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Sepsis often leads to long-term functional deficits and increased mortality in survivors. Post-acute rehabilitation can decrease long-term sepsis mortality, but its impact on nursing care dependency, health care use and costs is insufficiently understood.To assess the short-term (7-12 months post-discharge) and long-term (13-36 months post-discharge) effect of inpatient rehabilitation within six months after hospitalization on mortality, nursing care dependency, health care use and costs.Observational cohort study using health claims data from the health insurer AOK (Allgemeine Ortskrankenkasse). Among 24.3 million AOK beneficiaries, we identified adult beneficiaries hospitalized with sepsis in 2013/14 by explicit ICD-10 codes. We included patients who were non-employed pre-sepsis, for whom rehabilitation is reimbursed by the AOK and thus included in the dataset, and who survived at least six months post-discharge. The effect of rehabilitation was estimated by statistical comparisons of patients with rehabilitation (treatment group) and those without (reference group). Possible differential effects were investigated for the subgroup of Intensive Care Unit (ICU)-treated sepsis survivors. We used inverse probability of treatment weighting based on propensity scores to adjust for differences in relevant covariates. Costs for rehabilitation in the six months post-sepsis were not included in the costs analysis.Among 41,918 six-months sepsis survivors, 17.2% (n=7,224) received rehabilitation. There was no significant difference in short-term survival between survivors with and without rehabilitation. Long-term survival rates were significantly higher in the rehabilitation group (90.4% vs. 88.7% (odds ratio [OR]=1.2 95% confidence interval [CI], 1.1-1.3) p=0.003)). Survivors with rehabilitation had a higher mean number of hospital readmissions (7-12 months after sepsis, 0.82 vs. 0.76, p=0.014) and were more frequently dependent on nursing care (7-12 and 13-36 months after sepsis, 47.8% vs. 42.3%, OR=1.2 (95% CI, 1.2-1.3), p0.001, and 52.5% vs. 47.5%, OR=1.2 (95% CI, 1.1-1.3), p0.001, respectively) compared to those without rehabilitation, while total health care costs 7-36 months did not differ between groups. ICU-treated sepsis patients with rehabilitation had higher short and long-term survival rates (93.5% vs. 90.9%, OR=1.5 (95% CI, 1.2-1.7), p0.001; 89.1% vs. 86.3%, OR= 1.3 (95% CI, 1.1-1.5), p0.001, respectively) than ICU-treated sepsis patients without rehabilitation.Rehabilitation within the first 6 months after ICU- and non-ICU treated sepsis is associated with increased long-term survival within three years after sepsis without added total health care costs. Future work should aim to confirm and explain these exploratory findings.

ZusammenfassungHunderttausende Menschen mit Sepsis- und Infektionsfolgen werden derzeit in Deutschland nicht optimal versorgt. Dieses White Paper stellt Maßnahmen zur Verbesserung der Versorgung vor, die von einer multidisziplinären Expertengruppe im Rahmen des Innovationsfonds-Projektes SEPFROK erarbeitet wurden. Eine optimale Versorgung beruht auf 4 Säulen: 1. der sektorenübergreifenden Erfassung der Folgen und einem strukturierten Entlass- und Überleitungsmanagement, 2. einem gezielten Angebot von interdisziplinärer Rehabilitation- und Nachsorge mit struktureller Unterstützung, 3. der Stärkung der spezifischen Gesundheitskompetenz von Betroffenen und Angehörigen und 4. der Intensivierung der Forschung zu Ursachen, Prävention und Therapie der Folgen. Hierfür müssen entsprechende sektorenübergreifende Versorgungsstrukturen und sozialrechtliche Rahmenbedingungen geschaffen werden.

