Patients Undergoing Elective Inpatient Major Therapeutic Procedures in Florida Had No Significant Change in Hospital Mortality or Mortality-Related Comorbidities Between 2007 and 2019.

BACKGROUND: In a recent study, rapid response team implementation at 1 hospital was associated with only a 0.1% reduction in inpatient mortality from 2005 to 2018, characterized in the accompanying editorial as a "tepid" improvement. The editorialist postulated that an increase in the degree of illness of hospitalized patients might have masked a larger reduction that otherwise might have occurred. Impressions of greater patient acuity during the studied period might have been an artifact of efforts to document more comorbidities and complications, possibly facilitated by the change in diagnosis coding from the International Classification of Diseases , Ninth Revision ( ICD-9 ) to the Tenth Revision ( ICD-10 ). METHODS: We used inpatient data from every nonfederal hospital in Florida from the last quarter of 2007 through 2019. We studied hospitalizations for major therapeutic surgical procedures with lengths of stay ≥2 days. Using logistic regression with clustering by the Clinical Classification Software (CCS) code of the primary surgical procedure, we evaluated the trends for decreased mortality, changes in the prevalence of Medicare Severity Diagnosis Related Groups (MS-DRG) with complications or comorbidities (CC) or major complications or major comorbidities (MCC), and changes in the van Walraven index (vWI), a measure of patient comorbidities associated with increased inpatient mortality. Also incorporated in the modeling was the change from ICD-9 to ICD-10 . RESULTS: There were 3,151,107 hospitalizations comprising 130 distinct CCS codes and 453 MS-DRG groups among 213 hospitals. Despite a progressive increase of 4.1% per year in the odds of a CC or MCC ( P = .001), there were no significant changes in the marginal estimates of in-house mortality over time (net estimated decrease, 0.036%; 99% confidence interval [CI], -0.168% to 0.097%; P = .49). There was also absence of a significantly greater fraction of discharges with vWI >0 attributable to the year of the study (odds ratio, 1.017 per year; 99% CI, 0.995-1.041). The changes in MS-DRG to those with CC or MCC were not increased significantly from either the ICD-10 coding change or the number of years after the change. CONCLUSIONS: Consistent with the previous study, there was at most a small decrease in the mortality rate over a 12-year period. We found no reliable evidence that patients undergoing elective inpatient surgical procedures were any sicker in 2019 than in 2007. There were substantively more comorbidities and complications documented over time, but this was unrelated to the change to ICD-10 coding.

More surgery in December among US patients with commercial insurance is offset by unrelated but lesser surgery among patients with Medicare insurance.

STUDY OBJECTIVE: Evaluate whether there is more surgery (in the US State of Florida) at the end of the year, specifically among patients with commercial insurance. DESIGN: Observational cohort study. SETTING: The 712 facilities in Florida that performed inpatient or outpatient elective surgery from January 2010 through December 2019. RESULTS: Among patients with commercial insurance, December had more cases than November (1.108 [1.092-1.125]) or January (1.257 [1.229-1.286]). In contrast, among patients with Medicare insurance (traditional or managed care), December had fewer cases than November (ratio 0.917 [99% confidence interval 0.904-0.930]) or January (0.823 [0.807-0.839]) of the same year. Summing among all cases, December did not have more cases than November (ratio 1.003 [0.992-1.014]) or January (0.998 [0.984-1.013]). Comparing December versus November (January) ratios for cases among patients with commercial insurance to the corresponding ratios for cases among patients with Medicare, years with more commercial insurance cases had more Medicare cases (Spearman rank correlation +0.36 [+0.25], both p < 0.0001). CONCLUSIONS: In the US State of Florida, although some surgeons' procedural workloads may have seasonal variation if they care mostly for patients with one category of insurance, surgical facilities with patients undergoing many procedures will have less variability. Importantly, more commercial insurance cases were not causing Medicare cases to be postponed or vice-versa, providing mechanistic explanation for why forecasts of surgical demand can reasonably be treated as the sum of the independent workloads among many surgeons.

Construct Validation of the American Board of Anesthesiology's APPLIED Examination for Initial Certification.

