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Background: Thiamine di-phosphate is an essential cofactor in glucose metabolism, glutamate transformation and acetylcholinesterase activity, pathways associated with delirium occurrence. We hypothesised that a deficiency in whole blood thiamine and intravenous thiamine supplementation could impact delirium occurrence. Aim: To establish whether a deficiency in whole blood thiamine and/or intravenous thiamine supplementation within 72 h of intensive care admission is associated with delirium occurrence. Method: The first dataset was secondary analysis of a previous study in an intensive care unit in the Netherlands, reported in 2017. The second dataset contained consecutive intensive care admissions 2 years before (period 1: October 2014 to October 2016) and after (period 2: April 2017 to April 2019) routine thiamine supplementation was introduced within 72 h of admission. Delirium was defined as a positive Confusion Assessment Method-Intensive Care Unit score(s) in 24 h. Results: Analysis of the first dataset (n = 57) using logistic regression showed no relationship between delirium and sepsis or whole blood thiamine, but a significant association with age (p = 0.014). In the second dataset (n = 3074), 15.1% received IV thiamine in period 1 and 62.6% during period 2. Hierarchical regression analysis reported reduction in delirium occurrence in the second period; this did not reach statistical significance, OR = 0.81 (95% CI 0.652–1.002); p = 0.052. Conclusion: No relationship was detected between whole blood thiamine and delirium occurrence on admission, at 24 and 48 h. It remains unclear whether routine intravenous thiamine supplementation during intensive care admission impacts delirium occurrence. Further prospective randomised clinical trials are needed. [ABSTRACT FROM AUTHOR]

Introduction: Many COVID-19 survivors suffer from persisting sequelae after acute disease. This is referred to as long COVID. The objectives of this study were to assess factors associated with long COVID and to analyze differences in persistent symptoms, findings on chest imaging, and pulmonary function between intensive care unit (ICU) and non-ICU hospitalized patients. Methods: We conducted a retrospective study including patients hospitalized with COVID-19. Patients were stratified into ICU patients and non-ICU patients. We analyzed the outcomes of patients who were in clinical follow-up 6 months after discharge with persistent symptoms, radiological and/or functional abnormalities. Logistic regression was used to examine the association between long COVID and patient characteristics. Results: A total of 549 patients were included. Eighty-one ICU patients (66%) and 146 (34%) non-ICU patients had persistent symptoms or abnormalities on chest imaging or lung function test minimally 6 months after discharge. Significantly more ICU patients had residual fibrotic abnormalities on chest CT and functional impairment. Female gender, myocardial infarction, OSAS, low PCO2 at admission, and longer hospital stay were associated with a higher risk of developing long COVID. Diabetes and treatment with tocilizumab were associated with a lower risk of developing long COVID. Conclusion: Of the patients hospitalized for COVID-19, 34–66% suffered from persistent symptoms, residual abnormalities on chest imaging, or reduced lung function at around 6 months after discharge. While persistent sequelae were more frequent in ICU patients, admission to the ICU was not found to be an independent risk factor for developing long COVID. [ABSTRACT FROM AUTHOR]

Objective: This study aims (1) to understand the needs and challenges of the current intensive care unit (ICU) environments in supporting patient well-being from the perspective of healthcare professionals (HCPs) and (2) to explore the new potential of ICU environments enabled by technology. Background: Evidence-based design has yielded how the design of environments can advocate for patient well-being, and digital technology offers new possibilities for indoor environments. However, the role of technology in facilitating ICU patient well-being has been unexplored. Method: This study was conducted in two phases. First, a mixed-method study was conducted with ICU HCPs from four Dutch hospitals. The study investigated the current environmental support for care activities, as well as the factors that positively and negatively contribute to patient experience. Next, a co-creation session was held involving HCPs and health technology experts to explore opportunities for technology to support ICU patient well-being. Results: The mixed-method study revealed nine negative and eight positive patient experience factors. HCPs perceived patient emotional care as most challenging due to the ICU workload and a lack of environmental support in fulfilling patient emotional needs. The co-creation session yielded nine technology-enabled solutions to address identified challenges. Finally, drawing from insights from both studies, four strategies were introduced that guide toward creating technology to provide holistic and personalized care for patients. Conclusion: Patient experience factors are intertwined, necessitating a multifactorial approach to support patient well-being. Viewing the ICU environment as a holistic unit, our findings provide guidance on creating healing environments using technology. [ABSTRACT FROM AUTHOR]

Background: Previously, we reported a decreased mortality rate among patients with COVID-19 who were admitted at the ICU during the final upsurge of the second wave (February–June 2021) in the Netherlands. We examined whether this decrease persisted during the third wave and the phases with decreasing incidence of COVID-19 thereafter and brought up to date the information on patient characteristics. Methods: Data from the National Intensive Care Evaluation (NICE)-registry of all COVID-19 patients admitted to an ICU in the Netherlands were used. Patient characteristics and rates of in-hospital mortality (the primary outcome) during the consecutive periods after the first wave (periods 2–9, May 25, 2020–January 31, 2023) were compared with those during the first wave (period 1, February–May 24, 2020). Results: After adjustment for patient characteristics and ICU occupancy rate, the mortality risk during the initial upsurge of the third wave (period 6, October 5, 2021–January, 31, 2022) was similar to that of the first wave (ORadj = 1.01, 95%-CI [0.88–1.16]). The mortality rates thereafter decreased again (e.g., period 9, October 5, 2022–January, 31, 2023: ORadj = 0.52, 95%-CI [0.41–0.66]). Among the SARS-CoV-2 positive patients, there was a huge drop in the proportion of patients with COVID-19 as main reason for ICU admission: from 88.2% during the initial upsurge of the third wave to 51.7%, 37.3%, and 41.9% for the periods thereafter. Restricting the analysis to these patients did not modify the results on mortality. Conclusions: The results show variation in mortality rates among critically ill COVID-19 patients across the calendar time periods that is not explained by differences in case-mix and ICU occupancy rates or by varying proportions of patients with COVID-19 as main reason for ICU admission. The consistent increase in mortality during the initial, rising phase of each separate wave might be caused by the increased virulence of the contemporary virus strain and lacking immunity to the new strain, besides unmeasured patient-, treatment- and healthcare system characteristics. [ABSTRACT FROM AUTHOR]

Aims: Knowledge about adverse drug events caused by drug–drug interactions (DDI‐ADEs) is limited. We aimed to provide detailed insights about DDI‐ADEs related to three frequent, high‐risk potential DDIs (pDDIs) in the critical care setting: pDDIs with international normalized ratio increase (INR+) potential, pDDIs with acute kidney injury (AKI) potential, and pDDIs with QTc prolongation potential. Methods: We extracted routinely collected retrospective data from electronic health records of intensive care units (ICUs) patients (≥18 years), admitted to ten hospitals in the Netherlands between January 2010 and September 2019. We used computerized triggers (e‐triggers) to preselect patients with potential DDI‐ADEs. Between September 2020 and October 2021, clinical experts conducted a retrospective manual patient chart review on a subset of preselected patients, and assessed causality, severity, preventability, and contribution to ICU length of stay of DDI‐ADEs using internationally prevailing standards. Results: In total 85 422 patients with ≥1 pDDI were included. Of these patients, 32 820 (38.4%) have been exposed to one of the three pDDIs. In the exposed group, 1141 (3.5%) patients were preselected using e‐triggers. Of 237 patients (21%) assessed, 155 (65.4%) experienced an actual DDI‐ADE; 52.9% had severity level of serious or higher, 75.5% were preventable, and 19.3% contributed to a longer ICU length of stay. The positive predictive value was the highest for DDI‐INR+ e‐trigger (0.76), followed by DDI‐AKI e‐trigger (0.57). Conclusion: The highly preventable nature and severity of DDI‐ADEs, calls for action to optimize ICU patient safety. Use of e‐triggers proved to be a promising preselection strategy. [ABSTRACT FROM AUTHOR]

Purpose: The unprecedented influx of patients in 2020 with COVID-19 to intensive care units (ICU) required redeployment of healthcare professionals without adequate previous ICUtraining. In these extraordinary circumstances, pivotal elements of effective clinical supervision emerged. This study sets out to explore the nature, aspects and key features of supervision under highly demanding circumstances among certified and redeployed healthcare professionals on COVID-19 ICUs. Materials and methods: A prospective qualitative, single center, semi-structured interview study among healthcare professionals at COVID-19 ICUs at University Medical Center Utrecht, the Netherlands between July and December 2020. Interview data were analyzed using an inductive coding style. Results: A total of 13 certified and 13 redeployed health'hcare professionals, including physicians, nurses, and operation room technicians participated. Seven themes were identified as essential for both certified (supervisors) and redeployed (trainees) personnel: an open attitude, observing boundaries, gauging coworkers' capacities, being available, providing feedback, continuity in care and teams, and combining supervision with workload. Conclusions: This study provides seven recommendations for both supervisors and trainees to help optimize clinical supervision. They align with the known five factors determining entrustment and supervision (trainee, supervisor, task, context, and relationship). To ensure good clinical supervision, be it either during normal circumstances or under pressure, efforts should primarily focus on factors that are within a supervisor or trainee's span of control. [ABSTRACT FROM AUTHOR]

