Dataset Information

The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network.

ABSTRACT:

Introduction

There is high variability amongst physicians' assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists.

Materials and methods

We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless of their base specialty as well as to all internists in 3 large teaching hospitals. For each case, we asked the participants to determine if the patient was an appropriate ICU admission and to assess different parameters (e.g. baseline function, likelihood of survival to ICU discharge, etc.). Agreement was measured using kappa values.

Results

21 intensivists and 22 internists filled out the survey (response rate = 87.5% and 35% respectively). Predictions of likelihood of survival to ICU admission, hospital discharge and return to baseline were not significantly different between the two groups. However, agreement between individuals within each group was only slight to fair (kappa range = 0.09-0.22). There was no statistically significant difference in predicting ICU survival and prediction of survival to hospital discharge between both groups. The accuracy with which physicians predicted actual outcomes ranged between 35% and 100% and did not significantly differ between the two groups. A greater proportion of internists favoured non resuscitative measures (24.6% of intensivists and 46.9% internists [p = 0.002]).

Conclusion

In a case-based survey, physician specialty base did not affect assessments of ICU admission benefit or accuracy in outcome prediction, but resulted in a statistically significant difference in level of care assignments. Of note, significant disagreement amongst individuals in each group was found.

SUBMITTER: Dahine J

PROVIDER: S-EPMC4752246 | biostudies-literature | 2016

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network.

Dahine Joseph J Mardini Louay L Jayaraman Dev D

PloS one 20160212 2

<h4>Introduction</h4>There is high variability amongst physicians' assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists.<h4>Materials and methods</h4>We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless o ...[more]

PMID: 26871587

Similar Datasets

Project description:ObjectivesThe primary objective was to estimate the incidence of patients in the Central Denmark Region triaged to bypass the local emergency department without being part of a predefined fast-track protocol. The secondary objective was to describe these triage decisions in more detail with regard to the most common diagnoses, incidence of direct referral sorted by the prehospital critical care team (PHCCT) and the destination hospital.DesignRetrospective descriptive study.Setting and participantsThe emergency medical service in the Central Denmark Region primarily consists of emergency medical technician (EMT)-staffed ambulances and anaesthesiologist-EMT-staffed PHCCTs. Patients treated by the nine ground-based PHCCTs in the region constituted the study population. The inclusion criteria were all patients treated by the PHCCTs during 2013 and 2014. The exclusion criteria were interhospital transfers, and patients with ST-segment elevation myocardial infarction, stroke or were in active labour.EndpointsIncidence of prehospital critical care anaesthesiologist-initiated direct referral, prehospital tentative diagnoses and transport destination.ResultsDuring the study period, the PHCCTs treated 39 396 patients and diverted 989 (2.5%) patients not covered by a predefined fast-track protocol to a specialised hospital department. 'Resuscitated from cardiac arrest' (n=143), 'treatment and observations following road traffic accident' (n=105) and 'observation and treatment for an unspecified disease/condition' (n=78) were the most common prehospital tentative diagnoses, accounting for 33.0% of all diverted patients. In total, 943 (95.3%) of the PHCCT-diverted patients were diverted to a department at Aarhus University Hospital.ConclusionOur results demonstrate that in 1 out of 40 patient contacts, the anaesthesiologist-staffed PHCCTs in the Central Denmark Region divert critically ill and injured patients directly to a specialised hospital department, bypassing local emergency departments and potentially reducing time to definitive care for these patients. There may be a potential for increased referral of patients with no predefined fast-track directly to specialised departments in the Central Denmark Region.

Project description:ImportanceDuring the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination.ObjectiveTo analyze the role of comorbidities and long-term prognosis in state triage procedures.Design, setting, and participantsThis cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication.Main outcomes and measuresPrevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival.ResultsOverall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state's list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term.Conclusions and relevanceIn this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.

Project description:BackgroundAlthough pulmonary artery catheters (PACs) have been the reference standard for calculating cardiac output, echocardiographic estimation of cardiac output (CO) by cardiologists has shown high accuracy compared to PAC measurements. A few studies have assessed the accuracy of echocardiographic estimation of CO in critically ill patients by intensivists with basic training. The aim of this study was to evaluate the accuracy of CO measurements by intensivists with basic training using pulsed-wave Doppler ultrasound vs. PACs in critically ill patients.MethodsCritically ill patients who required hemodynamic monitoring with a PAC were eligible for the study. Three different intensivists with basic critical care echocardiography training obtained three measurements of CO on each patient. The maximum of three separate left-ventricular outflow tract diameter measurements and the mean of three LVOT velocity time integral measurements were used. The inter-observer reliability and correlation of CO measured by PACs vs. critical care echocardiography were assessed.ResultsA total of 20 patients were included. Data were analyzed comparing the measurements of CO by PAC vs. echocardiography. The inter-observer reliability for measuring CO by echocardiography was good based on a coefficient of intraclass correlation of 0.6 (95% CI 0.48-0.86, p < 0.001). Bias and limits of agreement between the two techniques were acceptable (0.64 ± 1.18 L/min, 95% limits of agreement of - 1.73 to 3.01 L/min). In patients with CO < 6.5 L/min, the agreement between CO measured by PAC vs. echocardiography improved (0.13 ± 0.89 L/min; 95% limits of agreement of - 1.64 to 2.22 L/min). The mean percentage of error between the two methods was 17%.ConclusionsCritical care echocardiography performed at the bedside by intensivists with basic critical care echocardiography training is an accurate and reproducible technique to measure cardiac output in critically ill patients.

