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The interplay between critical illness and mental disorders is poorly understood. The purpose of this study is to measure both the treated prevalence of mental disorders and psychotropic medication use before and after hospitalization and the impact of intensive care unit (ICU) admission on these outcomes. Using a population-based administrative database in Manitoba, Canada, 49,439 ICU patients admitted between 2000 and 2012 were compared to two matched comparison groups (hospitalized; n = 146,968 and general population; n = 141,937). Treated prevalence of mental disorders and psychotropic medication prescriptions were measured in the 5-year periods before and after the hospitalization. Multivariable models compared adjusted prevalence ratios (APRs) between populations. The 5-year treated mental disorder prevalence in the ICU population increased from 41.5% pre-hospitalization to 55.6% post-hospitalization. Compared to non-ICU hospitalized patients, the adjusted treated mental disorder prevalence in ICU patients was lower prior to hospitalization (1-year APR 0.94, 95% CI 0.92–0.97, p

In response to the rapid spread of SARS-CoV-2, hospitals in Canada enacted temporary visitor restrictions to limit the spread of COVID-19 and preserve personal protective equipment supplies. This study describes the extent, variation, and fluctuation of Canadian adult intensive care unit (ICU) visitation policies before and during the first wave of the COVID-19 pandemic. We conducted an environmental scan of Canadian hospital visitation policies throughout the first wave of the pandemic. We conducted a two-phased study analyzing both quantitative and qualitative data. We collected 257 documents with reference to visitation policies (preCOVID, 101 [39%]; midCOVID, 71 [28%]; and lateCOVID, 85 [33%]). Of these 257 documents, 38 (15%) were ICU-specific and 70 (27%) referenced the ICU. Most policies during the midCOVID/lateCOVID pandemic period allowed no visitors with specific exceptions (e.g., end-of-life). Framework analysis revealed five overarching themes: 1) reasons for restricted visitation policies; 2) visitation policies and expectations; 3) exceptions to visitation policy; 4) patient and family-centred care; and 5) communication and transparency. During the first wave of the COVID-19 pandemic, most Canadian hospitals had public-facing visitor restriction policies with specific exception categories, most commonly for patients at end-of-life, patients requiring assistance, or COVID-19 positive patients (varying from not allowed to case-by-case). Further studies are needed to understand the consistency with which visitation policies were operationalized and how they may have impacted patient- and family-centred care.

During the first wave of the COVID-19 pandemic, restricted visitation policies were enacted at acute care facilities to reduce the spread of COVID-19 and conserve personal protective equipment. In this study, we aimed to describe the impact of restricted visitation policies on critically ill patients, families, critical care clinicians, and decision-makers; highlight the challenges faced in translating these policies into practice; and delineate strategies to mitigate their effects.A qualitative description design was used. We conducted semistructured interviews with critically ill adult patients and their family members, critical care clinicians, and decision-makers (i.e., policy makers or enforcers) affected by restricted visitation policies. We transcribed semistructured interviews verbatim and analyzed the transcripts using inductive thematic analysis.Three patients, eight family members, 30 clinicians (13 physicians, 17 nurses from 23 Canadian intensive care units [ICUs]), and three decision-makers participated in interviews. Thematic analysis was used to identify five themes: 1) acceptance of restricted visitation (e.g., accepting with concerns); 2) impact of restricted visitation (e.g., ethical challenges, moral distress, patients dying alone, intensified workload); 3) trust in the healthcare system during the pandemic (e.g., mistrust of clinical team); 4) modes of communication (e.g., communication using virtual platforms); and 5) impact of policy implementation on clinical practice (e.g., frequent changes and inconsistent implementation).Restricted visitation policies across ICUs during the COVID-19 pandemic negatively affected critically ill patients and their families, critical care clinicians, and decision-makers.RéSUMé: OBJECTIF: Au cours de la première vague de la pandémie de COVID-19, des politiques de visite restreintes ont été adoptées dans les établissements de soins aigus afin de réduire la propagation de la COVID-19 et d’économiser les équipements de protection individuelle. Dans cette étude, nous avons cherché à décrire l’impact des politiques de visite restreintes sur les patients gravement malades, les familles, les intensivistes et les décideurs, ainsi qu’à souligner les difficultés rencontrées dans la mise en pratique de ces politiques et à définir des stratégies pour en atténuer les effets. MéTHODE: Une méthodologie de description qualitative a été utilisée. Nous avons mené des entretiens semi-structurés avec des patients adultes gravement malades et les membres de leur famille, les intensivistes et les décideurs (c.-à-d. les stratèges ou les responsables de l’application de la loi) touchés par les politiques de visite restreintes. Nous avons transcrit textuellement les entretiens semi-structurés et analysé les transcriptions à l’aide d’une analyse thématique inductive. RéSULTATS: Trois patients, huit membres de leur famille, 30 cliniciens (13 médecins, 17 infirmières de 23 unités de soins intensifs canadiennes) et trois décideurs ont participé à ces entrevues. L’analyse thématique a été utilisée pour identifier cinq thèmes : 1) l’acceptation des visites restreintes (p. ex., accepter avec des préoccupations); 2) l’impact des visites restreintes (p. ex., défis éthiques, détresse morale, patients mourant seuls, charge de travail accrue); 3) la confiance dans le système de santé pendant la pandémie (p. ex., méfiance à l’égard de l’équipe clinique); 4) les modes de communication (p. ex., communication à l’aide de plateformes virtuelles); et 5) l’incidence de la mise en œuvre des politiques sur la pratique clinique (p. ex., changements fréquents et mise en œuvre incohérente). CONCLUSION: Les politiques de visite restreintes dans les unités de soins intensifs pendant la pandémie de COVID-19 ont eu un impact négatif sur les patients gravement malades et leurs familles, les intensivistes et les décideurs.

