MRI and the Critical Care Patient: Clinical, Operational, and Financial Challenges.

Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor (e.g., clinical decompensation) or major (e.g., requiring immediate intervention) and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety.

What the Joint Commission Medication Management Titration Standards Mean to Quality Care for Complex Patients.

ABSTRACT: The Joint Commission (TJC), the nation's largest healthcare accreditor, was founded in the 1950s. Its Standards for Medication Management (MM) of titratable medications focused on prescriptive ordering practices versus reliance on nurse clinical decision making. The use of measurable endpoints to guide nurse decision making regarding medication titration has been the standard of care since the inception of TJC. Evidence to support altering these practice patterns is lacking. Using the 6 aims for the healthcare system (safe, timely, effective, efficient, equitable, and patient-centered) from the National Academy of Medicine, formerly the Institute of Medicine, and the American Association of Critical-Care Nurses Healthy Work Environment essential standards (skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, authentic leadership), this article examines the impact of TJC MM standards on system design in critical care environments.

Survey of Nurses' Experiences Applying The Joint Commission's Medication Management Titration Standards.

BACKGROUND: Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making. OBJECTIVES: To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. METHODS: A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. RESULTS: The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. CONCLUSIONS: Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

Remote Continuous Glucose Monitoring With a Computerized Insulin Infusion Protocol for Critically Ill Patients in a COVID-19 Medical ICU: Proof of Concept.

OBJECTIVE: The use of remote real-time continuous glucose monitoring (CGM) in the hospital has rapidly emerged to preserve personal protective equipment and reduce potential exposures during coronavirus disease 2019 (COVID-19). RESEARCH DESIGN AND METHODS: We linked a hybrid CGM and point-of-care (POC) glucose testing protocol to a computerized decision support system for continuous insulin infusion and integrated a validation system for sensor glucose values into the electronic health record. We report our proof-of-concept experience in a COVID-19 intensive care unit. RESULTS: All nine patients required mechanical ventilation and corticosteroids. During the protocol, 75.7% of sensor values were within 20% of the reference POC glucose with an associated average reduction in POC of 63%. Mean time in range (70-180 mg/dL) was 71.4 ± 13.9%. Sensor accuracy was impacted by mechanical interferences in four patients. CONCLUSIONS: A hybrid protocol integrating real-time CGM and POC is helpful for managing critically ill patients with COVID-19 requiring insulin infusion.

Major publications in the critical care pharmacotherapy literature: 2019.

PURPOSE: To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019. MATERIALS AND METHODS: The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS: Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis. CONCLUSION: This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019.

Risk of Hypoglycemia During Insulin Infusion Directed by Paper Protocol Versus Electronic Glycemic Management System in Critically Ill Patients at a Large Academic Medical Center.

BACKGROUND: Insulin infusions are commonly utilized to control hyperglycemia in critically ill patients and decrease hyperglycemia associated complications. Safety concerns have been raised in trials evaluating methods of glycemic control regarding the incidence of hypoglycemia and its relationship to increased mortality. Electronic glycemic management systems (eGMS) may result in less variable blood glucose (BG) control and less hypoglycemia. This study aimed to compare BG control, time in target BG range, and the rate of hypoglycemia when critically ill patients were managed with an insulin infusion guided by paper-based protocol (PBP) versus eGMS. METHODS: This retrospective review compared critically ill patients ≥ 18 years old that received insulin infusion from March to May 2015 (PBP group) and October to January 2017 (eGMS group). The primary outcome was the incidence of hypoglycemia. Secondary outcomes included frequency and severity of hypoglycemia, duration in glycemic target, length of insulin therapy, as well as ICU and hospital length of stay. RESULTS: Fifty-four patients were evaluated, 27 in each group. Percentage of days with BG <70 mg/dL was significantly reduced after eGMS implementation (21.5% v 1.3%, P < .0001) including the frequency of severe hypoglycemia (BG < 40 mg/dL) (5.4% v 0.01%, P < .0001). Patients in the eGMS group spent a greater amount of time in target BG range (31.5% v 63.7%, P < .0001). CONCLUSIONS: An eGMS has the potential to address many of the unmet needs of an optimal glycemic control strategy, minimizing hypoglycemia, and glycemic variability in a heterogeneous critically ill population.

