Reverse Triggering: An Introduction to Diagnosis, Management, and Pharmacologic Implications.

Reverse triggering is an underdiagnosed form of patient-ventilator asynchrony in which a passive ventilator-delivered breath triggers a neural response resulting in involuntary patient effort and diaphragmatic contraction. Reverse triggering may significantly impact patient outcomes, and the unique physiology underscores critical potential implications for drug-device-patient interactions. The purpose of this review is to summarize what is known of reverse triggering and its pharmacotherapeutic consequences, with a particular focus on describing reported cases, physiology, historical context, epidemiology, and management. The PubMed database was searched for publications that reported patients presenting with reverse triggering. The current body of evidence suggests that deep sedation may predispose patients to episodes of reverse triggering; as such, providers may consider decreasing sedation or modifying ventilator settings in patients exhibiting ventilator asynchrony as an initial measure. Increased clinician awareness and research focus are necessary to understand appropriate management of reverse triggering and its association with patient outcomes.

Evaluation of Physicians' Electronic Health Records Experience Using Actual and Perceived Measures.

Background: Inadequate electronic health record (EHR) interface design hinders the physician-EHR experience, which may lead to increase physician frustration and fatigue levels. Objectives: The objective of this study was to examine the physician EHR experience by evaluating the congruency between actual and perceived measures among physicians with different EHR expertise and utilization levels. Methods: We conducted a cross-sectional EHR usability study of intensive care unit (ICU) physicians at a major Southeastern medical center. We used eye-tracking glasses to measure provider EHR-related fatigue and three surveys to measure the perceived EHR experience. Results: Of the 25 ICU physicians, 11 were residents, nine were fellows, and five were attending physicians. No significant differences were found between actual fatigue levels and their perceived EHR usability (p=0.159), workload (p=0.753), and satisfaction (p=0.773). Conclusion: We found that there was low congruency between physicians' EHR-related fatigue and the perceived ratings for usability, satisfaction, and workload, which suggests using actual and perceived measures for a comprehensive assessment of the user experience. EHR-related fatigue may not be instantly felt by some physicians, hence the similar rating of perceived EHR experience among physicians.

Physician experiences of screen-level features in a prominent electronic health record: Design recommendations from a qualitative study.

The goal of this qualitative study was to assess physicians' perceptions around features of key screens within a prominent commercial EHR, and to solicit end-user recommendations for improved retrieval of high-priority clinical information. We conducted a qualitative, descriptive study of 25 physicians in a medical ICU setting. at a tertiary academic medical center. An in-depth, semi-structured interview guide was developed to elicit physician perceptions on information retrieval as well as favorable and unfavorable features of specific EHR screens. Transcripts were independently coded in a qualitative software management tool by at least two trained coders using a common code book. We successfully obtained vendor permission to map physicians perception's on full Epic© screenshots. Among the 25 physician participants (13 female; 5 attending physicians, 9 fellows, 11 residents), the majority of participants reported experiencing challenges finding clinical information in the EHR. We present the most favorable and unfavorable screen-level features for four central EHR screens: Flowsheet, Notes/Chart Review, Results Review, and Vital Signs. We also compiled participants' recommendations for a comprehensive EHR dashboard screen to better support clinical workflow and information retrieval in the medical ICU through User-Centered Design. ICU physicians demonstrated a mix of positive and negative attitudes toward specific screen-level features in a major vendor-based EHR system. Physician perceptions of information overload emerged as a theme across multiple EHR screens. Our findings underscore the importance of qualitative research and end-user feedback in EHR software design and interface optimization at both the vendor and institutional level.

Association between ICU interruptions and physicians trainees' electronic health records efficiency.

The intensive care unit (ICU) is a stressful and complex environment in due to its dynamic nature and severity of admitted patients. EHR interface design can be cumbersome and lead to prolonged times to complete tasks. This paper investigated the relationship between a prominent EHR interface design and interruptions with physician's efficiency during patient chart review at ICU Pre-Rounds. We conducted a live observation of ICU physicians in a 30-bed MICU at a tertiary, southeastern medical center. Directly after the observation sessions, the physicians completed a modified System Usability Scale (SUS) survey. A total of 52 EHR patient chart reviews were observed at the MICU Pre-rounds. There was statistically significant positive correlation between time spent to review patient EHR with both number of scrolling(p-value<0.0001) across EHR interface; and with number of visited EHR  screens (p-value=0.0444). There was positive correlation between number of interruptions with time spent to review patient EHR during ICU prerounds. EHR design and the occurrence of interruptions lead to reduced physician-EHR efficiency levels. We report that the number of scrolling and visited screens executed by physicians to gather the required information was associated with increased screen time and consequently decreased physician efficiency.

