Open-source machine learning pipeline automatically flags instances of acute respiratory distress syndrome from electronic health records.

Physicians could greatly benefit from automated diagnosis and prognosis tools to help address information overload and decision fatigue. Intensive care physicians stand to benefit greatly from such tools as they are at particularly high risk for those factors. Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition affecting >10% of critical care patients and has a mortality rate over 40%. However, recognition rates for ARDS have been shown to be low (30-70%) in clinical settings. In this work, we present a reproducible computational pipeline that automatically adjudicates ARDS on retrospective datasets of mechanically ventilated adult patients. This pipeline automates the steps outlined by the Berlin Definition through implementation of natural language processing tools and classification algorithms. We train an XGBoost model on chest imaging reports to detect bilateral infiltrates, and another on a subset of attending physician notes labeled for the most common ARDS risk factor in our data. Both models achieve high performance-a minimum area under the receiver operating characteristic curve (AUROC) of 0.86 for adjudicating chest imaging reports in out-of-bag test sets, and an out-of-bag AUROC of 0.85 for detecting a diagnosis of pneumonia. We validate the entire pipeline on a cohort of MIMIC-III encounters and find a sensitivity of 93.5% - an extraordinary improvement over the 22.6% ARDS recognition rate reported for these encounters - along with a specificity of 73.9%. We conclude that our reproducible, automated diagnostic pipeline exhibits promising accuracy, generalizability, and probability calibration, thus providing a valuable resource for physicians aiming to enhance ARDS diagnosis and treatment strategies. We surmise that proper implementation of the pipeline has the potential to aid clinical practice by facilitating the recognition of ARDS cases at scale.

Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report.

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Validation of a tool for estimating clinician recognition of ARDS using data from the international LUNG SAFE study.

Under-recognition of acute respiratory distress syndrome (ARDS) by clinicians is an important barrier to adoption of evidence-based practices such as low tidal volume ventilation. The burden created by the COVID-19 pandemic makes it even more critical to develop scalable data-driven tools to improve ARDS recognition. The objective of this study was to validate a tool for accurately estimating clinician ARDS recognition rates using discrete clinical characteristics easily available in electronic health records. We conducted a secondary analysis of 2,705 ARDS and 1,261 non-ARDS hypoxemic patients in the international LUNG SAFE cohort. The primary outcome was validation of a tool that estimates clinician ARDS recognition rates from health record data. Secondary outcomes included the relative impact of clinical characteristics on tidal volume delivery and clinician documentation of ARDS. In both ARDS and non-ARDS patients, greater height was associated with lower standardized tidal volume (mL/kg PBW) (ARDS: adjusted ß = -4.1, 95% CI -4.5 --3.6; non-ARDS: ß = -7.7, 95% CI -8.8 --6.7, P<0.00009 [where α = 0.01/111 with the Bonferroni correction]). Standardized tidal volume has already been normalized for patient height, and furthermore, height was not associated with clinician documentation of ARDS. Worsening hypoxemia was associated with both increased clinician documentation of ARDS (ß = -0.074, 95% CI -0.093 --0.056, P<0.00009) and lower standardized tidal volume (ß = 1.3, 95% CI 0.94-1.6, P<0.00009) in ARDS patients. Increasing chest imaging opacities, plateau pressure, and clinician documentation of ARDS also were associated with lower tidal volume in ARDS patients. Our EHR-based data-driven approach using height, gender, ARDS documentation, and lowest standardized tidal volume yielded estimates of clinician ARDS recognition rates of 54% for mild, 63% for moderate, and 73% for severe ARDS. Our tool replicated clinician-reported ARDS recognition in the LUNG SAFE study, enabling the identification of ARDS patients at high risk of being unrecognized. Our approach can be generalized to other conditions for which there is a need to increase adoption of evidence-based care.

The first step is recognizing there is a problem: a methodology for adjusting for variability in disease severity when estimating clinician performance.

