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Lepre RDL, Mezzaroba AL, Cardoso LTQ, Matsuo T, Grion CMC. Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey. Rev Bras Ter Intensiva 2022; 34:484-491. [PMID: 36888829 PMCID: PMC9987007 DOI: 10.5935/0103-507x.20220264-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/27/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals. METHODS A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%. RESULTS In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds. CONCLUSIONS Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.
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Affiliation(s)
- Rafaela de Lemos Lepre
- Departamento de Clínica Cirúrgica, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | - Ana Luiza Mezzaroba
- Departamento de Clínica Médica, Universidade Estadual de Londrina - Londrina (PR), Brasil
| | | | - Tiemi Matsuo
- Departamento de Estatística, Universidade Estadual de Londrina - Londrina (PR), Brasil
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Prioritization of ICU beds with renal replacement therapy support by court order and mortality in a Brazilian metropolitan area. Sci Rep 2022; 12:3512. [PMID: 35241736 PMCID: PMC8894379 DOI: 10.1038/s41598-022-07429-4] [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: 07/03/2021] [Accepted: 02/17/2022] [Indexed: 11/28/2022] Open
Abstract
The shortage of intensive care unit (ICU) resources, including equipment and supplies for renal replacement therapy (RRT), is a critical problem in several countries. This study aimed to assess hospital mortality and associated factors in patients treated in public hospitals of the Federal District, Brazil, who requested admission to ICU with renal replacement therapy support (ICU-RRT) in court. Retrospective cohort study that included 883 adult patients treated in public hospitals of the Federal District who requested ICU-RRT admission in court from January 2017 to December 2018. ICU-RRT was denied to 407 patients, which increased mortality (OR 3.33, 95% CI 2.39–4.56, p ≪ 0.01), especially in patients with priority level I/II (OR 1.02, 95% CI 1.01–1.04, p ≪ 0.01). Of the requests made in court, 450 were filed by patients with priority levels III/IV, and 44.7% of these were admitted to ICU-RRT. In admitted patients, priority level III priority level I/II was associated with a low mortality (OR 0.47, 95% CI 0.32–0.69, p < 0.01), and not. The admission of patients classified as priority levels III/IV to ICU-RRT considerably jeopardized the admission of patients with priority levels I/II to these settings. The results found open new avenues for organizing public policies and improving ICU-RRT triage.
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Intensive Care Unit prioritization: The impact of ICU bed availability on mortality in critically ill patients who requested ICU admission in court in a Brazilian cohort. J Crit Care 2021; 66:126-131. [PMID: 34544015 DOI: 10.1016/j.jcrc.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE To assess hospital mortality in patients who requested ICU admission in court due to the scarcity of ICU beds in the Brazilian public health system and the consequences of these judicial litigations. MATERIAL AND METHODS Retrospective cohort study that included adult patients from the public health system of the Federal District, Brazil, who claimed ICU admission in court from January 2017 to December 2019. RESULTS Of the 1752 patients, 1031 were admitted to ICU (58.8%). Hospital mortality was 61.1% (1071/1752). Of the requests, 768 (43.8%) were made by patients with priority levels III or IV, resulting in the ICU admission of 33.9% of these patients. Denial of ICU admission (p < 0.001) increased mortality. ICU admission reduced hospital mortality in patients classified as priority level I (p < 0.001), priority level II (p < 0.001), and priority level III (p < 0.001), but not as priority level IV (p = 0.619). CONCLUSION A large proportion of patients was denied ICU admission and it was associated with an increased mortality. A considerable portion of the ICU-admitted patients were classified as priority level III and IV, impairing the ICU admission of patients with priority level I which are the ones with the greatest benefit from it.
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Merlo F, Lepori M, Malacrida R, Albanese E, Fadda M. Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study. Front Public Health 2021; 9:695231. [PMID: 34395369 PMCID: PMC8360847 DOI: 10.3389/fpubh.2021.695231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022] Open
Abstract
Aims: One of the major ethical challenges posed by the Covid-19 pandemic comes in the form of fair triage decisions for critically ill patients in situations where life-saving resources are limited. In Spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the Covid-19 pandemic. While evidence has shown that the capacities of intensive care medicine throughout Switzerland were sufficient to take care of all critically ill patients during the first wave of the outbreak, no evidence is available regarding the acceptance of these guidelines by ICU staff. The aim of this qualitative study was to explore the acceptance and perceived implementation of the SAMS guidelines among a sample of senior physicians involved in the care of Covid-19 patients in the Canton of Ticino. Specific objectives included capturing and describing physicians' attitudes toward the guidelines, any challenges experienced in their application, and any perceived factors that facilitated or would facilitate their application. Methods: We conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed as either head of unity, deputy-head of unit, or medical director in either one of the two Covid-19 hospitals in the Canton of Ticino during the peak of the outbreak. Interviews were transcribed verbatim and thematically analyzed using an inductive approach. Results: We found that participants held different views regarding the nature of the guidelines, saw decisions on admission as a matter of collective responsibility, argued that decisions should be based on a medical futility principle rather than an age criterion, and found that difficulties to address end-of-life issues led to a comeback of paternalism. Conclusions: Results highlight the importance of clarifying the nature of the guidelines, establishing authority, and responsibility during triaging decisions, recognizing and addressing sources of interference with patients' autonomy, and the need of a cultural shift in timely and efficiently addressing end-of-life issues.
