Use of a Portable Electronic Interface Improves Clinical Handoffs and Adherence to Lung Protective Ventilation.

Background: Mechanical ventilation (MV) is used to support patients with respiratory impairment. Evidence supports the use of lung-protective ventilation (LPV) during MV to improve outcomes. However, studies have demonstrated poor adherence to LPV guidelines. We hypothesized that an electronic platform adapted to a hand-held tablet receiving real-time ventilatory parameters could increase clinician awareness of key LPV parameters. Furthermore, we speculated that an electronic shift-change tool could improve the quality of clinician handoffs. Methods: Using a specially designed Wi-Fi dongle to transmit data from three ventilators and a respiratory monitor, we implemented a system that displays data from all ventilators under the care of a Respiratory Care Practitioner (RCP) on an electronic tablet. In addition, the tablet created a handoff checklist to improve shift-change communication. In a simulated ICU environment, we monitored the performance of eight RCPs at baseline and while using the system. Results: Using the system, the time above guideline Pplat decreased by 74% from control, and the time outside the VT range decreased by 60% from control, p = 0.007 and 0.015, respectively. The handoff scores improved quality significantly from 2.8 to 1.6 on a scale of 1 to 5 (1 being best), p = 0.03. Conclusion: In a simulated environment, an electronic RT tool can significantly improve shift-change communication and increase the RCP's level of LPV adherence.

Culture-Negative Septic Shock Compared With Culture-Positive Septic Shock: A Retrospective Cohort Study.

OBJECTIVES: To determine the clinical characteristics and outcomes of culture-negative septic shock in comparison with culture-positive septic shock. DESIGN: Retrospective nested cohort study. SETTING: ICUs of 28 academic and community hospitals in three countries between 1997 and 2010. SUBJECTS: Patients with culture-negative septic shock and culture-positive septic shock derived from a trinational (n = 8,670) database of patients with septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients with culture-negative septic shock (n = 2,651; 30.6%) and culture-positive septic shock (n = 6,019; 69.4%) were identified. Culture-negative septic shock compared with culture-positive septic shock patients experienced similar ICU survival (58.3% vs 59.5%; p = 0.276) and overall hospital survival (47.3% vs 47.1%; p = 0.976). Severity of illness was similar between culture-negative septic shock and culture-positive septic shock groups ([mean and SD Acute Physiology and Chronic Health Evaluation II, 25.7 ± 8.3 vs 25.7 ± 8.1]; p = 0.723) as were serum lactate levels (3.0 [interquartile range, 1.7-6.1] vs 3.2 mmol/L [interquartile range, 1.8-5.9 mmol/L]; p = 0.366). As delays in the administration of appropriate antimicrobial therapy after the onset of hypotension increased, patients in both groups experienced congruent increases in overall hospital mortality: culture-negative septic shock (odds ratio, 1.56; 95% CI [1.47-1.66]; p < 0.0001) and culture-positive septic shock (odds ratio, 1.65; 95% CI [1.59-1.71]; p < 0.0001). CONCLUSIONS: Patients with culture-negative septic shock behave similarly to those with culture-positive septic shock in nearly all respects; early appropriate antimicrobial therapy appears to improve mortality. Early recognition and eradication of infection is the most obvious effective strategy to improve hospital survival.

Critical Care Organizations: Business of Critical Care and Value/Performance Building.

OBJECTIVE: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. DESIGN: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. SETTING: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. MEASUREMENTS AND MAIN RESULTS: Two phases of critical care organizations care integration are described: "horizontal," within the system and regionalization of care as an initial phase, and "vertical," with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. CONCLUSIONS: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world.

When is pneumonia not pneumonia: a clinicopathologic study of the utility of lung tissue biopsies in determining the suitability of cadaveric tissue for donation.