BACKGROUND: Adoption of innovations in the field of medicine is frequently hindered by a failure to recognize the condition targeted by the innovation. This is particularly true in cases where recognition requires integration of patient information from different sources, or where disease presentation can be heterogeneous and the recognition step may be easier for some patients than for others. METHODS: We propose a general data-driven metric for clinician recognition that accounts for the variability in patient disease severity and for institutional standards. As a case study, we evaluate the ventilatory management of 362 patients with acute respiratory distress syndrome (ARDS) at a large academic hospital, because clinician recognition of ARDS has been identified as a major barrier to adoption to evidence-based ventilatory management. We calculate our metric for the 48 critical care physicians caring for these patients and examine the relationships between differences in ARDS recognition performance from overall institutional levels and provider characteristics such as demographics, social network position, and self-reported barriers and opinions. RESULTS: Our metric was found to be robust to patient characteristics previously demonstrated to affect ARDS recognition, such as disease severity and patient height. Training background was the only factor in this study that showed an association with physician recognition. Pulmonary and critical care medicine (PCCM) training was associated with higher recognition (ß = 0.63, 95% confidence interval 0.46-0.80, p < 7 × 10- 5). Non-PCCM physicians recognized ARDS cases less frequently and expressed greater satisfaction with the ability to get the information needed for making an ARDS diagnosis (p < 5 × 10- 4), suggesting that lower performing clinicians may be less aware of institutional barriers. CONCLUSIONS: We present a data-driven metric of clinician disease recognition that accounts for variability in patient disease severity and for institutional standards. Using this metric, we identify two unique physician populations with different intervention needs. One population consistently recognizes ARDS and reports barriers vs one does not and reports fewer barriers.

Promoting Evidence-Based Practice in Acute Respiratory Distress Syndrome: A Systematic Review.

Low tidal volume ventilation and prone positioning are recommended therapies yet underused in acute respiratory distress syndrome. We aimed to assess the role of interventions focused on implementation of low tidal volume ventilation and prone positioning in mechanically ventilated adult patients with acute respiratory distress syndrome. DATA SOURCES: PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials. STUDY SELECTION: We searched the four databases from January 1, 2001, to January 28, 2021, for studies that met the predefined search criteria. Selected studies focused on interventions to improve implementation of low tidal volume ventilation and prone positioning in mechanically ventilated patients with acute respiratory distress syndrome. DATA EXTRACTION: Two authors independently performed study selection and data extraction using a standardized form. DATA SYNTHESIS: Due to methodological heterogeneity of included studies, meta-analysis was not feasible; thus, we provided a narrative summary and assessment of the literature. Eight nonrandomized studies met our eligibility criteria. Most studies looked at interventions to improve adherence to low tidal volume ventilation. Most interventions focused on education for providers. Studies were primarily conducted in the ICU and involved trainees, intensivists, respiratory therapists, and critical care nurses. Although overall quality of the studies was very low, the primary outcomes of interest suggest that interventions could improve adherence to or implementation of low tidal volume ventilation and prone positioning in acute respiratory distress syndrome. MEASUREMENTS AND MAIN RESULTS: Two authors independently performed study selection and data extraction using a standardized form. Due to methodologic heterogeneity of included studies, meta-analysis was not feasible; thus, we provided a narrative summary and assessment of the literature. Eight nonrandomized studies met our eligibility criteria. Most studies looked at interventions to improve adherence to low tidal volume ventilation. Most interventions focused on education for providers. Studies were primarily conducted in the ICU and involved trainees, intensivists, respiratory therapists, and critical care nurses. Although overall quality of the studies was very low, the primary outcomes of interest suggest that interventions could improve adherence to or implementation of low tidal volume ventilation and prone positioning in acute respiratory distress syndrome. CONCLUSIONS: There is a dearth of literature addressing interventions to improve implementation of evidence-based practices in acute respiratory distress syndrome. Existing interventions to improve clinician knowledge and facilitate application of low tidal volume ventilation and prone positioning may be effective, but supporting studies have significant limitations.

Informing Healthcare Decisions with Observational Research Assessing Causal Effect. An Official American Thoracic Society Research Statement.