Aim: We explored professionals' views on sharing decision‐making with parents before and after an extremely preterm birth and what healthcare professionals considered severe outcomes. Methods: A nationwide, multi‐centre online survey was carried out among a wide range of perinatal healthcare professionals in the Netherlands from 4 November 2020 to 10 January 2021. The medical chairs of all nine Dutch Level III and IV perinatal centres helped to disseminate the survey link. Results: We received 769 survey responses. Most respondents (53%) preferred to place equal emphasis on two treatment options during shared prenatal decision‐making: early intensive care or palliative comfort care. The majority (61%) wanted to include a conditional intensive care trial as a third treatment option, but 25% disagreed. Most (78%) felt that healthcare professionals were responsible for initiating postnatal conversations to justify continuing or withdrawing neonatal intensive care if complications were associated with poor outcomes. Finally, 43% were satisfied with the current definitions of severe long‐term outcomes, 41% were unsure and there were numerous for a broader definition. Conclusion: Although Dutch professionals expressed diverse preferences on how to reach decisions about extremely premature infants, we observed a trend towards shared decision‐making with parents. These results could inform future guidelines. [ABSTRACT FROM AUTHOR]

Introduction: In intensive care unit (ICU) patients with acute kidney injury, specific recommendations to guide the decision to cease continuous kidney replacement therapy (CKRT) are lacking. Methods: We performed a survey to identify criteria currently used to cease CKRT in real-life clinical practice in the Netherlands. We used an online questionnaire with multiple choice questions designed with web-based software from SurveyMonkey. Results: We received 169 completed questionnaires from intensivists (n = 126) and nephrologists (n = 43). Essential determinants for the cessation of CKRT were a spontaneously increasing diuresis (indicated by 92% of the respondents), absence of fluid overload (indicated by 88% of the respondents), and improvement in creatinine clearance (indicated by 61% of the respondents; intensivists 56%; nephrologists 77%, p = 0.03). Most often mentioned cut-off values used for increase in diuresis were 0.25 and 0.5 mL/kg/h (35% and 33%, respectively). Actual CKRT cessation was often postponed until the filter clots or until circuit disconnection is needed because of patient transport for diagnostic or intervention procedures (indicated by 58% of the respondents). Expected discharge from the ICU was the most frequently reported determinant to switch from CKRT to hemodialysis (indicated by 67% of the respondents). Conclusions: CKRT cessation in clinical practice is mostly based on spontaneously increasing diuresis, absence of fluid overload, and improvement in creatinine clearance and is often delayed until filter clotting or disconnection of the circuit because of logistic reasons. [ABSTRACT FROM AUTHOR]

Involvement of families in physiotherapy-related tasks of critically ill patients could be beneficial for both patients and their family. Before designing an intervention regarding family participation in the physiotherapy-related care of critically ill patients, there is a need to investigate the opinions of critically ill patients, their family and staff members in detail. Exploring the perceptions of critically ill patients, their family and staff members regarding family participation in physiotherapy-related tasks of critically ill patients and the future intervention. A multicenter study with a qualitative design is presented. Semistructured interviews were conducted with critically ill patients, family and intensive care staff members, until theoretical saturation was reached. The conventional content method was used for data analyses. Altogether 18 interviews were conducted between May 2019 and February 2020. In total, 22 participants were interviewed: four patients, five family members, and 13 ICU staff members. Six themes emerged: 1) prerequisites for family participation (e.g., permission and capability); 2) timing and interactive aspects of engaging family (e.g., communication); 3) eligibility of patients and family (e.g., first-degree relatives and spouses, and long stay patients); 4) suitability of physiotherapy-related tasks for family (e.g., passive, active and breathing exercises); 5) expected effects (e.g., physical recovery and psychological wellbeing); and 6) barriers and facilitators, which may affect the feasibility (e.g., safety, privacy, and responsibility). Patients, family members and staff members supported the idea of increased family participation in physiotherapy-related tasks and suggested components of an intervention. These findings are necessary to further design and investigate family participation in physiotherapy-related tasks. [ABSTRACT FROM AUTHOR]

Rationale: The positive end-expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID-19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO 2 ventilation on outcomes during the second wave in the Netherlands., Methods: Retrospective observational study of invasively ventilated COVID-19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90-day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality., Results: This analysis included 790 COVID-ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46-0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings., Conclusions: High PEEP ventilation was associated with improved ICU survival in patients with COVID-ARDS., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Timely identification of deteriorating COVID-19 patients is needed to guide changes in clinical management and admission to intensive care units (ICUs). There is significant concern that widely used Early warning scores (EWSs) underestimate illness severity in COVID-19 patients and therefore, we developed an early warning model specifically for COVID-19 patients. Methods: We retrospectively collected electronic medical record data to extract predictors and used these to fit a random forest model. To simulate the situation in which the model would have been developed after the first and implemented during the second COVID-19 'wave' in the Netherlands, we performed a temporal validation by splitting all included patients into groups admitted before and after August 1, 2020. Furthermore, we propose a method for dynamic model updating to retain model performance over time. We evaluated model discrimination and calibration, performed a decision curve analysis, and quantified the importance of predictors using SHapley Additive exPlanations values. Results: We included 3514 COVID-19 patient admissions from six Dutch hospitals between February 2020 and May 2021, and included a total of 18 predictors for model fitting. The model showed a higher discriminative performance in terms of partial area under the receiver operating characteristic curve (0.82 [0.80–0.84]) compared to the National early warning score (0.72 [0.69–0.74]) and the Modified early warning score (0.67 [0.65–0.69]), a greater net benefit over a range of clinically relevant model thresholds, and relatively good calibration (intercept = 0.03 [− 0.09 to 0.14], slope = 0.79 [0.73–0.86]). Conclusions: This study shows the potential benefit of moving from early warning models for the general inpatient population to models for specific patient groups. Further (independent) validation of the model is needed. [ABSTRACT FROM AUTHOR]

Background: Thirst is one of the most intense and distressing symptoms experienced by patients in the intensive care unit (ICU), and no validated measurement tools exist. Validating a thirst measurement tool for the ICU population could be a first step in gaining a better understanding of thirst in ICU patients and aid the development and implementation of strategies regarding the prevention and control of thirst. Aim: The objective of this study was to determine the validity and reliability of the "Thirst distress scale for patients with heart failure (TDS‐HF)" in measuring thirst distress in adult ICU patients. Methods: Content validity was established by an expert panel consisting of ICU nurses, intensivists and five ICU patients. Concurrent validity, known‐groups validity and internal consistency were determined in a consecutive sample of 56 awake and oriented ICU patients with a median age of 70 years (IQR: 57‐74). Results: Content validity of the TDS‐HF in the ICU population was low, with item‐content validity indexes between 0.25 and 0.75. Concurrent validity was high as Spearman's correlation between TDS‐HF and the numeric rating score (0‐10) for thirst distress was 0.71. Internal consistency was high (Cronbach's alpha 0.78). When comparing groups, only higher blood urea nitrogen was significantly related to higher scores on the TDS‐HF (P =.003). Conclusion: The TDS‐HF has high concurrent validity and reliability in measuring thirst distress in ICU patients. Nevertheless, questions remain regarding the applicability and content validity of the scale, which should be further explored before the TDS‐HF can be used in the ICU. Relevance for clinical practice: The TDS‐HF can be used to explore thirst distress and to evaluate interventions. Individual items of the scale can be used to explore the nature of thirst distress in individual patients. [ABSTRACT FROM AUTHOR]

Background: Oxygen therapy is a widely used intervention in acutely ill patients in the intensive care unit (ICU). It is established that not only hypoxia, but also prolonged hyperoxia is associated with poor patient-centered outcomes. Nevertheless, a fundamental knowledge gap remains regarding optimal oxygenation for critically ill patients. In this randomized clinical trial, we aim to compare ventilation that uses conservative oxygenation targets with ventilation that uses conventional oxygen targets with respect to mortality in ICU patients.Methods: The "ConservatIve versus CONventional oxygenation targets in Intensive Care patients" trial (ICONIC) is an investigator-initiated, international, multicenter, randomized clinical two-arm trial in ventilated adult ICU patients. The ICONIC trial will run in multiple ICUs in The Netherlands and Italy to enroll 1512 ventilated patients. ICU patients with an expected mechanical ventilation time of more than 24 h are randomized to a ventilation strategy that uses conservative (PaO2 55-80 mmHg (7.3-10.7 kPa)) or conventional (PaO2 110-150 mmHg (14.7-20 kPa)) oxygenation targets. The primary endpoint is 28-day mortality. Secondary endpoints are ventilator-free days at day 28, ICU mortality, in-hospital mortality, 90-day mortality, ICU- and hospital length of stay, ischemic events, quality of life, and patient opinion of research and consent in the emergency setting.Discussion: The ICONIC trial is expected to provide evidence on the effects of conservative versus conventional oxygenation targets in the ICU population. This study may guide targeted oxygen therapy in the future.Trial Registration: Trialregister.nl NTR7376 . Registered on 20 July, 2018. [ABSTRACT FROM AUTHOR]

