Functional recovery of chronically critically ill patients in the first days after discharge from the intensive care unit: Feasibility of the 6-minute step test

BACKGROUND

Survivors of chronic critical illness often experience weakness and functional dependence to various degrees after their intensive care unit (ICU) stay. Evaluating their functional status with the traditional six-minute walk test is challenging due to space constraints or patient intolerance.

OBJECTIVE

Our aim was to evaluate the feasibility of using the six-minute step test (6MST) as a measure of functional capacity in chronically critically ill patients early after ICU discharge.

METHODS

This prospective study was undertaken in a private Brazilian hospital. From July 2019 to July 2020, all chronically critically ill patients were asked to participate 48 hours after ICU discharge. On the day of study inclusion and a week later, those who consented underwent functional assessment comprised of the 6MST, peripheral muscle strength using handgrip strength (HGS), and mobility using the ICU mobility scale (IMS).

RESULTS

A total of 40 patients were included. The 6MST was feasible in 40% on the first evaluation and 57% on the second. The median 6MST was 0 [0-5] on the first evaluation and 3.5 [0-7.75] on the second (P = 0.005). The median HGS increased from 11.50 [9.25-18] on the first evaluation to 14.5 [10-20] on the second (P = 0.006). The median IMS was 4.5 [3.25-7] on the first evaluation and 6 [3.25-7] on the second (P<0.001). Despite the significant improvement, all parameters measured remained well below normal.

CONCLUSION

The 6MST was a feasible measure of functional capacity in chronically critically ill patients early after ICU discharge. Patients had functional capacity well below predicted values.

Ninety-day outcomes in patients diagnosed with COVID-19 in São Paulo, Brazil: a cohort study

OBJECTIVE

COVID-19 has been associated with a significant burden to those who survive the acute phase. We aimed to describe the quality of life and symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) at 90 days after hospital discharge of COVID-19 patients.

METHODS

Patients with COVID-19 admitted to a private hospital in the city of São Paulo, Brazil, between April of 2020 and April of 2021 were interviewed by telephone at 30 and 90 days after discharge to assess the quality of life and symptoms of depression, anxiety, and PTSD.

RESULTS

A total of 2,138 patients were included. The mean age was 58.6 ± 15.8 years, and the median length of hospital stay was 9.0 (5.0-15.8) days. Between the two time points, depression increased from 3.1% to 7.2% (p < 0.001), anxiety increased from 3.2% to 6.2% (p < 0.001), and PTSD increased from 2.3% to 5.0% (p < 0.001). At least one physical symptom related to COVID-19 diagnosis persisted in 32% of patients at day 90.

CONCLUSIONS

Persistence of physical symptoms was high even at 90 days after discharge. Although the prevalence of symptoms of anxiety, depression, and PTSD was low, these symptoms persisted for three months, with a significant increase between the time points. This finding indicates the need to identify at-risk patients so that they can be given an appropriate referral at discharge.

Clinical outcomes and lung mechanics characteristics between COVID-19 and non-COVID-19-associated acute respiratory distress syndrome: a propensity score analysis of two major randomized trials

OBJECTIVE

To compare the lung mechanics and outcomes between COVID-19-associated acute respiratory distress syndrome and non-COVID-19-associated acute respiratory distress syndrome.

METHODS

We combined data from two randomized trials in acute respiratory distress syndrome, one including only COVID-19 patients and the other including only patients without COVID-19, to determine whether COVID-19-associated acute respiratory distress syndrome is associated with higher 28-day mortality than non-COVID-19 acute respiratory distress syndrome and to examine the differences in lung mechanics between these two types of acute respiratory distress syndrome.

RESULTS

A total of 299 patients with COVID-19-associated acute respiratory distress syndrome and 1,010 patients with non-COVID-19-associated acute respiratory distress syndrome were included in the main analysis. The results showed that non-COVID-19 patients used higher positive end-expiratory pressure (12.5cmH2O; SD 3.2 versus 11.7cmH2O SD 2.8; p < 0.001), were ventilated with lower tidal volumes (5.8mL/kg; SD 1.0 versus 6.5mL/kg; SD 1.2; p < 0.001) and had lower static respiratory compliance adjusted for ideal body weight (0.5mL/cmH2O/kg; SD 0.3 versus 0.6mL/cmH2O/kg; SD 0.3; p = 0.01). There was no difference between groups in 28-day mortality (52.3% versus 58.9%; p = 0.52) or mechanical ventilation duration in the first 28 days among survivors (13 [IQR 5 - 22] versus 12 [IQR 6 - 26], p = 0.46).