Analysing EHR navigation patterns and digital workflows among physicians during ICU pre-rounds.

BACKGROUND: Some physicians in intensive care units (ICUs) report that electronic health records (EHRs) can be cumbersome and disruptive to workflow. There are significant gaps in our understanding of the physician-EHR interaction. OBJECTIVE: To better understand how clinicians use the EHR for chart review during ICU pre-rounds through the characterisation and description of screen navigation pathways and workflow patterns. METHOD: We conducted a live, direct observational study of six physician trainees performing electronic chart review during daily pre-rounds in the 30-bed medical ICU at a large academic medical centre in the Southeastern United States. A tailored checklist was used by observers for data collection. RESULTS: We observed 52 distinct live patient chart review encounters, capturing a total of 2.7 hours of pre-rounding chart review activity by six individual physicians. Physicians reviewed an average of 8.7 patients (range = 5-12), spending a mean of 3:05 minutes per patient (range = 1:34-5:18). On average, physicians visited 6.3 (±3.1) total EHR screens per patient (range = 1-16). Four unique screens were viewed most commonly, accounting for over half (52.7%) of all screen visits: results review (17.9%), summary/overview (13.0%), flowsheet (12.7%), and the chart review tab (9.1%). Navigation pathways were highly variable, but several common screen transition patterns emerged across users. Average interrater reliability for the paired EHR observation was 80.0%. CONCLUSION: We observed the physician-EHR interaction during ICU pre-rounds to be brief and highly focused. Although we observed a high degree of "information sprawl" in physicians' digital navigation, we also identified common launch points for electronic chart review, key high-traffic screens and common screen transition patterns. IMPLICATIONS: From the study findings, we suggest recommendations towards improved EHR design.

Randomized, Placebo-controlled Trial of Inhaled Treprostinil for Patients at Risk for Acute Respiratory Distress Syndrome.

Rationale: Inhaled treprostinil may improve oxygenation and have additional antiinflammatory effects in early acute hypoxemic respiratory failure, potentially preventing or reducing the severity of acute respiratory distress syndrome (ARDS).Objectives: To determine whether administration of inhaled treprostinil to patients at risk for ARDS is feasible, safe, and efficacious.Methods: We performed a double-blind, placebo-controlled, single-center randomized pilot trial at a quaternary care academic medical center. Patients with acute hypoxemia due to pneumonia or signs of low-pressure pulmonary edema with a unilateral or bilateral infiltrate on chest imaging and a 4 L/min supplemental oxygen requirement not requiring positive pressure ventilation were evaluated. Randomized patients received study drug or placebo (2:1 ratio). Treatment was initiated at 6 breaths every 4 hours and titrated up to 12 breaths. Subjects were maintained on treatment for 7 days and then tapered off over a period of 4 days. Study drug was stopped if positive pressure ventilation was required (invasive or noninvasive).Results: Fourteen patients were enrolled over a period of 31 months. Baseline characteristics were not significantly different between treatment groups with respect to age, sex, race, Acute Physiologic Assessment and Chronic Health Evaluation score, lung injury prediction score, or baseline mean oxygen saturation as measured by pulse oximetry (SpO2):fraction of inspired oxygen (FiO2) ratio. Trends in daily baseline and 30-minute postdose SpO2:FiO2 ratio for all treatment points were not significantly different between placebo and treprostinil. Four patients required positive pressure ventilation in the treprostinil group versus one in the placebo group.Conclusions: Inhaled treprostinil administration is feasible in patients at risk for ARDS but was not associated with improvement in the SpO2:FiO2 ratio relative to placebo. Drug-associated adverse events were not severe nor unexpected based on the known adverse effect profile of inhaled treprostinil. The clinical benefit of this intervention is unclear at this time in the absence of larger studies.Clinical trial registered with Clinicaltrials.gov (NCT02370095).

Association of Electronic Health Record Use With Physician Fatigue and Efficiency.

Importance: The use of electronic health records (EHRs) is directly associated with physician burnout. An underlying factor associated with burnout may be EHR-related fatigue owing to insufficient user-centered interface design and suboptimal usability. Objective: To examine the association between EHR use and fatigue, as measured by pupillometry, and efficiency, as measured by mouse clicks, time, and number of EHR screens, among intensive care unit (ICU) physicians completing a simulation activity in a prominent EHR. Design, Setting, and Participants: A cross-sectional, simulation-based EHR usability assessment of a leading EHR system was conducted from March 20 to April 5, 2018, among 25 ICU physicians and physician trainees at a southeastern US academic medical center. Participants completed 4 simulation patient cases in the EHR that involved information retrieval and task execution while wearing eye-tracking glasses. Fatigue was quantified through continuous eye pupil data; EHR efficiency was characterized through task completion time, mouse clicks, and EHR screen visits. Data were analyzed from June 1, 2018, to August 31, 2019. Main Outcomes and Measures: Primary outcomes were physician fatigue, measured by pupillometry (with lower scores indicating greater fatigue), and EHR efficiency, measured by task completion times, number of mouse clicks, and number of screens visited during EHR simulation. Results: The 25 ICU physicians (13 women; mean [SD] age, 32.1 [6.1] years) who completed a simulation exercise involving 4 patient cases (mean [SD] completion time, 34:43 [11:41] minutes) recorded a total of 14 hours and 27 minutes of EHR activity. All physician participants experienced physiological fatigue at least once during the exercise, and 20 of 25 participants (80%) experienced physiological fatigue within the first 22 minutes of EHR use. Physicians who experienced EHR-related fatigue in 1 patient case were less efficient in the subsequent patient case, as demonstrated by longer task completion times (r = -0.521; P = .007), higher numbers of mouse clicks (r = -0.562; P = .003), and more EHR screen visits (r = -0.486; P = .01). Conclusions and Relevance: This study reports high rates of fatigue among ICU physicians during short periods of EHR simulation, which were negatively associated with EHR efficiency and included a carryover association across patient cases. More research is needed to investigate the underlying causes of EHR-associated fatigue, to support user-centered EHR design, and to inform safe EHR use policies and guidelines.

Intermediate Care Units: A Survey of Organization Practices Across the United States.

PURPOSE: Intermediate care units (IMCUs) represent an alternative care setting with nurse staffing levels between those of the general ward and the intensive care unit (ICU). Despite rising prevalence, little is known about IMCU practices across US hospitals. The purpose of this study is to characterize utilization patterns and assess for variation. MATERIALS AND METHODS: A 14-item survey was distributed to a random nationwide sample of pulmonary and critical care physicians between January and April 2017. RESULTS: A total of 51 physicians from 24 different states completed the survey. Each response represented a unique institution, the majority of which were public (59%), academic (73%), and contained at least 1 IMCU (65%). Of the IMCUs surveyed, 58% operated as 1 mixed unit that admitted medical, cardiac, and surgical patients as opposed to having separate subspecialty units. Ninety-one percent of units admitted step-down patients from the ICU, but 39% of units accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department. Intensivists managed care in 21% of units whereas 36% had no intensivist involvement. CONCLUSION: Organization practices vary considerably between IMCUs across institutions. The impact of different organization practices on patient outcomes should be assessed.

Physicians' gender and their use of electronic health records: findings from a mixed-methods usability study.

OBJECTIVE: Physician burnout associated with EHRs is a major concern in health care. A comprehensive assessment of differences among physicians in the areas of EHR performance, efficiency, and satisfaction has not been conducted. The study sought to study relationships among physicians' performance, efficiency, perceived workload, satisfaction, and usability in using the electronic health record (EHR) with comparisons by age, gender, professional role, and years of experience with the EHR. MATERIALS AND METHODS: Mixed-methods assessments of the medical intensivists' EHR use and perceptions. Using simulated cases, we employed standardized scales, performance measures, and extensive interviews. NASA Task Load Index (TLX), System Usability Scale (SUS), and Questionnaire on User Interface Satisfaction surveys were deployed. RESULTS: The study enrolled 25 intensive care unit (ICU) physicians (11 residents, 9 fellows, 5 attendings); 12 (48%) were men, with a mean age of 33 (range, 28-55) years and a mean of 4 (interquartile range, 2.0-5.5) years of Epic experience. Overall task performance scores were similar for men (90% ± 9.3%) and women (92% ± 4.4%), with no statistically significant differences (P = .374). However, female physicians demonstrated higher efficiency in completion time (difference = 7.1 minutes; P = .207) and mouse clicks (difference = 54; P = .13). Overall, men reported significantly higher perceived EHR workload stress compared with women (difference = 17.5; P < .001). Men reported significantly higher levels of frustration with the EHR compared with women (difference = 33.15; P < .001). Women reported significantly higher satisfaction with the ease of use of the EHR interface than men (difference = 0.66; P =.03). The women's perceived overall usability of the EHR is marginally higher than that of the men (difference = 10.31; P =.06). CONCLUSIONS: Among ICU physicians, we measured significant gender-based differences in perceived EHR workload stress, satisfaction, and usability-corresponding to objective patterns in EHR efficiency. Understanding the reasons for these differences may help reduce burnout and guide improvements to physician performance, efficiency, and satisfaction with EHR use. DESIGN: Mixed-methods assessments of the medical intensivists' EHR use and perceptions. Using simulated cases, we employed standardized scales, performance measures, and extensive interviews.