Background: To assess trends in the quality of care for COVID-19 patients at the ICU over the course of time in the Netherlands. Methods: Data from the National Intensive Care Evaluation (NICE)-registry of all COVID-19 patients admitted to an ICU in the Netherlands were used. Patient characteristics and indicators of quality of care during the first two upsurges (N = 4215: October 5, 2020–January 31, 2021) and the final upsurge of the second wave, called the 'third wave' (N = 4602: February 1, 2021–June 30, 2021) were compared with those during the first wave (N = 2733, February–May 24, 2020). Results: During the second and third wave, there were less patients treated with mechanical ventilation (58.1 and 58.2%) and vasoactive drugs (48.0 and 44.7%) compared to the first wave (79.1% and 67.2%, respectively). The occupancy rates as fraction of occupancy in 2019 (1.68 and 1.55 vs. 1.83), the numbers of ICU relocations (23.8 and 27.6 vs. 32.3%) and the mean length of stay at the ICU (HRs of ICU discharge = 1.26 and 1.42) were lower during the second and third wave. No difference in adjusted hospital mortality between the second wave and the first wave was found, whereas the mortality during the third wave was considerably lower (OR = 0.80, 95% CI [0.71–0.90]). Conclusions: These data show favorable shifts in the treatment of COVID-19 patients at the ICU over time. The adjusted mortality decreased in the third wave. The high ICU occupancy rate early in the pandemic does probably not explain the high mortality associated with COVID-19. [ABSTRACT FROM AUTHOR]

The primary aim of this study was to evaluate computed tomography (CT)-based bone density analysis at the level of thoracic vertebra 12 (Th12) as a screening method for decreased bone density in patients admitted to the intensive care unit (ICU). Interobserver variability was analyzed. Secondary aims were to assess the prevalence of CT-based low bone density upon ICU admission in a cohort of COVID-19 patients and to assess the potential effect of long-term ICU stay on bone density in these patients. Retrospective single-center cohort study. ICU of the Leiden University Medical Center (LUMC), the Netherlands. Patients admitted to the ICU of the LUMC between March 1st, 2020 and February 1st, 2022 with a diagnosis of COVID-19, and a length of ICU stay of ≥ 21 days. In the included patients both baseline chest CT scans (obtained upon ICU admission) and follow-up chest CT scans (obtained ≥ 21 days after ICU admission) were available for analysis. A total of 118 CT scans in 38 patients were analyzed. There was a good interobserver variability, with an overall mean absolute difference (between measurements of three observers) of 9.7 Hounsfield Units (HU) and an intraclass correlation coefficient (ICC) of 0.93 (95% CI 0.88-0.96). The effect of intravenous contrast administration on bone density measurements was small (+ 7.5 HU (95% CI 3.4-11.5 HU)) higher in contrast enhanced CT images compared to non contrast enhanced CT images). Thirty-seven percent of patients had a bone density < 140 HU, suggestive of osteoporosis. No significant difference was found between bone density upon ICU admission and bone density at follow-up (≥ 21 days after ICU admission). Vertebral CT-based bone density analysis using routine CT scans is an easily applicable method to identify ICU patients with decreased bone density, which could enable enrollment in osteoporosis prevention programs. A high prevalence of low bone density was found in our cohort of ICU patients. There were no changes observed in bone density between baseline and follow-up measurements., (© 2024. The Author(s).)

Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day.Measurements and Main Results: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion. [ABSTRACT FROM AUTHOR]

Objectives: Haloperidol is commonly administered in the ICU to reduce the burden of delirium and its related symptoms despite no clear evidence showing haloperidol helps to resolve delirium or improve survival. We evaluated the association between haloperidol, when used to treat incident ICU delirium and its symptoms, and mortality.Design: Post hoc cohort analysis of a randomized, double-blind, placebo-controlled, delirium prevention trial.Setting: Fourteen Dutch ICUs between July 2013 and December 2016.Patients: One-thousand four-hundred ninety-five critically ill adults free from delirium at ICU admission having an expected ICU stay greater than or equal to 2 days.Interventions: Patients received preventive haloperidol or placebo for up to 28 days until delirium occurrence, death, or ICU discharge. If delirium occurred, treatment with open-label IV haloperidol 2 mg tid (up to 5 mg tid per delirium symptoms) was administered at clinician discretion.Measurements and Main Results: Patients were evaluated tid for delirium and coma for 28 days. Time-varying Cox hazards models were constructed for 28-day and 90-day mortality, controlling for study-arm, delirium and coma days, age, Acute Physiology and Chronic Health Evaluation-II score, sepsis, mechanical ventilation, and ICU length of stay. Among the 1,495 patients, 542 (36%) developed delirium within 28 days (median [interquartile range] with delirium 4 d [2-7 d]). A total of 477 of 542 (88%) received treatment haloperidol (2.1 mg [1.0-3.8 mg] daily) for 6 days (3-11 d). Each milligram of treatment haloperidol administered daily was associated with decreased mortality at 28 days (hazard ratio, 0.93; 95% CI, 0.91-0.95) and 90 days (hazard ratio, 0.97; 95% CI, 0.96-0.98). Treatment haloperidol administered later in the ICU course was less protective of death. Results were stable by prevention study-arm, predelirium haloperidol exposure, and haloperidol treatment protocol adherence.Conclusions: Treatment of incident delirium and its symptoms with haloperidol may be associated with a dose-dependent improvement in survival. Future randomized trials need to confirm these results. [ABSTRACT FROM AUTHOR]

Background: The incidence of pulmonary thromboembolism is high in SARS-CoV-2 patients admitted to the Intensive Care. Elevated biomarkers of coagulation (fibrinogen and D-dimer) and inflammation (c-reactive protein (CRP) and ferritin) are associated with poor outcome in SARS-CoV-2. Whether the time-course of fibrinogen, D-dimer, CRP and ferritin is associated with the occurrence of pulmonary thromboembolism in SARS-CoV-2 patients is unknown. We hypothesise that patients on mechanical ventilation with SARS-CoV-2 infection and clinical pulmonary thromboembolism have lower concentrations of fibrinogen and higher D-dimer, CRP, and ferritin concentrations over time compared to patients without a clinical pulmonary thromboembolism. Methods: In a prospective study, fibrinogen, D-dimer, CRP and ferritin were measured daily. Clinical suspected pulmonary thromboembolism was either confirmed or excluded based on computed tomography pulmonary angiography (CTPA) or by transthoracic ultrasound (TTU) (i.e., right-sided cardiac thrombus). In addition, patients who received therapy with recombinant tissue plasminogen activator were included when clinical instability in suspected pulmonary thromboembolism did not allow CTPA. Serial data were analysed using a mixed-effects linear regression model, and models were adjusted for known risk factors (age, sex, APACHE-II score, body mass index), biomarkers of coagulation and inflammation, and anticoagulants. Results: Thirty-one patients were considered to suffer from pulmonary thromboembolism ((positive CTPA (n = 27), TTU positive (n = 1), therapy with recombinant tissue plasminogen activator (n = 3)), and eight patients with negative CTPA were included. After adjustment for known risk factors and anticoagulants, patients with, compared to those without, clinical pulmonary thromboembolism had lower average fibrinogen concentration of − 0.9 g/L (95% CI: − 1.6 – − 0.1) and lower average ferritin concentration of − 1045 μg/L (95% CI: − 1983 – − 106) over time. D-dimer and CRP average concentration did not significantly differ, 561 μg/L (− 6212–7334) and 27 mg/L (− 32–86) respectively. Ferritin lost statistical significance, both in sensitivity analysis and after adjustment for fibrinogen and D-dimer. Conclusion: Lower average concentrations of fibrinogen over time were associated with the presence of clinical pulmonary thromboembolism in patients at the Intensive Care, whereas D-dimer, CRP and ferritin were not. Lower concentrations over time may indicate the consumption of fibrinogen related to thrombus formation in the pulmonary vessels. [ABSTRACT FROM AUTHOR]