BACKGROUND: The American Board of Anesthesiology administers the APPLIED Examination as a part of initial certification, which as of 2018 includes 2 components-the Standardized Oral Examination (SOE) and the Objective Structured Clinical Examination (OSCE). The goal of this study is to investigate the measurement construct(s) of the APPLIED Examination to assess whether the SOE and the OSCE measure distinct constructs (ie, factors). METHODS: Exploratory item factor analysis of candidates' performance ratings was used to determine the number of constructs, and confirmatory item factor analysis to estimate factor loadings within each construct and correlation(s) between the constructs. RESULTS: In exploratory item factor analysis, the log-likelihood ratio test and Akaike information criterion index favored the 3-factor model, with factors reflecting the SOE, OSCE Communication and Professionalism, and OSCE Technical Skills. The Bayesian information criterion index favored the 2-factor model, with factors reflecting the SOE and the OSCE. In confirmatory item factor analysis, both models suggest moderate correlation between the SOE factor and the OSCE factor; the correlation was 0.49 (95% confidence interval [CI], 0.42-0.55) for the 3-factor model and 0.61 (95% CI, 0.54-0.64) for the 2-factor model. The factor loadings were lower for Technical Skills stations of the OSCE (ranging from 0.11 to 0.25) compared with those of the SOE and Communication and Professionalism stations of the OSCE (ranging from 0.36 to 0.50). CONCLUSIONS: The analyses provide evidence that the SOE and the OSCE measure distinct constructs, supporting the rationale for administering both components of the APPLIED Examination for initial certification in anesthesiology.

An online, interactive, screen-based simulator for learning basic EEG interpretation.

OBJECTIVE: Develop and pilot test a simulator that presents ten commonly encountered representative clinical contexts for trainees to learn basic electroencephalogram (EEG) interpretation skills. METHODS: We created an interactive web-based training simulator that allows self-paced, asynchronous learning and assessment of basic EEG interpretation skills. The simulator uses the information retrieval process via a free-response text box to enhance learning. Ten scenarios were created that present dynamic (scrolling) EEG tracings resembling the clinical setting, followed by questions with free-text answers. The answer was checked against an accepted word/phrase list. The simulator has been used by 76 trainees in total. We report pilot study results from the University of Florida's neurology residents (N = 24). Total percent correct for each scenario and average percent correct for all scenarios were calculated and correlated with most recent In-training Examination (ITE) and United States Medical License Examination (USMLE) scores. RESULTS: Neurology residents' mean percent correct scenario scores ranged from 27.1-86.0% with an average scenario score of 61.2% ± 7.7. We showed a moderately strong correlation r = 0.49 between the ITE and the average scenario score. CONCLUSION: We developed an online interactive EEG interpretation simulator to review basic EEG content and assess interpretation skills using an active retrieval approach. The pilot study showed a moderately strong correlation r = 0.49 between the ITE and the average scenario score. Since the ITE is a measure of clinical practice, this is evidence that the simulator can provide self-directed instruction and shows promise as a tool for assessment of EEG knowledge.

Gender distribution in United States anaesthesiology residency programme directors: trends and implications.

The under-representation of women in academic leadership roles, including in anaesthesiology, is a well-documented phenomenon that has persisted for decades despite more women attending medical school, participating in anaesthesiology residencies, and joining academic faculties. The percentage of female anaesthesiologists who hold senior academic ranks or leadership roles, such as chair, lags behind the percentage of female anaesthesiologists overall. Trends towards increasing the numbers of women serving in educational leadership roles, specifically residency programme directors, suggest that there are areas in which academic anaesthesiology has been, and can continue, improving gender imbalance. Continued institutional efforts to recruit women into anaesthesiology, reduce gender bias, and promote interventions that foster gender equity in hiring and promotion will continue to benefit women, academic anaesthesiology departments, and the healthcare system overall.

First-Year Results of the American Board of Anesthesiology's Objective Structured Clinical Examination for Initial Certification.