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Affiliation(s)
- Federica Merlo
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland.,Sasso Corbaro Foundation, Bellinzona, Switzerland
| | - Mattia Lepori
- Ente Ospedaliero Cantonale, Area Medica Direzione Generale, Bellinzona, Switzerland
| | | | - Emiliano Albanese
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland
| | - Marta Fadda
- Faculty of Biomedical Sciences, Institute of Public Health, Università della Svizzera italiana, Lugano, Switzerland
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Nassar Junior AP, Trevisani MDS, Bettim BB, Caruso P. Long-term mortality in very old patients with cancer admitted to intensive care unit: A retrospective cohort study. J Geriatr Oncol 2020; 12:106-111. [PMID: 32565146 DOI: 10.1016/j.jgo.2020.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/23/2020] [Accepted: 06/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Long-term outcomes of older patients referred to intensive care unit (ICU) are of paramount importance for care planning and counseling of patients and relatives. METHODS We performed a retrospective study with patients aged ≥80 years admitted to ICU from 2011 to 2017 in a cancer center. We performed two Cox proportional hazard regressions. In the first, we tested whether type of cancer (solid locoregional, solid metastatic or hematologic), Eastern Cooperative Oncology Group Performance Status (ECOG PS), and comorbidities [Charlson Comorbidity Index - CCI]) were associated with one-year mortality in all patients. In the second, we assessed whether delirium, use of vasopressors, mechanical ventilation, renal replacement therapy, and forgoing life-sustaining therapies were associated with one-year mortality in survivors to hospital discharge. RESULTS Of 763 patients included, 482 (62.3%) patients died at one year. Metastatic cancer was significantly associated with one-year mortality (HR = 1.97; CI 95%, 1.16-3.36), but hematologic cancer, CCI and ECOG PS were not. Among patients who survived to hospital discharge, delirium, use of vasopressors, mechanical ventilation, renal replacement therapy and decisions to forgo life-sustaining therapies in ICU were not associated with one-year mortality. CONCLUSIONS Metastatic disease at ICU admission was associated with one-year mortality in patients aged ≥80 years. Delirium, use of vasopressors, mechanical ventilation and renal replacement therapy and decisions to forgo life-sustaining therapies in ICU were not associated with one-year mortality among the patients discharged from hospital.
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Affiliation(s)
| | | | | | - Pedro Caruso
- Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil; Discipline of Pulmonology, Heart Institute (InCor), University of São Paulo, Brazil
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Ramos JGR, Ranzani OT, Perondi B, Dias RD, Jones D, Carvalho CRR, Velasco IT, Forte DN. A decision-aid tool for ICU admission triage is associated with a reduction in potentially inappropriate intensive care unit admissions. J Crit Care 2019; 51:77-83. [PMID: 30769294 DOI: 10.1016/j.jcrc.2019.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Intensive care unit (ICU) admission triage occurs frequently and often involves highly subjective decisions that may lead to potentially inappropriate ICU admissions. In this study, we evaluated the effect of implementing a decision-aid tool for ICU triage on ICU admission decisions. METHODS This was a prospective, before-after study. Urgent ICU referrals to ten ICUs in a tertiary hospital in Brazil were assessed before and after the implementation of the decision-aid tool. Our primary outcome was the proportion of potentially inappropriate ICU referrals (defined as priority 4B or 5 referrals, accordingly to the Society of Critical Care Medicine guidelines of 1999 and 2016, respectively) admitted to the ICU within 48 h. We conducted multivariate analyses to adjust for potential confounders and evaluated the interaction between phase and triage priority. RESULTS Of the 2201 patients analyzed, 1184 (53.8%) patients were admitted to the ICU. After adjustment for confounders, implementation of the decision-aid tool was associated with a reduction in potentially inappropriate ICU admissions using either the 1999 [adjOR (95% CI) = 0.36 (0.13-0.97)] or 2016 [adjOR (95%CI) = 0.35 (0.13-0.96)] definitions. CONCLUSION Implementation of a decision-aid tool for ICU triage was associated with a reduction in potentially inappropriate ICU admissions.
