A Comparison of Palliative Care Delivery between Ethnically Chinese and Non-Chinese Canadians in the Last Year of Life.

BACKGROUND: Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life. OBJECTIVE: To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults. DESIGN: Population-based cohort study. PARTICIPANTS: All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada. EXPOSURES: Chinese ethnicity. MAIN MEASURES: Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation. KEY RESULTS: The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38). CONCLUSIONS: Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.

Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure.

Evidence suggests system-level norms and care processes influence individual patients' medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient's critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients' individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure.

Long-term survival and functional outcomes of critically ill patients with hematologic malignancies: a Canadian multicenter prospective study.

PURPOSE: Patients with hematologic malignancy (HM) commonly develop critical illness. Their long-term survival and functional outcomes have not been well described. METHODS: We conducted a prospective, observational study of HM patients admitted to seven Canadian intensive care units (ICUs) (2018-2020). We followed survivors at 7 days, 6 months and 12 months following ICU discharge. The primary outcome was 12-month survival. We evaluated functional outcomes at 6 and 12 months using the functional independent measure (FIM) and short form (SF)-36 as well as variables associated with 12-month survival. RESULTS: We enrolled 414 patients including 35% women. The median age was 61 (interquartile range, IQR: 52-69), median Sequential Organ Failure Assessment (SOFA) score was 9 (IQR: 6-12), and 22% had moderate-severe frailty (clinical frailty scale [CFS] ≥ 6). 51% had acute leukemia, 38% lymphoma/multiple myeloma, and 40% had received a hematopoietic stem cell transplant (HCT). The most common reasons for ICU admission were acute respiratory failure (50%) and sepsis (40%). Overall, 203 (49%) were alive 7 days post-ICU discharge (ICU survivors). Twelve-month survival of the entire cohort was 21% (43% across ICU survivors). The proportion of survivors with moderate-severe frailty was 42% (at 7 days), 14% (6 months), and 8% (12 months). Median FIM at 7 days was 80 (IQR: 50-109). Physical function, pain, social function, mental health, and emotional well-being were below age- and sex-matched population scores at 6 and 12 months. Frailty, allogeneic HCT, kidney injury, and cardiac complications during ICU were associated with lower 12- month survival. CONCLUSIONS: 49% of all HM patients were alive at 7 days post-ICU discharge, and 21% at 12 months. Survival varied based upon hematologic diagnosis and frailty status. Survivors had important functional disability and impairment in emotional, physical, and general well-being.

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.

Using the Hospital Frailty Risk Score to assess mortality risk in older medical patients admitted to the intensive care unit.

BACKGROUND: Prognostic information at the time of hospital discharge can help guide goals-of-care discussions for future care. We sought to assess the association between the Hospital Frailty Risk Score (HFRS), which may highlight patients' risk of adverse outcomes at the time of hospital discharge, and in-hospital death among patients admitted to the intensive care unit (ICU) within 12 months of a previous hospital discharge. METHODS: We conducted a multicentre retrospective cohort study that included patients aged 75 years or older admitted at least twice over a 12-month period to the general medicine service at 7 academic centres and large community-based teaching hospitals in Toronto and Mississauga, Ontario, Canada, from Apr. 1, 2010, to Dec. 31, 2019. The HFRS (categorized as low, moderate or high frailty risk) was calculated at the time of discharge from the first hospital admission. Outcomes included ICU admission and death during the second hospital admission. RESULTS: The cohort included 22 178 patients, of whom 1767 (8.0%) were categorized as having high frailty risk, 9464 (42.7%) as having moderate frailty risk, and 10 947 (49.4%) as having low frailty risk. One hundred patients (5.7%) with high frailty risk were admitted to the ICU, compared to 566 (6.0%) of those with moderate risk and 790 (7.2%) of those with low risk. After adjustment for age, sex, hospital, day of admission, time of admission and Laboratory-based Acute Physiology Score, the odds of ICU admission were not significantly different for patients with high (adjusted odds ratio [OR] 0.99, 95% confidence interval [CI] 0.78 to 1.23) or moderate (adjusted OR 0.97, 95% CI 0.86 to 1.09) frailty risk compared to those with low frailty risk. Among patients admitted to the ICU, 75 (75.0%) of those with high frailty risk died, compared to 317 (56.0%) of those with moderate risk and 416 (52.7%) of those with low risk. After multivariable adjustment, the risk of death after ICU admission was higher for patients with high frailty risk than for those with low frailty risk (adjusted OR 2.86, 95% CI 1.77 to 4.77). INTERPRETATION: Among patients readmitted to hospital within 12 months, patients with high frailty risk were similarly likely as those with lower frailty risk to be admitted to the ICU but were more likely to die if admitted to ICU. The HFRS at hospital discharge can inform prognosis, which can help guide discussions for preferences for ICU care during future hospital stays.