Background Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals. Methods We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate. Results Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (n = 31, 20%) and mental health outcomes (n = 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (n = 107, 69%), connection and communication (n = 107, 69%), and awareness of state of well-being (n = 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (n = 61, 70%), patients (n = 51, 59%), and healthcare professionals (n = 40, 46%). Conclusions Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals. Trial registration: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.

The interplay between critical illness and mental disorders is poorly understood. The purpose of this study is to measure both the treated prevalence of mental disorders and psychotropic medication use before and after hospitalization and the impact of intensive care unit (ICU) admission on these outcomes.Using a population-based administrative database in Manitoba, Canada, 49,439 ICU patients admitted between 2000 and 2012 were compared to two matched comparison groups (hospitalized; n = 146,968 and general population; n = 141,937). Treated prevalence of mental disorders and psychotropic medication prescriptions were measured in the 5-year periods before and after the hospitalization. Multivariable models compared adjusted prevalence ratios (APRs) between populations.The 5-year treated mental disorder prevalence in the ICU population increased from 41.5% pre-hospitalization to 55.6% post-hospitalization. Compared to non-ICU hospitalized patients, the adjusted treated mental disorder prevalence in ICU patients was lower prior to hospitalization (1-year APR 0.94, 95% CI 0.92-0.97, p 0.0001; 5-year APR 0.99, 95% CI 0.98-1.00, p = 0.1), but higher following discharge (1-year APR 1.08, 95% CI 1.05-1.11, p 0.0001, 5-year APR 1.03, 95% CI 1.01-1.05, p 0.0001). A high proportion of ICU patients received antidepressant, anxiolytic and sedative-hypnotic prescriptions before and after their hospitalization. In multivariable analyses, ICU exposure was associated with an increase in mood, anxiety and psychotic disorders, and sedative-hypnotics use (p 0.0001 for all Time × Group interactions).During the 5 years after admission to ICU, there is a significant increase in treated prevalence of mental disorders and psychotropic medication use compared to the 5 years prior to ICU and compared to general population and hospital cohorts. Prevention and intervention programs that identify and treat mental disorders among survivors of critical illness warrant further study.

Objective To estimate incidence of newly diagnosed mental disorders among ICU patients. Design Retrospective-matched cohort study using a population-based administrative database. Setting Manitoba, Canada. Participants A total of 49,439 ICU patients admitted between 2000 and 2012 were compared with two control groups (hospitalized: n = 146,968 and general population: n = 141,937), matched on age (± 2 yr), sex, region of residence, and hospitalization year. Intervention None. Measurements and main results Incident mental disorders (mood, anxiety, substance use, personality, posttraumatic stress disorder, schizophrenia, and psychotic disorders) not diagnosed during the 5-year period before the index ICU or hospital admission date (including matched general population group), but diagnosed during the subsequent 5-year period. Multivariable survival models adjusted for sociodemographic variables, Charlson comorbidity index, admission diagnostic category, and number of ICU and non-ICU exposures. ICU cohort had a 14.5% (95% CI, 14.0-15.0) and 42.7% (95% CI, 42.0-43.5) age- and sex-standardized incidence of any diagnosed mental disorder at 1 and 5 years post-ICU exposure, respectively. In multivariable analysis, ICU cohort had increased risk of any diagnosed mental disorder at all time points versus the hospitalized cohort (year 5: adjusted hazard ratio, 2.00; 95% CI, 1.80-2.23) and the general population cohort (year 5: adjusted hazard ratio, 3.52; 95% CI, 3.23-3.83). A newly diagnosed mental disorder was associated with younger age, female sex, more recent admitting years, presence of preexisting comorbidities, and repeat ICU admission. Conclusions ICU admission is associated with an increased incidence of mood, anxiety, substance use, and personality disorders over a 5-year period.

