Increasing Supportive Care for Patients With COVID-19-Related Respiratory Deterioration in Non-ICU Settings.

BACKGROUND: Prepandemic hospital guidelines were unable to support an acute influx of patients with respiratory deterioration. New processes for general care practice were needed to facilitate patient care. PURPOSE: To develop and evaluate guidelines to safely treat patients with COVID-19 respiratory deterioration in the general care setting. METHODS: A quality improvement project with 2 PDSA (Plan-Do-Study-Act) cycles was used to develop guidelines for high-flow oxygen and prone positioning, along with frequent monitoring and collaboration with virtual critical care support. RESULTS: Over 6 months, 126 patients with COVID-19 were cared for on general care units. Zero intubations occurred on the general care units, with 211 patient hospital days spent in general care that previously would have required an intensive care unit bed. CONCLUSIONS: Patients in the general care setting with respiratory decline can safely be managed with appropriate monitoring criteria, oxygen device settings, and nursing support unitizing technology.

Implementation and evaluation of sepsis surveillance and decision support in medical ICU and emergency department.

OBJECTIVE: To improve the timely diagnosis and treatment of sepsis many institutions implemented automated sepsis alerts. Poor specificity, time delays, and a lack of actionable information lead to limited adoption by bedside clinicians and no change in practice or clinical outcomes. We aimed to compare sepsis care compliance before and after a multi-year implementation of a sepsis surveillance coupled with decision support in a tertiary care center. DESIGN: Single center before and after study. SETTING: Large academic Medical Intensive Care Unit (MICU) and Emergency Department (ED). POPULATION: Patients 18 years of age or older admitted to *** Hospital MICU and ED from 09/4/2011 to 05/01/2018 with severe sepsis or septic shock. INTERVENTIONS: Electronic medical record-based sepsis surveillance system augmented by clinical decision support and completion feedback. MEASUREMENTS AND MAIN RESULTS: There were 1950 patients admitted to the MICU with the diagnosis of severe sepsis or septic shock during the study period. The baseline characteristics were similar before (N = 854) and after (N = 1096) implementation of sepsis surveillance. The performance of the alert was modest with a sensitivity of 79.9%, specificity of 76.9%, positive predictive value (PPV) 27.9%, and negative predictive value (NPV) 97.2%. There were 3424 unique alerts and 1131 confirmed sepsis patients after the sniffer implementation. During the study period average care bundle compliance was higher; however after taking into account improvements in compliance leading up to the intervention, there was no association between intervention and improved care bundle compliance (Odds ratio: 1.16; 95% CI: 0.71 to 1.89; p-value 0.554). Similarly, the intervention was not associated with improvement in hospital mortality (Odds ratio: 1.55; 95% CI: 0.95 to 2.52; p-value: 0.078). CONCLUSIONS: A sepsis surveillance system incorporating decision support or completion feedback was not associated with improved sepsis care and patient outcomes.

The Clinical Effect of an Early, Protocolized Approach to Mechanical Ventilation for Severe and Refractory Hypoxemia.

BACKGROUND: ARDS remains a source of significant morbidity and mortality in the critically ill patient. The mainstay of therapy entails invasive mechanical ventilation utilizing a lung-protective strategy designed to limit lung injury associated with excessive stress and strain while the underlying etiology of respiratory failure is identified and treated. Less is understood about what to do once conventional ventilation parameters have been optimized but the patient's respiratory status remains unchanged or worsens. In 2015, a protocolized, stepwise approach to mechanical ventilation with partially automated and clearly defined thresholds for management changes was implemented at our institution. We hypothesized that, by identifying appropriate patients earlier, time-to-escalation and rescue therapy implementation would be shortened. METHODS: Subjects with severe ARDS, treated with prone positioning based on our institution's protocolized approach from December 2013 to August 2016 were included. Their baseline characteristics, severity of illness scores, and mechanical ventilation parameters were collected and analyzed. RESULTS: Baseline characteristics, tidal volumes, PaO2 /FIO2 , duration of ventilation after proning, and mortality were similar in both groups. Median (interquartile range [IQR]) PEEP at the time of proning was higher after the protocol implementation (12.5 cm H2O [IQR 6.5-19.4] vs 18 cm H2O [IQR 10-22], P = .386), and mean (IQR) respiratory system driving pressure was lower (16 cm H2O [IQR 13-36.2] vs 12 cm H2O [IQR 9-19.6], P = .029). Median (IQR) time from refractory hypoxemia identification to proning was shorter after protocol implementation (42.2 h [IQR 6.83-347.2] vs 16.3 h [IQR 1-99.7], I = .02), and PaO2 /FIO2 at 1 h after proning was higher. ICU and hospital LOS were shorter after the protocol implementation. CONCLUSIONS: Following the implementation of an early, evidence-based, protocolized approach to optimizing mechanical ventilation, subjects with true refractory hypoxemia were identified earlier and time to proning was significantly shorter. Despite improvement in the evaluation and management of refractory hypoxemia as well as time to initiation of prone positioning, mortality was unchanged and there was variation in the duration of the position.

