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.

Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project.

IMPORTANCE: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. OBJECTIVE: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. PROCESS: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. EVIDENCE SYNTHESIS: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. RECOMMENDATIONS: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. CONCLUSIONS AND RELEVANCE: This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

The US Strategic National Stockpile Ventilators in Coronavirus Disease 2019: A Comparison of Functionality and Analysis Regarding the Emergency Purchase of 200,000 Devices.

BACKGROUND: Early in the coronavirus disease 2019 (COVID-19) pandemic, there was serious concern that the United States would encounter a shortfall of mechanical ventilators. In response, the US government, using the Defense Production Act, ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities, and whether all are able to support COVID-19 patients is not evident. RESEARCH QUESTION: Evaluate ventilator requirements for affected COVID-19 patients, assess the clinical performance of current US Strategic National Stockpile (SNS) ventilators employed during the pandemic, and finally, compare ordered ventilators' functionality based on COVID-19 patient needs. STUDY DESIGN AND METHODS: Current published literature, publicly available documents, and lay press articles were reviewed by a diverse team of disaster experts. Data were assembled into tabular format, which formed the basis for analysis and future recommendations. RESULTS: COVID-19 patients often develop severe hypoxemic acute respiratory failure and adult respiratory defense syndrome (ARDS), requiring high levels of ventilator support. Current SNS ventilators were unable to fully support all COVID-19 patients, and only approximately half of newly ordered ventilators have the capacity to support the most severely affected patients; ventilators with less capacity for providing high-level support are still of significant value in caring for many patients. INTERPRETATION: Current SNS ventilators and those on order are capable of supporting most but not all COVID-19 patients. Technologic, logistic, and educational challenges encountered from current SNS ventilators are summarized, with potential next-generation SNS ventilator updates offered.

Clinical review: Considerations for the triage of maternity care during an influenza pandemic--one institution's approach.

The ongoing pandemic of 2009 H1N1 swine-origin influenza A has heightened the world's attention to the reality of influenza pandemics and their unpredictable nature. Currently, the 2009 H1N1 influenza strain appears to cause mild clinical disease for the majority of those infected. However, the risk of severe disease from this strain or other future strains remains an ongoing concern and is noted in specific patient populations. Pregnant women represent a unique patient population that historically has been disproportionately affected by both seasonal and pandemic influenza outbreaks. Data thus far suggest that the current 2009 H1N1 outbreak is following this same epidemiologic tendency among pregnant women. The increased predilection to worse clinical outcomes among pregnant women has potential to produce an acute demand for critical care resources that may overwhelm supply in facilities providing maternity care. The ability of healthcare systems to optimize maternal-child health outcomes during an influenza pandemic or other biologic disaster may therefore depend on the equitable allocation of these limited resources. Triage algorithms for resource allocation have been delineated in the general medical population. However, no current guidance considers the unique aspects of pregnant women and their unborn fetuses. An approach is suggested that may help guide facilities faced with these challenges.

Design for Implementation of a System-Level ICU Pandemic Surge Staffing Plan.

BACKGROUND: The current coronavirus disease 2019 pandemic is causing significant strain on ICUs worldwide. Initial and subsequent regional surges are expected to persist for months and potentially beyond. As a result of this, as well as the fact that ICU provider staffing throughout the United States currently operate at or near capacity, the risk for severe and augmented disruption in delivery of care is very real. Thus, there is a pressing need for proactive planning for ICU staffing augmentation, which can be implemented in response to a local surge in ICU volumes. METHODS: We provide a description of the design, dissemination, and implementation of an ICU surge provider staffing algorithm, focusing on physicians, advanced practice providers, and certified registered nurse anesthetists at a system-wide level. RESULTS: The protocol was designed and implemented by the University of Pittsburgh Medical Center's Integrated ICU Service Center and was rolled out to the entire health system, a 40-hospital system spanning Pennsylvania, New York, and Maryland. Surge staffing models were developed using this framework to assure that local needs were balanced with system resource supply, with rapid enhancement and expansion of tele-ICU capabilities. CONCLUSIONS: The ICU pandemic surge staffing algorithm, using a tiered-provider strategy, was able to be used by hospitals ranging from rural community to tertiary/quaternary academic medical centers and adapted to meet specific needs rapidly. The concepts and general steps described herein may serve as a framework for hospital and other hospital systems to maintain staffing preparedness in the face of any form of acute patient volume surge.

Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience.

OBJECTIVE: We describe the implementation and experience with adding an obstetric-specific medical emergency team (called Condition O for obstetric crisis) to an existing rapid response system at Magee-Womens Hospital. STUDY DESIGN: In response to deficits identified during patient safety review of adverse obstetric events in 2004 and 2005, the hospital administration decided to add a crisis team with expertise specifically designed for maternal and/or fetal crises. RESULTS: During the first 6 months, staff rarely called Condition O (14 per 10,000 obstetric admissions). After reeducation efforts, use of Condition O increased to 62 per 10,000 obstetric admissions during 2006. CONCLUSION: We outline our hospital's experience with implementation, efforts to address low utilization, and 1.5 years of Condition O event data. Condition O is a work in progress. In light of this, we discuss the challenges of measuring its patient safety outcome, considerations for team size and composition, and our efforts to determine an optimal Condition O rate.

Special populations critical care considerations of the morbidly obese pregnant patient.

The critically ill pregnant patient poses a unique challenge to the clinician, requiring a thorough understanding of normal and abnormal maternal and fetal physiology associated with pregnancy. The morbidly obese patient presents even greater challenges to the clinician, and morbidity and mortality are proportionately increased. Because increased numbers of obese pregnant women are now admitted to intensive care units, practitioners must be aware of the physiology associated with both pregnancy and obesity. A multidisciplinary approach is imperative to prevent both maternal and fetal morbidity and mortality for these very complex patients, especially when they are admitted to the ICU with critical illness.

Impaired healthcare professional.

OBJECTIVE: The objective of the article is to present the available data from the literature on substance use disorders in healthcare professionals. Prevalence, risk factors, treatment options, and reentry into clinical practice are discussed. INTRODUCTION: Impairment of a healthcare professional is the inability or impending inability to practice according to accepted standards as a result of substance use, abuse, or dependency (addiction). The term substance use disorder can be divided into substance abuse and dependence (addiction). Substance abuse results in adverse social and professional consequences. Addiction manifests as physiologic and behavioral symptoms related to a maladaptive pattern of substance use. MAIN RESULTS: It is estimated that approximately 10% to 15% of all healthcare professionals will misuse drugs or alcohol at some time during their career. Although the rates of substance abuse and dependence are similar to those of the general population, the prevalence is disturbing because healthcare professionals are the caregivers responsible for the general health and well-being of the general population. Healthcare professionals have higher rates of abuse with benzodiazepines and opiates. Specialties such as anesthesia, emergency medicine, and psychiatry have higher rates of drug abuse, probably related to the high-risk environment associated with these specialties, the baseline personalities of these healthcare providers, and easy access to drugs in these areas. Drugs and alcohol are mostly used for "recreational" purposes by medical students. Residents and attending physicians use drugs of abuse for performance enhancement and as self-treatment for various reasons, such as, pain, anxiety, or depression. CONCLUSIONS: Institutional, local, and statewide impaired-physician programs are now available for the active treatment and rehabilitation of impaired healthcare professionals. Many of these programs are also designed to assist the clinician with reentry into clinical practice. Rarely is punitive action taken when the healthcare provider undergoes successful treatment and ongoing follow-up management. Overall recovery rates for impaired healthcare professionals seem to be higher compared with other groups, particularly with intensive inpatient management and subsequent follow-up care.

Expanding acute care nurse practitioner and clinical nurse specialist education: invasive procedure training and human simulation in critical care.

Programs educating advanced practice nurses (APNs), including acute care nurse practitioners (ACNPs) and clinical nurse specialists (CNSs) may struggle with the degree to which technical and cognitive skills necessary and unique to the care of critically ill patients should be incorporated within training programs, and the best ways these skills can be synthesized and retained for clinical practice. This article describes the critical care technical skills training mechanisms and use of a High-Fidelity Human Simulation (HFHS) Laboratory in the ACNP and CNS programs at the University of Pittsburgh School of Nursing. The mechanisms for teaching invasive procedures are reviewed including an abbreviated course syllabus and documentation tools. The use of HFHS is discussed as a measure to provide students with technical and cognitive preparation to manage critical incidents. The HFHS Laboratory, scenario development and implementation, and the debriefing process are discussed. Critical care technical skills training and the use of simulation in the curriculum have had a favorable response from students and preceptors at the University of Pittsburgh School of Nursing, and have enhanced faculty's ability to prepare APNs.