Rationale: Decisions in medicine are made on the basis of knowledge and reasoning, often in shared conversations with patients and families in consideration of clinical practice guideline recommendations, individual preferences, and individual goals. Observational studies can provide valuable knowledge to inform guidelines, decisions, and policy.Objectives: The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement to clarify the role of observational studies-alongside randomized controlled trials (RCTs)-in informing clinical decisions in pulmonary, critical care, and sleep medicine.Methods: The committee examined the strengths of observational studies assessing causal effects, how they complement RCTs, factors that impact observational study quality, perceptions of observational research, and, finally, the practicalities of incorporating observational research into ATS clinical practice guidelines.Measurements and Main Results: There are strengths and weakness of observational studies as well as RCTs. Observational studies can provide evidence in representative and diverse patient populations. Quality observational studies should be sought in the development of ATS clinical practice guidelines, and medical decision-making in general, when 1) no RCTs are identified or RCTs are appraised as being of low- or very low-quality (replacement); 2) RCTs are of moderate quality because of indirectness, imprecision, or inconsistency, and observational studies mitigate the reason that RCT evidence was downgraded (complementary); or 3) RCTs do not provide evidence for outcomes that a guideline committee considers essential for decision-making (e.g., rare or long-term outcomes; "sequential").Conclusions: Observational studies should be considered in developing clinical practice guidelines and in making clinical decisions.

Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM.

Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.

Educational Strategies for Training in Quality Improvement and Implementation Medicine.

Education in quality improvement (QI) is endorsed by the Association of American Medical Colleges across the spectrum of undergraduate, graduate, and postgraduate training. QI training is also a required component of graduate medical training per the American College of Graduate Medical Education. Despite widespread recognition of the importance of QI education and high levels of trainee involvement in QI as reported by pulmonary and critical care fellowship program directors, significant barriers to the implementation of effective and meaningful QI education during training exist. This creates an opportunity for the promotion of successfully implemented QI programs. Research demonstrates that successful QI educational programs involve the teaching of key QI concepts, participation in QI projects, protected time for QI project development, and institutional support. Using QI models such as the Plan-Do-Study-Act cycle and the Standards for Quality Improvement Reporting Excellence framework for reporting new knowledge about healthcare improvements also enhances both the educational value of the QI project and prospects for wider scholarly dissemination. In this perspective article, three examples of QI projects are discussed that serve to illustrate effective strategies of QI implementation.

Performance Measure Development, Use, and Measurement of Effectiveness Using the Guideline on Mechanical Ventilation in Acute Respiratory Distress Syndrome. An Official American Thoracic Society Workshop Report.

Guideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012. This report summarizes the proceedings of a follow-up workshop convened to advance the ATS's work in performance measure development and guideline implementation. To illustrate the application of the ATS's performance measure development framework, we used the example of a low-tidal volume ventilation performance measure created de novo from the 2017 ATS/European Society of Intensive Care Medicine/Society of Critical Care Medicine mechanical ventilation in acute respiratory distress syndrome clinical practice guideline. We include a detailed explanation of the rationale for the specifications chosen, identification of areas in need of further validity testing, and a preliminary strategy for pilot testing of the performance measure. Pending additional resources and broader performance measure expertise, issuing "preliminary performance measures" and their specifications alongside an ATS clinical practice guideline offers a first step to further the ATS's guideline implementation agenda. We recommend selectively proceeding with full performance measure development for those measures with positive early user feedback and the greatest potential impact in accordance with ATS leadership guidance.

A quantitative approach for the analysis of clinician recognition of acute respiratory distress syndrome using electronic health record data.

