Charles Sprung - Profile on Academia.edu (original) (raw)
Papers by Charles Sprung
Medizinische Klinik, Sep 28, 2022
Background: End-of-life care is common in German intensive care units (ICUs) but little is known ... more Background: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. Objectives: To study the practice of end-of-life care. Methods: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus-2 Study (2015 including consecutive ICU patients with limitation of life-sustaining therapy or who died. Results: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). Conclusions: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.
Intensive Care Medicine, Mar 7, 2010
Purpose: To provide recommendations and standard operating procedures for intensive care unit and... more Purpose: To provide recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza pandemic or mass disaster with a specific focus on essential equipment, pharmaceuticals and supplies. Methods: Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including essential equipment, pharmaceuticals and supplies. Results: Key recommendations include: (1) ensure that adequate essential medical equipment, pharmaceuticals and important supplies are available during a disaster; (2) develop a communication and coordination system between health care facilities and local/regional/state/ country governmental authorities for the provision of additional support; (3) determine the required resources, order and stockpile adequate resources, and judiciously distribute them; (4) acquire additional mechanical ventilators that are portable, provide adequate gas exchange for a range of clinical conditions, function with low-flow oxygen and without high pressure, and are safe for patients and staff; (5) provide advanced ventilatory support and rescue therapies including high levels of inspired oxygen and positive end-expiratory pressure, volume and pressure control ventilation, inhaled nitric oxide, highfrequency ventilation, prone positioning ventilation and extracorporeal membrane oxygenation; (6) triage scarce resources including equipment, pharmaceuticals and supplies based on those who are likely to benefit most or on a 'first come, first served' basis. Conclusions: Judicious planning and adoption of protocols for providing adequate equipment, pharmaceuticals and supplies are necessary to optimize outcomes during a pandemic.
Journal of Critical Care, Apr 1, 2015
Introduction: When terminal illness exists, it is common clinical practice worldwide to withhold ... more Introduction: When terminal illness exists, it is common clinical practice worldwide to withhold (WH) or withdraw (WD) life-sustaining treatments. Systematic documentation of professional opinion and perceived practice similarities and differences may allow recommendations to be developed. Materials and methods: Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress that took place in Durban (2013), with an interest in ethics, were approached to participate in an ethics round table. Key domains of health care professional end-of-life decision making were defined, explored by discussion, and then questions related to current practice and opinion developed and subsequently answered by round-table participants to establish the presence or absence of agreement. Results: Agreement was established for the desirability for early goal-of-care discussions and discussions between health care professionals to establish health care provider consensus and confirmation of the grounds for WH/WD, before holding formal WH/WD discussions with patients/surrogates. Nurse and other health care professional involvement were common in most but not all countries/regions. Principles and practical triggers for initiating discussions on WH/WD, such as multiorgan failure, predicted short-term survival, and predicted poor neurologic outcome, were identified. Conclusions: There was majority agreement for many but not all statements describing health care professional end-of-life decision making.
Critical Care, 2011
The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission... more The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Methods: Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to singlepatient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Results: Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Conclusions: Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.
Numerous lines of evidence support the premise that withholding and withdrawing life support meas... more Numerous lines of evidence support the premise that withholding and withdrawing life support measures in the intensive care unit are not the same. These include questionnaires, practical observations and an examination of national medical guidelines. It is important to distinguish between the two end of life options as their outcomes and management are significantly different. Appreciation of these differences allows the provision of accurate information, and facilitates decision making that is compassionate, caring and adherent to the needs of the patient and their family.