CONCLUSION

This analysis showed that patients with non-COVID-19-associated acute respiratory distress syndrome have different lung mechanics but similar outcomes to COVID-19-associated acute respiratory distress syndrome patients. After propensity score matching, there was no difference in lung mechanics or outcomes between groups.

Burnout syndrome in intensive care physicians in time of the COVID-19: a cross-sectional study

OBJECTIVES

To assess the prevalence of burnout syndrome among intensive care physicians working in a tertiary private hospital as well as their perceived impact of the COVID-19 pandemic on their life.

DESIGN

A cross-sectional study.

SETTING

Intensive care units dedicated to the care of COVID-19 in Hospital Sirio-Libanes, Sao Paulo, Southeastern part of Brazil.

PARTICIPANTS

Intensive care physicians.

INTERVENTIONS

Each participant received an envelope with a questionnaire composed of demographic and occupational variables, information related to their personal and professional experiences facing the COVID-19 pandemic and the Maslach Burnout Inventory questionnaire.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was to assess the prevalence of burnout syndrome among physicians working in an intensive care unit dedicated to the care of COVID-19.

RESULTS

A total of 51 from the universe of 63 (82%) intensive care physicians participated in the study. Nineteen (37.2%) met the criteria for burnout syndrome. In the three domains that characterise burnout syndrome, we found a low level of personal achievement in 96.1% of physicians interviewed, a high level of depersonalisation in 51.0% and 51.0% with a high level of emotional exhaustion. Decision-making conflicts between the intensive care unit team and other attending physicians were frequent (50% of all conflicts). A third of the participants had been diagnosed with COVID-19, 22 (43.1%) reported having a family member infected and 8 (15.7%) lost someone close to the COVID-19 pandemic. Participants felt that fear of infecting their loved ones was the aspect of their lives that changed most as compared with the prepandemic period.

CONCLUSIONS

Burnout syndrome was frequent among intensive care unit physicians treating patients with COVID-19 in a large tertiary private hospital. Future studies should expand our results to other private and public hospitals and test strategies to promote intensive care unit physicians' mental health.

Cancer-Related Characteristics Associated With Invasive Mechanical Ventilation or In-Hospital Mortality in Patients With COVID-19 Admitted to ICU: A Cohort Multicenter Study

Background

Coexistence of cancer and COVID-19 is associated with worse outcomes. However, the studies on cancer-related characteristics associated with worse COVID-19 outcomes have shown controversial results. The objective of the study was to evaluate cancer-related characteristics associated with invasive mechanical ventilation use or in-hospital mortality in patients with COVID-19 admitted to intensive care unit (ICU).

Methods

We designed a cohort multicenter study including adults with active cancer admitted to ICU due to COVID-19. Seven cancer-related characteristics (cancer status, type of cancer, metastasis occurrence, recent chemotherapy, recent immunotherapy, lung tumor, and performance status) were introduced in a multilevel logistic regression model as first-level variables and hospital was introduced as second-level variable (random effect). Confounders were identified using directed acyclic graphs.

Results

We included 274 patients. Required to undergo invasive mechanical ventilation were 176 patients (64.2%) and none of the cancer-related characteristics were associated with mechanical ventilation use. Approximately 155 patients died in hospital (56.6%) and poor performance status, measured with the Eastern Cooperative Oncology Group (ECOG) score was associated with increased in-hospital mortality, with odds ratio = 3.54 (1.60–7.88, 95% CI) for ECOG =2 and odds ratio = 3.40 (1.60–7.22, 95% CI) for ECOG = 3 to 4. Cancer status, cancer type, metastatic tumor, lung cancer, and recent chemotherapy or immunotherapy were not associated with in-hospital mortality.

Conclusions

In patients with active cancer and COVID-19 admitted to ICU, poor performance status was associated with in-hospital mortality but not with mechanical ventilation use. Cancer status, cancer type, metastatic tumor, lung cancer, and recent chemotherapy or immunotherapy were not associated with invasive mechanical ventilation use or in-hospital mortality.

