Does a Starting Positive End-Expiratory Pressure of 8 cmH2O Decrease the Probability of a Ventilator-Associated Event?

Introduction: Ventilator-associated events (VAEs) are objective measures as defined by the Centers for Disease Control and Prevention (CDC). To reduce VAEs, some hospitals have started patients on higher baseline positive end-expiratory pressure (PEEP) to avoid triggering VAE criteria due to respiratory fluctuations. Methods: At our institution, VAEs were gathered from January 2014 through December 2019. Using the CDC-defined classifications, VAEs were split into two groups to separate patients with hypoxemia only (VAC) and those with hypoxemia and evidence of inflammation or infection (IVAC-plus). We used the geometric distribution to calculate the daily event probability before and after the protocol implementation. A probability threshold was used to determine if the days between events was exceeded during the post-protocol period. Results: A total of 306 VAEs were collected over the study period. Of those, 155 were VACs and 107 were IVAC-plus events during the pre-protocol period. After implementing the protocol, 24 VACs and 20 IVAC-plus events were reported. There was a non-significant decrease in daily event probabilities in both the VAC and IVAC-plus groups (0.083 vs. 0.068 and 0.057 vs. 0.039, respectively). Conclusion: We concluded a starting PEEP of 8 cmH2O is unlikely to be an effective intervention at reducing the probability of a VAE. Until specific guidelines by the CDC are established, hospitals should consider alternative methods to reduce VAEs.

H-1B Visa Sponsorship and Physician Trainee Retention: A Single Institution Experience.

BACKGROUND: International medical graduates (IMGs) form a significant portion of the physician workforce in the United States and are vital in filling training slots due to a shortage of American medical graduates. Most often, IMGs require visa sponsorship, which must be solidified before applying for a residency or fellowship. OBJECTIVE: We examined the association of H-1B visa sponsorship on retention of physician trainees within the state of Ohio. METHODS: This was a single institutional study that examined all visa-sponsored residency and fellowship graduates who entered fully licensed clinical practice between 2006 and 2015. Practice location was ascertained immediately upon completion of training and at follow-up to determine which visa group (H-1B or J-1) were more likely to initially practice in Ohio after graduation and remain within the state. RESULTS: Of 103 visa-sponsored residency and fellowship graduates, 42 were H-1B sponsored and 61 were J-1-sponsored. Fifty-two percent (22) of H-1B visa-sponsored trainees and 31% (19) of J-1 visa-sponsored trainees were retained in Ohio after graduation. At follow-up, 40% (17) of H-1B and 26% (16) of J-1 visa holders remained in the state. CONCLUSIONS: H-1B visa-sponsored trainees were more likely than those with J-1 visas to practice in the state of Ohio after graduation. Regardless of visa status, graduates tended not to change their geographical location over time.

Case-control study investigating parameters affecting ventilator-associated events in mechanically ventilated patients.

We analyzed a set of clinical parameters using Cox proportional hazard regressions to yield significant factors associated with the development of ventilator-associated events. In our study, intubation site, certain comorbidities, morphine, prednisone, and nutrition emerged as factors. Additionally, we presented potential mechanisms that require further research to validate.

Assessment of ventilator-associated events using the geometric distribution.

Hospital-acquired rare events, such as nosocomial infections and other low-occurring incidents, in the clinical environment are difficult to monitor using traditional quality indicators. Using the Centers for Disease Control and Prevention definition of ventilator-associated events, we demonstrate an alternative method for assessment of rare events.