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Objective: Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies., Data Sources: Systematic searches of Medline, Embase, and Cochrane Central Register were performed., Study Selection: We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019., Data Extraction: Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies., Data Synthesis: From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813-4,295); the median number of clusters was 12 (interquartile range, 5-24); and the median patients per cluster was 141 (interquartile range, 54-452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01-0.13])., Conclusions: Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate., Competing Interests: Dr. Scales’ institution received funding from the Canadian Institutes for Health Research. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Granular data related to the likelihood of individuals of different ages accessing acute and critical care services over time is lacking., Methods: We used population-based, administrative data from Ontario to identify residents of specific ages (20, 30, 40, etc. to 100) on January 1st every year from 1995-2019. We assessed rates of emergency department (ED) visits (2003-19), hospitalizations, intensive care unit (ICU) admissions (2003-19), and mechanical ventilation., Findings: Overall the 25-year study period, ED were the most common acute healthcare encounter with 100-year-olds having the lowest rate (138.7/1,000) and 90-year-olds the highest (378.5/1,000). Rates of hospitalization ranged from 24.2/1,000 for those age 20 up to 224.9/1,000 for those age 90. Rates of ICU admission and mechanical ventilation were lowest for those age 20 (1.0 and 0.4/1,000), more than tripled by age 50 (3.3 and 1.7/1,000) and peaked at age 80 (20.3 and 10.1/1,000). Over time rates of ED visits increased (164.3 /1,000 in 2003 vs 199.1 /1,000 in 2019) as did rates of invasive mechanical ventilation (2.0/1,000 in 1995 vs 2.9/1,000 in 2019), whereas rates of ICU admission remained stable (4.8/1,000 in 2003 vs 4.9/1,000 in 2019) and hospitalization declined (66.8/1,000 in 1995 vs 51.5/1,000 in 2019). Age stratified analysis demonstrated that rates of ED presentation increased for those age 70 and younger while hospitalization decreased for all age groups; ICU admission and mechanical ventilation rates changed variably by age, with increasing rates demonstrated primarily among people under the age of 50., Interpretation: Rates of hospitalizations have decreased over time across all age groups, whereas rates of ED presentation, ICU admissions, and mechanical ventilation have increased, primarily driven by younger adults. These findings suggest that although the delivery of healthcare may be moving away from inpatient medicine, there is a growing population of young adults requiring significant healthcare resources., Competing Interests: The authors have declared that no competing interests exist.

Purpose: Critical care beds are commonly described in three levels (highest level 3, lowest level 1). We aimed to describe the actual level of care for patients assigned to level 2 in a tertiary hospital with inadequate level 1 bed capacity., Materials and Methods: Prospective cohort study with daily assessment of level of care. The primary outcome was the proportion of patients who could be triaged to level 1 for the entirety of their ICU stay. Secondary outcomes included the percentage of patients who could receive level 1 care on any given day., Results: 289 patients originally classified as level 2 were assessed for the primary, and 335 for the secondary outcomes. 14.9% could be level 1 for their entire ICU stay. 20.6%, once appropriate for level 1, remained in that level for the rest of their ICU stay. 23.6% of the assessments were suitable for level 1 on any given day., Conclusion: In a single centre, 14.9% of level 2 patients could have been cared for in a lower acuity bed for the entirety of their ICU stay. We believe this methodology is reproducible and can help resource allocation with regard to the high demand for critical care beds., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Requests for a second medical opinion (SMO) by patients or substitute decision-makers (SDMs) can arise during end-of-life disputes in critical care. Such disagreements between patients or SDMs and physicians often pertain to specific elements of the decision-making process related to withholding or withdrawing of life-sustaining treatments. When these disputes occur in the critical care setting in Canada, practicalities and policy barriers prevent an SDM from obtaining an SMO without support from healthcare providers; moreover, in a majority of these cases the SDM will require the facilitation of a physician who is often the same individual with whom they are in conflict. Institutional and a national society's policy statements propose SMOs as an important component of a conflict resolution process for end-of-life disputes (Bosslet et al. 2015; Singer et al. 2001). However, these policies do not provide specific guidance to physicians on how to fairly consider SMO requests. Given the vulnerable position of patients and their SDMs in the critical care context and in order to promote fairness, physicians should apply consistent standards in deciding whether to facilitate a request for an SMO. To guide physicians' decision-making and inform future policy development, we propose three ethical principles for considering SDM requests for an SMO in critical care at the end of life.

