Interprofessional Staffing Pattern Clusters in U.S. ICUs.

OBJECTIVES: To identify interprofessional staffing pattern clusters used in U.S. ICUs. DESIGN: Latent class analysis. SETTING AND PARTICIPANTS: Adult U.S. ICUs. PATIENTS: None. INTERVENTIONS: None. ANALYSIS: We used data from a staffing survey that queried respondents (n = 596 ICUs) on provider (intensivist and nonintensivist), nursing, respiratory therapist, and clinical pharmacist availability and roles. We used latent class analysis to identify clusters describing interprofessional staffing patterns and then compared ICU and hospital characteristics across clusters. MEASUREMENTS AND MAIN RESULTS: We identified three clusters as optimal. Most ICUs (54.2%) were in cluster 1 ("higher overall staffing") characterized by a higher likelihood of good provider coverage (both intensivist [onsite 24 hr/d] and nonintensivist [orders placed by ICU team exclusively, presence of advanced practice providers, and physicians-in-training]), nursing leadership (presence of charge nurse, nurse educators, and managers), and bedside nursing support (nurses with registered nursing degrees, fewer patients per nurse, and nursing aide availability). One-third (33.7%) were in cluster 2 ("lower intensivist coverage & nursing leadership, higher bedside nursing support") and 12.1% were in cluster 3 ("higher provider coverage & nursing leadership, lower bedside nursing support"). Clinical pharmacists were more common in cluster 1 (99.4%), but present in greater than 85% of all ICUs; respiratory therapists were nearly universal. Cluster 1 ICUs were larger (median 20 beds vs. 15 and 17 in clusters 2 and 3, respectively; p < 0.001), and in larger (> 250 beds: 80.6% vs. 66.1% and 48.5%; p < 0.001), not-for-profit (75.9% vs. 69.4% and 60.3%; p < 0.001) hospitals. Telemedicine use 24 hr/d was more common in cluster 3 units (71.8% vs. 11.7% and 14.1%; p < 0.001). CONCLUSIONS: More than half of U.S. ICUs had higher staffing overall. Others tended to have either higher provider presence and nursing leadership or higher bedside nursing support, but not both.

Implementation of simulation training in the Intensive Care Units (ICU) during the COVID-19 pandemic: A scoping review.

INTRODUCTION: In response to the important influx of critically ill patients as well as resources limitation, simulation would be a tool ensuring the continuum of medical training. AIM: To assess the impact of simulation training on both education and performance related to protocol development during COVID-19 pandemic, in critical care. METHODS: This scoping review was written in accordance with the PRISMA Guideline. Data sources and studies were identified by searching "MEDLINE", "Cochrane library" databases and "Clinical trial.gov". Study inclusion adhered to the PICO criteria: Population, Intervention, Comparison, and Outcomes. The Kirkpatrick Model, is a tool for evaluating the level of impact of training results according to four levels Results: The search algorithm yielded sixteen articles of which eight were meeting criteria for inclusion and finally seven were available. The number of participants ranged from 12 to 108 with a median of 61 (IQR: 8-76). The length of intervention ranged from 12 min to three hours with a median of 38 min (IQR: 12-135). Studies reported that incorporating simulation yields a more pronounced impact compared to theoretical and clinical training alone in enhancing knowledge and confidence. Regarding the role of simulation in protocol development, results have shown that in the pre-test, all the participants failed donning and doffing Personal Protective Equipment (PPE), the mean cognitive load was high (7.43±0.9 points) and the performance was low (2.5±0.8) while in the post-test, 100% of participants were successful in donning the PPE, the mean of the cognitive load decreased (4.1±1.4 points), and the performance substantially increased (7.9±1.1). In addition, five studies showed behavioral changes after training and thus the simulation reached Kirkpatrick level three. CONCLUSION: Results supported the impact of simulation, in critical care, as an effective method to enhance knowledge and confidence, and to improve protocol development during pandemics such as COVID-19.

Effect of an evidence-based early rehabilitation program on adult patients with venovenous extracorporeal membrane oxygenation: A cohort study.

