Thomas Fassier

Conflicts and communication gaps in the intensive care unit.

Purpose of reviewConflicts occur frequently in the ICU. Research on ICU conflicts is an emerging field, with only few recent studies being available on intrateam and team–family conflicts. Research on communication in the ICU is developing at a faster pace. Recent findingsRecent findings come from one multinational epidemiological survey on intrateam conflicts and one qualitative study on the causes and consequences of conflicts. Advances in research on communication with families in the ICU have improved our understanding of team–family and intrateam conflicts, thus suggesting targets for improvement. SummaryData about ICU conflicts depend on conflict definition, study designs (qualitative versus quantitative), patient case-mix, and detection bias. Conflicts perceived by caregivers are frequent and consist mainly in intrateam conflicts. The two main sources of conflicts in the ICU are end-of-life decisions and communication issues. Conflicts negatively impact patient safety, patient/family-centered care, and team welfare and cohesion. They generate staff burnout and increase healthcare costs. Further qualitative studies rooted in social-science theories about workplace conflicts are needed to better understand the typology of ICU conflicts (sources and consequences) and to address complex ICU conflicts that involve systems as opposed to people. Conflict prevention and resolution are complex issues requiring multimodal interventions. Clinical research in this field is insufficiently developed, and no guidelines are available so far. Prevention strategies need to be developed along two axes: improved understanding of family experience, preferences, and values, as well as evidence-based communication may reduce team–family conflicts and organizational measures including restoring leadership, multidisciplinary teamwork, and improved communication within the team may prevent intrateam conflicts in the ICU.

Care at the end of life in critically ill patients: the European perspective.

Purpose of reviewCare surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe. Recent findingsAlthough decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patients autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity. SummaryTo optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.

One-day quantitative cross-sectional study of family information time in 90 intensive care units in France

Rationale: Providing family members with clear, honest, and timely information is a major task for intensive care unit physicians. Time spent informing families has been associated with effectiveness of information but has not been measured in specifically designed studies. Objectives: To measure time spent informing families of intensive care unit patients. Methods: One‐day cross‐sectional study in 90 intensive care units in France. Measurements: Clocked time spent by physicians informing the families of each of 951 patients hospitalized in the intensive care unit during a 24‐hr period. Main Results: Median family information time was 16 (interquartile range, 8–30) mins per patient, with 20% of the time spent explaining the diagnosis, 20% on explaining treatments, and 60% on explaining the prognosis. One third of the time was spent listening to family members. Multivariable analysis identified one factor associated with less information time (room with more than one bed) and seven factors associated with more information time, including five patient‐related factors (surgery on the study day, higher Logistic Organ Dysfunction score, coma, mechanical ventilation, and worsening clinical status) and two family‐related factors (first contact with family and interview with the spouse). Median information time was 20 (interquartile range, 10–39) mins when three factors were present and 106.5 (interquartile range, 103–110) mins when five were present. Conclusion: This study identifies factors associated with information time provided by critical care physicians to family members of critically ill patients. Whether information time correlates with communication difficulties or communication skills needs to be evaluated. Information time provided by residents and nurses should be studied.

Impact of a multifaceted program to prevent postoperative delirium in the elderly: the CONFUCIUS stepped wedge protocol

BackgroundPostoperative delirium is common in the elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology based on randomized study design. Our purpose is to present the methodology and expected results of the CONFUCIUS trial, which aims to measure the impact of a multifaceted program on the prevention of postoperative delirium in elderly.Method/DesignStudy design is a stepped wedge cluster randomized trial within 3 surgical wards of three French university hospitals. All patients aged 75 and older, and admitted for scheduled surgery will be included. The multifaceted program will be conducted by mobile geriatric team, including geriatric preoperative consultation, training of the surgical staff and implementation of the Hospital Elder Life Program, and morbidity and mortality conference related to delirium cases. The primary outcome is based on postoperative delirium rate within 7 days after surgery. This program is planned to be implemented along four successive time periods within all the surgical wards. Each one will be affected successively to the control arm and to the intervention arm of the trial and the order of program introduction within each surgical ward will be randomly assigned. Based on a 20% reduction of postoperative delirium rate (ICC = 0.25, α = 0.05, β = 0.1), three hundred sixty patients will be included i.e. thirty patients per service and per time period. Endpoints comparison between intervention and control arms of the trial will be performed by considering the cluster and time effects.DiscussionBetter prevention of delirium is expected from the multifaceted program, including a decrease of postoperative delirium, and its consequences (mortality, morbidity, postoperative complications and length of hospital stay) among elderly patients. This study should allow better diagnosis of delirium and strengthen the collaboration between surgical and mobile geriatric teams. Should the program have a substantial impact on the prevention of postoperative delirium in elderly, it could be extended to other facilities.Trial registrationClinicalTrials.gov: NCT01316965