Epidemiology, outcomes, and the use of intensive care unit resources of critically ill patients diagnosed with COVID-19 in Sao Paulo, Brazil: A cohort study

Background

The coronavirus disease (COVID-19) pandemic has brought significant challenges worldwide, with high mortality, increased use of hospital resources, and the collapse of healthcare systems. We aimed to describe the clinical outcomes of critically ill COVID-19 patients and assess the impact on the use of hospital resources and compare with critically ill medical patients without COVID-19.

Methods and findings

In this retrospective cohort study, we included patients diagnosed with COVID-19 admitted to a private ICU in Sao Paulo, Brazil from March to June 2020. We compared these patients with those admitted to the unit in the same period of the previous year. A total of 212 consecutive patients with a confirmed diagnosis of COVID-19 were compared with 185 medical patients from the previous year. Patients with COVID-19 were more frequently males (76% vs. 56%, p<0.001) and morbidly obese (7.5% vs. 2.2%, p = 0.027), and had lower SAPS 3 (49.65 (12.19) vs. 55.63 (11.94), p<0.001) and SOFA scores (3.78 (3.53) vs. 4.48 (3.11), p = 0.039). COVID-19 patients had a longer ICU stay (median of 7 vs. 3 days, p<0.001), longer duration of mechanical ventilation (median of 9 vs. 4 days, p = 0.003), and more frequent tracheostomies (10.8 vs. 1.1%, p<0.001). Survival rates until 28 days were not statistically different (91% vs. 85.4%, p = 0.111). After multivariable adjustment for age, gender, SAPS 3, and Charlson Comorbidity Index, COVID-19 remained not associated with survival at 28 days (HR 0.59, 95% CI 0.33–1.06, p = 0.076). Among patients who underwent invasive mechanical ventilation, the observed mortality at 28-days was 16.2% in COVID-19 patients compared to 34.6% in the previous year.

Conclusions

COVID-19 required more hospital resources, including invasive and non-invasive ventilation, had a longer duration of mechanical ventilation, and a more prolonged ICU and hospital length of stay. There was no difference in all-cause mortality at 28 and 60 days, suggesting that health systems preparedness be an important determinant of clinical outcomes.

Spirituality alleviates the burden on family members caring for patients receiving palliative care exclusively

Background

Spirituality can give meaning to life, providing support and guidance in complex situations. Despite its importance in palliative care, the role of spirituality for family caregivers of patients under exclusive palliative care has not received enough attention in the literature. We aimed to address the correlation between spirituality and the emotional burden of family members of patients under exclusive palliative care.

Methods

This transversal study was conducted in a tertiary private teaching hospital, in São Paulo, Brazil. The study comprised family members of patients receiving palliative care exclusively. Only one caregiver who cared for the patient for at least 2 months was invited to participate. Family members answered the following questionnaires: WHOQOL spirituality, religiousness and personal beliefs (SRPB), Zarit Burden Interview (ZBI) and Self-Reporting Questionnaire (SRQ-20). They were excluded if patients were residing in a Long Stay Institution. Continuous variables were expressed by median and quartiles and analyzed with the Kruskal-Wallis test with Muller-Dunn post-test adjusted by Bonferroni or with the Mann-Whitney test for two groups. We used multivariable linear regression to identify independent predictors of caregiver burden.

Results

A total of 178 family members were interviewed in a median of 8 [4–13.25] days after patient admission. Almost 40% of families presented high score of burden. Faith and Meaning in Life were the facets that scored the highest, with a median of 4.50 [4.00–5.00] for both facets. There was an inverse correlation between Zarit score and all of the WHOQOL-SRPB facets, indicating that the lower the spirituality, the greater the emotional burden. Inner peace was the strongest protective factor associated with burden.

Conclusions

Psycho-socio-spiritual interaction can improve the coping ability of family caregivers of patients under exclusive palliative care, addressing a critical gap in the provision of holistic palliative care services.

Single-Bed or Multibed Room Designs Influence ICU Staff Stress and Family Satisfaction, But Do Not Influence ICU Staff Burnout

OBJECTIVE

To compare the impact of single-bed versus multibed room intensive care units (ICU) architectural designs on the stress and burnout of ICU staff and on the stress and satisfaction of family visitors.