Project description:ObjectivesPediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use.DesignRetrospective cohort study.SettingSeattle Children's Hospital.PatientsPICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206).InterventionsNone.Measurements and main resultsWe developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay.ConclusionsA model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

Project description:IntroductionRecent evidence suggests that early, aggressive resuscitation in patients with septic shock reduces mortality. The objective of this survey was to characterize reported resuscitation practices of Canadian physicians caring for adult critically ill patients with early septic shock.MethodsA scenario-based self-administered national survey was sent out to Canadian critical care physicians. One hypothetical scenario was developed to obtain information on several aspects of resuscitation in early septic shock, including monitoring and resuscitation end-points, fluid administration, red blood cell transfusion triggers, and use of inotropes. The sampling frame was physician members of Canadian national and provincial critical care societies.ResultsThe survey response rate was 232 out of 355 (65.3%). Medicine was the most common primary specialty (60.0%), most respondents had practiced for 6 to 10 years (30.0%), and 82.0% were male. The following monitoring devices/parameters were reported as used/measured 'often' or 'always' by at least 89% of respondents: oxygen saturation (100%), Foley catheters (100%), arterial blood pressure lines (96.6%), telemetry (94.3%), and central venous pressure (89.2%). Continuous monitoring of central venous oxygen saturation was employed 'often' or 'always' by 9.8% of respondents. The two most commonly cited resuscitation end-points were urine output (96.5%) and blood pressure (91.8%). Over half of respondents used normal saline (84.5%), Ringers lactate (52.2%), and pentastarch (51.3%) 'often' or 'always' for early fluid resuscitation. In contrast, 5% and 25% albumin solutions were cited as used 'often' or 'always' by 3.9% and 1.3% of respondents, respectively. Compared with internists, surgeons and anesthesiologists (odds ratio (95% confidence interval): 9.8 (2.9 to 32.7) and 3.8 (1.7 to 8.7), respectively) reported greater use of Ringers lactate. In the setting of a low central venous oxygen saturation, 52.5% of respondents reported use of inotropic support 'often' or 'always'. Only 7.6% of physicians stated they would use a red blood cell transfusion trigger of 100 g/l to optimize oxygen delivery further.ConclusionOur survey results suggest that there is substantial practice variation in the resuscitation of adult patients with early septic shock. More randomized trials are needed to determine the optimal approach.

Project description:ObjectivesTo determine the total numbers of privileged and full-time equivalent intensivists in acute care hospitals with intensivists and compare the characteristics of hospitals with and without intensivists.DesignRetrospective analysis of the American Hospital Association Annual Survey Database (Fiscal Year 2015).SettingTwo-thousand eight-hundred fourteen acute care hospitals with ICU beds.PatientsNone.InterventionsNone.Measurements and main resultsOf the 2,814 acute care hospitals studied, 1,469 (52%) had intensivists and 1,345 (48%) had no intensivists. There were 28,808 privileged and 19,996 full-time equivalent intensivists in the 1,469 hospitals with intensivists. In these hospitals, the median (25-75th percentile) numbers of privileged and full-time equivalent intensivists were 11 (5-24) and 7 (2-17), respectively. Compared with hospitals without intensivists, hospitals with privileged intensivists were primarily located in metropolitan areas (91% vs 50%; p < 0.001) and at the aggregate level had nearly thrice the number of hospital beds (403,522 [75%] vs 137,146 [25%]), 3.6 times the number of ICU beds (74,222 [78%] vs 20,615 [22%]), and almost twice as many ICUs (3,383 [65%] vs 1,846 [35%]). At the hospital level, hospitals with privileged intensivists had significantly more hospital beds (median, 213 vs 68; p < 0.0001), ICU beds (median, 32 vs 8; p < 0.0001), a higher ratio of ICU to hospital beds (15.6% vs 12.6%; p < 0.0001), and a higher number of ICUs per hospital (2 vs 1; p < 0.0001) than hospitals without intensivists.ConclusionsAnalyzing the intensivist section of the American Hospital Association Annual Survey database is a novel approach to estimating the numbers of privileged and full-time equivalent intensivists in acute care hospitals with ICU beds in the United States. This methodology opens the door to an enhanced understanding of the current supply and distribution of intensivists as well as future research into the intensivist workforce.

Dataset Information

The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network.

Introduction

Materials and methods

Results

Conclusion

Publications

The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets