BACKGROUND: Prognostic assessments of the mortality of critically ill patients are frequently performed in daily clinical practice and provide prognostic guidance in treatment decisions. In contrast to several sophisticated tools, prognostic estimations made by healthcare providers are always available and accessible, are performed daily, and might have an additive value to guide clinical decision-making. The aim of this study was to evaluate the accuracy of students', nurses', and physicians' estimations and the association of their combined estimations with in-hospital mortality and 6-month follow-up.METHODS: The Simple Observational Critical Care Studies is a prospective observational single-center study in a tertiary teaching hospital in the Netherlands. All patients acutely admitted to the intensive care unit were included. Within 3 h of admission to the intensive care unit, a medical or nursing student, a nurse, and a physician independently predicted in-hospital and 6-month mortality. Logistic regression was used to assess the associations between predictions and the actual outcome; the area under the receiver operating characteristics (AUROC) was calculated to estimate the discriminative accuracy of the students, nurses, and physicians.RESULTS: In 827 out of 1,010 patients, in-hospital mortality rates were predicted to be 11%, 15%, and 17% by medical students, nurses, and physicians, respectively. The estimations of students, nurses, and physicians were all associated with in-hospital mortality (OR 5.8, 95% CI [3.7, 9.2], OR 4.7, 95% CI [3.0, 7.3], and OR 7.7 95% CI [4.7, 12.8], respectively). Discriminative accuracy was moderate for all students, nurses, and physicians (between 0.58 and 0.68). When more estimations were of non-survival, the odds of non-survival increased (OR 2.4 95% CI [1.9, 3.1]) per additional estimate, AUROC 0.70 (0.65, 0.76). For 6-month mortality predictions, similar results were observed.CONCLUSIONS: Based on the initial examination, students, nurses, and physicians can only moderately predict in-hospital and 6-month mortality in critically ill patients. Combined estimations led to more accurate predictions and may serve as an example of the benefit of multidisciplinary clinical care and future research efforts.
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Objectives: In Europe, there is a distinction between two different healthcare organisation systems, the tax-based healthcare system (THS) and the social health insurance system (SHI). Our aim was to investigate whether the characteristics, treatment and mortality of older, critically ill patients in the intensive care unit (ICU) differed between THS and SHI. Setting: ICUs in 16 European countries. Participants: In total, 7817 critically ill older (≥80 years) patients were included in this study, 4941 in THS and 2876 in the SHI systems. Primary and secondary outcomes measures: We chose generalised estimation equations with robust standard errors to produce population average adjusted OR (aOR). We adjusted for patient-specific variables, health economic data, including gross domestic product (GDP) and human development index (HDI), and treatment strategies. Results: In SHI systems, there were higher rates of frail patients (Clinical Frailty Scale>4; 46% vs 41%; p<0.001), longer length of ICU stays (90±162 vs 72±134 hours; p<0.001) and increased levels of organ support. The ICU mortality (aOR 1.50, 95%CI 1.09 to 2.06; p=0.01) was consistently higher in the SHI; however, the 30-day mortality (aOR 0.89, 95%CI 0.66 to 1.21; p=0.47) was similar between THS and SHI. In a sensitivity analysis stratifying for the health economic data, the 30-day mortality was higher in SHI, in low GDP per capita (aOR 2.17, 95%CI 1.42 to 3.58) and low HDI (aOR 1.22, 95%CI 1.64 to 2.20) settings. Conclusions: The 30-day mortality was similar in both systems. Patients in SHI were older, sicker and frailer at baseline, which could be interpreted as a sign for a more liberal admission policy in SHI. We believe that the observed trend towards ICU excess mortality in SHI results mainly from a more liberal admission policy and an increase in treatment limitations.
