Nonbronchoscopic Bronchoalveolar Lavage Improves Respiratory Culture Accuracy in Critically Ill Patients.

OBJECTIVES: Diagnosis of pneumonia is challenging in critically ill, intubated patients due to limited diagnostic modalities. Endotracheal aspirate (EA) cultures are standard of care in many ICUs; however, frequent EA contamination leads to unnecessary antibiotic use. Nonbronchoscopic bronchoalveolar lavage (NBBL) obtains sterile, alveolar cultures, avoiding contamination. However, paired NBBL and EA sampling in the setting of a lack of gold standard for airway culture is a novel approach to improve culture accuracy and limit antibiotic use in the critically ill patients. DESIGN: We designed a pilot study to test respiratory culture accuracy between EA and NBBL. Adult, intubated patients with suspected pneumonia received concurrent EA and NBBL cultures by registered respiratory therapists. Respiratory culture microbiology, cell counts, and antibiotic prescribing practices were examined. SETTING: We performed a prospective pilot study at the Cleveland Clinic Main Campus Medical ICU in Cleveland, Ohio for 22 months from May 2021 through March 2023. PATIENTS OR SUBJECTS: Three hundred forty mechanically ventilated patients with suspected pneumonia were screened. Two hundred fifty-seven patients were excluded for severe hypoxia (Fio2 ≥ 80% or positive end-expiratory pressure ≥ 12 cm H2O), coagulopathy, platelets less than 50,000, hemodynamic instability as determined by the treating team, and COVID-19 infection to prevent aerosolization of the virus. INTERVENTIONS: All 83 eligible patients were enrolled and underwent concurrent EA and NBBL. MEASUREMENTS AND MAIN RESULTS: More EA cultures (42.17%) were positive than concurrent NBBL cultures (26.51%, p = 0.049), indicating EA contamination. The odds of EA contamination increased by eight-fold 24 hours after intubation. EA was also more likely to be contaminated with oral flora when compared with NBBL cultures. There was a trend toward decreased antibiotic use in patients with positive EA cultures if paired with a negative NBBL culture. Alveolar immune cell populations were recovered from NBBL samples, indicating successful alveolar sampling. There were no major complications from NBBL. CONCLUSIONS: NBBL is more accurate than EA for respiratory cultures in critically ill, intubated patients. NBBL provides a safe and effective technique to sample the alveolar space for both clinical and research purposes.

One-Year Outcomes of Patients Requiring Tracheostomy Placement Due to Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes (COVID-19) have resulted in an increase in critical illness and in the prevalence of acute respiratory failure with the need for tracheostomy. The characteristics and long-term outcomes of this patient cohort are not well identified. RESEARCH QUESTION: What are the characteristics of patients who develop the need for tracheostomy due to SARS-CoV-2 with acute respiratory distress syndrome (ARDS)? What is their 90-day and 1-year survival and are there any identifiable risk factors for mortality and ventilator dependency? STUDY DESIGN AND METHODS: Retrospective, follow-up cohort study of adult patients with COVID-19 infection and ARDS who required tracheostomy placement in a large healthcare system. RESULTS: One hundred sixty-four consecutive patients with SARS-CoV-2 admitted to ICUs for ARDS who required tracheostomy placement between March 2020 and March 2021 were identified. One hundred nine (66.5%) were male. Average age was 63.5 years. The most common comorbidities were obesity, hypertension, diabetes mellitus, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and asthma. The most common complications during hospitalization were delirium, secondary infections, acute kidney injury, pneumothorax, and venous thromboembolism. Ninety-day and 1-year mortality were 29.9% and 44.5%, respectively. Ninety-six patients (58.5%) were liberated from the ventilator, and 84 (51.2%) had the tracheostomy tube decannulated. Asthma, COPD, atrial fibrillation, and renal replacement therapy requirement in the ICU correlated with increased risk of ventilator dependency. Among survivors at 1 year, 71 patients (43.3%) were residing at home and 20 patients (12.2%) remained in a skilled nursing facility. INTERPRETATION: COVID-19 has resulted in a significant burden of acute critical illness and acute respiratory failure with the need for tracheostomy. A significant percentage of patients with SARS-CoV-2 requiring tracheostomy were alive and at home 1 year after tracheostomy placement. Long-term care support, including tracheostomy, beyond 90 days appears to be beneficial in this patient population and warrants further investigation.