In 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate an Objective Structured Clinical Examination (OSCE) into its initial certification examination system. Previously, the ABA's staged examination system consisted of 2 written examinations (the BASIC and ADVANCED examinations) and the Standardized Oral Examination (SOE). The OSCE and the existing SOE are now 2 separate components of the APPLIED Examination. This report presents the results of the first-year OSCE administration. A total of 1410 candidates took both the OSCE and the SOE in 2018. Candidate performance approximated a normal distribution for both the OSCE and the SOE, and was not associated with the timing of the examination, including day of the week, morning versus afternoon session, and order of the OSCE and the SOE. Practice-based Learning and Improvement was the most difficult station, while Application of Ultrasonography was the least difficult. The correlation coefficient between SOE and OSCE scores was 0.35 ([95% confidence interval {CI}, 0.30-0.39]; P < .001). Scores for the written ADVANCED Examination were modestly correlated with scores for the SOE (r = 0.29 [95% CI, 0.25-0.34]; P < .001) and the OSCE (r = 0.15 [95% CI, 0.10-0.20]; P < .001). Most of the candidates who failed the SOE passed the OSCE, and most of the candidates who failed the OSCE passed the SOE. Of the 1410 candidates, 77 (5.5%) failed the OSCE, 155 (11.0%) failed the SOE, and 25 (1.8%) failed both. Thus, 207 (14.7%) failed at least 1 component of the APPLIED Examination. Adding an OSCE to a board certification examination system is feasible. Preliminary evidence indicates that the OSCE measures aspects of candidate abilities distinct from those measured by other examinations used for initial board certification.

Development of an Objective Structured Clinical Examination as a Component of Assessment for Initial Board Certification in Anesthesiology.

With its first administration of an Objective Structured Clinical Examination (OSCE) in 2018, the American Board of Anesthesiology (ABA) became the first US medical specialty certifying board to incorporate this type of assessment into its high-stakes certification examination system. The fundamental rationale for the ABA's introduction of the OSCE is to include an assessment that allows candidates for board certification to demonstrate what they actually "do" in domains relevant to clinical practice. Inherent in this rationale is that the OSCE will capture competencies not well assessed in the current written and oral examinations-competencies that will allow the ABA to judge whether a candidate meets the standards expected for board certification more properly. This special article describes the ABA's journey from initial conceptualization through first administration of the OSCE, including the format of the OSCE, the process for scenario development, the standardized patient program that supports OSCE administration, examiner training, scoring, and future assessment of reliability, validity, and impact of the OSCE. This information will be beneficial to both those involved in the initial certification process, such as residency graduate candidates and program directors, and others contemplating the use of high-stakes summative OSCE assessments.

The American Board of Anesthesiology's Standardized Oral Examination for Initial Board Certification.

The American Board of Anesthesiology (ABA) has been administering an oral examination as part of its initial certification process since 1939. Among the 24 member boards of the American Board of Medical Specialties, 13 other boards also require passing an oral examination for physicians to become certified in their specialties. However, the methods used to develop, administer, and score these examinations have not been published. The purpose of this report is to describe the history and evolution of the anesthesiology Standardized Oral Examination, its current examination development and administration, the psychometric model and scoring, physician examiner training and auditing, and validity evidence. The many-facet Rasch model is the analytic method used to convert examiner ratings into scaled scores for candidates and takes into account how difficult grader examiners are and the difficulty of the examination tasks. Validity evidence of the oral examination includes that it measures aspects of clinical performance not accounted for by written certifying examinations, and that passing the oral examination is associated with a decreased risk of subsequent license actions against the anesthesiologist. Explaining the details of the Standardized Oral Examination provides transparency about this component of initial certification in anesthesiology.

The Technology of Processed Electroencephalogram Monitoring Devices for Assessment of Depth of Anesthesia.

Commercial brain function monitors for depth of anesthesia have been available for more than 2 decades; there are currently more than 10 devices on the market. Advances in this field are evidenced by updated versions of existing monitors, development of new monitors, and increasing research unveiling the mechanisms of anesthesia on the brain. Electroencephalography signal processing forms an integral part of the technology supporting the brain function monitors for derivation of a depth-of-anesthesia index. This article aims to provide a better understanding of the technology and functionality behind these monitors. This review will highlight the general design principles of these devices and the crucial stages in electroencephalography signal processing and classification, with a focus on the key mathematical techniques used in algorithm development for final derivation of the index representing anesthetic state. We will briefly discuss the advantages and limitations of this technology in the clinical setting as a tool in our repertoire used for optimizing individualized patient care. Also included is a table describing 10 available commercial depth-of-anesthesia monitors.

Understanding Conflict Management Styles in Anesthesiology Residents.