Acute Respiratory Distress Syndrome: Cost (Early and Long-Term).

Costs of care in the intensive care unit are a frequent area of concern in our current health care system. Utilization of critical care services in the United States, particularly near the end of life, has been steadily increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently experience prolonged hospitalizations and consume significant health care resources. Many patients are discharged with functional limitations and require significant postdischarge services. These patients have a high susceptibility to new complications which require significant additional health care resources. There is a slowly growing literature on the cost-effectiveness of the treatment of ARDS; despite its high costs, treatment remains a cost-effective intervention by most societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment may become less cost-effective. In addition, the provision of extracorporeal life support adds another layer of complexity to these cases. Small reductions in intensive care unit length of stay may benefit patients, but they do not lead to significant reductions in overall hospital costs. Early discharge to postacute care facilities can reduce hospital costs but is unlikely to significantly decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes. However, the most significant cost-saving interventions are early recognition and treatment of conditions to potentially prevent the development of this serious complication.

A mixed-methods evaluation framework for electronic health records usability studies.

BACKGROUND: Poor EHR design adds further challenges, especially in the areas of order entry and information visualization, with a net effect of increased rates of incidents, accidents, and mortality in ICU settings. OBJECTIVE: The purpose of this study was to propose a novel, mixed-methods framework to understand EHR-related information overload by identifying and characterizing areas of suboptimal usability and clinician frustration within a vendor-based, provider-facing EHR interface. METHODS: A mixed-methods, live observational usability study was conducted at a single, large, tertiary academic medical center in the Southeastern US utilizing a commercial, vendor based EHR. Physicians were asked to complete usability patient cases, provide responses to three surveys, and participant in a semi-structured interview. RESULTS: Of the 25 enrolled ICU physician participants, there were 5(20%) attending physicians, 9 (36%) fellows, and 11 (44%) residents; 52% of participants were females. On average, residents were the quickest in completing the tasks while attending physician took the longest to complete the same task. Poor usability, complex interface screens, and difficulty to navigate the EHR significantly correlated with high frustration levels. Significant association were found between the occurrence of error messages and temporal demand such that more error messages resulted in longer completion time (p = .03). DISCUSSION: Physicians remain frustrated with the EHR due to difficulty in finding patient information. EHR usability remains a critical challenge in healthcare, with implications for medical errors, patient safety, and clinician burnout. There is a need for scientific findings on current information needs and ways to improve EHR-related information overload.

Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline.

BACKGROUND: This document provides clinical recommendations for the diagnosis of idiopathic pulmonary fibrosis (IPF). It represents a collaborative effort between the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Society. METHODS: The evidence syntheses were discussed and recommendations formulated by a multidisciplinary committee of IPF experts. The evidence was appraised and recommendations were formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: The guideline panel updated the diagnostic criteria for IPF. Previously defined patterns of usual interstitial pneumonia (UIP) were refined to patterns of UIP, probable UIP, indeterminate, and alternate diagnosis. For patients with newly detected interstitial lung disease (ILD) who have a high-resolution computed tomography scan pattern of probable UIP, indeterminate, or an alternative diagnosis, conditional recommendations were made for performing BAL and surgical lung biopsy; because of lack of evidence, no recommendation was made for or against performing transbronchial lung biopsy or lung cryobiopsy. In contrast, for patients with newly detected ILD who have a high-resolution computed tomography scan pattern of UIP, strong recommendations were made against performing surgical lung biopsy, transbronchial lung biopsy, and lung cryobiopsy, and a conditional recommendation was made against performing BAL. Additional recommendations included a conditional recommendation for multidisciplinary discussion and a strong recommendation against measurement of serum biomarkers for the sole purpose of distinguishing IPF from other ILDs. CONCLUSIONS: The guideline panel provided recommendations related to the diagnosis of IPF.

Classifying Provider-EHR Screen Interactions During ICU Pre-Rounds.

Electronic health records (EHR) usability is paramount for high quality of care delivery, clinician productivity and effectiveness, and patient outcomes. This paper investigates clinicians EHR pathways during pre-rounds by characterizing the top EHR screens, duration per screen, and the path taken to complete a task. Structured observations were conducted of ICU providers interacting with the EHR in a real-time, real-world setting to better characterize the information retrieval process. Based on preliminary results of the observations, key areas of information needs have been identified and a preliminary model of EHR workflow has been established. The study highlights that there is a clear discrepancy in usage in EHR screens among ICU residents suggesting that there is a perceived clinician's pathology to finding patient information.