OBJECTIVES: To assess the efficacy of early rehabilitation program for VV-ECMO patients and observe the influence on the respiratory and skeletal muscles. DESIGN: A cohort study. SETTING: The study was conducted with VVECMO patients in a comprehensive ICU with 32 beds. MAIN OUTCOME MEASURES: Ultrasound measurements were performed on each patients on day 1, 4, 7, 10, and 14, including diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), intercostal muscle thickening fraction (ICMTF), thickness of the rectus femoris (RF), thickness of vastus intermedius (VI), and rectus femoris cross-sectional area (RF-CSA). Data on basic characteristics, results of ultrasound measurements, patients outcomes and adverse events were collected. RESULTS: 22 patients received usual rehabilitation measures were set as the control group and 23 patients underwent early rehabilitation program were set as the study group. There were no differences in diaphragmatic excursion, diaphragmatic thickening fraction, intercostal muscle thickening fraction, thickness of rectus femoris, thickness of vastus intermedius, rectus femoris cross-sectional area between two groups on day 1 after VV-ECMO treatment (P > 0.05). The variation of diaphragmatic thickening fraction and intercostal muscle thickening fraction decreased on the day 7 and 14 after treatment (P < 0.05). The variation of vastus intermedius thickness and rectus femoris cross-sectional area in the study group was less compared with those in the control group on day 4, 7, 10 and 14. The ECMO duration in the study group was shorter than that in the control group (12.00 [10.00-16.25] days vs. 8.00 [6.00-12.25] days, P = 0.002), but there was no difference in the duration of mechanical ventilation. CONCLUSION: Early rehabilitation program can ameliorate muscle atrophy. We recommend implementation of our rehabilitation program in VV-ECMO patients. This program can improve skeletal muscle atrophy and dysfunction in patients with VV-ECMO effectively and perhaps improve quality of life for patients in the future. IMPLICATIONS FOR CLINICAL PRACTICE: Early rehabilitation program put higher demands bedside nurses. It requires them to observe conditions of VVECMO patients closely, assess the feasibility of rehabilitation promptly, and monitor for any adverse reactions. Ultrasound measurement is a noninvasive and useful tool to assess muscle atrophy in ICU patients. Early rehabilitation program can improve skeletal muscle atrophy and dysfunction in patients with VV-ECMO effectively.

Role of age as eligibility criterion for ECMO in patients with ARDS: meta-regression analysis.

BACKGROUND: Age as an eligibility criterion for V-V ECMO is widely debated and varies among healthcare institutions. We examined how age relates to mortality in patients undergoing V-V ECMO for ARDS. METHODS: Systematic review and meta-regression of clinical studies published between 2015 and June 2024. Studies involving at least 6 ARDS patients treated with V-V ECMO, with specific data on ICU and/or hospital mortality and patient age were included. The search strategy was executed in PubMed, limited to English-language. COVID-19 and non-COVID-19 populations were analyzed separately. Meta-regressions of mortality outcomes on age were performed using gender, BMI, SAPS II, APACHE II, Charlson comorbidity index or SOFA as covariates. RESULTS: In non-COVID ARDS, the meta-regression of 173 studies with 56,257 participants showed a significant positive association between mean age and ICU/hospital mortality. In COVID-19 ARDS, a significant relationship between mean age and ICU mortality, but not hospital mortality, was found in 103 studies with 21,255 participants. Sensitivity analyses confirmed these findings, highlighting a linear relationship between age and mortality in both groups. For each additional year of mean age, ICU mortality increased by 1.2% in non-COVID ARDS and 1.9% in COVID ARDS. CONCLUSIONS: The relationship between age and ICU mortality is linear and shows no inflection point. Consequently, no age cut-off can be recommended for determining patient eligibility for V-V ECMO.

Factors associated with COVID-19 death in pregnant women hospitalized in Intensive Care Units.