Objectives:Critical illness can have a significant psychological impact on patients and their families. To inform the design of a larger trial, we assessed feasibility of ICU diaries and psychoeducation to prevent posttraumatic stress disorder, depression, and anxiety following ICU stays.Design:Four

Background The consistently observed male predominance of patients in intensive care units (ICUs) has raised concerns about gender-based disparities in ICU access. Comparing rates of ICU admission requires choosing a normalizing factor (denominator), and the denominator usually used to compare such rates between subpopulations is the size of those subpopulations. However, the appropriate denominator is the number of people whose medical condition warranted ICU care. We devised an estimate of the number of critically ill people in the general population, and used it to compare rates of ICU admission by gender and income. Methods This population-based, retrospective analysis included all adults in the Canadian province of Manitoba, 2004–2015. We created an estimate for the number of critically ill people who warrant ICU care, and used it as the denominator to generate critical illness-normalized rates of ICU admission. These were compared to the usual population-normalized rates of ICU care. Results Men outnumbered women in ICUs for all age groups; population-normalized male:female rate ratios significantly exceed 0 for every age group, ranging from 1.15 to 2.10. Using critical-illness normalized rates, this male predominance largely disappeared; critically ill men and women aged 45–74 years were admitted in equivalent proportions (critical-illness normalized rate ratios 0.96–1.01). While population-normalized rates of ICU care were higher in lower income strata (p

IntroductionFlexible visitation policies in hospitals are an important component of care that contributes to reduced stress and increased satisfaction among patients and their family members. Early evidence suggests restricted visitation policies enacted in hospitals during the COVID-19 pandemic are having unintended consequences on patients, family members and healthcare providers. There is a need for a comprehensive summary of the impacts of restricted visitation policies on key stakeholders and approaches to mitigate that impact.Methods and analysisWe will conduct a scoping review as per the Arksey-O’Malley 5-stage scoping review method and the Scoping Review Methods Manual by the Joanna Briggs Institute. We will search relevant electronic databases (eg, CINAHL, MEDLINE, PsycINFO), grey literature and preprint repositories. We will include all study designs including qualitative and quantitative methodologies (excluding protocols) as well as reports, opinions and editorials, to identify the broad impact of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members or healthcare providers of hospitalised patients, and approaches taken or proposed to mitigate this impact. Two reviewers will calibrate the screening criteria and data abstraction form and will independently screen studies and abstract the data. Narrative synthesis with thematic analysis will be performed.Ethics and disseminationEthical approval is not applicable as this review will be conducted on published literature only. This scoping review will identify, describe and categorise impacts of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members and healthcare providers of hospitalised patients, and approaches that have been taken to mitigate impact. We will provide a comprehensive synthesis by developing a framework of restricted visitation policies and associated impacts. Our results will inform the development of consensus statements on restricted visitation policies to be implemented in future pandemics.PROSPERO registration numberCRD42020221662.

Purpose The purpose was to describe characteristics and outcomes of restrained and nonrestrained patients enrolled in a randomized trial of protocolized sedation compared with protocolized sedation plus daily sedation interruption and to identify patient and treatment factors associated with physical restraint. Methods This was a post hoc secondary analysis using Cox proportional hazards modeling adjusted for center- and time-varying covariates to evaluate predictors of restraint use. Results A total of 328 (76%) of 430 patients were restrained for a median of 4 days. Restrained patients received higher daily doses of benzodiazepines (105 vs 41 mg midazolam equivalent, P μ g fentanyl equivalents, P P P = .02), and more daily benzodiazepine boluses (0.2 vs 0.1, P P = .02) and atypical antipsychotics (17% vs 4%, P = .003). More restrained patients experienced unintentional device removal (26% vs 3%, P P = .01). In the multivariable analysis, alcohol use was associated with decreased risk of restraint (hazard ratio, 0.22; 95% confidence interval, 0.08-0.58). Conclusions Physical restraint was common in mechanically ventilated adults managed with a sedation protocol. Restrained patients received more opioids and benzodiazepines. Except for alcohol use, patient characteristics and treatment factors did not predict restraint use.

