BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
Summary Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision‐making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision‐making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient‐centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient’s functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision‐making. However, a supportive, adequately resourced context is also needed.
BACKGROUND: Nutrition in the first 1000 days between pregnancy and 24 months of life is critical for child health, and exclusive breastfeeding is promoted as the infant's best source of nutrition in the first 6 months. Caffeine is a central nervous system stimulant occurring naturally in some foods and used to treat primary apnoea in premature babies. However high caffeine intake can be harmful, and caffeine is transmitted into breastmilk. AIM: To systematically review the evidence on the effects of maternal caffeine consumption during breastfeeding on the breastfed child. : METHOD: A systematic search was conducted to October 2017 in MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane Library. The British Library catalogue, which covers doctoral theses, was searched and PRISMA guidelines followed. Two reviewers screened for experimental, cohort, or case-control studies and performed independent quality assessment using the Newcastle-Ottawa scale. The main reviewer performed data extraction, checked by the second reviewer. RESULTS: Two cohort, two crossover studies, and one N-of-1 trial were included for narrative synthesis. One crossover and two cohort studies of small sample sizes directly investigated maternal caffeine consumption. No significant effects on 24-hour heart rate, 24-hour sleep time, or frequent night waking of the breastfed child were found. One study found a decreased rate of full breastfeeding at 6 months postpartum. Two studies indirectly investigated caffeine exposure. Maternal chocolate and coffee consumption was associated with increased infant colic, and severe to moderate exacerbation of infant atopic dermatitis. However, whether caffeine was the causal ingredient is questionable. The insufficient and inconsistent evidence available had quality issues impeding conclusions on the effects of maternal caffeine consumption on the breastfed child.CONCLUSION: Evidence for recommendations on caffeine intake for breastfeeding women is scant, of limited quality and inconclusive. Birth cohort studies investigating the potential positive and negative effects of various levels of maternal caffeine consumption on the breastfed child and breastfeeding mother could improve the knowledge base and allow evidence-based advice for breastfeeding mothers.Systematic review registration number: CRD42017078790
BACKGROUNDPatient safety is a key concern of anaesthesiology practice. However, good practices are often not widely shared between departments and hospitals, whether within or between countries.OBJECTIVEWe aimed to collect and analyse safety practices and tips from anaesthesiology departments around Europe in order to facilitate successful transfer of safety knowledge.DESIGNReview of previously collected safety practices; allocation of numerical scores in order to rank them on 0–5 scales in terms of anticipated impact, and speed, cost, and ease of implementation; free text comment on any possible difficulties or unintended harms which might arise from adopting any of the collected practices.SETTINGCollaborative remote working of expert group.PARTICIPANTSNineteen experts in patient safety in anaesthesiology from nine European countries.MAIN OUTCOME MEASURESRankings of safety practices for anticipated practice impact, cost, speed, and ease of implementation.RESULTSWe collected 117 practices. The highest-ranked items for potential beneficial impact were: standardising the layout of drug trolleys (4.82); involving all staff in new safety initiatives in the operating theatre (4.73); ensuring patients’ medical records are available at the time of surgery (4.71); running regular simulation training sessions in departments of anaesthesia (4.67); and creating a difficult airway management trolley (4.65). A major theme to emerge from the qualitative analysis of the experts’ free text comments was the risk that practices aimed at enhancing patient safety might not achieve the effect intended, as introducing new safety activities can cause more mistakes during the implementation phase.CONCLUSIONMany useful practices to promote patient safety were identified, but as some practices appear to be context-dependent, we recommend that a proper, prospective risk assessment is carried out before they are introduced in a new setting. The full list of items is available online as Supplementary Digital Content, http://links.lww.com/EJA/A785.TRIAL REGISTRATIONNot applicable.
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