Technological Distractions (Part 2): A Summary of Approaches to Manage Clinical Alarms With Intent to Reduce Alarm Fatigue.

OBJECTIVE: Alarm fatigue is a widely recognized safety and quality problem where exposure to high rates of clinical alarms results in desensitization leading to dismissal of or slowed response to alarms. Nonactionable alarms are thought to be especially problematic. Despite these concerns, the number of clinical alarm signals has been increasing as an everincreasing number of medical technologies are added to the clinical care environment. DATA SOURCES: PubMed, SCOPUS, Embase, and CINAHL. STUDY SELECTION: We performed a systematic review of the literature focused on clinical alarms. We asked a primary key question; "what interventions have been attempted and resulted in the success of reducing alarm fatigue?" and 3-secondary key questions; "what are the negative effects on patients/families; what are the balancing outcomes (unintended consequences of interventions); and what human factor approaches apply to making an effective alarm?" DATA EXTRACTION: Articles relevant to the Key Questions were selected through an iterative review process and relevant data was extracted using a standardized tool. DATA SYNTHESIS: We found 62 articles that had relevant and usable data for at least one key question. We found that no study used/developed a clear definition of "alarm fatigue." For our primary key question 1, the relevant studies focused on three main areas: quality improvement/bundled activities; intervention comparisons; and analysis of algorithm-based false and total alarm suppression. All sought to reduce the number of total alarms and/or false alarms to improve the positive predictive value. Most studies were successful to varying degrees. None measured alarm fatigue directly. CONCLUSIONS: There is no agreed upon valid metric(s) for alarm fatigue, and the current methods are mostly indirect. Assuming that reducing the number of alarms and/or improving positive predictive value can reduce alarm fatigue, there are promising avenues to address patient safety and quality problem. Further investment is warranted not only in interventions that may reduce alarm fatigue but also in defining how to best measure it.

Technologic Distractions (Part 1): Summary of Approaches to Manage Alert Quantity With Intent to Reduce Alert Fatigue and Suggestions for Alert Fatigue Metrics.

OBJECTIVE: To provide ICU clinicians with evidence-based guidance on tested interventions that reduce or prevent alert fatigue within clinical decision support systems. DESIGN: Systematic review of PubMed, Embase, SCOPUS, and CINAHL for relevant literature from 1966 to February 2017. PATIENTS: Focus on critically ill patients and included evaluations in other patient care settings, as well. INTERVENTIONS: Identified interventions designed to reduce or prevent alert fatigue within clinical decision support systems. MEASUREMENTS AND MAIN RESULTS: Study selection was based on one primary key question to identify effective interventions that attempted to reduce alert fatigue and three secondary key questions that covered the negative effects of alert fatigue, potential unintended consequences of efforts to reduce alert fatigue, and ideal alert quantity. Data were abstracted by two reviewers independently using a standardized abstraction tool. Surveys, meeting abstracts, "gray" literature, studies not available in English, and studies with non-original data were excluded. For the primary key question, articles were excluded if they did not provide a comparator as key question 1 was designed as a problem, intervention, comparison, and outcome question. We anticipated that reduction in alert fatigue, including the concept of desensitization may not be directly measured and thus considered interventions that reduced alert quantity as a surrogate marker for alert fatigue. Twenty-six articles met the inclusion criteria. CONCLUSION: Approaches for managing alert fatigue in the ICU are provided as a result of reviewing tested interventions that reduced alert quantity with the anticipated effect of reducing fatigue. Suggested alert management strategies include prioritizing alerts, developing sophisticated alerts, customizing commercially available alerts, and including end user opinion in alert selection. Alert fatigue itself is studied less frequently, as an outcome, and there is a need for more precise evaluation. Standardized metrics for alert fatigue is needed to advance the field. Suggestions for standardized metrics are provided in this document.