Critical Care, Feb 1, 2011
Intensive Care Medicine, Mar 7, 2010
To provide recommendations and standard operating procedures for intensive care unit (ICU) and ho... more To provide recommendations and standard operating procedures for intensive care unit (ICU) and hospital preparations for a mass disaster or influenza epidemic with a specific focus on surge capacity and infrastructure considerations. Methods: Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including surge capacity and infrastructure considerations. Results: Key recommendations include: (1) hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas; (2) hospitals should have appropriate beds and monitors for these expansion areas; hospitals should develop contingency plans at the facility and government (local, state, provincial, national) levels to provide additional ventilators; (3) hospitals should develop a phased staffing plan (nursing and physician) for ICUs that provides sufficient patient care supervision during contingency and crisis situations; (4) hospitals should provide expert input to the emergency management personnel at the hospital both during planning for surge capacity as well as during response; (5) hospitals should assure that adequate infrastructure support is present to support critical care activities; (6) hospitals should prioritize locations for expansion by expanding existing ICUs, using postanesthesia care units and emergency departments to capacity, then stepdown units, large procedure suites, telemetry units and finally hospital wards. Conclusions: Judicious planning and adoption of protocols for surge capacity and infrastructure considerations are necessary to optimize outcomes during a pandemic.
JAMA, Aug 13, 2003
dying patients should be treated with respect and compassionisbroadlyaccepted among health care p... more dying patients should be treated with respect and compassionisbroadlyaccepted among health care professionals, medical practices for end-of-life care differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination. 1,2 Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that may prolong dying rather than facilitate recovery. In Europe, patient-physician relationships are still somewhat paternalistic. Different cultures and countries deal in diverse ways with the ethical dilem-mas arising as a consequence of the wider availability of life-sustaining therapies. Some have not adopted the Western emphasis on patient autonomy or methods of terminating life support. In the past, patients died in intensive care units (ICUs) despite ongoing aggressive therapy. 7 Theoretical discussions 7 and attitudes of critical care Author Affiliations and the members of the Ethicus Study Group are listed at the end of this article.
Critical Care, Apr 13, 2022
Global Comparison of Communication of End-of-Life Decisions in the ICU
CHEST
Journal of the National Comprehensive Cancer Network, 2022
Background: To describe short-term outcomes and independent predictors of 28-dayx mortality in ad... more Background: To describe short-term outcomes and independent predictors of 28-dayx mortality in adult patients with hematologic malignancies and septic shock defined by the new Third International Consensus Definitions (Sepsis-3) criteria. Methods: We performed a retrospective cohort study of patients admitted to the medical ICU with septic shock from April 2016 to March 2019. Demographic and clinical features and short-term outcomes were collected. We used descriptive statistics to summarize patient characteristics, logistic regression to identify predictors of 28-day mortality, and Kaplan-Meier plots to assess survival. Results: Among the 459 hematologic patients with septic shock admitted to the ICU, 109 (23.7%) had received hematopoietic stem cell transplant. The median age was 63 years (range, 18–89 years), and 179 (39%) were women. Nonsurvivors had a higher Charlson comorbidity index (P=.007), longer length of stay before ICU admission (P=.01), and greater illness severity at d...
Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study
The Lancet Respiratory Medicine, 2021
BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences ca... more BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING None.
CHEST, 2021
for the Task Force for Mass Critical Care Writing Group * BACKGROUND: After the publication of a ... more for the Task Force for Mass Critical Care Writing Group * BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.
Intensive Care Medicine, 2020
Journal of Critical Care, 2019
Purpose: Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwid... more Purpose: Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwide. Assessing the impact of delayed admission must account for illness severity. This study examined both the relationship between triage-to-admission time and 28-day mortality and the impact of controlling for Simplified Acute Physiology Score (SAPS) II scores on that relationship. Methods: Prospective cross-sectional analysis of referrals to eleven ICUs in seven European countries between 2003 and 2005. Outcomes among patients admitted within versus after 4 hours were compared using a Chi-square test. Triage-to-admission time was also analyzed as a continuous variable; outcomes were assessed using a non-parametric Kruskal-Wallis test. Results: Among 3,175 patients analyzed, triage-to-admission time was 2.1±3.9 hours. Patients admitted within 4 hours had higher SAPS II scores (33.6 versus 30.6, Pearson correlation coefficient -0.07, p<0.0001). 28-day mortality was surprisingly higher among patients admitted earlier (29.6 vs 25.2%, OR 1.25, 95% CI 0.99-1.58, p=0.06). Even after adjusting for SAPS II scores, delayed admission was not associated with higher mortality (OR 1.08, p=0.58). Conclusions: Even after accounting for quantifiable parameters of illness severity, delayed admission did not negatively impact outcome. Triage practices likely influence outcomes. Severity scores may not fully reflect illness acuity or trajectory.