Surge capacity and capability of intensive care units across a large healthcare system: An operational blueprint for regional integration.

OBJECTIVE: Many hospitals were unprepared for the surge of patients associated with the spread of coronavirus disease 2019 (COVID-19) pandemic. We describe the processes to develop and implement a surge plan framework for resource allocation, staffing, and standardized management in response to the COVID-19 pandemic across a large integrated regional healthcare system. SETTING: A large academic medical center in the Cleveland metropolitan area, with a network of 10 regional hospitals throughout Northeastern Ohio with a daily capacity of more than 500 intensive care unit (ICU) beds. RESULTS: At the beginning of the pandemic, an equitable delivery of healthcare services across the healthcare system was developed. This distribution of resources was implemented with the potential needs and resources of the individual ICUs in mind, and epidemiologic predictions of virus transmissibility. We describe the processes to develop and implement a surge plan framework for resource allocation, staffing, and standardized management in response to the COVID-19 pandemic across a large integrated regional healthcare system. We also describe an additional level of surge capacity, which is available to well-integrated institutions called "extension of capacity." This refers to the ability to immediately have access to the beds and resources within a hospital system with minimal administrative burden. CONCLUSIONS: Large integrated hospital systems may have an advantage over individual hospitals because they can shift supplies among regional partners, which may lead to faster mobilization of resources, rather than depending on local and national governments. The pandemic response of our healthcare system highlights these benefits.

An Algorithm for Classifying Patients Most Likely to Develop Severe Coronavirus Disease 2019 Illness.

OBJECTIVES: To develop an algorithm that predicts an individualized risk of severe coronavirus disease 2019 illness (i.e., ICU admission or death) upon testing positive for coronavirus disease 2019. DESIGN: A retrospective cohort study. SETTING: Cleveland Clinic Health System. PATIENTS: Those hospitalized with coronavirus disease 2019 between March 8, 2020, and July 13, 2020. INTERVENTIONS: A temporal coronavirus disease 2019 test positive cut point of June 1 was used to separate the development from validation cohorts. Fine and Gray competing risk regression modeling was performed. MEASUREMENTS AND MAIN RESULTS: The development set contained 4,520 patients who tested positive for coronavirus disease 2019 between March 8, 2020, and May 31, 2020. The validation set contained 3,150 patients who tested positive between June 1 and July 13. Approximately 9% of patients were admitted to the ICU or died of coronavirus disease 2019 within 2 weeks of testing positive. A prediction cut point of 15% was proposed. Those who exceed the cutoff have a 21% chance of future severe coronavirus disease 2019, whereas those who do not have a 96% chance of avoiding the severe coronavirus disease 2019. In addition, application of this decision rule identifies 89% of the population at the very low risk of severe coronavirus disease 2019 (< 4%). CONCLUSIONS: We have developed and internally validated an algorithm to assess whether someone is at high risk of admission to the ICU or dying from coronavirus disease 2019, should he or she test positive for coronavirus disease 2019. This risk should be a factor in determining resource allocation, protection from less safe working conditions, and prioritization for vaccination.

Critical Illness Secondary to Synthetic Cannabinoid Ingestion.

