The development of ICUs as the final option for seriously ill patients, especially the elderly frail patient at the end of his/her life, has meant that intensivists have increasingly taken on the ...role of diagnosing the dying. Our society, and even our medical colleagues, do not necessarily understand what we can achieve in ICUs, and even more importantly, what we cannot achieve. The next crucial step for us as individuals, and through our professional bodies, is to engage our society in discussions on our role and encourage debate and discussion, being aware of the controversies that will inevitably result. Birthing in the 1950s was medicalised without discussion with women and their families. In a similar manner, dying has been medicalised in the twenty-first century. It has not been a conspiracy and the use of futile and expensive treatment at the EoL transition is not necessarily anyone's choice. The specialty of intensive care has a particularly important role in facilitating discussions with our society in order to define different ways of managing dying.
Highlights • DAs at the end of life appear to increase knowledge and reduce decisional conflict. • Treatment options and patient preferences are generally covered and acceptable. • DAs fall short of ...quantified prognosis and incorporating patient goals and values. • Genuinely informed decision making cannot happen while those gaps in the instruments remain
Proposed causes for increased mortality following weekend admission (the 'weekend effect') include poorer quality of care and sicker patients. The aim of this study was to analyse the 7 days ...post-admission time patterns of excess mortality following weekend admission to identify whether distinct patterns exist for patients depending upon the relative contribution of poorer quality of care (care effect) or a case selection bias for patients presenting on weekends (patient effect).
Emergency department admissions to all 501 hospitals in New South Wales, Australia, between 2000 and 2007 were linked to the Death Registry and analysed. There were a total of 3 381 962 admissions for 539 122 patients and 64 789 deaths at 1 week after admission. We computed excess mortality risk curves for weekend over weekday admissions, adjusting for age, sex, comorbidity (Charlson index) and diagnostic group.
Weekends accounted for 27% of all admissions (917 257/3 381 962) and 28% of deaths (18 282/64 789). Sixteen of 430 diagnosis groups had a significantly increased risk of death following weekend admission. They accounted for 40% of all deaths, and demonstrated different temporal excess mortality risk patterns: early care effect (cardiac arrest); care effect washout (eg, pulmonary embolism); patient effect (eg, cancer admissions) and mixed (eg, stroke).
The excess mortality patterns of the weekend effect vary widely for different diagnostic groups. Recognising these different patterns should help identify at-risk diagnoses where quality of care can be improved in order to minimise the excess mortality associated with weekend admission.
To report procedural characteristics and outcomes from a central venous catheter placement service operated by advanced practice nurses.
Single-center observational study.
A tertiary care university ...hospital in Sydney, Australia.
Adult patients from the general wards and from critical care areas receiving a central venous catheter, peripherally inserted central catheter, high-flow dialysis catheter, or midline catheter for parenteral therapy between November 1996 and December 2009.
None.
Prevalence rates by indication, site, and catheter type were assessed. Nonparametric tests were used to calculate differences in outcomes for categorical data. Catheter infection rates were determined per 1,000 catheter days after derivation of the denominator. A total of 4,560 catheters were placed in 3,447 patients. The most common catheters inserted were single-lumen peripherally inserted central catheters (n = 1,653; 36.3%) and single-lumen central venous catheters (n = 1,233; 27.0%). A small proportion of high-flow dialysis catheters were also inserted over the reporting period (n = 150; 3.5%). Sixty-one percent of all catheters placed were for antibiotic administration. The median device dwell time (in d) differed across cannulation sites (p < 0.001). Subclavian catheter placement had the longest dwell time with a median of 16 days (interquartile range, 8-26 d). Overall catheter dwell was reported at a cumulative 63,071 catheter days. The overall catheter-related bloodstream infection rate was 0.2 per 1,000 catheter days. The prevalence rate of pneumothorax recorded was 0.4%, and accidental arterial puncture (simple puncture-with no dilation or cannulation) was 1.3% using the subclavian vein.