This ethnography explores communication around critically ill surgical patients in three surgical intensive care units (ICUs) in Canada. A boundary framework is used to articulate how surgeons', intensivists', and nurses' communication practices shape and are shaped by their respective disciplinary perspectives and experiences. Through 50 hours of observations and 43 interviews, these health care providers are found to engage in seven communication behaviors that either mitigate or magnify three contested symbolic boundaries: expertise, patient ownership, and decisional authority. Where these boundaries are successfully mitigated, experiences of collaborative, high-quality patient care are produced; by contrast, boundary magnification produces conflict and perceptions of unsafe patient care. Findings reveal that high quality and safe patient care are produced through complex social and cultural interactions among surgeons, intensivists, and nurses that are also expressions of knowledge and power. This enhances our understanding of why current quality improvement efforts targeting communication may be ineffective., (© The Author(s) 2015.)

Background: Evidence supporting selective decontamination of the digestive tract (SDD) is reasonably strong. We set out to determine use in UK critical care units and to compare patient outcomes between units that do and those that do not use SDD., Methods: A total of 250 UK general critical care units were surveyed. Case mix, outcomes, and lengths of stay for admissions to SDD units (with and without an i.v. component) and non-SDD units were compared using data from the Intensive Care National Audit & Research Centre Case Mix Programme database., Results: A response was received from all the 250 critical care units surveyed. Of these, 13 (5.2%) reported using SDD on some or all admissions, and of these, 3 reported using an i.v. component. Data on 284,690 admissions (April 2008-March 2011) from units reporting to the ICNARC Case Mix Programme (CMP) were included in the analyses. Admissions to SDD (n=196) and non-SDD (n=9) units were a similar case mix with similar infection rates and average lengths of stay in the unit and hospital. There was no difference in risk-adjusted unit or hospital mortality. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component., Conclusions: Use of SDD in UK critical care is very low. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component, but did not translate into a difference in acute hospital mortality or length of stay. There is a need to better understand the barriers to adoption of SDD into clinical practice and such work is underway., (© The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: Following intensive care discharge, many patients suffer severe physical and psychological morbidity and a continuing high use of health services. Follow-up programmes have been proposed to improve the outcomes for these patients. We tested the hypothesis that nurse-led intensive care follow-up programmes are cost-effective., Methods: A pragmatic, multicentre, randomised controlled trial of nurse-led intensive care unit follow-up programmes versus standard care. A cost-utility analysis was conducted after 12 months' follow-up to compare the two interventions. Costs were assessed from the perspective of the UK NHS and outcomes were measured in quality-adjusted life years (QALYs) based upon responses to the EQ-5D administered at baseline, 6 and 12 months., Results: A total of 286 patients were recruited to the trial. Total mean cost was £ 5,789 for standard care and £ 7,577 for the discharge clinic. The adjusted difference in means was £ 2,435 [95 % confidence interval (CI) -297 to 5,566]. Mean QALYs were 0.58 for standard care and 0.60 for the discharge clinic. The adjusted mean difference was -0.003 (95 % CI -0.066 to 0.060). If society were willing to pay £ 20,000 per QALY then there would be a 93 % chance that standard care would be considered most efficient., Conclusions: A nurse-led intensive care unit (ICU) follow-up programme showed no evidence of being cost-effective at 12 months. Further work should focus on evidence-based development of discharge clinic services and current ICU follow-up programmes should review their practice in light of these results.

Background: Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1-36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking., Objective: To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England., Data Sources: Sixteen electronic bibliographic databases - including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases - were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references., Review Methods: References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI., Results: Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year., Limitations: Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data., Conclusions: Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI., Study Registration: The study is registered with PROSPERO as CRD42012001840., Funding: The National Institute for Health Research Health Technology Assessment programme.

Introduction: Selective decontamination of the digestive tract (SDD) is a prophylactic antibiotic regimen that is not widely used in practice. We aimed to describe the opinions of key 'stakeholders' about the validity of the existing evidence base, likely consequences of implementation, relative importance of their opinions in influencing overall practice, likely barriers to implementation and perceptions of the requirement for further research to inform the decision about whether to embark on a further large randomised controlled trial., Methods: This was a Delphi study informed by comprehensive framework of possible determinants of health professionals' behaviour to study Critical Care practice in four countries. There were four key stakeholder participant groups including ICU physicians, pharmacists, clinical leads, and clinical microbiologists/ infectious disease physicians. Round one comprised participant interviews and Rounds two and three were online questionnaires using Delphi method., Results: In this study, 141 participants were recruited of whom 82% were retained. Participants rated themselves as knowledgeable about SDD. Antibiotic resistance was identified as the most important issue. SDD was seen as a low clinical priority but few participants reported strong opposition. There was moderate agreement that research to date has not adequately addressed concerns about antibiotic resistance and lacks generalizability. Participants indicated equipoise with regard to benefits and harms of SDD, and indicated strong support for a further randomised trial., Conclusions: Clinicians have clinical equipoise about the effectiveness of SDD. Future research requires longer follow up to assess antibiotic resistance as well as greater validity/generalizability to provide definitive answers on the effectiveness of decontamination and effects on antibiotic resistance. SDD was regarded as not being a high clinical priority, which may limit future trial participation. These results have identified that further large randomised controlled trial of SDD in critical care is both warranted and appropriate.

Background: This study sought to identify and describe the clinical and behavioural components (e.g. the what, how, when, where and by whom) of 'selective decontamination of the digestive tract' (SDD) as routinely implemented in the care of critically ill patients., Methods: Multi-methods study, consisting of semi-structured observations of SDD delivery, interviews with clinicians and documentary analysis, conducted in two ICUs in the UK that routinely deliver SDD. Data were analysed within-site to describe clinical and behavioural SDD components and synthesised across-sites to describe SDD in context., Results: SDD delivery involved multiple behaviours extending beyond administration of its clinical components. Not all behaviours were specified in relevant clinical documentation. Overall, SDD implementation and delivery included: adoption (i.e. whether to implement SDD), operationalisation (i.e. implementing SDD into practice), provision (i.e. delivery of SDD) and surveillance (i.e. monitoring the ecological effects). Implementation involved organisational, team and individual-level behaviours. Delivery was perceived as easy by individual staff, but displayed features of complexity (including multiple interrelated behaviours, staff and contexts)., Conclusions: This study is the first to formally outline the full spectrum of clinical and behavioural aspects of SDD. It identified points in the delivery process where complex behaviours occur and outlined how SDD can be interpreted and applied variably in practice. This comprehensive specification allows greater understanding of how this intervention could be implemented in units not currently using it, or replicated in research studies. It also identified strategies required to adopt SDD and to standardise its implementation., (Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: The article reviews the methods of health economic analysis (HEA) in clinical trials of critically ill patients. Emphasis is placed on the usefulness of HEA in the context of positive and 'no effect' studies, with recent examples., Recent Findings: The need to control costs and promote effective spending in caring for the critically ill has garnered considerable attention due to the high cost of critical illness. Many clinical trials focus on short-term mortality, ignoring costs and quality of life, and fail to change clinical practice or promote efficient use of resources. Incorporating HEA into clinical trials is a possible solution. Such studies have shown some interventions, although expensive, provide good value, whereas others should be withdrawn from clinical practice. Incorporating HEA into randomized controlled trials (RCTs) requires careful attention to collect all relevant costs. Decision trees, modeling assumptions and methods for collecting costs and measuring outcomes should be planned and published beforehand to minimize bias., Summary: Costs and cost-effectiveness are potentially useful outcomes in RCTs of critically ill patients. Future RCTs should incorporate parallel HEA to provide both economic outcomes, which are important to the community, alongside patient-centered outcomes, which are important to individuals.