Importance: Synthetic cannabinoids (SCs), commonly known as K2, spice, or fake weed, are cheap, artificially manufactured recreational drugs that have emerged as a major public health threat in various regions of the US. Objective: To describe the clinical manifestations of SC intoxication. Design, Setting, and Participants: This case series assessed adults admitted to the intensive care unit from 2014 to 2016 with acute life-threatening complications of SC use. Data analysis was completed in October 2016. Exposures: Use of SCs such as K2, spice, or other synthetic versions of cannabinoids. Main Outcomes and Measures: Data collected included patient demographic data, medical history, presenting symptoms, physical findings, laboratory and imaging data, and intensive care unit and hospital course. Results: Thirty patients (mean age, 41 years [range, 21-59 years]; 24 men [80%]) with SC ingestion were admitted to the intensive care unit over a 2-year period. Thirteen patients were undomiciled. The majority had a history of polysubstance abuse, psychiatric illness, or personality disorder. The admission diagnoses were coma (10 patients [33%]), agitation (10 patients [33%]), and seizure (6 patients [20%]). Eighteen patients (60%) had acute respiratory failure, and tracheal intubation was required in 21 patients (70%) for either airway protection or acute respiratory failure. Rhabdomyolysis was noted in 8 patients (26%). A man developed transient cerebral edema with loss of gray-white differentiation but had complete recovery. A woman with history of asthma died of acute respiratory distress syndrome. All patients underwent routine toxicology testing, which was unrevealing in 16 cases and revealed coingestion in the remainder. Sixteen patients (53%) left the hospital against medical advice. Conclusions and Relevance: Ingestion of SCs can lead to life-threatening complications, including severe toxic encephalopathy, acute respiratory failure, and death. Synthetic cannabinoids are undetectable in routine serum and urine toxicology testing but can be suspected on the basis of history and clinical presentation, which may include extreme agitation or coma. Frontline clinicians must be aware of the presentation and be vigilant in suspecting SC intoxication.

Lessons on Outbreak Preparedness From the Cleveland Clinic.

Disasters, including infectious disease outbreaks, are inevitable. Hospitals need to plan in advance to ensure that their systems can adapt to a rapidly changing environment if necessary. This review provides an overview of 10 general principles that hospitals and health-care systems should consider when developing disaster plans. The principles are consistent with an "all-hazards" approach to disaster mitigation. This approach is adapted to planning for a multiplicity of threats but emphasizes highly relevant scenarios, such as the coronavirus disease 2019 pandemic. We also describe specific ways these principles helped prepare our hospital for this pandemic. Key points include acting quickly, identifying and engaging key stakeholders early, providing accurate information, prioritizing employee safety and mental health, promoting a fully integrated clinical response, developing surge plans, preparing for ethical dilemmas, and having a cogent exit strategy for post-disaster recovery.

Treating acute anxiety in patients with COVID-19.

At present, there are no firm guidelines for the treatment of COVID-19-related emotional distress. The current approach is based on our knowledge of how to manage anxiety in medically ill patients, taking into consideration all associated medical comorbidities, drug-drug interactions, and the patient's specific needs and preexisting mental illness. Interventions should be implemented at the bedside to augment the patient's own resiliency in coping with these stressful events. A targeted combination of psychopharmacology (targeting acute anxiety and panic symptoms) and psychotherapy (relaxation techniques, breathing exercises, and encouragement) is recommended.

Simulation-based training for emergency medicine residents in sterile technique during central venous catheterization: impact on performance, policy, and outcomes.