Healthcare-associated pneumonia (HCAP) represents a major diagnostic challenge because of the relatively low sensitivity and specificity of clinical criteria, radiological findings, and microbiologic culture results. It is often difficult to distinguish between pneumonia, underlying pulmonary disease, or conditions with pulmonary complications; this is compounded by the often-subjective clinical diagnosis of pneumonia. We conducted this study to determine the utility of post-mortem lung biopsies for diagnosing pneumonia in tissue donors diagnosed with pneumonia prior to death. Subjects were deceased patients who had been hospitalized at death and diagnosed with pneumonia. Post-mortem lung biopsies were obtained from the anatomic portion of the cadaveric lung corresponding to chest radiograph abnormalities. Specimens were fixed, stained with hematoxylin and eosin, and read by a single board-certified pathologist. Histological criteria for acute pneumonia included intense neutrophilic infiltration, fibrinous exudates, cellular debris, necrosis, or bacteria in the interstitium and intra-alveolar spaces. Of 143 subjects with a diagnosis of pneumonia at time of death, 14 (9.8 %) had histological evidence consistent with acute pneumonia. The most common histological diagnoses were emphysema (53 %), interstitial fibrosis (40 %), chronic atelectasis (36 %), acute and chronic passive congestion consistent with underlying cardiomyopathy (25 %), fibro-bullous disease (12 %), and acute bronchitis (11 %). HCAP represents a major diagnostic challenge because of the relatively low sensitivity and specificity of clinical criteria, radiological findings, and microbiologic testing. We found that attending physician-diagnosed pneumonia did not correlate with post-mortem pathological diagnosis. We conclude that histological examination of cadaveric lung tissue biopsies enables ascertainment or rule out of underlying pneumonia and prevents erroneous donor deferrals.

Biomarkers in Hepatic Disease: A Review Focused on Critically Ill Patients.

The ability to make a diagnosis early and appropriately is paramount for the survival of the critically ill ICU patient. Along with the myriad physical examination and imaging modalities available, biomarkers provide a window on the disease process. Herein we review hepatic biomarkers in the context of the critical care patient.

Hospital-acquired infections and thermally injured patients: chlorhexidine gluconate baths work.

BACKGROUND: Thermally injured patients are at high risk for infections, including hospital acquired infections (HAIs). We modeled a twice-daily chlorhexidine gluconate (CHG) bath protocol aimed at decreasing HAIs. METHODS: Bathing with a 0.9% CHG solution in sterile water was provided twice daily as part of routine care. Institutional HAI prevention bundles were in place and did not change during the study. Baseline HAI rates were collected for 12 months before the quality study implementation. Centers for Disease Control and Prevention definitions for HAIs were used; our blinded Infection Control physician made each determination. This was an Institutional Review Board-exempt protocol. RESULTS: The study cohort included 203 patients before the quality trial and 277 patients after the quality trial. The median burn area was 25% of total body surface area. Baseline HAI rates were as follows: ventilator-associated pneumonia, 2.2 cases/1,000 ventilator-days; cathether-associated urinary tract infection, 2.7 cases/1,000 catheter-days; central line-associated bloodstream infection, 1.4 cases/1,000 device-days. With implementation of this protocol, the rates dropped to zero and have stayed at that level with the exception of 1 cathether-associated urinary tract infection. There were no untoward effects or observed delays in wound healing with this protocol. All of these changes were clinically significant, although not statistically significant; the study was not powered for statistical significance. CONCLUSIONS: Using this nurse-driven protocol, we decreased, in a sustainable manner, the HAI rate in our intensive care unit to zero. No integumentary difficulties or wound healing delays were related to this protocol.

What we don't know may hurt us: urinary drainage system tubing coils and CA-UTIs-A prospective quality study.

Catheter-associated urinary tract infections account for >30% of infections in acute care hospitals. We hypothesized that coiling of/kinks in the indwelling urinary bladder catheter (IUBC) drainage bag tubing would increase the occurrence of infection/bacteriuria. Ninety-one patient events were evaluated over 60 days. All outcome variables trended with greater frequency among those with a coil in the IUBC tubing; only fever (temperature > 38.1°C) correlated significantly between groups (P = .003). If IUBC is unavoidable, strategies such as keeping collection bag below the level of bladder and avoiding any coiling in the drainage system should be employed. Further study of these phenomena is needed.

Decreasing ventricular infections through the use of a ventriculostomy placement bundle: experience at a single institution.

