Uncertainty and decision-making in Critical Care: lessons from managing COVID-19 ARDS for the next pandemic (preprint)

Purpose COVID-19 ARDS was an emergent syndrome that led to high volumes of critically ill ventilated patients. We explored influences on decision-making regarding management of COVID-19 ARDS mechanical ventilation to identify modifiable factors to improve preparedness for future pandemics. Methods A systematic review of existing literature and small group interviews informed the development of an international questionnaire (UK, Italy, Germany and Netherlands) on factors influencing COVID-19 ARDS ventilation decision-making in critical care professionals. Participants were asked to rank four high-level themes in order of importance: disease (uncertainties around COVID-19 ARDS), contextual (cognitive strain), environmental (structural logistics) and team factors. Participants also ranked the subthemes within each theme. Thematic analysis was used to derive findings from qualitative data. Kruskal-Wallis, Mann-Whitney U and Kendall’s Tau were used for quantitative data analysis. Results Patient factors (co-morbidities, clinical and biochemical parameters) were the most heavily studied influences in the literature on decision-making regarding organ support, whereas uncertainty was one of the least explored subthemes. In total, 371 critical care professionals from 4 professional groups in 4 countries responded to the questionnaire. Disease uncertainty (lack of applicable guidelines and unfamiliarity with pathophysiology) was ranked as the most important influence on ventilation decision-making for COVID-19 ARDS across regions, professions and experience levels. This was followed by team, then contextual, then environmental factors (p<0.001). Participants were underconfident in their decision-making (median score: 9 out of 20), and this was unaffected by experience (p=0.79) or profession (p=0.58). Higher disease certainty, however, led to increased confidence (p<0.001). Major influences on disease uncertainty were the pathophysiology and natural history of COVID-19 ARDS, information sharing and experience over time. Modifiable influences on disease uncertainty were positive team factors and resource limitations. Conclusion Future pandemic preparedness programmes should target modifiable influences such as information sharing, teamworking and resource limitations to mitigate against the negative influence of uncertainty and thereby improve decision-making overall.

ABCDEF Bundle and Supportive ICU Care Practices for patients with COVID-19 infection: An international point prevalence study ~The ISIIC Study~ (preprint)

BackgroundAlthough the number of patients with COVID-19 infection is increasing and concerns for their long-term disabilities are increasing, there is a lack of data about the delivery of the ABCDEF-bundle and supportive care in Intensive Care Units (ICUs). The aim of this study is to investigate the implementation of the ABCDEF-bundle and supportive care provided to patients with COVID-19 infections in ICUs. MethodsThis was a world-wide two-day point prevalence study, on June 3 and July 1, 2020. A total of 212 ICUs in 38 countries (166 ICUs on Day 1 and 212 on Day 2) participated. Clinicians in each participating ICU completed web-based online surveys. The implementation rate for elements of the ABCDEF-bundle, other supportive ICU care measures and implementation associated structures were investigated.RESULTSData for 262 patients was collected during the two-day study. Of patients included, 124 (47.3%) underwent mechanical ventilation (MV) and 12 (4.6%) patients were treated with extracorporeal membrane oxygenation (ECMO). The proportion of patients with implementation of each element was: Element A (regular pain assessment) 45%; B (both spontaneous awakening and breathing trials) 28%; C (regular sedation assessment) 52%; D (regular delirium assessment) 38%; E (early mobility and exercise) 47%; and F (family engagement and empowerment) 16%. The implementation of element E for patients on MV was 16% and ECMO was 17%. Supportive care, such as providing protein throughout the ICU stay (under 1.2g/kg for more than 50% of the patients) and introduction of an ICU diary (25%) was inadequate. A higher implementation rate of elements A and D were recognized in ICUs with specific protocols for ICU care and lower numbers of ICU beds exclusively for patients with COVID-19 infection. Element E was implemented at a higher rate in ICUs with more ICU beds for patients with COVID-19 infection.CONCLUSIONSThis worldwide two-day point prevalence study found low implementation of the ABCDEF-bundle. Specific protocols and the number of ICU beds reserved for patients with COVID-19 infections might be key factors to deliver appropriate supportive care.Trial registration: UMIN, UMIN000040405. Registered 14 May 2020, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000046103