Early Combination Therapy with Immunoglobulin and Steroids Is Associated with Shorter Icu Length of Stay in Multisystem Inflammatory Syndrome in Children Associated with Covid19

BACKGROUND AND AIM: Suggested therapeutic options for Multisystem Inflammatory Syndrome in Children (MIS-C) include intravenous immunoglobulins (IVIG) and steroids. Prior studies have shown the benefit of combination therapy with both agents on fever control or the resolution of organ dysfunction. The objective of this study was to analyze the impact of IVIG and steroids on hospital and ICU length of stay (LOS). METHOD(S): This was a retrospective study on 356 hospitalized MIS-C patients from 03/20-9/21 (28 U.S. sites) in the SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. The effect of IVIG and steroids initiated in the first two days of admission, alone or in combination, on LOS was analyzed using intention to treat analysis. Adjustment for confounders was made by multivariable mixed regression with a random intercept for the site. RESULT(S): Median age of the study population was 8.8 (IQR 4.0, 13) years. 247/356 (70%) patients required ICU admission during hospitalization. Of the total patients, 153 (43%) received IVIG and steroids, 33 (9%) received IVIG only, 43 (12%) received steroids only, and 127 (36%) received neither within first two days. After adjustment of confounders, only combination therapy showed a significant decrease of ICU LOS by 1.6 days compared to no therapy (exponentiated coefficient 0.71 [95% CI 0.51, 0.97, p=0.03]). No significant difference was observed in hospital LOS or the secondary outcome variables. CONCLUSION(S): Combination therapy with IVIG and steroids initiated in the first 2 days of admission favorably impacts ICU LOS in children with MIS-C.

Stop-Virus Collaborative: A Qualitative Analysis to Forming a Virtual Landscape of Practice

INTRODUCTION: The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 (STOP-VIRUS) Collaborative was a virtual adaptation to healthcare collaboration and quality improvement during COVID-19 pandemic. The learning that happens in this space is complex, nuanced, and multi-dimensional, best explained using Wenger's social learning theory of the Landscape of Practice, where one needs knowledgeability and the ability to identify and cross the boundaries to achieve learning. METHOD(S): We conducted a qualitative study using thematic analysis to explore STOP-VIRUS participants' perspective on their experience. We used identified themes to inform the creation of the continuum of readiness for change to better characterize common challenges that institutions face at different QI readiness stages. We used a blended framework of the ADKAR model for changes start at the individual level, McKinsey's 7S framework to focus our efforts on different components necessary for change at the organizational level, and the overarching theory of landscape of practice to guide analysis and development of our conceptual framework. RESULT(S): We constructed a blended conceptual framework based on the ADKAR stages of change and the necessary components for successful change implementation based on the McKinsey's 7S framework. The 7S framework effectively demonstrates a systematic and comprehensive approach to change on an organizational level, including the 7 constructs: staff, style/culture, skills, strategy, systems, structure, with shared culture at the center of change. However, change starts at the individual level. Within the STOP-VIRUS Collaborative, the participants from each site are the catalyst for change. As a result, this is reflected through the stages of change embodied in the ADKAR model: awareness, desire, knowledge, ability, and reinforcement. Together, they provided a continuum that enable individual healthcare providers to impact change on an organization level. CONCLUSION(S): STOP-VIRUS collaborative was a multicenter, interprofessional, and diverse learning environment that re-emphasized best-practice guidelines. It provides valuable support to institutions at various stages of readiness for quality improvement initiatives, with important lessons that can be applied to future virtual collaboratives.

Observational Cohort Study of Mayo Clinic Virus Registry Covid-19 Inpatients

INTRODUCTION: Several state-based and single center studies have demonstrated evidence of higher COVID-19 exposure rates, infection rates, and worse morbidity and mortality outcomes among minorities. Furthermore, challenges with vaccine access, hesitancy, distrust of the medical system further influenced who was protected from COVID-19.This study combines databases to conduct a multisite study across diverse states during the pandemic. METHOD(S): We conducted an ancillary study using the VIRUS (Viral Infection and Respiratory illness Universal Study) registry data supplemented by electronic medical record data from Mayo Clinic enterprise to assess demographics and outcomes among hospitalized patients with severe COVID-19. We included hospitalized adult patients admitted in five participating sites between April 2020 and January 2022 including academic hospitals in MN, AZ, and FL and two community hospitals in MN and WI. Selfidentified race and ethnicity data was categorized as White, Black, Asian, and Other;Hispanic and non-Hispanic. Other baseline characteristics, disease severity, and vaccination status were included in the analyses. The primary outcome was hospital mortality, the secondary outcomes were length of stay and healthcare utilization. Multivariable regression models were developed to analyze the interactions of relevant variables to predict outcomes. RESULT(S): 6904 patients were included. 3398 (57.8%) were male and 86.9% White,3.6% Black,3.3% Asian,6.2% Other. The mean age of Whites was 64.9 years v.53.8, 58, 52.8 respectively (p< 0.0005). Whites had higher Charlson comorbidity scores-5.2 v.4.0,3.6,3.0 respectively (p< 0.005). Vaccination rates were low in cohort, but higher among Whites 11.2% v.5.4%,4.6%,5.0% respectively (p< 0.0005). Mortality outcomes between different racial groups did not differ (p=0.41). Non-Hispanics were older than Hispanics- mean age 64.5 years v.53 (p< 0.005) and had higher Charlson comorbidity scores-5.2 v.3.4 (p< 0.005) Vaccination rates among non-Hispanics were 10.7 v 3.4% (p< 0.005)). Mortality outcomes between ethnic groups did not differ(p=0.86). Mortality outcomes between vaccinated and unvaccinated patients did not differ (p=0.9). CONCLUSION(S): Despite differences in risk factors between demographic groups, outcomes did not differ significantly in this cohort.

GAINING CONSENSUS ON EXPERT RULE STATEMENTS FOR A DIGITAL TWIN PATIENT MODEL IN THE ICU USING A DELPHI METHOD

SESSION TITLE: Optimizing Resources in the ICU SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: The COVID-19 pandemic has exposed worldwide heterogeneity in the application of fundamental critical care principles and best practices. New methods and strategies to facilitate timely and accurate interventions are needed. If built on a robust foundation of physiologic principles, a virtual critically ill patient (aka digital twin) could better inform decision making in critical care. When used in clinical practice, a digital twin may allow bedside providers to preview how organ systems interact to cause a clinical effect, providing the opportunity to test the effects of various interventions virtually, without exposing an actual patient to potential harm. Building on our previous work with a digital twin model of critically ill patients with sepsis, this current project focuses specifically on the respiratory system. METHODS: We assembled a modified Delphi panel of 36 international critical care experts. We modeled elements of respiratory system pathophysiology using directed acyclic graphs (DAG) and derived several statements describing associated ICU clinical processes. Panelists participated in three Delphi rounds to gauge agreement on 71 final statements using a 6-point Likert scale. Agreement was defined as >80% selection of a 5 (“agree”) or 6 (“strongly agree”). RESULTS: The first Delphi round included statements of pulmonary physiology affecting critically ill patients, eg pulmonary edema, hypoxemic and hypercapnic respiratory failure, shock, acute respiratory distress syndrome (ARDS), airway obstruction, restrictive lung disease, and ventilation-perfusion mismatch. Agreement was achieved on 60 (84.5%) of expert statements after completion of two rounds. After partial completion of the third round, agreement increased to 62 (87%). Statements with the most agreement included the physiology and management of airway obstruction decreasing alveolar ventilation and the effects of alveolar infiltrates on ventilation-perfusion matching. Lowest agreement was noted for the statements describing the interaction between shock and hypoxemic respiratory failure due to increased oxygen consumption and ARDS increasing dead space. CONCLUSIONS: An international cohort of critical care experts reached 87% agreement on our rule statements for respiratory system pathophysiology. The Delphi approach appears to be an effective way to refine content for our digital twin model. CLINICAL IMPLICATIONS: Expert consensus can be used to strengthen the respiratory physiology statements used to direct the ICU digital twin patient model. With a digital twin based on refined respiratory physiology statements, bedside providers may preview how organ systems interact to cause a clinical effect without exposing an actual patient to various interventions. DISCLOSURES: No relevant relationships by Ognjen Gajic, value=Royalty Removed 06/06/2022 by Ognjen Gajic No relevant relationships by Amos Lal No relevant relationships by John Litell No relevant relationships by Amy Montgomery

