Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists.

OBJECTIVE: In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults. DESIGN: Narrative review/perspective. SETTING: Not applicable. PATIENTS: Not applicable. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU. CONCLUSIONS: This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise.

"Top Performing" US Hospitals and the Health Status of Counties they Serve.

This study (a) examined the relationships between "top performing" US hospitals and the health status of counties they serve and (b) compared the health status of "top performing" US hospital counties versus that of remaining US counties. Statistical analyses considered US News and World Report Honor Roll ranking data, as a measure of hospital performance, and County Health Rankings (CHR) data, as a measure of county health status. "Top performing" hospital Honor Roll scores were correlated with measures of Clinical Care (p < 0.001). Counties with "top performing" US hospitals presented greater health status with regard to All Health Outcomes (p < 0.001), Length of Life (p < 0.001), Quality of Life (p < 0.001), All Health Factors (p < 0.001), Health Behaviors (p < 0.001), and Clinical Care (p < 0.001), than compared to remaining US counties. Hospital impact on county health status remains primarily recognized in clinical care and not in overall health. Also, counties that contain a "top performing" US hospital tend to present lower health risks to their citizens than compared to other US counties.

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography.

OBJECTIVE: To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites. METHODS: Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and to determine the "strength" of recommendations as either strong (strength class 1) or conditional/weak (strength class 2), thus generating six "grades" of recommendations (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation was used for all questions with clinically relevant outcomes. RAND Appropriateness Method, incorporating the modified Delphi technique, was used in formulating recommendations related to terminology or definitions or in those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias. RESULTS: Forty-five statements were considered. Among these statements, six did not achieve agreement based on RAND appropriateness method rules (majority of at least 70%). Fifteen statements were approved as conditional recommendations (strength class 2). The rest (24 statements) were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence and the required level of echo expertise of the intensivist. Key recommendations, listed by category, included the use of cardiac ultrasonography to assess preload responsiveness in mechanically ventilated (1B) patients, left ventricular (LV) systolic (1C) and diastolic (2C) function, acute cor pulmonale (ACP) (1C), pulmonary hypertension (1B), symptomatic pulmonary embolism (PE) (1C), right ventricular (RV) infarct (1C), the efficacy of fluid resuscitation (1C) and inotropic therapy (2C), presence of RV dysfunction (2C) in septic shock, the reason for cardiac arrest to assist in cardiopulmonary resuscitation (1B-2C depending on rhythm), status in acute coronary syndromes (ACS) (1C), the presence of pericardial effusion (1C), cardiac tamponade (1B), valvular dysfunction (1C), endocarditis in native (2C) or mechanical valves (1B), great vessel disease and injury (2C), penetrating chest trauma (1C) and for use of contrast (1B-2C depending on indication). Finally, several recommendations were made regarding the use of bedside cardiac ultrasound in pediatric patients ranging from 1B for preload responsiveness to no recommendation for RV dysfunction. CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding several class 1 recommendations for the use of bedside cardiac ultrasound, echocardiography, in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients and guiding appropriate integration of ultrasound into critical care practice.

A probabilistic method for the estimation of residual risk in donated blood.

The residual risk (RR) of transfusion-transmitted infections, including the human immunodeficiency virus and hepatitis B and C viruses, is typically estimated by the incidence[Formula: see text]window period model, which relies on the following restrictive assumptions: Each screening test, with probability 1, (1) detects an infected unit outside of the test's window period; (2) fails to detect an infected unit within the window period; and (3) correctly identifies an infection-free unit. These assumptions need not hold in practice due to random or systemic errors and individual variations in the window period. We develop a probability model that accurately estimates the RR by relaxing these assumptions, and quantify their impact using a published cost-effectiveness study and also within an optimization model. These assumptions lead to inaccurate estimates in cost-effectiveness studies and to sub-optimal solutions in the optimization model. The testing solution generated by the optimization model translates into fewer expected infections without an increase in the testing cost.

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography.