Amniotic fluid embolism.

INCIDENCE: Amniotic fluid embolism is a catastrophic syndrome that occurs during pregnancy or in the immediate postpartum period. Multiple case reports have described the clinical findings and have reported variable success with supportive care. There has been discrepancy with respect to the incidence and mortality of amniotic fluid embolism. One likely explanation for this inconsistency is the lack of sensitive and specific diagnostic studies to definitively identify cases of amniotic fluid embolism, leading to both over- and underreporting. Despite the variation in reported incidence and mortality, amniotic fluid embolism remains a life-threatening condition with significant morbidity and mortality for the pregnant woman. It is the fifth most common cause of maternal mortality in the world. DIAGNOSIS: The diagnosis of amniotic fluid embolism continues to be a clinical diagnosis and a diagnosis of exclusion based on the rapid development of a complex constellation of findings with sudden cardiovascular collapse, acute left ventricular failure with pulmonary edema, disseminated intravascular coagulation, and neurologic impairment. Given the significant morbidity and mortality associated with this condition, a high index of suspicion is warranted. Suspected risk factors have included tumultuous labor, trauma, multiparity, increased gestational age, and increased maternal age. However, many patients who develop amniotic fluid embolism have no obvious risk factors. MANAGEMENT: Patients with amniotic fluid embolus are best managed using a multidisciplinary approach. There are no pharmacologic or other therapies that prevent or treat the amniotic fluid embolism syndrome, and supportive care typically involves aggressive treatment of multiple types of shock simultaneously. In this article we discuss the clinical presentation of amniotic fluid embolism syndrome as well as current opinions regarding pathophysiology, diagnosis, and management.

Peripartum cardiomyopathy.

OBJECTIVE: To provide a review of the cardiac and obstetrical literature regarding the development of peripartum cardiomyopathy and, in particular, to examine risk factors, incidence, diagnosis, prognosis, and evidence-based treatment modalities. DESIGN: An extensive review of the current literature. RESULTS: Peripartum cardiomyopathy is a cardiomyopathy of unknown cause that occurs in pregnant females, most commonly in the early postpartum period. It shares many clinical characteristics with idiopathic dilated cardiomyopathy but occurs at a younger age and is associated with a better prognosis. Diagnosis is based upon the clinical presentation of congestive heart failure and objective evidence of left ventricular systolic dysfunction. Conventional pharmacologic therapy for congestive heart failure, such as diuretics, digoxin, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and beta-adrenergic blockers, are routinely used and are quite effective. For those patients who remain refractory to conventional pharmacologic therapy, cardiac transplantation and mechanical circulatory support are viable options. CONCLUSION: Mortality rates in peripartum cardiomyopathy have decreased, and this is most likely related to advances over the past 5 yrs in medical therapy for heart failure. Aggressive use of implantable defibrillators has significantly reduced the risk of sudden death in these patients. For >50% of peripartum cardiomyopathy patients, left ventricular function normalizes with pharmacologic therapy. However, subsequent pregnancies almost always are associated with recurrence of left ventricular systolic dysfunction.

Hemodynamic assessment in a pregnant and peripartum patient.

PATHOPHYSIOLOGY: Critical care in obstetrics has many similarities in pathophysiology to the care of nonpregnant women. However, changes in the physiology of pregnant woman necessary to maintain homeostasis for both mother and fetus, especially during critical illness, result in complex pathophysiology. Understanding the normal physiologic changes during pregnancy, intrapartum, and postpartum is the key to managing critically ill obstetric patients with underlying medical diseases and pregnancy-related complications. HEMODYNAMIC MONITORING: When the pathophysiology of critically ill obstetric patients cannot be explained by noninvasive hemodynamic monitoring and the patient fails to respond to conservative medical management, invasive hemodynamic monitoring may be helpful in guiding management. Most important, the proper interpretation of hemodynamic data is predicated on knowledge of normal values during pregnancy and immediately postpartum. Invasive hemodynamic monitoring with pulmonary artery catherization has been used in the obstetric population, particularly in patients with severe preeclampsia associated with pulmonary edema and renal failure.