Abstract
Background
Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of ...restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals.
Methods
We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate.
Results
Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (
n
= 31, 20%) and mental health outcomes (
n
= 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (
n
= 107, 69%), connection and communication (
n
= 107, 69%), and awareness of state of well-being (
n
= 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (
n
= 61, 70%), patients (
n
= 51, 59%), and healthcare professionals (
n
= 40, 46%).
Conclusions
Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals.
Trial registration
: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.
To describe international variation in ethics and contract processes, identify predictors of approval times, and reasons for nonparticipation in an international observational study of ventilation ...discontinuation practices.
A nested cross-sectional survey of research personnel at 111 participating sites (representing 142 intensive care units ICUs) from six geographic regions (Canada, India, the United Kingdom, Europe, Australia/New Zealand, and the United States).
We analyzed responses from 80 sites (72.1% response rate). A single local or central approval was required at 34/80 (42.5%) and 23/80 (28.75%), respectively. Of those requiring central ethics approval, 20/23 (87.0%) sites required an additional approval. Sites with central vs. other ethics approval processes had significantly longer times to ethics approval (176 vs. 42 days; P < 0.0001). The median time to contract execution was 140 days (range: 11-1,215) with sites in India and the United States having the shortest and longest times to contract execution, respectively. We did not identify independent predictors of approval times. Of 190 sites that initially agreed to participate, 78 (41%) sites (89 ICUs) were ultimately unable to participate.
International ethics and contract approval times were lengthy and highly variable. Central ethics review processes significantly increased approval times.
There is a large gender gap in critical care medicine with women underrepresented, particularly in positions of leadership. Yet gender diversity better reflects the current critical care community ...and has multiple beneficial effects at individual and societal levels. In this Viewpoint, we discuss some of the reasons for the persistent gender imbalance in critical care medicine, and suggest some possible strategies to help achieve greater equity and inclusion. An explicit and consistent focus on eliminating gender inequity is needed until gender diversity and inclusion become the norms in critical care medicine.
Clinicians use several measures to ascertain whether individual patients will tolerate liberation from mechanical ventilation, including the rapid shallow breathing index (RSBI).
Given varied use of ...different thresholds, patient populations, and measurement characteristics, how well does RSBI predict successful extubation?
We searched six databases from inception through September 2019 and selected studies reporting the accuracy of RSBI in the prediction of successful extubation. We extracted study data and assessed quality independently and in duplicate.
We included 48 studies involving RSBI measurements of 10,946 patients. Pooled sensitivity for RSBI of < 105 in predicting extubation success was moderate (0.83 95% CI, 0.78-0.87, moderate certainty), whereas specificity was poor (0.58 95% CI, 0.49-0.66, moderate certainty) with diagnostic ORs (DORs) of 5.91 (95% CI, 4.09-8.52). RSBI thresholds of < 80 or 80 to 105 yielded similar sensitivity, specificity, and DOR. These findings were consistent across multiple subgroup analyses reflecting different patient characteristics and operational differences in RSBI measurement.
As a stand-alone test, the RSBI has moderate sensitivity and poor specificity for predicting extubation success. Future research should evaluate its role as a permissive criterion to undergo a spontaneous breathing trial (SBT) for patients who are at intermediate pretest probability of passing an SBT.
PROSPERO; No.: CRD42020149196; URL: www.crd.york.ac.uk/prospero/.
High-flow nasal cannula (HFNC) can be used as an initial support strategy for patients with acute respiratory failure (ARF) and after extubation. However, no clear evidence exists to support or ...oppose HFNC use in clinical practice. We summarized the effects of HFNC, compared to conventional oxygen therapy (COT) and noninvasive ventilation (NIV), on important outcomes including treatment failure and intubation/reintubation rates in adult patients with ARF and after extubation.
We searched 4 electronic databases (Pubmed, EMBASE, Scopus, and Web of Science) to identify randomized controlled trials (RCTs) comparing the effects of HFNC with either COT or NIV on rates of 1) treatment failure and 2) intubation/reintubation in adult critically ill patients.