OBJECTIVES: to evaluate the factors associated with COVID-19 death in pregnant women hospitalized in Intensive Care Units in Brazil. METHODS: this ecological study was conducted using secondary data from Brazilian pregnant women with COVID-19 hospitalized in Intensive Care Units between March 2020 and March 2022. Univariate analysis and logistic regression were employed. RESULTS: out of 3,547 pregnant women with COVID-19 hospitalized in Intensive Care Units, 811 died (22.8%). It was found that lack of COVID-19 vaccination (OR: 2.73; 95% CI: 1.83; 4.04), dyspnea (OR: 1.73; 95% CI: 1.17; 2.56), obesity (OR: 1.51; 95% CI: 1.05; 2.17), chronic cardiovascular disease (OR: 1.65; 95% CI: 1.14; 2.38), and non-white race/color (OR: 1.29; 95% CI: 1.00; 1.66) were independently and significantly associated with death. CONCLUSIONS: it is concluded that vaccination status, presence of comorbidities, and clinical and ethnic-racial characteristics are associated with COVID-19 death in pregnant women hospitalized in Intensive Care Units in Brazil.

Intensive care unit guidelines for admission and discharge, 2023.

The Directorate General of Health Services (DGHS), India, has released guidelines for intensive care unit (ICU) admission and discharge [1] to guide intensivists and registered medical practitioners (RMPs) in an Expert Consensus Statement (ECS). This is based on the recommendations of 24 experts working in different ICU settings. This team deserves applause for their efforts in creating guidelines for clinicians working in ICU settings. The Delphi method [2], considered one of the most scientific methods for such statements, has been used for this ECS.

Longer ICU stay and invasive mechanical ventilation accelerate telomere shortening in COVID-19 patients 1 year after recovery.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes virus-induced-senescence. There is an association between shorter telomere length (TL) in coronavirus disease 2019 (COVID-19) patients and hospitalization, severity, or even death. However, it remains unknown whether virus-induced-senescence is reversible. We aim to evaluate the dynamics of TL in COVID-19 patients 1 year after recovery from intensive care units (ICU). Longitudinal study enrolling 49 patients admitted to ICU due to COVID-19 (August 2020 to April 2021). Relative telomere length (RTL) quantification was carried out in whole blood by monochromatic multiplex real-time quantitative PCR (MMqPCR) assay at hospitalization (baseline) and 1 year after discharge (1-year visit). The association between RTL and ICU length of stay (LOS), invasive mechanical ventilation (IMV), prone position, and pulmonary fibrosis development at 1-year visit was evaluated. The median age was 60 years, 71.4% were males, median ICU-LOS was 12 days, 73.5% required IMV, and 38.8% required a prone position. Patients with longer ICU-LOS or who required IMV showed greater RTL shortening during follow-up. Patients who required pronation had a greater RTL shortening during follow-up. IMV patients who developed pulmonary fibrosis showed greater RTL reduction and shorter RTL at the 1-year visit. Patients with longer ICU-LOS and those who required IMV had a shorter RTL in peripheral blood, as observed 1 year after hospital discharge. Additionally, patients who required IMV and developed pulmonary fibrosis had greater telomere shortening, showing shorter telomeres at the 1-year visit. These patients may be more prone to develop cellular senescence and lung-related complications; therefore, closer monitoring may be needed.

The kidney: the critical organ system for guiding nutrition therapy in the ICU-patient?

Most randomized controlled studies on nutrition in intensive care patients did not yield conclusive results or were neutral or negative concerning the primary endpoints but also in most secondary endpoints. However, there is a consistent observation that in several of these studies there was a negative effect of the nutrition intervention on the kidneys in one of the study arms. During the early phase and in unstable periods during further course of disease an inadequate clinical nutrition can damage the kidneys, can elicit or aggravate acute kidney injury and/ or increase requirements of renal replacement therapy (RRT). This relates to total energy intake, glucose intake/hyperglycemia and protein/ amino acid intake at various stages of renal dysfunction. The kidney could present a critical organ system for guiding nutrition therapy, a close monitoring of kidney function should be observed and nutrition therapy may need to be adapted accordingly. The long-held dogma of performing full nutrition and accept an otherwise not necessary RRT is definitely to be refuted.

Utility and rationale for continuous EEG monitoring: a primer for the general intensivist.

This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.