Prolonging life in the ICU increasingly is possible, so decisions to limit life-sustaining therapies frequently are made and communicated to patients and families or surrogates. Little is known about worldwide communication practices and influencing factors.Are there regional differences in end-of-life communication practices in ICUs worldwide?This analysis of data from a prospective, international study specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6 months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively for each ICU using a 12-point questionnaire developed previously.Of 87,951 patients admitted, 12,850 died or experienced a limitation of therapy (14.6%). Of these, 1,199 patients (9.3%) were known to have an advance directive, and wishes were elicited from 6,456 patients (50.2%). Limitations of life-sustaining therapy were implemented for 10,401 patients (80.9%), 1,970 (19.1%) of whom had mental capacity at the time, and were discussed with 1,507 patients (14.5%) and 8,461 families (81.3%). Where no discussions with patients occurred (n = 8,710), this primarily was because of a lack of mental capacity in 8,114 patients (93.2%), and where none occurred with families (n = 1,622), this primarily was because of unavailability (n = 720 [44.4%]). Regional variation was noted for all end points. In generalized estimating equation (GEE) analyses, the odds for discussions with the patient or family increased by 30% (OR, 1.30; 95% CI, 1.18-1.44; P .001) for every one-point increase in the Ethical Practice Score and by 92% (OR, 1.92; 95% CI, 1.28-2.89; P = .002) in the presence of an advance directive.End-of-life communication with patients and families or surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes.

PURPOSE We investigated changes in communication practice about end-of-life decisions in European ICUs over 16��years. MATERIALS AND METHODS This prospectively planned secondary analysis of two observational studies in 22 European ICUs in 1999-2000 (Ethicus-1) and 2015-16 (Ethicus-2) included consecutive patients who died or with limitation of life-sustaining therapy. ICUs were grouped into North, Central and South European regions. RESULTS A total 4592 patients were included in 1999-2000 (n��=��2807) and 2015-16 (n��=��1785). Information about patient wishes increased overall (from 25.4% [570] to 51.1% [840]) and in all regions (42% to 61% [North], 22% to 56% [Central] and 20% to 32% [South], all p��Central>South) followed by patient decision-making capacity. CONCLUSION End-of-life decisions are increasingly discussed but communication practices vary by region and follow a North-South gradient. Despite increased availability of information, patient preferences still remain unknown in every second patient. This calls for increased efforts to assess patient preference in advance and make them known to ICU clinicians.

Purpose Return to a normal state of living is a key patient-relevant outcome for sepsis survivors. The Reintegration to Normal Living Index (RNLI) assesses self-perceived participation in patients with chronic disease, but its psychometric properties have been analyzed neither for patients after sepsis nor in a German patient cohort. This study aims to analyze the psychometric properties of the German version of the RNLI in sepsis survivors. Methods In a prospective multicenter survey study, 287 sepsis survivors were interviewed 6 and 12 months after hospital discharge. Multiple-group categorical confirmatory factor analyses with three competing models were used to explore the factor structure of the RNLI. Concurrent validity was evaluated in relation to the EQ-5D-3L and the Barthel Index of Activities of Daily Living (ADL). Results Regarding structural validity, all models showed an acceptable model fit. Because of high correlation between the latent variables in the two-factor models (up to r = 0.969) and for reason of parsimony, we opted for the common factor model to analyze the concurrent validity. Our analyses showed moderate positive correlations between RNLI score and ADL score (r ≥ 0.630), EQ-5D-3L visual analogue scale (r ≥ 0.656) and EQ-5D-3L utility score (r ≥ 0.548). The reliability assessed by McDonald’s Omega was 0.94. Conclusion We found convincing evidence for good reliability, structural and concurrent validity of the RNLI in German sepsis survivors. We propose to use the RNLI in addition to generic health-related quality of life measures to assess the reintegration to normal living after sepsis.

