Recent Submissions

  • Predicting 30-day mortality in patients with sepsis: An exploratory analysis of process of care and patient characteristics

    Simmonds, Mark J.R. (2018)
    BACKGROUND: Sepsis represents a significant public health burden, costing the NHS 2.5 billion annually, with 35% mortality in 2006. The aim of this exploratory study was to investigate risk factors predictive of 30-day mortality amongst patients with sepsis in Nottingham. METHODS: Data were collected prospectively from adult patients with sepsis in Nottingham University Hospitals NHS Trust as part of an on-going quality improvement project between November 2011 and March 2014. Patients admitted to critical care with the diagnosis of sepsis were included in the study. In all, 97 separate variables were investigated for their association with 30-day mortality. Variables included patient demographics, symptoms of systemic inflammatory response syndrome, organ dysfunction or tissue hypoperfusion, locations of early care, source of sepsis and time to interventions. RESULTS: A total of 455 patients were included in the study. Increased age (adjOR = 1.05 95%CI = 1.03-1.07 p p = 0.016), hospital-acquired sepsis (adjOR = 3.34 95%CI = 1.78-6.27 p p = 0.02) and mottling (adjOR = 3.80 95%CI = 1.06-13.55 p = 0.04) increased 30-day mortality odds. Conversely, fever (adjOR = 0.46 95%CI = 0.28-0.75 p = 0.002), fluid refractory hypotension (adjOR = 0.29 95%CI = 0.10-0.87 p = 0.027) and being diagnosed in surgical wards (adjOR = 0.35 95%CI = 0.15-0.81 p = 0.015) were protective. Treatment timeliness were not significant factors. CONCLUSION: Several important predictors of 30-day mortality were found by this research. Retrospective analysis of our sepsis data has revealed mortality predictors that appear to be more patient-related than intervention-specific. With this information, care can be improved for those identified most at risk of death.
  • Ch.9 Diagnosis of death in modern hospital practice

    Gardiner, Dale C. (2016)
    There is the potential for many death diagnoses in hospitals to not satisfy a philosopher’s definition of irreversibility. It is estimated there are 360,000 deaths in UK hospitals each year. Our results of death diagnosis practices in a modern hospital indicates that in the UK over 133,000 patients each year would have to have the way their deaths were diagnosed to satisfy a 60 minutes standard and 300,000 (83% of all hospital deaths) to satisfy a three hour standard. The radicalness of an insistence on irreversibility as impossible to reverse has not been appreciated and is inconsistent with what is regarded as normal hospital practice. We note that physicians use permanence, being the chance that something will happen rather than could happen (impossible to reverse) to make their death declaration. This is a dignity-consistent approach to making a diagnosis of death, as it is both safe and timely. The five-minute observation standard, as first proposed by Eugene Bouchut in 1846, remains the most valid physiological and patient-centered criteria for modern doctors to employ when diagnosing death after cardio-respiratory arrest.
  • Diagnosing death

    Gardiner, Dale C. (2020)
  • Assessing whether COVID-19 patients will benefit from critical care, and an objective approach to capacity challenges during a pandemic: An Intensive Care Society clinical guideline.

    Gardiner, Dale C.; Harvey, Daniel J. (2021)
    This national professional society guidance lays out operational and ethical principles for decision-making during a pandemic, in the immediate context of COVID-19 in the early 2020 surge iteration but with potential ongoing relevance. It identifies the different phases of a pandemic and the implications for capacity and mutual aid within a national healthcare system, and introduces a revised CRITCON-PANDEMIC framework for shared operational responsibilities and clinical decision-making. Usual legal and ethical frameworks should continue to apply while capacity and mutual aid are available (CRITCON-PANDEMIC levels 0-3); clinicians should focus on current clinical needs and should not treat patients differently because of anticipated future pressures. In conditions of resource limitation (CRITCON-PANDEMIC 4), a structured and equitable approach is necessary and an objective Decision Support Aid is proposed. In producing this guidance, we emphasise that all patients must be treated with respect and without discrimination, because everyone is of equal value. The guidance has been put together with input from patient and public groups and aims to provide standards that are fair to everyone. We acknowledge that COVID-19 is a new disease with a partial and evolving knowledge base, and aim to provide an objective clinical decision-making framework based on the best available information. It is recognised that a factual assessment of likely benefit may take into account age, frailty and comorbidities, but the guidance emphasises that every assessment must be individualised on a balanced, case by case, basis and may inform clinical judgement but not replace it. The effects of a comorbidity on someone's ability to benefit from critical care should be individually assessed. Measures of frailty should be used with care, and should not disadvantage those with stable disability. Copyright © The Intensive Care Society 2020.
  • CRITCON-pandemic levels: A stepwise ethical approach to clinician responsibility.

    Harvey, Daniel J.; Gardiner, Dale C.; DeBeer, Thearina (2022)
    CRITCON-Pandemic levels with an associated operational responsibility matrix were recently published by the Intensive Care Society as a modification to Winter Flu CRITCON levels, to better account for differences between a winter flu surge in critical care activity and the capacity challenges of the COVID-19 pandemic. In this paper, we propose an expansion and explanation of the operational matrix to suggest a stepwise ethical approach to clinician responsibility. We propose and outline the main ethical risks created at each level and discuss how those risks can be mitigated through a balanced application of the predominant ethical principle which in turn provides practical guidance to clinician responsibility. We thus seek to specify the ethical and legal principles that should be used in applying the operational matrix, and what the practical effects could be.Copyright © The Intensive Care Society 2020.
  • Permanent brain arrest as the sole criterion of death in systemic circulatory arrest

    Gardiner, Dale C. (2020)
    Historically, there has been a tendency to think that there are two types of death: circulatory and neurological. Holding onto this tendency is making it harder to navigate emerging resuscitative technologies, such as extracorporeal membrane oxygenation and the recent well-publicised experiment that demonstrated the possibility of restoring cellular function to some brain neurons 4 h after normothermic circulatory arrest (decapitation) in pigs. Attempts have been made to respond to these difficulties by proposing a unified brain-based criterion for human death, which we call 'permanent brain arrest'. The clinical characteristics of permanent brain arrest are the permanent loss of capacity for consciousness and permanent loss of all brainstem functions, including the capacity to breathe. These losses could arise from a primary brain injury or as a result of systemic circulatory arrest. We argue that permanent brain arrest is the true and sole criterion for the death of human beings and show that this is already implicit in the circulatory-respiratory criterion itself. We argue that accepting the concept of permanent cessation of brain function in patients with systemic permanent circulatory arrest will help us better navigate the medical advances and new technologies of the future whilst continuing to provide sound medical criteria for the determination of death. Copyright © 2020 Association of Anaesthetists.
  • Diagnosis of death using neurological criteria in adult patients on extracorporeal membrane oxygenation: Development of UK guidance.

    Gardiner, Dale C. (2020)
    The diagnosis of death using neurological criteria is an important legal method of establishing death in the UK. The safety of the diagnosis lies in the exclusion of conditions which may mask the diagnosis and the testing of the fundamental reflexes of the brainstem including the apnoea reflex. Extracorporeal membrane oxygenation for cardiac or respiratory support can impact upon these tests, both through drug sequestration in the circuit and also through the ability to undertake the apnoea test. Until recently, there has been no nationally accepted guidance regarding the conduct of the tests to undertake the diagnosis of death using neurological criteria for a patient on extracorporeal membrane oxygenation. This article considers both the background to and the process of guideline development. Copyright © The Intensive Care Society 2019.