Improving the Quality of Visualization Dashboards in Critical Care: A Mixed-Methods Study.

Intensive care units (ICUs) lack both standardized performance indicators to better understand the effectiveness of interventions and uniform platforms to present these indicators. The goal of this study was to identify ICU metrics meaningful to stakeholders to help guide the development of a local visualization dashboard. Individual ICU directors were interviewed to collate their input on metrics important to their units. These qualitative data were used to develop a dashboard draft, after which the authors surveyed 20 stakeholders from different hospital departments for feedback on its content and structure. The varied survey results reinforced the inherent difficulties of adapting previously developed measurement tools while also selecting ICU performance measures that are simultaneously widely accepted yet relevant to local practice. These results also call attention to the importance of interdisciplinary input in quality dashboard development, thereby enabling more successful implementation and utilization for ICU quality improvement.

The Use of High-Flow Nasal Oxygen in the ICU as a First-Line Therapy for Acute Hypoxemic Respiratory Failure Secondary to Coronavirus Disease 2019.

OBJECTIVES: Limited evidence is available regarding the role of high-flow nasal oxygen in the management of acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Our objective was to characterize outcomes associated with high-flow nasal oxygen use in critically ill adult patients with coronavirus disease 2019-associated acute hypoxemic respiratory failure. DESIGN: Observational cohort study between March 18, 2020, and June 3, 2020. SETTING: Nine ICUs at three university-affiliated hospitals in Philadelphia, PA. PATIENTS: Adult ICU patients with confirmed coronavirus disease 2019 infection admitted with acute hypoxemic respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 266 coronavirus disease 2019 ICU admissions during the study period, 124 (46.6%) received some form of noninvasive respiratory support. After exclusions, we analyzed 83 patients who were treated with high-flow nasal oxygen as a first-line therapy at or near the time of ICU admission. Patients were predominantly male (63.9%). The most common comorbidity was hypertension (60.2%). Progression to invasive mechanical ventilation was common, occurring in 58 patients (69.9%). Of these, 30 (51.7%) were intubated on the same day as ICU admission. As of June 30, 2020, hospital mortality rate was 32.9% and the median hospital length of stay was 15 days. Among survivors, the most frequent discharge disposition was home (51.0%). In comparing patients who received high-flow nasal oxygen alone (n = 54) with those who received high-flow nasal oxygen in conjunction with noninvasive positive-pressure ventilation via face mask (n = 29), there were no differences in the rates of endotracheal intubation or other clinical and utilization outcomes. CONCLUSIONS: We observed an overall high usage of high-flow nasal oxygen in our cohort of critically ill patients with acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Rates of endotracheal intubation and mortality in this cohort were on par with and certainly not higher than other published series. These findings should prompt further considerations regarding the use of high-flow nasal oxygen in the management algorithm for coronavirus disease 2019-associated acute hypoxemic respiratory failure.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage.

PURPOSE: To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. MATERIALS AND METHODS: Retrospective, observational study of patients refused MICU admission at an urban university hospital. RESULTS: Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). CONCLUSIONS: Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety.