Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience.

Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiatives, led mostly by Europe and Oceania, have tried to mitigate ICUs' notable environmental impact with varying success. However, there exists a significant gap in the U.S. knowledge and published literature related to sustainability in the ICU. After a narrative review of the literature and related industry standards, we share our experience with a Green ICU initiative at a large hospital system in Texas. Our process has led to a 3-step pathway to inform similar initiatives for sustainable (green) critical care. This pathway involves (1) establishing a baseline by quantifying the status quo carbon footprint of the affected ICU as well as the cumulative footprint of all the ICUs in the healthcare system; (2) forming alliances and partnerships to target each major source of these pollutants and implement specific intervention programs that reduce the ICU-related greenhouse gas emissions and solid waste; and (3) finally to implement a systemwide Green ICU which requires the creation of multiple parallel pathways that marshal the resources at the grass-roots level to engage the ICU staff and institutionalize a mindset that recognizes and respects the impact of ICU functions on our environment. It is expected that such a systems-based multi-stakeholder approach would pave the way for improved sustainability in critical care.

Atherosclerotic Cardiovascular Disease, Cancer, and Financial Toxicity Among Adults in the United States.

BACKGROUND: Financial toxicity (FT) is a well-established side-effect of the high costs associated with cancer care. In recent years, studies have suggested that a significant proportion of those with atherosclerotic cardiovascular disease (ASCVD) experience FT and its consequences. OBJECTIVES: This study aimed to compare FT for individuals with neither ASCVD nor cancer, ASCVD only, cancer only, and both ASCVD and cancer. METHODS: From the National Health Interview Survey, we identified adults with self-reported ASCVD and/or cancer between 2013 and 2018, stratifying results by nonelderly (age <65 years) and elderly (age ≥65 years). We defined FT if any of the following were present: any difficulty paying medical bills, high financial distress, cost-related medication nonadherence, food insecurity, and/or foregone/delayed care due to cost. RESULTS: The prevalence of FT was higher among those with ASCVD when compared with cancer (54% vs. 41%; p < 0.001). When studying the individual components of FT, in adjusted analyses, those with ASCVD had higher odds of any difficulty paying medical bills (odds ratio [OR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.36), inability to pay bills (OR: 1.25; 95% CI: 1.04 to 1.50), cost-related medication nonadherence (OR: 1.28; 95% CI: 1.08 to 1.51), food insecurity (OR: 1.39; 95% CI: 1.17 to 1.64), and foregone/delayed care due to cost (OR: 1.17; 95% CI: 1.01 to 1.36). The presence of ≥3 of these factors was significantly higher among those with ASCVD and those with both ASCVD and cancer when compared with those with cancer (23% vs. 30% vs. 13%, respectively; p < 0.001). These results remained similar in the elderly population. CONCLUSIONS: Our study highlights that FT is greater among patients with ASCVD compared with those with cancer, with the highest burden among those with both conditions.

Ethical Considerations When Using a Mobile Eye Tracker in a Patient-Facing Area: Lessons from an Intensive Care Unit Observational Protocol.

This article describes the process of designing, approving, and conducting an investigator-initiated protocol to use an eye-tracking device in a health care setting. Participants wore the device, which resembles eyeglasses, in a front-facing manner in an intensive care unit for the study of personnel gaze patterns, producing a visual record of workflow. While the data of interest for our study was not specifically the health information protected by the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA), a wide variety of such data was captured by the eye-tracking device, and the prospective consent of all people who might have been incidentally videotaped was not feasible. The protocol therefore required attention to unique ethical considerations-including consent, privacy and confidentiality, HIPAA compliance, institutional liability, and the use of secondary data. The richness of eye-tracker data suggests various beneficial applications in health care occupational research and quality improvement. Therefore, sharing our study's successful design and execution, including proactive researcher-institutional review board communication, can inform and encourage similarly valuable, ethical, and innovative audiovisual research techniques.

Adapting an Outpatient Psychiatric Clinic to Telehealth During the COVID-19 Pandemic: A Practice Perspective.

