Mitä hyötyä tehohoidosta? : Tehohoitoa sisältäneiden hoitojaksojen vaikuttavuuden arviointi

Intensive care is to be provided to patients benefiting from it, in an ethical, efficient, effective and cost-effective manner. This implies a long-term qualitative and quantitative analysis of intensive care procedures and related resources. The study population consists of 2709 patients treated in the general intensive care unit (ICU) of Helsinki University Hospital. Study sectors investigate intensive care patients mortality, quality of life (QOL), Quality-Adjusted Life-Years (QALY units) and factors related to severity of illness, length of stay (LOS), patient s age, evaluation period as well as experiences and memories connected with the ICU episode. In addition, the study examines the qualities of two QOL measures, the RAND 36 Item Health Survey 1.0 (RAND-36) and the 5 Item EuroQol-5D (EQ-5D) and assesses the correlation of the test results. Patients treated in 1995 responded to the RAND-36 questionnaire in 1996. All patients, treated from 1995-2000, received a QOL questionnaires in 2001, when 1 7 years had lapsed from the intensive treatment. Response rate was 79.5 %. Main Results 1) Of the patients who died within the first year (n = 1047) 66 % died during the intensive care period or within the following month. The non-survivors were more aged than the surviving patients, had generally a higher than average APACHE II and SOFA score depicting the severity of illness, their ICU LOS was longer and hospital stay shorter than of the surviving patients (p < 0.001). Mortality of patients receiving conservative treatment was higher than of those receiving surgical treatment. Patients replying to the QOL survey in 2001 (n = 1099) had recovered well: 97 % of those lived at home. More than half considered their QOL as good or extremely good, 40 % as satisfactory and 7 % as bad. All QOL indexes of those of working-age were considerably lower (p < 0.001) than comparable figures of the age- and gender-adjusted Finnish population. The 5-year monitoring period made evident that mental recovery was slower than physical recovery. 2) The results of RAND-36 and EQ-5D correlated well (p < 0.01). The RAND-36 profile measure distinguished more clearly between the different categories of QOL and their levels. EQ-5D measured well the patient groups general QOL and the sum index was used to calculate QALY units. 3) QALY units were calculated by multiplying the time the patient survived after ICU stay or expected life-years by the EQ-5D sum index. Aging automatically lowers the number of QALY units. Patients under the age of 65 receiving conservative treatment benefited from treatment to a greater extent measured in QALY units than their peers receiving surgical treatment, but in the age group 65 and over patients with surgical treatment received higher QALY ratings than recipients of conservative treatment. 4) The intensive care experience and QOL ratings were connected. The QOL indices were statistically highest for those recipients with memories of intensive care as a positive experience, albeit their illness requiring intensive care treatment was less serious than average. No statistically significant differences were found in the QOL indices of those with negative memories, no memories or those who did not express the quality of their experiences.Tehohoitoa tulee antaa siitä hyötyville potilaille eettisesti, tehokkaasti, vaikuttavasti ja kus-tannustietoisesti, mikä edellyttää hoitotulosten jatkuvaa arviointia. Tutkimuksissa selvitetään yliopistosairaalan yleisellä tehohoito-osastolla vuosina 1995-2000 hoidettujen 2709 tehohoitopotilaan kuolleisuuden, elämänlaadun ja laatupainotteisten lisäelinvuosien (Quality-Adjusted Life-Year, QALY) määrää ja niihin liittyviä tekijöitä: sairauden vakavuutta, hoitoaikaa, ikää, seuranta-aikaa sekä potilaiden tehohoitokokemuksia ja muistikuvia. Lisäksi tutkimuksessa verrataan kahden elämänlaatumittarin, pitkän 36-kysymyksinen RAND 36-Item Health Survey 1.0:n (RAND-36) ja lyhyen, 5-kysymyksisen EuroQol-5D:n (EQ-5D) ominaisuuksia ja mittaustulosten yhtenevyyttä. Vuonna 1995 hoidetut potilaat vastasivat elämänlaatukyselyyn kaksi kertaa, muut elossa olevat potilaat saivat kyselyn kerran. Keskeiset tulokset 1) Ensimmäisenä tehohoitoa seuranneena vuotena menehtyi 1047 potilasta, joista 66 % kuoli tehohoitojakson tai sitä seuranneen kuukauden aikana. Menehtyneet potilaat olivat selviytyneitä potilaita iäkkäämpiä, heillä oli keskimääräistä vakavampi sairaus, tehohoitojakso oli pidempi ja sairaalahoitojakso lyhyempi kuin eloon jääneillä potilailla. Konservatiivisesti hoidettujen potilaiden kuolleisuus oli suurempi kuin kirurgisesti hoidettujen potilaiden. Elämänlaatukyselyn täytti 1099 vastaajaa; kyselyn palautti 79,5 % sen saaneista. Vastaajat olivat toipuneet hyvin: 97 % asui edelleen kotona. Yli puolet heistä piti elämänlaatuaan hyvänä tai erittäin hyvänä, 40 % tyydyttävänä ja 7 % huonona. Viisivuotisseurannassa ilmeni, että henkinen toipuminen oli fyysistä toipumista hitaampaa. Kaikki työikäisten elämänlaatuindeksit olivat vertaisväestön vastaavia arvoja merkitsevästi huonompia. 2) Elämänlaatumittareiden tulokset olivat yhteneviä. Pitkä RAND-36-mittari erotteli tarkemmin elämänlaadun eri osa-alueet, niiden tasot ja yksittäisen vastaajan elämänlaadun. Lyhyt EQ-5D-mittari kuvasi hyvin potilasryhmien yleistä elämänlaatua ja sen summalukua käytettiin QALY-yksikköjen laskemisessa. 3) QALY-yksiköt saadaan kertomalla vastaajan elinaika tai elinajanodote vastaajan elämänlaadun summaluvulla. Ikääntyminen alentaa automaattisesti QALY-yksiköiden määrää. QALY-yksikköinä mitattuna alle 65-vuotiaat, konservatiivisesti hoidetut potilaat hyötyivät hoidosta enemmän kuin kirurgisesti hoidetut ikätoverinsa, mutta 65 vuotta täyttäneiden ryhmissä kirurgiset potilaat hyötyivät hoidosta konservatiivisesti hoidettuja enemmän. 4) Tehohoitokokemuksilla ja elämänlaatuarvoilla oli keskinäistä yhteyttä. Tehohoidon positiivisena kokemuksena muistaneiden vastaajien elämänlaatuarvot olivat tilastollisesti parhaita, mutta heidän tehohoitoa vaatinut sairautensa oli sairauden vakavuutta mittaavilla pisteillä arvioituna keskimääräistä lievempi. Tehohoidon negatiivisena kokeneiden, tehoaikaa muistamattomien tai kokemustensa laatua ilmaisemattomien elämänlaatuarvoissa ei ollut tilastollisesti merkitseviä eroja