Impact of Interprofessional Teamwork on Aligning Intensive Care Unit Care with Patient Goals: A Qualitative Study of Transactive Memory Systems.

Rationale: Although aligning care with patient goals is fundamental to critical care, this process is often delayed and leads to conflict among patients, families, and intensive care unit (ICU) teams. Interprofessional collaboration within ICU teams is an opportunity to improve goal-aligned care, yet this collaboration is poorly understood. A better understanding of how ICU team members work together to provide goal-aligned care may identify new strategies for improvement. Objectives: Transactive memory systems is a theory of group mind that explains how high-performing teams use a shared memory and collective cognition. We applied this theory to characterize the process of interprofessional collaboration within ICU teams and its relationship with goal-aligned care. Methods: We conducted a secondary analysis of focus group (n = 10) and semistructured interview (n = 8) transcripts, gathered during a parent study at two academic medical centers on the process of ICU care delivery in acute respiratory failure. Participants (N = 70) included interprofessional ICU and palliative care team members, surrogates, and patient survivors. We used directed content analysis, applying transactive memory systems theory and its major components (specialization, coordination, credibility) to examine ICU team collaboration. Results: Participants described each ICU profession as having a specialized role in aligning care with patient goals. Different professions have different opportunities to gather knowledge about patient goals and priorities, which results in dispersion of this knowledge among different team members. To share and use this dispersed knowledge, ICU teams rely on an informal coordination process and "side conversations." This process is a workaround for formal channels (e.g., health records, interprofessional rounds) that do not adequately convey knowledge about patient goals. This informal process does not occur if team members are discouraged from asserting their knowledge because of hierarchy or lack of psychological safety. Conversely, coordination succeeds when team members recognize each other as credible sources of valued knowledge. Conclusions: We found that ICU team members work together to align care with patient goals and priorities, using transactive memory systems. The successful function of these systems can be disrupted or promoted by ICU organizational and cultural factors, which are potential targets for efforts to increase goal-aligned care.

The association between nutritional risk index and ICU outcomes across hematologic malignancy patients with acute respiratory failure.

Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51-68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9-14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79-99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2-7). Mortality across those at severe malnutrition (NRI < 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04-5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure.

Clinical diagnostic accuracy of respiratory failure in critically ill hematopoietic stem cell transplant patients.

RATIONALE: Acute respiratory failure (ARF) is a frequent complication following hematopoietic cell transplantation (HCT). We aimed to characterize the etiologies of ARF in patients who died in the intensive care unit following HCT based on autopsy findings. We then evaluated agreement between the clinical and pathologic diagnosis. METHODS: We performed a chart review of all HCT patients who died and underwent autopsy in our ICU between 2006-2016. We evaluated the presumed clinical diagnosis and confidence in the diagnosis by chart review, the pathologic diagnosis on autopsy, and whether the clinical-pathologic diagnoses were concordant. When there was discordance, we evaluated whether knowledge of the pathology could have changed management. RESULTS: Thirteen patients underwent autopsy after dying. Infection was the presumed cause in 11/13 cases. The clinical and pathologic diagnoses were concordant in 6/13(46%). In the seven discordant cases (all clinically diagnosed as infection), autopsy revealed two non-infectious inflammatory causes, one post-transplant lymphoproliferative disorder, and three non-bacterial infectious etiology. Pathologic findings may have changed management in 7/13(54%) cases. CONCLUSIONS: In a subset of HCT-recipients who died from respiratory failure, discordance was frequent between clinical and pathologic diagnoses. The risks and benefits of obtaining tissue to improve our diagnostic accuracy requires further evaluation.