OBJECTIVES: ICU professionals are at risk of developing burnout due to coronavirus disease 2019. This study assesses the prevalence and incidence of burnout symptoms and moral distress in ICU professionals before and during the coronavirus disease 2019 crisis. DESIGN: This is a longitudinal open cohort study. SETTING: Five ICUs based in a single university medical center plus another adult ICU based on a separate teaching hospital in the Netherlands. SUBJECTS: All ICU professionals were sent a baseline survey in October-December 2019 (252 respondents, response rate: 53%), and a follow-up survey was sent in May-June 2020 (233 respondents, response rate: 50%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Burnout symptoms and moral distress measured with the Maslach Burnout Inventory and the Moral Distress Scale, respectively. The prevalence of burnout symptoms was 23.0% before coronavirus disease 2019 and 36.1% at postpeak time, with higher rates in nurses (38.0%) than in physicians (28.6%). Reversely, the incidence rate of new burnout cases among physicians was higher (26.7%) than nurses (21.9%). Higher prevalence of burnout symptoms was observed in the postpeak coronavirus disease 2019 period (odds ratio, 1.83; 95% CI, 1.32-2.53), for nurses (odds ratio, 1.77; 95% CI, 1.03-3.04), for professionals working overtime (odds ratio 2.11; 95% CI, 1.48-3.02), and for professionals directly engaged with care for coronavirus disease 2019 patients (odds ratio, 1.87; 95% CI, 1.35-2.60). Physicians were more likely than nurses to develop burnout symptoms due to coronavirus disease 2019 (odds ratio, 3.56; 95% CI, 1.06-12.21). CONCLUSIONS: This study shows that overburdening of ICU professionals during an extended period of time leads to symptoms of burnout. Working long hours and under conditions of scarcity of staff, time, and resources comes at the price of ICU professionals' mental health. [ABSTRACT FROM AUTHOR]

Objectives: Although the Surviving Sepsis Campaign bundle recommends obtaining blood cultures within 1 hour of sepsis recognition, adherence is suboptimal in many settings. We, therefore, implemented routine blood culture collection for all nonelective ICU admissions (regardless of infection suspicion) and evaluated its diagnostic yield.Design: A before-after analysis.Setting: A mixed-ICU of a tertiary care hospital in the Netherlands.Patients: Patients acutely admitted to the ICU between January 2015 and December 2018.Measurements and Main Results: Automatic orders for collecting a single set of blood cultures immediately upon ICU admission were implemented on January 1, 2017. Blood culture results and the impact of contaminated blood cultures were compared for 2015-2016 (before period) and 2017-2018 (after period). Positive blood cultures were categorized as bloodstream infection or contamination. Blood cultures were obtained in 573 of 1,775 patients (32.3%) and in 1,582 of 1,871 patients (84.5%) in the before and after periods, respectively (p < 0.0001), and bloodstream infection was diagnosed in 95 patients (5.4%) and 154 patients (8.2%) in both study periods (relative risk 1.5; 95% CI 1.2-2.0; p = 0.0006). The estimated number needed to culture for one additional patient with bloodstream infection was 17. Blood culture contamination occurred in 40 patients (2.3%) and 180 patients (9.6%) in the before period and after period, respectively (relative risk 4.3; 95% CI 3.0-6.0; p < 0.0001). Rate of vancomycin use or presumed episodes of catheter-related bloodstream infections treated with antibiotics did not differ between both study periods.Conclusions: Implementation of routine blood cultures was associated with a 1.5-fold increase of detected bloodstream infection. The 4.3-fold increase in contaminated blood cultures was not associated with an increase in vancomycin use in the ICU. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8, protein C and bicarbonate have been identified in patients admitted with acute respiratory distress syndrome (ARDS) that are prognostic of outcome and predictive of treatment response. We hypothesized that if these inflammatory subphenotypes previously identified among ARDS patients are assigned at ICU discharge in a more general critically ill population, they are associated with short- and long-term outcome., Methods: A secondary analysis of a prospective observational cohort study conducted in two Dutch ICUs between 2011 and 2014 was performed. All patients discharged alive from the ICU were at ICU discharge adjudicated to the previously identified inflammatory subphenotypes applying a validated parsimonious model using variables measured median 10.6 h [IQR, 8.0-31.4] prior to ICU discharge. Subphenotype distribution at ICU discharge, clinical characteristics and outcomes were analyzed. As a sensitivity analysis, a latent class analysis (LCA) was executed for subphenotype identification based on plasma protein biomarkers at ICU discharge reflective of coagulation activation, endothelial cell activation and inflammation. Concordance between the subphenotyping strategies was studied., Results: Of the 8332 patients included in the original cohort, 1483 ICU-survivors had plasma biomarkers available and could be assigned to the inflammatory subphenotypes. At ICU discharge 6% (n = 86) was assigned to the hyperinflammatory and 94% (n = 1397) to the hypoinflammatory subphenotype. Patients assigned to the hyperinflammatory subphenotype were discharged with signs of more severe organ dysfunction (SOFA scores 7 [IQR 5-9] vs. 4 [IQR 2-6], p < 0.001). Mortality was higher in patients assigned to the hyperinflammatory subphenotype (30-day mortality 21% vs. 11%, p = 0.005; one-year mortality 48% vs. 28%, p < 0.001). LCA deemed 2 subphenotypes most suitable. ICU-survivors from class 1 had significantly higher mortality compared to class 2. Patients belonging to the hyperinflammatory subphenotype were mainly in class 1., Conclusions: Patients assigned to the hyperinflammatory subphenotype at ICU discharge showed significantly stronger anomalies in coagulation activation, endothelial cell activation and inflammation pathways implicated in the pathogenesis of critical disease and increased mortality until one-year follow up., (© 2024. The Author(s).)

• Exposure to drugs with anticholinergic effects before ICU admission increases the risk of developing delirium. • The effect is more pronounced in the first days of the ICU admission. • Advanced age and septic shock increases the risk for delirium in ICU patients. • The ADS scale can be effectively used to measure anticholinergic load in ICU patients. Anticholinergic drugs may increase the risk of delirium in non-critically ill patients, but it is unclear whether exposure to these drugs is also a risk factor for Intensive Care Unit (ICU) delirium. In this study the hypothesis was tested that anticholinergic drug exposure at ICU admission increases the risk to develop delirium during ICU stay, particularly in patients with advanced age and severe sepsis. A prospective cohort study was performed in the mixed 32-bed medical-surgical ICU of the University Medical Center Utrecht, the Netherlands in the period from January 2011 till June 2013. Included were nonneurological patients that were consecutively admitted for more than 24 hours. The presence of delirium was evaluated each day using a validated algorithm based on the Confusion Assessment Method for the ICU (CAM-ICU), the initiation of delirium treatment as well as chart review by researchers. Anticholinergic drug exposure at ICU admission was assessed using the Anticholinergic Drug Scale (ADS). To evaluate the association between anticholinergic drug exposure at ICU admission and the risk of developing delirium, we performed multivariable competing risk Cox proportional hazard analysis corrected for confounding factors. Approximately half (47%, n=513) of the 1090 included patients developed delirium during ICU admission. The absolute risk for delirium development increased with more anticholinergic drug exposure: 42% in patients with ADS score=0, 49% in patients with ADS score=1, and 53% in patients with ADS higher than 1. Taking competing events (death and discharge) and potential confounding factors into account, the subdistribution hazard ratio (SHR) was 1.13 (95% CI: 0.91-1.40) for ADS score=1 point and 1.35 (95% CI: 1.09-1.68) for ADS ≥2 compared with an ADS score=0 (no anticholinergic drug exposure). The effect was strongest during the first days of ICU admittance and was strongest in patients above 65 year without severe sepsis and/or septic shock (SHR 2.15, 95% CI 1.43-3.25). Anticholinergic drug exposure at ICU admission increases the risk of delirium in critically ill patients. This effect was most pronounced in patients older than 65 years without severe sepsis and/or septic shock, and declining over time. [ABSTRACT FROM AUTHOR]

Background: Multiple factors contribute to mortality after ICU, but it is unclear how the predictive value of these factors changes during ICU admission. We aimed to compare the changing performance over time of the acute illness component, antecedent patient characteristics, and ICU length of stay (LOS) in predicting 1-year mortality.Methods: In this retrospective observational cohort study, the discriminative value of four generalized mixed-effects models was compared for 1-year and hospital mortality. Among patients with increasing ICU LOS, the models included (a) acute illness factors and antecedent patient characteristics combined, (b) acute component only, (c) antecedent patient characteristics only, and (d) ICU LOS. For each analysis, discrimination was measured by area under the receiver operating characteristics curve (AUC), calculated using the bootstrap method. Statistical significance between the models was assessed using the DeLong method (p value < 0.05).Results: In 400,248 ICU patients observed, hospital mortality was 11.8% and 1-year mortality 21.8%. At ICU admission, the combined model predicted 1-year mortality with an AUC of 0.84 (95% CI 0.84-0.84). When analyzed separately, the acute component progressively lost predictive power. From an ICU admission of at least 3 days, antecedent characteristics significantly exceeded the predictive value of the acute component for 1-year mortality, AUC 0.68 (95% CI 0.68-0.69) versus 0.67 (95% CI 0.67-0.68) (p value < 0.001). For hospital mortality, antecedent characteristics outperformed the acute component from a LOS of at least 7 days, comprising 7.8% of patients and accounting for 52.4% of all bed days. ICU LOS predicted 1-year mortality with an AUC of 0.52 (95% CI 0.51-0.53) and hospital mortality with an AUC of 0.54 (95% CI 0.53-0.55) for patients with a LOS of at least 7 days.Conclusions: Comparing the predictive value of factors influencing 1-year mortality for patients with increasing ICU LOS, antecedent patient characteristics are more predictive than the acute component for patients with an ICU LOS of at least 3 days. For hospital mortality, antecedent patient characteristics outperform the acute component for patients with an ICU LOS of at least 7 days. After the first week of ICU admission, LOS itself is not predictive of hospital nor 1-year mortality. [ABSTRACT FROM AUTHOR]