Seit einigen Jahren ist eine stetige Zunahme des Einsatzes von mechanischen extrakorporalen Herz-Kreislauf- und Lungenunterstutzungssystemen (ECLS/ECMO) zu verzeichnen. So wurden seit 2015 in Deutschland jahrlich bei etwa 3000 Patienten ECLS/ECMO-Systeme implantiert. Trotz dieser haufigen Anwendung der passageren Unterstutzungssysteme existieren zurzeit national und international nur Leitlinien zum Einsatz der ECMO/ECLS, die erkrankungsbezogene Teilaspekte komplexer Therapiekaskaden adressieren. Vor diesem Hintergrund erschien es notwendig, evidenzbasierte Empfehlungen zur ECLS/ECMO-Therapie im Hinblick auf Indikationen und das komplexe Patientenmanagement zu verfassen, in denen personelle, prozessuale und infrastrukturelle Anforderungen definiert werden. Aus diesem Grund erfolgte im Juli 2015 durch die Deutsche Gesellschaft fur Thorax‑, Herz- und Gefaschirurgie (DGTHG) die Anmeldung einer diesbezuglichen S3-Leitlinie bei der zustandigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF). Im Mittelpunkt der Leitlinie steht die klinische Anwendung der ECLS/ECMO-Therapie; erganzend werden auch strukturelle und okonomische Aspekte adressiert. Unter Federfuhrung der DGTHG wurde mit Einbindung von Experten aus Deutschland, Osterreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, die S3-Leitlinie im Februar 2021 publiziert. Dieser Artikel stellt eine kurze Zusammenfassung des methodischen Konzepts sowie aller konsentierten Empfehlungen fur jede bearbeitete Fragestellung der Leitlinie dar.

The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.

Mangelhafte Kenntnis des Patientenwillens tragt zum Risiko der Uberversorgung bei. Advance Care Planning (ACP) ist ein neues Konzept fur aussagefahige Vorausverfugungen, das in Deutschland noch wenig praktiziert wird. Es wird ein Uberblick uber Konzept, Entwicklung und Umsetzung von ACP aus der Sicht der Intensivmedizin gegeben. Es wurde ein narrativer Literaturreview durchgefuhrt. Advance Care Planning ist ein breites Konzept, das Beratungsgesprache durch geschultes medizinisches Gesundheitspersonal voraussetzt. Im Ergebnis werden verschiedene ACP-Dokumente erstellt. Auch die ACP-Beratung von Patientenvertreter*innen ist moglich. Das Potenzial besteht in der nachgewiesen verbesserten Aussagekraft und die zeitnahe Umsetzbarkeit in der Notfallsituation. Voraussetzung sind die aufzubauenden Ressourcen, insbesondere die Schulung geeigneter Berater*innen und die Erweiterung bestehender bzw. der Aufbau neuer Beratungsstrukturen in der Klinik. Advance Care Planning ist ein vielversprechendes Konzept. Damit es in die Praxis umgesetzt werden kann, mussen einige Voraussetzungen erfullt werden.

ZusammenfassungUngeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.

In view of the globally evolving coronavirus disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary group of authors with the support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethicolegal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supraindividual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. The assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient’s general health status prior to the current illness.

Angesichts der beginnenden COVID-19-Pandemie haben die deutschen Krankenhauser ihre intensivmedizinischen Kapazitaten erhoht. Trotz optimaler Nutzung erscheint es moglich, dass die intensivmedizinischen Ressourcen nicht mehr fur alle Patienten ausreichen, die ihrer bedurfen. Vor diesem Hintergrund wurden von einer multidisziplinaren Autorengruppe und mit Unterstutzung von acht medizinisch-wissenschaftlichen Fachgesellschaften Empfehlungen zur Verteilung intensivmedizinischer Ressourcen im Kontext der COVID-19-Pandemie erarbeitet. Die Empfehlungen zu Verfahren und Kriterien fur Priorisierungsentscheidungen bei Ressourcenknappheit wurden auf Grundlage der verfugbaren wissenschaftlichen Evidenz, ethischer und rechtlicher Uberlegungen sowie praktischer Erfahrungen erstellt. Medizinische Entscheidungen mussen sich immer am Bedarf und den Behandlungspraferenzen des einzelnen Patienten orientieren. Erganzend zu dieser patientenzentrierten Betrachtung kommt mit der Priorisierung bei absoluter Mittelknappheit eine uberindividuelle Perspektive hinzu. In dieser Situation sollte die Priorisierung anhand des Kriteriums der Erfolgsaussicht einer Behandlung erfolgen, um die Anzahl der vermeidbaren Todesfalle zu minimieren und eine Diskriminierung von Patienten aufgrund des Alters, von Behinderungen oder des sozialen Status zu vermeiden. Die Einschatzung der klinischen Erfolgsaussicht berucksichtigt den Schweregrad der aktuellen Erkrankung, das Vorliegen schwerer Komorbiditaten und den allgemeinen pramorbiden Gesundheitsstatus des Patienten.