OBJECT: Ventricular infection after ventriculostomy placement carries a high mortality rate. Responding to ventriculostomy infection rates, a multidisciplinary performance improvement team was formed, a comprehensive protocol for ventriculostomy placement was developed, and the efficacy was evaluated. METHODS: A best-practice protocol was developed, including hand hygiene before the procedure; prophylactic antibiotics; sterile gloves changed between preparation, draping, and procedure; hair removal by clipping for dressing adherence; skin preparation using iodine povacrylex (0.7% available iodine) and isopropyl alcohol (74%); full body and head drape; full surgical attire for the surgeon and other bedside providers; and an antimicrobial-impregnated catheter. A checklist of critical components was used to confirm proper insertion and to monitor practice. Procedure-specific infection rates were calculated using the number of infections divided by the number of patients in whom an external ventricular drainage (EVD) device was inserted × 100 (%). Data were reported back to providers and to the committee. Bundle compliance was monitored over a 4-year period. RESULTS: At the authors' institution, 2928 ventriculostomies were performed between the beginning of the fourth quarter of 2006 and the end of the first quarter of 2012. Although the best-evidence bundle was applied to all patients, only 588 (20.1%) were checklist monitored (increasing from 7% to 23% over the study period). The infection rate for the 2 quarters before bundle implementation was 9.2%. During the study period, the rate decreased quarterly to 2.6% and then to 0%. Over a 4-year period, the rate was 1.06% (2007), 0.66% (2008), 0.15% (2009), and 0.34% (2010); it was 0% in 2011 and the first quarter of 2012. The overall EVD infection rate was 0.46% after bundle implementation. CONCLUSIONS: Bundle implementation including an antimicrobial-impregnated catheter dramatically decreased EVD-related infections. Training and situational awareness of appropriate practice, assisted by the checklist, plus use of the antibiotic-impregnated catheter resulted in sustained reduction in ventriculitis.

The effect of increased mobility on morbidity in the neurointensive care unit.

OBJECT: The detrimental effects of immobility on intensive care unit (ICU) patients are well established. Limited studies involving medical ICUs have demonstrated the safety and benefit of mobility protocols. Currently no study has investigated the role of increased mobility in the neurointensive care unit population. This study was a single-institution prospective intervention trial to investigate the effectiveness of increased mobility among neurointensive care unit patients. METHODS: All patients admitted to the neurointensive care unit of a tertiary care center over a 16-month period (April 2010 through July 2011) were evaluated. The study consisted of a 10-month (8025 patient days) preintervention observation period followed by a 6-month (4455 patient days) postintervention period. The intervention was a comprehensive mobility initiative utilizing the Progressive Upright Mobility Protocol (PUMP) Plus. RESULTS: Implementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300% (p < 0.0001). Initiation of this protocol also correlated with a reduction in neurointensive care unit length of stay (LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneumonias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05). Additionally, increased mobility did not lead to increases in adverse events as measured by falls or inadvertent line disconnections. CONCLUSIONS: Among neurointensive care unit patients, increased mobility can be achieved quickly and safely with associated reductions in LOS and hospital-acquired infections using the PUMP Plus program.

Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success.

OBJECT: To date, there has been a shortage of evidence-based quality improvement initiatives that have shown positive outcomes in the neurosurgical patient population. A single-institution prospective intervention trial with continuous feedback was conducted to investigate the implementation of a urinary tract infection (UTI) prevention bundle to decrease the catheter-associated UTI rate. METHODS: All patients admitted to the adult neurological intensive care unit (neuro ICU) during a 30-month period were included. The study consisted of two 1-month preintervention observation periods (approximately 1200 catheter days) followed by a 30-month intervention phase (20,394 catheter days). A comprehensive evidence-based UTI bundle encompassing avoidance of catheter insertion, maintenance of sterility, product standardization, and early catheter removal was enacted. RESULTS: The urinary catheter utilization rate dropped from 100% to 73.3% during the intervention phase (p < 0.0001) without any increase in the rate of sacral decubitus ulcers or other skin breakdown. The rate of catheter-associated UTI was also significantly reduced from 13.3 to 4.0 infections per 1000 catheter days (p < 0.001). There was a linear relationship between the decreased quarterly catheter utilization rate and the decreased catheter-associated UTI rate (r(2) = 0.79, p < 0.0001). CONCLUSIONS: This single-center prospective study demonstrated that a comprehensive UTI prevention bundle along with a continuous quality improvement program can significantly reduce the duration of urinary catheterization and rate of catheter-associated UTI in a neuro ICU.

Noninvasive work of breathing improves prediction of post-extubation outcome.