We identified 18 RCTs (n = 4251 patients) in pooled analyses. As a primary mode of support, HFNC treatment reduced the risk of treatment failure Odds Ratio (OR) 0.65; 95% confidence interval (CI) 0.43-0.98; p = 0.04; I
= 32% but had no effect on preventing intubation (OR, 0.74; 95%CI 0.45-1.21; p = 0.23; I
= 0%) compared to COT. When used after extubation, HFNC (vs. COT) treatment significantly decreased reintubation rate (OR 0.46; 95%CI 0.33-0.63; p < 0.00001; I
= 30%) and extubation failure (OR 0.43; 95%CI 0.25-0.73; p = 0.002; I
= 66%). Compared to NIV, HFNC significantly reduced intubation rate (OR 0.57; 95%CI 0.36-0.92; p = 0.02; I
= 0%) when used as initial support, but did no favorably impact clinical outcomes post extubation in few trials.
HFNC was superior to COT in reducing treatment failure when used as a primary support strategy and in reducing rates of extubation failure and reintubation when used after extubation. In few trials, HFNC reduced intubation rate compared to NIV when used as initial support but demonstrated no beneficial effects after extubation.
The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in ...patients with acute kidney injury (AKI).
MEDLINE, EMBASE and CENTRAL databases and conference abstracts were searched to June 2012 for parallel-group or crossover randomized and quasi-randomized controlled trials (RCTs) evaluating hemofiltration vs. hemodialysis in patients with AKI. Two authors independently selected studies and abstracted data on study quality and outcomes. Additional information was obtained from trial authors. We pooled data using random-effects models.
Of 6,657 citations, 19 RCTs (10 parallel-group and 9 crossover) met inclusion criteria. Sixteen trials used continuous RRT. Study quality was variable. The primary analysis included three parallel-group trials comparing similar doses of hemofiltration and hemodialysis; sensitivity analyses included trials comparing combined hemofiltration-hemodialysis or dissimilar doses. We found no effect of hemofiltration on mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.25, P = 0.76; three trials, n = 121 (primary analysis); RR 1.10, 95% CI 0.88 to 1.38, P = 0.38; eight trials, n = 540 (sensitivity analysis)) or other clinical outcomes (RRT dependence in survivors, vasopressor use, organ dysfunction) compared to hemodialysis. Hemofiltration appeared to shorten time to filter failure (mean difference (MD) -7 hours, 95% CI (-19,+5), P = 0.24; two trials, n = 50 (primary analysis); MD -5 hours, 95% CI (-10, -1), P = 0.01; three trials, n = 113 (including combined hemofiltration-hemodialysis trials comparing similar doses); MD -6 hours, 95% CI (-10, -1), P = 0.02; five trials, n = 383 (sensitivity analysis)). Data primarily from crossover RCTs suggested that hemofiltration increased clearance of medium to larger molecules, including inflammatory cytokines, compared to hemodialysis, although almost no studies measured changes in serum concentrations. Meta-analyses were based on very limited data.
Data from small RCTs do not suggest beneficial clinical outcomes from hemofiltration, but confidence intervals were wide. Hemofiltration may increase clearance of medium to larger molecules. Larger trials are required to evaluate effects on clinical outcomes.
The effect of alternative spontaneous breathing trial (SBT) techniques on extubation success and other clinically important outcomes is uncertain.
We searched MEDLINE, EMBASE, CENTRAL, CINAHL, ...Evidence-Based Medicine Reviews, Ovid Health Star, proceedings of five conferences (1990-2016), and reference lists for randomized trials comparing SBT techniques in intubated adults or children. Primary outcomes were initial SBT success, extubation success, or reintubation. Two reviewers independently screened citations, assessed trial quality, and abstracted data.
We identified 31 trials (n = 3541 patients). Moderate-quality evidence showed that patients undergoing pressure support (PS) compared with T-piece SBTs (nine trials, n = 1901) were as likely to pass an initial SBT (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.89-1.11; I
= 77%) but more likely to be ultimately extubated successfully (RR 1.06, 95% CI 1.02-1.10; 11 trials, n = 1904; I
= 0%). Exclusion of one trial with inconsistent results for SBT and extubation outcomes suggested that PS (vs T-piece) SBTs also improved initial SBT success (RR 1.06, 95% CI 1.01-1.12; I
= 0%). Limited data suggest that automatic tube compensation plus continuous positive airway pressure (CPAP) vs CPAP alone or PS increase SBT but not extubation success.