Practical Implementation of Failure Mode and Effects Analysis for Extracorporeal Membrane Oxygenation Activation.

Extracorporeal membrane oxygenation (ECMO) is used to treat severe hypoxemic respiratory failure and as a rescue therapy for patients with cardiopulmonary arrest within a narrow window of time. A failure modes and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to delays in initiating ECMO. FMEA determined these highest-risk failure modes that were contributing to process failure: (1) ECMO candidacy not determined in time, (2) no or incomplete evaluation for ECMO prior to consult or arrest, (3) ECMO team not immediately available, and (4) cannulation not completed in time. When implemented collectively, a total of 4 interventions addressed more than 95% of the system failures. These interventions were (1) ECMO response pager held by a team required for decision, (2) distribution of institutionally defined inclusion/exclusion criteria, (3) educational training for clinicians consulting the ECMO team, and (4) establishment of a mobile ECMO insertion cart.

Expanding the Presence of Primary Services at Rapid Response Team Activations: A Quality Improvement Project.

Rapid response teams (RRTs) were implemented to provide critical care services for deteriorating patients outside of intensive care units. To date, research on RRT has been conflicting, with some studies showing significant mortality benefit and reduction in cardiac arrest events and others showing no benefit. However, studies have consistently showed improved outcomes when RRTs work closely with primary services. Baseline data analysis at our institution found that primary services were present only on 50% of RRT activations. This quality improvement project aimed to improve the presence of primary services during RRT activations by 25%. With a survey, the main barrier that prevented primary services to be present was identified as the primary services' failure to recognize them as a crucial part of the RRT. Education tools and in-person sessions were implemented reinforcing the importance of primary services presence during RRT activations. The intervention leads to increasing presence of primary services at RRT activations, transfers to higher level of care, and changes in code status. However, there was no difference in hospital or intensive care unit length of stay or in survival.

Multifaceted interventions to decrease mortality in patients with severe sepsis/septic shock-a quality improvement project.

Despite knowledge that EGDT improves outcomes in septic patients, staff education on EGDT and compliance with the CPOE order set has been variable. Based on results of a resident survey to identify barriers to decrease severe sepsis/septic shock mortality in the medical intensive care unit (MICU), multifaceted interventions such as educational interventions to improve awareness to the importance of early goal-directed therapy (EGDT), and the use of the Computerized Physician Order Entry (CPOE) order set, were implemented in July 2013. CPOE order set was established to improve compliance with the EGDT resuscitation bundle elements. Orders were reviewed and compared for patients admitted to the MICU with severe sepsis/septic shock in July and August 2013 (controls) and 2014 (following the intervention). Similarly, educational slide sets were used as interventions for residents before the start of their ICU rotations in July and August 2013. While CPOE order set compliance did not significantly improve (78% vs. 76%, p = 0.74), overall EGDT adherence improved from 43% to 68% (p = 0.0295). Although there was a trend toward improved mortality, this did not reach statistical significance. This study shows that education interventions can be used to increase awareness of severe sepsis/septic shock and improve overall EGDT adherence.

Intensive Care Nurses' Knowledge About Use of Neuromuscular Blocking Agents in Patients With Respiratory Failure.

