Evaluation of ICU Risk Models Adapted for Use as Continuous Markers of Severity of Illness Throughout the ICU Stay.

OBJECTIVES: Evaluate the accuracy of different ICU risk models repurposed as continuous markers of severity of illness. DESIGN: Nonintervention cohort study. SETTING: eICU Research Institute ICUs using tele-ICU software calculating continuous ICU Discharge Readiness Scores between January 2013 and March 2016. PATIENTS: Five hundred sixty-one thousand four hundred seventy-eight adult ICU patients with an ICU length of stay between 4 hours and 30 days. INTERVENTIONS: Not available. MEASUREMENTS AND MAIN RESULTS: Hourly Acute Physiology and Chronic Health Evaluation IV, Sequential Organ Failure Assessment, and Discharge Readiness Scores were calculated beginning hour 4 of the ICU stay. Primary outcome was the area under the receiver operating characteristic curve for the mean score with ICU mortality. Secondary outcomes included area under the receiver operating characteristic curves for ICU mortality with admission, median, maximum and last scores, and for death within 24 hours. The trajectories of each score were visualized by plotting the hourly averages against time in the ICU, stratified by mortality and length of stay. The area under the receiver operating characteristic curves for mean Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores were 0.90 (0.89-0.90), 0.86 (0.86-0.86), and 0.94 (0.94-0.94), respectively. The area under the receiver operating characteristic curves for hourly Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores predicting 24-hour mortality were 0.81 (0.81-0.81), 0.76 (0.76-0.76), and 0.86 (0.86-0.86). Discharge Readiness Scores had a higher area under the receiver operating characteristic curve than both Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment for each metric. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores increased throughout the first 24 hours in both survivors and nonsurvivors; Discharge Readiness Scores continuously decreased in survivors and temporarily decreased before increasing by hour 36 in nonsurvivors with longer length of stays. CONCLUSIONS: Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores all have relatively high discrimination for ICU mortality when used continuously; Discharge Readiness Scores tended to have slightly higher area under the receiver operating characteristic curves for each endpoint. These findings validate the use of these models on a population level for continuous risk adjustment in the ICU, although Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment appear slower to respond to improvements in patient status than Discharge Readiness Scores, and Discharge Readiness Scores may reflect physiologic improvement from interventions, potentially underestimating risk.

Tele-ICU and Patient Safety Considerations.

The tele-ICU is designed to leverage, not replace, the need for bedside clinical expertise in the diagnosis, treatment, and assessment of various critical illnesses. Tele-ICUs are primarily decentralized or centralized models with differing advantages and disadvantages. The centralized model has sufficiently powered published data to be associated with improved mortality and ICU length of stay in a cost-effective manner. Factors associated with improved clinical outcomes include improved compliance with best practices; providing off-hours implementation of the bedside physician's care plan; and identification of and rapid response to physiological instability (initial clinical review within 1 hour) and rapid response to alerts, alarms, or direct notification by bedside clinicians. With improved communication and frequent review of patients between the tele-ICU and the bedside clinicians, the bedside clinician can provide the care that only they can provide. Although technology continues to evolve at a rapid pace, technology alone will most likely not improve clinical outcomes. Technology will enable us to process real or near real-time data into complex and powerful predictive algorithms. However, the remote and bedside teams must work collaboratively to develop care processes to better monitor, prioritize, standardize, and expedite care to drive greater efficiencies and improve patient safety.

The Obesity Paradox Is Not Observed in Critically Ill Patients on Early Enteral Nutrition.

