Brief description of media:

This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.

Brief description of media:

This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.

Brief description of media:

• BACKGROUND Improving communication and collaboration among doctors and nurses can improve satisfaction among participants and improve patients’ satisfaction and quality of care.
• OBJECTIVE To determine the impact of a multidisciplinary intervention on communication and collaboration among doctors and nurses on an acute inpatient medical unit.
• METHODS During a 2-year period, an intervention unit was created that differed from the control unit by the addition of a nurse practitioner to each inpatient medical team, the appointment of a hospitalist medical director, and the institution of daily multidisciplinary rounds. Surveys about communication and
collaboration were administered to personnel in both units. Physicians were surveyed at the completion of each rotation on the unit; nurses, biannually.
• RESULTS Response rates for house staff (n = 111), attending physicians (n = 45), and nurses (n = 123) were 58%, 69%, and 91%, respectively. Physicians in the intervention group reported greater collaboration with nurses than did physicians in the control group (P< .001); the largest effect was among the residents. Physicians in the intervention group reported better collaboration with the nurse practitioners than with the staff nurses (P< .001). Physicians in the intervention group also reported better communication with fellow physicians than did physicians in the control group (P=.006). Nurses in both groups reported similar levels of communication (P= .59) and collaboration (P= .47) with physicians. Nurses in the intervention group reported better communication with nurse practitioners than with physicians (P<.001).
• CONCLUSIONS The multidisciplinary intervention resulted in better communication and collaboration
among the participants. (American Journal of Critical Care. 2005;14:71-77)

Brief description of media:

The study investigated a multiple-site intensive care unit telemedicine programme. This remote care programme used intensivists and physician extenders to provide supplemental monitoring and management of intensive care unit (ICU) patients for 19 hours per day from a centralised, off-site facility. Supporting software, including electronic data display, physician note- and order-writing applications, and a computer-based decision support-tool, were available both in the ICU and at the remote site. This programme was compared to usual the usual standard of care in the ICU.

Brief description of media:

Importance: Previous research suggested that soluble human recombinant thrombomodulin may reduce mortality among patients with sepsis-associated coagulopathy.
Objective: To determine the effect of human recombinant thrombomodulin vs placebo on 28-day all-cause mortality among patients with sepsis-associated coagulopathy.
Design, Setting, and Participants: The SCARLET trial was a randomized, double-blind, placebo-controlled, multinational, multicenter phase 3 study conducted in intensive care units at 159 sites in 26 countries. All adult patients admitted to one of the participating intensive care units between October 2012 and March 2018 with sepsis-associated coagulopathy and concomitant cardiovascular and/or respiratory failure, defined as an international normalized ratio greater than 1.40 without other known etiology and a platelet count in the range of 30 to 150 × 109/L or a greater than 30% decrease in platelet count within 24 hours, were considered for inclusion. The final date of follow-up was February 28, 2019. Interventions: Patients with sepsis-associated coagulopathy were randomized and treated with an intravenous bolus or a 15-minute infusion of thrombomodulin (0.06 mg/kg/d [maximum, 6 mg/d]; n = 395) or matching placebo (n = 405) once daily for 6 days. Main Outcome and Measures: The primary end point was 28-day all-cause mortality.
Results: Among 816 randomized patients, 800 (mean age, 60.7 years; 437 [54.6%] men) completed the study and were included in the full analysis set. In these patients, the 28-day all-cause mortality rate was not statistically significantly different between the thrombomodulin group and the placebo group (106 of 395 patients [26.8%] vs 119 of 405 patients [29.4%], respectively; P =.32). The absolute risk difference was 2.55% (95% CI, -3.68% to 8.77%). The incidence of serious major bleeding adverse events (defined as any intracranial hemorrhage; life-threatening bleeding; or bleeding event classified as serious by the investigator, with administration of at least 1440 mL [typically 6 units] of packed red blood cells over 2 consecutive days) was 23 of 396 patients (5.8%) in the thrombomodulin group and 16 of 404 (4.0%) in the placebo group.
Conclusions and Relevance: Among patients with sepsis-associated coagulopathy, administration of a human recombinant thrombomodulin, compared with placebo, did not significantly reduce 28-day all-cause mortality.

Brief description of media:

An educational programme directed toward respiratory care practitioners and intensive care unit (ICU) nurses was considered. The programme consisted of a 10 page self study module on risk factors and practice modifications involved in ventilator associated pneumonia (VAP, inservices at staff meetings, and formal didactic lectures. Each participant was required to take a pre-intervention test before the study module and an identical post-intervention test following completion of the study module. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICUs and the Department of Respiratory Care Services.

