Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Influence of Aerosol Mask Design on Fugitive Aerosol Concentrations During Nebulization.

BACKGROUND: Secondhand exposure to fugitive aerosols may cause airway diseases in health providers. We hypothesized that redesigning aerosol masks to be closed-featured would reduce the fugitive aerosol concentrations during nebulization. This study aimed to evaluate the influence of a mask designed for a jet nebulizer on the concentration of fugitive aerosols and delivered doses. METHODS: An adult intubation manikin was attached to a lung simulator to mimic normal and distressed adult breathing patterns. The jet nebulizer delivered salbutamol as an aerosol tracer. The nebulizer was attached to 3 aerosol face masks: an aerosol mask, a modified non-rebreathing mask (NRM, with no vent holes), and an AerosoLess mask. An aerosol particle sizer measured aerosol concentrations at parallel distances of 0.8 m and 2.2 m and a frontal distance of 1.8 m from the manikin. The drug dose delivered distal to the manikin's airway was collected, eluted, and analyzed using a spectrophotometer at a 276 nm wavelength. RESULTS: With a normal breathing pattern, the trends of aerosol concentrations were higher with an NRM followed by an aerosol mask and AerosoLess mask (P < .001) at 0.8 m; however, the concentrations were higher with an aerosol mask followed by NRM and AerosoLess mask at 1.8 m (P < .001) and 2.2 m (P < .001). With a distressed breathing pattern, the aerosol concentrations were higher with an aerosol mask followed by an NRM and AerosoLess mask at 0.8 m, 1.8 m (P < .001), and 2.2 m (P = .005). The delivered drug dose was significantly higher with AerosoLess mask with a normal breathing pattern and with an aerosol mask with a distressed breathing pattern. CONCLUSIONS: Mask design influences fugitive aerosol concentrations in the environment, and a filtered mask reduces the concentration of aerosols at 3 different distances and with 2 breathing patterns.

Transpulmonary Pressure-Guided Lung-Protective Ventilation Improves Pulmonary Mechanics and Oxygenation Among Obese Subjects on Mechanical Ventilation.

BACKGROUND: Transpulmonary pressure (PL) is used to assess pulmonary mechanics and guide lung-protective mechanical ventilation (LPV). PL is recommended to individualize LPV settings for patients with high pleural pressures and hypoxemia. We aimed to determine whether PL-guided LPV settings, pulmonary mechanics, and oxygenation improve and differ from non-PL-guided LPV among obese patients after 24 h on mechanical ventilation. Secondary outcomes included classification of hypoxemia severity, count of ventilator-free days, ICU length of stay, and overall ICU mortality. METHODS: This is a retrospective analysis of data. Ventilator settings, pulmonary mechanics, and oxygenation were recorded on the initial day of PL measurement and 24 h later. PL-guided LPV targeted inspiratory PL < 20 cm H2O and expiratory PL of 0-6 cm H2O. Comparisons were made to repeat measurements. RESULTS: Twenty subjects (13 male) with median age of 49 y, body mass index 47.5 kg/m2, and SOFA score of 8 were included in our analysis. Fourteen subjects received care in a medical ICU. PL measurement occurred 16 h after initiating non-PL-guided LPV. PL-guided LPV resulted in higher median PEEP (14 vs 18 cm H2O, P = .009), expiratory PL (-3 vs 1 cm H2O, P = .02), respiratory system compliance (30.7 vs 44.6 mL/cm H2O, P = .001), and [Formula: see text] (156 vs 240 mm Hg, P = .002) at 24 h. PL-guided LPV resulted in lower [Formula: see text] (0.53 vs 0.33, P < .001) and lower PL driving pressure (10 vs 6 cm H2O, P = .001). Tidal volume (420 vs 435 mL, P = .64) and inspiratory PL (7 vs 7 cm H2O, P = .90) were similar. Subjects had a median of 7 ventilator-free days, and median ICU length of stay was 14 d. Three of 20 subjects died within 28 d after ICU admission. CONCLUSIONS: PL-guided LPV resulted in higher PEEP, lower [Formula: see text], improved pulmonary mechanics, and greater oxygenation when compared to non-PL-guided LPV settings in adult obese subjects.

