Brief description of media:

Researchers in Denmark have developed a new algorithm that predicts an individual patient’s risk of mortality in the ICU. Their work, recently published in the journal Digital Health, demonstrates that the algorithm outperforms current non-computational methods of estimating mortality. Algorithms of this nature can help direct resources where they are needed most to best improve patient outcomes, and help catch problems early.

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:

Study indicated that clinical management of critically ill patients with a pulmonary artery catheter, as currently practised in the UK, neither improves hospital survival for adult, general intensive care patients nor reduces length of stay in hospital.

Brief description of media:

Profound muscle weakness during and after critical illness is termed intensive care unit–acquired weakness (ICUAW). This document aims to develop diagnostic recommendations for ICUAW.

Brief description of media:

The American Thoracic Society/American College of Chest Physicians recommendations are intended to support healthcare professionals in their decisions related to liberating critically ill adults from mechanical ventilation.

Brief description of media:

The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

Brief description of media:

AAGBI released the first ‘Independent Practice’ guideline in 2008,  intending to provide advice and guidance to consultants involved in independent practice. Working in an independent hospital provides different challenges to working within an NHS hospital, regardless of the funding for the individual patient involved. Since 2008 there has been a rapid growth in NHS-funded patients within the independent sector. The term ‘private practice’ is probably better replaced by ‘independent practice’ to more accurately reflect current activity. Now many anaesthetists find themselves delivering clinical care in independent hospitals funded from a variety of sources – NHS, private medical insurance and patient self-pay.

The change in demographics of patients undergoing treatment in independent hospitals, in combination with increased regulation, brings new challenges and opportunities to anaesthetic practice. Pre-operative assessment and optimisation, and the anaesthetist as ‘peri-operative physician’, are areas that are currently often poorly addressed and remunerated within independent hospitals.

Brief description of media:

With evidence building about the long-term effects of Covid-19, attention is beginning to turn to how the health and care service will respond and the key role that nurses, particularly in the community, will play in meeting the needs of this new patient group.

At the same time, it is becoming clear that many nurses themselves are among the “significant minority” of people who are experiencing ongoing symptoms beyond the expected two-to-three-week Covid-19 recovery window, including breathlessness, chronic fatigue, “brain fog” and anxiety.

Brief description of media:

The Post-Intensive Care Syndrome and COVID-19: Crisis after a Crisis? study says, “At least 20% of the COVID-19 patients are reported to require supportive care in the critical care units. Patients infected with COVID-19 who are admitted to critical care often need 10 days of supportive care utilizing mechanical ventilation.”

Since workers’ compensation represents only between one and two percent of the overall medical spend, insurers, employers and third-party administrators will not see a huge number of COVID-19 claims with ICU treatment. However, the seriously ill workers they do see may suffer from post-intensive care syndrome or PICS.

Brief description of media:

Asthma is a chronic respiratory condition that affects over 300 million adults and children worldwide. It is characterised by wheeze, cough, chest tightness, and shortness of breath. Symptoms typically are intermittent and may worsen over a short time, leading to an exacerbation. Asthma exacerbations can be serious, leading to hospitalisation or even death in rare cases. Exacerbations may be treated by increasing an individual's usual medication and providing additional medication, such as oral steroids. Although antibiotics are sometimes included in the treatment regimen, bacterial infections are thought to be responsible for only a minority of exacerbations, and current guidance states that antibiotics should be reserved for cases in which clear signs, symptoms, or laboratory test results are suggestive of bacterial infection.

Brief description of media:

Background

Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However, the value of antibiotics remains uncertain, as systematic reviews and clinical trials have shown conflicting results.
Objectives

To assess effects of antibiotics on treatment failure as observed between seven days and one month after treatment initiation (primary outcome) for management of acute COPD exacerbations, as well as their effects on other patient‐important outcomes (mortality, adverse events, length of hospital stay, time to next exacerbation).
Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, MEDLINE, Embase, and other electronically available databases up to 26 September 2018.
Selection criteria

We sought to find randomised controlled trials (RCTs) including people with acute COPD exacerbations comparing antibiotic therapy and placebo and providing follow‐up of at least seven days.
Data collection and analysis