Objectives: Studies have shown contradicting results on the association of nursing workload and mortality. Most of these studies expressed workload as patients per nurse ratios; however, this does not take into account that some patients require more nursing time than others. Nursing time can be quantified by tools like the Nursing Activities Score. We investigated the association of the Nursing Activities Score per nurse ratio, respectively, the patients per nurse ratio with in-hospital mortality in ICUs.Design: Retrospective analysis of the National Intensive Care Evaluation database.Setting: Fifteen Dutch ICUs.Patients: All ICU patients admitted to and registered ICU nurses working at 15 Dutch ICUs between January 1, 2016, and January 1, 2018, were included. The association of mean or day 1 patients per nurse ratio and Nursing Activities Score per nurse ratio with in-hospital mortality was analyzed using logistic regression models.Interventions: None.Measurements and Main Results: Nursing Activities Score per nurse ratio greater than 41 for both mean Nursing Activities Score per nurse ratio as well as Nursing Activities Score per nurse ratio on day 1 were associated with a higher in-hospital mortality (odds ratios, 1.19 and 1.17, respectively). After case-mix adjustment the association between a Nursing Activities Score per nurse ratio greater than 61 for both mean Nursing Activities Score per nurse ratio as well as Nursing Activities Score per nurse ratio on day 1 and in-hospital mortality remained significant (odds ratios, 1.29 and 1.26, respectively). Patients per nurse ratio was not associated with in-hospital mortality.Conclusions: A higher Nursing Activities Score per nurse ratio was associated with higher in-hospital mortality. In contrast, no association was found between patients per nurse ratios and in-hospital mortality in The Netherlands. Therefore, we conclude that it is more important to focus on the nursing workload that the patients generate rather than on the number of patients the nurse has to take care of in the ICU. [ABSTRACT FROM AUTHOR]

Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments. • ICU professionals use paradigmatic cases to address ethical issues. • Paradigm cases include spinal cord injury patients and patients with cancer. • Casuistic reasoning is not always critically appraised by ICU professionals. • Case-analogies from the literature can provide a false sense of moral certainty. • Clinicians should be trained so that they can appraise casuistic arguments. [ABSTRACT FROM AUTHOR]

Objective: Acute kidney injury requiring continuous renal replacement therapy is a serious treatment-related complication in pediatric cancer and hematopoietic stem cell transplant patients. The purpose of this study was to assess epidemiology and outcome of these patients requiring continuous renal replacement therapy in the PICU.Design: A nationwide, multicenter, retrospective, observational study.Setting: Eight PICUs of a tertiary care hospitals in the Netherlands.Patients: Pediatric cancer and hematopoietic stem cell transplant patients (cancer and noncancer) who received continuous renal replacement therapy from January 2006 to July 2017 in the Netherlands.Interventions: None.Measurement and Main Results: Of 1,927 PICU admissions of pediatric cancer and hematopoietic stem cell transplant patients, 68 of 70 evaluable patients who received continuous renal replacement therapy were included. Raw PICU mortality was 11.2% (216/1,972 admissions). PICU mortality of patients requiring continuous renal replacement therapy was 54.4% (37/68 patients). Fluid overload (odds ratio, 1.08; 95% CI, 1.01-1.17) and need for inotropic support (odds ratio, 6.53; 95% CI, 1.86-23.08) at the start of continuous renal replacement therapy were associated with PICU mortality. Serum creatinine levels increased above 150% of baseline 3 days before the start of continuous renal replacement therapy. Urine production did not reach the critical limit of oliguria. In contrast, body weight (fluid overload) increased already 5 days prior to continuous renal replacement therapy initiation.Conclusions: PICU mortality of pediatric cancer and hematopoietic stem cell transplant patients requiring continuous renal replacement therapy is sadly high. Fluid overload at the initiation of continuous renal replacement therapy is the most important and earliest predictor of PICU mortality. Our results suggest that the most commonly used criteria of acute kidney injury, that is, serum creatinine and urine production, are not useful as a trigger to initiate continuous renal replacement therapy. This highlights the urgent need for prospective studies to generate recommendations for effective therapeutic interventions at an early phase in this specific patient population. [ABSTRACT FROM AUTHOR]

Background: Systematic assessment of pain is necessary for adequate treatment of pain. Patient self‐reported pain is a superior assessment but is of limited use for intubated patients in the intensive care unit. For these patients, the critical‐care pain observation tool (CPOT) has been developed. Aim: To perform a validation of the Dutch CPOT. Study design: Cross‐sectional observational study. Methods: The Dutch translation of the CPOT was used. Clinimetric characteristics were analysed in a cross‐sectional design. Internal consistency (Cronbach's alpha) was tested by collecting CPOT scores in patients at rest and during turning. Inter‐rater reliability was tested by collecting CPOT scores simultaneously by two different nurses who were blinded to each other's scores. Criterion validity (area under the curve, sensitivity and specificity) of the Dutch CPOT (index test) was analysed using patient self‐reported pain (reference test). Results: Cronbach's alpha was 0.56. During rest, the inter‐rater reliability was 0.38 (95% confidence interval (CI): 0.20–0.53). During turning, the inter‐rater reliability was 0.56 (95% CI: 0.42–0.68; area under the curve = 0.65 [95% CI 0.57–0.73]). At a threshold CPOT score of 2, the sensitivity and specificity were 39% and 85%, respectively. Conclusion: The Dutch CPOT is available for pain assessment in intubated patients unable to self‐report. Inter‐rater reliability is moderate. At the threshold, a CPOT score of 2, the sensitivity was 39% and the specificity of 85%. Relevance to clinical practice: The CPOT is easy to use for systematic assessment of pain. Additional information about the threshold is valuable for use in daily practice. [ABSTRACT FROM AUTHOR]

Objectives: To determine the point prevalence of medication errors at the time of transition of care from an ICU to non-ICU location and assess error types and risk factors for medication errors during transition of care.Design: This was a multicenter, retrospective, 7-day point prevalence study.Setting: Fifty-eight ICUs within 34 institutions in the United States and two in the Netherlands.Patients: Nine-hundred eighty-five patients transferred from an ICU to non-ICU location.Interventions: None.Measurements and Main Results: Of 985 patients transferred, 450 (45.7%) had a medication error occur during transition of care. Among patients with a medication error, an average of 1.88 errors per patient (SD, 1.30; range, 1-9) occurred. The most common types of errors were continuation of medication with ICU-only indication (28.4%), untreated condition (19.4%), and pharmacotherapy without indication (11.9%). Seventy-five percent of errors reached the patient but did not cause harm. The occurrence of errors varied by type and size of institution and ICU. Renal replacement therapy during ICU stay and number of medications ordered following transfer were identified as factors associated with occurrence of error (odds ratio, 2.93; 95% CI, 1.42-6.05; odds ratio 1.08, 95% CI, 1.02-1.14, respectively). Orders for anti-infective (odds ratio, 1.66; 95% CI, 1.19-2.32), hematologic agents (1.75; 95% CI, 1.17-2.62), and IV fluids, electrolytes, or diuretics (odds ratio, 1.73; 95% CI, 1.21-2.48) at transition of care were associated with an increased odds of error. Factors associated with decreased odds of error included daily patient care rounds in the ICU (odds ratio, 0.15; 95% CI, 0.07-0.34) and orders discontinued and rewritten at the time of transfer from the ICU (odds ratio, 0.36; 95% CI, 0.17-0.73).Conclusions: Nearly half of patients experienced medication errors at the time of transition of care from an ICU to non-ICU location. Most errors reached the patient but did not cause harm. This study identified risk factors upon which risk mitigation strategies should be focused. [ABSTRACT FROM AUTHOR]

Pediatric Early Warning Scores were developed to monitor clinical deterioration of children admitted to the hospital. Pediatric Early Warning Scores could also be useful in the Emergency Department to quickly identify critically ill patients so treatment can be started without delay. To determine if a newly designed, fast, and easy to use Modified Pediatric Early Warning Score can identify critically ill children in the Emergency Department. We conducted a retrospective observational study in the Emergency Department of an urban district hospital in Rotterdam, the Netherlands. Patients < 16 years attending the Emergency Department with an internal medical problem were included. Immediate intensive care unit admission was used as a measure for critically ill children. During the study period 2980 children attended the Emergency Department, ten (0.4%) of them required immediate intensive care unit admission. The Modified Pediatric Early Warning Score can identify critically ill children in the general pediatric Emergency Department population (area under the ROC curve 0.82). A sensitivity of 80% and specificity of 85% show potential to rule out critical illness in children visiting the Emergency Department when these results are validated in a larger population. A model containing both the Modified Pediatric Early Warning Score and the Manchester Triage System did not perform significantly better than the Manchester Triage System alone but did show a positive tendency in favor of the model containing the Modified Pediatric Early Warning Score and Manchester Triage System, area under the ROC curve 0.89 [95% CI 0.77-1.00] versus area under the ROC curve 0.82 [95% CI 0.68-0.95].Conclusions: In this feasibility study, the Modified Pediatric Early Warning Score could be a fast and easy to use tool to identify critically ill children in the general pediatric Emergency Department population. The effectiveness of the Modified Pediatric Early Warning Score may be optimized if combined with triage systems such as the Manchester Triage System. A larger prospective study is needed to confirm our results. What is known: • Pediatric Early Warning Scores can identify children who are in need for immediate intensive care unit admission at the Emergency Department. • Pediatric Early Warning Scores can be time-consuming, contain subjective parameters or parameters which are difficult to obtain in a reliable and standardized method. What is new: • We introduce a simplified, manageable and smartly designed Pediatric Early Warning Score on a pocket card based on an existing and previously investigated Pediatric Early Warning Score. • In this feasibility study the diagnostic performance of the Modified Pediatric Early Warning Score to predict immediate intensive care unit admission in the Emergency Department is in line with the original Pediatric Early Warning Scores but has to be validated on a larger scale. [ABSTRACT FROM AUTHOR]

Objective: Hospital boards are legally responsible for the quality of care delivered by healthcare professionals in their hospitals, but experience difficulties in overseeing quality and safety risks. This study aimed to select a core set of parameters for boards to govern quality of care in the intensive care unit (ICU).Design: Two-round Delphi study.Setting: Two university hospitals in the Netherlands.Participants: An expert panel of 12 former ICU patients or their family members, 12 ICU nurses, 12 ICU physicians and 12 members of boards of directors and quality managers.Main Outcome Measures: Participants indicated the relevance of existing parameters for assessing the quality of ICU care for governance purposes (round 1) and selected 10 quality parameters that together provide boards of directors with a good representation of quality of care in their ICU (round 2).Results: We identified 122 quality parameters related to care in the ICU, which we limited to a short list to present to participants in round 1. The response rate was 94% in round 1 and 85% in round 2. The final set consisted of the 10 most frequently selected quality parameters per hospital. Five parameters were included in both sets; all related to patient safety and continuous quality improvement.Conclusions: Parameters in the core set were mostly qualitative and generic, rather than quantitative and ICU-specific in nature. To engage in a true dialog about quality of care, boards are more interested in the story behind the numbers than in just the numbers themselves. [ABSTRACT FROM AUTHOR]

Since there are no scientific data available about the role of spiritual care (SC) in Dutch ICUs, the goal of this quantitative study was twofold: first, to map the role of SC as a part of daily adult ICU care in The Netherlands from the perspective of intensivists, ICU nurses, and spiritual caregivers and second, to identify similarities and differences among these three perspectives. This study is the quantitative part of a mixed methods approach. To conduct empirical quantitative cohort research, separate digital questionnaires were sent to three different participant groups in Dutch ICUs, namely intensivists, ICU nurses, and spiritual caregivers working in academic and general hospitals and one specialist oncology hospital. Overall, 487 participants of 85 hospitals (99 intensivists, 290 ICU nurses, and 98 spiritual caregivers) responded. The majority of all respondents (>70%) considered the positive effects of SC provision to patients and relatives: contribution to mental well-being, processing and channeling of emotions, and increased patient and family satisfaction. The three disciplines diverged in their perceptions of how SC is currently evolving in terms of information, assessment, and provision. Nationwide, SC is not implemented in daily ICU care. The majority of respondents, however, attached great importance to interdisciplinary collaboration. In their view SC contributes positively to the well-being of patients and relatives in the ICU. Further qualitative research into how patients and relatives experience SC in the ICU is required in order to implement and standardize SC as a scientifically based integral part of daily ICU care. [ABSTRACT FROM AUTHOR]

A strategy of defining and checking explicitly formulated patient-specific treatments targets or "daily goals" in the intensive care unit has been associated with improved communication. We investigated the effect of incorporation of daily goals into daily care planning on length of stay in the intensive care unit. Furthermore, the type of daily goals and deviations from daily goals in daily care with or without documented reason were evaluated. Four university hospitals in the Netherlands, of which 2 study "daily goal" hospitals and 2 control hospitals, participated in a prospective before-after study. During the before phase of the study, daily goals were formulated by the attending physician but kept blinded from doctors and nurses caring for the patient. During the after phase of the study, daily goals were integrated in the care plan for patients admitted to the 2 study hospitals but not for patients admitted to the control hospitals. The implementation of daily goals was, after case-mix correction, not associated with a change in intensive care unit length of stay. However, this study showed that an improved administrative discipline, that is, the recording of the reason why a daily goal or standard protocol was not accomplished, is in favor of the daily goal implementation. [ABSTRACT FROM AUTHOR]

Purpose: To describe the trends in short-term and long-term mortality in very elderly intensive care unit (ICU) patients between 2008 and 2014.Methods: A retrospective cohort study was conducted using data from the National Intensive Care Evaluation Foundation from 31 Dutch ICUs. Generalized linear mixed-effects models were used to determine the change in adjusted short-term mortality (ICU/hospital deaths) and long-term mortality (3, 6, and 12 months after ICU admission) over the period 2008-2014 in very elderly patients and in patients less than 80 years old admitted to the ICU.Results: A total of 216,196 patients admitted to 31 ICUs in the period from 2008 to 2014 were included in the study, including 28,284 (13.1%) very elderly patients (80 years or older). Follow-up data for determination of 3-, 6-, and 12-month mortality were available for, respectively, 210,005 (97.1%), 202,551 (93.7%), and 176,847 (81.8%) ICU admissions. The crude ICU and in-hospital mortality decreased, respectively, from 17.6% to 13.0% and from 30.7% to 21.0%. The annual risk-adjusted ICU and in-hospital mortality of very elderly patients (adjusted for APACHE III score, comorbidities, and admission type) decreased significantly during the study period [adjusted odds ratio 0.97 (0.95-0.99) and 0.92 (0.91-0.93), respectively]. Additionally, the annual risk-adjusted 3-, 6-, and 12-month mortality decreased significantly from 2008 to 2014 [adjusted odds ratio 0.96 (0.95-0.97), 0.96 (0.94-0.97), and 0.97 (0.95-0.98), respectively]. A similar significant annual decrease in risk-adjusted short-term and long-term mortality was observed in patients aged less than 80 years.Conclusions: Both short-term and long-term risk-adjusted mortality decreased significantly during the study period in both very elderly ICU patients and patients aged less than 80 years in the Netherlands. This study clearly shows that in our setting very elderly patients benefit almost as much as their younger counterparts from improvement in quality of care over time. [ABSTRACT FROM AUTHOR]

Background: Audit and feedback is often used as a strategy to improve quality of care, however, its effects are variable and often marginal. In order to learn how to design and deliver effective feedback, we need to understand their mechanisms of action. This theory-informed study will investigate how electronic audit and feedback affects improvement intentions (i.e. information-intention gap), and whether an action implementation toolbox with suggested actions and materials helps translating those intentions into action (i.e. intention-behaviour gap). The study will be executed in Dutch intensive care units (ICUs) and will be focused on pain management.Methods and Design: We will conduct a laboratory experiment with individual ICU professionals to assess the impact of feedback on their intentions to improve practice. Next, we will conduct a cluster randomised controlled trial with ICUs allocated to feedback without or feedback with action implementation toolbox group. Participants will not be told explicitly what aspect of the intervention is randomised; they will only be aware that there are two variations of providing feedback. ICUs are eligible for participation if they submit indicator data to the Dutch National Intensive Care Evaluation (NICE) quality registry and agree to allocate a quality improvement team that spends 4 h per month on the intervention. All participating ICUs will receive access to an online quality dashboard that provides two functionalities: gaining insight into clinical performance on pain management indicators and developing action plans. ICUs with access to the toolbox can develop their action plans guided by a list of potential barriers in the care process, associated suggested actions, and supporting materials to facilitate implementation of the actions. The primary outcome measure for the laboratory experiment is the proportion of improvement intentions set by participants that are consistent with recommendations based on peer comparisons; for the randomised trial it is the proportion of patient shifts during which pain has been adequately managed. We will also conduct a process evaluation to understand how the intervention is implemented and used in clinical practice, and how implementation and use affect the intervention's impact.Discussion: The results of this study will inform care providers and managers in ICU and other clinical settings how to use indicator-based performance feedback in conjunction with an action implementation toolbox to improve quality of care. Within the ICU context, this study will produce concrete and directly applicable knowledge with respect to what is or is not effective for improving pain management, and under which circumstances. The results will further guide future research that aims to understand the mechanisms behind audit and feedback and contribute to identifying the active ingredients of successful interventions.Trial Registration: ClinicalTrials.gov NCT02922101 . Registered 26 September 2016. [ABSTRACT FROM AUTHOR]

