Outcomes of prolonged mechanical ventilation and tracheostomy in critically ill elderly patients: a historical cohort study.

PURPOSE: With an aging global population, the increased proportion of elderly patients in the intensive care unit (ICU) raises important questions regarding optimal management. Currently, data on tracheostomy and its outcomes in the elderly are limited. We aimed to determine the in-hospital survival of elderly ICU patients following tracheostomy, and describe impacts on discharge disposition and functional outcomes. METHODS: We conducted a historical cohort study at two academic hospitals in Toronto. All patients aged ≥ 70 yr who received a tracheostomy during their ICU stay between January 2010 and June 2016 were included in a retrospective chart review. Data on patient demographics, frailty, tracheostomy indication, and outcomes were collected. RESULTS: The study included 270 patients with a mean (standard deviation) age of 81 (6) yr. The majority were admitted to ICU for respiratory failure (147/270, 54%) and received a tracheostomy for prolonged mechanical ventilation (202/270, 75%). Intensive care unit and hospital mortality were 26% (68/270) and 46% (125/270), respectively. Twenty-five percent (67/270) of patients were decannulated during hospital admission, a median [interquartile range (IQR)] of 41 [25-68] days after tracheostomy. Intensive care unit and hospital length of stay were 31 [17-53] and 81 [46-121] days, respectively. At hospital discharge, 6% (17/270) of patients were discharged home, all were frail (median Clinical Frailty Score of 7) and most were tube-fed (101/270, 70%), unable to speak (81/270, 56%), and nonambulatory (98/270, 68%). CONCLUSIONS: In patients aged ≥ 70 yr, tracheostomy during ICU stay marked a transition toward prolonged chronic critical illness. Nearly half of the patients died during the admission, and although a quarter were successfully decannulated, the majority of survivors were left with severe frailty and functional impairment.

RéSUMé: OBJECTIF: Avec le vieillissement de la population mondiale, la proportion accrue de patients âgés aux soins intensifs (USI) soulève d'importantes questions concernant leur prise en charge optimale. À l'heure actuelle, les données sur la trachéotomie et ses issues chez les personnes âgées sont limitées. Nous avions pour objectif de déterminer la survie hospitalière des patients âgés en soins intensifs après une trachéotomie et d'examiner les impacts sur la disposition au congé et les devenirs fonctionnels. MéTHODE: Nous avons mené une étude de cohorte historique dans deux hôpitaux universitaires de Toronto. Tous les patients âgés de ≥ 70 ans ayant reçu une trachéotomie pendant leur séjour à l'USI entre janvier 2010 et juin 2016 ont été inclus dans un examen rétrospectif des dossiers. Les données sur la démographie des patients, leur fragilité, l'indication pour la trachéotomie et les devenirs ont été recueillies. RéSULTATS: L'étude a inclus 270 patients avec un âge moyen (écart type) de 81 (6) ans. La majorité d'entre eux ont été admis à l'USI pour insuffisance respiratoire (147/270, 54 %) et ont subi une trachéotomie pour une ventilation mécanique prolongée (202/270, 75 %). La mortalité à l'USI et à l'hôpital était de 26 % (68/270) et 46 % (125/270), respectivement. Vingt-cinq pour cent (67/270) des patients ont été décanulés pendant leur admission à l'hôpital, [écart interquartile (ÉIQ)] 41 [25-68] jours après la trachéotomie en moyenne. La durée du séjour à l'USI et à l'hôpital était de 31 [17-53] et 81 [46-121] jours, respectivement. Lors du congé de l'hôpital, 6 % (17/270) des patients sont rentrés chez eux, tous étaient fragiles (score médian de fragilité clinique de 7) et la plupart étaient nourris par sonde (101/270, 70 %), incapables de parler (81/270, 56 %) et non ambulatoires (98/270, 68 %). CONCLUSIONS: Chez les patients âgés de ≥ 70 ans, la trachéotomie pendant le séjour aux soins intensifs a marqué une transition vers une maladie chronique grave prolongée. Près de la moitié des patients sont décédés pendant leur séjour, et bien qu'un quart aient été décanulés avec succès, la majorité des survivants se sont retrouvés avec une fragilité sévère et une déficience fonctionnelle.

