Global Challenges in Triage and Discharge Services Available to Intensive Care Patients. A Mixed-Methods Study.

Introduction Integrated care improves patients’ outcome. Integration of services to provide care for the critically ill includes appropriate triage processes and delivery of post intensive care treatment in order to promote continuity of care. It is hypothesised that low resource settings limit the possibility of admitting patients to intensive care units and the service offered after discharge. Methods This mixed methods study involved 14 intensive care doctors from Europe, Africa and Asia. 14 doctors participated in a online survey and five of them in in-depth interviews. Nine of the 14 participants who completed the questionnaires described practice in a Low-Middle-Income Country, five respondents provided details of High-Income Country practice. Descriptive statistics and thematic analysis have been used to analise data. Results The study showed that resources impact on capacity and capability of intensive care triage and post discharge services (see additional information, figure 1 and 2), but countries with different level of income share the same criteria for triage and offer similar level of care to intensive care survivors (figure 3 and 4). Bed availability, lack of end of life procedures, and shortage of trained personnel are considered the main barriers to appropriate admission processes regardless of the locations represented in the study (figure 5). Participants identified the outreach services as a valid solution for timely decision making during triage and discharge from intensive care. Also it is agreed that post discharge services need to be strengthened in order to preserve and improve the health status achieved with critical care. The study participants shared the notion that relatives play an important role in supporting continuity of care and should be educated to assist the critically ill and their multiple needs. Limitations: The generalisability of results is limited by the study sample size. Also, the processes and services described in the study are not representative of the different levels of care available in each countries. Conclusion The global burden of critical illness could be tackled providing continuity of care. This could be achieved with appropriate infrastructures and education of professionals and relatives. Therefore the health systems in all resource settings may need to restructure they services to provide integrated care in order to address the multiple needs of critical care patients.Peer reviewedFinal Published versio

Global Challenges in Continuity of Critical Care. A Mixed-Methods Study

Integrated health services are embedded in a process that provides a continuum of care and have been advocated by the World Health Organisation (WHO) as the vehicle to improve health outcomes worldwide (Regional Office for Europe of the WHO, 2016). The health loss to injuries, conditions and risk factors are quantified using an index called the global burden of disease (GBD). The three leading causes of GBD in the 1990-2016 period have been ischaemic heart disease, cerebrovascular disease, and lower respiratory infections (GBD 2016 DALYs and HALE Collaborators, 2017), all conditions that often need intensive care. The GBD and sequelae in Intensive Care Unit (ICU) survivors depends on the number of critically ill patients, the resources available to treat them and the morbidity protracted after discharge (Stevens et al., 2014). It is hypothesised that low resources limit the possibility of admitting patients to intensive care units and the services offered after ICU discharge. Objectives To identify how critically ill patients are triaged in Low-Middle-Income Country (LMIC) compared to High-Income Country (HIC) to determine whether triage practice is linked to resource settings; To evaluate which post discharge services are available to critically ill patients in LMIC compared to HIC to detect if there is a difference in service provision; To explore barriers and facilitators of continuity of critical care and identify potential opportunities for quality improvement initiatives driven by crosscountry learning. Methods 14 intensive care doctors from Europe, Africa, America and Asia participated in a online survey and five of them in in-depth interviews. The survey included three sections in order to collect data on the services’ context, the triage and the post ICU practice. The interviews were conducted to explore barriers and facilitators of ICU triage and post ICU care in different settings. Descriptive statistics and thematic analysis have been used to analyse data. Triangulation has been applied to identify convergence, complementarity or discrepancy between data collected via the two research methods. Results Nine of the 14 participants who completed the questionnaire described practice in a LMIC, while five respondents provided examples of HIC practice. Globally, there are several models of care: public, governmental funding (6 LMIC and 4 HIC study units); private funding (1 LMIC unit); fee-for-service model where family/relatives contributes (2 LMIC units); access to health insurance (1 HIC unit). According to study results, when family needs to contribute financially there may be no other choice than limit treatment during and after intensive care. Also, lack of standardised end of life procedures in LMIC make triage a challenging process. Post discharge services are limited by resources according to the majority of participants with a tendency to holistic care in the LMIC units. Staffing, bed availability, and infrastructures (equipment, logistics) have been named as potential barriers to triage and discharges from ICU in all resource settings. Outreach services have been advocated for appropriate triage and after discharge monitoring Conclusions Barriers and facilitators of triage are similar between LMIC and HIC study units despite resources available. Capacity of triage and post discharge services are limited in settings where relatives need to contribute to cost of care. Indeed, triage may be easier in the context of low resources because there may be no other choice than refusing admission. Therefore deciding which patient to admit or not should be planned as soon as possible. Outreach and post discharge services could facilitate the prevention of deterioration and therefore help to decrease the global burden of critical illness.Peer reviewedFinal Published versio