Objectives: To identify the behaviors senior physicians (e.g., specialists, staff attendings) report using to lead multidisciplinary teams in the intensive care unit., Design: Semistructured interviews focusing on team leadership, crisis management, and development of an environment that enable effective team performance in the intensive care unit., Setting: Seven general intensive care units based in National Health Service hospitals in the United Kingdom., Participants: Twenty-five senior intensive care medicine physicians., Measurements and Main Results: Responses to a semistructured interview were transcribed and subjected to "content" analysis. The interview analysis focused on references to the "functional" behaviors used by leaders to manage team performance and the "team development behaviors" used to build the conditions that enable effective team performance. Seven of the interviews were coded by a second psychologist to measure inter-rater reliability. Inter-rater reliability (Cohen's κ) was acceptable for both scales (κ = 0.72 and κ = 0.75). In total, 702 functional leadership behaviors (behaviors for information gathering, planning and decision-making, managing team members) were coded as being used to manage the intensive care unit, along with 216 team development behaviors (for providing team direction and establishing team norms). These behaviors were grouped together in a theoretically driven framework of intensive care unit team leadership., Conclusions: Intensive care unit senior physicians report using a variety of leadership behaviors to ensure high levels of team performance. The data described in this study provide insight into the team leadership behaviors used by intensive care unit team leaders and have implications for the development of team leadership training and assessment tools.

Purpose of Review: It has recently been argued that the future of intensive care medicine will rely on high quality management and teamwork. Therefore, this review takes an organizational psychology perspective to examine the most recent research on the relationship between teamwork, care processes, and patient outcomes in intensive care., Recent Findings: Interdisciplinary communication within a team is crucial for the development of negotiated shared treatment goals and short-team patient outcomes. Interventions for maximizing team communication have received substantial interest in recent literature. Intensive care coordination is not a linear process, and intensive care teams often fail to discuss how to implement goals, trigger and align activities, or reflect on their performance. Despite a move toward interdisciplinary team working, clinical decision-making is still problematic and continues to be perceived as a top-down and authoritative process. The topic of team leadership in intensive care is underexplored and requires further research., Summary: Based on findings from the most recent research evidence in medicine and management, four principles are identified for improving the effectiveness of team working in intensive care: engender professional efficacy, create stable teams and leaders, develop trust and participative safety, and enable frequent team reflexivity.

Background: Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery., Methods/design: A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery., Discussion: We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice., Trial Registration: Trial registration number - ISRCTN32188676.

Background: Early warning scores (EWS) are widely used to allow early recognition of the deteriorating patient. We aimed to test their ability to predict major deterioration in medical patients., Methods: Two cohorts were prospectively identified who were admitted to an acute medical admissions unit and to the respiratory unit but not admitted to the intensive care unit (ICU): medical-non ICU and respiratory-non ICU groups. Two further cohorts were retrospectively identified that required ICU admission from these units (medical-ICU and respiratory-ICU groups). Discriminant analysis and receiver operating characteristic curves were used to discriminate between groups, and time relationships were analysed., Results: Heart rate (HR) and respiratory rate (RR) were significantly higher--and oxygen saturation (SaO₂) significantly lower--in the medical-ICU group as compared with the medical non-ICU group, and in the respiratory-ICU group as compared with [corrected] the respiratory-non ICU group. Discriminant functions incorporating HR, RR and SaO₂ performed at least as well as existing EWS systems in predicting ICU admission., Conclusions: Commonly used physiological parameters and existing EWS systems are useful at identifying sick patients. The discriminant functions described here appear to have a role in this setting but require validation in future studies.

Objectives: To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care., Design: A pragmatic, non-blinded, multicentre, randomised controlled trial., Setting: Three UK hospitals (two teaching hospitals and one district general hospital)., Participants: 286 patients aged >or=18 years were recruited after discharge from intensive care between September 2006 and October 2007., Intervention: Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed., Results: 286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI -1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (-3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective., Conclusions: A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients' quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results., Trial Registration: ISRCTN 24294750.

Background: Despite initial recovery from critical illness, many patients deteriorate after discharge from the intensive care unit (ICU). We examined prospectively collected data in an attempt to identify patients at risk of readmission or death after intensive care discharge., Methods: This was a secondary analysis of clinical audit data from patients discharged alive from a mixed medical and surgical (non-cardiac) ICU., Results: Four hundred and seventy-five patients (11.2%) died in hospital after discharge from the ICU. Increasing age, time in hospital before intensive care admission, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and discharge Therapeutic Intervention Scoring System (TISS) score were independent risk factors for death after intensive care discharge. Three hundred and eighty-five patients (8.8%) were readmitted to intensive care during the same hospital admission. Increasing age, time in hospital before intensive care, APACHE II score, and discharge to a high dependency unit were independent risk factors for readmission. One hundred and forty-three patients (3.3%) were readmitted within 48 h of intensive care discharge. APACHE II scores and discharge to a high dependency or other ICU were independent risk factors for early readmission. The overall discriminant ability of our models was moderate with only marginal benefit over the APACHE II scores alone., Conclusions: We identified risk factors associated with death and readmission to intensive care. It was not possible to produce a definitive model based on these risk factors for predicting death or readmission in an individual patient.