BACKGROUND

There are countless architectural variations among ICUs, but all involve single-bed or multibed rooms. Although it is well known that ICU design affects important patient outcomes, the effect of ICU design on family and staff has been insufficiently studied.

METHODS

Among ICU staff and family visitors, stress was evaluated with Lipp's Inventory of Stress Symptoms. ICU staff burnout was evaluated with the Maslach Burnout Inventory. Family visitor satisfaction was evaluated with Molter's Critical Care Family Needs Inventory.

RESULTS

Among 156 ICU professionals who were interviewed, similar burnout rates were observed between ICU staff who worked single-bed versus multibed rooms. However, stress reported by ICU staff within the previous 24 hr was higher among the ICU staff who worked in single-bed rooms (14.3% vs. 4.7%, p = .04). Among 176 family visitors who were interviewed, a similar level of stress was reported by family members who visited patients in single-bed or multibed rooms. However, the satisfaction of family members visiting patients in single-bed rooms was higher (96.0% vs. 84.6%, p = .02).

CONCLUSIONS

Single-bed ICU design was associated with greater satisfaction of family visitors yet with higher levels of stress for ICU staff. Meanwhile, similar burnout levels were observed for ICU staff who worked in single-bed or multibed rooms.

Mental health and quality of life outcomes in family members of patients with chronic critical illness admitted to the intensive care units of two Brazilian hospitals serving the extremes of the socioeconomic spectrum

Chronic critical illness (CCI) is a relevant clinical, social and financial health issue. The aim of this study was to compare the mental outcomes (symptoms of anxiety and depression) and quality of life outcomes of the family members of patients with CCI from different socioeconomic backgrounds who were admitted to one of the intensive care units (ICUs) in two Brazilian hospitals, one private and one public. It is a prospective study involving a public hospital that serves a low-income population and a tertiary private hospital that serves a high-income population. Family members of patients with CCI answered the Hospital Anxiety and Depression Scale (HADS) and The World Health Organization Quality of Life–WHOQOL-bref questionnaires. They responded to the European Quality of life Five Dimension three Level (EuroQol-5D-3L) and the Activities of Daily Living (ADL) questionnaires on behalf of the patients at three time points: during the ICU stay, 30 and 90 days after the patient was discharged. We used logistic regression models to evaluate the main predictors of a binary outcome regarding symptoms of anxiety and depression. We enrolled 186 patients with CCI. Many patients from public hospitals who were independent became dependent for their ADLs at 90 days (41.7% versus 14.3%, p = 0.03). At 30 days, family members from public hospital had worse impact on all domains of WHOQOL-bref compared with families from private hospital. At 90-days, the difference persists in the physical domain, worse for families from public hospital (p = 0.006). The symptoms of depression at 30-days (p = 0.008) and at 90-days (p = 0.013) were worse in the public hospital. CCIs affected quality of life and the emotional condition of family members, especially in families with fewer resources when the patients became more dependent. Family members with higher education were more likely to experience depression, while depression was associated with cohabiting with the patient in low-income families.

Would you like to be admitted to the ICU? The preferences of intensivists and general public according to different outcomes

BACKGROUND

Discussions about invasiveness of care (advanced directives) and end-of-life issues have become frequent among intensivists and patients. Nevertheless, there are considerable divergences in the attitudes between intensivists and patients toward end-of-life care in the intensive care units (ICU).

METHODS

The goal was to compare the preferences between intensivists and general public regarding ICU admission of a hypothetical patient with six different clinical outcomes. For that, intensivists and the general public (university graduate professionals outside the area of health) were invited to participate in this study. A survey was conducted with a hypothetical patient with six different clinical outcomes ranging from ICU discharge without any neurological sequelae, nor dependence for daily activities, to death. The WHOQOL-BREF was applied. Comparisons were made between the answers provided by intensivists regarding what they would choose for themselves and their patients, and the preferences of general public.

RESULTS

Between July 2013 and July 2016, 300 participants in 5 hospitals in São Paulo, Brazil were invited to participate in this study, of whom 257 (85.7%) responded the survey. Eighty-two intensivists responded what they would choose for themselves, 81 intensivists responded what they would choose for their patients, and 94 people from general public responded what they would choose for themselves. Quality of life did not differ among the groups. In all scenarios, except when the outcome was severe disability or death, intensivists were more likely to choose ICU admission for their patients than for themselves (p < .05 for all). Compared with general public, intensivists were more likely to choose ICU admission for themselves only when the best clinical scenario outcome is considered (p < .001). General public was significantly less prone to choosing ICU admission than intensivists when choosing for their patients, in three out of six scenarios (p < .001 for all).

