Objectives To determine the relationship between preadmission glycemia, reflected by hemoglobin A1c level, glucose metrics, and mortality in critically ill patients. Design Retrospective cohort investigation. Setting University affiliated adult medical-surgical ICU. Patients The investigation included 5,567 critically ill patients with four or more blood glucose tests and hemoglobin A1c level admitted between October 11, 2011 and November 30, 2019. The target blood glucose level was 90-120 mg/dL for patients admitted before September 14, 2014 (n = 1,614) and 80-140 mg/dL or 110-160 mg/dL for patients with hemoglobin A1c less than 7% or greater than or equal to 7% (n = 3,953), respectively, subsequently. Interventions None. Measurements and main results Patients were stratified by hemoglobin A1c: less than 6.5.(n = 4,406), 6.5-7.9% (n = 711), and greater than or equal to 8.0% (n = 450). Increasing hemoglobin A1c levels were associated with significant increases in mean glycemia, glucose variability, as measured by coefficient of variation, and hypoglycemia (p for trend Conclusions Preadmission glycemia, reflected by hemoglobin A1c obtained at the onset of ICU admission, has a significant effect on the relationship of ICU glycemia to mortality. The different responses to increasing mean glycemia support a personalized approach to glucose control practices in the ICU.

The Interaction of Acute and Chronic Glycemia on the Relationship of Hyperglycemia, Hypoglycemia, and Glucose Variability to Mortality in the Critically Ill.

Background The Vancouver Island Health Authority (VIHA) implemented a standard advance care planning (ACP) document called the medical order for scope of treatment (MOST) in February 2016 to improve end of life communication and documentation. This study aims to see if the MOST implementation improves inpatient ACP documentation when compared with the ‘do not resuscitate’ (DNR) order. Improvement is measured by: (1) proportion of inpatients with documented orders for life-sustaining treatment, (2) discordance between patient’s expressed wishes and chart documentation, (3) patient satisfaction and (4) days admitted to an acute care hospital within 90 days of study inclusion. Methods We performed a single-centre quality improvement study tracking the effects of MOST implementation. 329 consecutive patients were enrolled at a 215-bed community hospital located in Comox, British Columbia, Canada. Results The MOST integrated well into the process of care, significantly improving ACP documentation from 33% preimplementation to 100% over 8 months of implementation. MOST completion was associated with a significant decrease in discordance between patients’ wishes and documented goals of care. Patients with a MOST were significantly older and had a higher charlson comorbidity score than those without a MOST. Despite this, there was no difference in the number of days study patients were admitted to hospital within 90 days of study inclusion. Conclusions MOST implementation improves the frequency and quality of inpatient ACP documentation with no effect on acute care utilisation.

https://bmjopenquality.bmj.com/content/bmjqir/8/2/e000396.full.pdf

Improving hospital-based communication and decision-making about scope of treatment using a standard documentation tool.

There is a complex bidirectional relationship between critical illness and disordered glucose metabolism. This review aims to provide a comprehensive summary of the recent evidence focused on the relationship between critical illness and disordered glucose metabolism through the distinct phases of prior to, during, and after an acute illness that requires admission to the intensive care unit (ICU).Recent data suggest that preexisting glucose metabolism affects the optimal blood glucose target during critical illness, with preliminary data suggesting that glucose targets should be 'personalized' based on preexisting glycemia. Because of the close association between critical illness and disordered glucose metabolism, there is a need to optimize glucose monitoring in the ICU with rapid, precise, and cost-efficient measurements at the bedside. Recent studies have evaluated the use of various methodologies, with a focus on the use of near-continuous glucose monitoring. For those patients with preexisting diabetes who survive ICU, nocturnal hypoglycemia may be an unrecognized and important issue when discharged to the ward. There is increasing evidence that patients with high blood glucose during their acute illness, so called 'stress hyperglycemia', are at increased risk of developing diabetes in the years following recovery from the inciting event. Critically ill patients with COVID-19 appear at greater risk.There have been important recent insights in the approach to glucose monitoring and glucose targets during critical illness, monitoring and administration of glucose-lowering drugs on discharge from the ICU, and longitudinal follow-up of patients with stress hyperglycemia. 

Update on glucose control during and after critical illness

Although tracheostomies are often performed in critical patients with prolonged or presumed prolonged mechanical ventilation, the recommendation, benefits and risks of the procedure remain controversial. Informed consent is widely established as a necessary process in surgical procedures and should be obtained prior to the performing of a tracheostomy. The present article provides a narrative review of the process of the medical recommendation of this procedure and, through the use of the tracheostomy in the critical patient, addresses the application of the informed consent term. Theoretical aspects are discussed, such as what should be included in written documents and what should be verbally explained to patients and their families, together with other practical aspects. It was found that the current terms of consent for tracheostomies in critical patients do not prioritize autonomy, as they avoid the allocation of the resources necessary for the recommendation of the procedure.