Patients undergoing PS (vs T-piece) SBTs appear to be 6% (95% CI 2-10%) more likely to be extubated successfully and, if the results of an outlier trial are excluded, 6% (95% CI 1-12%) more likely to pass an SBT. Future trials should investigate patients for whom SBT and extubation outcomes are uncertain and compare techniques that maximize differences in support.
Purpose
We examined the association between surveillance for deep vein thrombosis (DVT) among medical-surgical critically ill patients by twice-weekly ultrasonography and 90-day all-cause mortality.
...Methods
This was a pre-planned sub-study of the Pneumatic Compression for Preventing Venous Thromboembolism (PREVENT) trial (Clinicaltrials.gov: NCT02040103) that compared addition of intermittent pneumatic compression (IPC) to pharmacologic prophylaxis versus pharmacologic prophylaxis alone. The surveillance group included enrolled patients in the trial, while the non-surveillance group included eligible non-enrolled patients. Using logistic regression and Cox proportional hazards models, we examined the association of surveillance with the primary outcome of 90-day mortality. Secondary outcomes were DVT and pulmonary embolism (PE).
Results
The surveillance group consisted of 1682 patients and the non-surveillance group included 383 patients. Using Cox proportional hazards model with bootstrapping, surveillance was associated with a decrease in 90-day mortality (adjusted HR 0.75; 95% CI 0.57, 0.98). Surveillance was associated with earlier diagnosis of DVT (median 4 days (IQR 2, 10) vs. 20 days (IQR 16, 22) and PE median 4 days (IQR 2.5, 5) vs. 7.5 days (IQR 6.1, 28.9). There was an increase in diagnosis of DVT (adjusted HR 5.49; 95% CI 2.92, 13.02) with no change in frequency in diagnosis of PE (adjusted HR 0.56; 95% CI 0.19, 1.91).
Conclusions
Twice-weekly surveillance ultrasonography was associated with an increase in DVT detection, reduction in diagnostic testing for non-lower limb DVT and PE, earlier diagnosis of DVT and PE, and lower 90-day mortality.
Trial registration
The PREVENT trial is registered at ClinicalTrials.gov, ID: NCT02040103. Registered on 3 November 2013; Current controlled trials, ID: ISRCTN44653506. Registered on 30 October 2013.
Objective To review the literature on the use of inhaled nitric oxide to treat acute lung injury/acute respiratory distress syndrome (ALI/ARDS) and to summarise the effects of nitric oxide, compared ...with placebo or usual care without nitric oxide, in adults and children with ALI or ARDS.Design Systematic review and meta-analysis.Data sources Medline, CINAHL, Embase, and CENTRAL (to October 2006), proceedings from four conferences, and additional information from authors of 10 trials.Review methods Two reviewers independently selected parallel group randomised controlled trials comparing nitric oxide with control and extracted data related to study methods, clinical and physiological outcomes, and adverse events.Main outcome measures Mortality, duration of ventilation, oxygenation, pulmonary arterial pressure, adverse events. Results 12 trials randomly assigning 1237 patients met inclusion criteria. Overall methodological quality was good. Using random effects models, we found no significant effect of nitric oxide on hospital mortality (risk ratio 1.10, 95% confidence interval 0.94 to 1.30), duration of ventilation, or ventilator-free days. On day one of treatment, nitric oxide increased the ratio of partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2 ratio) (13%, 4% to 23%) and decreased the oxygenation index (14%, 2% to 25%). Some evidence suggested that improvements in oxygenation persisted until day four. There was no effect on mean pulmonary arterial pressure. Patients receiving nitric oxide had an increased risk of developing renal dysfunction (1.50, 1.11 to 2.02).Conclusions Nitric oxide is associated with limited improvement in oxygenation in patients with ALI or ARDS but confers no mortality benefit and may cause harm. We do not recommend its routine use in these severely ill patients.