CONCLUSIONS

Considerable divergences exist between intensivists' and patients' preferences toward end-of-life care. Advanced care planning and effective ongoing communication among intensivists, patients and relatives are essential to improve end-of-life decisions and the quality of care.

Satisfaction of family members of critically ill patients admitted to a public hospital intensive care unit and correlated factors

Objective

To analyze the satisfaction, medical situation understanding and symptoms of anxiety and depression in family members of patients admitted to the intensive care unit.

Methods

The family members of patients who were hospitalized for ≥ 72 hours were invited to participate in the study, which was performed in a public hospital. Questionnaires were answered to assess the understanding of the diagnosis, treatment and prognosis, and the support received in the intensive care unit. The family needs were also evaluated using a modified version of the Critical Care Family Needs Inventory (CCFNI). The Hospital Anxiety and Depression Scale (HADS) was used to assess the symptoms of anxiety and depression.

Results

A total of 35 family members were interviewed within the patients' first week of stay in the intensive care unit. Most patients (57.1%) were male, aged 54 ± 19 years. Sepsis was the main reason for admission to the intensive care unit (40%); the median of the Simplified Acute Physiology Score (SAPS) 3 was 68 (48 - 77), and 51.4% of the patients died in the intensive care unit. The majority of the family members were female (74.3%) and were sons or daughters of patients (54.3%), with a mean age of 43.2 ± 14 years. Overall, 77.1% of the family members were satisfied with the intensive care unit. A total of 37.1% of the family members did not understand the prognosis. Receiving clear and complete information in the intensive care unit and the doctor being accessible were factors that were significantly correlated with the overall family satisfaction. The prevalence of symptoms of anxiety (60%) and depression (54.3%) in the family members was high.

Conclusion

The emotional distress of family members is high during a patient's hospitalization in the intensive care unit, although satisfaction is also high. Clear and complete information provided by the intensivist and the support received in the intensive care unit are significantly correlated with the satisfaction of family members in a public hospital.

Sex and spouse conditions influence symptoms of anxiety, depression, and posttraumatic stress disorder in both patients admitted to intensive care units and their spouses

Objectives

To assess the effect of sex and spouse condition on symptoms of anxiety, depression and posttraumatic stress symptoms in patients and their spouses.

Methods

A prospective study conducted in a 22-bed adult mixed intensive care unit in a tertiary hospital in São Paulo, Brazil. Patients and their spouses were enrolled 2 days after intensive care unit admission. They were interviewed while in the intensive care unit using the Hospital Anxiety and Depression Scale. At 30 and 90 days after intensive care unit discharge, they completed the Impact of Event Scale and Hospital Anxiety and Depression Scale by phone.

Results

From March 2011 to March 2013, we analyzed 118 patients and their spouses. We observed that female sex was associated with higher scores than male sex was in terms of the anxiety Hospital Anxiety and Depression Scale - subscale (p = 0.032) and depression (p = 0.034). There was no association between sex and posttraumatic stress disorder symptoms. However, spouses had higher Impact of Event Scale points compared with patients (p = 0.001).

Conclusions

Female sex was associated with anxiety and depression, and spouses were more vulnerable to post-traumatic stress symptoms than the patients were. Increasing age and a later time of assessment were also associated with lower scores on the Impact of Event Scale.

Moral distress and its contribution to the development of burnout syndrome among critical care providers

Background

Burnout appears to be common among critical care providers. It is characterized by three components: emotional exhaustion, depersonalization and personal accomplishment. Moral distress is the inability of a moral agent to act according to his or her core values and perceived obligations due to internal and external constraints. We aimed to estimate the correlation between moral distress and burnout among all intensive care unit (ICU) and the step-down unit (SDU) providers (physicians, nurses, nurse technicians and respiratory therapists).

Methods

A survey was conducted from August to September 2015. For data collection, a self-administered questionnaire for each critical care provider was used including basic demographic data, the Maslach Burnout Inventory (MBI) and the Moral Distress Scale-Revised (MDS-R). Correlation analysis between MBI domains and moral distress score and regression analysis to assess independent variables associated with burnout were performed.