Clinical characteristics and outcomes of immunocompromised critically ill patients with cytomegalovirus end-organ disease: a multicenter retrospective cohort study.

BACKGROUND: Cytomegalovirus (CMV) infection in patients with cellular immune deficiencies is associated with significant morbidity and mortality. However, data on CMV end-organ disease (CMV-EOD) in critically ill, immunocompromised patients are scarce. Our objective here was to describe the clinical characteristics and outcomes of CMV-EOD in this population. METHODS: We conducted a multicenter, international, retrospective, observational study in adults who had CMV-EOD and were admitted to any of 18 intensive care units (ICUs) in France, Israel, and Spain in January 2010-December 2021. Patients with AIDS were excluded. We collected the clinical characteristics and outcomes of each patient. Survivors and non-survivors were compared, and multivariate analysis was performed to identify risk factors for hospital mortality. RESULTS: We studied 185 patients, including 80 (43.2%) with hematologic malignancies, 55 (29.7%) with solid organ transplantation, 31 (16.8%) on immunosuppressants, 16 (8.6%) with solid malignancies, and 3 (1.6%) with primary immunodeficiencies. The most common CMV-EOD was pneumonia (n = 115, [62.2%] including 55 [47.8%] with a respiratory co-pathogen), followed by CMV gastrointestinal disease (n = 64 [34.6%]). More than one organ was involved in 16 (8.8%) patients. Histopathological evidence was obtained for 10/115 (8.7%) patients with pneumonia and 43/64 (67.2%) with GI disease. Other opportunistic infections were diagnosed in 69 (37.3%) patients. Hospital mortality was 61.4% overall and was significantly higher in the group with hematologic malignancies (75% vs. 51%, P = 0.001). Factors independently associated with higher hospital mortality were hematologic malignancy with active graft-versus-host disease (OR 5.02; 95% CI 1.15-27.30), CMV pneumonia (OR 2.57; 95% CI 1.13-6.03), lymphocytes < 0.30 × 109/L at diagnosis of CMV-EOD (OR 2.40; 95% CI 1.05-5.69), worse SOFA score at ICU admission (OR 1.18; 95% CI 1.04-1.35), and older age (OR 1.04; 95% CI 1.01-1.07). CONCLUSIONS: Mortality was high in critically ill, immunocompromised patients with CMV-EOD and varied considerably with the cause of immunodeficiency and organ involved by CMV. Three of the four independent risk factors identified here are also known to be associated with higher mortality in the absence of CMV-EOD. CMV pneumonia was rarely proven by histopathology and was the most severe CMV-EOD.

Effectiveness of Rapid Response Team implementation in a tertiary hospital in Egypt: an interventional study.

BACKGROUND: Rapid response teams (RRTs) help in the early recognition of deteriorating patients in hospital wards and provide the needed management at the bedside by a qualified team. RRT implementation is still questionable because there is insufficient evidence regarding its effects. To date, according to our knowledge, no published studies have addressed the effectiveness of RRT implementation on inpatient care outcomes in Egypt. OBJECTIVE: We aimed to assess the impact of an RRT on the rates of inpatient mortality, cardiopulmonary arrest calls and unplanned intensive care unit (ICU) admission in an Egyptian tertiary hospital. METHODS: An interventional study was conducted at a university hospital. Data was evaluated for 24 months before the intervention (January 2018 till December 2019, which included 4242 admissions). The intervention was implemented for 12 months (January 2021 till December 2021), ending with postintervention evaluation of 2338 admissions. RESULTS: RRT implementation was associated with a significant reduction in inpatient mortality rate from 88.93 to 46.44 deaths per 1000 discharges (relative risk reduction (RRR)=0.48; 95% CI, 0.36 to 0.58). Inpatient cardiopulmonary arrest rate decreased from 7.41 to 1.77 calls per 1000 discharges (RRR, 0.76; 95% CI, 0.32 to 0.92), while unplanned ICU admissions decreased from 5.98 to 4.87 per 1000 discharges (RRR, 0.19; 95% CI, -0.65 to 0.60). CONCLUSIONS: RRT implementation was associated with a significantly reduced hospital inpatient mortality rate, cardiopulmonary arrest call rate as well as reduced unplanned ICU admission rate. Our results reveal that RRT can contribute to improving the quality of care in similar settings in developing countries.