The Impact of Visualization Dashboards on Quality of Care and Clinician Satisfaction: Integrative Literature Review.

BACKGROUND: Intensive Care Units (ICUs) in the United States admit more than 5.7 million people each year. The ICU level of care helps people with life-threatening illness or injuries and involves close, constant attention by a team of specially-trained health care providers. Delay between condition onset and implementation of necessary interventions can dramatically impact the prognosis of patients with life-threatening diagnoses. Evidence supports a connection between information overload and medical errors. A tool that improves display and retrieval of key clinical information has great potential to benefit patient outcomes. The purpose of this review is to synthesize research on the use of visualization dashboards in health care. OBJECTIVE: The purpose of conducting this literature review is to synthesize previous research on the use of dashboards visualizing electronic health record information for health care providers. A review of the existing literature on this subject can be used to identify gaps in prior research and to inform further research efforts on this topic. Ultimately, this evidence can be used to guide the development, testing, and implementation of a new solution to optimize the visualization of clinical information, reduce clinician cognitive overload, and improve patient outcomes. METHODS: Articles were included if they addressed the development, testing, implementation, or use of a visualization dashboard solution in a health care setting. An initial search was conducted of literature on dashboards only in the intensive care unit setting, but there were not many articles found that met the inclusion criteria. A secondary follow-up search was conducted to broaden the results to any health care setting. The initial and follow-up searches returned a total of 17 articles that were analyzed for this literature review. RESULTS: Visualization dashboard solutions decrease time spent on data gathering, difficulty of data gathering process, cognitive load, time to task completion, errors, and improve situation awareness, compliance with evidence-based safety guidelines, usability, and navigation. CONCLUSIONS: Researchers can build on the findings, strengths, and limitations of the work identified in this literature review to bolster development, testing, and implementation of novel visualization dashboard solutions. Due to the relatively few studies conducted in this area, there is plenty of room for researchers to test their solutions and add significantly to the field of knowledge on this subject.

To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill.

The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.

Cost and health care utilization in ARDS--different from other critical illness?

Costs of care in the intensive care unit are a frequent target for concern in the current health care system. Utilization of critical care services in the United States is increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently have long hospitalizations and consume a significant amount of health care resources. Many patients are discharged with functional limitations and high susceptibility to new complications that require significant additional health care resources. There is increasing literature on the cost-effectiveness of the treatment of ARDS, and despite its high costs, treatment remains a cost-effective intervention by current societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment becomes less cost-effective. Current research seeks to find interventions that lead to reductions in duration of mechanical ventilation and intensive care unit (ICU) length of stay. Limited reductions in ICU length of stay have benefits for the patient, but they do not lead to significant reductions in overall hospital costs. Early discharge to post-acute care facilities can reduce hospital costs but are unlikely to decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes.

Incidence and risk factors of recurrent acute lung injury.

OBJECTIVE: To determine risk factors for development of recurrent acute lung injury. DESIGN: A population-based case-control study. SETTING: The study was conducted in Olmsted County, MN, from 1999 to 2008. PATIENTS: Using a validated electronic screening protocol, investigators identified intensive care patients with acute hypoxemia and bilateral pulmonary infiltrates. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The presence of acute lung injury was independently confirmed according to American-European Consensus Conference criteria. Recurrent acute lung injury cases were subsequently matched (1:1:1) with two controls (single acute lung injury and no acute lung injury) on age, gender, duration of follow-up, and predisposing conditions. Risk factors evaluated included gastroesophageal reflux disease, alcohol consumption, smoking, chronic opioid use, and transfusions. We identified 917 patients with acute lung injury, 19 of which developed a second episode, yielding a frequency of 2.02 (95% confidence interval 1.10-2.93) per 100,000 person years. The median time to development of the second episode was 264 days (interquartile range 80-460 days), with a mortality of 47% during the episode. The history of gastroesophageal reflux disease was highly prevalent in patients who developed recurrent acute lung injury: 15 of 19 patients (79%) compared to 5 of 19 (26%) matches with a single episode of acute lung injury (p = .006) and 8 of 19 (42%) matches without acute lung injury (p = .016). Other exposures were similar between the cases and the two matched controls. CONCLUSIONS: Recurrent acute lung injury is not a rare phenomenon in the intensive care unit and may continue to increase with improvements in survival following acute lung injury. Gastroesophageal reflux disease was identified as an important risk factor for recurrent acute lung injury and may suggest an important role of gastric aspiration in the development of this syndrome.