IntroductionMechanical ventilation (MV) is an important intervention used in critically ill patients. Accurately identifying MV use in Hospital Discharge Abstracts will be extremely useful in population-based research. Although Canadian Institute for Health Information collects information on MV for all hospitalization, its validity in intensive care unit (ICU) patients is unknown. Objectives and ApproachWe validated MV use within ICU patients in Hospital Discharge Abstracts. Winnipeg Regional Health Authority (WRHA) ICU database prospectively collects use of MV by trained nurses. All patients admitted to a WRHA ICU (82 beds) between April 1, 2000 and March 31, 2012 were identified in Hospital Discharge Abstracts. MV was identified in Hospital Discharge Abstracts through International Classification of Diseases (ICD-9-CM), prior to 2004, while Canadian Classification of Health Interventions (CCI) were used 2004 onwards. Agreement between the WRHA database (gold standard) and Hospital Discharge Abstracts for invasive ventilation, non-invasive ventilation or neither was calculated at ICU encounter level. ResultsThere were 54,680 WRHA ICU admission during the study period. The linking of these two sources was highly successful with accurate identification exceeding 99%. There were 26,083 mechanical ventilations (25,387 invasive; 696 non-invasive) from the Hospital Discharge Abstracts and 30,455 (28,315 invasive; 4,554 non-invasive) from the CIC data. Hospital Discharge Abstracts had a sensitivity of 82.8%, specificity of 96.4%, Positive Predictive Value (PPV) of 96.7%, and Negative Predictive Value (NPV) of 81.7% for identifying mechanical ventilation. For invasive ventilation, Sensitivity was 85.5%, Specificity was 95.6%, PPV was 95.4% and NPV was 86.0%. Validation of non-invasive ventilation was poor in sensitivity (9.38%) and PPV (61.35%): with specificity 99.5% and NPV 92.36%. Conclusion/ImplicationsHospital Abstracts data are a good source to identity mechanically ventilated patients for ICU containing hospital stays especially invasive mechanical ventilations. Future research needs to explore the poor agreement with non-invasive mechanical ventilation.

Further explication of the Potential ICU Admission Pool and critical illness-normalized rates of ICU care. Table S1. Comparison of three different rates of ICU care, by gender and age. Data are unweighted averages over all 11Â years, at the level of individuals. p values compare average rates for women vs men. Table S2. Estimated age composition of male predominance of ICU admission in Manitoba for 2010. Figure S1. Comparison of male:female ratios of four different rates of ICU care, by age. Data are unweighted averages over all 11Â years. Figure S2. Comparison of male:female ratios of four different rates of ICU care, by age. Data are unweighted averages over all 11Â years (DOC 130 kb)

To 1) describe factual, emotional, and delusional memories of ICU stay for patients enrolled in the SLEAP (Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol) trial; 2) compare characteristics of patients with and without ICU recall, and patients with and without delusional memories; and 3) determine factors associated with delusional memories 28 days after ICU discharge.Prospective cohort.Sixteen North American medical and surgical ICUs.Critically ill, mechanically ventilated adults randomized in the SLEAP trial.Post-ICU interviews on days 3, 28, and 90 using the validated ICU Memory Tool.Overall, 289 of 297 ICU survivors (97%) (146 protocolized sedation and 143 protocolized sedation plus daily interruption patients) were interviewed at least once. Because there were no differences in recall status or types of memories between the two sedation groups, we present the findings for all patients rather than by study group. On days 3, 28, and 90, 28%, 26%, and 36% of patients, respectively, reported no recall of being in the ICU (overall perception, self-reported) (p = 0.75). Mean daily doses of benzodiazepines and opioids were lower in patients with no ICU recall than those with recall (p0.0001 for both). Despite one third of patients reporting no recall of ICU stay on day 3, 97% and 90% reported at least one factual and one emotional memory from ICU, respectively. Emotional memories declined with time after ICU discharge, particularly panic and confusion. Delusional memories 28 days after discharge were common (70%) yet unrelated to delirium (p = 0.84), recall status (p = 0.15), total dose of benzodiazepine (p = 0.78), or opioid (p = 0.21). Delusional memories were less likely with longer duration of mechanical ventilation (odds ratio, 0.955; 95% CI, 0.91-1.00; p = 0.04).Recall of ICU stay and types of memories reported were not influenced by the trial sedation strategy. Lack of ICU recall and delusional memories were common after ICU discharge despite the use of sedation strategies that promoted wakefulness.

Many studies of critical illness outcomes have been restricted to short-term outcomes, selected diagnoses, and patients in one or a few intensive care units (ICUs).Evaluate a range of relevant outcomes in a population-based cohort of patients admitted to ICUs.Among all adult residents of the Canadian province of Manitoba admitted to ICUs over a 9-year period, we assessed ICU, hospital, 30-day, and 180-day mortality rates; ICU and hospital lengths-of-stay; Post-hospital use of hospital care, ICU care, outpatient physician care, medications, and home care; and Post-hospital residence location. We explored data stratified by age, sex, and separate categories of geocoded income for urban and rural residents. For Post-hospital use variables we compared ICU patients with those admitted to hospitals without the need for ICU care.After ICU admission there was a high initial death rate, which declined between 30 and 180 days and thereafter remained at the lower value. Hospital mortality was 19.0%, with 21.7% dying within 6 months of ICU admission. Women had higher hospital mortality than men (20.8 vs. 17.8%; P = 0.0008). Among urban residents there was a steady gradient of declining hospital mortality with rising income (P 0.0001). Mean ICU length of stay was 3.96 days, increasing 0.11 d/yr over the study period (P = 0.001); median ICU length of stay was 2.33 days and did not change over time. In the year after ICU care, 41% were rehospitalized, 10% were readmitted to an ICU, 98% had outpatient physician visits, 96% used prescription medications, and 27% used home care services. Although most of these parameters were statistically higher than for hospitalizations not requiring ICU care, differences were generally small. Among hospital survivors, 2.7% were discharged to chronic care facilities, with 2.5% living in such facilities 3 months later.Post-hospital medical resource use among ICU survivors is substantial, although similar to that after non-ICU hospitalization. Although the fraction of survivors unable to live independently was small, a larger fraction required home care services. Identifying Post-hospital supports needed by ICU survivors can be useful for policy makers and others responsible for healthcare planning.

Background Mechanically ventilated patients may receive more sedation during the night than during the day, potentially delaying extubation. We compared nighttime and daytime benzodiazepine and opioid administration in adult patients enrolled in a multicenter sedation trial comparing protocolized sedation alone or protocolized sedation combined with daily sedation interruption; and we evaluated whether nighttime and daytime doses were associated with liberation from mechanical ventilation. Methods This is a secondary analysis of a randomized trial which was conducted in 16 North American medical-surgical ICUs. In all 423 patients, nurses applied a validated sedation scale hourly to titrate benzodiazepine and opioid infusions to achieve a light level of sedation. Using fentanyl equivalents and midazolam equivalents, we compared dosages administered during night (19:00 to 07:00) and day (07:00 to 19:00) shifts. Using multivariable logistic regression we evaluated the association between nighttime and daytime opioid and sedative doses, and spontaneous breathing trial (SBT) conduct, SBT success, and extubation. Results Nighttime benzodiazepine and opioid doses were significantly higher than daytime doses (mean difference midazolam equivalents 23.3 mg, 95 % CI 12.9, 33.8, p

Variation in diurnal sedation in mechanically ventilated patients who are managed with a sedation protocol alone or a sedation protocol and daily interruption. (DOC 74Â kb)

BACKGROUND: During the 2009 H1N1 pandemic (pH1N1), patients requiring mechanical ventilation for respiratory failure received high doses of sedation and analgesia. OBJECTIVE: To examine sedation and analgesia use among patients with respiratory failure due to severe pH1N1 infection compared to other infectious pneumonias. METHODS: In this observational cohort study of intensive care unit (ICU) patients with respiratory failure, we compared doses of sedatives and analgesics administered to patients with pH1N1, non-pH1N1 viral pneumonia, and adult respiratory distress syndrome (ARDS) secondary to bacterial pneumonia, on days 1, 3, 7, 14, and 28 of ICU admission. Cumulative drug use, daily drug use, and weight-adjusted medication doses were examined. RESULTS: The study population consisted of 37 patients with pH1N1 infection, 22 patients with non-pH1N1 viral pneumonia, and 46 patients with ARDS secondary to bacterial pneumonia. To achieve similar levels of sedation using the Richmond Agitation Sedation Scale, patients with pH1N1 were administered the highest cumulative median doses of fentanyl (11, 230 μg; interquartile range [IQR] 3240-21, 000), compared to 2400 μg (IQR 130-7130) in viral pneumonia and 2880 μg (IQR 600-6950) in ARDS (p < 0.001). Patients with pH1N1 were also administered the highest cumulative median doses of midazolam at 820 mg (IQR 330-1160), compared to 160 mg (IQR 20-390) in viral pneumonia and 160 mg (IQR 20-480 mg) in ARDS (p < 0.001). The pH1N1 group received the highest median daily fentanyl and midazolam doses on all study days. The pH1N1 group did not differ significantly in cumulative propofol dose compared with the other 2 study groups. CONCLUSIONS: Sedative and analgesic use may be uniquely higher in critically ill patients with pH1N1 infection compared to patients with other infectious pneumonias. This finding may be important for resource planning in future pandemics. Further study is required to explore the underlying mechanisms for potentially higher sedative and analgesic requirements in this patient population.

Rationale: Many studies of critical illness outcomes have been restricted to short-term outcomes, selected diagnoses, and patients in one or a few Intensive Care Units (ICUs). Objective: Evaluate a range of relevant outcomes in a population-based cohort of patients admitted to ICUs. Methods: Among all adult residents of the Canadian province of Manitoba admitted to ICUs over a nine year period we assessed ICU, hospital, 30 day and 180 day mortality rates; ICU and hospital lengths-of-stay; post-hospital utilization of hospital care, ICU care, outpatient physician care, medications, and home care; and post-hospital residence location. We explored data stratified by age, sex, and separate categories of geocoded income for urban and rural residents. For post-hospital utilization variables we compared ICU patients with those admitted to hospitals without the need for ICU care. Measurements and Main Results: After ICU admission there was a high initial death rate, which declined between 30 and 180 days and ther...