PURPOSE: We hypothesized that non-invasively determined work of breathing per minute (WOB(N)/min) (esophageal balloon not required) may be useful for predicting extubation outcome, i.e., appropriate work of breathing values may be associated with extubation success, while inappropriately increased values may be associated with failure. METHODS: Adult candidates for extubation were divided into a training set (n = 38) to determine threshold values of indices for assessing extubation and a prospective validation set (n = 59) to determine the predictive power of the threshold values for patients successfully extubated and those who failed extubation. All were evaluated for extubation during a spontaneous breathing trial (5 cmH(2)O pressure support ventilation, 5 cmH(2)O positive end expiratory pressure) using routine clinical practice standards. WOB(N)/min data were blinded to attending physicians. Area under the receiver operating characteristic curves (AUC), sensitivity, specificity, and positive and negative predictive values of all extubation indices were determined. RESULTS: AUC for WOB(N)/min was 0.96 and significantly greater (p < 0.05) than AUC for breathing frequency at 0.81, tidal volume at 0.61, breathing frequency-to-tidal volume ratio at 0.73, and other traditionally used indices. WOB(N)/min had a specificity of 0.83, the highest sensitivity at 0.96, positive predictive value at 0.84, and negative predictive value at 0.96 compared to all indices. For 95% of those successfully extubated, WOB(N)/min was ≤10 J/min. CONCLUSIONS: WOB(N)/min had the greatest overall predictive accuracy for extubation compared to traditional indices. WOB(N)/min warrants consideration for use in a complementary manner with spontaneous breathing pattern data for predicting extubation outcome.

Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial.

INTRODUCTION: Most patients are readily liberated from mechanical ventilation (MV) support, however, 10% - 15% of patients experience failure to wean (FTW). FTW patients account for approximately 40% of all MV days and have significantly worse clinical outcomes. MV induced inspiratory muscle weakness has been implicated as a contributor to FTW and recent work has documented inspiratory muscle weakness in humans supported with MV. METHODS: We conducted a single center, single-blind, randomized controlled trial to test whether inspiratory muscle strength training (IMST) would improve weaning outcome in FTW patients. Of 129 patients evaluated for participation, 69 were enrolled and studied. 35 subjects were randomly assigned to the IMST condition and 34 to the SHAM treatment. IMST was performed with a threshold inspiratory device, set at the highest pressure tolerated and progressed daily. SHAM training provided a constant, low inspiratory pressure load. Subjects completed 4 sets of 6-10 training breaths, 5 days per week. Subjects also performed progressively longer breathing trials daily per protocol. The weaning criterion was 72 consecutive hours without MV support. Subjects were blinded to group assignment, and were treated until weaned or 28 days. RESULTS: Groups were comparable on demographic and clinical variables at baseline. The IMST and SHAM groups respectively received 41.9 ± 25.5 vs. 47.3 ± 33.0 days of MV support prior to starting intervention, P = 0.36. The IMST and SHAM groups participated in 9.7 ± 4.0 and 11.0 ± 4.8 training sessions, respectively, P = 0.09. The SHAM group's pre to post-training maximal inspiratory pressure (MIP) change was not significant (-43.5 ± 17.8 vs. -45.1 ± 19.5 cm H2O, P = 0.39), while the IMST group's MIP increased (-44.4 ± 18.4 vs. -54.1 ± 17.8 cm H2O, P < 0.0001). There were no adverse events observed during IMST or SHAM treatments. Twenty-five of 35 IMST subjects weaned (71%, 95% confidence interval (CI) = 55% to 84%), while 16 of 34 (47%, 95% CI = 31% to 63%) SHAM subjects weaned, P = .039. The number of patients needed to be treated for effect was 4 (95% CI = 2 to 80). CONCLUSIONS: An IMST program can lead to increased MIP and improved weaning outcome in FTW patients compared to SHAM treatment. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00419458.

Pressure support ventilation advisory system provides valid recommendations for setting ventilator.