Results

A total of 283 out of 389 (72.7%) critical care providers agreed to participate. The same team of physicians attended both ICU and SDU, and severe burnout was identified in 18.2% of them. Considering all others critical care providers of both units, we identified that overall 23.1% (95% CI 18.0–28.8%) presented severe burnout, and it did not differ between professional categories. The mean MDS-R rate for all ICU and SDU respondents was 111.5 and 104.5, respectively, p = 0.446. Many questions from MDS-R questionnaire were significantly associated with burnout, and those respondents with high MDS-R score (>100 points) were more likely to suffer from burnout (28.9 vs 14.4%, p = 0.010). After regression analysis, moral distress was independently associated with burnout (OR 2.4, CI 1.19–4.82, p = 0.014).

Conclusions

Moral distress, resulting from therapeutic obstinacy and the provision of futile care, is an important issue among critical care providers’ team, and it was significantly associated with severe burnout.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0293-2) contains supplementary material, which is available to authorized users.

Limitation to Advanced Life Support in patients admitted to intensive care unit with integrated palliative care

Objective

To estimate the incidence of limitations to Advanced Life Support in critically ill patients admitted to an intensive care unit with integrated palliative care.

Methods

This retrospective cohort study included patients in the palliative care program of the intensive care unit of Hospital Paulistano over 18 years of age from May 1, 2011, to January 31, 2014. The limitations to Advanced Life Support that were analyzed included do-not-resuscitate orders, mechanical ventilation, dialysis and vasoactive drugs. Central tendency measures were calculated for quantitative variables. The chi-squared test was used to compare the characteristics of patients with or without limits to Advanced Life Support, and the Wilcoxon test was used to compare length of stay after Advanced Life Support. Confidence intervals reflecting p ≤ 0.05 were considered for statistical significance.

Results

A total of 3,487 patients were admitted to the intensive care unit, of whom 342 were included in the palliative care program. It was observed that after entering the palliative care program, it took a median of 2 (1 - 4) days for death to occur in the intensive care unit and 4 (2 - 11) days for hospital death to occur. Many of the limitations to Advanced Life Support (42.7%) took place on the first day of hospitalization. Cardiopulmonary resuscitation (96.8%) and ventilatory support (73.6%) were the most adopted limitations.

Conclusion

The contribution of palliative care integrated into the intensive care unit was important for the practice of orthothanasia, i.e., the non-extension of the life of a critically ill patient by artificial means.

"Burnout in Medical Oncology Fellows: a Prospective Multicenter Cohort Study in Brazilian Institutions"

Burnout syndrome is a common occurrence among oncologists. Doctors enrolled in residency programs in clinical oncology are exposed to similar risk factors; however, few data are available in this population. This study assessed the occurrence of burnout and associated factors among first-year residents at Brazilian institutions. The present prospective, multicenter, cohort study was conducted with doctors enrolled in residency programs in clinical oncology at Brazilian institutions affiliated with the public health system. The participants answered a sociodemographic questionnaire, the Maslach Burnout Inventory (MBI), Lipp's Stress Inventory, and the Beck Depression Inventory (BDI), upon admission to the program and 6 and 12 months later. Of 37 eligible residency programs in 2009, 11 (30.6 %) agreed to participate in the study. Fifty-four residents, representing 100 % of new admissions to the participating institutions, were included. Most of the participants met the criteria for severe burnout upon admission to the residency programs (emotional exhaustion in 49.0 % and depersonalization in 64.7 %). The scores on MBI domains emotional exhaustion and depersonalization increased significantly (p < 0.01) during the first year of residency, and the prevalence of burnout increased to 88 % at the end of that first year. The present study found a high prevalence of burnout among doctors enrolled in residency programs in clinical oncology at Brazilian institutions. A large fraction of the participants met the criteria for burnout syndrome upon admission to the program, which suggests that the problem began during the course of the previous residency program in internal medicine.

Intensive care unit visitation policies in Brazil: a multicenter survey

Objective

This study aimed to determine which visitation policy was the most predominant in Brazilian intensive care units and what amenities were provided to visitors.