https://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/download/1524/1734

Traqueostomia no doente crítico na era do consentimento livre e esclarecido





Background. Patient satisfaction is an essential concept to consider for the improvement of quality care in healthcare centres and hospitals and has been linked to increased patient compliance with treatment plans, better patient safety and improved clinical outcomes.
Objective. As part of a before-and-after clinical trial aimed to investigate the implementation of an evidence-based and -validated physiotherapy protocol within a surgical intensive care unit (ICU), we decided to include the patient perception of physiotherapy received in the intervention unit.
Method. A nested, exploratory, descriptive, qualitative study design was adopted. Purposively selected adult patients discharged from ICU during the implementation phase of the trial were interviewed.
Results. Eighteen patients (10 male) with a median age of 44 years and median ICU length of stay (LOS) of six days were included. Three themes and nine categories emerged: (i) linking therapy to clinical outcome (patient expectations and understanding; physiotherapy activities and the implication of mobilisation; physiotherapy benefits and progression); (ii) the importance of developing a trusting relationship (physiotherapy value; safety; continuity of care); and (iii) communication (satisfaction; interactions and patient perception and experience of physiotherapy).
Conclusion. While confirming barriers to early mobility, patients perceived participation in mobility activities as a marked jolt in their journey to recovery following a critical incident. Effective communication and preservation of trust between physiotherapist and patient are essential for understanding expectations and can facilitate improved outcomes. Clinicians can use the information when managing critically ill patients. Including patient-reported outcomes to measure physiotherapy interventions used in the ICU is feasible and can inform the development of such outcomes.




 
 

Patient perceptions of ICU physiotherapy: ‘Your body needs to go somewhere to be recharged ... ’

Objective To describe the awareness of intensive care unit patients and their next of kin (NoK) about invasive procedures and their expectations of informed consent for procedures in the ICU. Design and setting A written survey of patients and their NoK in a tertiary, university-affiliated ICU, using multiplechoice questions, Likert scales and comments to generate semiquantitative and qualitative data. Participants Fifty-one ICU patients and 69 NoK completed the survey. Inclusion criteria were unplanned ICU admission, ICU length-of-stay > 24 hours, English speaking and competent to consent to participate. Main outcome measures Proportion of procedures respondents were aware had occurred during ICU admission; satisfaction with information received; preferred method of receiving information and giving consent; and expectations of when procedural consent is required. Results Patients and NoK were unaware of many procedures performed during their admission. Respondents correctly identified 49% (95% CI, 45%-53%) of procedures performed during the patient's ICU admission. Despite this, most patients (80%; 95% CI, 69%-91%) and NoK (94%; 95% CI, 89%-100%) were satisfied with information provided about procedures. Over half of respondents (55%; 95% CI, 46%-64%) only expected consent for procedures that were "risky or not routine". About one-quarter (27%; 95% CI, 23%-31%) expected to give consent before every procedure and 15% (95% CI, 11%-18%) expected no procedural consent process. Patients and NoK strongly preferred a verbal rather than written consent process. Conclusions Our results suggest there is a limited degree of support for routine procedural consent from ICU patients and their NoK.

Informed consent in the intensive care unit: the experiences and expectations of patients and their families.

BACKGROUND

Critically ill patients with diabetes mellitus (DM) are at increased risk of in-hospital complications and the optimal glycemic target for such patients remains unclear. A more liberal approach to glucose control has recently been suggested for patients with DM, but uncertainty remains regarding its impact on complications.

METHODS

We aimed to test the hypothesis that complications would be more common with a liberal glycemic target in ICU patients with DM. Thus, we compared hospital-acquired complications in the first 400 critically ill patients with DM included in a sequential before-and-after trial of liberal (glucose target: 10-14 mmol/L) vs conventional (glucose target: 6-10 mmol/L) glucose control.

RESULTS

Of the 400 patients studied, 165 (82.5%) patients in the liberal and 177 (88.5%) in the conventional-control group were coded for at least one hospital-acquired complication (P = 0.09). When comparing clinically relevant complications diagnosed between ICU admission and hospital discharge, we found no difference in the odds for infectious (adjusted odds ratio [aOR] for liberal-control: 1.15 [95% CI: 0.68-1.96], P = 0.60), cardiovascular (aOR 1.40 [95% CI: 0.63-3.12], P = 0.41) or neurological complications (aOR: 1.07 [95% CI: 0.61-1.86], P = 0.81), acute kidney injury (aOR 0.83 [95% CI: 0.43-1.58], P = 0.56) or hospital mortality (aOR: 1.09 [95% CI: 0.59-2.02], P = 0.77) between the liberal and the conventional-control group.

CONCLUSION

In this prospective before-and-after study, liberal glucose control was not associated with an increased risk of hospital-acquired infectious, cardiovascular, renal or neurological complications in critically ill patients with diabetes.

/pdf/hospital-acquired-complications-in-intensive-care-unit-36bg78fpj1.pdf

Hospital-acquired complications in intensive care unit patients with diabetes: A before-and-after study of a conventional versus liberal glucose control protocol

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Informed consent in the intensive care unit: the experiences and expectations of patients and their families.

Hospital-acquired complications in intensive care unit patients with diabetes: A before-and-after study of a conventional versus liberal glucose control protocol