Ethical issues associated with in-hospital emergency from the medical emergency team's perspective: a national survey

Medical Emergency Teams (METs) are frequently involved in ethical issues associated to in-hospital emergencies, like decisions about end-of-life care and intensive care unit (ICU) admission. MET involvement offers both advantages and disadvantages, especially when an immediate decision must be made. We performed a survey among Italian intensivists/anesthesiologists evaluating MET's perspective on the most relevant ethical aspects faced in daily practice

Methodology for the reduction and integration of data in the performance measurement of industries cement plants

The investigation responded to the need outlined by directive and interested parts, in relation to the lack of mechanisms for the administration control and the need to reduce the amount of data when making measurements of performance in the cement industry. Throughout the employment of an outlined methodology, it was obtained an Integral Index of Acting that relates to the aspects that controlled the acting of the processes in function of managerial strategies, of easy mensuration as a result, automatic and that it facilitates to summarize a big amount of criteria and data, through their standardization, and thus the realization of comparisons with other production plants

Temporal changes in the epidemiology, management, and outcome from acute respiratory distress syndrome in European intensive care units: a comparison of two large cohorts

Background: Mortality rates for patients with ARDS remain high. We assessed temporal changes in the epidemiology and management of ARDS patients requiring invasive mechanical ventilation in European ICUs. We also investigated the association between ventilatory settings and outcome in these patients. Methods: This was a post hoc analysis of two cohorts of adult ICU patients admitted between May 1–15, 2002 (SOAP study, n = 3147), and May 8–18, 2012 (ICON audit, n = 4601 admitted to ICUs in the same 24 countries as the SOAP study). ARDS was defined retrospectively using the Berlin definitions. Values of tidal volume, PEEP, plateau pressure, and FiO2 corresponding to the most abnormal value of arterial PO2 were recorded prospectively every 24 h. In both studies, patients were followed for outcome until death, hospital discharge or for 60 days. Results: The frequency of ARDS requiring mechanical ventilation during the ICU stay was similar in SOAP and ICON (327[10.4%] vs. 494[10.7%], p = 0.793). The diagnosis of ARDS was established at a median of 3 (IQ: 1–7) days after admission in SOAP and 2 (1–6) days in ICON. Within 24 h of diagnosis, ARDS was mild in 244 (29.7%), moderate in 388 (47.3%), and severe in 189 (23.0%) patients. In patients with ARDS, tidal volumes were lower in the later (ICON) than in the earlier (SOAP) cohort. Plateau and driving pressures were also lower in ICON than in SOAP. ICU (134[41.1%] vs 179[36.9%]) and hospital (151[46.2%] vs 212[44.4%]) mortality rates in patients with ARDS were similar in SOAP and ICON. High plateau pressure (> 29 cmH2O) and driving pressure (> 14 cmH2O) on the first day of mechanical ventilation but not tidal volume (> 8 ml/kg predicted body weight [PBW]) were independently associated with a higher risk of in-hospital death. Conclusion: The frequency of and outcome from ARDS remained relatively stable between 2002 and 2012. Plateau pressure > 29 cmH2O and driving pressure > 14 cmH2O on the first day of mechanical ventilation but not tidal volume > 8 ml/kg PBW were independently associated with a higher risk of death. These data highlight the continued burden of ARDS and provide hypothesis-generating data for the design of future studies

The clinical relevance of oliguria in the critically ill patient : Analysis of a large observational database