Critical care providers' support of families in bereavement: a mixed-methods study.

PURPOSE: When people die in intensive care units (ICUs), as many as half of their family members may experience a severe grief reaction. While families report a need for bereavement support, most ICUs do not routinely follow-up with family members. Clinicians are typically involved in supporting families during death and dying, yet little is known about how they work with families in bereavement. Our goal was to explore how clinicians support bereaved families, identify factors that facilitate and hinder support, and understand their interest and needs for follow-up. METHODS: Mixed-methods study of nurses and physicians working in one of nine adult medical-surgical ICUs in academic hospitals across Canada. Qualitative interviews followed quantitative surveys to reflect, expand, and explain the quantitative results. RESULTS: Both physicians and nurses perceived that they provided empathetic support to bereaved families. Emotional engagement was a crucial element of support, but clinicians were not always able to engage with families because of their roles, responsibilities, experiences, or unit resources. Another important factor that could facilitate or challenge engagement was the degree to which families accepted death. Clinicians were interested in participating in a follow-up bereavement program, but their participation was contingent on time, training, and the ability to manage their own emotions related to death and bereavement in the ICU. CONCLUSIONS: Multiple opportunities were identified to enhance current bereavement support for families, including the desire of ICU clinicians for formal follow-up programs. Many psychological, sociocultural, and structural factors would need to be considered in program design.

RéSUMé: OBJECTIF: Lorsque des personnes décèdent dans une unité de soins intensifs (USI), jusqu'à la moitié des membres de leur famille pourraient souffrir d'une réaction émotionnelle grave. Bien que les familles rapportent le besoin d'un soutien en cas de deuil, la plupart des USI ne font pas un suivi de routine avec les membres de la famille. Les cliniciens sont traditionnellement impliqués dans le soutien aux familles pendant la mort et le décès, mais nous ne connaissons que peu de choses concernant leur travail avec les familles en deuil. Notre objectif était d'explorer la façon dont les cliniciens viennent en soutien aux familles en deuil, d'identifier les facteurs qui facilitent ou entravent le soutien, et de comprendre leur intérêt et leurs besoins en matière de suivi. MéTHODE: Nous avons réalisé une étude par méthodes mixtes auprès du personnel infirmier et des médecins travaillant dans l'une de neuf USI médico-chirurgicales pour adultes dans des hôpitaux universitaires du Canada. Des entretiens qualitatifs suivaient des sondages quantitatifs afin de refléter, approfondir et expliquer les résultats quantitatifs. RéSULTATS: Selon leur perception, les médecins et le personnel infirmier fournissent un soutien empathique aux familles en deuil. L'implication émotionnelle a été identifiée comme étant un élément crucial du soutien, mais les cliniciens ne sont pas toujours capables de s'impliquer auprès des familles en raison de leurs rôles, de leurs responsabilités, de leurs expériences ou des ressources de l'unité. Un autre facteur important qui pourrait faciliter ou au contraire entraver leur implication est la mesure dans laquelle les familles acceptent la mort. Les cliniciens seraient intéressés à participer à un programme de suivi de deuil, mais leur participation dépend de leur temps, de leur formation et de leur capacité à gérer leurs propres émotions liées à la mort et au deuil à l'USI. CONCLUSION: De nombreuses cibles ont été identifiées pour améliorer le soutien actuel aux familles en deuil, y compris le désir des cliniciens de l'USI de disposer de programmes formels de suivi. Il faudra toutefois tenir compte de nombreux facteurs psychologiques, socioculturels et structurels dans la conception de tels programmes.

A qualitative study of bereaved family members with complicated grief following a death in the intensive care unit.