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Affiliation(s)
- Joao Gabriel Rosa Ramos
- Medical Sciences PhD program, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, Brazil; Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil.
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Beatriz Perondi
- Emergency Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
| | - Roger Daglius Dias
- Emergency Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil; Emergency Department, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Daryl Jones
- Monash University, School of Public Health and Preventive Medicine, Australia; University of Melbourne, Australia; Austin Health, Melbourne, Australia.
| | - Carlos Roberto Ribeiro Carvalho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
| | - Irineu Tadeu Velasco
- Emergency Medicine Discipline, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil.
| | - Daniel Neves Forte
- Medical Sciences PhD program, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, Brazil; Teaching and Research on Palliative Care Program, Hospital Sirio-Libanes, Sao Paulo, Brazil
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Zampieri FG, Araújo F, Santos RHN, Cavalcanti AB. Existing capacity for renal replacement therapy and site-specific practices for managing acute kidney injury at centers participating in the BaSICS trial. Rev Bras Ter Intensiva 2018; 30:264-285. [PMID: 30328984 PMCID: PMC6180470 DOI: 10.5935/0103-507x.20180058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/25/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To investigate the existing capacity for renal replacement therapy and site-specific practices for managing acute kidney injury at centers participating in the BaSICS trial. METHODS A questionnaire was provided to the chairs of 61 intensive care units enrolled in a randomized clinical trial in Brazil. A total of 124 physicians completed the questionnaire. RESULTS Approximately 15% of the patients admitted to the analyzed intensive care units received renal replacement therapy at the time of data collection. At least one renal replacement method was available in all of the analyzed units. Continuous methods were available more frequently at the private units than at the public units. The time from indication to onset of treatment was longer at the public units than at private units. The main obstacles to treatment initiation at public intensive care units were related to the availability of equipment and personnel, while the main bottleneck at private units was the nephrologist assessment. A considerable proportion of the participants stated that they would change their approach to renal replacement therapy if there were no limitations on the availability of methods in their units. CONCLUSION There was wide variation in the availability of resources for renal replacement therapy and in the management of acute kidney injury in Brazilian intensive care units. This information should be taken into account when planning clinical trials focused on this topic in Brazil.
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Affiliation(s)
| | - Flavio Araújo
- Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
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Gopalan PD, Pershad S. Decision-making in ICU - A systematic review of factors considered important by ICU clinician decision makers with regard to ICU triage decisions. J Crit Care 2018; 50:99-110. [PMID: 30502690 DOI: 10.1016/j.jcrc.2018.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The ICU is a scarce resource within a high-stress, high-stakes, time-sensitive environment where critically ill patients with life-threatening conditions receive expensive life-sustaining care under the guidance of expert qualified personnel. The implications of decisions such as suitability for admission into ICU are potentially dire and difficult. OBJECTIVES To conduct a systematic review of clinicians' subjective perceptions of factors that influence the decision to accept or refuse patients referred to ICU. RESULTS Twenty studies yielded 56 different factors classified into patient, physician and environmental. Common, important factors were: acute illness severity and reversibility; presence and severity of comorbidities; patient age, functional status, state-of-mind and wishes; physician level of experience and perception of patient QOL; and bed availability. Within-group variability among physicians and thought-deed discordance were demonstrated. CONCLUSIONS The complex and dynamic ICU triage decision is affected by numerous interacting factors. The literature provides some indication of these factors, but fail to show complexities and interactions between them. A decision tree is proposed. Further research should include a reflection on how decisions for admission to ICU are made, such that a better understanding of these processes can be achieved allowing for improved individual and group consistency.
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Affiliation(s)
- Pragasan Dean Gopalan
- Discipline of Anaesthesiology & Critical Care, School of Clinical Medicine, Nelson R Mandela School of Medicine, University of KwaZulu Natal, 719 Umbilo Road, Durban 4001, South Africa; Intensive Care Unit, King Edward VIII Hospital, Congella, Durban, South Africa.
| | - Santosh Pershad
- Discipline of Anaesthesiology & Critical Care, School of Clinical Medicine, Nelson R Mandela School of Medicine, University of KwaZulu Natal, 719 Umbilo Road, Durban 4001, South Africa; Intensive Care Unit, Inkosi Albert Luthuli Central Hospital, 800 Vusi Mzimela Road, Cato Manor, Durban, South Africa.
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