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The aim of this study was to assess the prevalence of inappropriate treatment among hospitalised patients affected by SARS-CoV-2 infection before hospital admission during the Omicron era. This single-centre, retrospective observational study included all the patients hospitalised because of SARS-CoV-2 infection during three periods characterised by the Italian prevalence of an Omicron variant of concern: (1) January–May 2022 (BA.1–BA.2), (2) June–October 2022 (BA.5), and (3) November 2022–March 2023 (BQ.1-XBB). Inappropriate treatment was defined as pre-hospitalisation exposure to antibiotics and/or steroids in the absence of a documented bacterial infection or the need for steroid treatment of an underlying medical condition. A total of 931 subjects were hospitalised: 394 in period 1, 334 in period 2, and 203 in period 3. Of the 157 patients undergoing inappropriate treatment (16.9%), 142 (15.3%) received antibiotics and 52 (5.6%) steroids. The proportion of inappropriately treated patients significantly decreased over time, from 23.1% in period 1 to 11.7% in period 2 and 13.3% in period 3 (p < 0.001), and there was a parallel decrease in antibiotic (p < 0.001) and steroid treatment (p < 0.013). Only 13 subjects (1.4%) received early pre-hospitalisation treatment for SARS-CoV-2. A significant proportion of hospitalised COVID-19 patients were exposed to inappropriate treatment before hospital admission. [ABSTRACT FROM AUTHOR]

Background: The determination of what makes a medical treatment inappropriate is unclear with a small likelihood of consensus. Objectives: This study aimed to explore how clinicians in cardiology perceive "inappropriate treatment" and to collate the common profiles of cardiology patients receiving likely "inappropriate treatment" as perceived by clinicians in a multiethnic Asian context. Methods: A qualitative study was conducted using semistructured in-depth interviews with 32 clinicians involved in the care for cardiology patients at a large national cardiology center in Singapore. Results: Clinicians' accounts indicated that elements of potentially inappropriate treatment encompass patient-related treatment elements as well as quantitative and probability-based elements such as resource use and probability of treatment benefit. Patient prognostic profiles, characterized as likely to have received inappropriate treatment by clinicians, were organized into six categories according to demographic, clinical, and functional factors. Conclusions: The perception of inappropriateness of treatments among clinicians in cardiology was primarily focused on patient-related outcomes. Collated patient profiles may serve as meaningful indicators of patient cases receiving potentially inappropriate treatment for further research and intervention. [ABSTRACT FROM AUTHOR]

Background: Unfounded concerns regarding fever are increasingly observed among nurses worldwide. However, no study has so far explored the preferred approach towards pediatric fever among nursing students. Therefore, we aimed to investigate the attitude towards pediatric fever among final-year nursing students. Methods: Between February and June 2022, final-year nursing students of 5 Italian university hospitals were asked to answer an online survey on their approach to fever in children. Both quantitative and qualitative methods were utilized. Multiple regression models were employed to explore the existence of moderators on fever conceptions. Results: The survey was filled in by 121 nursing students (response rate 50%). Although most students (98%) do not consider discomfort to treat fever in children, only a minority would administer a second dose of the same antipyretic in nonresponsive cases (5.8%) or would alternate antipyretic drugs (13%). Most students would use physical methods to decrease fever (84%) and do not think that fever has mainly beneficial effects in children (72%). The own know-how adequacy on fever was inversely associated (OR 0.33, 95% CI 0.13–0.81) with the beliefs that high fever might lead to brain damage. No further predictive variable was significantly associated with the concern that fever might be associated with brain damage, the advice of physical methods use, and the assumption that fever has mostly positive effects. Discussion: This study shows for the first time that misconceptions and inappropriate attitudes towards fever in children are common among final-year nursing students. Nursing students could potentially be ideal candidates for improving fever management within clinical practice and amongst caregivers. [ABSTRACT FROM AUTHOR]

We investigated the role of infectious disease consultation (IDC) on therapeutic appropriateness in Gram-negative bloodstream infections (GNBSIs) in a setting with a high proportion of antibiotic resistance. Secondary outcomes were in-hospital mortality and the impact of rapid diagnostic tests (RDTs). Retrospective study on hospitalised patients with GNBSIs. Therapy was deemed appropriate if it had the narrowest spectrum considering infection and patients' characteristics. Interventional-IDC (I-IDC) group included patients with IDC-advised first appropriate or last non-appropriate therapy. Time to first appropriate therapy and survival were evaluated by Kaplan-Meier curves. Factors associated with therapy appropriateness were assessed by multivariate Cox proportional-hazard models. 471 patients were included. High antibiotic resistance rates were detected: quinolones 45.5%, third-generation cephalosporins 37.4%, carbapenems 7.9%. I-IDC was performed in 31.6% of patients (149/471), RDTs in 70.7% (333/471). The 7-day probability of appropriate treatment was 91.9% (95% confidence interval [95%CI]: 86.4–95.8%) vs. 75.8% (95%CI: 70.9–80.4%) with and without I-IDC, respectively (p-value = 0.0495); 85.5% (95%CI: 81.3–89.1%) vs. 69.4% (95%CI: 61.3–77.2%) with and without RDTs, respectively (p-value = 0.0023). Compared to RDTs alone, the combination with I-IDC was associated with a higher proportion of appropriate therapies at day 7: 81.9% (95%CI: 76.4–86.7%) vs. 92.6% (95%CI: 86.3–96.7%). At multivariate analysis, I-IDC and RDTs were associated with time to first appropriate therapy [adjusted hazard-ratio 1.292 (95%CI: 1.014–1.647) and 1.383 (95%CI: 1.080–1.771), respectively], with no impact on mortality. In a setting with a high proportion of antibiotic resistance, IDC and RDTs were associated with earlier prescription of appropriate therapy in GNBSIs, without impact on mortality. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Provision of unnecessary medical services is one of the problems that have driven up health care budgets. The crowding of emergency departments (ED) and sometimes patients 'unreasonable expectations, may lead to ED staff burnout and increase the provision of unnecessary services. METHODS: In this study, the Hospital Urgencies Appropriateness Protocol (HUAP) was used to assess the appropriateness of services provided in the ED. The sample size of this study consisted of 445 patients who were selected among the patients admitted in Rasoul Akram and Firouzgar hospitals in Iran by stratified sampling. Chi-square and logistic regression tests were used to analyze the data. RESULTS: The rate of inappropriate admissions in the ED of the studied hospitals was measured at about 13%. Patients admitted to the Firouzgar ED showed a higher probability of inappropriate admission. Among the considered factors, gender and the interval between the onset of symptoms and ED admission are factors affecting inappropriate admission. CONCLUSION: The rate of inappropriate admission is seen as high in this study. Gender and the interval between the onset of symptoms and an ED admission can be considered as predictors of the provision of unnecessary services. Outcomes from this study are that it is significant to provide operational and evidence-based solutions regarding the issues related to the provision of identified unnecessary services in the ED. [ABSTRACT FROM AUTHOR]

Background: Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life. Aim: To define and understand determinants of non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life. Design: Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles. Data sources: Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science. Results: Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences. Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to 'Motivation to Address Conflict & Seek Agreement' helped to lessen uncertainty around decision-making. Establishing agreement was reliant on 'Valuing Clear Communication and Sharing of Information'. Reaching consensus was dependent on 'Choices around Timing & Documenting of end-of-life Decisions'. Conclusion: A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool. Trial registration: PROSPERO Protocol CRD42021214137. [ABSTRACT FROM AUTHOR]

Few institutions have published reviews concerning the case consultation history of their ethics committees, and policies used by ethics committees to address inappropriate treatment are infrequently reviewed. We sought to characterize the operation of our institution's ethics committee as a representative example of a volunteer ethics committee, and outline its use of a policy to address inappropriate treatment, the Conscientious Practice Policy (CPP). Patients were identified for retrospective review from the ethics consultation database. Patient demographics, medical admission information, and consultation information were obtained from the medical record. Consultation notes were analyzed with directed content analysis. The use of the CPP was documented in each case. Groups of interest were compared via two-sample t-tests. There were 178 consultations between 2013 and 2018. The majority originated from medicine services (N = 145, 82.4%). The most common consultation reasons were end-of-life balances of acute and palliative care (N = 85, 47.2%), best interest standard (N = 82, 46.1%), medical futility (N = 68, 38.2%), and code status and intubation status (N = 67, 37.6%). Average age was 65.5 years and average hospitalization before consultation was 51.4 days. 92 patients (53.3%) had a code status change that occurred after consultation. A policy to address inappropriate treatment (CPP) was used in 42 (23.9%) of the consultations. Bivariate analysis demonstrated a reduction in policy use over time, with use in 32.1% of consultations from 2013 to 2016 and 11.4% of consultations 2017-2018, p = 0.002. End-of-life issues were the most common reason for consultation. Our consultation volume was lower than previously-published reports. A policy used to address inappropriate treatment was frequently used, although use decreased over time. [ABSTRACT FROM AUTHOR]

Background: Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment.Methods: We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0-100%.Results: Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0-33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients.Conclusion: No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the "inappropriateness" of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates. [ABSTRACT FROM AUTHOR]

Background We aimed to describe the current rates of inappropriate empirical antibiotic treatment (IEAT) in oncohematological patients with febrile neutropenia (FN) and its impact on mortality. Methods This was a multicenter prospective study of all episodes of bloodstream infection (BSI) in high-risk FN patients (2006–2017). Episodes receiving IEAT were compared with episodes receiving appropriate empirical therapy. Adherence to Infectious Diseases Society of America (IDSA) recommendations was evaluated. Multivariate analysis was performed to identify independent risk factors for mortality in Pseudomonas aeruginosa episodes. Results Of 1615 episodes, including Escherichia coli (24%), coagulase-negative staphylococci (21%), and P. aeruginosa (16%), 394 (24%) received IEAT despite IDSA recommendations being followed in 87% of cases. Patients with multidrug-resistant gram-negative bacilli (MDR-GNB), accounting for 221 (14%) of all isolates, were more likely to receive IEAT (39% vs 7%, P <.001). Overall mortality was higher in patients with GNB BSI who received IEAT (36% vs 24%, P =.004); when considering individual microorganisms, only patients with infection caused by P. aeruginosa experienced a significant increase in mortality when receiving IEAT (48% vs 31%, P =.027). Independent risk factors for mortality in PA BSI (odds ratio [95% confidence interval] were IEAT (2.41 [1.19–4.91]), shock at onset (4.62 [2.49–8.56]), and pneumonia (3.01 [1.55–5.83]). Conclusions IEAT is frequent in high-risk patients with FN and BSI, despite high adherence to guidelines. This inappropriate treatment primarily impacts patients with P. aeruginosa –related BSI mortality and in turn is the only modifiable factor to improve outcomes. [ABSTRACT FROM AUTHOR]

As medical decisions fall under more scrutiny and society demands increasing transparency of care, it is likely that more opportunities for conflicts will emerge. Similarly, with increasing demand and a static supply, the issue of who receives treatment and for how long naturally will arise. This mismatch leads to discussions of resource utilization and limitation of care in light of patients' values and rights. Clinicians should always be forthcoming with the uncertainty of prognostication while also articulating the severity of a patient's disease in relation to the risk and benefits of an intervention. However, dispute over treatment course and the idea of futile care can arise for in a variety of reasons, both from the clinician and the patient. Without identifying the cause of these conflicts, it is impossible to have effective communication. At times, it is important to utilize various negotiating skills when resolving these disagreements. Regardless of the approach, practitioners need more training in and exposure to these types of conflicts. In this review, we provide a framework for the origins and current state of futility, challenges in the application of the term, and recommendations on how to approach conflict in these situations. [ABSTRACT FROM AUTHOR]

Background : Over recent years, there have been increasing concerns regarding an increase in the number of futile and inappropriate admissions to pediatric intensive care units (PICUs) in the United Kingdom (UK). Methods : A prospective cross-sectional survey was carried out using a data collection form distributed by mail to the directors of all PICUs in the UK. Respondents were asked to give details of all patients on their unit on a specific day including age, reason for admission and any preexisting medical conditions. An assessment was made by respondents of whether the care being provided in each case was, in their opinion, appropriate, futile or inappropriate according to standard definitions. Results : We received responses from 21 units (68%) who reported the details of 111 patients. Care was felt to be appropriate in 88 of these cases (79%), futile in nine cases (8%) and inappropriate in 14 cases (13%). Futile cases were most commonly admitted with respiratory failure and all had preexisting medical conditions, most commonly developmental delay. Where care was felt to be inappropriate, respiratory failure was again the most common reason for admission and all had a preexisting medical condition, most commonly cardiovascular disease. Conclusions : The care being provided in 21% of the PICU cases, described in this study, was felt to be either futile or inappropriate by the directors of those units. There is an urgent need to, accurately, establish the resource consumption associated with these patients and to establish a standard approach to futility and inappropriate care in PICU in the UK. [ABSTRACT FROM AUTHOR]