PURPOSE: Grief is a normal reaction, and most family members (FMs) experience grief following a death. Typically, grief subsides without any major psychological or medical impairment. Nevertheless, some FMs may experience complicated grief (CG) reactions, with symptoms lasting months or years, and CG is particularly prominent among FMs of those who die in the intensive care unit (ICU). The purpose of this study was to examine how FMs experience grief, particularly CG, to inform future early screening and support programs in the ICU. METHODS: This was a multicentre qualitative study focusing on semi-structured interviews with FMs who displayed symptoms of CG. Family members of patients who died in the ICU and who had a six-month inventory of CG score > 25 were included. Semi-structured interviews were conducted with FMs post-loss, with follow-up interviews three months after the initial interviews. RESULTS: Major themes identified following thematic analysis from eight participants with CG included 1) ante-mortem experience: the impact of the ICU experience prior to death of a loved on subsequent grief; 2) post-mortem experience: unpredictable post death reactions; 3) coping strategies: techniques used to reduce the severity of grief reactions; 4) sources of support: focusing on resources that the FM draws from for emotional support; and 5) perspectives on future ICU bereavement screening and support programs: advice that FM participants provided for future bereavement support. CONCLUSION: Bereaved FMs with CG described their experiences with grief, how ICU events influenced their bereavement, their coping strategies and sources of support, and their advice for future bereavement support programs for FMs of deceased ICU patients.

RéSUMé: OBJECTIF: Le deuil est une réaction normale et la plupart des membres d'une famille l'éprouvent après un décès. Habituellement, le deuil décroit sans laisser de troubles psychologiques ou médicaux majeurs. Néanmoins, certains membres d'une famille peuvent présenter des réactions de deuil compliquées, avec des symptômes durant des mois ou des années et ce deuil compliqué est particulièrement visible lorsqu'un membre de la famille est décédé dans une unité de soins intensifs (USI). Cette étude avait pour objectif d'examiner comment les membres d'une famille vivent un deuil, en particulier un deuil compliqué, pour renseigner de futurs programmes de dépistage précoce et de soutien en USI. MéTHODES: Il s'est agi d'une étude qualitative multicentrique utilisant principalement des entretiens semi-structurés avec des membres de familles qui présentaient des symptômes de deuil compliqué. Des membres de la famille de patients décédés en USI qui dans les derniers 6 mois avaient un score > 25 au questionnaire de deuil compliqué ont été inclus. Les entretiens semi-structurés ont été menés après le décès avec des membres de la famille et des entretiens de suivi ont eu lieu trois mois après l'entretien initial. RéSULTATS: Les principaux thèmes identifiés après une analyse thématique de huit participants ayant un deuil compliqué ont inclus : 1) le vécu avant le décès : l'impact de l'expérience de l'USI avant le décès d'un être cher sur le deuil qui a suivi; 2) le vécu après le décès : les réactions imprévisibles après le décès; 3) les stratégies de réponse face au stress : Les techniques utilisées pour réduire les réactions de deuil; 4) les sources de soutien : en se concentrant sur les ressources que le membre de la famille utilise pour un soutien émotionnel; et 5) le point de vue sur de futurs programmes de dépistage et de soutien en USI : les conseils que les membres participants des familles ont donnés pour un futur soutien du deuil. CONCLUSION: Les membres de familles endeuillées présentant un deuil compliqué ont décrit leur vécu du deuil, comment les événements vécus en USI l'ont influencé, leurs stratégies de réponse et la source des soutiens utilisés, ainsi que leurs conseils pour de futurs programmes de soutien du deuil destinés aux familles de patients décédés en USI.

One-Year Outcomes in Caregivers of Critically Ill Patients.

BACKGROUND: Few resources are available to support caregivers of patients who have survived critical illness; consequently, the caregivers' own health may suffer. We studied caregiver and patient characteristics to determine which characteristics were associated with caregivers' health outcomes during the first year after patient discharge from an intensive care unit (ICU). METHODS: We prospectively enrolled 280 caregivers of patients who had received 7 or more days of mechanical ventilation in an ICU. Using hospital data and self-administered questionnaires, we collected information on caregiver and patient characteristics, including caregiver depressive symptoms, psychological well-being, health-related quality of life, sense of control over life, and effect of providing care on other activities. Assessments occurred 7 days and 3, 6, and 12 months after ICU discharge. RESULTS: The caregivers' mean age was 53 years, 70% were women, and 61% were caring for a spouse. A large percentage of caregivers (67% initially and 43% at 1 year) reported high levels of depressive symptoms. Depressive symptoms decreased at least partially with time in 84% of the caregivers but did not in 16%. Variables that were significantly associated with worse mental health outcomes in caregivers were younger age, greater effect of patient care on other activities, less social support, less sense of control over life, and less personal growth. No patient variables were consistently associated with caregiver outcomes over time. CONCLUSIONS: In this study, most caregivers of critically ill patients reported high levels of depressive symptoms, which commonly persisted up to 1 year and did not decrease in some caregivers. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00896220.).

Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults.

OBJECTIVE: To provide a management approach for adults with calcium channel blocker poisoning. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits. DATA SYNTHESIS: We recommend 1) for asymptomatic patients, observation and consideration of decontamination following a potentially toxic calcium channel blocker ingestion (1D); 2) as first-line therapies (prioritized based on desired effect), IV calcium (1D), high-dose insulin therapy (1D-2D), and norepinephrine and/or epinephrine (1D). We also suggest dobutamine or epinephrine in the presence of cardiogenic shock (2D) and atropine in the presence of symptomatic bradycardia or conduction disturbance (2D); 3) in patients refractory to the first-line treatments, we suggest incremental doses of high-dose insulin therapy if myocardial dysfunction is present (2D), IV lipid-emulsion therapy (2D), and using a pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block without significant alteration in cardiac inotropism (2D); 4) in patients with refractory shock or who are periarrest, we recommend incremental doses of high-dose insulin (1D) and IV lipid-emulsion therapy (1D) if not already tried. We suggest venoarterial extracorporeal membrane oxygenation, if available, when refractory shock has a significant cardiogenic component (2D), and using pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block in the absence of myocardial dysfunction (2D) if not already tried; 5) in patients with cardiac arrest, we recommend IV calcium in addition to the standard advanced cardiac life-support (1D), lipid-emulsion therapy (1D), and we suggest venoarterial extracorporeal membrane oxygenation if available (2D). CONCLUSION: We offer recommendations for the stepwise management of calcium channel blocker toxicity. For all interventions, the level of evidence was very low.

Validation of quality indicators for end-of-life communication: results of a multicentre survey.

BACKGROUND: The lack of validated quality indicators is a major barrier to improving end-of-life communication and decision-making. We sought to show the feasibility of and provide initial validation for a set of quality indicators related to end-of-life communication and decision-making. METHODS: We administered a questionnaire to patients and their family members in 12 hospitals and asked them about advance care planning and goals-of-care discussions. Responses were used to calculate a quality indicator score. To validate this score, we determined its correlation with the concordance between the patients' expressed wishes and the medical order for life-sustaining treatments recorded in the hospital chart. We compared the correlation with concordance for the advance care planning component score with that for the goal-of-care discussion scores. RESULTS: We enrolled 297 patients and 209 family members. At all sites, both overall quality indicators and individual domain scores were low and there was wide variability around the point estimates. The highest-ranking institution had an overall quality indicator score (95% confidence interval) of 40% (36%-44%) and the lowest had a score of 18% (11%-25%). There was a strong correlation between the overall quality indicator score and the concordance measure (r = 0.72, p = 0.008); the estimated correlation between the advance care planning score and the concordance measure (r = 0.35) was weaker than that between the goal-of-care discussion scores and the concordance measure (r = 0.53). INTERPRETATION: Quality of end-of-life communication and decision-making appears low overall, with considerable variability across hospitals. The proposed quality indicator measure shows feasibility and partial validity. Study registration: ClinicalTrials.gov, no. NCT01362855.

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation.

RATIONALE: Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design. OBJECTIVES: To stratify patients for post-ICU disability and recovery to 1 year after critical illness. METHODS: We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling. MEASUREMENTS AND MAIN RESULTS: The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year. CONCLUSIONS: ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families.

BACKGROUND: The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families. METHODS: We used a cross-sectional study design involving patients from 9 Canadian hospitals. We asked older adult patients with serious illness and their family members about the occurrence and importance of 11 guideline-recommended elements of goals-of-care discussions. In addition, we assessed concordance between prescribed goals of care and patient preferences, and we measured patient satisfaction with goals-of-care discussions using the Canadian Health Care Evaluation Project (CANHELP) questionnaire. RESULTS: Our study participants included 233 patients (mean age 81.2 yr) and 205 family members (mean age 60.2 yr). Participants reported that clinical teams had addressed individual elements of goals-of-care discussions infrequently (range 1.4%-31.7%). Patients and family members identified the same 5 elements as being the most important to address: preferences for care in the event of life-threatening illness, values, prognosis, fears or concerns, and questions about goals of care. Addressing more elements was associated with both greater concordance between patients' preferences and prescribed goals of care, and greater patient satisfaction. INTERPRETATION: We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting.

Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit.

INTRODUCTION: Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk. METHODS: We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. RESULTS: We enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23). CONCLUSIONS: Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.

Impact of acute stress on resident performance during simulated resuscitation episodes: a prospective randomized cross-over study.

BACKGROUND: Medical trainees have identified stress as an important contributor to their medical errors in acute care environments. PURPOSES: The objective of this study was to determine if the addition of acute stressors to simulated resuscitation scenarios would impact on residents' simulated clinical performance. METHODS: Fifty-four residents completed a control and a high-stress simulated scenario on separate visits. Stress measures were collected before and after scenarios. Two assessors independently evaluated residents' videotaped performance. RESULTS: Both control and high-stress scenarios triggered significant stress responses among participants; however, stress responses were not significantly different between control and high-stress conditions. No difference in performance was found between control and high-stress conditions (F value = 2.84, p = .098). CONCLUSIONS: Residents exposed to simulated resuscitation scenarios experienced significant stress responses irrespective of the presence of acute stressors during these scenarios. This anticipatory stressful response could impact on resident learning and performance and should be further explored.

Scarcity: the context of rationing in an Ontario ICU.

OBJECTIVES: Clinicians' perceptions of scarcity influence rationing of critical care resources, which may lead to serious adverse outcomes for patients who are denied access. We sought to better understand the phenomenon of scarcity in the critical care setting. DESIGN: Qualitative research methods. We used purposeful sampling to recruit ICU clinicians who were frequently involved in decisions to allocate ICU resources. Thematic analysis was performed to identify concepts related to the phenomenon of scarcity. SETTING: An ICU of a university-affiliated hospital in Toronto, Canada, between October and December 2007. SUBJECTS: We conducted 22 interviews with 12 ICU physicians, 4 ICU fellows, 2 ICU nursing team leaders, and 4 ICU resource nurses. MAIN RESULTS: The perception of scarcity arose from a complex interaction of factors within the institution including: 1) practices of non-ICU physicians (e.g., failure to specify end-of-life treatment plans or to secure an ICU bed prior to elective high-risk surgery), 2) family demands for life support and clinicians' perception of a lack of legal support if they opposed these, and 3) inability to transfer patients to non-ICU care settings in a timely manner. Implications of scarcity included: 1) diversions of critically ill patients, 2) premature patient transfers, 3) temporary delivery of critical care in non-ICU locations (e.g., emergency department, postanesthesia care unit), and 4) interprofessional conflicts. CONCLUSIONS: ICU clinicians' perceptions of scarcity may lead to rationing of critical care resources. We found that nonmedical factors strongly influenced prioritization activity, both for admission and discharge. Although scarcity of ICU beds might be mitigated by process improvements such as patient flow or proactive communication, our findings highlight the importance of a fair process for inevitable limit setting at the bedside.

Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study.

OBJECTIVE: Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates. DESIGN: Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009. SETTING: Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs. PATIENTS: At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months). INTERVENTION: Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p < .001), as did aggregate concordance (mean [SD]): 50.7% (6.1), 54.4% (7.1), 56.2% (5.9), 58.7% (6.7) (p = .007). Over the study period, ventilator-associated pneumonia rates decreased (events/330 patients): 47 (14.2%), 34 (10.3%), 38 (11.5%), 29 (8.8%) (p = .03). CONCLUSIONS: A 2-yr multifaceted intervention to enhance ventilator-associated pneumonia guideline uptake was associated with a significant increase in guideline concordance and a reduction in ventilator-associated pneumonia rates.

Knowledge translation interventions for critically ill patients: a systematic review*.

OBJECTIVE: We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. DATA SOURCES: We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. STUDY SELECTION: Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. DATA EXTRACTION: Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. DATA SYNTHESIS: From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. CONCLUSIONS: Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Safety and efficacy of noninvasive ventilation in patients with blunt chest trauma: a systematic review.

