Communicating with patients (original) (raw)
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What factors influence suboptimal ward care in the acutely ill ward patient?
Intensive and Critical Care Nursing, 2009
Care of the acutely ill ward patient; Suboptimal ward care; Adverse events; Patient outcomes; Quality of care Summary As technological developments continue to offer patients more health care choices patient acuity increases. Patients that traditionally would have been cared for in a critical care environment are increasingly located on general wards. This change impacts on the acute care sector in a number of ways. Patients who are inpatients have more complex problems and a greater number of co-morbidities and are therefore more likely to suffer physiological deterioration. Procedures requiring inpatient stays are often more complex and associated with higher rates of mortality and morbidity. As patient acuity has increased research has highlighted that the care of the acutely ill ward patient is suboptimal. Suboptimal care implies a lack of knowledge regarding the significance of clinical findings relating to dysfunction of airway, breathing and circulation.
British Journal of Anaesthesia, 2004
Units used in this book Standard International (SI) units are used throughout this book, with metric units in brackets where these differ. Below are some reference ranges for common blood results. Reference ranges vary from laboratory to laboratory. Metric units × conversion factor = SI units ix Conversion Test Metric units factor SI units Sodium 135-145 meq/litre Please find below a list of common abbreviations used throughout this book. ACTH adrenocorticotropic hormone ADH antidiuretic hormone AF atrial fibrillation ALI acute lung injury APC activated protein C ARDS acute respiratory distress syndrome ARF acute renal failure AS aortic stenosis ATLS Advanced Trauma and Life Support ATN acute tubular necrosis BE base excess BiPAP biphasic or bilevel positive airway pressure BP blood pressure BUN blood urea nitrogen CAVH continuous arteriovenous haemofiltration CBF cerebral blood flow CO cardiac output COPD chronic obstructive pulmonary disease CPAP continuous positive airway pressure CPP cerebral perfusion pressure CPR cardiopulmonary resuscitation CT computed tomography CVP central venous pressure CVVH continuous venovenous haemofiltration DIC disseminated intravascular coagulation DO 2 oxygen delivery DVT deep vein thrombosis ECF extracellular fluid xi physiological deterioration occurred within 6 hours in 66% of patients with cardiac arrest, but no action was taken. Researchers have commented that there appears to be a failure of the system to recognise and effectively intervene when patients in hospital deteriorate. There is little postgraduate training in the resuscitation of critically ill adults (that is, A, B, C, D-airway, breathing, circulation and disability), and in the UK there are too few available senior staff who have the skills to manage these patients effectively. This impacts on the quality of admissions to the Intensive Care Unit (ICU). In 1999, McGloin et al. observed that 36% ICU admissions received suboptimal care beforehand and that survival was worse in this group. In 1998 McQuillan et al. looked at 100 emergency ICU admissions. Two external assessors observed that only 20 cases were well managed beforehand. The majority (54) received suboptimal care prior to admission to ICU and there was disagreement over the remaining 26 cases. The patients were of a similar case-mix and APACHE II (acute physiological and chronic health evaluation) scores. In the suboptimal group, ICU admission was considered late in 69% cases and avoidable altogether in 41%. The main causes of suboptimal care were considered to be failure of organisation, lack of knowledge, failure to appreciate the clinical urgency, lack of supervision, and failure to seek advice. Other studies have shown that suboptimal care before admission to ICU increases mortality by around 50%. ICU mortality is doubled if the patient is admitted from a general ward rather than from theatres or the Emergency Department,
Reasons for refusal of admission to intensive care and impact on mortality
Intensive Care Medicine, 2010
Purpose: To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward. Methods: A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality. Results: Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in
Causes and consequences of disproportionate care in intensive care medicine
Current opinion in critical care, 2013
Increased use of advanced life-sustaining measures in patients with poor long-term expectations secondary to more chronic organ dysfunctions, comorbidities and/or a poor quality of life has become a worrying trend over the last decade. This can lead to futile, disproportionate or inappropriate care in the ICU. This review summarizes the causes and consequences of disproportionate care in the ICU. Disproportionate care seems to be common in European and North American ICUs. The initiation and prolongation of disproportionate care can be related to hospital facilities, healthcare providers, the patient and his/her representatives and society. This can have serious consequences for patients, their relatives, physicians, nurses and society. Disproportionate care is common in western ICUs. It can lead to violation of basic bioethical principles, suffering of patients and relatives and compassion fatigue and moral distress in healthcare providers. Avoiding inappropriate use of ICU resourc...
Intensive care provision: a global problem
Revista Brasileira de terapia intensiva, 2012
Recently, many countries have described a growing gap between the supply and the demand of intensivists and the consequent capability of the country to provide adequate intensive care. (1,2) This gap is mainly driven by the increasing population size of many nations, together with the recognition that life expectancy is increasing in tandem with the proliferation of the socalled "civilisation" diseases, such as diabetes, coronary heart disease, stroke and obesity. These aged groups of patients, who have (or will have) significant comorbid diseases, are the very population that present to intensive care medicine in North America and in most European countries; often being admitted to the hospital because of an acute illness or a complication after major elective surgery. (3) The proper use of intensive care medicine can save a significant number of these patients and may enable them to return to an active life; however, these efforts will also consume a great deal of resources for a group of patients who may not benefit. Unless this increased demand for beds is appropriately managed, there will be problems, as a skilled and trained staff will not have been identified and be available. Consequently, healthcare providers will need to either provide intensive care using untrained and unqualified staff, or they will need to change to a model of providing intensive care that uses professional groups with delegated competency from physicians working according to protocols and guidelines. Either option will permit these healthcare providers to operate with limited understanding of their work and the available treatment alternatives for any specific patient. The first step towards planning for a change (in this case, an increase in the provided services) is to understand what is currently provided. Unfortunately, this understanding is rarely present and needs to be urgently addressed. Recent studies assessing the provision of intensive care between countries and the surgical outcomes provide interesting insights into this issue. (4-6) Most of these studies have been designed to look at European populations; however, many of the salient factors present in Europe likely exist in Brazil, and the lessons derived from these studies are equally relevant. If intensive care bed numbers are restricted-either formally or informallypatient selection must occur; this practice is commonly referred to as rationing. (7) When intensive care is not available, services react in different manners, including the early or premature discharge of patients already in the service, delayed admission of presenting patients, changing thresholds for the withdrawal of care, cancellation of elective patients who are planned to be admitted after routine surgery or restriction of admission to certain patient Conflicts of interest: None.
Intensive Care Medicine, 2002
Objective: To identify objective trends of the course of illness that might be used as benchmarks in the auditing of the organization/performance of Intensive Care Units (ICU). Design: Retrospective analysis. Patients and setting: A group of 12,615 patients and 55,464 patientdays prospectively collected in 89 ICUs of 12 European countries. Methods: The complexity of daily care in the ICU was classified as high (HT) or low (LT), according to six activities registered in NEMS, a daily therapeutic index for ICUs. Results: Six trends of clinical course were identified: LT during the whole ICU stay (5,424 patients, mortality 1.8%); HT (3,480 patients, mortality 30.4%); HT followed by LT (2,781 patients, mortality 2.8%); LT followed by HT (197 patients, mortality 39.1%); finally, LT/HT/LT in 298 patients (mortality 10.5%); and HT/LT/HT (mortality 20.1%) in 438 patients. A group of 930 patients had the complexity of treatment increased (mortality 21.1%) and 3,711 patients received both treat-ments. Low-care before high-care periods had a mean duration of 2.2±3.5 days, low-care after highcare 2.7±3.1 days, and between two high-care periods 2.1±2.2 days. A group of 1,538 'surgical scheduled' patients only received LT, whereas 2,231 received HT (whether or not exclusively). Overall ICU mortality rate was low (3%) and the length of stay short, regardless of diagnosis and complexity of care received. Conclusions: The use of therapeutic indexes help to classify the daily complexity of ICU care. The classification can be used as an indicator of clinical performance and resource utilization.
Intensive Care Medicine, 2012
Purpose: To report determinants and outcomes associated with decisions to deny or to delay intensive care unit (ICU) admission in critically ill patients. Methods: An observational prospective study over a 6-month period. All adult patients triaged for admission to a medical ICU were included prospectively. Age, gender, reasons for requesting ICU admission, severity of underlying disease, severity of acute illness, mortality and ICU characteristics were recorded. Multinomial logistic regression analysis was used for evaluating predicting factors of refused ICU admission. Results: ICU admission was requested for 398 patients: 110 were immediately admitted (27.8%), 142 were never admitted (35.6%), and 146 were admitted at a later time (36.6%). The reasons for refusal were: too sick to benefit (31, 10.8%), too well to benefit (55, 19.1%), unit full (117, 40.6%), and more data about the patient were needed to make a decision 29.5%). Multivariate analysis revealed that late ICU admission was associated with the lack of available ICU beds (OR 1.91; 95% CI 1.46-2.50; p = 0.003), cardiac disease (OR 7.77; 95% CI 2.41-25.04; p \ 0.001), neurological disease (OR 3.78; 95% CI 1.40-10.26; p = 0.009), shock and sepsis (OR 2.55; 95% CI 1.06-6.13; p = 0.03), and metabolic disease (OR 2.84; 95% CI 1.11-7.30; p = 0.02). Factors for ICU refusal for never admitted patients were: severity of acute illness (OR 4.83; 95% CI 1.11-21.01; p = 0.03), cardiac disease (OR 14.26; 95% CI 3.95-51.44;
From Internal Wards to Intensive Care Units and backwards: the paths of the difficult patient
Italian Journal of Medicine, 2016
Sepsis-induced organ dysfunction may be occult; therefore, its presence should be considered in any patient presenting with infection. Conversely, unrecognized infection may be the cause of new-onset organ dysfunction. Any unexplained organ dysfunction should thus raise the possibility of underlying infection. Severe sepsis is a heterogeneous clinical entity with a wide spectrum of manifestations and severity, and over half of patients never receive care in an Intensive Care Unit (ICU). Due to ageing of the population, patients with severe sepsis are frequently admitted to general wards and, given the standard diagnostic approach, treatment must be tailored to the single patient, taking into account the burden of comorbidities. From Internal Medicine Wards the single patient could be transferred to ICU, but again admitted to our Units, due to his/her frailty, to complete the path of cure. First of all, we have to be aware of the illness and more, according to the recent literature, ...