Background: Variation in intensive care unit (ICU) readmissions and in-hospital mortality after ICU discharge may indicate potential for improvement and could be explained by ICU discharge practices. Our objective was threefold: (1) describe variation in rates of ICU readmissions within 48 h and post-ICU in-hospital mortality, (2) describe ICU discharge practices in Dutch hospitals, and (3) study the association between rates of ICU readmissions within 48 h and post-ICU in-hospital mortality and ICU discharge practices.Methods: We analysed data on 42,040 admissions to 82 (91.1%) Dutch ICUs in 2011 from the Dutch National Intensive Care Evaluation (NICE) registry to describe variation in standardized ICU readmission and post-ICU mortality rates using funnel-plots. We send a questionnaire to all Dutch ICUs. 75 ICUs responded and their questionnaire data could be linked to 38,498 admissions in the NICE registry. Generalized estimation equations analyses were used to study the association between ICU readmissions and post-ICU mortality rates and the identified discharge practices, i.e. (1) ICU discharge criteria; (2) bed managers; (3) early discharge planning; (4) step-down facilities; (5) medication reconciliation; (6) verbal and written handover; (7) monitoring of post-ICU patients; and (8) consulting ICU nurses. In all analyses, the outcomes were corrected for patient-related confounding factors.Results: The standardized rate of ICU readmissions varied between 0.14 and 2.67 and 20.8% of the hospitals fell outside the 95% control limits and 3.6% outside the 99.8% control limits. The standardized rate of post-ICU mortality varied between 0.07 and 2.07 and 17.1% of the hospitals fell outside the 95% control limits and 4.9% outside the 99.8% control limits. We could not demonstrate an association between the eight ICU discharge practices and rates of ICU readmissions or post-ICU in-hospital mortality. Implementing a higher number of ICU discharge practices was also not associated with better patient outcomes.Conclusions: We found both variation in patient outcomes and variation in ICU discharge practices between ICUs. However, we found no association between discharge practices and rates of ICU readmissions or post-ICU mortality. Further research is necessary to find factors, which may influence these patient outcomes, in order to improve quality of care. [ABSTRACT FROM AUTHOR]

Background: Evidence indicates that suboptimal clinical handover from the intensive care unit (ICU) to general wards leads to unnecessary ICU readmissions and increased mortality. We aimed to gain insight into barriers and facilitators to implement and use ICU discharge practices.Methods: A mixed methods approach was conducted, using 1) 23 individual and four focus group interviews, with post-ICU patients, ICU managers, and nurses and physicians working in the ICU or general ward of ten Dutch hospitals, and 2) a questionnaire survey, which contained 27 statements derived from the interviews, and was completed by 166 ICU physicians (21.8%) from 64 Dutch hospitals (71.1% of the total of 90 Dutch hospitals).Results: The interviews resulted in 66 barriers and facilitators related to: the intervention (e.g., feasibility); the professional (e.g., attitude towards checklists); social factors (e.g., presence or absence of a culture of feedback); and the organisation (e.g., financial resources). A facilitator considered important by ICU physicians was a checklist to structure discharge communication (92.2%). Barriers deemed important were lack of a culture of feedback (55.4%), an absence of discharge criteria (23.5%), and an overestimation of the capabilities of general wards to care for complex patients by ICU physicians (74.7%).Conclusions: Based on the barriers and facilitators found in this study, improving handover communication, formulating specific discharge criteria, stimulating a culture of feedback, and preventing overestimation of the general ward are important to effectively improve the ICU discharge process. [ABSTRACT FROM AUTHOR]

Background Delirium is a common disorder in Intensive Care Unit (ICU) patients and is associated with serious short- and long-term consequences, including re-intubations, ICU readmissions, prolonged ICU and hospital stay, persistent cognitive problems, and higher mortality rates. Considering the high incidence of delirium and its consequences, prevention of delirium is imperative. This study focuses on a program of standardized nursing and physical therapy interventions to prevent delirium in the ICU, called UNDERPIN-ICU (nUrsiNg DEliRium Preventive INterventions in the ICU). Objective : To determine the effect of the UNDERPIN-ICU program on the number of delirium-coma-free days in 28 days and several secondary outcomes, such as delirium incidence, the number of days of survival in 28 and 90 days and delirium-related outcomes. Design and setting A multicenter stepped wedge cluster randomized controlled trial. Methods Eight to ten Dutch ICUs will implement the UNDERPIN-ICU program in a randomized order. Every two months the UNDERPIN-ICU program will be implemented in an additional ICU following a two months period of staff training. UNDERPIN-ICU consists of standardized protocols focusing on several modifiable risk factors for delirium, including cognitive impairment, sleep deprivation, immobility and visual and hearing impairment. Participants ICU patients aged ≥18 years (surgical, medical, or trauma) and at high risk for delirium, E-PRE-DELIRIC ≥35%, will be included, unless delirium was detected prior ICU admission, expected length of ICU stay is less then one day or when delirium assessment is not possible. Discussion For every intervention the balance between putative benefit and potential unwanted side effects needs to be considered. In non-ICU patients, it has been shown that a similar program resulted in a significant reduction of delirium incidence and duration. Recent small studies using multi component interventions to prevent delirium in ICU patients have also shown beneficial effect, without unwanted side effects. We therefore feel that the proportionality of potential positive effects of the UNDERPIN-ICU program, weighed against potential unwanted side effects is favourable. Since this has not been rigorously proven in ICU patients, we will study the effects of this program in ICU patients using a stepped wedge design. Trial registration The study is registered in the clinical trials registry: https://clinicaltrials.gov/ . Reporting method Standard Protocol Items: Recommendations for Interventional Trails (SPIRIT). [ABSTRACT FROM AUTHOR]

ABSTRACT Background Nurses' participation in decisions about new care procedures and protocols is potentially of benefit for patient outcomes. Whether nurses' participation in decisions is allowed in the implementation of innovations depends on the implementation approach used for the introduction. A planned change implementation approach does not allow it, an emergent change implementation approach does. Aim To compare a planned change and an emergent change implementation approach to introduce an intensive insulin therapy to an intensive care unit ( ICU). Design A prospective comparative study in an ICU in the Netherlands of two teams of nurses using either implementation approach. Methods Pre-introduction of the comparability of the two teams was assessed. The nurse compliance to the protocol was assessed as being nurses' behaviour according to the protocol and leading to acceptable glucose values. The effectiveness of the implementation was assessed by measuring the percentage of patients' glucose values within the target range, the occurrence of hypoglycaemic events and the time to glucose value normalization. Data were collected from December 2007 till January 2009. Results In the emergent change approach team there was better nurse compliance measurements than in the planned change approach team (83.5% vs 66,8% conform protocol), a better percentage of glucose values in the target range (53,5% vs 52.8%) and a shorter time to glucose value normalization. Conclusion The implementation approach allowing nurse participation was associated with better nurse compliance and patient outcome measurements. The implementation approach did not conflict with introducing an evidence-based innovation. It was also associated with more effective adaptation of the protocol to changing circumstances. Relevance for clinical practice When a new treatment requires adaptability to changing circumstances to be most effective, nurses' participation in decisions about the implementation of the treatment should be considered. [ABSTRACT FROM AUTHOR]

Objective To evaluate the impact of a virtual pet visit system ('TelePet' System, TPS) on owners and staff of a companion animal ICU. Design Longitudinal interventional study (2010-2013). Setting Companion animal ICU at a university veterinary medical teaching hospital. Study Populations Pet owners, ICU technicians. Interventions The introduction of the TPS, with live video streaming of patient images over the Internet, in a companion animal ICU. Measurements and Main Results Pet owners experienced TPS as a valuable extra service. Most TPS users (72.4%) experienced less anxiety and felt less need (40.4% of TPS users) to visit their hospitalized pet in person. Most users (83.5%) shared TPS access with their family. The introduction of the TPS did not improve overall owner satisfaction, except for the score on 'quality of medical treatment.' Seven of 26 indicators of owner satisfaction were awarded higher scores by TPS users than by TPS nonusers in the survey after the introduction of the system. However, the lack of randomization of owners might have influenced findings. The enthusiasm of the ICU technicians for the system was tempered by the negative feedback from a small number of owners. Nevertheless they recognized the value of the system for owners. The system was user friendly and ICU staff and TPS users experienced few technical problems. Conclusions As veterinary healthcare is moving toward a more client-centered approach, a virtual pet visit system, such as TPS, is a relatively simple application that may improve the well-being of most owners during the hospitalization of their pet. [ABSTRACT FROM AUTHOR]