INTRODUCTION: This systematic review looks at the use of noninvasive ventilation (NIV), inclusive of noninvasive positive pressure ventilation (NPPV) and continuous positive pressure ventilation (CPAP), in patients with chest trauma to determine its safety and clinical efficacy in patients with blunt chest trauma who are at high risk of acute lung injury (ALI) and respiratory failure. METHODS: We searched the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Pairs of reviewers abstracted relevant clinical data and assessed the methodological quality of randomized controlled trials (RCTs) using the Cochrane domain and observational studies using the Newcastle-Ottawa Scale. RESULTS: Nine studies were included (three RCTs, two retrospective cohort studies and four observational studies without a comparison group). There was significant heterogeneity among the included studies regarding the severity of injuries, degree of hypoxemia and timing of enrollment. One RCT of moderate quality assessed the use of NPPV early in the disease process before the development of respiratory distress. All others evaluated the use of NPPV and CPAP in patients with blunt chest trauma after the development of respiratory distress. Overall, up to 18% of patients enrolled in the NIV group needed intubation. The duration of NIV use was highly variable, but NIV use itself was not associated with significant morbidity or mortality. Four low-quality observational studies compared NIV to invasive mechanical ventilation in patients with respiratory distress and showed decreased ICU stay (5.3 to 16 days vs 9.5 to 15 days), complications (0% to 18% vs 38% to 49%) and mortality (0% to 9% vs 6% to 50%) in the NIV group. CONCLUSIONS: Early use of NIV in appropriately identified patients with chest trauma and without respiratory distress may prevent intubation and decrease complications and ICU length of stay. Use of NIV to prevent intubation in patients with chest trauma who have ALI associated with respiratory distress remains controversial because of the lack of good-quality data.

Exploring spiritual health practitioners' roles and activities in critical care contexts.

Family members of patients admitted to the intensive care unit (ICU) experience multidimensional distress. Many clinicians lack an understanding of spiritual health practitioners' role and approaches to providing spiritual support. Through semi-structured interviews and focus groups with 10 spiritual health practitioners, we explored how spiritual health practitioners support families of patients in the ICU to better understand their scope of practice and role within an interdisciplinary critical care team. Spiritual health practitioners' work was described through clinical roles (family support, clinician support, bridging family members and clinicians), activities (companioning, counseling, facilitating difficult conversations, addressing individual needs), tensions (within and between roles and activities, navigating between hope and anticipated clinical trajectory, balancing supportive care and workload) and foundational principles (holistic perspective, resilience). A more comprehensive understanding of these roles and skills may enable clinicians to better integrate spiritual health practitioners into the fabric of care for patients, families, and clinicians themselves.

An official American Thoracic Society policy statement: pay-for-performance in pulmonary, critical care, and sleep medicine.

RATIONALE: Pay-for-performance is a model for health care financing that seeks to link reimbursement to quality. The American Thoracic Society and its members have a significant stake in the development of pay-for-performance programs. OBJECTIVES: To develop an official ATS policy statement addressing the role of pay-for-performance in pulmonary, critical care and sleep medicine. METHODS: The statement was developed by the ATS Health Policy Committee using an iterative consensus process including an expert workshop and review by ATS committees and assemblies. MEASUREMENTS AND MAIN RESULTS: Pay-for-performance is increasingly utilized by health care purchasers including the United States government. Published studies generally show that programs result in small but measurable gains in quality, although the data are heterogeneous. Pay-for-performance may result in several negative consequences, including the potential to increase costs, worsen health outcomes, and widen health disparities, among others. Future research should be directed at developing reliable and valid performance measures, increasing the efficacy of pay-for-performance programs, minimizing negative unintended consequences, and examining issues of costs and cost-effectiveness. The ATS and its members can play a key role in the design and evaluation of these programs by advancing the science of performance measurement, regularly developing quality metrics alongside clinical practice guidelines, and working with payors to make performance improvement a routine part of clinical practice. CONCLUSIONS: Pay-for-performance programs will expand in the coming years. Pulmonary, critical care and sleep practitioners can use these programs as an opportunity to partner with purchasers to improve health care quality.

Vicarious spiritual distress in intensive care unit healthcare providers: A qualitative study.