BACKGROUND: Successful conflict resolution is vital for effective teamwork and is critical for safe patient care in the operating room. Being able to appreciate the differences in training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing various clinical and professional scenarios. The goal of this study was to assess conflict styles in anesthesiology residents via self- and counterpart assessment during participation in simulated conflict scenarios. METHODS: Twenty-two first-year anesthesiology residents (first postgraduate year) participated in this study, which aimed to assess and summarize conflict management styles by 3 separate metrics. One metric was self-assessment with the Thomas-Kilmann Conflict Mode Instrument (TKI), summarized as percentile scores (0%-99%) for 5 conflict styles: collaborating, competing, accommodating, avoiding, and compromising. Participants also completed self- and counterpart ratings after interactions in a simulated conflict scenario using the Dutch Test for Conflict Handling (DUTCH), with scores ranging from 5 to 25 points for each of 5 conflict styles: yielding, compromising, forcing, problem solving, and avoiding. Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. Sign tests were used to compare self- and counterpart ratings on the DUTCH scores, and Spearman correlations were used to assess associations between TKI and DUTCH scores. RESULTS: On the TKI, the anesthesiology residents had the highest median percentile scores (with first quartile [Q1] and third quartile [Q3]) in compromising (67th, Q1-Q3 = 27-87) and accommodating (69th, Q1-Q3 = 30-94) styles, and the lowest scores for competing (32nd, Q1-Q3 = 10-57). After each conflict scenario, residents and their counterparts on the DUTCH reported higher median scores for compromising (self: 16, Q1-Q3 = 14-16; counterpart: 16, Q1-Q3 = 15-16) and problem solving (self: 17, Q1-Q3 = 16-18; counterpart: 16, Q1-Q3 = 16-17), and lower scores for forcing (self: 13, Q1-Q3 = 10-15; counterpart: 13, Q1-Q3 = 13-15) and avoiding (self: 14, Q1-Q3 = 10-16; counterpart: 14.5, Q1-Q3 = 11-16). There were no significant differences (P > .05) between self- and counterpart ratings on the DUTCH. Overall, the correlations between TKI and DUTCH scores were not statistically significant (P > .05). CONCLUSIONS: Findings from our study demonstrate that our cohort of first postgraduate year anesthesiology residents predominantly take a more cooperative and problem-solving approach to handling conflict. By understanding one's dominant conflict management style through this type of analysis and appreciating the value of other styles, one may become better equipped to manage different conflicts as needed depending on the situations.

Gender Distribution of the American Board of Anesthesiology Diplomates, Examiners, and Directors (1985-2015).

To understand the potential role of women in leadership positions, data from the American Board of Anesthesiology (ABA) were analyzed to explore the impact of women in the specialty of anesthesiology. The number of newly certified ABA diplomates, oral examiners, and directors from 1985 to 2015 was obtained from the ABA database. The percentages of women in each group were calculated for each year. Because it took an average of 10 years for a diplomate to become an oral examiner and an average of 7 years for an oral examiner to be elected as a director during the study period, the following percentages were compared: women oral examiners versus newly certified women diplomates 10 years prior and women directors versus women oral examiners 7 years prior. The correlation coefficients between the percentages of women oral examiners and of newly certified women diplomates 10 years prior and between the percentages of women directors and women oral examiners 7 years prior were calculated. From 1985 to 2015, the percentage of newly certified women diplomates increased from 15% to 38% with an average annual increase of 0.74%, percentage of women oral examiners increased from 8% to 26% with an average annual increase of 0.63%, and percentage of women directors increased from 8% to 25% with an average annual increase of 0.56%. The percentage of women examiners consistently lagged behind the percentage of women diplomates who were certified 10 years earlier; the average difference over 21 years from 1995 to 2015 was -3.7% with a standard deviation of 2.1%. The correlation coefficient between the percentages of women examiners and newly certified women diplomates 10 years earlier from 1995 to 2015 was 0.86 (P < .001). However, the percentage of women directors was generally higher than that of women examiners 7 years earlier; the average difference over 24 years from 1992 to 2015 was 3.5% with a standard deviation of 4.0%. The correlation coefficient between the percentages of women directors and women examiners 7 years prior from 1992 to 2015 was 0.86 (P < .001). The percentage of newly certified women diplomates, examiners, and directors increased steadily from 1985 to 2015. The percentage of women examiners lagged behind that of women diplomates 10 years prior from 1995 to 2015; however, the percentage of women directors was, on average, higher than that of the women examiners 7 years prior from 1992 to 2015.

EEG Artifact Versus Subclinical Status Epilepticus in a Patient Following Cardiac Arrest.

BACKGROUND: A challenge in ICU EEG interpretation is identifying subclinical status epilepticus versus patterns on the ictal-interictal continuum versus other repetitive patterns. In the electrically noisy intensive care unit, identifying and eliminating interference and artifact allow accurate diagnoses from the EEG, avoiding unnecessary treatment or sedation. METHODS: We present a case during Impella (Abiomed Inc, Danvers, MA) continuous flow left ventricular assist device use where the EEG artifact was initially misinterpreted as seizure by the resident and treated as status epilepticus because of the "focal" sharply contoured repetitive pattern. During percutaneous coronary intervention (PCI), an 88-year-old developed ventricular tachycardia followed by ventricular fibrillation requiring chest compressions for 10 min, multiple defibrillations, and treatment with epinephrine, amiodarone, calcium, bicarbonate, and magnesium. The patient had an Impella placed during PCI with therapeutic hypothermia initiated after the cardiopulmonary arrest. His neurological exam demonstrated preserved pupillary, corneal, gag and cough reflexes and spontaneous respirations. RESULTS: Long-term video EEG monitoring is included in our institution's hypothermia protocol. Initial baseline EEG performed 2 h after PCI showed a persistent rhythmic sharp discharge from the left central temporal region resembling left hemisphere status epilepticus. The sharp waves have an alternating repeating 2:1 relationship with the EKG rhythm strip. This is best seen in the left hemisphere, which we posit is related to the Impella's positioning across the aortic valve pointing toward the patient's left side. A chest x-ray confirmed the device's position immediately before EEG monitoring. Arterial pressure tracings were not available in the chart. CONCLUSIONS: There is a low-amplitude spiky artifact; however, there was no pacing at that time. It is possible that synergistic flow with systole/diastole reinforced the pulsatility with movement of the Impella, resulting in the alternating pattern. The patient's hemodynamic instability precluded extensive troubleshooting with the Impella device, but after EEG repositioning, the artifact was eliminated.

The Economic and Clinical Impact of Sustained Use of a Progressive Mobility Program in a Neuro-ICU.

OBJECTIVE: To investigate a progressive mobility program in a neurocritical care population with the hypothesis that the benefits and outcomes of the program (e.g., decreased length of stay) would have a significant positive economic impact. DESIGN: Retrospective analysis of economic and clinical outcome data before, immediately following, and 2 years after implementation of the Progressive Upright Mobility Protocol Plus program (UF Health Shands Hospital, Gainesville, FL) involving a series of planned movements in a sequential manner with an additional six levels of rehabilitation in the neuro-ICU at UF Health Shands Hospital. SETTING: Thirty-bed neuro-ICU in an academic medical center. PATIENTS: Adult neurologic and neurosurgical patients: 1,118 patients in the pre period, 731 patients in the post period, and 796 patients in the sustained period. INTERVENTIONS: Implementation of Progressive Upright Mobility Protocol Plus. MEASUREMENTS AND MAIN RESULTS: ICU length of stay decreased from 6.5 to 5.8 days in the immediate post period and 5.9 days in the sustained period (F(2,2641) = 3.1; p = 0.045). Hospital length of stay was reduced from 11.3 ± 14.1 days to 8.6 ± 8.8 post days and 8.8 ± 9.3 days sustained (F(2,2641) = 13.0; p < 0.001). The impact of the study intervention on ICU length of stay (p = 0.031) and hospital length of stay (p < 0.001) remained after adjustment for age, sex, diagnoses, sedation, and ventilation. Hospital-acquired infections were reduced by 50%. Average total cost per patient after adjusting for inflation was significantly reduced by 16% (post period) and 11% (sustained period) when compared with preintervention (F(2,2641) = 3.1; p = 0.045). Overall, these differences translated to an approximately $12.0 million reduction in direct costs from February 2011 through the end of 2013. CONCLUSIONS: An ongoing progressive mobility program in the neurocritical care population has clinical and financial benefits associated with its implementation and should be considered.

Resident Physicians Improve Nontechnical Skills When on Operating Room Management and Leadership Rotation.