Gaps in Documented Assessments at the Time of Intensive Care Unit Admission

RATIONALE During this unprecedented COVID-19 pandemic intensive care units (ICU) need efficient ways to deliver patient care. As hospital workload increases, so does the risk for medical error and delays in care. A systematic initial approach and timely documentation is important to provide an efficient and thorough assessment and to facilitate communication within the interprofessional team. We aimed to evaluate documentation of key assessment elements at ICU admission. METHODS The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) is a validated tool that reduces errors in the initial assessment and ongoing care of critically ill patients. With Mayo IRB approval, electronic medical records (EMR) of a convenience sample of ICU patients admitted to medical, surgical and mixed ICUs at our institution during October 2021 were reviewed to assess documentation of the CERTAIN primary survey, including assessment of airway, breathing, cardiac, disability, and exposure (ABCDE);vital signs;intravenous access;point of care labs and ultrasound (POCUS);differential diagnosis;and plan by systems including code status and goals of care. Patients admitted for post-operative monitoring and those who declined the use of their medical records for research were excluded. RESULTS Forty patient EMRs were reviewed. Median age was 65 years, 47.5% were female, and respiratory failure was the most common reason for ICU admission. Documented frequency of airway assessment was 32.5%, breathing 92.5%, cardiac 70%, disability 42.5%, and exposure 85%. Thorough vital sign review including temperature was documented in 47.5% of ICU admissions. A comment or plan for intravenous or intraosseous access was documented in 75% of patients. Completion or review of same day point of care labs was documented in 55%. Cardiac POCUS was documented in 9 of 40 ICU admissions. No patients had documented lung or abdominal POCUS. 80% had a differential diagnosis documented as part of their initial assessment. All patients had a complete plan by systems. 85% of patients had a documented code status, although it was unclear if it had been actively re-addressed on ICU admission. CONCLUSION EMR documentation of key findings at the time of ICU admission leaves significant opportunities for improvement, with particularly large gaps in primary survey and POCUS assessment. The results of this study, combined with ongoing direct observation of ICU admissions using the CERTAIN checklist, will inform future recommendations to improve the performance and documentation of key assessment elements during the “golden first hour” of ICU admission.

Modeling of Critically Ill Patient Pathways to Support Intensive Care Delivery

The COVID-19 pandemic has exposed long standing deficiencies in critical care knowledge and practice in hospitals worldwide. New methods and strategies to facilitate timely and accurate interventions are needed. A virtual counterpart (digital twin) to critically ill patients would allow bedside providers to visualize how the organ systems interact to cause a clinical effect, offering them the opportunity to evaluate the effect of a specific intervention on a virtual patient before exposing an actual patient to potential harm. This work aims at developing a digital simulation that models the clinical pathway of critically ill patients. Using the mixed-methods approach with the support of multiprofessional clinical experts, we first identify the causal and associative relationships between organ systems, medical conditions, clinical markers, and interventions. We record these relationships as structured expert rules, depict them in a directed acyclic graph (DAG) format, and store them in a graph database (Neo4j). These structured expert rules are subsequently utilized to drive a simulation application that enables users to simulate the state trajectory of critically ill patients over a given simulated time period to test the impact of different interventions on patient outcomes. This simulation model will be the engine driving a future digital twin prototype, which will be used as an educational tool for medical students, and as a bedside decision support tool to enable clinicians to make faster and more informed treatment decisions. IEEE

A GLOBAL REMOTE QUALITY IMPROVEMENT INITIATIVE: NEEDS ASSESSMENT FROM INTERPROFESSIONAL CRITICAL CARE PROVIDERS FROM BOSNIA AND HERZEGOVINA