OBJECTIVES: Central line-associated bloodstream infection (CLABSI) is a preventable nosocomial infection. Simulation-based training in sterile technique during central venous catheter (CVC) placement for emergency medicine (EM) residents, and its effect on changing the medical intensive care unit (MICU) practice of routine replacement of CVCs placed under sterile technique in the emergency department (ED), has not been evaluated. METHODS: Emergency medicine residents received simulation-based sterile technique training during CVC placement between May 2008 and September 2010. Between June 2008 and January 2011, the authors reviewed records of patients who had CVCs placed in the ED under sterile technique by EM residents and were admitted to the MICU (group 1) and CVCs placed in the MICU under sterile technique by internal medicine (IM) residents (group 2). IM residents completed similar simulation-based training before May 2008. Changes in EM residents' sterile technique performance scores were compared, as well as CLABSI rates in both groups. EM residents' CVC procedural skills were not assessed. RESULTS: Seventy-six EM residents completed simulation-based training with significant improvement in performance (median scores 13 out of 24 before training, 24 out of 24 after training; p < 0.001). CLABSI rates per 1,000 catheter-days were 1.02 in group 1 and 1.02 in group 2 (p = 0.99). Both groups had similar demographics, acuity, and mortality (p > 0.5). CONCLUSIONS: Routine replacement of CVCs placed in the ED under sterile technique after simulation-based training would appear to be unnecessary. These findings demonstrate patient-centered outcomes that are comparable for CVCs in ED-admitted MICU patients, regardless of whether the CVC was placed in the ED or MICU.

Simulation-based training for nurses in sterile techniques during central vein catheterization.

BACKGROUND: The effectiveness of simulation-based training of critical care nurses in sterile techniques has not been determined. OBJECTIVE: To evaluate the effectiveness of simulation-based training of critical care nurses to use sterile techniques during central vein catheterization and the effect of such training on infection rates. METHODS: A prospective controlled study with 12-month observational follow-up to assess the rate of catheter-related bloodstream infections in a 23-bed medical, surgical, neurological critical care unit. RESULTS: Forty-six critical care nurses completed assessment and training in sterile technique skills in the simulation laboratory. Performance scores at baseline were poor: median scores in each category ranging from 0 to 2 out of a maximum score of 4 and a median total score of 7 out of a maximum score of 24. After simulation-based training, nurses' median scores in each ST category and their total scores improved significantly, with the median total score increasing to 23 (P < .01; median difference, 15; 95% CI, 14-16). After completion of the simulation-based training intervention, the mean infection rate in the unit was reduced by 85% from 2.61 to 0.4 infections per 1000 catheter-days (P = .02). The incidence rate-ratio derived from the Poisson regression (0.15; 95% CI, 0.03-0.78) indicates an 85% reduction in the incidence of catheter-related bloodstream infections in the unit after the intervention. CONCLUSION: Simulation-based training of critical care nurses in sterile technique is an important component in the strategy to reduce the occurrence of such infections and promote patient safety.

Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians.

PURPOSE: Ventilator weaning protocols can improve clinical outcomes, but their impact may vary depending on intensive care unit (ICU) structure, staffing, and acceptability by ICU physicians. This study was undertaken to examine their relationship. DESIGN/METHODS: We prospectively examined outcomes of 102 mechanically ventilated patients for more than 24 hours and weaned using nurse-driven protocol-directed approach (nurse-driven group) in an intensivist-led ICU with low respiratory therapist staffing and compared them with a historic control of 100 patients who received conventional physician-driven weaning (physician-driven group). We administered a survey to assess ICU physicians' attitude. RESULTS: Median durations of mechanical ventilation (MV) in the nurse-driven and physician-driven groups were 2 and 4 days, respectively (P = .001). Median durations of ICU length of stay (LOS) in the nurse-driven and physician-driven groups were 5 and 7 days, respectively (P = .01). Time of extubation was 2 hours and 13 minutes earlier in the nurse-driven group (P < .001). There was no difference in hospital LOS, hospital mortality, rates of ventilator-associated pneumonia, or reintubation rates between the 2 groups. We identified 4 independent predictors of weaning duration: nurse-driven weaning, Acute Physiology and Chronic Health Evaluation II score, vasoactive medications use, and blood transfusion. Intensive care unit physicians viewed this protocol implementation positively (mean scores, 1.59-1.87 on a 5-point Likert scale). CONCLUSIONS: A protocol for liberation from MV driven by ICU nurses decreased the duration of MV and ICU LOS in mechanically ventilated patients for more than 24 hours without adverse effects and was well accepted by ICU physicians.