This report has demonstrated low complication rates for a hospital-wide service delivered by advance practice nurses. The results suggest that a centrally based service with specifically trained operators can be beneficial by potentially improving patient safety and promoting organizational efficiencies.
This study aimed to investigate the pattern of general practice services utilization for Australian children and to examine socio-demographic disparities in general practitioner (GP) visits.
We used ...the linked data from the nationally representative Longitudinal Study of Australian Children (LSAC) and the Medicare Australia claims data record. We used survey negative binomial and logistic regression to examine the socio-demographic factors associated with the utilisation of general practice services.
The average number of annual GP visits gradually declined from 7.0 at 0-1 year old to 2.4 at 5-8 years (p< .001 for trend) in the infant cohort and from 3.5 at 2-4 years to 2.0 at 9-12 years (p < .001 for trend) in the child cohort. Girls were more likely to visit GPs than boys at 0-1 year old in the infant cohort (RR = 1.06, 95%CI: 1.02-1.11) and at 2-4 years in the child cohort (RR = 1.09, 95%CI: 1.04-1.14), but there were no differences at 2-4 to 5-8 year age periods in the infant cohort and at 5-8 to 9-12 year age period in the child cohort. Children from non-English speaking background were more likely to have a greater number of GP visits compared with their counterparts from English-speaking and Indigenous background up to eight year old in both cohorts (all p < .001). Children from families with the higher socio-economic position, children without private health insurance and children living in non-metropolitan were less likely to have GP consultations in both cohorts. Fair or poor parent-rated health status was associated with greater number of GP visits.
Socio-demographic disparities existed in the utilisation of general practice services and varied at different age periods. Family socio-economic position, private health insurance coverage and region of residence strongly associates with the utilisation disparities over all age period. Further policy interventions are called to minimise the disparities in GP utilisation for children in Australian context.
To determine the impact of introducing a two-tier system for responding to deteriorating ward patients on ICU admissions after medical emergency team review.
Retrospective database review before ...(2006-2009) and after (2011-2013) the introduction of a two-tier system.
Tertiary, university-affiliated hospital.
A total of 1,564 ICU admissions.
Two-tier rapid response system.
The median number of medical emergency team activations/1,000 hospitalizations increased from 22 to 31 (difference 95% CI, 9 5-10; p<0.0001) with a decreased rate of medical emergency team activations leading to ICU admission (from median 11 to 8; difference 95% CI, 3 3-4; p=0.03). The median proportion of medical emergency team reviews leading to ICU admission increased for those triggered by tachypnoea (from 11% to 15%; difference 95% CI, 4 3-5; p<0.0001) and by hypotension (from 27% to 43%; difference 95% CI, 15 12-19; p<0.0001) and decreased for those triggered by reduced level of consciousness (from 20% to 17%; difference 95% CI, 3 2-4; p<0.0001) and by clinical concern (from 18% to 9%; difference 95% CI, 10 9-13; p<0.0001). The proportions of ICU admissions following medical emergency team review did not change significantly for tachycardia, seizure, or cardiorespiratory arrest. The overall ICU mortality for admissions following medical emergency team review for tachypnoea, tachycardia, and clinical concern decreased (from 29% to 9%: difference 95% CI, 20 11-29; p<0.0001) but did not change for the other triggers. The Acute Physiology and Chronic Health Evaluation predicted and observed ICU mortality and the proportion of patients dying with a not-for-resuscitation order decreased.
The introduction of a two-tier response to clinical deterioration increased ICU admissions triggered by cardiorespiratory criteria, whereas admissions triggered by more subjective criteria decreased. The overall ICU mortality for patients admitted following medical emergency team review decreased, suggesting that the two-tier system led to earlier recognition of reversible pathology or a decision not to escalate the level of care.
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led ...to confusion and difficulty in comparing one study to another.
An international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes.
Prior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS).
IAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient.
State-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.
PDF