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: The need for swift international collaboration alongside rapidly deployable remote medical knowledge transition and implementation programs has been highlighted during the ongoing COVID-19 pandemic. Virtual programs have emerged as cost-effective alternatives to in-person education to spread best practices to resource-limited locations and garner purposeful learner engagement. Understanding local practice needs is paramount to the development of an effective quality improvement initiative. This study aimed to gain insight into the interests, clinical challenges, and attitudes of a group of interprofessional critical care providers from Bosnia and Herzegovina in preparation for a longitudinal remote education and quality improvement program. METHODS: A novel learning needs assessment tool was implemented in a cohort of critical care professionals from four hospitals in Bosnia and Herzegovina. A sequential explanatory design was employed, and a mixed-method assessment was conducted in three phases. 1) Utilizing the Delphi method, twenty statements containing common critical care entrustable professional activities (EPAs) were developed by a board of intensivists and medical education specialists. 2) Local learners used Q Sort methodology to rank-order EPAs based on self-perceived learning priorities, with subsequent by-person factor analysis. 3) Learners were invited for focus-group interviews to gather details of the rationale behind their rankings. RESULTS: Forty nine out of 105 participants completed the rank-order survey (response rate 47%). Factor analysis categorized the participants into two main groups based on the typology of their opinions, 22 participants into factor 1 and 9 participants into factor 2. The highest-ranked EPAs amongst the two factors were “evaluation and management of the patients with shock, stabilization, and resuscitation of critically ill patients” and “evaluation and management of ARDS,” respectively. Statements regarding common ICU complications and procedures were regarded as neutral. The lowest rank amongst factor 1 was “patient-centered care, communication skills, and interprofessional collaboration.” Participants in factor 2 ranked “preoperative evaluation and management” and “common hematologic and oncologic complications” the lowest. The rationale behind rank orders focused on the current patient population and perceived EPA importance to critical care practice. Participants in factor 1 displayed pessimistic attitudes toward patient-centered care and interprofessional collaboration due to cultural and healthcare system constraints. Interviewees in both factors described local challenges and expressed a need for change. CONCLUSIONS: We conducted a remote needs assessment in an international, interprofessional group of critical care providers. In addition to building trust with learners, the acquired knowledge of cultural differences, needs, and barriers to implementation will guide an ongoing remote education and quality improvement initiative. CLINICAL IMPLICATIONS: This investigation will shape a critical care best practices quality improvement initiative and remote education program in a country with limited resources. DISCLOSURES: No relevant relationships by Marija Bogojevic, source=Web Response No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty no disclosure on file for Pedja Kovacevic;No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Aida Mujakovic, source=Web Response No relevant relationships by Alexander Niven, source=Web Response No relevant relationships by Manja Spahalic, source=Web Response no disclosure on file for Slavenka Straus;No relevant relationships by Simon Zec, source=Web Response

IMPLEMENTATION OF A GLOBAL REMOTE INTERPROFESSIONAL QUALITY IMPROVEMENT INITIATIVE: RESULTS OF A NEEDS ASSESSMENT CONDUCTED FOR A BALKAN LEARNING COLLABORATIVE

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Background: The ongoing COVID-19 pandemic has created an urgent need for international collaboration and programs to rapidly share evolving medical knowledge and implementation strategies. Virtual programs offer a cost-effective option to provide meaningful engagement and disseminate best practices to remote locations with limited resources. A thorough understanding of the local practice needs is essential to design an effective quality improvement initiative. The purpose of this study was to conduct a novel learning needs assessment among an interprofessional group of Balkan healthcare professionals to better understand their current clinical challenges, interests, and opinions to inform a longitudinal remote education and quality improvement program. METHODS: We developed and performed a learning needs assessment with a group of interprofessional healthcare providers from Montenegro. This qualitative assessment was conducted in three phases using sequential explanatory design: 1) A board of intensivists and education experts developed 20 statements describing common critical care entrustable professional activities (EPAs) using a Delphi method. 2) Local healthcare providers rank-ordered these statements using Q Sort methodology, which were analyzed using by-person factor analysis. 3) A focus group interview was performed to understand the reasoning behind participant responses and analyzed using thematic analysis. RESULTS: 24 out of 63 participants answered the survey (response rate 38%). Most participants were grouped into one factor. Surveyed participants showed the highest interest in the evaluation and management of patients with shock, resuscitation, and stabilization of critically ill patients, and evaluation and management of common critical care infections. Moderate interest was expressed for procedural skills and the evaluation and management of the most common complications in the intensive care unit. Less common priorities were communication skills and interprofessional collaboration. The focus group interviewees agreed that they need improvement in a systemic approach, better protocols, and interprofessional collaboration and provided important insights into local practice constraints and cultural values. CONCLUSIONS: We describe an effective qualitative approach to conduct a remote needs assessment among an international, interprofessional group of healthcare professionals. This information has informed a tailored instructional design of our ongoing education and quality improvement initiative and has proved crucial to building cultural appreciation, trust, and an understanding of the expectations, needs, and implementation challenges of our Balkan participants. CLINICAL IMPLICATIONS: Description of a novel learning needs assessment tool to help build a customized remote education and quality improvement initiative for an interprofessional group of critical care healthcare professionals from the Balkan. DISCLOSURES: No relevant relationships by Marija Bogojevic, source=Web Response No relevant relationships by Milan Bogojevic, source=Web Response No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Alexander Niven, source=Web Response No relevant relationships by Zoja Stankovic, source=Web Response No relevant relationships by Simon Zec, source=Web Response