IMPORTANCE: Despite its efficacy, low tidal volume ventilation (LTVV) remains severely underutilized for patients with acute respiratory distress syndrome (ARDS). Physician under-recognition of ARDS is a significant barrier to LTVV use. We propose a computational method that addresses some of the limitations of the current approaches to automated measurement of whether ARDS is recognized by physicians. OBJECTIVE: To quantify patient and physician factors affecting physicians' tidal volume selection and to build a computational model of physician recognition of ARDS that accounts for these factors. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, electronic health record data were collected for 361 ARDS patients and 388 non-ARDS hypoxemic (control) patients in nine adult intensive care units at four hospitals between June 24 and December 31, 2013. METHODS: Standardized tidal volumes (mL/kg predicted body weight) were chosen as a proxy for physician decision-making behavior. Using data-science approaches, we quantified the effect of eight factors (six severity of illness, two physician behaviors) on selected standardized tidal volumes in ARDS and control patients. Significant factors were incorporated in computational behavioral models of physician recognition of ARDS. RESULTS: Hypoxemia severity and ARDS documentation in physicians' notes were associated with lower standardized tidal volumes in the ARDS cohort. Greater patient height was associated with lower standardized tidal volumes (which is already normalized for height) in both ARDS and control patients. The recognition model yielded a mean (99% confidence interval) physician recognition of ARDS of 22% (9%-42%) for mild, 34% (19%-49%) for moderate, and 67% (41%-100%) for severe ARDS. CONCLUSIONS AND RELEVANCE: In this study, patient characteristics and physician behaviors were demonstrated to be associated with differences in ventilator management in both ARDS and control patients. Our model of physician ARDS recognition measurement accounts for these clinical variables, providing an electronic approach that moves beyond relying on chart documentation or resource intensive approaches.

Why do we fail to deliver evidence-based practice in critical care medicine?

PURPOSE OF REVIEW: The use of evidence-based practices in clinical practice is frequently inadequate. Recent research has uncovered many barriers to the implementation of evidence-based practices in critical care medicine. Using a comprehensive conceptual framework, this review identifies and classifies the barriers to implementation of several major critical care evidence-based practices. RECENT FINDINGS: The many barriers that have been recently identified can be classified into domains of the consolidated framework for implementation research (CFIR). Barriers to the management of patients with acute respiratory distress syndrome (ARDS) include ARDS under-recognition. Barriers to the use of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle for mechanically ventilated patients and the sepsis bundle include patient-related, clinician-related, protocol-related, contextual-related, and intervention-related factors. Although these many barriers can be classified into all five CFIR domains (intervention, outer setting, inner setting, individuals, and process), most barriers fall within the individuals and inner setting domains. SUMMARY: There are many barriers to the implementation of evidence-based practice in critical care medicine. Systematically classifying these barriers allows implementation researchers and clinicians to design targeted implementation strategies, giving them the greatest chance of success in improving the use of evidence-based practice.

A Critical Care Clinician Survey Comparing Attitudes and Perceived Barriers to Low Tidal Volume Ventilation with Actual Practice.

RATIONALE: Low-Vt ventilation lowers mortality in patients with acute respiratory distress syndrome (ARDS) but is underused. Little is known about clinician attitudes toward and perceived barriers to low-Vt ventilation use and their association with actual low-Vt ventilation use. OBJECTIVES: The objectives of this study were to assess clinicians' attitudes toward and perceived barriers to low-Vt ventilation (Vt <6.5 ml/kg predicted body weight) in patients with ARDS, to identify differences in attitudes and perceived barriers among clinician types, and to compare attitudes toward and perceived barriers to actual low-Vt ventilation use in patients with ARDS. METHODS: We conducted a survey of critical care physicians, nurses, and respiratory therapists at four non-ARDS Network hospitals in the Chicago region. We compared survey responses with performance in a cohort of 362 patients with ARDS. RESULTS: Survey responses included clinician attitudes toward and perceived barriers to low-Vt ventilation use. We also measured low-Vt ventilation initiation by these clinicians in 347 patients with ARDS initiated after ARDS onset as well as correlation with clinician attitudes and perceived barriers. Of 674 clinicians surveyed, 467 (69.3%) responded. Clinicians had positive attitudes toward and perceived few process barriers to ARDS diagnosis or initiation of low-Vt ventilation. Physicians had more positive attitudes and perceived fewer barriers than nurses or respiratory therapists. However, use of low-Vt ventilation by all three clinician groups was low. For example, whereas physicians believed that 92.5% of their patients with ARDS warranted treatment with low-Vt ventilation, they initiated low-Vt ventilation for a median (interquartile range) of 7.4% (0 to 14.3%) of their eligible patients with ARDS. Clinician attitudes and perceived barriers were not correlated with low-Vt ventilation initiation. CONCLUSIONS: Clinicians had positive attitudes toward low-Vt ventilation and perceived few barriers to using it, but attitudes and perceived process barriers were not correlated with actual low-Vt ventilation use, which was low. Implementation strategies should be focused on examining other issues, such as ARDS recognition and process solutions, to improve low-Vt ventilation use.

