality was 32.6% and marginally significantly higher in LICs/LMICs than HICs on multivariable generalized mixed model analysis (adjusted odds ratio, 1.84; 95% confidence interval, 1.00-3.37; P = 0.049). Sepsis bundle compliance was 21.5% at 1 hour (26.0%, 22.1%, and 16.2% in LICs/LMICs, upper middle-income countries/regions, and HICs, respectively; P < 0.001) and 36.6% at 3 hours (39.3%, 32.8%, and 38.5%, respectively; P = 0.001). Delaying antibiotic administration beyond 3 hours was the only element independently associated with increased mortality (adjusted odds ratio, 2.53; 95% confidence interval, 2.07-3.08; P < 0.001). Conclusions: Sepsis is a common cause of admission to Asian ICUs. Mortality remains high and is higher in LICs/LMICs after controlling for confounders. Sepsis bundle compliance remains low. Delaying antibiotic administration beyond 3 hours from diagnosis is associated with increased mortality. Clinical trial registered with www.ctri.nic.in (CTRI/2019/01/016898).

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study

BACKGROUND

We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010-2011.

METHODS

An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs.

RESULTS

On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality.

CONCLUSIONS

Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927).

HOW TO CITE THIS ARTICLE

Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093-1107.

Ethical Framework to Guide Decisions of Treatment Over Objection

BACKGROUND

Whether to proceed with a medical intervention over the objection of a patient who lacks capacity is a common problem facing practitioners. Despite this, there is a notable gap in the literature describing how to proceed in such situations in an ethically rigorous and consistent fashion. We elaborate on the practical application of the 2018 Rubin/Prager seven-question algorithm for ethics consultations regarding treatment over objection and we describe the impact of each of the seven questions.

STUDY DESIGN

We retrospectively review a series of consultations at Columbia University Irving Medical Center for treatment over objection in adult patients determined to lack capacity between April 2017 and May 2020. Outcomes regarding the final ethics recommendation and the assessment of each of the seven questions are reported. The statistical analysis was designed to determine which of the seven questions in the algorithm were most predictive of the final ethics recommendation.

RESULTS

In our series, there was an ethics recommendation to proceed over the objection of a patient in 63% of consultations. While all seven questions were considered to be important to the ethical analysis of a patient's situation, the presence of logistical barriers to treatment and the imminence of harm to a patient without treatment emerged as the most significant drivers of the recommendation of whether to proceed over objection or not.

CONCLUSIONS

Cases of treatment over objection in a patient lacking capacity are frequently encountered problems that requires a careful balance of patient autonomy and a physician's duty of beneficence. The application of the Rubin/Prager seven-question algorithm reliably guides a care team through such a complex ethical dilemma.

Reducing rates of discharge against medical advice in the neonatal intensive care unit in a tertiary care hospital in South India: a mixed-methods study

OBJECTIVE

To elucidate characteristics among neonates and their mothers who were discharged against medical advice (DAMA), providers' perspectives on DAMA and the effect of an intervention to reduce DAMA in a tertiary care hospital in South India.

METHODS

We conducted a mixed-methods study to identify neonates at risk of DAMA. We reviewed charts of neonates and their mothers who were DAMA and conducted logit regression analysis to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to determine associations with DAMA. We conducted focus group discussions with nurses and doctors. We developed an intervention that included family counselling, supplemental funds for hospital bills and involving family members to reduce DAMA.

RESULTS

Of 10 834 neonates, 179 (1.7%) were DAMA over the study period. Maternal characteristics associated with DAMA included higher previous parity (aOR 1.9, 95% CI 1.1-2.3, P = 0.001). Mothers who received antenatal care had lower odds of DAMA (aOR 0.2, 95% CI 0.1-0.7, P = 0.039). Neonates with lower birth weight (aOR 2.1, 95% CI 1.7-9.4, P = 0.002) and congenital malformations (aOR 3.3, 95% CI 1.1-5.3, P = 0.005) also had higher odds of DAMA. The most commonly cited reasons for DAMA were financial constraints, inadequate counselling and perceived poor prognosis. The average monthly number of neonates who were DAMA decreased from 3.6 (1.6%) to 1.5 (0.6%) after our multi-pronged intervention.

CONCLUSIONS

Neonates with severe illness and poor prognosis had higher odds of DAMA. A multi-pronged intervention demonstrated reductions in the rates of DAMA. This intervention may be trialled in similar settings to reduce DAMA.

The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India

INTRODUCTION

Ambulance-based emergency medical systems (EMS) are expensive and remain rare in low- and middle-income countries, where trauma victims are usually transported to hospital by passing vehicles. Recent developments in transportation network technologies could potentially disrupt this status quo by allowing coordinated emergency response from layperson networks. We sought to understand the barriers to bystander assistance for trauma victims in Delhi, India, and implications for a layperson-EMS.

METHODS

We used qualitative methods to analyse data from 50 interviews with frontline stakeholders (including taxi drivers, medical professionals, legal experts and police), one stakeholder consultation and a review of documents.

RESULTS

Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis and police. While ambulances are common, they are primarily used for interfacility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe the role of police and force for-profit hospitals to stabilise patients appear to have been unsuccessful.

CONCLUSIONS

Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India's ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.