Delirium is common during critical illness and associated with adverse outcomes. We compared characteristics and outcomes of delirious and nondelirious patients enrolled in a multicenter trial comparing protocolized sedation with protocolized sedation plus daily sedation interruption.Randomized trial.Sixteen North American medical and surgical ICUs.Four hundred thirty critically ill, mechanically ventilated adults.All patients had hourly titration of opioid and benzodiazepine infusions using a validated sedation scale. For patients in the interruption group, infusions were resumed, if indicated, at half of previous doses. Delirium screening occurred daily; positive screening was defined as an Intensive Care Delirium Screening Checklist score of 4 or more at any time.Delirium was diagnosed in 226 of 420 assessed patients (53.8%). Coma was identified in 32.7% of delirious compared with 22.7% of nondelirious patients (p = 0.03). The median time to onset of delirium was 3.5 days (interquartile range, 2-7), and the median duration of delirium was 2 days (interquartile range, 1-4). Delirious patients were more likely to be male (61.1% vs 46.6%; p = 0.005), have a surgical/trauma diagnosis (21.2% vs 11.0%; p = 0.030), and history of tobacco (31.5% vs 16.2%; p = 0.002) or alcohol use (34.6% vs 20.9%; p = 0.009). Patients with positive delirium screening had longer duration of ventilation (13 vs 7 d; p0.001), ICU stay (12 vs 8 d; p0.0001), and hospital stay (24 vs 15 d; p0.0001). Delirious patients were more likely to be physically restrained (86.3% vs 76.7%; p = 0.014) and undergo tracheostomy (34.6% vs 15.5%; p0.0001). Antecedent factors independently associated with delirium onset were restraint use (hazard ratio, 1.87; 95% CI, 1.33-2.63; p = 0.0003), antipsychotic administration (hazard ratio, 1.67; 95% CI, 1.005-2.767; p = 0.047), and midazolam dose (hazard ratio, 0.998; 95% CI, 0.997-1.0; p = 0.049). There was no difference in delirium prevalence or duration between the interruption and control groups.In mechanically ventilated adults, delirium was common and associated with longer duration of ventilation and hospitalization. Physical restraint was most strongly associated with delirium.

Objective To compare methods of characterizing intensive care unit (ICU) bed use and estimate the number of beds needed. Study Setting Three geographic regions in the Canadian province of Manitoba. Study Design Retrospective analysis of population-based data from April 1, 2000, to March 31, 2007. Methods We compared three methods to estimate ICU bed requirements. Method 1 analyzed yearly patient-days. Methods 2 and 3 analyzed day-to-day fluctuations in patient census; these differed by whether each hospital needed to independently fulfill its own demand or this resource was shared across hospitals. Principal Findings Three main findings were as follows: (1) estimates based on yearly average usage generally underestimated the number of beds needed compared to analysis of fluctuations in census, especially in the smaller regions where underestimation ranged 25–58 percent; (2) 4–29 percent fewer beds were needed if it was acceptable for demand to exceed supply 18 days/year, versus 4 days/year; and (3) 13–36 percent fewer beds were needed if hospitals within a region could effectively share ICU beds. Conclusions Compared to using yearly averages, analyzing day-to-day fluctuations in patient census gives a more accurate picture of ICU bed use. Failing to provide adequate “surge capacity” can lead to demand that frequently and severely exceeds supply.

To identify the determinants of short-term and long-term survival in adult patients admitted to intensive care units (ICUs). This population-based, observational cohort study included all eleven adult ICUs in the Winnipeg Health Region of Manitoba, Canada, analyzing initial ICU admissions during the period 1999–2010 of all Manitobans ≥17 years old. Analysis included Kaplan–Meier survival curves and multivariable regression models of 30-day mortality and post-90-day survival among those who survived to day 90. We used likelihood ratios to compare the predictive power of clusters of variables in these models. After 33,324 initial ICU admissions, mortality rates within 30 and 90 days were 15.9 and 19.5 %, respectively. The survival curve demonstrated an early phase with a high rate of death, followed by a markedly lower death rate that was only clearly established after several months. 30-day mortality was predominantly determined by characteristics of the acute illness; with its relative contribution set at 1.00, the next largest contributors were age (0.19) and comorbidity (0.16). In contrast, post-90-day mortality was mainly determined by age (relative contribution 1.00) and comorbidity (0.95); the next largest contributor was characteristics of acute illness (0.28). We observed two phases of survival related to critical illness. Short-term mortality was mainly determined by the acute illness, but its effect decayed relatively rapidly. Mortality beyond 3 months, among those who survived to that point, was mainly determined by age and comorbidity. Recognition of these findings is relevant to discussions with patients and surrogates about achievable goals of care.

Background Prior studies of patients leaving hospital against medical advice (AMA) have been limited by not being population-based or assessing only one type of patient. Methods We used administrative data at the Manitoba Centre for Health Policy to evaluate all adult residents of Manitoba, Canada discharged alive from acute care hospitals between April 1, 1990 and February 28, 2009. We identified the rate of leaving AMA, and used multivariable logistic regression to identify socio-demographic and diagnostic variables associated with leaving AMA. Results Of 1 916 104 live hospital discharges, 21 417 (1.11%) ended with the patient leaving AMA. The cohort contained 610 187 individuals, of whom 12 588 (2.06%) left AMA once and another 2 986 (0.49%) left AMA more than once. The proportion of AMA discharges did not change over time. Alcohol and drug abuse was the diagnostic group with the highest proportion of AMA discharges, at 11.71%. Having left AMA previously had the strongest association with leaving AMA (odds ratio 170, 95% confidence interval 156–185). Leaving AMA was more common among men, those with lower average household incomes, histories of alcohol or drug abuse or HIV/AIDS. Major surgical procedures were associated with a much lower chance of leaving the hospital AMA. Conclusions The rate of leaving hospital AMA did not systematically change over time, but did vary based on patient and illness characteristics. Having left AMA in the past was highly predictive of subsequent AMA events.

Background: Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death. Methods: In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice. Results: Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18–2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99–2.21; between-person OR 3.04, CI 2.79–3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge. Interpretation: Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.

Protocolized sedation and daily sedation interruption are 2 strategies to minimize sedation and reduce the duration of mechanical ventilation and intensive care unit (ICU) stay. We hypothesized that combining these strategies would augment the benefits.To compare protocolized sedation with protocolized sedation plus daily sedation interruption in critically ill patients.Randomized controlled trial of 430 critically ill, mechanically ventilated adults conducted in 16 tertiary care medical and surgical ICUs in Canada and the United States between January 2008 and July 2011.Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation. For patients receiving daily interruption, nurses resumed infusions, if indicated, at half of previous doses. Patients were assessed for delirium and for readiness for unassisted breathing.Time to successful extubation. Secondary outcomes included duration of stay, doses of sedatives and opioids, unintentional device removal, delirium, and nurse and respiratory therapist clinical workload (on a 10-point visual analog scale [VAS]).Median time to successful extubation was 7 days in both the interruption and control groups (median [IQR], 7 [4-13] vs 7 [3-12]; interruption group hazard ratio, 1.08; 95% CI, 0.86-1.35; P = .52). Duration of ICU stay (median [IQR], 10 [5-17] days vs 10 [6-20] days; P = .36) and hospital stay (median [IQR], 20 [10-36] days vs 20 [10-48] days; P = .42) did not differ between the daily interruption and control groups, respectively. Daily interruption was associated with higher mean daily doses of midazolam (102 mg/d vs 82 mg/d; P = .04) and fentanyl (median [IQR], 550 [50-1850] vs 260 [0-1400]; P.001) and more daily boluses of benzodiazepines (mean, 0.253 vs 0.177; P = .007) and opiates (mean, 2.18 vs 1.79; P.001). Unintentional endotracheal tube removal occurred in 10 of 214 (4.7%) vs 12 of 207 patients (5.8%) in the interruption and control groups, respectively (relative risk, 0.82; 95% CI, 0.36-1.84; P = .64). Rates of delirium were not significantly different between groups (53.3% vs 54.1%; relative risk, 0.98; 95% CI, 0.82-1.17; P = .83). Nurse workload was greater in the interruption group (VAS score, 4.22 vs 3.80; mean difference, 0.41; 95% CI, 0.17-0.66; P = .001).For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.clinicaltrials.gov Identifier: NCT00675363.