OBJECTIVES: To investigate the association between body mass index and mortality in a large, ICU population and determine if the relationship is observed among a subgroup of patients ordered early enteral nutrition. DESIGN: Retrospective cohort study within a national clinical mixed ICU database of patients admitted between January 1, 2008, and June 30, 2015. SETTING: Initial ICU admissions among patients monitored by tele-ICU programs and recorded in the Philips eICU Research Institute database. PATIENTS: A total of 1,042,710 adult patient stays with ICU length of stay more than 24 hours, of which 74,771 were ordered enteral nutrition within the first 48 hours. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Patient stays from 409 ICUs were included. The average age, Acute Physiology and Chronic Health Evaluation IV score, and hospital mortality were 63.6 years, 56.7, and 9.0%, respectively. Hospital mortality among body mass index categories was estimated by multivariable modified Poisson regression models. Compared with the body mass index category 25.0-29.9 kg/m, hospital mortality was higher among underweight (body mass index, < 18.5; relative risk, 1.35; 95% CI, 1.32-1.39), normal weight (body mass index, 18.5-24.9; relative risk, 1.10; 95% CI, 1.09-1.12), and the extremely obese (body mass index, ≥ 50.0; relative risk, 1.10; 95% CI, 1.05-1.15). However, the risk was not statistically different from patients with body mass index 30.0-49.9 kg/m. Among patients ordered early enteral nutrition, the risk of mortality in the body mass index category 25.0-29.9 kg/m was not statistically different from those in the normal weight or extremely obese groups. CONCLUSIONS: A survival advantage for overweight and obese patients was observed in this large cohort of critically ill patients. However, among those ordered early enteral nutrition, the survival disadvantage for body mass index categories less than 25.0 kg/m was minimal or unobservable when compared with higher body mass index categories.

Using technology to prevent adverse drug events in the intensive care unit.

Critically ill patients are particularly susceptible to adverse drug events (ADEs) due to their rapidly changing and unstable physiology, complex therapeutic regimens, and large percentage of medications administered intravenously. There are a wide variety of technologies that can help prevent the points of failure commonly associated with ADEs (i.e., the five "Rights": right patient; right drug; right route; right dose; right frequency). These technologies are often categorized by their degree of complexity to design and engineer and the type of error they are designed to prevent. Focusing solely on the software and hardware design of technology may over- or underestimate the degree of difficulty to avoid ADEs at the bedside. Alternatively, we propose categorizing technological solutions by identifying the factors essential for success. The two major critical success factors are: 1) the degree of clinical assessment required by the clinician to appropriately evaluate and disposition the issue identified by a technology; and 2) the complexity associated with effective implementation. This classification provides a way of determining how ADE-preventing technologies in the intensive care unit can be successfully integrated into clinical practice. Although there are limited data on the effectiveness of many technologies in reducing ADEs, we will review the technologies currently available in the intensive care unit environment. We will also discuss critical success factors for implementation, common errors made during implementation, and the potential errors using these systems.

Intravenous to oral conversion of antihypertensives: a toolkit for guideline development.

OBJECTIVE: To provide a toolkit of information for hospitals to use in developing intravenous to oral conversion protocols for antihypertensives. DATA SOURCES: Articles describing intravenous to oral conversion protocols for any therapeutic category were identified in an English-language MEDLINE search (1990-April 2010) using a wide variety of MeSH terms. References from selected articles were reviewed for additional material. STUDY SELECTION AND DATA EXTRACTION: Experimental and observational English-language studies and review articles that focused on oral transition of intravenous drugs were selected. DATA SYNTHESIS: Most of the literature on conversion from intravenous to oral formulations involves antimicrobials. There is considerable evidence documenting reduced costs and improved patient flow through the health-care system following implementing these protocols with drugs like antimicrobials, histamine-2 receptor antagonists, and proton pump inhibitors. Although antihypertensives have not been studied, principles and implementation strategies used for other drug classes can be applied to antihypertensives. Guidance is provided on framing the problem, issues surrounding oral absorption principles, information pertaining to oral conversion in specific disease states, and implementation and documentation strategies. Detailed tables of oral and intravenous antihypertensives are provided. CONCLUSIONS: We recommend that hospitals consider developing protocols on conversion of intravenous to oral antihypertensives in an attempt to reduce unnecessarily prolonged intravenous therapy. Information contained in this article can be used as a toolkit to select information specific to the characteristics of individual health-care systems.

Hyperglycemia management in the hospital setting.