BACKGROUND: The recent increase in use of neuromuscular blocking agents (NMBAs) in patients with acute respiratory distress syndrome is set against a backdrop of concerns about harm associated with use of these high-risk drugs. Bedside nurses play a pivotal role in the safe and effective use of these agents. OBJECTIVE: To describe critical care nurses' knowledge of the therapeutic properties, adverse effects, and monitoring parameters associated with NMBAs. METHODS: A prospective, multicenter survey of medical intensive care unit nurses between July 2012 and May 2013. The web-based survey instrument was designed, pretested, and administered under the direction of a multidisciplinary group of individuals. RESULTS: Responses from 160 nurses (22% of eligible nurses) were analyzed. Most respondents were able to identify NMBAs correctly as nonanalgesic (93%) and nonanxiolytic (83%). The perceived durations of action of NMBAs varied widely, and few nurses were familiar with patient-specific considerations related to drug elimination. Most (70%) recognized the independent associations between NMBAs and footdrop, muscle breakdown, and corneal ulceration. Pressure ulcers and a history of neuromuscular disease were the characteristics of patients perceived to most heighten the risk of NMBA use. CONCLUSIONS: Critical care nurses are knowledgeable about the importance of concurrent analgesia and sedation during use of NMBAs. Routes of elimination, duration of action, and adverse effects were less commonly known and represent areas for focused education and quality improvement surrounding use of NMBAs in the intensive care unit.

Preliminary noise reduction efforts in a medical intensive care unit.

Noise is a significant contributor to sleep disruption in the intensive care unit (ICU) that may result in increased patient morbidity such as delirium and prolonged length of stay in ICU. We conducted a pre-post intervention study in a 24-bed tertiary care academic medical ICU to reduce the mean noise levels. Baseline dosimeter recordings of ICU noise levels demonstrated a mean noise level of 54.2 A-weighted decibels (dBA) and peak noise levels of 109.9 dBA, well above the Environmental Protection Agency's recommended levels. There were 1735 episodes of "defects" (maximum noise levels > 60 dBA). Following implementation of multipronged interventions, although the mean noise levels did not change significantly between pre- and post-intervention (54.2 vs 53.8 dBA; p = 0.96), there was a significant reduction in the number of "defects" post-intervention (1735 vs 1289, p ≤ 0.000), and the providers felt that the patients were sleeping longer in the ICU post-intervention.

The role of the primary care team in the rapid response system.

PURPOSE: The purpose of the study is to evaluate the impact of primary service involvement on rapid response team (RRT) evaluations. MATERIALS AND METHODS: The study is a combination of retrospective chart review and prospective survey-based evaluation. Data included when and where the activations occurred and the patient's code status, primary service, and ultimate disposition. These data were correlated with survey data from each event. A prospective survey evaluated the primary team's involvement in decision making and the overall subjective quality of the interaction with primary service through a visual analog scale. RESULTS: We analyzed 4408 RRTs retrospectively and an additional 135 prospectively. The primary team's involvement by telephone or in person was associated with significantly more transfers to higher care levels in retrospective (P < .01) and prospective data sets. Code status was addressed more frequently in primary team involvement, with more frequent changes seen in the retrospective analysis (P = .01). Subjective ratings of communication by the RRT leader were significantly higher when the primary service was involved (P < .001). CONCLUSIONS: Active primary team involvement influences RRT activation processes of care. The RRT role should be an adjunct to, but not a substitute for, an engaged and present primary care team.

Widely used track and trigger scores: are they ready for automation in practice?

INTRODUCTION: Early Warning Scores (EWS) are widely used for early recognition of patient deterioration. Automated alarm/alerts have been recommended as a desirable characteristic for detection systems of patient deterioration. We undertook a comparative analysis of performance characteristics of common EWS methods to assess how they would function if automated. METHODS: We evaluated the most widely used EWS systems (MEWS, SEWS, GMEWS, Worthing, ViEWS and NEWS) and the Rapid Response Team (RRT) activation criteria in use in our institution. We compared their ability to predict the composite outcome of Resuscitation call, RRS activation or unplanned transfer to the ICU, in a time-dependent manner (3, 8, 12, 24 and 36 h after the observation) by determining the sensitivity, specificity and positive predictive values (PPV). We used a large vital signs database (6,948,689 unique time points) from 34,898 unique consecutive hospitalized patients. RESULTS: PPVs ranged from less than 0.01 (Worthing, 3 h) to 0.21 (GMEWS, 36 h). Sensitivity ranged from 0.07 (GMEWS, 3 h) to 0.75 (ViEWS, 36 h). Used in an automated fashion, these would correspond to 1040-215,020 false positive alerts per year. CONCLUSIONS: When the evaluation is performed in a time-sensitive manner, the most widely used weighted track-and-trigger scores do not offer good predictive capabilities for use as criteria for an automated alarm system. For the implementation of an automated alarm system, better criteria need to be developed and validated before implementation.