Changes in health-related quality of life and factors predicting long-term outcomes in older adults admitted to intensive care units.

OBJECTIVES: The aims of this study were to determine predictors of survival after hospital discharge and to describe the impact of intensive care unit admission on health-related quality of life at 6 months after hospital discharge in older adults admitted to intensive care units. DESIGN: Prospective longitudinal observational study with administered questionnaire. SETTINGS AND PATIENTS: Patients 65 yrs of age and older who were admitted to the medical, surgical, and coronary intensive care units for >24 hrs in a large urban teaching hospital system from August 2007 to May 2008 with a follow-up period ending April 2009. INTERVENTIONS: Administered questionnaire to patients or proxies. MEASUREMENTS AND MAIN RESULTS: Four hundred eighty-four patients 65 yrs old and older were enrolled. Data were collected on demographics, comorbidities, intensive care unit admission diagnoses, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment score, Glasgow Coma Scale score at intensive care unit admission, intensive care unit interventions, and disposition after hospital discharge. A health-related quality of life survey was administered to patients, their proxies, or caregivers at intensive care unit admission, and to hospital survivors at 6 months after hospital discharge. Three hundred sixty-seven (75.8%) and 318 (65.7%) of enrolled patients were alive at hospital discharge and at 6 months, respectively. Mean age of survivors was 77.8 ± 8.5. Independent predictors of death at 6 months were: number of days during the 30 days before hospitalization that the patient felt their "physical health was not good" on the health-related quality of life survey [odds ratio = 1.08; confidence interval 1.04-1.12], a higher Acute Physiology and Chronic Health Evaluation II score [odds ratio = 1.09; 95% confidence interval 1.06-1.12], and chronic pulmonary disease as a comorbidity [odds ratio = 2.22; 95% confidence interval 1.04-4.78]. Of the 318 survivors at 6 months after hospital discharge, 297 (93.4%) completed the health-related quality of life questionnaire. When assessing whether changes in health-related quality of life over time were affected by age in our study cohort of 65 yrs old and older, we found that the oldest survivors, age 86.3 yrs old and older, had worse health-related quality of life over time, including more days spent with poor physical health (p < .004) and mental health (p < .001), while the youngest survivors, age 65-69.3 yrs old, showed improvement in health-related quality of life with fewer days spent with poor physical health (p < .004) and mental health (p < .001) at follow-up compared to baseline. These differences remained after adjusting for severity of illness and other potential confounders. CONCLUSIONS: One-third of adults 65 yrs old and older admitted to the intensive care unit die within 6 months of hospital discharge. Among survivors at 6 months, health-related quality of life has significantly worsened over time in the oldest patients but improved in the youngest. Our study in a large cohort of mixed intensive care unit patients identifies additional prognostic factors and significant quality of life information in intensive care unit survivors well after hospital discharge. This additional information may guide clinicians in their discussions with patients, families, and other providers as they decide on what treatments and interventions to pursue.

Performance of medical residents in sterile techniques during central vein catheterization: randomized trial of efficacy of simulation-based training.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is a preventable cause of a potentially lethal ICU infection. The optimal method to teach health-care providers correct sterile techniques during central vein catheterization (CVC) remains unclear. METHODS: We randomly assigned second- and third-year internal medicine residents trained by a traditional apprenticeship model to simulation-based plus video training or video training alone from December 2007 to January 2008, with a follow-up period to examine CRBSI ending in July 2009. During the follow-up period, a simulation-based training program in sterile techniques during CVC was implemented in the medical ICU (MICU). A surgical ICU (SICU) where no residents received study interventions was used for comparison. The primary outcome measures were median residents' scores in sterile techniques and rates of CRBSI per 1,000 catheter-days. RESULTS: Of the 47 enrolled residents, 24 were randomly assigned to the simulation-based plus video training group and 23 to the video training group. Median baseline scores in both groups were equally poor: 12.5 to 13 (52%-54%) out of maximum score of 24 (P = .95; median difference, 0; 95% CI, 0.2-2.0). After training, median score was significantly higher for the simulation-based plus video training group: 22 (92%) vs 18 (75%) for the video training group (P < .001; median difference, 4; 95% CI, 3-6). During the follow-up period, there was a significantly lower rate of CRBSI in the MICU (1.0 per 1,000 catheter-days) compared with the SICU (3.4 per 1,000 catheter-days) (P = .03). The incidence rate ratio derived from the Poisson regression (0.30; 95% CI, 0.10-0.91) indicated there was a 70% reduction in the incidence of CRBSI in the postintervention MICU compared with the preintervention MICU and the postintervention SICU. CONCLUSIONS: Simulation-based training in sterile techniques during CVC is superior to traditional training or video training alone and is associated with decreased rate of CRBSI. Simulation-based training in CVC should be routinely used to reduce iatrogenic risk. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00612131; URL: clinicaltrials.gov.