Critical care medicine, 2017
To provide clinicians with evidence-based strategies to optimize the support of the family of cri... more To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recomm...
JAMA : the journal of the American Medical Association, 2003
The expression and release of tissue factor is a major trigger for the activation of coagulation ... more The expression and release of tissue factor is a major trigger for the activation of coagulation in patients with sepsis. Tissue factor pathway inhibitor (TFPI) forms a complex with tissue factor and blood protease factors leading to inhibition of thrombin generation and fibrin formation.
Critical Care Medicine, 2008
Intensive Care Medicine, Nov 24, 2010
z ORIGINAL associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was sti... more z ORIGINAL associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p \ 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Conclusions: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections. Keywords Community acquired pneumonia Á Pandemic (H1N1)v influenza A infection Á Corticosteroid therapy Á ARDS
Critical Care Medicine, Apr 1, 2007
; for the Corticus Study Group Objective: To refine the value of baseline and adrenocorticotropin... more ; for the Corticus Study Group Objective: To refine the value of baseline and adrenocorticotropin hormone (ACTH)-stimulated cortisol levels in relation to mortality from severe sepsis or septic shock. Design: Retrospective multicenter cohort study. Setting: Twenty European intensive care units. Patients: Patients included 477 patients with severe sepsis and septic shock who had undergone an ACTH stimulation test on the day of the onset of severe sepsis. Interventions: None. Measurements and Main Results: Compared with survivors, nonsurvivors had higher baseline cortisol levels (29.5 ؎ 33.5 vs. 24.3 ؎ 16.5 g/dL, p ؍ .03) but similar peak cortisol values (37.6 ؎ 40.2 vs. 35.2 ؎ 22.9 g/dL, p ؍ .42). Thus, nonsurvivors had lower ⌬max (i.e., peak cortisol minus baseline cortisol) (6.4 ؎ 22.6 vs. 10.9 ؎ 12.9 g/dL, p ؍ .006). Patients with either baseline cortisol levels <15 g/dL or a ⌬max <9 g/dL had a likelihood ratio of dying of 1.26 (95% confidence interval, 1.11-1.44), a longer duration of shock, and a shorter survival time. Patients with a ⌬max <9 g/dL but any baseline cortisol value had a likelihood ratio of dying of 1.38 (95% confidence interval, 1.18-1.61). Conclusions: Although delta cortisol and not basal cortisol level was associated with clinical outcome, further studies are still needed to optimize the diagnosis of adrenal insufficiency in critical illness. Etomidate influenced ACTH test results and was associated with a worse outcome.
Medizinische Klinik, Sep 28, 2022
Background: End-of-life care is common in German intensive care units (ICUs) but little is known ... more Background: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. Objectives: To study the practice of end-of-life care. Methods: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus-2 Study (2015 including consecutive ICU patients with limitation of life-sustaining therapy or who died. Results: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). Conclusions: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.