The number of patients who survive sepsis is growing. However, two of three sepsis survivors suffer from new physical or mental sequelae. Cognitive deficits, depression or limitations of the activities of daily living can seriously impair quality of life and working ability. Sepsis sequelae cover a range of lesions; current rehabilitation therapies appear unsuited because they are focused on only one organ system. An interdisciplinary approach is necessary to evaluate and treat sepsis sequelae. Survivors and their relatives should be informed about sepsis and possible sequelae as early as possible. Further studies are needed to improve the understanding of pathomechanisms and effectivity of treatment interventions for sepsis sequelae.

Hundreds of thousands of individuals who experience lasting sequelae after sepsis and infections in Germany do not receive optimal care. In this White Paper we present measures for improvement, which were developed by a multidisciplinary expect panel as part of the SEPFROK project. Improved care rests on four pillars: 1. cross-sectoral assessment of sequelae and a structured discharge and transition management, 2. interdisciplinary rehabilitation and aftercare with structural support, 3. strengthening the specific health literacy of patients and families, and 4. increased research into causes, prevention and treatment of sequelae. To achieve this, appropriate cross-sectoral care structures and legal frameworks must be created.Hunderttausende Menschen mit Sepsis- und Infektionsfolgen werden derzeit in Deutschland nicht optimal versorgt. Dieses White Paper stellt Maßnahmen zur Verbesserung der Versorgung vor, die von einer multidisziplinären Expertengruppe im Rahmen des Innovationsfonds-Projektes SEPFROK erarbeitet wurden. Eine optimale Versorgung beruht auf 4 Säulen: 1. der sektorenübergreifenden Erfassung der Folgen und einem strukturierten Entlass- und Überleitungsmanagement, 2. einem gezielten Angebot von interdisziplinärer Rehabilitation- und Nachsorge mit struktureller Unterstützung, 3. der Stärkung der spezifischen Gesundheitskompetenz von Betroffenen und Angehörigen und 4. der Intensivierung der Forschung zu Ursachen, Prävention und Therapie der Folgen. Hierfür müssen entsprechende sektorenübergreifende Versorgungsstrukturen und sozialrechtliche Rahmenbedingungen geschaffen werden.

International audience; Background: The COVID-19 pandemic has caused a shortage of intensive care resources. Intensivists' opinion of triage and ventilator allocation during the COVID-19 pandemic is not well described.Methods: This was a survey concerning patient numbers, bed capacity, triage guidelines, and three virtual cases involving ventilator allocations. Physicians from 400 ICUs in a research network were invited to participate. Preferences were assessed with a five-point Likert scale. Additionally, age, gender, work experience, geography, and religion were recorded.Results: Of 437 responders 31% were female. The mean age was 44.4 (SD 11.1) with a mean ICU experience of 13.7 (SD 10.5) years. Respondents were mostly European (88%). Sixty-six percent had triage guidelines available. Younger patients and caretakers of children were favoured for ventilator allocation although this was less clear if this involved withdrawal of the ventilator from another patient. Decisions did not differ with ICU experience, gender, religion, or guideline availability. Consultation of colleagues or an ethical committee decreased with age and male gender.Conclusion: Intensivists appeared to prioritise younger patients for ventilator allocation. The tendency to consult colleagues about triage decreased with age and male gender. Many found such tasks to be not purely medical and that authorities should assume responsibility for triage during resource scarcity.