Validity of the FOUR score coma scale in the medical intensive care unit.

OBJECTIVE: To evaluate the validity of the FOUR (Full Outline of UnResponsiveness) score (ranging from 0 to 16), a new coma scale consisting of 4 components (eye response, motor response, brainstem reflexes, and respiration pattern), when used by the staff members of a medical intensive care unit (ICU). PATIENTS AND METHODS: This interobserver agreement study prospectively evaluated the use of the FOUR score to describe the condition of 100 critically ill patients from May 1, 2007, to April 30, 2008. We compared the FOUR score to the Glasgow Coma Scale (GCS) score. For each patient, the FOUR score and the GCS score were determined by a randomly selected staff pair (nurse/fellow, nurse/consultant, fellow/fellow, or fellow/consultant). Pair wise weighted kappa values were calculated for both scores for each observer pair. RESULTS: The interrater agreement with the FOUR score was excellent (weighted kappa: eye response, 0.96; motor response, 0.97; brainstem reflex, 0.98; respiration pattern, 1.00) and similar to that obtained with the GCS (weighted kappa: eye response, 0.96; motor response, 0.97; verbal response, 0.98). In terms of the predictive power for poor neurologic outcome (Modified Rankin Scale score, 3-6), the area under the receiver operating characteristic curve was 0.75 for the FOUR score and 0.76 for the GCS score. The mortality rate for patients with the lowest FOUR score of 0 (89%) was higher than that for patients with the lowest GCS score of 3 (71%). CONCLUSION: The interrater agreement of FOUR score results was excellent among medical intensivists. In contrast to the GCS, all components of the FOUR score can be rated even when patients have undergone intubation. The FOUR score is a good predictor of the prognosis of critically ill patients and has important advantages over the GCS in the ICU setting.

Comparison of a nurse initiated insulin infusion protocol for intensive insulin therapy between adult surgical trauma, medical and coronary care intensive care patients.

BACKGROUND: Sustained hyperglycemia is a known risk factor for adverse outcomes in critically ill patients. The specific aim was to determine if a nurse initiated insulin infusion protocol (IIP) was effective in maintaining blood glucose values (BG) within a target goal of 100-150 mg/dL across different intensive care units (ICUs) and to describe glycemic control during the 48 hours after protocol discontinuation. METHODS: A descriptive, retrospective review of 366 patients having 28,192 blood glucose values in three intensive care units, Surgical Trauma Intensive Care Unit (STICU), Medical (MICU) and Coronary Care Unit (CCU) in a quaternary care hospital was conducted. Patients were > 15 years of age, admitted to STICU (n = 162), MICU (n = 110) or CCU (n = 94) over 8 months; October 2003-June 2004 and who had an initial blood glucose level > 150 mg/dL. We summarized the effectiveness and safety of a nurse initiated IIP, and compared these endpoints among STICU, MICU and CCU patients. RESULTS: The median blood glucose values (mg/dL) at initiation of insulin infusion protocol were lower in STICU (188; IQR, 162-217) than in MICU, (201; IQR, 170-268) and CCU (227; IQR, 178-313); p < 0.0001. Mean time to achieving a target glucose level (100-150 mg/dL) was similar between the three units: 4.6 hours in STICU, 4.7 hours in MICU and 4.9 hours in CCU (p = 0.27). Hypoglycemia (BG < 60 mg/dL) occurred in 7% of STICU, 5% of MICU, and 5% of CCU patients (p = 0.85). Protocol violations were uncommon in all three ICUs. Mean blood glucose 48 hours following IIP discontinuation was significantly different for each population: 142 mg/dL in STICU, 167 mg/dL in MICU, and 160 mg/dL in CCU (p < 0.0001). CONCLUSION: The safety and effectiveness of nurse initiated IIP was similar across different ICUs in our hospital. Marked variability in glucose control after the protocol discontinuation suggests the need for further research regarding glucose control in patients transitioning out of the ICU.