Intensive Care Medicine, Mar 7, 2010
Purpose: To provide recommendations and standard operating procedures for intensive care unit and... more Purpose: To provide recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza pandemic or mass disaster with a specific focus on essential equipment, pharmaceuticals and supplies. Methods: Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including essential equipment, pharmaceuticals and supplies. Results: Key recommendations include: (1) ensure that adequate essential medical equipment, pharmaceuticals and important supplies are available during a disaster; (2) develop a communication and coordination system between health care facilities and local/regional/state/ country governmental authorities for the provision of additional support; (3) determine the required resources, order and stockpile adequate resources, and judiciously distribute them; (4) acquire additional mechanical ventilators that are portable, provide adequate gas exchange for a range of clinical conditions, function with low-flow oxygen and without high pressure, and are safe for patients and staff; (5) provide advanced ventilatory support and rescue therapies including high levels of inspired oxygen and positive end-expiratory pressure, volume and pressure control ventilation, inhaled nitric oxide, highfrequency ventilation, prone positioning ventilation and extracorporeal membrane oxygenation; (6) triage scarce resources including equipment, pharmaceuticals and supplies based on those who are likely to benefit most or on a 'first come, first served' basis. Conclusions: Judicious planning and adoption of protocols for providing adequate equipment, pharmaceuticals and supplies are necessary to optimize outcomes during a pandemic.
Journal of Critical Care, Apr 1, 2015
Introduction: When terminal illness exists, it is common clinical practice worldwide to withhold ... more Introduction: When terminal illness exists, it is common clinical practice worldwide to withhold (WH) or withdraw (WD) life-sustaining treatments. Systematic documentation of professional opinion and perceived practice similarities and differences may allow recommendations to be developed. Materials and methods: Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress that took place in Durban (2013), with an interest in ethics, were approached to participate in an ethics round table. Key domains of health care professional end-of-life decision making were defined, explored by discussion, and then questions related to current practice and opinion developed and subsequently answered by round-table participants to establish the presence or absence of agreement. Results: Agreement was established for the desirability for early goal-of-care discussions and discussions between health care professionals to establish health care provider consensus and confirmation of the grounds for WH/WD, before holding formal WH/WD discussions with patients/surrogates. Nurse and other health care professional involvement were common in most but not all countries/regions. Principles and practical triggers for initiating discussions on WH/WD, such as multiorgan failure, predicted short-term survival, and predicted poor neurologic outcome, were identified. Conclusions: There was majority agreement for many but not all statements describing health care professional end-of-life decision making.
Critical Care, 2011
The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission... more The role of ICU design and particularly single-patient rooms in decreasing bacterial transmission between ICU patients has been debated. A recent change in our ICU allowed further investigation. Methods: Pre-move ICU-A and pre-move ICU-B were open-plan units. In March 2007, ICU-A moved to singlepatient rooms (post-move ICU-A). ICU-B remained unchanged (post-move ICU-B). The same physicians cover both ICUs. Cultures of specified resistant organisms in surveillance or clinical cultures from consecutive patients staying >48 hours were compared for the different ICUs and periods to assess the effect of ICU design on acquisition of resistant organisms. Results: Data were collected for 62, 62, 44 and 39 patients from pre-move ICU-A, post-move ICU-A, pre-move ICU-B and post-move ICU-B, respectively. Fewer post-move ICU-A patients acquired resistant organisms (3/62, 5%) compared with post-move ICU-B patients (7/39, 18%; P = 0.043, P = 0.011 using survival analysis) or pre-move ICU-A patients (14/62, 23%; P = 0.004, P = 0.012 on survival analysis). Only the admission period was significant for acquisition of resistant organisms comparing pre-move ICU-A with post-move ICU-A (hazard ratio = 5.18, 95% confidence interval = 1.03 to 16.06; P = 0.025). More antibiotic-free days were recorded in post-move ICU-A (median = 3, interquartile range = 0 to 5) versus post-move ICU-B (median = 0, interquartile range = 0 to 4; P = 0.070) or pre-move ICU-A (median = 0, interquartile range = 0 to 4; P = 0.017). Adequate hand hygiene was observed on 140/242 (58%) occasions in post-move ICU-A versus 23/66 (35%) occasions in post-move ICU-B (P < 0.001). Conclusions: Improved ICU design, and particularly use of single-patient rooms, decreases acquisition of resistant bacteria and antibiotic use. This observation should be considered in future ICU design.
