Advanced Practice Providers as Leaders of a Rapid Response Team: A Prospective Cohort Study.

In view of the shortage of medical staff, the quality and continuity of care may be improved by employing advanced practice providers (APPs). This study aims to assess the quality of these APPs in critical care. In a large teaching hospital, rapid response team (RRT) interventions led by APPs were assessed by independent observers and intensivists and compared to those led by medical residents MRs. In addition to mortality, the MAELOR tool (assessment of RRT intervention), time from RRT call until arrival at the scene and time until completion of clinical investigations were assessed. Process outcomes were assessed with the crisis management skills checklist, the Ottawa global rating scale and the Mayo high-performance teamwork scale. The intensivists assessed performance with the handoff CEX recipient scale. Mortality, MAELOR tool, time until arrival and clinical investigation in both groups were the same. Process outcomes and performance observer scores were also equal. The CEX recipient scores, however, showed differences between MRs and APPs that increased with experience. Experienced APPs had significantly better situational awareness, better organization, better evaluations and better judgment than MRs with equal experience (p < 0.05). This study shows that APPs perform well in leading an RRT and may provide added quality over a resident. RRTs should seriously consider the deployment of APPs instead of junior clinicians.

Advanced practice providers versus medical residents as leaders of rapid response teams: A 12-month retrospective analysis.

PURPOSE: In a time of worldwide physician shortages, the advanced practice providers (APPs) might be a good alternative for physicians as the leaders of a rapid response team. This retrospective analysis aimed to establish whether the performance of APP-led rapid response teams is comparable to the performance of rapid response teams led by a medical resident of the ICU. MATERIAL AND METHODS: In a retrospective single-center cohort study, the electronic medical record of a tertiary hospital was queried during a 12-months period to identify patients who had been visited by our rapid response team. Patient- and process-related outcomes of interventions of rapid response teams led by an APP were compared with those of teams led by a medical resident using various parameters, including the MAELOR tool, which measures the performance of a rapid response team. RESULTS: In total, 179 responses of the APP-led teams were analyzed, versus 275 responses of the teams led by a resident. Per APP, twice as many calls were handled than per resident. Interventions of teams led by APPs, and residents did not differ in number of admissions (p = 0.87), mortality (p = 0.8), early warning scores (p = 0.2) or MAELOR tool triggering (p = 0.19). Both groups scored equally on time to admission (p = 0.67) or time until any performed intervention. CONCLUSION: This retrospective analysis showed that the quality of APP-led rapid response teams was similar to the quality of teams led by a resident. These findings need to be confirmed by prospective studies with balanced outcome parameters.

Effect of Automated Closed-loop ventilation versus convenTional VEntilation on duration and quality of ventilation in critically ill patients (ACTiVE) - study protocol of a randomized clinical trial.

BACKGROUND: INTELLiVENT-Adaptive Support Ventilation (ASV) is a fully automated closed-loop mode of ventilation for use in critically ill patients. Evidence for benefit of INTELLiVENT-ASV in comparison to ventilation that is not fully automated with regard to duration of ventilation and quality of breathing is largely lacking. We test the hypothesis that INTELLiVENT-ASV shortens time spent on a ventilator and improves the quality of breathing. METHODS: The "Effects of Automated Closed-loop VenTilation versus Conventional Ventilation on Duration and Quality of Ventilation" (ACTiVE) study is an international, multicenter, two-group randomized clinical superiority trial. In total, 1200 intensive care unit (ICU) patients with an anticipated duration of ventilation of > 24 h will be randomly assigned to one of the two ventilation strategies. Investigators screen patients aged 18 years or older at start of invasive ventilation in the ICU. Patients either receive automated ventilation by means of INTELLiVENT-ASV, or ventilation that is not automated by means of a conventional ventilation mode. The primary endpoint is the number of days free from ventilation and alive at day 28; secondary endpoints are quality of breathing using granular breath-by-breath analysis of ventilation parameters and variables in a time frame of 24 h early after the start of invasive ventilation, duration of ventilation in survivors, ICU and hospital length of stay (LOS), and mortality rates in the ICU and hospital, and at 28 and 90 days. DISCUSSION: ACTiVE is one of the first randomized clinical trials that is adequately powered to compare the effects of automated closed-loop ventilation versus conventional ventilation on duration of ventilation and quality of breathing in invasively ventilated critically ill patients. The results of ACTiVE will support intensivist in their choices regarding the use of automated ventilation. TRIAL REGISTRATION: ACTiVE is registered in clinicaltrials.gov (study identifier: NCT04593810 ) on 20 October 2020.

Diagnostic performance of echocardiography to predict cardiac tamponade after cardiac surgery.

OBJECTIVES: Cardiac tamponade is a life-threatening complication after cardiac surgery. Echocardiography, both transthoracic (TTE) and transesophageal (TEE), may help to identify cardiac tamponade after surgery, but its diagnostic value remains unverified after cardiac surgery. METHODS: This retrospective single-centre cohort study used the electronic medical record and echocardiography database of the Catharina Hospital Eindhoven, a tertiary referral cardiothoracic centre, to identify patients who received echocardiography because they were clinically suspected of having cardiac tamponade within the 4 weeks after cardiac surgery. Overall diagnostic accuracy of both TTE and TEE was calculated (sensitivity, specificity, positive predictive value, negative predictive value, and receiver operation characteristics curves). Subgroup analyses were performed based on the timing of the echocardiography after primary surgery (<24, 24-72, >72 h). RESULTS: The query identified 427 echocardiographs, 373 TTEs and 54 TEEs, being performed in 414 patients (65% males, mean age 67 years). Of them, 116 patients underwent surgical re-exploration in which a cardiac tamponade was determined in 105 patients with a 30-day mortality of 8.6%. The area under the receiver operation characteristics curve for echocardiography in the 4 weeks after cardiac surgery was 0.78 [95% confidence interval (CI): 0.72-0.84, P < 0.001]. In the first 24 h after surgery was the positive predictive value of echocardiography 58.3% (95% CI: 28.6-83.5) with an area under the curve of 0.64 (95% CI: 0.49-0.80, P = 0.06). The diagnostic accuracy improved over time for both TTE and TEE. CONCLUSIONS: Diagnostic accuracy of echocardiography in the 4 weeks after cardiac surgery for cardiac tamponade is acceptable and improves over time. However, in the early postoperative phase (<24 h), the diagnostic accuracy of echocardiography is poor.