Background Databases used to study the care of patients in hospitals and Intensive Care Units (ICUs) typically contain a separate entry for each segment of hospital or ICU care. However, it is not uncommon for patients to be transferred between hospitals and/or ICUs, and when transfers occur it is necessary to combine individual entries to accurately reconstruct the complete episodes of hospital and ICU care. Failure to do so can lead to erroneous lengths-of-stay, and rates of admissions, readmissions, and death. Methods This study used a clinical ICU database and administrative hospital abstracts for the adult population of Manitoba, Canada from 2000–2008. We compared five methods for identifying patient transfers and constructing hospital episodes, and the ICU episodes contained within them. Method 1 ignored transfers. Methods 2–5 considered the time gap between successive entries (≤1 day vs. ≤2 days), with or without use of data fields indicating inter-hospital transfer. For the five methods we compared the resulting number and lengths of hospital and ICU episodes. Results During the study period, 48,551 hospital abstracts contained 53,246 ICU records. For Method 1 these were also the number of hospital and ICU episodes, respectively. Methods 2–5 gave remarkably similar results, with transfers included in approximately 25% of ICU-containing hospital episodes, and 10% of ICU episodes. Comparison with Method 1 showed that failure to account for such transfers resulted in overestimating the number of episodes by 7-10%, and underestimating mean or median lengths-of-stay by 9-30%. Conclusions In Manitoba is it not uncommon for critically ill patients to be transferred between hospitals and between ICUs. Failure to account for transfers resulted in inaccurate assessment of parameters relevant to researchers, clinicians, and policy-makers. The details of the method used to identify transfers, at least among the variations tested, made relatively little difference. In addition, we showed that these methods for constructing episodes of hospital and ICU care can be implemented in a large, complex dataset.

Background A prerequisite for using administrative data to study the care of critically ill patients in intensive care units (ICUs) is that it accurately identifies such care. Only limited data exist on this subject. Objective To assess the accuracy of administrative data in the Canadian province of Manitoba for identifying the existence, number, and timing of admissions to adult ICUs. Research design For the period 1999 to 2008, we compared information about ICU care from Manitoba hospital abstracts, with the criterion standard of a clinical ICU database that includes all admissions to adult ICUs in its largest city of Winnipeg. Comparisons were made before and after a national change in administrative data requirements that mandated specific data elements identifying the existence and timing of ICU care. Results In both time intervals, hospital abstracts were extremely accurate in identifying the presence of ICU care, with positive predictive values exceeding 98% and negative predictive values exceeding 99%. Administrative data correctly identified the number of separate ICU admissions for 93% of ICU-containing hospitalizations; inaccuracy increased with more ICU stays per hospitalization. Hospital abstracts were highly accurate for identifying the timing of ICU care, but only for hospitalizations containing a single ICU admission. Conclusions Under current national-reporting requirements, hospital administrative data in Canada can be used to accurately identify and quantify ICU care. The high accuracy of Manitoba administrative data under the previous reporting standards, which lacked standardized coding elements specific to ICU care, may not be generalizable to other Canadian jurisdictions.

To determine whether a lack of intensive care unit beds was leading to premature patient discharge from the intensive care unit and subsequent early readmission or death.Prospective cohort study.A single Canadian tertiary care teaching hospital.All intensive care unit admissions between January 1, 1989 and December 31, 1996 were collected prospectively for inclusion in a registry database.None.There was a positive correlation between early readmission or death and average quarterly intensive care unit percent occupancy (p = .001). During the study period, 8693 patients experienced 10,185 admissions to intensive care. Of the 8222 patients remaining under active treatment (patients under palliative care were excluded), there were 455 (5.5%) adverse events (431 intensive care unit readmissions and 24 deaths) in the first 7 days post intensive care unit discharge. Patients requiring a new surgical intervention with postoperative intensive care unit admission were not considered readmissions. In a multivariate analysis, significant risk factors for an adverse event included age35 yrs, particular diagnoses (respiratory diagnoses, sepsis, neurosurgery, thoracic surgery, and gastrointestinal diagnoses), Acute Physiology and Chronic Health Evaluation II score, and intensive care unit length of stay. Discharge from the intensive care unit at a time of no vacancy was also a significant risk factor for intensive care unit readmission or unexpected death with an adjusted relative risk of 1.56 (95% confidence interval 1.05, 2.31).Increased patient occupancy within an intensive care unit is associated with an increased risk of early death or intensive care unit readmission post intensive care unit discharge. Overloading the capacity of an intensive care unit to care for critically ill patients may affect physician decision-making, resulting in premature discharge from the intensive care unit.

To determine the role of the Tat protein of the human immunodeficiency virus type 1 (HIV-1) in the pathogenesis of HIV-1 associated dementia, recombinant Tat was injected intraventricularly as a single or repeated dose into male Sprague-Dawley rats. Histopathological evaluation showed an initial infiltration of neutrophils one day after Tat injection, followed by macrophages and lymphocytes by 7 days. Tat-injected brains also exhibited astrocytosis, apoptotic cells, and ventricular enlargement 7 days following the last injection. Nuclear magnetic resonance spectroscopic analysis of tissue extracts of hippocampi from Tat-injected rats showed a decrease in the glutamate/g aminobutyric acid ratio. We conclude that the transient extracellular exposure of the central nervous system to Tat protein of HIV can cause a cascade of events leading to the influx of inflammatory cells, glial cell activation, and neurotoxicity.