An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients.

BACKGROUND: Studies of nighttime intensivist staffing have yielded mixed results. GOALS: To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients. METHODS: We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models. RESULTS: Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes. CONCLUSIONS: Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.

An Official American Thoracic Society Research Statement: Implementation Science in Pulmonary, Critical Care, and Sleep Medicine.

BACKGROUND: Many advances in health care fail to reach patients. Implementation science is the study of novel approaches to mitigate this evidence-to-practice gap. METHODS: The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement on implementation science in pulmonary, critical care, and sleep medicine. The committee used an iterative consensus process to define implementation science and review the use of conceptual frameworks to guide implementation science for the pulmonary, critical care, and sleep community and to explore how professional medical societies such as the ATS can promote implementation science. RESULTS: The committee defined implementation science as the study of the mechanisms by which effective health care interventions are either adopted or not adopted in clinical and community settings. The committee also distinguished implementation science from the act of implementation. Ideally, implementation science should include early and continuous stakeholder involvement and the use of conceptual frameworks (i.e., models to systematize the conduct of studies and standardize the communication of findings). Multiple conceptual frameworks are available, and we suggest the selection of one or more frameworks on the basis of the specific research question and setting. Professional medical societies such as the ATS can have an important role in promoting implementation science. Recommendations for professional societies to consider include: unifying implementation science activities through a single organizational structure, linking front-line clinicians with implementation scientists, seeking collaborations to prioritize and conduct implementation science studies, supporting implementation science projects through funding opportunities, working with research funding bodies to set the research agenda in the field, collaborating with external bodies responsible for health care delivery, disseminating results of implementation science through scientific journals and conferences, and teaching the next generation about implementation science through courses and other media. CONCLUSIONS: Implementation science plays an increasingly important role in health care. Through support of implementation science, the ATS and other professional medical societies can work with other stakeholders to lead this effort.

Low Tidal Volume Ventilation Use in Acute Respiratory Distress Syndrome.

OBJECTIVE: Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use. DESIGN: Retrospective cross-sectional study. SETTING: One academic and three community hospitals in the Chicago region. PATIENTS: A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013. MEASUREMENTS AND MAIN RESULTS: Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight. CONCLUSIONS: More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed.

American Thoracic Society and National Heart, Lung, and Blood Institute Implementation Research Workshop Report.

To advance implementation research (IR) in respiratory, sleep, and critical care medicine, the American Thoracic Society and the Division of Lung Diseases from the NHLBI cosponsored an Implementation Research Workshop on May 17, 2014. The goals of IR are to understand the barriers and facilitators of integrating new evidence into healthcare practices and to develop and test strategies that systematically target these factors to accelerate the adoption of evidence-based care. Throughout the workshop, presenters provided examples of IR that focused on the rate of adoption of evidence-based practices, the feasibility and acceptability of interventions to patients and other stakeholders who make healthcare decisions, the fidelity with which practitioners use specific interventions, the effects of specific barriers on the sustainability of an intervention, and the implications of their research to inform policies to improve patients' access to high-quality care. During the discussions that ensued, investigators' experience led to recommendations underscoring the importance of identifying and involving key stakeholders throughout the research process, ensuring that those who serve as reviewers understand the tenets of IR, managing staff motivation and turnover, and tackling the challenges of scaling up interventions across multiple settings.

Attitudes of Pulmonary and Critical Care Training Program Directors toward Quality Improvement Education.