Low-dose tenecteplase during cardiopulmonary resuscitation due to massive pulmonary embolism: a case report and review of previously reported cases.

The case of a 29 year-old man who suffered a cardiac arrest due to a massive pulmonary embolism while he was undergoing surgical repair of a complex tibial plateau fracture is presented. After 70 min of unsuccessful cardiopulmonary resuscitation a bolus of 20 mg tenecteplase was given, with a return of spontaneous circulation 2 min after administration of the drug. Pulmonary embolism was subsequently demonstrated on a pulmonary angiogram. To our knowledge this is the first report to show that the use of a low dose of tenecteplase might be useful to achieve the return of spontaneous circulation in the resuscitation of patients with cardiac arrest secondary to massive pulmonary embolism. Previously reported cases are reviewed.

Efficacy of deep venous thrombosis prophylaxis in the medical intensive care unit.

The purpose of this study was to determine the incidence of deep venous thrombosis in medical intensive care unit patients receiving deep venous thrombosis prophylaxis. This was a prospective cohort study of 141 consecutive adult patients anticipated to remain in the medical intensive care unit for >48 hours. Deep venous thrombosis prophylaxis was provided using subcutaneous unfractionated heparin or a sequential compression device according to risk-stratified protocol. Compression ultrasound was performed. Fourteen patients (9.9%) developed deep venous thrombosis on follow-up studies. Incidence of deep venous thrombosis was 7.9% per person year (95% confidence interval, 4.8-12.8). Two of 14 developed pulmonary embolism. Eight patients required full anticoagulation with intravenous heparin or coumadin. In-hospital mortality was similar in both groups. Patients with deep venous thrombosis had a statistically higher risk of pulmonary embolism: 14.2% (95% confidence interval, 2.0-43.0) versus 0.0% (95% confidence interval, 0-3; P = .009). Incidence of deep venous thrombosis is high in medical intensive care unit patients receiving standard prophylaxis. Adherence to strict deep venous thrombosis prophylaxis protocol and exploration of other prophylaxis regimens should be pursued.

Outcome of critically ill human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy.

The purpose of this study was to determine the effect of prior use of highly active antiretroviral therapy (HAART) on outcome of human immunodeficiency virus (HIV)- patients admitted to intensive care units (ICUs). This study was a retrospective chart review of 242 HIV-infected patients who required 259 consecutive admissions to a university-affiliated hospital ICU during a 3-year period. Patient demographics, CD4 count, admission diagnosis, prior HAART, Pneumocystis jiroveci prophylaxis, length of stay, and ICU and hospital mortality were determined. Overall hospital mortality was 39%. Comparing patients who had received HAART before an ICU admission to those who had not, we found no difference between ICU or hospital mortality, need of mechanical ventilation, ICU and hospital length of stay, and incidence of P jiroveci. Pulmonary diagnosis was the most frequent ICU admission diagnosis (30%). Logistic regression analysis showed HIV-related illness and mechanical ventilation were significant independent predictors of increased hospital mortality.