Misdiagnosed Postpartum Psychosis Revealing a late-onset Urea Cycle Disorder

pected. on readmission to the obstetric ward, her treatment included risperidone (2 mg/day), alprazolam (1.5 mg/day), the phenothiazine antipsychotic cyamemazine (62.5 mg/day), and the anticholinergic tropatepine (10 mg/day). Antibiotic treatment was started to treat a possible infection. Unlike in her previous postpartum episodes, Mrs. G’s mental status responded only partially to antipsychotic treatment. A liaison psychiatry consultation was requested. the liaison psychiatrist found a mildly agitated and disoriented young woman who had wet herself and was circling around her bed. the patient was logorrheic, and her speech, which was mostly incoherent, revealed memory impairment. Strikingly, this mild state of confusion fluctuated during the interview, confirming midwives’ reports of hourly changes in the patient’s behavior. Mrs. G anxiously expressed feelings of guilt toward her newborn and the belief that her diagnosis of postpartum psychosis made her less able to take care of her children. She displayed no anger toward her children and no ideas of persecution, infanticide, or suicide. She also expressed the belief that “God talks to humankind through premonitory dreams or providential meetings,” a claim that had previously been interpreted as a mystic delusion. However, it appeared that this view was part of her cultural and religious background, as was later confirmed by her husband, who reported that she had held this belief for a long time and that it was shared by her relatives. overall, Mrs. G was more confused and less delusional than one would have expected in a typical postpartum psychosis. Puzzled by this clinical picture, the psychiatrist reconsidered the diagnosis of postpartum psychosis and extended his examination to assess the differential diagnosis. He found that Mrs. G had chronic headaches and a habitual reluctance to consume meat. His clinical examination revealed little; the patient had a well-tolerated fever, stable blood pressure and pulse, and no signs of severe sepsis. A neurological examination was unremarkable. the psychiatrist ordered immediate blood tests, including ammonia levels. Within an hour, hyperammonemia was confirmed (224 μmol/liter, controls <50 μmol/liter), along with a respiratory alkalosis and a marked inflammatory syndrome. Results of liver function tests, as well as all the other blood tests, were normal. the psychiatrist contacted the internal medicine fellow, who confirmed the need for an immediate multidisciplinary management of a probable late-onset urea cycle disorder. He decided to transfer the patient to the intensive care unit (ICU), despite the reluctance of the obstetrical team, who felt that the patient should instead be in a secure psychiatric facility. In the ICU, an etiologic treatment of urea cycle disorderinduced hyperammonemia was immediately started unMisdiagnosed Postpartum Psychosis Revealing a late-onset Urea Cycle Disorder

Elderly patients hospitalized in the ICU in France: a population-based study using secondary data from the national hospital discharge database

RATIONALE, AIMS AND OBJECTIVES In the global context of population ageing, understanding and monitoring intensive care use by the elderly is a strategic issue. National-level data are needed to overcome sampling biases that often limit epidemiologic studies of the critically ill elderly. The objective of this study was to describe intensive care use for hospitalized elderly patients using secondary data from the French national hospital discharge database. METHOD Structured assessment of the national database coverage and accuracy; cross-sectional analysis of hospitalizations including at least one admission in an intensive care unit (ICU) for patients aged ≥ 80 years from 1 January to 31 December 2009. RESULTS In 2009, people aged ≥ 80 years accounted for 5.4% of the population but 15.3% of the 215 210 adult hospitalizations involving intensive care in France. In this elderly group, the mean age was 84.0 (± 3.56) years, and 51.6% were male. In-hospital mortality was 33.9%. The median time spent in the ICU was 3 [interquartile range (IQR), 2-8] days, the median time spent in hospital was 14 (IQR, 8-24) days and 9% of hospitalizations ended by the patients death involved intensive care. A surgical procedure was included in 43% of hospitalizations. Medical and surgical diagnosis-related group hospitalizations were characterized by significant differences in volume, mortality, ICU days and costs. CONCLUSIONS There was marked clinical heterogeneity in the population of elderly patients hospitalized in the ICU. These data provide baseline information and prompt further studies comparing intensive care utilization across age groups, between countries and over time.

Elderly patients hospitalized in the ICU in France

RATIONALE, AIMS AND OBJECTIVES In the global context of population ageing, understanding and monitoring intensive care use by the elderly is a strategic issue. National-level data are needed to overcome sampling biases that often limit epidemiologic studies of the critically ill elderly. The objective of this study was to describe intensive care use for hospitalized elderly patients using secondary data from the French national hospital discharge database. METHOD Structured assessment of the national database coverage and accuracy; cross-sectional analysis of hospitalizations including at least one admission in an intensive care unit (ICU) for patients aged ≥ 80 years from 1 January to 31 December 2009. RESULTS In 2009, people aged ≥ 80 years accounted for 5.4% of the population but 15.3% of the 215 210 adult hospitalizations involving intensive care in France. In this elderly group, the mean age was 84.0 (± 3.56) years, and 51.6% were male. In-hospital mortality was 33.9%. The median time spent in the ICU was 3 [interquartile range (IQR), 2-8] days, the median time spent in hospital was 14 (IQR, 8-24) days and 9% of hospitalizations ended by the patients death involved intensive care. A surgical procedure was included in 43% of hospitalizations. Medical and surgical diagnosis-related group hospitalizations were characterized by significant differences in volume, mortality, ICU days and costs. CONCLUSIONS There was marked clinical heterogeneity in the population of elderly patients hospitalized in the ICU. These data provide baseline information and prompt further studies comparing intensive care utilization across age groups, between countries and over time.