Brief description of media:

Each year, millions of patients throughout the world survive a hospitalization that included a stay in an intensive care unit (ICU). ICU survivors can experience a variety of physical, cognitive, and emotional sequelae. In particular, mental health disorders associated with an ICU stay include anxiety, depression symptoms, post traumatic stress disorder (PTSD) symptoms, and complicated grief for families.

It is possible that impaired recall of the ICU stay, potentially accompanied by hallucinations or delusions, contributes to the post traumatic stress. Thus, use of an ICU diary given to the patient at discharge to consult at will could offer benefit. By providing objective information to patients, which could help fill in memory gaps, ICU diaries have allowed them to abandon unrealistic experiences, reconstruct their experience, gain a sense of reality, and resolve differences in experience with their families. However, studies exploring the usefulness of ICU diaries in preventing psychological post–intensive care syndrome were often conducted with small numbers of patients or select samples or with various design characteristics, outcome measures, and length of follow-up that compromised comparision.
This multicenter study was designed to assess the effect of an ICU diary on the occurrence of mental health consequences in patients and their families in the ICU setting.

Brief description of media:

IMPORTANCE Dexamethasone initiated after the first week of life reduces the rate of death or bronchopulmonary dysplasia (BPD) but may cause long-term adverse effects in very preterm infants. Hydrocortisone is increasingly used as an alternative, but evidence supporting its efficacy and safety is lacking.
OBJECTIVE To assess the effect of hydrocortisone initiated between 7 and 14 days after birth on death or BPD in very preterm infants.
DESIGN, SETTING, AND PARTICIPANTS Double-blind, placebo-controlled randomized trial conducted in 19 neonatal intensive care units in the Netherlands and Belgium from November 15, 2011, to December 23, 2016, among preterm infants with a gestational age of less than 30 weeks and/or birth weight of less than 1250 g who were ventilator dependent between 7 and 14 days of life, with follow-up to hospital discharge ending December 12, 2017.
INTERVENTIONS Infants were randomly assigned to receive a 22-day course of systemic hydrocortisone (cumulative dose, 72.5 mg/kg) (n = 182) or placebo (n = 190). MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or BPD assessed at 36 weeks’ postmenstrual age. Twenty-nine secondary outcomes were analyzed up to hospital discharge, including death and BPD at 36 weeks’ postmenstrual age.
RESULTS Among 372 patients randomized (mean gestational age, 26 weeks; 55% male), 371 completed the trial; parents withdrew consent for 1 child treated with hydrocortisone. Death or BPD occurred in 128 of 181 infants (70.7%) randomized to hydrocortisone and in 140 of 190 infants (73.7%) randomized to placebo (adjusted risk difference, −3.6% [95% CI, −12.7% to 5.4%]; adjusted odds ratio, 0.87 [95% CI, 0.54-1.38]; P = .54). Of 29 secondary outcomes, 8 showed significant differences, including death at 36 weeks’ postmenstrual age (15.5% with hydrocortisone vs 23.7% with placebo; risk difference, −8.2% [95% CI, −16.2% to −0.1%]; odds ratio, 0.59 [95% CI, 0.35-0.995]; P = .048). Twenty-one outcomes showed nonsignificant differences, including BPD (55.2% with hydrocortisone vs 50.0% with placebo; risk difference, 5.2% [95% CI, −4.9% to 15.2%]; odds ratio, 1.24 [95% CI, 0.82-1.86]; P = .31). Hyperglycemia requiring insulin therapy was the only adverse effect reported more often in the hydrocortisone group (18.2%) than in the placebo group (7.9%).
CONCLUSIONS AND RELEVANCE Among mechanically ventilated very preterm infants, administration of hydrocortisone between 7 and 14 days after birth, compared with placebo, did not improve the composite outcome of death or BPD at 36 weeks’ postmenstrual age. These findings do not support the use of hydrocortisone for this indication.

Brief description of media:

Background
Critical illness leading to prolonged length of stay (LOS) in an intensive care unit (ICU) is associated with significant mortality and resource utilization. This study assessed the independent effect of ICU LOS on in-hospital and long-term mortality after hospital discharge.
Methods
Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox's regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and long-term mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson's co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the χ2 statistic contribution to the total χ2 statistic.
Results
Most hospital deaths occurred within the first few days of ICU admission. Increasing LOS in ICU was not associated with an increased risk of in-hospital mortality after adjusting for other covariates, but was associated with an increased risk of long-term mortality after hospital discharge. The variability on the long-term mortality effect associated with ICU LOS (2.3%) appeared to reach a plateau after the first 10 days in ICU and was not as important as age (35.8%), co-morbidities (18.6%), diagnosis (10.9%), and APS (3.6%).
Conclusions
LOS in ICU was not an independent risk factor for in-hospital mortality, but it had a small effect on long-term mortality after hospital discharge after adjustment for other risk factors.