PurposeTo quantify the frequency and co-occurrence of new diagnoses consistent with post-sepsis morbidity, mortality, new nursing care dependency, and total healthcare costs after sepsis.MethodsPopulation-based cohort study using healthcare claims data from 23 million beneficiaries of a German health insurance provider. We included adult patients with incident hospital-treated sepsis identified by ICD-10 codes in 2013-2014. New medical, psychological and cognitive diagnoses associated with post-sepsis morbidity; mortality; dependency on nursing care; and total health care costs in survivors were assessed to 3 years after hospital discharge.ResultsAmong 116,507 sepsis patients who survived hospitalization for sepsis, 74.3% had a new medical, psychological or cognitive diagnosis in the first year after discharge. 20.6% and 3.8% had new diagnoses in two and three domains, respectively. 31.5% were newly dependent on nursing care, and 30.7% died within the first year. In the second and third year, 65.8% and 59.4% of survivors had new diagnoses, respectively. Healthcare costs totaled an average 36,585 Euro/patient in three years, including index hospitalization costs. Occurrence of new diagnoses in predefined subgroups was: 73.7% (survivors of non-severe sepsis), 75.6% (severe sepsis), 78.3% (ICU-treated sepsis), 72.8% (non-ICU treated sepsis) and 68.5% (survivors without prior diagnoses).ConclusionsNew medical, psychological and cognitive diagnoses consistent with post-sepsis morbidity are common after sepsis, including among patients with less severe sepsis, no prior diagnoses, and younger age. This calls for more efforts to elucidate the underlying mechanisms, define optimal screening for common new diagnoses, and test interventions to prevent and treat post-sepsis morbidity.Trial RegistrationDRKS00016340Take home messageThis large population-based cohort of over 100,000 survivors of hospital-treated sepsis found high rates and a broad spectrum of new diagnoses consistent with post-sepsis morbidity, frequent new nursing care dependency, and high long-term mortality 1-3 years post sepsis. Post-sepsis morbidity was not limited to the oldest survivors or those with the most severe illness, but also affected younger survivors and those without pre-existing diagnoses.

Background The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. Research Question How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? Study Design and Methods Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. Results We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). Interpretation Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.

BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p

BACKGROUND: The role of intensive insulin therapy in patients with severe sepsis is uncertain. Fluid resuscitation improves survival among patients with septic shock, but evidence is lacking to support the choice of either crystalloids or colloids. METHODS: In a multicenter, two-by-two factorial trial, we randomly assigned patients with severe sepsis to receive either intensive insulin therapy to maintain euglycemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation. The rate of death at 28 days and the mean score for organ failure were coprimary end points. RESULTS: The trial was stopped early for safety reasons. Among 537 patients who could be evaluated, the mean morning blood glucose level was lower in the intensive-therapy group (112 mg per deciliter [6.2 mmol per liter]) than in the conventional-therapy group (151 mg per deciliter [8.4 mmol per liter], P

Background Assessing the impact of coronavirus disease 2019 (COVID-19) on intensive care unit (ICU) providers’ perceptions of resource availability and evaluating the factors associated with emotional distress/burnout can inform interventions to promote provider well-being. Methods Between 23 April and 7 May 2020, we electronically administered a survey to physicians, nurses, respiratory therapists (RTs), and advanced practice providers (APPs) caring for COVID-19 patients in the United States. We conducted a multivariate regression to assess associations between concerns, a reported lack of resources, and 3 outcomes: a primary outcome of emotional distress/burnout and 2 secondary outcomes of (1) fear that the hospital is unable to keep providers safe; and (2) concern about transmitting COVID-19 to their families/communities. Results We included 1651 respondents from all 50 states: 47% were nurses, 25% physicians, 17% RTs, and 11% APPs. Shortages of intensivists and ICU nurses were reported by 12% and 28% of providers, respectively. The largest supply restrictions reported were for powered air purifying respirators (56% reporting restricted availability). Provider concerns included worries about transmitting COVID-19 to their families/communities (66%), emotional distress/burnout (58%), and insufficient personal protective equipment (PPE; 40%). After adjustment, emotional distress/burnout was significantly associated with insufficient PPE access (adjusted relative risk [aRR], 1.43; 95% confidence interval [CI], 1.32–1.55), stigma from community (aRR, 1.32; 95% CI, 1.24–1.41), and poor communication with supervisors (aRR, 1.13; 95% CI, 1.06–1.21). Insufficient PPE access was the strongest predictor of feeling that the hospital is unable to keep providers safe and worries about transmitting infection to their families/communities. Conclusions Addressing insufficient PPE access, poor communication from supervisors, and community stigma may improve provider mental well-being during the COVID-19 pandemic.