Hemodynamics of Acute Right Heart Failure in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome.

In critically ill patients with circulatory shock, the role of the left ventricle has long been appreciated and the object of measurement and therapeutic targeting. The right ventricle is often under appreciated and dysfunction may be overlooked. Generally, the right ventricle operates passively to support the ejection of the left ventricular diastolic volume. A loss of right ventricular wall compliance secondary to pulmonary pressures may result in an alteration in the normal pressure-volume relationship, ultimately affecting the stroke volume and cardiac output. Traditional right heart filling indices may increase because of decreasing compliance, further complicating the picture. The pathophysiology of pulmonary vascular dysfunction in acute respiratory distress syndrome combined with the effects of a mean airway pressure strategy may create an acute cor pulmonale.

Acute respiratory failure and intensive measures.

Critical patients presenting with acute respiratory failure (ARF) offer a plentiful, dynamic, and complex picture, which requires a deep understanding of gas exchange, pulmonary dynamics, and mechanical ventilation strategies. The most frequent cause of ARF is chronic disease with exacerbation. Interventions treating acute exacerbation, along with ventilatory support, physical therapy, and evidence-based strategies, may improve immediate outcomes. However, follow-up is essential and for the chronic obstructive pulmonary disease patient the goal is to avoid relapse or rehospitalization. This article discusses the evaluation of gas exchange failures, pulmonary mechanics, and the properties of obstructive airway disease as they relate to ARF.

Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis.

BACKGROUND: Immobility is associated with complications involving many body systems. OBJECTIVE: To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients. METHODS: Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses. RESULTS: A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality. CONCLUSIONS: Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.

Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies--American College of Critical Care Medicine Task Force 2001-2002.

OBJECTIVE: To develop clinical practice guidelines for the use of restraining therapies to maintain physical and psychological safety of adult and pediatric patients in the intensive care unit. PARTICIPANTS: A multidisciplinary, multispecialty task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM), the Society of Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses (AACN). EVIDENCE: The task force members reviewed the published literature (MEDLINE articles, textbooks, etc.) and provided expert opinion from which consensus was derived. Relevant published articles were reviewed individually for validity using the Cochrane methodology (http://hiru.mcmaster.ca/cochrane/ or www.cochrane.org). CONSENSUS PROCESS: The task force met as a group and by teleconference to identify the pertinent literature and derive consensus recommendations. Consideration was given to both the weight of scientific information within the literature and expert opinion. Draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft then was reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. CONCLUSIONS: The task force developed nine recommendations with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the intensive care unit.

Reporting quality of nursing home care to consumers: the Maryland experience.

OBJECTIVE: To design and implement a reporting system for quality of long-term care to empower consumers and to create incentives for quality improvement. To identify a model to approach this technically and politically difficult task. APPROACH: Establishment of a credible and transparent decision process using a public forum. Development of the system based on: (1) review of the literature and existing systems, and discussions with stakeholders about strengths and weaknesses; (2) focus on consumer preferences in the design; and (3) responsiveness to industry concerns in the implementation. LESSONS LEARNED: None of the existing systems appeared to be a suitable model. We decided to develop an entirely new system based on three key design principles that allowed us to tailor the system to consumer needs: (1) designing a decision tool rather than a database; (2) summarizing rather than simplifying information; and (3) accounting for the target audience in the creative execution. Industry concerns focused on the burden of the system, the potential for errors, and the possible communication of a negative impression of the industry. As methodological and data limitations prevented us from resolving those concerns, we addressed them by using cautionary language in the presentation and by making a commitment to incorporate improvements in the future. All stakeholders regarded the final design as an acceptable compromise. CONCLUSIONS: Despite its potentially controversial nature and many methodological challenges, the system has been well received by both the public and the industry. We attribute this success to two key factors: a collaborative decision process, in which all critical design and execution choices were laid out explicitly and debated with stakeholders in a public forum, and realism and honesty regarding the limitations of the system.