Association between sepsis survivorship and long-term cardiovascular outcomes in adults: a systematic review and meta-analysis.

PURPOSE: We aimed to determine the association between sepsis and long-term cardiovascular events. METHODS: We conducted a systematic review of observational studies evaluating post-sepsis cardiovascular outcomes in adult sepsis survivors. MEDLINE, Embase, and the Cochrane Controlled Trials Register and Database of Systematic Reviews were searched from inception until April 21st, 2021. Two reviewers independently extracted individual study data and evaluated risk of bias. Random-effects models estimated the pooled crude cumulative incidence and adjusted hazard ratios (aHRs) of cardiovascular events compared to either non-septic hospital survivors or population controls. Primary outcomes included myocardial infarction, stroke, and congestive heart failure; outcomes were analysed at maximum reported follow-up (from 30 days to beyond 5 years post-discharge). RESULTS: Of 12,649 screened citations, 27 studies (25 cohort studies, 2 case-crossover studies) were included with a median of 4,289 (IQR 502-68,125) sepsis survivors and 18,399 (IQR 4,028-83,506) controls per study. The pooled cumulative incidence of myocardial infarction, stroke, and heart failure in sepsis survivors ranged from 3 to 9% at longest reported follow-up. Sepsis was associated with a higher long-term risk of myocardial infarction (aHR 1.77 [95% CI 1.26 to 2.48]; low certainty), stroke (aHR 1.67 [95% CI 1.37 to 2.05]; low certainty), and congestive heart failure (aHR 1.65 [95% CI 1.46 to 1.86]; very low certainty) compared to non-sepsis controls. CONCLUSIONS: Surviving sepsis may be associated with a long-term, excess hazard of late cardiovascular events which may persist for at least 5 years following hospital discharge.

Severe Hyponatremia and Seizure From Peripheral Infusion of Norepinephrine Diluted in Dextrose 5% in Water: A Case Report.

Recent studies have demonstrated that vasopressors can be delivered safely through peripheral intravenous lines. While norepinephrine is usually delivered at a concentration of 16 to 32 µg/mL, out of concern for extravasation and interstitial necrosis, some patients receive more dilute norepinephrine solutions through peripheral intravenous catheters. We describe a case of severe hyponatremia and seizure resulting from administration of norepinephrine concentrated at 4 µg/mL in dextrose 5% in water. After the incident, the institutional policy changed to recommend normal saline as the default diluent for peripheral norepinephrine, with a more concentrated option available. The incident also informed similar guidelines at other hospitals.

Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?"

BACKGROUND: Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. METHODS: This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. RESULTS: Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). CONCLUSION: Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.

Perspectives on Advance Care Planning for Patients with Hematologic Malignancy: An International Clinician Questionnaire.

Rationale: Critical illness is common in patients with hematologic malignancy (HM). Advance care planning (ACP) can allow these patients to express their care preferences before life-threatening illnesses. Objectives: To evaluate physicians' perspectives surrounding ACP in patients with HM. Methods: We administered a survey to intensivists and hematologic oncologists who care for patients with HM across Canada and the United Kingdom. Potential respondents were identified from institutions that have a hematologic-oncology program. The survey was disseminated electronically. Results: A total of 111 physicians completed the survey, with a response rate of 19% (39% across those who opened the e-mail); 52% of respondents were intensivists, and 48% of respondents were hematologic oncologists. Of the responses, 15.5% of physicians reported that ACP happens routinely at their institution, whereas 8.3% of physicians stated that code status is routinely discussed. ACP discussions were most commonly reported at the onset of critical illness (84.3% of respondents), during disease recurrence (52.9% of respondents), or during the transition to a strictly palliative approach (54.9% of respondents). Commonly cited barriers to ACP centered on physicians' concern about the reaction of the patient or family. Conclusions: This study emphasizes the need for earlier and more frequent ACP discussions in this high-risk population with a variety of barriers identified.

Association of Thoracic Computed Tomographic Measurements and Outcomes in Patients with Hematologic Malignancies Requiring Mechanical Ventilation.