A cohort study on detecting delirium using 4 ‘A’s Test in a London, UK, hospital

© 2016 Research & Reviews. This is an Open Access article. Content in the UH Research Archive is made available for personal research, educational, and non-commercial purposes only. Unless otherwise stated, all content is protected by copyright, and in the absence of an open license, permissions for further re-use should be sought from the publisher, the author, or other copyright holder.Delirium is a common neuropsychiatric disorder in hospitalised older adults. Often unrecognized, delirium is associated with increased morbidity and mortality, length of hospital stay, institutionalisation and costs to healthcare providers. The objective of this prospective cohort study was to detect the prevalence of delirium in a London (UK) hospital testing the feasibility and reliability of the 4 A's Test (4AT). Over a seven day period 174 inpatients were assessed by non-psychiatrically trained doctors using the 4AT and three widely adopted screening tools. The 4AT helped detect 21 (10.2%) delirious patients uncovering a delirium prevalence of 8.63 per 1000 hospital days. The 4AT showed a compatibility of 75% with other tools used. Changes in consciousness are often missed, but can be easily detected introducing a screening tool as the 4AT.Peer reviewe

Evaluation of early administration of simvastatin in the prevention and treatment of delirium in critically ill patients undergoing mechanical ventilation (MoDUS): : a randomised, double-blind, placebo-controlled trial

This document is the Accepted Manuscript version of the following article: Valerie J. Page, et al, ‘Evaluation of early administration of simvastatin in the prevention and treatment of delirium in critically ill patients undergoing mechanical ventilation (MoDUS): a randomised, double-blind, placebo-controlled trial’, The Lancet Respiratory Medicine, Vol. 5 (9): 727-737, September 2017. Under embargo until 19 July 2018. The final, definitive version is available online at doi: https://doi.org/10.1016/S2213-2600(17)30234-5.Summary Background Delirium in critically ill patients is associated with poor clinical outcomes. Neuroinflammation might be an important mechanism in the pathogenesis of delirium, and since simvastatin has anti-inflammatory properties it might reduce delirium. We aimed to establish whether early treatment with simvastatin would decrease the time that survivors of critical illness spent in delirium or coma. Methods We undertook this randomised, double-blind, placebo-controlled trial in a general adult intensive care unit (ICU) in Watford General Hospital (Watford, UK). We enrolled critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission. We randomly assigned patients (1:1 ratio) to receive either simvastatin 80 mg or placebo daily for up to a maximum of 28 days, irrespective of coma or delirium status. We assessed delirium using the Confusion Assessment Method for the ICU (CAM-ICU). The primary outcome was number of days alive and was assessed as delirium-free and coma-free in the first 14 days after being randomly allocated to receive treatment or placebo. ICU clinical and research staff and patients were masked to treatment. We did intention-to-treat analyses with no extrapolation. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN89079989. Findings Between Feb 1, 2013, and July 29, 2016, 142 patients were randomly assigned to receive simvastatin (n=71) or placebo (n=71), and were included in the final analysis. The mean number of days alive without delirium and without coma at day 14 did not differ significantly between the two groups (5·7 days [SD 5·1] with simvastatin and 6·1 days [5·2] with placebo; mean difference 0·4 days, 95% CI −1·3 to 2·1; p=0·66). The most common adverse event was an elevated creatine kinase concentration to more than ten times the upper limit of normal (eight [11%] in the simvastatin group vs three [4%] in the placebo group p=0·208). No patient had a serious adverse event related to the study drug. Interpretation These results do not support the hypothesis that simvastatin modifies duration of delirium and coma in critically ill patients. Funding National Institute for Health Research.Peer reviewedFinal Accepted Versio

Evaluating early administration of the hydroxymethylglutaryl-CoA reductase inhibitor simvastatin in the prevention and treatment of delirium in critically ill ventilated patients (MoDUS trial): Study protocol for a randomized controlled trial