Introduction: Tele-intensive care (teleIC) can be used to increase the level of care in the intensive care unit (ICU) with the tele-intensivist being at a remote site. In this study we describe the implementation and outcomes, including patient and family satisfaction, of the first Dutch teleIC.Methods: In a retrospective analysis the patient characteristics are described with a focus on patient outcomes and patient and family satisfaction. The teleIC started on 6 December 2010 in an ICU with three beds. Data for all admitted patients were collected from 1 January 2011 through 31 December 2013 from available systems. Severity of disease (APACHE IV) and standardized mortality ratios (SMR) were available over the complete calendar years 2012 and 2013. A prospective self-made survey of patient and family satisfaction was performed over a 14-month period after the implementation of teleIC.Results: In 2012 and 2013, 556 patients were admitted. The number of operating room recovery patients in the ICU declined over time. One hundred and seven patients were transferred to a higher-level ICU (19%). The SMR for non-transferred patients was 0.73 (95% CI (confidence interval) 0.54-0.98) and 0.66 (95% CI (confidence interval) 0.40-1.02) for transferred patients. These numbers are in line with national data. Thirty-six percent of family and 38% of the patients responded to the survey and showed a positive response concerning communication within the tele IC setting.Conclusion: Implementation of teleIC in a Dutch situation was successful and showed favourable results in patient outcomes and the satisfaction of patients and family members. [ABSTRACT FROM AUTHOR]

Objective: Knowledge on characteristics and outcome of ICU patients with AIDS is highly limited. We aimed to determine the main reasons for admission and outcome in ICU patients with AIDS and trends over time therein.Design: A retrospective study within the Dutch National Intensive Care Evaluation registry.Setting: Dutch ICUs.Patients: We used data collected between 1997 and 2014. Characteristics of patients with AIDS were compared with ICU patients without AIDS, matched for age, sex, admission type, and admission year. Joinpoint regression analysis was applied to study trends over time.Interventions: None.Measurements and Main Results: We included 1,127 patients with AIDS and 4,479 matched controls. The main admission diagnoses of patients with AIDS were respiratory infection (28.6%) and sepsis (16.9%), which were less common in controls (7.7% and 7.5%, respectively; both p < 0.0001). Patients with AIDS had increased severity of illness and in-hospital mortality (28.2% vs 17.8%; p < 0.0001) compared with controls, which was associated with a higher rate of infections at admission in patients with AIDS (58.4% vs 25.5%). Over time, the proportion of patients with AIDS admitted with an infection decreased (75% in 1999 to 56% in 2013). Mortality declined in patients with AIDS (39% in 1999 to 16% in 2013), both in patients with or without an infection. Mortality also declined in matched controls without AIDS, but to a lesser extent.Conclusion: Infections are still the main reason for ICU admission in patients with AIDS, but their prevalence is declining. Outcome of patients with AIDS continued to improve during a time of widespread availability of combination antiretroviral therapy, and mortality is reaching levels similar to ICU patients without AIDS. [ABSTRACT FROM AUTHOR]

Introduction: Central venous catheters (CVCs) can lead to central line-related bloodstream infections (CRBSIs). A six-item bundle was introduced in 2009 to prevent CRBSI in Dutch hospitals., Aim: This study aimed to determine the impact of an intervention bundle on CRBSI risk., Methods: Data were obtained from hospitals participating in the national CRBSI surveillance between 2009 and 2019. Bundle compliance was evaluated as a total ('overall') bundle (all six items) and as an insertion bundle (four items) and a maintenance bundle (two daily checks). We estimated the impact of the overall and partial bundles, using multi-level Cox regression., Findings: Of the 66 hospitals in the CRBSI surveillance 56 (84.8%) recorded annual bundle (non)compliance for >80% of the CVCs, for one to nine years. In these 56 hospitals CRBSI incidence decreased from 4.0 to 1.6/1000 CVC days. In the intensive care units (ICUs), compliance was not associated with CRBSI risk (hazard ratio (HR) for the overall, insertion and maintenance bundle were 1.14 (95% confidence interval 0.80-1.64), 1.05 (0.56-1.95) and 1.13 (0.79-1.62)), respectively. Outside the ICU the non-significant association of compliance with the overall bundle (HR 1.36 (0.96-1.93)) resulted from opposite effects of the insertion bundle, associated with decreased risk (HR 0.50 (0.30-0.85)) and the maintenance bundle, associated with increased risk (HR 1.68 (1.19-2.36))., Conclusion: Following a national programme to introduce an intervention bundle, CRBSI incidence decreased significantly. In the ICU, bundle compliance was not associated with CRBSI risk, but outside the ICU improved compliance with the insertion bundle resulted in a decreased CRBSI risk., (Copyright © 2022 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Context: Because anticipation of death is common within the intensive care unit, attention must be paid to the prevention of distressing signs and symptoms, enabling the patient to die peacefully. In the relevant studies on this subject, there has been a lack of focus on measuring determinants of comfort in this population.Objectives: To evaluate whether dying without distressing signs after the withdrawal of life-sustaining measures is possible using a newly introduced protocol and to analyze the potential influence of opioids and sedatives on time till death.Methods: This was a prospective observational study, in two nonacademic Dutch intensive care units after the introduction of a national protocol for end-of-life care. The study lasted two years and included adult patients in whom mechanical ventilation and/or vasoactive medication was withdrawn. Exclusion criteria included all other causes of death.Results: During the study period, 450 patients died; of these, 305 patients were eligible, and 241 were included. Ninety percent of patients were well sedated before and after withdrawal. Severe terminal restlessness, death rattle, or stridor was seen in less than 6%. Dosages of opioids and sedatives increased significantly after withdrawal, but did not contribute to a shorter time till death according the regression analysis.Conclusion: The end-of-life protocol seems effective in realizing adequate patient comfort. Most patients in whom life-sustaining measures are withdrawn are well sedated and show few signs of distress. Dosages of opioids and sedatives increase significantly during treatment withdrawal but do not contribute to time until death. Dying with a minimum of distressing signs is thus practically possible and ethically feasible. [ABSTRACT FROM AUTHOR]

Objective: To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units. Methods: We used the EBRO method, as recommended by the ‘Dutch Evidence Based Guideline Development Platform’ to develop an ‘evidence statement for physiotherapy in the intensive care unit’. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts. Results: Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment. Conclusions: These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014. [ABSTRACT FROM AUTHOR]

Aim. To provide insight into the individual and contextual factors that are related to intensive care nursing staff perceptions of work pressure and turnover. Background. Hospitals are facing a shortage of intensive care nurses that will only become more pressing owing to demographic changes. Nurses' sickness absence and turnover are considered important threats to the supply of intensive care. Design. A quantitative, cross-sectional research design was used that was preceded by a qualitative, explorative study. Method. First, interviews and observations took place to better understand intensive care nurses' work situation. Next, quantitative data were obtained in 2010 from 461 Dutch qualified intensive care nurses who completed a questionnaire. Findings. The outcomes of multiple regression analyses indicated that nurses' perceptions of work pressure were predicted by emotional demands, physical demands, threats from patients' relatives, social support and autonomy. Turnover intention was predicted by age, ability to deal with night shifts, social support and development opportunities. Conclusions. Given the importance of the availability of staff to secure intensive care, this study indicates that hospitals should pay more attention to intensive care nurses' work situation. Decreasing emotional and physical demands and increasing nurses' development opportunities are some of the measures hospitals can take to create a work environment that better accommodates the needs of their intensive care nursing staff. [ABSTRACT FROM AUTHOR]

Aim. To report the development and psychometric testing of the Dutch version of the Nursing Activity Scale in a Dutch intensive care unit nursing population. Background. The Nursing Activity Scale developed by Schutzenhofer measures professional clinical autonomy, by inquiring about the nurses' intention to exercise their own clinical decisions. This autonomy is increasingly relevant due to the ongoing professionalization, nurses increasingly have to make their own clinical decisions. Design. Instrument development. Method. The study was conducted from November 2007-February 2008 and consisted of the following steps: translation, expert panel content validation, reliability testing and further content validation, test-retest stability examination, additional internal consistency, and validity assessment. Results. After the first reliability testing two items seen to describe a situation not applicable to intensive care unit nursing in the Netherlands were deleted from the questionnaire. In the test-retest stability assessment the intra class correlation coefficient was 0·76. The Cronbach's alpha of the final questionnaire was 0·82. The alphas of the subsamples with higher scores were significantly different from those with lower scores, supporting the validity of the weighing of the items. Conclusion. The Dutch version of the nursing activity scale consists of 28 items and provides the opportunity to measure professional clinical autonomy for Dutch intensive care nurses using a well-established method. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Severe acute asthma in children is associated with substantial morbidity and may require pediatric ICU (PICU) admission. The aim of the study was to determine risk factors for PICU admission. METHODS: The study used a retrospective multicenter case-control design. The cases included children admitted to the PICU because of severe acute asthma and a history of out-patient treatment by pediatricians or pediatric pulmonologists. Controls were children with asthma without a PICU admission for severe acute asthma. The children were matched for sex, age, hospital, and time elapsed since the diagnosis of asthma. Fourteen possible risk factors were analyzed. RESULTS: Sixty-six cases were matched to 164 controls. In univariate analysis, all but one of the analyzed variables were significantly associated with PICU-hospitalization. After multivariate conditional logistic regression analysis, 4 risk factors remained significant. These included active or passive smoking, allergies, earlier hospitalization for asthma, and non-sanitized home. CONCLUSIONS: Physicians and parents should be aware of these risk factors, and efforts should be made to counteract them. [ABSTRACT FROM AUTHOR]