The use of noninvasive ventilation for patients with cardiogenic pulmonary edema and acute respiratory failure has been studied extensively. We identified 20 relevant ...RCTs.42-46,48-51,53-57,59,61,62,64-66 These trials examined the use of noninvasive posi tive-pressure ventilation plus usual therapy versus usual therapy alone,48,49,53 continuous positive airway pressure by mask plus usual therapy versus usual therapy alone,42-44,46,51,55,66 continuous positive airway pressure by mask plus usual therapy versus noninvasive positive-pressure ventilation plus usual therapy45,54,57,59,61,62 or all three of these treatments.50,56,64,65 Before publication of a recent large RCT,65 which accounted for 40% of all patients who have been studied in RCTs of continuous positive airway pressure for cardiogenic pulmonary edema and 70% of patients receiving noninvasive positive-pressure ventilation for this indication, five separate systematic reviews162-166 had consistently demonstrated a significant reduction in endotracheal intubation with both types of noninvasive ventilation. When this large trial was included in the metaanalysis, there was a trend toward reduction in endotracheal intubation with noninvasive positive- pressure ventilation (RR 0.55, 95% CI 0.29-1.03) and a significant reduction in endotracheal intubation with continuous positive airway pressure by mask (RR 0.42, 95% CI 0.28- 0.63) relative to oxygen alone. Notably, this recent large trial65 differed from most others, in that patients who met the criteria for treatment failure were allowed to cross over to one of the two forms of noninvasive ventilation rather than undergoing insertion of an endotracheal tube. Although the rate of endotracheal intubation did not differ between arms, a much higher proportion of patients in the oxygen arm crossed over to noninvasive ventilation (56/367 patients v. 5/346 from continuous positive airway pressure to noninvasive positive-pressure ventilation and 12/356 from noninvasive positive-pressure ventilation to continuous positive airway pressure). In addition, the proportion of patients who did not remain in their assigned treatment arm because of respiratory distress was significantly higher in the oxygen-only arm (8.4% v. 3.4% for noninvasive positive-pressure ventilation and 1.4% for continuous positive airway pressure; p < 0.001). Because of the potential for crossover in this trial to confound the outcomes of endo tracheal intubation and hospital mortality, we considered the outcome of "treatment failure" in developing our final guideline statement. Pooled treatment failure for all trials was sig nificantly lower for both noninvasive positivepressure ventilation (RR 0.36, 95% CI 0.25- 0.51) and continuous positive airway pressure (RR 0.23, 95% CI 0.17-0.32). Including all trials, there was a trend toward lower hospital mortality (for noninvasive positive-pressure ventilation, RR 0.84, 95% CI 0.63-1.13; for continuous positive airway pressure, RR 0.73, 95% CI 0.51-1.05). Two RCTs studied noninvasive positivepressure ventilation in patients with communityacquired pneumonia and acute hypoxemic res piratory failure but no prior history of COPD. In one trial, patients with COPD were included, and results for patients who did and did not have this condition were reported separately.38 In the subgroup of patients who did not have COPD (n = 33), the addition of noninvasive positivepressure ventilation did not reduce endotracheal intubation (6/16 v. 8/17 in control group) or hospital mortality (6/16 v. 4/17). In the other trial, which involved patients with acute hypoxemic respiratory failure but no underlying COPD, there was benefit (reduced endotracheal intubation and ICU mortality) for the subgroup of patients (n = 34) with severe communityacquired pneumonia.39 For these two small subgroups (67 patients in total) from two RCTs, the results were conflicting regarding the addition of noninvasive positive-pressure ventilation to usual therapy for patients with severe com munity-acquired pneumonia but no prior history of COPD (pooled results: RR 0.54, 95% CI 0.24-1.17 for endotracheal intubation and RR 0.70, 95% CI 0.13-3.63 for hospital mortality). We did not identify any RCTs on the use of continuous positive airway pressure for patients with severe community-acquired pneumonia and without COPD.
PDF