Methods

Eight hundred invitations were sent to the e-mail addresses of intensivist physicians and nurses who were listed in the research groups of the Brazilian Association of Intensive Care Network and the Brazilian Research in Intensive Care Network. The e-mail contained a link to a 33-item questionnaire about the profile of their intensive care unit.

Results

One hundred sixty-two questionnaires from intensive care units located in all regions of the country, but predominantly in the Southeast and South (58% and 16%), were included in the study. Only 2.6% of the intensive care units reported having liberal visitation policies, while 45.1% of the intensive care units allowed 2 visitation periods and 69.1% allowed 31-60 minutes of visitation per period. In special situations, such as end-of-life cases, 98.7% of them allowed flexible visitation. About half of them (50.8%) did not offer any bedside amenities for visitors. Only 46.9% of the intensive care units had a family meeting room, and 37% did not have a waiting room.

Conclusion

Restrictive visitation policies are predominant in Brazilian intensive care units, with most of them allowing just two periods of visitation per day. There is also a lack of amenities for visitors.

[Is the ICU staff satisfied with the computerized physician order entry? A cross-sectional survey study]

OBJECTIVE

To evaluate the satisfaction of the intensive care unit staff with a computerized physician order entry and to compare the concept of the computerized physician order entry relevance among intensive care unit healthcare workers.

METHODS

We performed a cross-sectional survey to assess the satisfaction of the intensive care unit staff with the computerized physician order entry in a 30-bed medical/surgical adult intensive care unit using a self-administered questionnaire. The questions used for grading satisfaction levels were answered according to a numerical scale that ranged from 1 point (low satisfaction) to 10 points (high satisfaction).

RESULTS

The majority of the respondents (n=250) were female (66%) between the ages of 30 and 35 years of age (69%). The overall satisfaction with the computerized physician order entry scored 5.74±2.14 points. The satisfaction was lower among physicians (n=42) than among nurses, nurse technicians, respiratory therapists, clinical pharmacists and diet specialists (4.62±1.79 versus 5.97±2.14, p<0.001); satisfaction decreased with age (p<0.001). Physicians scored lower concerning the potential of the computerized physician order entry for improving patient safety (5.45±2.20 versus 8.09±2.21, p<0.001) and the ease of using the computerized physician order entry (3.83±1.88 versus 6.44±2.31, p<0.001). The characteristics independently associated with satisfaction were the system's user-friendliness, accuracy, capacity to provide clear information, and fast response time.

CONCLUSION

Six months after its implementation, healthcare workers were satisfied, albeit not entirely, with the computerized physician order entry. The overall users' satisfaction with computerized physician order entry was lower among physicians compared to other healthcare professionals. The factors associated with satisfaction included the belief that digitalization decreased the workload and contributed to the intensive care unit quality with a user-friendly and accurate system and that digitalization provided concise information within a reasonable time frame.

Emotional disorders in pairs of patients and their family members during and after ICU stay

INTRODUCTION

Patients and family members undergo different experiences of suffering from emotional disorders during ICU stay and after ICU discharge. The purpose of this study was to compare the incidence of anxiety, depression and post-traumatic stress disorder (PTSD) symptoms in pairs (patient and respective family member), during stay at an open visit ICU and at 30 and 90-days post-ICU discharge. We hypothesized that there was a positive correlation with the severity of symptoms among pairs and different patterns of suffering over time.

METHODS

A prospective study was conducted in a 22-bed adult general ICU including patients with >48 hours stay. The Hospital Anxiety and Depression Scale (HADS) was completed by the pairs (patients/respective family member). Interviews were made by phone at 30 and 90-days post-ICU discharge using the Impact of Event Scale (IES) and the HADS. Multivariate models were constructed to predict IES score at 30 days for patients and family members.

RESULTS

Four hundred and seventy one family members and 289 patients were interviewed in the ICU forming 184 pairs for analysis. Regarding HADS score, patients presented less symptoms than family members of patients who survived and who deceased at 30 and 90-days (p<0.001). However, family members of patients who deceased scored higher anxiety and depression symptoms (p = 0.048) at 90-days when compared with family members of patients who survived. Patients and family members at 30-days had a similar IES score, but it was higher in family members at 90-days (p = 0.019). For both family members and patients, age and symptoms of anxiety and depression during ICU were the major determinants for PTSD at 30-days.

CONCLUSIONS

Anxiety, depression and PTSD symptoms were higher in family members than in the patients. Furthermore, these symptoms in family members persisted at 3 months, while they decreased in patients.