RATIONALE: Quality improvement (QI) is a required component of fellowship training in pulmonary, critical care, and sleep medicine. However, little is known about how training programs approach QI education. OBJECTIVES: We sought to understand the perceptions of pulmonary, critical care, and sleep medicine training program directors toward QI education. METHODS: We developed and fielded an internet survey of pulmonary, critical care, and sleep medicine training program directors during 2013. Survey domains included program characteristics, the extent of trainee and faculty involvement in QI, attitudes toward QI education, and barriers to successful QI education in their programs. MEASUREMENTS AND MAIN RESULTS: A total of 75 program directors completed the survey (response rate = 45.2%). Respondents represented both adult (n = 43, 57.3%) and pediatric (n = 32, 42.7%) programs. Although the majority of directors (n = 60, 80.0%) reported substantial fellow involvement in QI, only 19 (26.0%) reported having a formal QI education curriculum. QI education was primarily based around faculty mentoring (n = 46, 61.3%) and lectures (n = 38, 50.7%). Most directors agreed it is an important part of fellowship training (n = 63, 84.0%). However, fewer reported fellows were well integrated into ongoing QI activities (n = 45, 60.0%) or graduating fellows were capable of carrying out independent QI (n = 28, 50.7%). Key barriers to effective QI education included lack of qualified faculty, lack of interest among fellows, and lack of time. CONCLUSIONS: Training program directors in pulmonary, critical care, and sleep medicine value QI education but face substantial challenges to integrating it into fellowship training.

Autonomic dysfunction independently predicts poor cardiovascular outcomes in asymptomatic individuals with type 2 diabetes in the DIAD study.

OBJECTIVE: The primary aim of this secondary analysis was to determine whether cardiac autonomic neuropathy independently predicted adverse cardiac outcomes in asymptomatic individuals with type 2 diabetes. Additional aims include the determination of the correlation of standard autonomic testing measures and power spectral analysis of heart rate variability, and the association of diabetes-related and cardiac risk factors with cardiac autonomic neuropathy measures. METHODS: Cardiac autonomic neuropathy was assessed at the study entry into the Detection of Ischemia in Asymptomatic Diabetics study, using autonomic heart rate and blood pressure testing, and power spectral analysis of heart rate variability. All participants were prospectively followed for the composite clinical outcome of cardiac death, acute coronary syndromes, heart failure, or coronary revascularization. RESULTS: Over 5 years of follow-up, 94 of 1119 (8.4%) subjects developed symptomatic cardiac disease. In unadjusted bivariate analyses, abnormalities in several cardiac autonomic neuropathy tests, including lower Valsalva and Standing Heart Rate Ratios, higher resting Heart Rate, greater systolic blood pressure decrease on standing, and lower low-frequency power, were predictive of symptomatic disease. Independent predictors of poor cardiac outcome were a lower Valsalva Heart Rate Ratio, non-Black ethnicity, longer diabetes duration, higher glycated hemoglobin (HbA1c), insulin use, reported numbness in the extremities, higher pulse pressure, family history of coronary artery disease, and higher waist-to-hip ratio. Clinical factors independently associated with a lower Valsalva Heart Rate Ratio were insulin use, clinical proteinuria, higher pulse pressure, use of angiotensin-converting enzyme inhibitor and non-Black ethnicity. CONCLUSION: Cardiac autonomic neuropathy predicted adverse cardiac outcomes in asymptomatic type 2 diabetes without known cardiac disease. Clinical variables may help to identify patients who might have cardiac autonomic neuropathy and warrant consideration for autonomic testing.

Adoption of a High-Impact Innovation in a Homogeneous Population.

Adoption of innovations, whether new ideas, technologies, or products, is crucially important to knowledge societies. The landmark studies of adoption dealt with innovations having great societal impact (such as antibiotics or hybrid crops) but where determining the utility of the innovation was straightforward (such as fewer side effects or greater yield). Recent large-scale studies of adoption were conducted within heterogeneous populations and focused on products with little societal impact. Here, we focus on a case with great practical significance: adoption by small groups of highly trained individuals of innovations with large societal impact but for which it is impractical to determine the true utility of the innovation. Specifically, we study experimentally the adoption by critical care physicians of a diagnostic assay that complements current protocols for the diagnosis of life-threatening bacterial infections and for which a physician cannot estimate the true accuracy of the assay based on personal experience. We show through computational modeling of the experiment that infection-spreading models-which have been formalized as generalized contagion processes-are not consistent with the experimental data, while a model inspired by opinion models is able to reproduce the empirical data. Our modeling approach enables us to investigate the efficacy of different intervention schemes on the rate and robustness of innovation adoption in the real world. While our study is focused on critical care physicians, our findings have implications for other settings in education, research, and business, where small groups of highly qualified peers make decisions about the adoption of innovations whose utility is difficult if not impossible to gauge.