As the demand for telepsychiatry increases during the COVID-19 pandemic, the strengths and challenges of telepsychiatry implementation must be articulated to improve clinical practices in the long term. Currently, observations within US contexts are lacking; therefore, we report on the rapid implementation of telepsychiatry and workflow experiences in a psychiatric practice based within a large health care system in southeast Texas with a national catchment area. We discuss the logistics of the implementation, including modes of communication, scheduling, coordination, and capacity; the psychological effects of web-based services, including both the loss of the physical therapeutic environment and the unique interpersonal dynamics experienced in the virtual environment; and postadoption patterns of engagement with our services and with other clinical functions affected by the rapid adaptation to telemedicine. Our art therapy group programming serves as an applied case study, demonstrating the value of a well-managed web-based program (eg, patients were receptive and well-engaged, and they appreciated the continuity of accessible service) as well as the challenges (eg, the need for backup plans and technological fallbacks, managing interruptions and telecommunication learning curves, and working around the difference in resources for art and music therapy between a well-stocked clinical setting versus clients' home spaces). We conclude from our experience that the overall strengths of telepsychiatry include receptive and well-engaged responses from patients as well as the expansion of boundaries, which provides a directly contextualized view into patients' home lives. Challenges and corresponding recommendations include the need for more careful safety planning for high-risk patients; maintaining professional boundaries in the newly informal virtual setting; designing the physical space to both frame the patient encounter and maintain work-life balance for the therapist; allowing for delays and interruptions (including an initial acclimation session); and preserving interprofessional care team collaboration when the physical locations that normally facilitate such encounters are not accessible. We believe that careful observations of the strengths and challenges of telepsychiatry during this pandemic will better inform practices that are considering telepsychiatry adoption both within pandemic contexts and more broadly thereafter.

Disaster Ergonomics: Human Factors in COVID-19 Pandemic Emergency Management.

OBJECTIVE: We aimed to identify opportunities for application of human factors knowledge base to mitigate disaster management (DM) challenges associated with the unique characteristics of the COVID-19 pandemic. BACKGROUND: The role of DM is to minimize and prevent further spread of the contagion over an extended period of time. This requires addressing large-scale logistics, coordination, and specialized training needs. However, DM-related challenges during the pandemic response and recovery are significantly different than with other kinds of disasters. METHOD: An expert review was conducted to document issues relevant to human factors and ergonomics (HFE) in DM. RESULTS: The response to the COVID-19 crisis has presented complex and unique challenges to DM and public health practitioners. Compared to other disasters and previous pandemics, the COVID-19 outbreak has had an unprecedented scale, magnitude, and propagation rate. The high technical complexity of response and DM coupled with lack of mental model and expertise to respond to such a unique disaster has seriously challenged the response work systems. Recent research has investigated the role of HFE in modeling DM systems' characteristics to improve resilience, accelerating emergency management expertise, developing agile training methods to facilitate dynamically changing response, improving communication and coordination among system elements, mitigating occupational hazards including guidelines for the design of personal protective equipment, and improving procedures to enhance efficiency and effectiveness of response efforts. CONCLUSION: This short review highlights the potential for the field's contribution to proactive and resilient DM for the ongoing and future pandemics.

Correction to: The past, present and future of opioid withdrawal assessment: a scoping review of scales and technologies.

Following publication of the original article [1], the authors reported an error in one of the authors' names. In this Correction the incorrect and correct author name are shown. The original publication of this article has been corrected.

The past, present and future of opioid withdrawal assessment: a scoping review of scales and technologies.

BACKGROUND: A common challenge with all opioid use disorder treatment paths is withdrawal management. When withdrawal symptoms are not effectively monitored and managed, they lead to relapse which often leads to deadly overdose. A prerequisite for effective opioid withdrawal management is early identification and assessment of withdrawal symptoms. OBJECTIVE: The objective of this research was to describe the type and content of opioid withdrawal monitoring methods, including surveys, scales and technology, to identify gaps in research and practice that could inform the design and development of novel withdrawal management technologies. METHODS: A scoping review of literature was conducted. PubMed, EMBASE and Google Scholar were searched using a combination of search terms. RESULTS: Withdrawal scales are the main method of assessing and quantifying opioid withdrawal intensity. The search yielded 18 different opioid withdrawal scales used within the last 80 years. While traditional opioid withdrawal scales for patient monitoring are commonly used, most scales rely heavily on patients' self-report and frequent observations, and generally suffer from lack of consensus on the criteria used for evaluation, mode of administration, type of reporting (e.g., scales used), frequency of administration, and assessment window. CONCLUSIONS: It is timely to investigate how opioid withdrawal scales can be complemented or replaced with reliable monitoring technologies. Use of noninvasive wearable sensors to continuously monitor physiologic changes associated with opioid withdrawal represents a potential to extend monitoring outside clinical setting.