FEASIBILITY, DELIVERY, AND IMPLEMENTATION OF A REMOTE CRITICAL CARE TRAINING PROGRAM IN CHINA: THE CERTAIN APPROACH

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: To describe the development, implementation, and learner engagement in a longitudinal international remote critical care continuing medical education program in China. METHODS: Based on the Mayo Clinic Checklist for Early Recognition and Treatment of Acute and Illness and iNjury (CERTAIN) program, we designed and delivered a longitudinal 40-week remote coaching program for a community-based teaching hospital in Shandong Province, China. Based on a mixed-methods needs assessment that included learner feedback using an exploratory sequential design and ICU process and outcomes data, we developed a curriculum that included asynchronous, online learning modules with multiple language captions and weekly remote education sessions using a blend of didactic presentations on common critical care syndromes, virtual simulation, journal club, and case-based discussions. Faculty included a diverse group of critical care experts and bilingual facilitators. The program also included clinical research and quality improvement workshops to facilitate implementation of key concepts identified during these activities. Participants completed a survey using a 5 point anchored Likert scale after each educational activity to provide feedback and guide course improvement. RESULTS: Twenty-two Chinese clinicians (18 physicians, 4 nurses) enrolled in this CERTAIN longitudinal program. Learners completed a total of 163 hours (mean 7.4 hr/learner) asynchronous online learning, and to date have completed 23 weekly education sessions (total 28 hours, including an extended virtual simulation experience). Survey response rate was 56%. Learners reported a high rate of overall satisfaction with the course (112, 61% Excellent;55 (30%) Very Good) and specific topic discussions (110,60% Excellent;57, 31% Very Good), with steady improvement over time. Perceived practice relevance was also high (110, 59% Excellent;55,30% Very Good), and this effort has informed ongoing local performance improvement initiatives. CONCLUSIONS: Remote delivery of longitudinal critical care continuing education program in China using asynchronous learning, case-based discussion, and virtual simulation is feasible, associated with a high rate of learner satisfaction, and increases engagement in quality improvement initiatives. This innovative global education initiative offers an important potential solution to strengthen critical care services in remote, resource-limited settings at low cost, especially during the ongoing COVID-19 pandemic. CLINICAL IMPLICATIONS: The World Health Organization has identified remote education programs as a priority to strengthen international critical care services and better meet growing global clinical demand. The best method to effectively deliver continuing medical education to international healthcare providers with unique cultural, organizational, and practice backgrounds is not well defined. DISCLOSURES: no disclosure on file for Wenjuan Cui;No relevant relationships by Yue Dong, source=Web Response Patent/IP rights for a licensed product relationship with Ambient Clinical Analytics Please note: From 2016 Added 05/23/2021 by Ognjen Gajic, source=Web Response, value=Royalty No relevant relationships by Heyi Li, source=Web Response No relevant relationships by Alexander Niven, source=Web Response no disclosure on file for Lujun Qiao;No relevant relationships by Yuqiang Sun, source=Web Response no disclosure on file for Qingzhong Yuan;

Variation in use of anti-viral and anti-inflammatory medications in patients hospitalized with COVID-19: Results from the international viral infection and respiratory illness universal study (virus)