Brief description of media:

Background

Serum procalcitonin (PCT) evaluation has been proposed for early diagnosis and accurate staging and to guide decisions regarding patients with sepsis, severe sepsis and septic shock, with possible reduction in mortality.
Objectives

To assess the effectiveness and safety of serum PCT evaluation for reducing mortality and duration of antimicrobial therapy in adults with sepsis, severe sepsis or septic shock.
Search methods

We searched the Central Register of Controlled Trials (CENTRAL; 2015, Issue 7); MEDLINE (1950 to July 2015); Embase (Ovid SP, 1980 to July 2015); Latin American Caribbean Health Sciences Literature (LILACS via BIREME, 1982 to July 2015); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO host, 1982 to July 2015), and trial registers (ISRCTN registry, ClinicalTrials.gov and CenterWatch, to July 2015). We reran the search in October 2016. We added three studies of interest to a list of ‘Studies awaiting classification' and will incorporate these into formal review findings during the review update.
Selection criteria

We included only randomized controlled trials (RCTs) testing PCT‐guided decisions in at least one of the comparison arms for adults (≥ 18 years old) with sepsis, severe sepsis or septic shock, according to international definitions and irrespective of the setting.
Data collection and analysis

Two review authors extracted study data and assessed the methodological quality of included studies. We conducted meta‐analysis with random‐effects models for the following primary outcomes: mortality and time spent receiving antimicrobial therapy in hospital and in the intensive care unit (ICU), as well as time spent on mechanical ventilation and change in antimicrobial regimen from a broad to a narrower spectrum.
Main results

We included 10 trials with 1215 participants. Low‐quality evidence showed no significant differences in mortality at longest follow‐up (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.01; I2 = 10%; 10 trials; N = 1156), at 28 days (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; four trials; N = 316), at ICU discharge (RR 1.03, 95% CI 0.50 to 2.11; I2 = 49%; three trials; N = 506) and at hospital discharge (RR 0.98, 95% CI 0.75 to 1.27; I2 = 0%; seven trials; N = 805; moderate‐quality evidence). However, mean time receiving antimicrobial therapy in the intervention groups was ‐1.28 days (95% CI to ‐1.95 to ‐0.61; I2 = 86%; four trials; N = 313; very low‐quality evidence). No primary study has analysed the change in antimicrobial regimen from a broad to a narrower spectrum.
Authors' conclusions

Up‐to‐date evidence of very low to moderate quality, with insufficient sample power per outcome, does not clearly support the use of procalcitonin‐guided antimicrobial therapy to minimize mortality, mechanical ventilation, clinical severity, reinfection or duration of antimicrobial therapy of patients with septic conditions.

Brief description of media:

Objective: To determine the effects of dexmedetomidine versus propofol on extubation time, intensive care unit (ICU) length of stay, total hospital length of stay and in-hospital mortality rates in cardiac surgery patients.

Brief description of media:

INTRODUCTION: Neuromuscular weakness resulting in severe functional impairment is common in critical care survivors. This study aimed to evaluate effects of an early progressive rehabilitation intervention in mechanically ventilated adults at risk.METHODS: This was a parallel, two-arm, assessor-blinded, randomised controlled trial with 6-months follow-up that was conducted in a mixed ICU of an academic centre in Switzerland. Previously independent, mechanically ventilated, critically ill adults with expected critical care stay =72 hours (n = 115) were randomised to a control group receiving standard physiotherapy including early mobilisation or to an experimental group with early endurance and resistance training combined with mobilisation. Primary endpoints were functional capacity (6-Minute Walk Distance) and functional independence (Functional Independence Measure) at hospital discharge. Secondary endpoints including muscle strength were assessed at critical care discharge. Safety was monitored closely by standard monitoring and predefined adverse events.RESULTS: Physiotherapy started within 48 hours of critical care admission while 97% of participants were still ventilated and 68% on inotropes. Compared to the control group (n = 57), the experimental group (n = 58) received significantly more physiotherapy (sessions: 407 vs 377, p<0.001; time/session: 25min vs 18min, p<0.001) and had less days with sedation (p<0.001). Adverse events were rare (0.6%) and without consequences. There were no significant between-group differences in 6-Minute Walk Distance (experimental 123m (IQR 25-280) vs control 100m (IQR 0-300); p = 0.542) or functional independence (98 (IQR 66-119) vs 98 (IQR 18-115); p = 0.308). Likewise, no differences were found for the secondary outcomes, except a trend towards improved mental health in the experimental group after 6 months (84 (IQR 68-88) vs 70 (IQR 64-76); p = 0.023).CONCLUSIONS: Early endurance and resistance training in mechanically ventilated, intensive care patients does not improve functional capacity or independence at hospital discharge compared to early standard physiotherapy but may improve mental health 6-months after critical care discharge.TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00004347, registered on 10 September 2012.