AARC Clinical Practice Guideline: Management of Adult Patients with Tracheostomy in the Acute Care Setting.

Management of patients with a tracheostomy tube includes many components of care provided by clinicians from various health care disciplines. In recent years, clinicians worldwide have demonstrated a renewed interest in the management of patients with tracheostomy due to the recognition that more effective and efficient management of this patient population is necessary to decrease morbidity and mortality and to optimize the value of the procedure. Commensurate with the goal of enhancing the care of patients with tracheostomy, we conducted a systematic review to facilitate the development of recommendations relevant to the care of adult patients with tracheostomy in the acute care setting. From our systematic review, clinical practice guidelines were developed to address questions regarding the impact of tracheostomy bundles, tracheostomy teams, and protocol-directed care on time to decannulation, length of stay, tracheostomy-related cost, tracheostomy-related adverse events, and other tracheostomy-related outcomes in tracheostomized adult patients in the acute care setting. Using a modification of the RAND/UCLA Appropriateness Method, 3 recommendations were developed to assist clinicians with tracheostomy management of adult patients in the acute care setting: (1) evidence supports the use of tracheostomy bundles that have been evaluated and approved by a team of individuals experienced in tracheostomy management to decrease time to decannulation, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, improved tolerance of oral diet; (2) evidence supports the addition of a multidisciplinary tracheostomy team to improve time to decannulation, length of stay, tracheostomy-related adverse events, and other tracheostomy-related outcomes, namely, increased speaking valve use; (3) evidence supports the use of a weaning/decannulation protocol to guide weaning and removal of the tracheostomy tube to improve time to decannulation.

A Randomized Controlled Trial Comparing Two Lung Expansion Therapies After Upper Abdominal Surgery.

BACKGROUND: Lung expansion therapy is often ordered after surgery to improve alveolar ventilation and reduce risks of postoperative pulmonary complications. The impact of lung expansion therapy at altering ventilation in patients who are not intubated has not been described. The primary purpose of this study was to determine if there is a difference in dorsal redistribution of ventilation and incidences of postoperative pulmonary complications when comparing incentive spirometry (IS) with EzPAP lung expansion therapy after upper abdominal surgery. Our a priori null hypothesis was that there are no differences. METHODS: This randomized controlled trial enrolled adult human subjects after upper- abdominal surgery from January 2017 to November 2018. The subjects were allocated to receive IS or EzPAP 3 times a day on postoperative days 1-5. An electrical impedance tomography device was connected to the subjects for a single lung expansion therapy session on postoperative days 1, 3, and 5 to measure the change in post-lung expansion therapy dorsal end-expiratory lung impedance (ΔEELI%). Lung expansion therapy sessions with electrical impedance tomography included 2 min of normal breathing, 3 cycles of 10 breaths, and 2 min of normal breathing after cycle 3. Postoperative pulmonary complications were screened until hospital discharge. Mann-Whitney, chi-square, and Fisher exact tests were applied. Data were reported as count (n), percentage, and median (interquartile range) for primary and secondary outcomes. Alpha (2-tailed) was < 0.05. RESULTS: A total of 112 subjects were enrolled to receive IS (n = 56) or EzPAP (n = 56). Baseline characteristics were equal. Post-lung expansion therapy dorsal ΔEELI% increased for both groups, but the dorsal ΔEELI% for IS versus EzPAP on postoperative day 1 (16% versus 12%, P = .39), postoperative day 3 (6% versus 6%, P = .68), and postoperative day 5 (9% versus 6%, P = .46) was not significantly different. Hospital length of stay (4 d; P = .30) and incidence of postoperative pulmonary complications (3.6% versus 7.1%, P = .19) were similar. CONCLUSIONS: There was no significant post-lung expansion therapy dorsal ΔEELI% or postoperative pulmonary complications among the adults who received IS or EzPAP 3 times a day after upper abdominal surgery. (ClinicalTrials.gov registration NCT02892773.).