Funding Information: Marc Leone reports receiving consulting fees from Amomed and Aguettant; lecture fees from MSD, Pfizer, Octapharma, 3 M, Aspen, Orion; travel support from LFB; and grant support from PHRC IR and his institution. JLV is the Editor-in-Chief of Critical Care. The other authors declare that they have no relevant financial interests. Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. Results: Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient - oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged - oliguria resolved > 48 h after the admission day (n = 141 [10.5%]), and permanent - oliguria persisting for the whole ICU stay or again present at the end of the ICU stay (n = 818 [60.6%]). ICU and hospital mortality rates were higher in patients with oliguria than in those without, except for patients with transient oliguria who had significantly lower mortality rates than non-oliguric patients. In multilevel analysis, the need for RRT was associated with a significantly higher risk of death (OR = 1.51 [95% CI 1.19-1.91], p = 0.001), but the presence of oliguria on admission was not (OR = 1.14 [95% CI 0.97-1.34], p = 0.103). Conclusions: Oliguria is common in ICU patients and may have a relatively benign nature if only transient. The duration of oliguria and need for RRT are associated with worse outcome.publishersversionPeer reviewe

Effect of a quality improvement program on compliance to the sepsis bundle in non-ICU patients: a multicenter prospective before and after cohort study

ObjectiveSepsis and septic shock are major challenges and economic burdens to healthcare, impacting millions of people globally and representing significant causes of mortality. Recently, a large number of quality improvement programs focused on sepsis resuscitation bundles have been instituted worldwide. These educational initiatives have been shown to be associated with improvements in clinical outcomes. We aimed to evaluate the impact of a multi-faceted quality implementing program (QIP) on the compliance of a “simplified 1-h bundle” (Sepsis 6) and hospital mortality of severe sepsis and septic shock patients out of the intensive care unit (ICU).MethodsEmergency departments (EDs) and medical wards (MWs) of 12 academic and non-academic hospitals in the Lombardy region (Northern Italy) were involved in a multi-faceted QIP, which included educational and organizational interventions. Patients with a clinical diagnosis of severe sepsis or septic shock according to the Sepsis-2 criteria were enrolled in two different periods: from May 2011 to November 2011 (before-QIP cohort) and from August 2012 to June 2013 (after-QIP cohort).Measurements and main resultsThe effect of QIP on bundle compliance and hospital mortality was evaluated in a before–after analysis. We enrolled 467 patients in the before-QIP group and 656 in the after-QIP group. At the time of enrollment, septic shock was diagnosed in 50% of patients, similarly between the two periods. In the after-QIP group, we observed increased compliance to the “simplified rapid (1 h) intervention bundle” (the Sepsis 6 bundle – S6) at three time-points evaluated (1 h, 13.7 to 18.7%, p = 0.018, 3 h, 37.1 to 48.0%, p = 0.013, overall study period, 46.2 to 57.9%, p < 0.001). We then analyzed compliance with S6 and hospital mortality in the before- and after-QIP periods, stratifying the two patients’ cohorts by admission characteristics. Adherence to the S6 bundle was increased in patients with severe sepsis in the absence of shock, in patients with serum lactate <4.0 mmol/L, and in patients with hypotension at the time of enrollment, regardless of the type of admission (from EDs or MWs). Subsequently, in an observational analysis, we also investigated the relation between bundle compliance and hospital mortality by logistic regression. In the after-QIP cohort, we observed a lower in-hospital mortality than that observed in the before-QIP cohort. This finding was reported in subgroups where a higher adherence to the S6 bundle in the after-QIP period was found. After adjustment for confounders, the QIP appeared to be independently associated with a significant improvement in hospital mortality. Among the single S6 procedures applied within the first hour of sepsis diagnosis, compliance with blood culture and antibiotic therapy appeared significantly associated with reduced in-hospital mortality.ConclusionA multi-faceted QIP aimed at promoting an early simplified bundle of care for the management of septic patients out of the ICU was associated with improved compliance with sepsis bundles and lower in-hospital mortality

Bene comune e comportamenti responsabili. Storie di imprese e di istituzioni

Questo libro raccoglie storie di imprese e di istituzioni, raccontate secondo i canoni ormai consolidati che definiscono il \u201cgenere letterario\u201d dei casi aziendali: si rilevano e si espongono con intenzionale obiettivit\ue0 fatti e comportamenti reali di cui si compone la storia di aziende concrete, opportunamente scelte, osservate su lunghi archi di tempo. Un elemento di innovazione di questo libro \ue8 l\u2019accostamento di storie di organizzazioni molto diverse fra loro per tipo di \u201cmissione produttiva\u201d e di assetto giuridico-istituzionale: imprese, aziende del settore sanitario, aziende no profit, enti pubblici territoriali. Gli undici casi oggetto delle storie narrate in questo libro sono i seguenti: \u2013 tre imprese: Buzzi-Unicem, \u201cGruppo\u201d Bruno, Brunello Cucinelli; \u2013 tre aziende sanitarie: ASL 10 di Firenze; Policlinico Universit\ue0 Campus Bio-Medico; IC Humanitas; \u2013 due aziende no profit: Teatro la Fenice; Gruppo Cooperativo CGM; \u2013 tre enti pubblici territoriali: Comune di Reggio Emilia; Comune di Sassari; Comune di Peccioli (PI). Essi sono stati selezionati in quanto presentavano \u2013 sulla base delle conoscenze disponibili, delle informazioni raccolte o delle indicazioni ricevute \u2013 alcuni tratti propri di modi di gestire responsabili. Ci\uf2 sembra doversi attribuire, in primo luogo, all\u2019azione di una leadership animata dal desiderio e dalla volont\ue0 di realizzare la missione produttiva, diffondendo e praticando un insieme di valori indirizzati a perseguire il bene comune dell\u2019azienda in armonia con il bene della societ\ue0: innovazione, imprenditorialit\ue0, produttivit\ue0 e sviluppo.Si tratta di una raccolta di "casi aziendali", ossia di "storie" di organizzazioni diverse fra loro - imprese, aziende sanitarie, istituti non profit, enti pubblici territoriali - selezionate in quanto presentavano \u2013 sulla base delle conoscenze disponibili, delle informazioni raccolte o delle indicazioni ricevute \u2013 alcuni tratti propri di modi di gestire responsabili. Ci\uf2 sembra doversi attribuire, in primo luogo, all\u2019azione di una leadership animata dal desiderio e dalla volont\ue0 di realizzare la missione produttiva, diffondendo e praticando un insieme di valori indirizzati a perseguire il bene comune dell\u2019azienda in armonia con il bene della societ\ue0: innovazione, imprenditorialit\ue0, produttivit\ue0 e sviluppo. I casi diversi dalle imprese sono stati scelti anche perch\ue9 ben si prestano a esemplificare e illustrare alcuni processi di trasferimento di competenze e tecniche manageriali dal mondo delle imprese verso altri tipi di istituti e organizzazioni produttive

Impresa distrettuale e competizione globale

La prospettiva del distretto industriale come una realt\ue0 composta da un grande numero di piccole e piccolissime imprese, molto simili fra loro, per lo pi\uf9 incapaci di sopravvivere senza le \u201ceconomie esterne\u201d di cui possono godere all\u2019interno del territorio distrettuale si rivela sempre pi\uf9 inadeguata a interpretare il rapporto fra il distretto e le imprese che vi appartengono, costrette dai processi di globalizzazione da tempo in atto a ripensare la propria strategia e, in particolare, il loro modo di essere nel distretto. Il libro, anche con l\u2019ausilio di alcuni casi empirici, mette in evidenza come vi siano molte imprese distrettuali che non solo hanno intrapreso con successo un percorso di crescita dimensionale, ma hanno anche saputo affrancarsi progressivamente dal distretto nel quale sono nate, pur continuando quasi sempre a rimanervi insediate. La relazione fra impresa distrettuale e distretto si fa via via pi\uf9 variegata e complessa: vi sono imprese che contribuiscono allo sviluppo e alla prosperit\ue0 del distretto, altre che concorrono a determinarne il declino o la crisi, altre ancora che svolgono un ruolo determinante nel rilanciarlo o rivitalizzarlo. D\u2019altra parte, un distretto pu\uf2 risultare decisivo, almeno per un certo periodo, ai fini della sopravvivenza di alcune imprese, per altre pressoch\ue9 irrilevante, per altre ancora addirittura un fattore di rischio, soprattutto quando una diffusa rilassatezza da successo e da benessere rende pi\uf9 difficile riconoscere e quindi affrontare i cambiamenti ambientali rilevanti. L\u2019analisi empirica e la riflessione teorica suggeriscono che la qualit\ue0 delle conoscenze diffuse localmente e del fattore imprenditoriale costituiscono le risorse decisive ai fini della competitivit\ue0 di lungo periodo di un distretto