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Abstract Background The incidence of delirium in ventilated patients is estimated at up to 82%, and it is associated with longer intensive care and hospital stays, and long-term cognitive impairment and mortality. The pathophysiology of delirium has been linked with inflammation and neuronal apoptosis. Simvastatin has pleiotropic properties; it penetrates the brain and, as well as reducing cholesterol, reduces inflammation when used at clinically relevant doses over the short term. This is a single centre randomised, controlled trial which aims to test the hypothesis that treatment with simvastatin will modify delirium incidence and outcomes. Methods/Design The ongoing study will include 142 adults admitted to the Watford General Hospital Intensive Care Unit who require mechanical ventilation in the first 72 hours of admission. The primary outcome is the number of delirium- and coma-free days in the first 14 days. Secondary outcomes include incidence of delirium, delirium- and coma-free days in the first 28 days, days in delirium and in coma at 14 and 28 days, number of ventilator-free days at 28 days, length of critical care and hospital stay, mortality, cognitive decline and healthcare resource use. Informed consent will be taken from patient’s consultee before randomisation to receive either simvastatin (80 mg) or placebo once daily. Daily data will be recorded until day 28 after randomisation or until discharge from the ICU if sooner. Surviving patients will be followed up on at six months from discharge. Plasma and urine samples will be taken to investigate the biological effect of simvastatin on systemic markers of inflammation, as related to the number of delirium- and coma-free days, and the potential of cholinesterase activity and beta-amyloid as predictors of the risk of delirium and long-term cognitive impairment. Discussion This trial will test the efficacy of simvastatin on reducing delirium in the critically ill. If patients receiving the statin show a reduced number of days in delirium compared with the placebo group, the inflammatory theory implicated in the pathogenesis of delirium will be strengthened. Trial registration The trial was registered with the International Standard Randomised Controlled Trial Registry (ISRCTN89079989) on 26 March 2013.Peer reviewe

Complementary and Alternative Medicine and Kidney Health

Complementary and Alternative Medicine and Kidney Health provides a thorough examination on the application of alternative medicine in conventional hospital settings with a focus on kidney diseases. Including a range of academic perspectives on topics such as decision management, herbal-drug reactions, and chronic illnesses, this book is an ideal reference source for medical practitioners, professionals, students, researchers, and nurses interested in scientific evidence on the benefits of complementary and alternative medicine

An overview of complementary and alternative medicine

Complementary and Alternative Medicine and Kidney Health provides a thorough examination on the application of alternative medicine in conventional hospital settings with a focus on kidney diseases. Including a range of academic perspectives on topics such as decision management, herbal-drug reactions, and chronic illnesses, this book is an ideal reference source for medical practitioners, professionals, students, researchers, and nurses interested in scientific evidence on the benefits of complementary and alternative medicine

A Cohort Study on Detecting Delirium Using 4 'A's Test in a London, UK, Hospital

ABSTRACT Delirium is a common neuropsychiatric disorder in hospitalised older adults. Often unrecognized, delirium is associated with increased morbidity and mortality, length of hospital stay, institutionalisation and costs to healthcare providers. The objective of this prospective cohort study was to detect the prevalence of delirium in a London (UK) hospital testing the feasibility and reliability of the 4 A's Test (4AT). Over a seven day period 174 inpatients were assessed by non-psychiatrically trained doctors using the 4AT and three widely adopted screening tools. The 4AT helped detect 21 (10.2%) delirious patients uncovering a delirium prevalence of 8.63 per 1000 hospital days. The 4AT showed a compatibility of 75% with other tools used. Changes in consciousness are often missed, but can be easily detected introducing a screening tool as the 4AT

A Cohort Study on Detecting Delirium Using 4 'A's Test in a London, UK, Hospital

ABSTRACT Delirium is a common neuropsychiatric disorder in hospitalised older adults. Often unrecognized, delirium is associated with increased morbidity and mortality, length of hospital stay, institutionalisation and costs to healthcare providers. The objective of this prospective cohort study was to detect the prevalence of delirium in a London (UK) hospital testing the feasibility and reliability of the 4 A's Test (4AT). Over a seven day period 174 inpatients were assessed by non-psychiatrically trained doctors using the 4AT and three widely adopted screening tools. The 4AT helped detect 21 (10.2%) delirious patients uncovering a delirium prevalence of 8.63 per 1000 hospital days. The 4AT showed a compatibility of 75% with other tools used. Changes in consciousness are often missed, but can be easily detected introducing a screening tool as the 4AT