RATIONALE: In the absence of effective therapies at the start of the Coronavirus disease of 2019 (COVID-19) pandemic, anti-viral and antiinflammatory medications were used for management of COVID-19 without robust evidence of their benefit. The patterns of use, implementation, and de-implementation of these medications is unclear. METHODS: We performed a retrospective, observational study on an international cohort of adult patients hospitalized from March 2020 to November 2020 with laboratory confirmed COVID-19 infection, receiving supplemental oxygen, and enrolled in the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) Registry. The primary outcome of interest was to describe the hospital-level variation in the most commonly used medications repurposed for empiric management of patients hospitalized with COVID-19 (hydroxychloroquine, remdesivir, corticosteroids, and anti-IL-6 therapies). Secondary outcomes included geographic and temporal variation in medication use. RESULTS: Among 6,621 patients with COVID-19 across 86 hospitals (predominantly USbased [88%]), 1,373 (20.7%, hospital usage rates range 0%-96.4%) received corticosteroids, 1,302 (19.7%, range 0%-100%) received hydroxychloroquine, 602 (9.1%, range: 0%-65.7%) received remdesivir, and 405 (6.1%, range 0%-87.5%) received an anti-IL6 medication. USbased hospitals vs non-US hospitals showed differences in medication use with 9.9% vs. 0.8% use of remdesivir, 19.5% vs 33.2% use of corticosteroids, 18.7% vs 29.6% use of hydroxychloroquine and 6.3% vs. 3.9% use of anti-IL6 medications. Comparing use prior to July 2020 with use after July 2020, prescription of remdesivir increased from 6.5% to 20.5%, corticosteroid use increased from 17.5% to 35.0%, hydroxychloroquine use decreased from 23.9% to 1.1% and anti-IL6 use decreased from 7.0% to 2.4%. CONCLUSIONS: Hospital-level variation and geographic variation in use of repurposed anti-viral and anti-inflammatory medications for the management of COVID-19 infection was large. Coinciding with accrual of scientific evidence, the use of remdesivir and corticosteroids increased over time, while the use of hydroxychloroquine and anti-IL6 medications decreased over time. Further studies are needed to evaluate the drivers of hospital variation and impact on clinical outcomes.

Variation in high-flow nasal cannula and non-invasive ventilation practice patterns during the COVID-19 pandemic: Results from the international viral infection and respiratory illness universal study (virus)

RATIONALE: Critical care guidelines have supported use of non-invasive respiratory support modalities in patients with acute respiratory failure from COVID-19 since the beginning of the pandemic. However, concerns surrounding viral particle aerosolization, nosocomial spread, and patient self-induced lung injury have likely influenced choice of respiratory support strategies. To date, high flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) practice patterns have not been characterized for patients with COVID-19. METHODS: We enrolled hospitalized patients aged 18 years or older with laboratory confirmed COVID-19 infection who received supplemental oxygen, using the Society of Critical Care Medicine Discovery VIRUS Registry. The primary outcome was hospital-level variation in use of HFNC and NIPPV, summarized using the intraclass correlation coefficient and median odds ratio. Hierarchical random effects models were used to estimate patient and hospital factors associated with HFNC and NIPPV use. Risk-adjusted estimation of the association between hospital HFNC/NIPPV use and patient risk of receiving invasive mechanical ventilation (IMV) was assessed as a secondary outcome. RESULTS: Among 8,532 patients with COVID-19 receiving oxygen support across 73 hospitals, the majority were treated in the US (92.3%) and were older (median age 63 years, IQR 52-74), white (49.1%), men (56.8%) with median SOFA score of 4 (IQR 1-6) and admission PaO2:FiO2 below 300 (49.4%). Of these, 5,298 (62.1%) received low flow oxygen (nasal cannula or face mask), while 1,768 (20.7%) received HFNC, 773 (9.1%) received NIPPV and 693 (8.1%) received both HFNC/NIPPV. Patient SOFA score (OR 0.92, 95% CI 0.90, 0.95), treatment for COVID-19 after July versus March-June (OR 1.3, 95% CI 1.0, 1.6) and ICU versus floor admission (OR 10.3, 95% CI 8.2, 12.8) were associated with HFNC/NIPPV use. After adjusting for patient and hospital characteristics, the hospital of admission contributed to 27% of the variation in use of HFNC and/or NIPPV. Odds of receiving either modality at a randomly selected high vs. low HFNC/NIPPV utilization hospital was 2.9. Hospital rates of HFNC/NIPPV use were not associated with patient receipt of IMV (OR 0.87, 95% CI 0.7, 1.1). CONCLUSION: Throughout the course of the COVID-19 pandemic, use of HFNC and NIPPV varied widely across hospitals, though use of non-invasive respiratory support modalities was not associated with patient risk for invasive mechanical ventilation. Further evaluation of HFNC and NIPPV exposure, progression to IMV and subsequent mortality within these subgroups may provide additional insights regarding optimal oxygenation and ventilation strategies of patients with COVID-19.