As the physical care of individuals with critical illness has improved greater numbers have survived. However, until recently the psychological response to such critical illness has received comparatively little attention.

Objective: Early warning scoring systems are widely used in clinical practice to allow early recognition of the deteriorating patient, but they lack validation. We aimed to test the ability of physiologic variables, either alone or in existing early scoring systems, to predict major deterioration in a patient's condition and attempt to derive functions with superior accuracy., Design: A comparative cohort study., Setting: A teaching hospital in Scotland., Patients: Two cohorts of general surgical high-dependency patients. The cohorts are a group of surgical high-dependency care patients who did not require intensive care admission and another group of patients who did require admission., Interventions: None., Measurements and Main Results: Prospective physiologic data on consecutive surgical high-dependency unit patients were collected and compared with physiologic data on patients admitted to the intensive care unit from the same surgical high-dependency units. Data were quality checked and summarized, and discriminant analysis and receiver operator curves were used to discriminate between the groups. There were significant physiologic differences between groups with regard to heart rate (p<.001, area under the receiver operating characteristic curve [AUC] 0.7), respiratory rate (p<.001, AUC 0.71), and oxygen saturation (p<.001, AUC 0.78) across time points. This was not present for systolic blood pressure or temperature. Existing early warning scoring systems had good discriminatory power (AUC 0.83-0.86). We derived discriminant functions, which have a high predictive ability to determine differences between groups (p<.0001, AUC 0.86-0.90). We found that heart rate and respiratory rate could detect differences between groups at 6 and 8 hrs before ICU admission, but oxygen saturation and the discriminant function 2 could detect differences 48 hrs before ICU admission., Conclusions: Some commonly used physiologic variables have reasonable power in determining the difference between patients requiring intensive care unit admission, but others are poor. Existing early warning scores have comparatively good discriminatory power. We have derived functions with excellent predictive power in this derivation cohort.

An evaluation of critical care outreach services was published in the previous issue of Critical Care that fails to demonstrate any important outcome benefit associated with these services. It is now time to ask some difficult questions about the future of outreach, including whether the lack of evidence should lead to disinvestment in such services.

Intensive care follow-up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow-up clinics in the UK is unknown. We performed a survey of intensive care follow-up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow-up clinics and details of current follow-up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow-up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow-up clinic, 158 (88%) cited 'financial constraints' as the reason. Over half of the follow-up clinics (44 clinics, 55%) were nurse-led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4 days or longer. Nearly half of the follow-up clinics (39 clinics, 49%) have pre-negotiated access to at least one other out-patient service.

Quality of life is often thought to be poor before and after intensive care unit admission. The aim of this study was to investigate changes in quality of life before and after intensive care. A prospective cohort study of 300 consecutive patients admitted to intensive care was performed in a Scottish Teaching Hospital. Quality of life was assessed premorbidly and 3, 6 and 12 months after intensive care admission for surviving patients using SF-36 as well as EQ-5D scores at 12 months. The median value for age was 60.5 years and for APACHE II score, 18. The mean length of stay was 6.7 days. SF-36 physical component scores decreased from premorbid values at 3 months (p = 0.05) and then returned to premorbid values at 12 months (p < 0.001). The mean physical scores were below the population norm at all time points but the mean mental scores were similar or higher than these population norms. Patients who died after intensive care discharge had lower quality of life scores than did survivors (all p < 0.01). Poor premorbid quality of life was demonstrated and appears to reduce after ICU discharge. For survivors there was a slow increase in physical quality of life to premorbid levels by the end of the first year but these remained lower than in the general population. ICU patients experience a considerable longer-term burden of ill health.