OBJECTIVES: To explore the impact of caring for family members experiencing spiritual distress on Intensive Care Unit healthcare providers. DESIGN: A qualitative study involving interviews and focus groups between May 2016 and April 2017. PARTICIPANTS: Intensive care healthcare providers from nine teaching and three non-teaching units across Alberta, Canada. MEASUREMENTS: Transcribed data were analysed using interpretive description. FINDINGS: Forty-two participants variably described experiences of vicarious spiritual distress, along with coping strategies and outcomes related to these experiences. Vicarious spiritual distress was experienced as sorrow/distress, helplessness and preoccupation/rumination. Coping strategies were both adaptive (self-awareness/reflection, reframing/resiliency, team support/debriefing, self-care, accepting limitations) and maladaptive (compartmentalising/distancing, substance use). Lastly, the emotional burden of these experiences resulted in both favourable (satisfaction, appreciation) and unfavourable (moral distress, burnout, hopelessness) outcomes. CONCLUSION: Our findings describe the novel concept of vicarious spiritual distress as experienced by intensive care healthcare providers and highlight the importance of identifying effective ways to support these professionals throughout their careers to prevent unfavorable outcomes and the perpetuation of maladaptive coping strategies. The adaptive coping strategies described in this study may help inform wellness initiatives and resiliency training tailored to intensive care healthcare providers.

Spiritual Distress in Family Members of Critically Ill Patients: Perceptions and Experiences.

Background: Spiritual distress among family members of patients in the intensive care unit (ICU) has not been well characterized. This limits clinicians' understanding of how to best offer support. Objective: To explore how family members experience spiritual distress, and how it is recognized and support offered within the ICU context. Design: A qualitative study involving interviews and focus groups between May 2016 and April 2017. Setting/Subjects: Family members of ICU patients (n = 18), spiritual health practitioners (n = 10), and an interprofessional group of clinicians who work in the ICU (n = 32). Measurements: Transcribed data were analyzed using interpretive description. Results: The experience of spiritual distress was variably described by all three groups through concepts, modulators, expressions and manifestations, and ways in which spiritual distress was addressed. Concepts included loss of meaning, purpose and connection, tension in beliefs, and interconnected distress. Modulators were related to the patient and family context, the ICU context, and the relational context. Expressions and manifestations were unique and individual, involving verbal expressions of thoughts and emotions, as well as behavioral manifestations of coping. Clinical strategies for addressing spiritual distress were described through general principles, specific strategies for discussing spiritual distress, and ways in which spiritual support can be offered. Conclusions: Our study provides a rich description of how spiritual distress is experienced by family members of ICU patients, and how spiritual health practitioners and clinicians recognize spiritual distress and offer support. These findings will help inform clinician education and initiatives to better support families of critically ill patients.

Development of a Clinical Guide for Identifying Spiritual Distress in Family Members of Patients in the Intensive Care Unit.

Background: Spirituality is important for many family members of patients in the intensive care unit (ICU). Clinicians without training in spiritual care experience difficulty identifying when family members are experiencing distress of a spiritual nature. Objective: The purpose of this study was to develop a guide to help clinicians working in the ICU identify family members who may benefit from specialized spiritual support. Design: Cross-sectional study. Setting/Subjects: A national sample of spiritual health practitioners, family members, and ICU clinicians. Subjects: A panel of 21 spiritual health practitioners participated in a modified Delphi process to achieve consensus on items that suggest spiritual distress among family members of patients in the ICU through three rounds of remote review followed by an in-person conference and a final round of panelist feedback. Feedback on the final set of items was obtained from an end-user group of four family members and six ICU clinicians. Measurements: Quantitative data were summarized with descriptive statistics. Content analysis was used to analyze written comments. Results: A total of 220 items were iteratively reviewed and rated by panelists. Forty-six items were identified as essential for inclusion and developed into a clinical guide, including an introduction (n = 1), definitions (n = 2), risk factors (n = 10), expressed concerns (n = 12), emotions (n = 7) and behaviors (n = 7) that may suggest spiritual distress, questions to identify spiritual needs (n = 6), and introducing spiritual support (n = 1). Conclusions: We have developed an evidence-informed clinical guide that may help clinicians in the ICU identify family members experiencing spiritual distress.

WITHDRAWN: Vicarious spiritual distress in intensive care unit healthcare providers: A qualitative study.

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