Numerous lines of evidence support the premise that withholding and withdrawing life support meas... more Numerous lines of evidence support the premise that withholding and withdrawing life support measures in the intensive care unit are not the same. These include questionnaires, practical observations and an examination of national medical guidelines. It is important to distinguish between the two end of life options as their outcomes and management are significantly different. Appreciation of these differences allows the provision of accurate information, and facilitates decision making that is compassionate, caring and adherent to the needs of the patient and their family.
Critical Care, Feb 1, 2011
Intensive Care Medicine, Mar 7, 2010
To provide recommendations and standard operating procedures for intensive care unit (ICU) and ho... more To provide recommendations and standard operating procedures for intensive care unit (ICU) and hospital preparations for a mass disaster or influenza epidemic with a specific focus on surge capacity and infrastructure considerations. Methods: Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including surge capacity and infrastructure considerations. Results: Key recommendations include: (1) hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas; (2) hospitals should have appropriate beds and monitors for these expansion areas; hospitals should develop contingency plans at the facility and government (local, state, provincial, national) levels to provide additional ventilators; (3) hospitals should develop a phased staffing plan (nursing and physician) for ICUs that provides sufficient patient care supervision during contingency and crisis situations; (4) hospitals should provide expert input to the emergency management personnel at the hospital both during planning for surge capacity as well as during response; (5) hospitals should assure that adequate infrastructure support is present to support critical care activities; (6) hospitals should prioritize locations for expansion by expanding existing ICUs, using postanesthesia care units and emergency departments to capacity, then stepdown units, large procedure suites, telemetry units and finally hospital wards. Conclusions: Judicious planning and adoption of protocols for surge capacity and infrastructure considerations are necessary to optimize outcomes during a pandemic.
JAMA, Aug 13, 2003
dying patients should be treated with respect and compassionisbroadlyaccepted among health care p... more dying patients should be treated with respect and compassionisbroadlyaccepted among health care professionals, medical practices for end-of-life care differ around the world. In the United States, medicine has moved from a paternalistic model to one that promotes autonomy and self-determination. 1,2 Patient expectations and preferences now help shape end-of-life practices, limiting the use of technologies that may prolong dying rather than facilitate recovery. In Europe, patient-physician relationships are still somewhat paternalistic. Different cultures and countries deal in diverse ways with the ethical dilem-mas arising as a consequence of the wider availability of life-sustaining therapies. Some have not adopted the Western emphasis on patient autonomy or methods of terminating life support. In the past, patients died in intensive care units (ICUs) despite ongoing aggressive therapy. 7 Theoretical discussions 7 and attitudes of critical care Author Affiliations and the members of the Ethicus Study Group are listed at the end of this article.
Critical Care, Apr 13, 2022
Global Comparison of Communication of End-of-Life Decisions in the ICU
CHEST
Journal of the National Comprehensive Cancer Network, 2022
Background: To describe short-term outcomes and independent predictors of 28-dayx mortality in ad... more Background: To describe short-term outcomes and independent predictors of 28-dayx mortality in adult patients with hematologic malignancies and septic shock defined by the new Third International Consensus Definitions (Sepsis-3) criteria. Methods: We performed a retrospective cohort study of patients admitted to the medical ICU with septic shock from April 2016 to March 2019. Demographic and clinical features and short-term outcomes were collected. We used descriptive statistics to summarize patient characteristics, logistic regression to identify predictors of 28-day mortality, and Kaplan-Meier plots to assess survival. Results: Among the 459 hematologic patients with septic shock admitted to the ICU, 109 (23.7%) had received hematopoietic stem cell transplant. The median age was 63 years (range, 18–89 years), and 179 (39%) were women. Nonsurvivors had a higher Charlson comorbidity index (P=.007), longer length of stay before ICU admission (P=.01), and greater illness severity at d...
Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study
The Lancet Respiratory Medicine, 2021
BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences ca... more BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING None.
CHEST, 2021
for the Task Force for Mass Critical Care Writing Group * BACKGROUND: After the publication of a ... more for the Task Force for Mass Critical Care Writing Group * BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.