B-type natriuretic peptide is known to predict outcome in congestive cardiac failure and myocardial infarction. We aimed to determine whether measurement of B-type natriuretic peptide would predict hospital mortality in patients admitted to an intensive care unit. We conducted a prospective observational cohort study in 78 consecutive patients. Demographics, clinical details and clinical outcomes were recorded. Admission and 24 h B-type natriuretic peptide and cardiac troponin I levels were measured. B-type natriuretic peptide and cardiac troponin I levels taken on intensive care admission and 24 h after admission did not accurately predict hospital mortality for all patients, including patients with severe sepsis or septic shock (all p > 0.05). B-type natriuretic peptide levels were higher in patients with severe sepsis and septic shock (p = 0.02), in patients > or = 65 years (p = 0.04) and in patients with raised creatinine > or = 110 micromol.l(-1) (p = 0.02). We concluded that B-type natriuretic peptide, measured soon after admission to intensive care, does not usefully predict outcome after intensive care.

The purpose of this audit was to study reasons for starting antibiotic therapy, duration of antibiotic treatment, reasons for changing antibiotics and the agreement between clinical suspicion and microbiological results in intensive care practice. We conducted a multicentre observational audit of 316 patients. Data on demographic details, site, treatment and nature of infection were collected. The median duration of antibiotic therapy was 7 days. Infections were community-acquired in 160 patients (55%). Antibiotics were started on clinical suspicion of infection in 237 patients (75%). Pulmonary infections were the most common, representing 52% of all proven infections. Gram-negative organisms were the most common cause of proven infections (n = 90 (50%)). The antibiotic spectrum was narrowed in light of microbiology results in 78 patients (43%) and changed due to antibiotic resistance in 38 patients (21%). We conclude that the mean duration of treatment contrasts with existing published guidelines, highlighting the need for further studies on duration and efficacy of treatment in intensive care.

Objective: To determine the incidence and severity of symptoms related to the diagnosis of post-traumatic stress disorder (PTSD) in a cohort of general ICU patients., Design: A prospective cohort study 3 months after general ICU discharge., Setting: A general ICU in a teaching hospital in northern Scotland., Patients and Participants: Seventy-eight ICU survivors of general ICU., Interventions: Patients were contacted 3 months after ICU discharge and asked to complete a telephone assessment of the Davidson Trauma Scale., Measurements and Results: The median score was 8, with 22% recording a score of at least 27 and 14% meeting the full diagnostic criteria for PTSD. The overall score was not correlated with sex, ICU length of stay, or APACHE II score but was inversely correlated with age and directly correlated with length of mechanical ventilation. The overall score was also related to the patient reporting having visited a GP or a mental health professional for psychological distress previous to ICU., Conclusions: We found a high incidence of symptoms consistent with PTSD 3 months after ICU discharge in this general ICU cohort. This was associated with younger patients and those who visited their GP or a mental health professional complaining of psychological symptoms. Further research and a greater liaison between ICU staff and family practitioners and mental health practitioners is required to better identify individuals at risk and reduce psychological morbidity in this group.

Objective: Although unlicensed, inhaled nitric oxide (NO) therapy is now widely used in the United Kingdom. Our aim was to produce guidelines for the clinical application of inhaled NO in adult intensive care practice, based upon the current level of published information., Methods: The published data regarding the use of inhaled NO in the acute respiratory distress syndrome and right-sided cardiac failure was presented, analysed and discussed. Recommendations based on these data as well as on current experience in the United Kingdom were formulated., Design: An expert group comprising intensive care specialists from within the United Kingdom, representatives from the European Society of Intensive Care Medicine and the Society of Critical Care Medicine and individuals from the Departments of Health and Industry related to the field was assembled., Results: United Kingdom guidelines for the indications, contraindications, dose, delivery, monitoring and scavenging of inhaled NO therapy were produced., Conclusions: The need for additional quality research to establish evidence of efficacy and safety was emphasized. The guidelines are designed to act within the context of current practice and knowledge and should be revised as further data emerge.

The use of inhaled nitric oxide in the critically ill has increased significantly over the past few years but little published information exists on standards for current practice. Sixty-four intensive therapy units in the UK were surveyed by questionnaire from which 54 (84.4%) satisfactory replies were received. We present the survey results and put forward recommendations based on current literature and our own clinical experience for the safe use of inhaled nitric oxide.

Few areas of medicine have failed to be affected by the discovery of nitric oxide and the unravelling of its many physiological and pathophysiological roles. Possibly no other area of medicine has this discovery had so many potential therapeutic applications as in the field of critical care medicine. But will this widespread interest in nitric oxide result in the promised revolution in clinical care?