"Public" and "private" cross-locality networks: conditions for access, complementary roles and impact on industrial district competitiveness

Firms located in industrial districts are acknowledged to benefit from externalities of geographic colocation, like access to specialized inputs and labour skills, better infrastructure and so on. Nevertheless, there is no clear empirical evidence that their performance is, on average, better than that of \u2018isolated\u2019 firms. I argue that a contingent approach is required to better explore the relationship between clustering and performance and suggest that access to external, more codified and \u2018scientific\u2019 knowledge, that complement informal and tacit knowledge developed within an industrial district, is of increasing importance as a source of competitiveness both for a district as a whole and for individual district firms. After illustrating main features of \u2018public\u2019 and \u2018private\u2019 cross-locality networks as possible ways to facilitate access to external knowledge for an industrial district, I propose a theoretical framework that, with the aid of some Italian cases, explores conditions of access, complementary roles and impact of cross-locality networks on performance both of an industrial district as a whole and of individual firms located in it

Responsabilit\ue0 sociale e strategia. Alla ricerca di un'integrazione

La crescente domanda di responsabilit\ue0 sociale rivolta alle imprese e la pubblicazione, nel corso del 2001, del Libro Verde della Commissione Europea finalizzato a promuoverla hanno suscitato un\u2019ampia risonanza sia a livello accademico, sia fra gli operatori economici e hanno innescato un\u2019ampia e variegata gamma di azioni e di iniziative che, almeno a detta di chi le ha promosse, si iscrivono nell\u2019alveo della responsabilit\ue0 sociale delle imprese. A ben guardare, tuttavia, non sono molte le imprese che la praticano in modo autentico, incisivo ed efficace, meno ancora quelle che la integrano nella loro strategia. L\u2019obiettivo del libro \ue8 proprio quello di contribuire, anche con l\u2019ausilio di alcuni casi aziendali, a identificare condizioni, modalit\ue0 e processi attraverso i quali \u201ccompetitivit\ue0\u201d e \u201csocialit\ue0\u201d possano coniugarsi sinergicamente. Ci\uf2 si verifica allorch\ue9 la responsabilit\ue0 sociale entra a far parte della \u201cproposta di valore\u201d al cliente o favorisce l\u2019accesso a risorse di valore, scarse e difficili da imitare, alimentando in tal modo il vantaggio competitivo, e, nel contempo, le risorse e le competenze alla base di quest\u2019ultimo vengono utilizzate anche a beneficio dei diversi stakeholder, favorendo l\u2019efficacia e l\u2019incisivit\ue0 dell\u2019azione dell\u2019impresa sul fronte sociale e ambientale. L\u2019integrazione della responsabilit\ue0 sociale nella strategia implica il superamento dell\u2019impostazione neoclassica, secondo la quale il fine dell\u2019impresa \ue8 la massimizzazione del profitto per gli azionisti, l\u2019assunzione della \u201csocialit\ue0\u201d nella funzione-obiettivo dell\u2019impresa stessa, nonch\ue9 la ricerca di un profitto di lungo periodo e dalle solide basi, atto ad alimentare la funzionalit\ue0 duratura dell\u2019impresa in condizioni di autonomia e quindi, in ultima analisi, a far s\uec che la sua \u201cmissione\u201d economico-sociale possa realizzarsi autenticamente