Rationale: Patients with hematologic malignancies requiring mechanical ventilation have historically experienced poor outcomes.Objectives: We aimed to determine whether body composition characteristics derived from thoracic computed tomographic (CT) imaging were associated with time to liberation from mechanical ventilation.Methods: We evaluated mechanically ventilated patients with hematological malignancies admitted between 2014 and 2018. We included patients with thoracic CT imaging completed between 1 month before and 48 hours after intensive care unit (ICU) admission. We assessed the association of carinal skeletal muscle cross-sectional area (CSA), subcutaneous fat CSA, and fat index (fat/skeletal muscle ratio) with time to liberation from mechanical ventilation within 28 days. We accounted for the competing event of death within 28 days of mechanical ventilation.Results: One hundred fifty-six patients were included; the mean age was 57 years (standard deviation 14) and 39% were female. Thirty-seven percent had received a hematopoietic stem cell transplant, and the median ratio of arterial oxygen tension/pressure to fraction of inspired oxygen was 134 mm Hg (interquartile range [IQR], 92-205). Median skeletal muscle CSA was 68 cm2 (IQR, 54-88) and subcutaneous fat CSA was 38 cm2 (IQR, 27-52). Forty-two percent of patients were liberated from mechanical ventilation within 28 days and 56% died in the ICU. Subcutaneous fat CSA (subdistribution hazard ratio [sHR], 0.81; 95% confidence interval [95% CI], -0.68 to 0.97) and fat index (sHR, 0.81; 95% CI, -0.68 to 0.97) were significantly associated with longer time to liberation from mechanical ventilation. Skeletal muscle CSA was not associated with time to liberation from ventilation (sHR, 1.08; 95% CI, -0.94 to 1.23).Conclusions: Body composition measurements based on thoracic CT scans were associated with time to liberation from ventilation. These could represent novel surrogate markers of physical frailty in patients with hematologic malignancies receiving mechanical ventilation.

Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol.

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).

Factors associated with physicians' predictions of six-month mortality in critically ill patients.

BACKGROUND: Physician's estimates of a patient's prognosis are an important component in shared decision-making. However, the variables influencing physician's judgments are not well understood. We aimed to determine which physician and patient factors are associated with physicians' predictions of critically ill patients' six-month mortality and the accuracy and confidence of these predictions. METHODS: Prospective cohort study evaluating physicians' predictions of six-month mortality. Using univariate and multivariable generalized estimating equations, we assessed the association between baseline physician and patient characteristics with predictions of six-month death, as well as accuracy and confidence of these predictions. RESULTS: Our cohort was comprised 300 patients and 47 physicians. Physicians were asked to predict if patients would be alive or dead at six months and to report their confidence in these predictions. Physicians predicted that 99 (33%) patients would die. The key factors associated with both the direction and accuracy of prediction were older age of the patient, the presence of malignancy, being in a medical ICU, and higher APACHE III scores. The factors associated with lower confidence included older physician age, being in a medical ICU and higher APACHE III score. CONCLUSIONS: Patient level factors are associated with predictions of mortality at six months. The accuracy and confidence of the predictions are associated with both physician and patients' factors. The influence of these factors should be considered when physicians reflect on how they make predictions for critically ill patients.

Variation in antibiotic use across intensive care units (ICU): A population-based cohort study in Ontario, Canada.

OBJECTIVES: Antibiotics are commonly used in intensive care units (ICUs), yet differences in antibiotic use across ICUs are unknown. Herein, we studied antibiotic use across ICUs and examined factors that contributed to variation. METHODS: We conducted a retrospective cohort study using data from Ontario's Critical Care Information System (CCIS), which included 201 adult ICUs and 2,013,397 patient days from January 2012 to June 2016. Antibiotic use was measured in days of therapy (DOT) per 1,000 patient days. ICU factors included ability to provide ventilator support (level 3) or not (level 2), ICU type (medical-surgical or other), and academic status. Patient factors included severity of illness using multiple-organ dysfunction score (MODS), ventilatory support, and central venous catheter (CVC) use. We analyzed the effect of these factors on variation in antibiotic use. RESULTS: Overall, 269,351 patients (56%) received antibiotics during their ICU stay. The mean antibiotic use was 624 (range 3-1460) DOT per 1,000 patient days. Antibiotic use was significantly higher in medical-surgical ICUs compared to other ICUs (697 vs 410 DOT per 1,000 patient days; P < .0001) and in level 3 ICUs compared to level 2 ICUs (751 vs 513 DOT per 1,000 patient days; P < .0001). Higher antibiotic use was associated with higher severity of illness and intensity of treatment. ICU and patient factors explained 47% of the variation in antibiotic use across ICUs. CONCLUSIONS: Antibiotic use varies widely across ICUs, which is partially associated with ICUs and patient characteristics. These differences highlight the importance of antimicrobial stewardship to ensure appropriate use of antibiotics in ICU patients.