Prevalence and factors of intensive care unit conflicts: The conflicus study

Rationale: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. Objectives: To record the prevalence, characteristics, and risk factors for conflicts in ICUs. Methods: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). Measurements and Main Results: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing preand postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. Conclusions: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement

Determinants of procedural pain intensity in the intensive care unit: the Europain® study

Rationale:Intensive care unit (ICU) patients undergo several diagnostic and therapeutic procedures every day. The prevalence, intensity, and risk factors of pain related to these procedures are not well known. Objectives: To assess self-reported procedural pain intensity versus baseline pain, examine pain intensity differences across procedures, and identify risk factors for procedural pain intensity. Methods: Prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures. Data were obtained from 3,851 patients who underwent 4,812 procedures in 192 ICUs in 28 countries. Measurements andMain Results: Painintensity on a 0–10 numeric rating scale increased significantly from baseline pain during all procedures (P , 0.001). Chest tube removal, wound drain removal, and arterial line insertion were the three most painful procedures, with median pain scores of 5 (3–7), 4.5 (2–7), and 4 (2–6), respectively. By multivariate analysis, risk factors independently associated with greater procedural pain intensity were the specific procedure; opioid administration specifically for the procedure; preprocedural pain intensity; preprocedural pain distress; intensity of the worst pain on the same day, before the procedure; and procedure not performed by a nurse. A significant ICU effect was observed, with no visible effect of country because of its absorption by the ICU effect. Some of the risk factors became nonsignificant when each procedure was examined separately. Conclusions: Knowledge of risk factors for greater procedural pain intensity identified in this study may help clinicians select interventions that are needed to minimize procedural pain. Clinical trial registered with www.clinicaltrials.gov (NCT 01070082)