Mise au pointÉlévation modérée, persistante et inexpliquée des transaminasesUnexplained, subclinical chronically elevated transaminases

Unexplained, subclinical chronically elevated transaminases is mainly a marker of non-alcoholic fatty liver disease, metabolic syndrome, alcoholism and diabetes, which are very common situations but viral hepatitis and iatrogenic origin must also be considered. Before looking for hepatic or genetic rare diseases, it is worth considering hypertransaminasemia as a clue for muscular disease, particularly in paediatric settings, and creatine phosphokinase is a specific marker. Then, patient history, examination and appropriate biologic requests can permit the identification of less frequent disorders where isolated hypertransaminasemia is possibly the unique marker of the disease for a long while: hemochromatosis, celiac disease, autoimmune hepatitis, Wilsons disease, α1-anti-trypsine deficiency, thyroid dysfunctions, Addisons disease. Liver biopsy should be performed only in patients with aspartate aminotransferases upper the normal range or alanine aminotransferases higher than twice the normal range after 6 months delay with dietetic corrections.

Élévation modérée, persistante et inexpliquée des transaminases

Unexplained, subclinical chronically elevated transaminases is mainly a marker of non-alcoholic fatty liver disease, metabolic syndrome, alcoholism and diabetes, which are very common situations but viral hepatitis and iatrogenic origin must also be considered. Before looking for hepatic or genetic rare diseases, it is worth considering hypertransaminasemia as a clue for muscular disease, particularly in paediatric settings, and creatine phosphokinase is a specific marker. Then, patient history, examination and appropriate biologic requests can permit the identification of less frequent disorders where isolated hypertransaminasemia is possibly the unique marker of the disease for a long while: hemochromatosis, celiac disease, autoimmune hepatitis, Wilsons disease, α1-anti-trypsine deficiency, thyroid dysfunctions, Addisons disease. Liver biopsy should be performed only in patients with aspartate aminotransferases upper the normal range or alanine aminotransferases higher than twice the normal range after 6 months delay with dietetic corrections.

Decision to forgo life-sustaining therapies for elderly critically ill patients is a multidisciplinary challenge

Dear Editor, We read with attention the article by Le Conte et al. [1] concerning decision to forgo life-sustaining therapies (DFLST) in the emergency department (ED). Sharing Kompanje’s point of view [2] about the burning question of elderly care in the ED, we wish to add the following comment. DFLST for the elderly critically ill patient is a multidisciplinary challenge. In any case it should be cooped up in the ED. Methodological points can be debated. Only 2,512 patients died in 174 ED during 4 months, accounting for less than one death weekly by department, on average. Given that no information was available regarding the exhaustiveness of the detection of death cases, we cannot judge about the representativeness of the audited sample. Moreover, DFLST was studied only in patients dying in the ED. Yet, patients may die following emergency discharge, with or without DFLST. Thus, the lack of inpatient follow-up may have compromised the relevance of the studied sample. DFLST is a hard task. Time constraints and overcrowding, the rare information regarding patients’ characteristics and advance directives, and the lack of emergency staff training in geriatrics and palliative care make it especially difficult in the ED [3]. This life-and-death decision becomes even more difficult for the elderly, because they come to the ED as a heterogeneous cohort of both potentially treatable patients and dying patients. Thus, DFLST for critically ill patients requires multidisciplinarity [4]. Le Conte et al.’s results highlight how this is critical in the emergency setting: only 32.7% of DFLST involved medical advice from outside the ED. This raises questions about the different physicians’ implication in the decision-making process. Why did it so rarely involve the general practitioner? Supposed to be the primary ‘‘referent physician’’ in the French health-care system, he participated in only 4.8% of the decisions. Did it involve the intensivist? No details were provided about ICU refusal, a known form of DFLSTs among patients aged 80 and over [5]. Did it imply a correct geriatric evaluation? No specific geriatric scales were used. Were end-of-life needs assessed and met? Reported data about palliative care use for these dying patients are alarming. We suggest the following ideas for a research agenda about DFLST and end-of-life care in the emergency setting. Observational, patient-centred and multidisciplinary designs are required. Given the complexity of frail patients’ trajectories, sometimes jeopardizing the quality and safety of care, prospective cohorts are needed to assess the outcome of care following ED discharge, especially in the ICU and other hospital wards. Qualitative studies can be conducted to understand the decision-making process, inside the ED in the case of emergency, but also in the general practitioner’s office and in the nursing home, when advance decisions are possible. Only a better understanding of the decision-making process throughout the whole patient care pathway will lead to care improvement. This implies fast-track and careful multidisciplinary DFLST, appropriate intensive care and improved end-of-life care for the elderly critically ill.