Improving Transitions of Care between the Intensive Care Unit and General Internal Medicine Ward. A Demonstration Study.

Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre-post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre-post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre-post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.

Critical Care Management of Toxicities Associated With Targeted Agents and Immunotherapies for Cancer.

OBJECTIVES: To describe the most common serious adverse effects and organ toxicities associated with emerging therapies for cancer that may necessitate admission to the ICU. DATA SOURCES AND STUDY SELECTION: PubMed and Medline search of relevant articles in English on the management of adverse effects of immunotherapy for cancer. DATA EXTRACTION AND DATA SYNTHESIS: Targeted therapies including tyrosine kinase inhibitors, monoclonal antibodies, checkpoint inhibitors, and immune effector cell therapy have improved the outcome and quality of life of patients with cancer. However, severe and life-threatening side effects can occur. These toxicities include infusion or hypersensitivity reactions, cytokine release syndrome, pulmonary, cardiac, renal, hepatic, and neurologic toxicities, hemophagocytic lymphohistiocytosis, opportunistic infections, and endocrinopathies. Cytokine release syndrome is the most common serious toxicity after administration of monoclonal antibodies and immune effector cell therapies. Most of the adverse events from immunotherapy results from an exaggerated T-cell response directed against normal tissue, resulting in the generation of high levels of proinflammatory cytokines. Toxicities from targeted therapies are usually secondary to "on target toxicities." Management is largely supportive and may include discontinuation of the specific agent, corticosteroids, and other immune suppressing agents for severe (grade 3 or 4) immune-related adverse events like neurotoxicity and pneumonitis. CONCLUSIONS: The complexity of toxicities associated with modern targeted and immunotherapeutic agents for cancer require a multidisciplinary approach among ICU staff, oncologists, and organ specialists and adoption of standardized treatment protocols to ensure the best possible patient outcomes.

A suspected septic transfusion reaction associated with posttransfusion contamination of a platelet pool by vancomycin-resistant Enterococcus faecium.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are antibiotic-resistant organisms associated with both colonization and serious life-threatening infection in health care settings. Contamination of platelet concentrates (PCs) with Enterococcus can result in transfusion-transmitted infection. CASE PRESENTATION: This report describes the investigation of a septic transfusion case involving a 27-year-old male patient with relapsed acute leukemia who was transfused with a 5-day-old buffy coat PC pool and developed fever and rigors. DISCUSSION: Microbiology testing and pulse-field gel electrophoresis (PFGE) was done on patient blood cultures obtained from peripheral and central lines. Microbiology and molecular testing were also performed on the remaining posttransfusion PC pool, which was refrigerated for 24 hours before microbiology testing. Red blood cell (RBC) and plasma units associated with the implicated PCs were screened for microbial contamination. Patient blood cultures obtained from peripheral and central lines yielded vancomycin-resistant Enterococcus faecium. Gram stain of a sample from the platelet pool was negative but coagulase-negative Staphylococcus (CNST) and VRE were isolated on culture. Antibiotic sensitivity and PFGE profiles of several VRE isolates from the patient before and after transfusion, and the PC pool, revealed that all were closely related. Associated RBC and plasma components tested negative for microbial contamination. CONCLUSIONS: Microbiological and molecular investigations showed a relationship between VRE isolated from the patient before and after transfusion, and therefore it is postulated that a patient-to-PC retrograde contamination (from either blood or skin) occurred. As the CNST isolated from the PC pool was not isolated from patient samples, its implication in the transfusion event is unknown.