BACKGROUND: Anesthesiology residency primarily emphasizes the development of medical knowledge and technical skills. Yet, nontechnical skills (NTS) are also vital to successful clinical practice. Elements of NTS are communication, teamwork, situational awareness, and decision making. METHODS: The first 10 consecutive senior residents who chose to participate in this 2-week elective rotation of operating room (OR) management and leadership training were enrolled in this study, which spanned from March 2013 to March 2015. Each resident served as the anesthesiology officer of the day (AOD) and was tasked with coordinating OR assignments, managing care for 2 to 4 ORs, and being on call for the trauma OR; all residents were supervised by an attending AOD. Leadership and NTS techniques were taught via a standardized curriculum consisting of leadership and team training articles, crisis management text, and daily debriefings. Resident self-ratings and attending AOD and charge nurse raters used the Anaesthetists' Non-Technical Skills (ANTS) scoring system, which involved task management, situational awareness, teamwork, and decision making. For each of the 10 residents in their third year of clinical anesthesiology training (CA-3) who participated in this elective rotation, there were 14 items that required feedback from resident self-assessment and OR raters, including the daily attending AOD and charge nurse. Results for each of the items on the questionnaire were compared between the beginning and the end of the rotation with the Wilcoxon signed-rank test for matched samples. Comparisons were run separately for attending AOD and charge nurse assessments and resident self-assessments. Scaled rankings were analyzed for the Kendall coefficient of concordance (ω) for rater agreement with associated χ and P value. RESULTS: Common themes identified by the residents during debriefings were recurrence of challenging situations and the skills residents needed to instruct and manage clinical teams. For attending AOD and charge nurse assessments, resident performance of NTS improved from the beginning to the end of the rotation on 12 of the 14 NTS items (P < .05), whereas resident self-assessment improved on 3 NTS items (P < .05). Interrater reliability (across the charge nurse, resident, and AOD raters) ranged from ω = .36 to .61 at the beginning of the rotation and ω = .27 to .70 at the end of the rotation. CONCLUSIONS: This rotation allowed for teaching and resident assessment to occur in a way that facilitated resident education in several of the skills required to meet specific milestones. Resident physicians are able to foster NTS and build a framework for clinical leadership when completing a 2-week senior elective as an OR manager.

Academic Productivity of Accreditation Council for Graduate Medical Education-Accredited Critical Care Fellowship Program Directors.

OBJECTIVES: Academic productivity is an expectation for program directors of Accreditation Council for Graduate Medical Education-accredited subspecialty programs in critical care medicine. Within the adult critical care Accreditation Council for Graduate Medical Education-accredited programs, we hypothesized that program director length of time from subspecialty critical care certification would correlate positively with academic productivity, and primary field would impact academic productivity. DESIGN: This study received Institutional Review Board exemption from the University of Florida. Data were obtained from public websites on program directors from all institutions that had surgery, anesthesiology, and pulmonary Accreditation Council for Graduate Medical Education-accredited subspecialty critical care training programs during calendar year 2012. Information gathered included year of board certification and appointment to program director, academic rank, National Institutes of Health funding history, and PubMed citations. RESULTS: Specialty area was significantly associated with total (all types of publications) (p = 0.0002), recent (p < 0.0001), last author (p = 0.008), and original research publications (p < 0.0001), even after accounting for academic rank, years certified, and as a program director. These differences were most prominent in full professors, with surgery full professors having more total, recent, last author, and original research publications than full professors in the other critical care specialties. CONCLUSIONS: This study demonstrates that one's specialty area in critical care is an independent predictor of academic productivity, with surgery having the highest productivity. For some metrics, such as total and last author publications, surgery had more publications than both anesthesiology and pulmonary, whereas there was no difference between the latter groups. This suggests that observed differences in academic productivity vary by specialty.

Syringe Pump Performance Maintained with IV Filter Use During Low Flow Rate Delivery for Pediatric Patients.