PURPOSE: Recommendations for target blood glucose concentrations; factors that can complicate glycemic control; considerations that determine the aggressiveness of therapy to manage blood glucose levels; the role of oral antihyperglycemic drug therapy, sliding-scale insulin, continuous intravenous (i.v.) insulin infusions, and basal-bolus insulin therapy; the pharmacodynamics of various insulin products; computer decision support systems; and discharge planning for hospitalized patients with hyperglycemia are described. SUMMARY: Target blood glucose concentrations depend on whether patients are critically ill or not. Factors that can complicate glycemic control include the severity of illness, medications, and inconsistent dietary intake. The expected course of treatment, anticipated length of stay, and preadmission glycemic control influence the aggressiveness of therapy to manage hyperglycemia. The usefulness of oral antihyperglycemic agents for managing in-hospital hyperglycemia is limited by difficulty titrating the dosage and promptly achieving target blood glucose concentrations. Sliding-scale insulin is not recommended because it is ineffective and potentially dangerous. Continuous i.v. insulin therapy or intermittent subcutaneous (s.c.) basal-bolus plus correction injections is preferred. Basal-bolus plus correction insulin therapy usually involves a single daily dose of insulin glargine at bedtime to prevent gluconeogenesis and ketogenesis, bolus injections of a rapid-acting insulin shortly before or after meals to meet prandial requirements, and correction bolus injections of rapid-acting insulin as needed for blood glucose elevations before or between meals. Hypoglycemia is the primary limiting factor for achieving optimal glycemic control with insulin therapy. Computer decision support systems can help reduce the risk of insulin infusion rate calculation errors and standardize insulin therapy. Communication with the primary care physician in the outpatient setting is an important part of discharge planning. CONCLUSION: Sliding-scale insulin is not effective. Continuous i.v. insulin therapy or intermittent s.c. basal-bolus plus correction injections is preferred. Proactive management of hyperglycemia using these methods is needed to achieve and maintain glycemic control in hospitalized patients.

Telemedicine and the patient with sepsis.

Severe sepsis remains a significant medical problem affecting up to 18 million individuals worldwide. Mortality remains high ranging between 28% and 50%. Owing to this and the time-sensitive nature of this disease state, early identification and prompt interventions are necessary to improve outcomes. Technology associated with telemedicine may help in screening, identifying, and monitoring the attainment of the severe sepsis bundle elements in a timely manner. However, the heterogeneity of systemic inflammatory response syndrome and clinical assessment necessary to diagnose and assess patients with severe sepsis makes technology alone insufficient to improve the outcomes in these patients.

Critical care pharmacotherapy: issues and approaches.

Critically ill patients are a unique group with potentially altered pharmacokinetic and pharmacodynamic characteristics. The provision of optimal care to these patients is best accomplished via an intensivist-led multidisciplinary team. Included on this team should be a pharmacist specifically trained in critical care. The presence of a critical care pharmacist has been documented to not only decrease the cost of drug use in this setting but to improve the quality of care as well. Further investigations should focus on the impact of these interventions on outcomes. These will include pharmacoeconomic outcomes as well as their impact on other parts of the healthcare system in order to avoid cost shifting and improve morbidity and mortality.

Current issues regarding the use of drotrecogin alfa (activated).

The key issues clinicians are facing regarding drotrecogin alfa (activated) include questions concerning the pathophysiology and appropriate patient selection for administration of this drug. In the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial, the efficacy of drotrecogin alfa (activated) was demonstrated in patients with severe sepsis. Because of this trial's strict inclusion and exclusion criteria, however, the applicability of the study criteria to different types of patients raises important issues. Coupling the data from the PROWESS trial with additional information being gained from expanding clinical experience, as well as additional studies, clinicians will be able to better understand and refine the use of activated protein C within their respective practices.

Managing anemia in the critically ill patient.

Anemia of critical illness is a multifactorial condition caused by phlebotomy, ongoing blood loss, and inadequate production of red blood cells. It occurs early in the course of critical illness. Although red blood cell transfusion is the treatment of choice for immediate management of anemia in the intensive care unit, controversy surrounds the most appropriate hemoglobin concentration or hematocrit "trigger." Therapeutic options, including blood-conservation tools, minimization of phlebotomy, erythropoietic agents, and investigational oxygen-carrying agents, may be alternatives to red blood cell transfusions in critically ill patients with anemia. Patient selection for erythropoietic agents will depend on further work dealing with outcomes and the total cost of care in managing the anemia of critical illness.