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Wraparound care is een model voor het organiseren van integrale zorg aan gezinnen met een opeen-stapeling van problemen. Het benut hun oplossend vermogen, betrekt hun sociale netwerk en streeft hun empowerment na. Bovendien organiseert het samenwerking tussen verschillende sectoren. Ge-zinsbegeleiding en coördinatie van zorg liggen in één hand. In het kader van het programma Utrechtse Jeugd Centraal van de provincie Utrecht zijn in 2009 in de steden Utrecht en Amersfoort twee pilots wraparound care in het leven geroepen. Deze zijn vanaf de start door het Lectoraat Werken in Justitieel Kader van de HU met ontwikkelingsgericht handelingson-derzoek ondersteund. Daarnaast heeft zich in het najaar van 2010 een aantal initiatieven met elkaar verbonden die werken vanuit dezelfde ambities. Het gaat om de pilots wraparound care, de pilot ‘Eén kind, één plan’, ‘Talita’, een programma voor begeleid zelfstandig wonen voor tienermoeders en kwetsbare meisjes van stichting Timon, Hulp aan Huis, een samenwerkingsverband van instellingen die Intensieve Orthopedagogische Gezinsbehandeling (IOG) aanbieden, ‘Tien voor toekomst’ van het leger des Heils, Gezinscoaching’ van Vitras/CMD en Zuwe zorg, het project ‘Tussen-in’ van Al Amal, het project ‘Wisselgeld’ voor gezinnen met een Roma-achtergrond van de gemeente Nieuwegein. Sa-men met vertegenwoordigers van gemeentes en de provincie en onderzoekers en studenten van de HU vormden zij het ‘Kennisplatform Wraparound Care’ dat functioneerde als een ‘Community of Prac-tice’. Het is ondersteund met een door de provincie Utrecht gefinancierd onderzoeksprogramma
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Purpose: The aim of this study was to develop practical recommendations for physiotherapy for survivors of critical illness after hospital discharge. Methods: A modified Delphi consensus study was performed. A scoping literature review formed the basis for three Delphi rounds. The first round was used to gather input from the panel to finalize the survey for the next two rounds in which the panel was asked to rank each of the statements on an ordinal scale with the objective to reach consensus. Consensus was defined as a SIQR of ≤ 0.5. Ten Dutch panelists participated in this study: three primary care physiotherapists, four intensive care physiotherapists, one occupational therapist, one ICU-nurse and one former ICU-patient. All involved professionals have treated survivors of critical illness. Our study was performed in parallel with an international Delphi study with hospital-based health-care professionals and researchers. Results: After three Delphi rounds, consensus was reached on 95.5% of the statements. This resulted in practical recommendations for physiotherapy for critical illness survivors in the primary care setting. The panel agreed that the handover should include information on 14 items. Physiotherapy treatment goals should be directed toward improvement of aerobic capacity, physical functioning, activities in daily living, muscle strength, respiratory and pulmonary function, fatigue, pain, and health-related quality of life. Physiotherapy measurements and interventions to improve these outcomes are suggested. Conclusion: This study adds to the knowledge on post-ICU physiotherapy with practical recommendations supporting clinical decision-making in the treatment of survivors of critical illness after hospital discharge.
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Background: Cardiac output measurements may inform diagnosis and provide guidance of therapeutic interventions in patients with hemodynamic instability. The FloTrac™ algorithm uses uncalibrated arterial pressure waveform analysis to estimate cardiac output. Recently, a new version of the algorithm has been developed. The aim was to assess the agreement between FloTrac™ and routinely performed cardiac output measurements obtained by critical care ultrasonography in patients with circulatory shock.Methods: A prospective observational study was performed in a tertiary hospital from June 2016 to January 2017. Adult critically ill patients with circulatory shock were eligible for inclusion. Cardiac output was measured simultaneously using FloTrac™ with a fourth-generation algorithm (COAP) and critical care ultrasonography (COCCUS). The strength of linear correlation of both methods was determined by the Pearson coefficient. Bland-Altman plot and four-quadrant plot were used to track agreement and trending ability.Result: Eighty-nine paired cardiac output measurements were performed in 17 patients during their first 24 h of admittance. COAP and COCCUS had strong positive linear correlation (r2 = 0.60, p < 0.001). Bias of COAP and COCCUS was 0.2 L min-1 (95% CI - 0.2 to 0.6) with limits of agreement of - 3.6 L min-1 (95% CI - 4.3 to - 2.9) to 4.0 L min-1 (95% CI 3.3 to 4.7). The percentage error was 65.6% (95% CI 53.2 to 77.3). Concordance rate was 64.4%.Conclusions: In critically ill patients with circulatory shock, there was disagreement and clinically unacceptable trending ability between values of cardiac output obtained by uncalibrated arterial pressure waveform analysis and critical care ultrasonography.Trial registration: Clinicaltrials.gov, NCT02912624, registered on September 23, 2016.