Intelligent checklists improve checklist compliance in the intensive care unit: a prospective before-and-after mixed-method study.

BACKGROUND: We examined whether a context and process-sensitive 'intelligent' checklist increases compliance with best practice compared with a paper checklist during intensive care ward rounds. METHODS: We conducted a single-centre prospective before-and-after mixed-method trial in a 35 bed medical and surgical ICU. Daily ICU ward rounds were observed during two periods of 8 weeks. We compared paper checklists (control) with a dynamic (digital) clinical checklist (DCC, intervention). The primary outcome was compliance with best clinical practice, measured as the percentages of checked items and unchecked critical items. Secondary outcomes included ICU stay and the usability of digital checklists. Data are presented as median (interquartile range). RESULTS: Clinical characteristics and severity of critical illness were similar during both control and intervention periods of study. A total of 36 clinicians visited 197 patients during 352 ward rounds using the paper checklist, compared with 211 patients during 366 ward rounds using the DCC. Per ICU round, a median of 100% of items (94.4-100.0) were completed by DCC, compared with 75.1% (66.7-86.4) by paper checklist (P=0.03). No critical items remained unchecked by the DCC, compared with 15.4% (8.3-27.3) by the paper checklist (P=0.01). The DCC was associated with reduced ICU stay (1 day [1-3]), compared with the paper checklist (2 days [1-4]; P=0.05). Usability of the DCC was judged by clinicians to require further improvement. CONCLUSIONS: A digital checklist improved compliance with best clinical practice, compared with a paper checklist, during ward rounds on a mixed ICU. CLINICAL TRIAL REGISTRATION: NCT03599856.

Fully automated postoperative ventilation in cardiac surgery patients: a randomised clinical trial.

BACKGROUND: Ensuring that lung-protective ventilation is achieved at scale is challenging in perioperative practice. Fully automated ventilation may be more effective in delivering lung-protective ventilation. Here, we compared automated lung-protective ventilation with conventional ventilation after elective cardiac surgery in haemodynamically stable patients. METHODS: In this single-centre investigator-led study, patients were randomly assigned at the end of cardiac surgery to receive either automated (adaptive support ventilation) or conventional ventilation. The primary endpoint was the proportion of postoperative ventilation time characterised by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first three postoperative hours. Secondary outcomes included severe hypoxaemia (Spo2 <85%) and resumption of spontaneous breathing. Data are presented as mean (95% confidence intervals [CIs]). RESULTS: We randomised 220 patients (30.4% females; age: 62-76 yr). Subjects randomised to automated ventilation (n=109) spent a 29.7% (95% CI: 22.1-37.4) higher mean proportion of postoperative ventilation time receiving optimal postoperative ventilation after surgery (P<0.001) compared with subjects receiving conventional postoperative ventilation (n=111). Automated ventilation also reduced the proportion of postoperative ventilation time that subjects were exposed to injurious ventilatory settings by 2.5% (95% CI: 1-4; P=0.003). Severe hypoxaemia was less likely in subjects randomised to automated ventilation (risk ratio: 0.26 [0.22-0.31]; P<0.01). Subjects resumed spontaneous breathing more rapidly when randomised to automated ventilation (hazard ratio: 1.38 [1.05-1.83]; P=0.03). CONCLUSIONS: Fully automated ventilation in haemodynamically stable patients after cardiac surgery optimised lung-protective ventilation during postoperative ventilation, with fewer episodes of severe hypoxaemia and an accelerated resumption of spontaneous breathing. CLINICAL TRIAL REGISTRATION: NCT03180203.

The correlation of age with chemotherapy-induced ovarian function failure in breast cancer patients.

PURPOSE: To assess the incidence of chemotherapy-induced ovarian function failure (COFF) based on estradiol and follicle stimulating hormone (FSH) monitoring in premenopausal women with hormone-receptor positive breast cancer treated with second and third generation (neo-)adjuvant chemotherapy. RESULTS: We identified 115 eligible women. Two years after start of chemotherapy, COFF was significantly more often present in women ≥ 40 years (85.6%) as compared to women < 40 years (8.7%). Only age was significantly associated with COFF two years after start of chemotherapy (HR 12.26; 95% CI 5.21-28.86). In 50% of the patients, premenopausal hormone levels were the first or only evidence of ovarian function recovery (OFR). MATERIALS AND METHODS: We included all premenopausal women with hormone-receptor positive breast cancer treated with anthracycline-based chemotherapy, with or without taxanes, in our university hospital in the Netherlands in the years 2005-2013. Patients were 3-monthly monitored for ovarian function. Cox proportional hazards model was used to determine the predictive impact of various parameters on the occurrence of COFF. CONCLUSIONS: After second- or third generation (neo-)adjuvant chemotherapy, COFF was still present in 8.7% of patients < 40 years after two years. FSH and estradiol monitoring may be relevant for those in whom ovarian function suppression is considered an additional effective endocrine treatment.