BACKGROUND: Pressure support ventilation (PSV) should be applied so that the inspiratory muscles are unloaded appropriately. We developed a computerized advisory system that assesses the load on the inspiratory muscles to spontaneously inhale, reflected by the automatically and noninvasively measured work of breathing per minute, and tolerance for that load, reflected by spontaneous breathing frequency and tidal volume, in a fuzzy-logic algorithm that provides recommendations for setting PSV. We call this a load and tolerance strategy for determining PSV. METHODS: In a clinical validation study, we compared the recommendations from our PSV advisory system to the recommendations of experienced critical-care Registered Respiratory Therapists (RRTs) for setting PSV in patients with respiratory failure. With 76 adult patients in a university medical center surgical intensive care unit receiving PSV, a combined pressure/flow sensor, positioned between the endotracheal tube and patient Y-piece, sent measurements to the PSV advisory system. We compared the advisory system's recommendations (increase, maintain, or decrease the pressure support) to the RRTs' recommendations at the bedside. RESULTS: There were no significant differences between the RRTs' and the advisory system's recommendations (n = 109) to increase, maintain, or decrease PSV. The RRTs agreed with 91% of the advisory system's recommendations (kappa statistic 0.85, P < .001). The advisory system was very good at predicting the RRTs' pressure support recommendations (r(2) = 0.87, P < .02). CONCLUSIONS: A load and tolerance strategy with a computerized PSV advisory system provided valid recommendations for setting PSV to unload the inspiratory muscles, and the recommendations were essentially the same as the recommendations from experienced critical-care RRTs. The PSV advisory system operates continuously and automatically and may be useful in clinical environments where experts are not always available.

A massive pulmonary embolism treatment protocol: how trauma performance improvement affects outcome throughout the hospital system.

Trauma performance improvement is the hallmark of a mature trauma center. If loop closure is to be complete, preventable deaths must result in significant change in management and the establishment of protocol-driven improvements so such an instance does not recur. The trauma performance improvement committee reviewed a case of a massive pulmonary embolus and determined that this was a preventable death. The hospital performance improvement committee then initiated a root cause analysis, which led to creation of a treatment protocol for patients with massive or submassive pulmonary embolism. A focused review of the first 6 months of the implementation of the protocol was undertaken. Four patients over a 6-month period had massive or submassive pulmonary embolus. All four had sudden death or near sudden death and were appropriately resuscitated. All four sustained right heart failure. Two patients were treated by catheter-directed fibrinolysis, one with catheter-directed suction embolectomy, and one by surgical pulmonary embolectomy. All survived with full neurologic function. Trauma performance improvement is the model by which all hospital performance improvement should be done. Preventable deaths can result in change, which can have a future impact on survival in potentially lethal scenarios.

Drowning: Update 2009.

Over the past four decades, we have learned considerably more about the pathophysiology and treatment of drowning. This, coupled with increased emphasis in improvement in water safety and resuscitation, has produced a threefold decrease in the number of deaths, indexed to population, from drowning in the United States yearly. This review presents the current status of our knowledge of the epidemiology, the pathophysiology of drowning and its treatment, updates the definitions of drowning and the drowning process, and makes suggestions for further improvement in water safety.

Long-term risk of mortality and acute kidney injury during hospitalization after major surgery.

OBJECTIVE: To determine the relationship between long-term mortality and acute kidney injury (AKI) during hospitalization after major surgery. SUMMARY BACKGROUND DATA: AKI is associated with a risk of short-term mortality that is proportional to its severity; however the long-term survival of patients with AKI is poorly studied. METHODS: This is a retrospective cohort study of 10,518 patients with no history of chronic kidney disease who were discharged after a major surgery between 1992 and 2002. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss, and End-stage Kidney) classification, which requires at least a 50% increase in serum creatinine (sCr) and stratifies patients into 3 severity stages: risk, injury, and failure. Patient survival was determined through the National Social Security Death Index. Long-term survival was analyzed using a risk-adjusted Cox proportional hazards regression model. RESULTS: In the risk-adjusted model, survival was worse among patients with AKI and was proportional to its severity with an adjusted hazard ratio of 1.18 (95% confidence interval [CI], 1.08-1.29) for the RIFLE-Risk class and 1.57 (95% CI, 1.40-1.75) for the RIFLE-Failure class, compared with patients without AKI (P < 0.001). Patients with complete renal recovery after AKI still had an increased adjusted hazard ratio for death of 1.20 (95% CI, 1.10-1.31) compared with patients without AKI (P < 0.001). CONCLUSIONS: In a large single-center cohort of patients discharged after major surgery, AKI with even small changes in sCr level during hospitalization was associated with an independent long-term risk of death.