OBJECTIVE: To establish evidence-based guidelines for the use of bedside ultrasound by intensivists and specialists in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities. METHODS: The Grading of Recommendations, Assessment, Development and Evaluation system was used to determine the strength of recommendations as either strong or conditional/weak and to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and thus generating six "grades" of recommendation (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for all questions with clinically relevant outcomes. RAND appropriateness method, incorporating modified Delphi technique, was used in steps of GRADE that required panel judgment and for those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias. The process was conducted independent of industry funding. RESULTS: Twenty-four statements regarding the use of ultrasound were considered-three did not achieve agreement and nine were approved as conditional recommendations (strength class 2). The remaining 12 statements were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence. Key strong recommendations included the use of ultrasonography for ruling-in pleural effusion and assisting its drainage, ascites drainage, ruling-in pneumothorax, central venous cannulation, particularly for internal jugular and femoral sites, and for diagnosis of deep venous thrombosis. Conditional recommendations were given to the use of ultrasound by the intensivist for diagnosis of acalculous cholecystitis, renal failure, and interstitial and parenchymal lung diseases. No recommendations were made regarding static (vs dynamic) ultrasound guidance of vascular access or the use of needle guide devices. CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding several recommendations for the use of ultrasound in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients.

Accountable care organizations: impact on pharmacy.

The Patient Protection and Affordable Care Act (PPACA) has considerably transformed the approaches being used to deliver health care in the United States. It was enacted to expand health insurance access, improve funding for health professions education, and reform patient care delivery. The traditional fee-for-service payment system has been criticized for overspending and providing substandard quality of care. The Accountable Care Organization (ACO) was developed as a payment reform mechanism to slow rising health care costs and improve quality. Under this concept, networks of clinicians and hospitals share responsibility for a population of patients and are held accountable for the financial and clinical outcomes. Due to high rates of medication misuse, nonadherence to therapeutic medication regimens, and preventable adverse drug events, pharmacists are in an ideal position to manage drug therapy and reduce health care expenditures; as such, they may be valuable assets to the ACO team. This article discusses the role of the pharmacist in the era of ACOs specifically and health care reform globally. It outlines pharmacy-related quality of care measures, medication therapy management (MTM) programs (which may provide the foundation for pharmacist involvement in ACOs), and pharmacist functions in patient-centered medical homes (through which ACO services may be organized). The article concludes with a description of successful ACO models that have incorporated pharmacists into their programs.

Comparison of Quality Measures From US Hospitals With Physician vs Nonphysician Chief Executive Officers.

Importance: Patient experience and patient safety are 2 major domains of health care quality; however empirical data on the association of physician vs nonphysician chief executive officers (CEOs) with public and private quality measures are rare but critical to evaluate as hospitals increasingly seek out physician CEOs. Objectives: To evaluate whether there is an association of CEO background with hospital quality and to investigate differences in hospital characteristics between hospitals with a physician CEO vs those with a nonphysician CEO. Design, Setting, and Participants: This cross-sectional study used 2019 data from 3 sources (ie, the American Hospital Association [AHA] Annual Survey, the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS], and the Leapfrog Hospital Safety Grades) to identify statistical differences in hospital characteristics and outcomes. Data were analyzed from April to December 2021 . Main Outcomes and Measures: Multivariable ordinal logistic regression was used to examine the association of physician CEOs with hospital quality assessment outcomes while controlling for other confounding factors. Characteristics from the AHA Annual Survey database were assessed as potential confounders, including hospital control, bed size, region, teaching status, and patient volume. Results: The AHA database contained 6162 hospitals; 1759 (29%) had HCAHPS ratings, 1824 (30%) had Leapfrog grades, and 383 (6%) had physician CEOs. A positive Spearman correlation coefficient was found between physician CEOs and HCAHPS patient willingness to recommend the hospital (ρ = 0.0756; P = .002), but the association between CEO medical background and Leapfrog safety grades or HCAHPS ratings did not reach a level of significance in the multivariable ordinal logistic regression models. Conclusions and Relevance: In this study, a positive correlation was found between physician CEOs and HCAHPS patient willingness to recommend the hospital, but the multivariable analysis did not find an association between hospital physician CEOs and the examined quality and safety outcomes.