An implementation and longitudinal evaluation framework of remote quality improvement initiatives

Objective: Virtual learning experiences have become widely used during the ongoing COVID-19 global crisis. Given its cost-effectiveness, accessibility, and flexibility, remote training experiences are likely to assume a permanent and expanded role in medical education and quality improvement initiatives. However, little is known about how best to measure the effectiveness of remote training interventions. The Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) is an established critical care quality improvement program with evidence of improved care processes and patient outcomes in an international quality improvement trial. Our aim was to develop a structured implementation and longitudinal evaluation framework that measures the complex contributors to the impact of this remote training program, including incorporation into processes of care and sustainment over time. Methods: We convened an international topic review group that included individuals with diversity in clinical expertise, nationality, and experience in medical education, quality improvement, implementation science, and research methodology. We recruited individuals with experience designing and participating in various medical remote training programs, including teleconferences, tele-consults, online video/chat platforms, and virtual simulation classrooms. Through a series of facilitated discussions, we directed the group to develop a conceptual framework to guide the development of remote learning programs and accompanying evaluation tools to measure their impact. Results: The review group members included education experts and continuing medical education participants from China and the United States with practice backgrounds in Critical Care, Internal Medicine, Anesthesiology and Emergency Medicine. The group developed a conceptual framework based on the CIPP (context-input-process-product) quality evaluation model. The framework includes three phases: before, during, and after the remote training. The proposed quantitative and qualitative evaluation tools blend the Proctor taxonomy, an expansion of the popular RE-AIM framework used to categorize implementation outcomes, to include early (i.e. acceptability, appropriateness, feasibility), mid (i.e. adoptions, fidelity), and late (i.e. sustainability) stage outcomes to provide a more complete understanding of the implementation process and facilitate generalization of our findings. Elements of the Logic Model were also used to guide the program development process. Conclusions: We propose a dynamic, longitudinal implementation evaluation framework that has sufficient rigor and flexibility to meet the needs of the existing and emerging remote medical training programs in global practice settings. The outcomes from these mixed-methods analyses will provide a robust toolbox to guide the design, delivery, implementation, and sustainment of remote medical educational programs.

Successful implementation of modern critical care in the low-resources country Bosnia and Herzegovina : Single-center experience.

BACKGROUND: Critical care medicine is a relatively young discipline, developed in the mid-1950s in response to the outbreak of poliomyelitis. The mass application of mechanical ventilation and its subsequent technical advancement helped manage large numbers of patients with respiratory failure. This branch of medicine evolved much faster in high-income (HIC) than low- and middle-income countries (LMIC). Seventy years later, mankind's encounter with coronavirus disease 2019 (COVID-19) represents another major challenge for critical care medicine especially in LMIC countries where over two thirds of the world population live. METHODS: Systematic analysis of written documents related to the establishment of the first multidisciplinary medical intensive care unit (MICU) in Bosnia and Herzegovina and its development to the present day. RESULTS: We describe the experience of setting up a modern critical care program under LMIC constraints as a promising way forward to meet the increased worldwide demand for critical care. Successful development is contingent on formal education and continued mentorship from HIC, establishment of a multidisciplinary team, the support from local health care authorities, development of a formal subspecialty training, academic faculty development, and research. Novel technologies including tele-education provide additional opportunities for rapid development and dissemination of critical care medicine programs in LMIC. CONCLUSION: Critical care medicine is a critical public health need in HIC and LMIC alike. The challenges associated with the coronavirus pandemic should serve as a wakeup call for rapid development of critical care programs around the world.