A high incidence of care-relevant psychological problems in critical care medicine has been reported among patients, their families and professional care givers. International guidelines give appropriate recommendations for such care. What is unclear, however, is just how the care and support are provided in day-to-day practice and, in particular, which service providers are responsible for this support. The present care situation was studied in a web-based survey (38% response rate) among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN). Most respondents reported a moderate to substantial need for psychological support of patients in intensive care and a substantial to very substantial need in the case of their family members. The need for support in the case of staff showed a relatively broad scatter in the assessment. Providers of care are mainly the members of the intensive care team themselves, while clinical pastoral counsellors in particular are also involved and, to a lesser extent, counselling or liaison services specializing in psychotherapy.

The number of patients who survive sepsis is growing. However, two of three sepsis survivors suffer from new physical or mental sequelae. Cognitive deficits, depression or limitations of the activities of daily living can seriously impair quality of life and working ability. Sepsis sequelae cover a range of lesions; current rehabilitation therapies appear unsuited because they are focused on only one organ system. An interdisciplinary approach is necessary to evaluate and treat sepsis sequelae. Survivors and their relatives should be informed about sepsis and possible sequelae as early as possible. Further studies are needed to improve the understanding of pathomechanisms and effectivity of treatment interventions for sepsis sequelae.

Purpose Sepsis contributes considerably to global morbidity and mortality, while reasons for its increasing incidence remain unclear. We assessed risk adjusted secular trends in sepsis and infection epidemiology in Germany. Methods Retrospective cohort study using nationwide German hospital discharge data. We assessed incidence, outcomes and trends of hospital-treated sepsis and infections between 2010 and 2015. Sepsis was identified by explicit ICD-10 sepsis codes. As sensitivity analysis, results were compared with sepsis cases identified by implicit sepsis coding (combined infection and organ dysfunction codes). Results Among 18 664 877 hospital admissions in 2015, 4 213 116 (22.6%) patients had at least one infection code. There were 320 198 patients that had explicit sepsis codes including 136 542 patients with severe sepsis and septic shock; 183 656 patients were coded as sepsis without organ dysfunction. For patients with explicitly coded sepsis (including severe sepsis), or with severe sepsis alone, mortality rates over the period 2010–2015 decreased from 26.6 to 23.5%, and from 47.8 to 41.7%, respectively. Conclusions Sepsis and infection remain significant causes of hospital admission and death in Germany. Sepsis-related mortality is higher and has declined to a lesser degree than in other high-income countries. Although infection rates steadily increased, the observed annual increase of sepsis cases seems to result, to a considerable degree, from improved coding of sepsis. Electronic supplementary material The online version of this article (10.1007/s00134-018-5377-4) contains supplementary material, which is available to authorized users.

Background: End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play arole in the context of EOLC.Objective: Is the working environment associated with perception of NBT or clinician burnout?Material and Methods: Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.Results: The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91residents and 26consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p0.001) and the numbers of weekend working days per month (p=0.012). Protective factors against burnout included intensive care specialization (p=0.001) and emotional support within the team (p0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p0.001).Discussion: Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

Conflicts of interest are a normal part of human social intercourse. They become problematic when there is a power differential between participants in the setting of relationships requiring a high degree of trust, as in healthcare. In this white paper we consider how these conflicts may be detected and mitigated. Following Medline search and reference chaining, we undertook a narrative review of the literature with iterative discussion. Conflicts of interest may be financial, professional or personal, and may operate at the level of the individual or the organisation. Unmanaged, they become a source of bias which places the interests of the professional or the organisation before those of the patient. Reported with increasing frequency, conflicts damage trust, harm patients, and defraud the health system. We make 15 recommendations for minimising conflicts of interest. Nationally funded open-access registries should be established to permit complete disclosure of financial, professional, and personal relationships with the potential for driving bias in research, clinical practice, or health management. Governance of disclosure should be the responsibility of employing organisations through annual staff appraisals, audited by national research integrity committees. Research fraud should incur suspension of the license to practice. Organisations should monitor staff perceptions of ethical climate to enhance awareness of staff behaviours and the potential for misconduct driven by academic pressures. Clear separation of advisory and voting roles is needed in best practice guideline panels. Professional societies and scientific journals should display conflict of interest policies for their own staff and officers as well as for speakers and authors. Undergraduates should not be exposed to pharmaceutical promotions masquerading as education. Undergraduate and postgraduate training programmes should include teaching about managing conflicts of interest and identifying research misconduct.