Two review authors independently screened references and extracted data from trial reports. We kept the three groups of outpatients, inpatients, and patients admitted to the intensive care unit (ICU) separate for benefit outcomes and mortality because we considered them to be clinically too different to be summarised as a single group. We considered outpatients to have a mild to moderate exacerbation, inpatients to have a severe exacerbation, and ICU patients to have a very severe exacerbation. When authors of primary studies did not report outcomes or study details, we contacted them to request missing data. We calculated pooled risk ratios (RRs) for treatment failure, Peto odds ratios (ORs) for rare events (mortality and adverse events), and mean differences (MDs) for continuous outcomes using random‐effects models. We used GRADE to assess the quality of the evidence. The primary outcome was treatment failure as observed between seven days and one month after treatment initiation.
Main results

We included 19 trials with 2663 participants (11 with outpatients, seven with inpatients, and one with ICU patients).

For outpatients (with mild to moderate exacerbations), evidence of low quality suggests that currently available antibiotics statistically significantly reduced the risk for treatment failure between seven days and one month after treatment initiation (RR 0.72, 95% confidence interval (CI) 0.56 to 0.94; I² = 31%; in absolute terms, reduction in treatment failures from 295 to 212 per 1000 treated participants, 95% CI 165 to 277). Studies providing older antibiotics not in use anymore yielded an RR of 0.69 (95% CI 0.53 to 0.90; I² = 31%). Evidence of low quality from one trial in outpatients suggested no effects of antibiotics on mortality (Peto OR 1.27, 95% CI 0.49 to 3.30). One trial reported no effects of antibiotics on re‐exacerbations between two and six weeks after treatment initiation. Only one trial (N = 35) reported health‐related quality of life but did not show a statistically significant difference between treatment and control groups.

Evidence of moderate quality does not show that currently used antibiotics statistically significantly reduced the risk of treatment failure among inpatients with severe exacerbations (i.e. for inpatients excluding ICU patients) (RR 0.65, 95% CI 0.38 to 1.12; I² = 50%), but trial results remain uncertain. In turn, the effect was statistically significant when trials included older antibiotics no longer in clinical use (RR 0.76, 95% CI 0.58 to 1.00; I² = 39%). Evidence of moderate quality from two trials including inpatients shows no beneficial effects of antibiotics on mortality (Peto OR 2.48, 95% CI 0.94 to 6.55). Length of hospital stay (in days) was similar in antibiotic and placebo groups.

The only trial with 93 patients admitted to the ICU showed a large and statistically significant effect on treatment failure (RR 0.19, 95% CI 0.08 to 0.45; moderate‐quality evidence; in absolute terms, reduction in treatment failures from 565 to 107 per 1000 treated participants, 95% CI 45 to 254). Results of this trial show a statistically significant effect on mortality (Peto OR 0.21, 95% CI 0.06 to 0.72; moderate‐quality evidence) and on length of hospital stay (MD ‐9.60 days, 95% CI ‐12.84 to ‐6.36; low‐quality evidence).

Evidence of moderate quality gathered from trials conducted in all settings shows no statistically significant effect on overall incidence of adverse events (Peto OR 1.20, 95% CI 0.89 to 1.63; moderate‐quality evidence) nor on diarrhoea (Peto OR 1.68, 95% CI 0.92 to 3.07; moderate‐quality evidence).
Authors' conclusions

Researchers have found that antibiotics have some effect on inpatients and outpatients, but these effects are small, and they are inconsistent for some outcomes (treatment failure) and absent for other outcomes (mortality, length of hospital stay). Analyses show a strong beneficial effect of antibiotics among ICU patients. Few data are available on the effects of antibiotics on health‐related quality of life or on other patient‐reported symptoms, and data show no statistically significant increase in the risk of adverse events with antibiotics compared to placebo. These inconsistent effects call for research into clinical signs and biomarkers that can help identify patients who would benefit from antibiotics, while sparing antibiotics for patients who are unlikely to experience benefit and for whom downsides of antibiotics (side effects, costs, and multi‐resistance) should be avoided.

Brief description of media:

Survivors of intensive care are known to be at increased risk of developing longer-term psychopathology issues. We present a large UK multi centre study assessing the anxiety, depression and post-traumatic stress disorder (PTSD) caseness in the first year following discharge from an intensive care unit (ICU).