Perceptions of an open visitation policy by intensive care unit workers

BACKGROUND

An intensive care unit (ICU) admission is a stressful event for the patient and the patient's family. Several studies demonstrated symptoms of anxiety, depression, and posttraumatic stress disorder in family members of patients admitted to ICU. Some studies recognize that the open visitation policy (OVP) is related to a reduction in symptoms of anxiety and depression for the patient and an improvement in family satisfaction. However, some issues have been presented as barriers for the adoption of that strategy. This study was designed to evaluate perceptions of physicians, nurses, and respiratory therapists (RTs) of an OVP and to quantify visiting times in a Brazilian private intensive care unit (ICU).

METHODS

This observational and descriptive study was performed in the medical-surgical (22 beds) and neurologic ICU (8 beds) of Sírio-Libanês Hospital (HSL), São Paulo, Brazil. All physicians, nurses, and RTs from ICU were invited to participate in the study. A questionnaire was applied to all ICU workers who accepted to participate in the study. The questionnaire consisted of 22 questions about the visiting policy. During five consecutive days, we evaluated the time that the visitors stayed in the patient room, as well as the type of visitor.

RESULTS

A total of 106 ICU workers participated in this study (42 physicians, 39 nurses, and 25 RTs). Only three of the questions exposed a negative perception of the visiting policy: 53.3% of the participants do not think that the OVP consistently increases family satisfaction with patient's care; 59.4% of ICU workers think that the OVP impairs the organization of the patient's care; 72.7% of participants believe that their work suffers more interruptions because of the OVP. The median visiting time per day was 11.5 hours.

CONCLUSIONS

According to physicians, nurses, and respiratory therapists, the greatest impact of OVP is the benefit to the patients rather than to the family or to the staff. Furthermore, they feel that they need communication training to better interact with family members who are present in the ICU 24 hours per day.

Physician, patient and family attitudes regarding information on prognosis: a Brazilian survey

BACKGROUND

Communication between physicians and patients is a fundamental aspect of cancer care, yet most physicians' perceptions are often inconsistent with the patients' stated preferences while prognostic information is the most misunderstood.

PATIENTS AND METHODS

Members of the Brazilian Society of Oncology Physicians (n=609) were identified and asked to complete a mailed questionnaire. Outpatients (n=150) and their family members (n=150), oncologists and fellows (n=55) from a public healthcare hospital and a tertiary cancer hospital in Sao Paulo were also personally invited to participate.

RESULTS

A total of 202 physicians, 150 outpatients and 150 family members were participated. The majority of patients (92%) believe they should know about their terminal stage compared with 79.2% of physicians and 74.7% of families (P=0.0003). Cancer patients were most likely to support disclosure of diagnosis and terminality (P=0.001), to consider that this disclosure was not stressful (P<0.0001) and that this knowledge would improve their quality of life (P<0.0001).

CONCLUSIONS

Cancer patients seen in these centers in Southeastern Brazil prefer to know the truth about their poor prognosis more than their physicians and families think. Further studies with larger samples of patients and physicians are necessary to show if our results are representative of all Brazilian situations.

Measuring satisfaction in family members of critically ill cancer patients in Brazil

OBJECTIVE

To assess the determinants for satisfaction of cancer patients' family members with the intensive care unit.

DESIGN

Prospective cohort study.

SETTING

A 13-bed intensive care unit in a tertiary cancer centre.

PATIENTS AND PARTICIPANTS

164 families of consecutive patients with a length of stay greater than 48 h.

INTERVENTION

None.

MEASUREMENT

A modified version of the Critical Care Family Needs Inventory was applied and compared with the families' perception of prognosis, previous information given to them, and patients' severity of disease (SAPS).

RESULTS

The median score of the questionnaire was 11 (2-14), and the cut-off for satisfaction was established at 9 (1st quartile). SAPS >41 was associated with lower satisfaction [(p<0.05, chi-square, OR 2.49 (CI 1.1-5.4)]. When those interviewed surmised a prognosis different from the final outcome [p<0.05, chi-square, OR 2.70 (1.2-6.0)], a significant association with dissatisfaction was found.

CONCLUSION

More discussion about prognosis may improve the level of satisfaction of cancer patients' family members with the intensive care unit.