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PURPOSE OF REVIEW: The loss of muscle mass in critically ill patients contributes to morbidity and mortality, and results in impaired recovery of physical functioning. The number of publications on the topic is increasing. However, there is a lack of consistent methodology and the most optimal methodology remains unclear, hampering its broad use in clinical practice.RECENT FINDINGS: There is a large variety of studies recently published on the use of ultrasound for assessment of muscle mass. A selection of studies has been made, focusing on monitoring of muscle mass (repeated measurements), practical aspects, feasibility and possible nutrition and physical therapy interventions. In this review, 14 new small (n = 19-121) studies are categorized and reviewed as individual studies.SUMMARY: The use of ultrasound in clinical practice is feasible for monitoring muscle mass in critically ill patients. Assessment of muscle mass by ultrasound is clinically relevant and adds value for guiding therapeutic interventions, such as nutritional and physical therapy interventions to maintain muscle mass and promote recovery in critically ill patients.
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This book fills an important gap in the sport governance literature by engaging in critical reflection on the concept of ‘good governance’. It examines the theoretical perspectives that lead to different conceptualisations of governance and, therefore, to different standards for institutional quality. It explores the different practical strategies that have been employed to achieve the implementation of good governance principles. The first part of the book aims to shed light on the complexity and nuances of good governance by examining theoretical perspectives including leadership, value, feminism, culture and systems. The second part of the book has a practical focus, concentrating on reform strategies, from compliance policies and codes of ethics to external reporting and integrity systems. Together, these studies shed important new light on how we define and understand governance, and on the limits and capabilities of different methods for inducing good governance. With higher ethical standards demanded in sport business and management than ever before, this book is important reading for all advanced students and researchers with an interest in sport governance and sport policy, and for all sport industry professionals looking to improve their professional practice.
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A case study and method development research of online simulation gaming to enhance youth care knowlegde exchange. Youth care professionals affirm that the application used has enough relevance as an additional tool for knowledge construction about complex cases. They state that the usability of the application is suitable, however some remarks are given to adapt the virtual environment to the special needs of youth care knowledge exchange. The method of online simulation gaming appears to be useful to improve network competences and to explore the hidden professional capacities of the participant as to the construction of situational cognition, discourse participation and the accountability of intervention choices.
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eHealth education should be integrated into vocational training and continuous professional development programmes. In this opinion article, we aim to support organisers of Continuing Professional Development (CPD) and teachers delivering medical vocational training by providing recommendations for eHealth education. First, we describe what is required to help primary care professionals and trainees learn about eHealth. Second, we elaborate on how eHealth education might be provided
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Through a qualitative examination, the moral evaluations of Dutch care professionals regarding healthcare robots for eldercare in terms of biomedical ethical principles and non-utility are researched. Results showed that care professionals primarily focused on maleficence (potential harm done by the robot), deriving from diminishing human contact. Worries about potential maleficence were more pronounced from intermediate compared to higher educated professionals. However, both groups deemed companion robots more beneficiary than devices that monitor and assist, which were deemed potentially harmful physically and psychologically. The perceived utility was not related to the professionals' moral stances, countering prevailing views. Increasing patient's autonomy by applying robot care was not part of the discussion and justice as a moral evaluation was rarely mentioned. Awareness of the care professionals' point of view is important for policymakers, educational institutes, and for developers of healthcare robots to tailor designs to the wants of older adults along with the needs of the much-undervalued eldercare professionals.
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