BACKGROUND: Complex surgical and critically ill pediatric patients rely on syringe infusion pumps for precise delivery of IV medications. Low flow rates and in-line IV filter use may affect drug delivery. To determine the effects of an in-line filter to remove air and/or contaminants on syringe pump performance at low flow rates, we compared the measured rates with the programmed flow rates with and without in-line IV filters. METHODS: Standardized IV infusion assemblies with and without IV filters (filter and control groups) attached to a 10-mL syringe were primed and then loaded onto a syringe pump and connected to a 16-gauge, 16-cm single-lumen catheter. The catheter was suspended in a normal saline fluid column to simulate the back pressure from central venous circulation. The delivered infusate was measured by gravimetric methods at predetermined time intervals, and flow rate was calculated. Experimental trials for initial programmed rates of 1.0, 0.8, 0.6, and 0.4 mL/h were performed in control and filter groups. For each trial, the flow rate was changed to double the initial flow rate and was then returned to the initial flow rate to analyze pump performance for titration of rates often required during medication administration. These conditions (initial rate, doubling of initial rate, and return to initial rate) were analyzed separately for steady-state flow rate and time to steady state, whereas their average was used for percent deviation analysis. Differences between control and filter groups were assessed using Student t tests with adjustment for multiplicity (using n = 3 replications per group). RESULTS: Mean time from 0 to initial flow (startup delay) was <1 minute in both groups with no statistical difference between groups (P = 1.0). The average time to reach steady-state flow after infusion startup or rate changes was not statistically different between the groups (range, 0.8-5.5 minutes), for any flow rate or part of the trial (initial rate, doubling of initial rate, and return to initial rate), although the study was underpowered to detect small time differences. Overall, the mean steady-state flow rate for each trial was below the programmed flow rate with negative mean percent deviations for each trial. In the 1.0-mL/h initial rate trial, the steady-state flow rate attained was lower in the filter than the control group for the initial rate (P = 0.04) and doubling of initial rate (P = 0.04) with a trend during the return to initial rate (P = 0.06), although this same effect was not observed when doubling the initial rate trials of 0.8 or 0.6 mL/h or any other rate trials compared with the control group. CONCLUSIONS: With low flow rates used in complex surgical and pediatric critically ill patients, the addition of IV filters did not confer statistically significant changes in startup delay, flow variability, or time to reach steady-state flow of medications administered by syringe infusion pumps. The overall flow rate was lower than programmed flow rate with or without a filter.

Long-Term Outcomes for Different Forms of Stress Cardiomyopathy After Surgical Treatment for Subarachnoid Hemorrhage.

BACKGROUND: Stress-induced cardiomyopathy (SCM) after subarachnoid hemorrhage (SAH) includes predominant apical or basal regional left ventricular dysfunction (RLVD) with concomitant changes in electrocardiogram or increase in cardiac enzymes. We hypothesized that difference in outcome is associated with the type of RLVD after SAH. METHODS: We studied a single-center retrospective cohort of SAH patients hospitalized between 2000 and 2010 with follow-up until 2013. We classified patients who had an echocardiogram for clinically indicated reasons according to the predominate location of RLVD as classic SCM-apical form and variant SCM-basal form. A Cox proportional hazard model and logistic regression were used to estimate the risk for death and hospital complications associated with different RLVD after adjustment for propensity to undergo echocardiography given clinical characteristics on admission. RESULTS: Among 715 SAH patients, 28% (200/715) had an echocardiogram for clinical evidence of cardiac dysfunction during hospitalization, the most common being acute left ventricular dysfunction, suspected acute ischemic event, changes in electrocardiogram and cardiac enzymes, and arrhythmia. SCM was present in 59 patients (8% of all cohort and 30% of patients with echocardiogram, respectively) with similar distribution of SCM-basal (25/59) and SCM-apical forms (34/59). SAH patients who had an echocardiogram for clinically indicated reasons had a significantly decreased risk-adjusted long-term survival compared with those without an echocardiogram, regardless of the presence of RLVD. SCM-basal form was associated with cardiac complications (odds ratio, 6.1; 99% confidence interval, 1.8-20.2) and severe sepsis (odds ratio, 5.3; 99% confidence interval, 1.6-17.2). CONCLUSIONS: SAH patients with echocardiogram for a clinically indicated reason have a decreased long-term survival, regardless of the presence of RLVD. The association between severe sepsis and SCM-basal warrants future studies to determine their potential synergistic effect on left ventricular systolic dysfunction among SAH patients.

An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units.

BACKGROUND: There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered. PURPOSE: This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units. METHODS: The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care). MAIN RESULTS: The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term "potentially inappropriate" should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan they believe is appropriate. Conflicts regarding potentially inappropriate treatments that remain intractable despite intensive communication and negotiation should be managed by a fair process of conflict resolution; this process should include hospital review, attempts to find a willing provider at another institution, and opportunity for external review of decisions. When time pressures make it infeasible to complete all steps of the conflict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should seek procedural oversight to the extent allowed by the clinical situation and need not provide the requested treatment. (3) Use of the term "futile" should be restricted to the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal. Clinicians should not provide futile interventions. (4) The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used. CONCLUSIONS: The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.