The top 2,000 cited articles in critical care medicine: a bibliometric analysis.

BACKGROUND: The bibliometric analysis has been performed on several topics in critical care medicine (CCM) focusing on top 100 cited articles, but the analysis on CCM literature as a whole is missing. The present study aimed to perform a complete bibliometric analysis in the field of CCM. METHODS: An electronic search of the Scopus database was performed on Feb 13, 2018. The search strategy involved core terms related to CCM. The top 2,000 most cited articles in the field of CCM were included in the analysis. Descriptive statistics on these top-cited articles, country distributions, and journals are reported. Individual author's productivity was assessed with the Lotka's law. Co-occurrence of keywords was visualized with the Fruchterman-Reingold layout. The Walktrap algorithm was employed for clustering analysis. RESULTS: A total of 2,000 documents were included in the analysis with median citations of 386 times [interquartile range (IQR): 308-562 times]. The most cited article was the original paper that described the Acute Physiology and Chronic Health Evaluation (APACHE) II score. The included articles were published in 411 journals. The median number of documents published in one journal was 1, and the mean number was 4.9, indicating a skewed distribution. The maximum number of publications was 217 in CCM. Author's productivity profile was significantly different from the Lotka's law (P=0.001), with n and C values of 2.8 and 0.52, respectively. Fruchterman-Reingold network plot showed that studies involving human subject were the most common literature type. Sepsis was a major research topic that co-occurred with keywords such as disease severity, nonhuman, risk assessment and practice guideline. CONCLUSIONS: The study performed bibliometric analyses of 2,000 top-cited articles in CCM. The most cited article was the one which developed the APACHE II score. Author's productivity was significantly different from the Lotka's law.

Impact of a Respiratory Therapy Assess-and-Treat Protocol on Adult Cardiothoracic ICU Readmissions.

BACKGROUND: The purpose of this retrospective medical record review was to report on recidivism to the ICU among adult postoperative cardiac and thoracic patients managed with a respiratory therapy assess-and-treat (RTAT) protocol. Our primary null hypothesis was that there would be no difference in all-cause unexpected readmissions and escalations between the RTAT group and the physician-ordered respiratory care group. Our secondary null hypothesis was that there would be no difference in primary respiratory-related readmissions, ICU length of stay, or hospital length of stay. METHODS: We reviewed 1,400 medical records of cardiac and thoracic postoperative subjects between January 2015 and October 2016. The RTAT is driven by a standardized patient assessment tool, which is completed by a registered respiratory therapist. The tool develops a respiratory severity score for each patient and directs interventions for bronchial hygiene, aerosol therapy, and lung inflation therapy based on an algorithm. The protocol period commenced on December 1, 2015, and continued through October 2016. Data relative to unplanned admissions to the ICU for all causes as well as respiratory-related causes were evaluated. RESULTS: There was a statistically significant difference in the all-cause unplanned ICU admission rate between the RTAT (5.8% [95% CI 4.3-7.9]) and the physician-ordered respiratory care (8.8% [95% CI 6.9-11.1]) groups (P = .034). There was no statistically significant difference in respiratory-related unplanned ICU admissions with RTAT (36% [95% CI 22.7-51.6]) compared with the physician-ordered respiratory care (53% [95% CI 41.1-64.8]) group (P = .09). The RTAT protocol group spent 1 d less in the ICU (P < .001) and in the hospital (P < .001). CONCLUSIONS: RTAT protocol implementation demonstrated a statistically significant reduction in all-cause ICU readmissions. The reduction in respiratory-related ICU readmissions did not reach statistical significance.