The effect of web-based training given to nurses on the prevention of pressure injury in patients hospitalized in the anesthesiology and reanimation intensive care unit: quasi-experimental pre-test post-test research.

BACKGROUND: The knowledge, attitudes, and behaviors of intensive care nurses concerning the prevention of pressure injury (PI) may be positively affected by education. PURPOSE: To evaluate the effect of web-based training given to nurses on their knowledge of, attitudes about, and behaviors in the prevention of PI. METHODS: This study was conducted between May 2019 and December 2019 with a pre-test and post-test design. The study sample consisted of 22 nurses and 80 patients. A link to the educational video prepared for the prevention of PIs was sent to the nurses' mobile phones. RESULTS: The training had a significant positive effect on nurses' level of knowledge of and attitudes toward PI prevention (P < .001 and P = .042, respectively). In group 1, comprising 40 patients who received treatment before nurses' training, 2.5% of patients had stage 1 PI on day 1 and 7.5% had stage 1 PI on day 7, and 2.5% had stage 4 PI on day 7. In group 2, comprising 40 patients who received treatment after nurses' training, 2.5% of patients had stage 1 PI on day 1 and 2.5% had stage 1 PI on day 7. CONCLUSION: Nurses' knowledge of and attitudes and behaviors toward PI prevention were improved following the web-based training, and the stage and rate of PI were lower in patients who received care after nurses received the training.

Subgroups of ICU patients identified by self-reported symptoms - A prospective multicenter study.

BACKGROUND: Intensive care unit (ICU) patients experience several symptoms, yet patterns of symptoms and their relationship with demographic and clinical characteristics have not previously been investigated. OBJECTIVES: To identify and compare subgroups (i.e. latent symptom classes) of intensive ICU patients based on prevalence of co-occurring symptoms over seven days. RESEARCH METHODOLOGY: Prospective cohort study of adult ICU patients' self-reports of five symptoms during seven days in ICU. Latent class analysis was applied to identify subgroups of ICU patients. SETTING: Multicenter study with patients from six mixed ICUs in Norway. MAIN OUTCOME MEASURES: Patient Symptom Survey was used to assess five symptoms (i.e., thirst, pain, anxiousness, tiredness, shortness of breath). RESULTS: Among 353 included patients, median age was 63 years and 60.3 % were male. Subgroups of patients were identified in a Low class (n = 126, 35.7 %), Middle Class (n = 177, 50.1 %) and High Class (n = 50, 14.2 %) based on reporting of the prevalence of five symptoms. Patients in the Low class had a low prevalence of all symptoms. Middle Class patients had a high prevalence of thirst and tiredness and a low prevalence of pain, anxiousness and shortness of breath. The High class patients had a high prevalence of all symptoms. Symptom prevalence remained stable in the Low and Middle class over time and increased over time in the High class. There were significant differences among symptom classes in use of mechanical ventilation (p = 0.012), analgesics (p < 0.001), alpha-2 agonists (p = 0.004) and fluid restriction (p = 0.006). Patients in the High class received more of these ICU-treatments. CONCLUSIONS: Findings suggest that subgroups of ICU patients with distinct symptom experiences can be identified. The High prevalence class patients had consistently high levels of all symptoms across seven ICU days and received more ICU-related interventions. IMPLICATION FOR CLINICAL PRACTICE: Some ICU patients experience a consistently high prevalence of co-occurring symptoms. Clinicians should be aware of treatment factors that could be linked to a high burden of symptoms.

Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses.

BACKGROUND: Pain management of sedated and ventilated patients in intensive care units lacks consistency. OBJECTIVES: To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives. METHODS: A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to. OUTCOME MEASURES: Demographics, training, governance, clinical practice, knowledge, and attitudes. RESULTS/FINDINGS: 108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness." CONCLUSION: The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management. IMPLICATIONS FOR CLINICAL PRACTICE: Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.