Purpose of review End-of-life (EOL) care can be stressful for clinicians as well as patients and their relatives. Decisions to withhold or withdraw life-sustaining therapy vary widely depending on culture, beliefs and organizational norms. The following review will describe the current understanding of the problem and give an overview over interventional studies. Recent findings EOL care is a risk factor for clinician burnout; poor work conditions contribute to emotional exhaustion and intent to leave. The impact of EOL care on families is part of the acute Family Intensive Care Unit Syndrome (FICUS) and the Post Intensive Care Syndrome-Family (PICS-F). Family-centered care (FCC) acknowledges the importance of relatives in the ICU. Several interventions have been evaluated, but evidence for their effectiveness is at best moderate. Some interventions even increased family stress. Interventional studies, which address clinician burnout are rare. Summary EOL care is associated with negative outcomes for ICU clinicians and relatives, but strength of evidence for interventions is weak because we lack understanding of associated factors like work conditions, organizational issues or individual attitudes. In order to develop complex interventions that can successfully mitigate stress related to EOL care, more research is necessary, which takes into account all potential determinants.

Family-centered care in the ICU is a quality criterion of modern intensive care. Relatives are not just visitors, caregivers and involved stakeholders, but also partners for the medical team, especially when eliciting patient preferences and during shared decisionmaking. The move towards family-centered care signifies that traditional roles are changing; family-centered care is becoming a critical component of optimizing patient outcomes in the ICU.

Angehorige kommen nicht nur zum Krankenbesuch auf die Intensivstation. Angehorige leisten in einer Grenzsituation des Lebens hilfreichen Beistand und Fursorge fur Patienten und dienen als wichtige Informationsquelle fur Arzte und Pflegekrafte. Sie sehen sich, oft unerwartet und unvorbereitet, mit lebensbedrohlicher Erkrankung und lebenswichtigen Entscheidungen zu moglicher Therapiebegrenzung, Sterben und Tod konfrontiert und sind haufig selbst substanziell belastet und hilfebedurftig. Unstrittig ist, dass die Kommunikation mit Angehorigen dabei einen adaptiven oder auch traumatischen Einfluss auf die gemachten Erfahrungen haben kann.

Perceiving nonbeneficial treatment is stressful for ICU staff and may be associated with burnout. We aimed to investigate predictors and consequences of perceived nonbeneficial treatment and to compare nurses and junior and senior physicians.Cross-sectional, multicenter paper-pencil survey on personal and work-related characteristics, perceived nonbeneficial treatment, burnout, and intention to leave the job.Convenience sample of 23 German ICUs.ICU nurses and physicians.None.A total of 847 questionnaires were returned (51% response); 778 had complete data for final multivariate analyses. Nonbeneficial treatment was in median perceived "sometimes." Adjusted for covariates, it was perceived more often by nurses and junior physicians (both p ≤ 0.001 in comparison to senior physicians), while emotional exhaustion was highest in junior physicians (p ≤ 0.015 in comparison to senior physicians and nurses), who also had a higher intention to leave than nurses (p = 0.024). Nonbeneficial treatment was predicted by high workload and low quality collaboration with other departments (both p ≤ 0.001). Poor nurse-physician collaboration predicted perception of nonbeneficial treatment among junior physicians and nurses (both p ≤ 0.001) but not among senior physicians (p = 0.753). Nonbeneficial treatment was independently associated with the core burnout dimension emotional exhaustion (p ≤ 0.001), which significantly mediated the effect between nonbeneficial treatment and intention to leave (indirect effect: 0.11 [95% CI, 0.06-0.18]).Perceiving nonbeneficial treatment is related to burnout and may increase intention to leave. Efforts to reduce perception of nonbeneficial treatment should improve the work environment and should be tailored to the different experiences of nurses and junior and senior physicians.

Hydroxyethyl starch is a colloid plasma expander that has recently been reviewed by the European Medicines Agency (EMA) following safety concerns in critically ill patients or in patients with sepsis. The EMA decided to restrict HES use in these patients but continues to allow its use in surgical and trauma patients who suffer from hypovolemia due to blood loss that cannot be corrected by crystalloids alone. This narrative review explains the basis for initial approval of HES, the presumed action of HES as plasma expander, and the mechanisms of its adverse effects on coagulation and on extravascular tissue uptake, especially in the kidneys with resulting renal failure, and presents an overview of recent important studies with a focus on surgery and trauma. No definitive, large-scale randomized controlled trials with patient-relevant outcomes and long-term follow-up exist in this population. Existing studies provide no assurance of a lower risk of coagulopathy, mortality, or kidney failure than in other critically ill patients. There are sufficient data to suggest that HES has similar risks also in these patients and should therefore be avoided.

OBJECTIVES: To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses.DESIGN: Prospective observational study.SETTING: A total of 68 adult ICUs in 13 European countries and the United States.SUBJECTS: ICU physicians and nurses.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions.CONCLUSIONS: Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.

End-of-life (EOL) decision-making is stressful. We conducted a quality improvement initiative to EOL decision-making and reduce stress for clinicians and patients’ relatives. A before–after study running from 2010–2014 at four interdisciplinary intensive care units (ICU) in a German university hospital was performed. Between periods, a multifaceted intervention was implemented to improve timeliness, clinician involvement, and organisational support. Consecutive patients with severe sepsis and therapy limitations were included. Relatives were interviewed by telephone after 90 days to assess their psychological symptoms. Clinician burnout was assessed by staff surveys in each period. Participation in the pre- and postintervention period was 84/145 and 90/159 among relatives, and 174/284 and 122/297 among ICU clinicians. Staff judged intervention elements as mostly helpful, but implementation of intervention elements was heterogeneous. From pre- to postintervention, relatives’ risk of posttraumatic stress, depression and anxiety did not change (all p ≥ 0.464). Clinicians’ risk of burnout increased (29% vs. 41%, p = 0.05). Relatives were highly satisfied in both periods (median of 9 vs. 9.2 on a 1–10 scale each). Attendings involved residents and nurses more often (both p ≤ 0.018). Nurses more often had sufficient information to talk with relatives (41% vs. 62%, p = 0.002). Time to first EOL decision as well as barriers and facilitators of EOL decision-making did not change. The intervention may have increased involvement in EOL decision-making, but was accompanied by an increased risk of clinician burnout maybe due to lack of improving communication skills and organisational support. More research is needed to understand which interventions can decrease clinician burnout.

OBJECTIVES: There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.DATA SOURCES: We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.STUDY SELECTION: Three authors screened titles and abstracts in duplicate.DATA SYNTHESIS: Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.CONCLUSIONS: Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Background Even though data suggest that palliative care (PC) improves patient quality of life, caregiver burden, cost, and intensive care unit (ICU) length of stay, integration of PC in the ICU is far from being universally accepted. Poor understanding of what PC provides is one of the barriers to the widespread implementation of their services in ICU. Evidence suggests that the availability of specialist PC is lacking in most European countries and provided differently depending on geographical location. The aim of this systematic review is to compare the numbers and types of PC interventions and gauge their impact on stakeholder outcomes and ICU resource utilisation. Methods We will undertake a systematic review of the published peer-reviewed journal articles; our search will be carried out MEDLINE, Embase, Cochrane, CINAHL, and PsycINFO. The search strategy will include variations in the term ‘palliative care’ and ‘intensive care’. All studies with patient populations undergoing palliative care interventions will be selected. Only full-text articles will be considered, and conference abstracts excluded. There will be no date restrictions on the year of publications or on language. The primary aim of the present study is to compare the numbers and types of PC interventions in ICU and their impact on stakeholder (patient, family, clinician, other) outcomes. Reporting of findings will follow the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Discussion This review will provide insight into the implementation of palliative care in ICU, elucidate differences between countries and health systems, reveal most effective models, and contribute to identifying research priorities to improve outcomes. Systematic review registration International Prospective Register of Systematic reviews PROSPERO (CRD42018094315)