Intensive Care Medicine, 2020
Journal of Critical Care, 2019
Purpose: Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwid... more Purpose: Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwide. Assessing the impact of delayed admission must account for illness severity. This study examined both the relationship between triage-to-admission time and 28-day mortality and the impact of controlling for Simplified Acute Physiology Score (SAPS) II scores on that relationship. Methods: Prospective cross-sectional analysis of referrals to eleven ICUs in seven European countries between 2003 and 2005. Outcomes among patients admitted within versus after 4 hours were compared using a Chi-square test. Triage-to-admission time was also analyzed as a continuous variable; outcomes were assessed using a non-parametric Kruskal-Wallis test. Results: Among 3,175 patients analyzed, triage-to-admission time was 2.1±3.9 hours. Patients admitted within 4 hours had higher SAPS II scores (33.6 versus 30.6, Pearson correlation coefficient -0.07, p<0.0001). 28-day mortality was surprisingly higher among patients admitted earlier (29.6 vs 25.2%, OR 1.25, 95% CI 0.99-1.58, p=0.06). Even after adjusting for SAPS II scores, delayed admission was not associated with higher mortality (OR 1.08, p=0.58). Conclusions: Even after accounting for quantifiable parameters of illness severity, delayed admission did not negatively impact outcome. Triage practices likely influence outcomes. Severity scores may not fully reflect illness acuity or trajectory.
Critical care medicine, 2017
To provide clinicians with evidence-based strategies to optimize the support of the family of cri... more To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recomm...
JAMA : the journal of the American Medical Association, 2003
The expression and release of tissue factor is a major trigger for the activation of coagulation ... more The expression and release of tissue factor is a major trigger for the activation of coagulation in patients with sepsis. Tissue factor pathway inhibitor (TFPI) forms a complex with tissue factor and blood protease factors leading to inhibition of thrombin generation and fibrin formation.
Critical Care Medicine, 2008
Intensive Care Medicine, Nov 24, 2010
z ORIGINAL associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was sti... more z ORIGINAL associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p \ 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Conclusions: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections. Keywords Community acquired pneumonia Á Pandemic (H1N1)v influenza A infection Á Corticosteroid therapy Á ARDS
Critical Care Medicine, Apr 1, 2007
; for the Corticus Study Group Objective: To refine the value of baseline and adrenocorticotropin... more ; for the Corticus Study Group Objective: To refine the value of baseline and adrenocorticotropin hormone (ACTH)-stimulated cortisol levels in relation to mortality from severe sepsis or septic shock. Design: Retrospective multicenter cohort study. Setting: Twenty European intensive care units. Patients: Patients included 477 patients with severe sepsis and septic shock who had undergone an ACTH stimulation test on the day of the onset of severe sepsis. Interventions: None. Measurements and Main Results: Compared with survivors, nonsurvivors had higher baseline cortisol levels (29.5 ؎ 33.5 vs. 24.3 ؎ 16.5 g/dL, p ؍ .03) but similar peak cortisol values (37.6 ؎ 40.2 vs. 35.2 ؎ 22.9 g/dL, p ؍ .42). Thus, nonsurvivors had lower ⌬max (i.e., peak cortisol minus baseline cortisol) (6.4 ؎ 22.6 vs. 10.9 ؎ 12.9 g/dL, p ؍ .006). Patients with either baseline cortisol levels <15 g/dL or a ⌬max <9 g/dL had a likelihood ratio of dying of 1.26 (95% confidence interval, 1.11-1.44), a longer duration of shock, and a shorter survival time. Patients with a ⌬max <9 g/dL but any baseline cortisol value had a likelihood ratio of dying of 1.38 (95% confidence interval, 1.18-1.61). Conclusions: Although delta cortisol and not basal cortisol level was associated with clinical outcome, further studies are still needed to optimize the diagnosis of adrenal insufficiency in critical illness. Etomidate influenced ACTH test results and was associated with a worse outcome.