Sebastian M. Ugarte

Delirium epidemiology in critical care (DECCA): an international study

IntroductionDelirium is a frequent source of morbidity in intensive care units (ICUs). Most data on its epidemiology is from single-center studies. Our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in the ICU.MethodsA 1-day point-prevalence study was undertaken in 104 ICUs from 11 countries in South and North America and Spain.ResultsIn total, 975 patients were screened, and 497 fulfilled inclusion criteria and were enrolled (median age, 62 years; 52.5% men; 16.7% and 19.9% for ICU and hospital mortality); 64% were admitted to the ICU because of medical causes, and sepsis was the main diagnosis (n = 76; 15.3%). In total, 265 patients were sedated with the Richmond agitation and sedation scale (RASS) deeper than -3, and only 232 (46.6%) patients could be evaluated with the confusion-assessment method for the ICU. The prevalence of delirium was 32.3%. Compared with patients without delirium, those with the diagnosis of delirium had a greater severity of illness at admission, demonstrated by higher sequential organ-failure assessment (SOFA (P = 0.004)) and simplified acute physiology score 3 (SAPS3) scores (P < 0.0001). Delirium was associated with increased ICU (20% versus 5.7%; P = 0.002) and hospital mortality (24 versus 8.3%; P = 0.0017), and longer ICU (P < 0.0001) and hospital length of stay (LOS) (22 (11 to 40) versus 7 (4 to 18) days; P < 0.0001). Previous use of midazolam (P = 0.009) was more frequent in patients with delirium. On multivariate analysis, delirium was independently associated with increased ICU mortality (OR = 3.14 (1.26 to 7.86); CI, 95%) and hospital mortality (OR = 2.5 (1.1 to 5.7); CI, 95%).ConclusionsIn this 1-day international study, delirium was frequent and associated with increased mortality and ICU LOS. The main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives (midazolam).

Clinical characteristics and outcomes of patients with 2009 influenza A(H1N1) virus infection with respiratory failure requiring mechanical ventilation

PURPOSE The purpose of the study was to describe the clinical characteristics and outcomes of critically ill patients with 2009 influenza A(H1N1). METHODS An observational study of patients with confirmed or probable 2009 influenza A(H1N1) and respiratory failure requiring mechanical ventilation was performed. RESULTS We studied 96 patients (mean age, 45 [14] years [mean, SD]; 44% female). Shock and acute respiratory distress syndrome were diagnosed during the first 72 hours of admission in 43% and 72% of patients, respectively. Noninvasive positive pressure ventilation was used in 45% of the patients, but failed in 77% of them. Bacterial pneumonia was diagnosed in 33% of cases, 8% during the first week (due to community-acquired microorganisms) and 25% after the first week (due to gram-negative bacilli and resistant gram-positive cocci). Intensive care unit mortality was 50%. Nonsurvivors differed from survivors in the prevalence of cardiovascular, respiratory, and hematologic failure on admission and late pneumonia. Reported causes of death were refractory hypoxia, multiorgan failure, and shock (50%, 38%, and 12% of all causes of death, respectively). CONCLUSIONS Patients with 2009 influenza A(H1N1) and respiratory failure requiring mechanical ventilation often present with clinical criteria of acute respiratory distress syndrome and shock. Bacterial pneumonia is a frequent complication. Mortality is high and is primarily due to refractory hypoxia.

Evidence-based guidelines for the use of tracheostomy in critically ill patients.

Objectives: To provide evidence‐based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. Methods: A taskforce composed of representatives of 10 member countries of the Pan‐American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. Results: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. Conclusions: Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long‐term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico

OBJECTIVES Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Does better quality contracting improve pay and HR practices?: Evidence from for-profit and voluntary sector providers of adult care services in England

This article investigates the complex interaction between contracting arrangements and quality of human resources (HR) practices. It draws on quantitative and qualitative empirical evidence for the adult social care sector in England where most services are purchased by local authorities and delivered by private for-profit and voluntary sector organisations. The study finds sufficient evidence among surveyed care providers that higher fees and partnership-oriented contracting have positive influences on pay levels and quality of HR practices to suggest that better local authority contracting may be an enabling condition for the improvement of employment standards. However, the relatively weak statistical associations suggest other factors mediate, or distort, the anticipated relationship between quality of contracting and quality of HR practices. The type of provider is identified as a key mediator: private, for-profit providers and those managed by a national chain are least likely to distribute the benefits of better quality contracting fairly through improved employment standards.

The gender pay implications of institutional and organisational wage-setting practices in Banking – a case study of Argentina and Chile

Abstract This research explores the extent to which the interaction among payment systems and institutional arrangements together with internal and external labour market (ELM) dynamics influence gender pay processes and career progress for men and women graduates in the banking sectors of Argentina and Chile. The research follows a qualitative methods approach for the banking sector. The more inclusive Argentinian industrial relations system, reinforced by above-market collective pay agreements in banking and the economic instability of recent years, has restricted inter-firm mobility and generated a more gender-neutral distributional pay effect for graduates. By contrast, the more decentralised and individually-driven Chilean wage-setting system incentivises Chilean graduates to be more reactive to ELM opportunities to improve their wages. However, this greater mobility tends to benefit more men than women graduates because women tend to be more attached to their organisations. They also find their wage bargaining position weakened as a result of gender stereotyping, which reflects employer prejudices constructed in reaction to family support policies that are more generous than those in Argentina. Finally, the research argues that the more inclusive Argentinian industrial relations system limits gender bias in pay by providing more formalisation, centralisation and transparency in pay decisions compared to the more discretionally-driven decisions of the Chilean HRM system.