Teaching and Assessing Bedside Procedures: A Standardized Cross-Disciplinary Framework for Graduate Medical Education.

ABSTRACT: Performing bedside procedures requires knowledge, reasoning, physical adeptness, and self-confidence; however, no consensus on a specific, comprehensive strategy for bedside procedure training and implementation is available. Bedside procedure training and credentialing processes across large institutions may vary among departments and specialties, leading to variable standards, creating an environment that lacks consistent accountability, and making quality improvement difficult. In this Scholarly Perspective, the authors describe a standardized bedside procedure training and certification process for graduate medical education with a common, institution-wide educational framework for teaching and assessing the following 7 important bedside procedures: paracentesis; thoracentesis; central venous catheterization; arterial catheterization; bladder catheterization or Foley catheterization; lumbar puncture; and nasogastric, orogastric, and nasoenteric tube placement. The proposed framework is a 4-stage process that includes 1 preparatory learning stage with simulation practice for knowledge acquisition and 3 clinical stages to guide learners from low-risk to high-risk practice and from high to low supervision. The pilot rollout took place at Henry Ford Hospital from December 2020 to July 2021 for 165 residents in the emergency medicine and/or internal medicine residency programs. The program was fully implemented institution-wide in July 2021. Assessment strategies encompass critical action checklists to confirm procedural understanding and a global rating scale to measure performance quality. A major aim of the bedside procedure training and certification was to standardize assessments so that physician trainers from multiple specialties could train, assess, and supervise any participating trainee, regardless of discipline. The authors list considerations revealed from the pilot rollout regarding electronic tracking systems and several benefits and implementation challenges to establishing institution-wide standards. The proposed framework was assembled by a multidisciplinary physician task force and will assist other institutions in adopting best approaches for training physicians in performing these critically important and difficult-to-perform procedures.

Cardiac Arrest as the First Presentation of Gitelman Syndrome.

Gitelman syndrome is a salt-wasting tubulopathy characterized by profound hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. Cardiac arrest is a relatively rare manifestation of Gitelman syndrome. Here we present a case of Gitelman syndrome in a patient with recurrent cardiac arrest. A 43-year-old female was admitted for out-of-hospital cardiac arrest secondary to ventricular fibrillation. Initial workup revealed severe hypokalemia, hypomagnesemia, metabolic alkalosis, and prolonged QTc. The workup revealed a picture of salt-wasting tubulopathy with hypokalemia, hypomagnesemia, and hypocalciuria. Potassium was repleted aggressively, and the patient received potassium-sparing agents resulting in the stabilization of potassium levels. Before discharge, an implantable cardioverter defibrillator (ICD) was placed for secondary prevention of cardiac arrest. The patient remained symptom-free, and electrolytes remained stable. This case highlights the diagnostic challenges of Gitelman syndrome and the importance of accurate diagnosis in improving patient outcomes.

A roadmap for developing an emergency department based critical care consultation service: Building the early intervention team (EIT).

Emergency Department (ED) crowding and boarding impact safe and effective health care delivery. ED clinicians must balance caring for new arrivals who require stabilization and resuscitation as well as those who need longitudinal care and re-evaluation. These challenges are magnified in the setting of critically ill patients boarding for the intensive care unit. Boarding is a complex issue that has multiple solutions based on resources at individual institutions. Several different models have been described for delivery of critical care in the ED. Here, we describe the development of an ED based critical care consultation service, the early intervention team, at an urban academic ED.

Neurological monitoring in ECMO patients: current state of practice, challenges and lessons.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) in critically ill patients serves as a management option for end-stage cardiorespiratory failure in medical and surgical conditions. Patients on ECMO are at a high risk of neurologic adverse events including intracranial hemorrhage (ICH), acute ischemic stroke (AIS), seizures, diffuse cerebral edema, and hypoxic brain injury. Standard approaches to neurological monitoring for patients receiving ECMO support can be challenging for multiple reasons, including the severity of critical illness, deep sedation, and/or paralysis. This narrative literature review provides an overview of the current landscape for neurological monitoring in this population. METHODS: A literature search using PubMed was used to aid the understanding of the landscape of published literature in the area of neurological monitoring in ECMO patients. RESULTS: Review articles, cohort studies, case series, and individual reports were identified. A total of 73 varied manuscripts were summarized and included in this review which presents the challenges and strategies for performing neurological monitoring in this population. CONCLUSION: Neurological monitoring in ECMO is an area of interest to many clinicians, however, the literature is limited, heterogenous, and lacks consensus on the best monitoring practices. The evidence for optimal neurological monitoring that could impact clinical decisions and functional outcomes is lacking. Additional studies are needed to identify effective measures of neurological monitoring while on ECMO.

Prospective Validation of a Rapid Host Gene Expression Test to Discriminate Bacterial From Viral Respiratory Infection.

Importance: Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship. Objective: To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI. Design, Setting, and Participants: This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments. Participants were enrolled from October 3, 2014, to September 1, 2019, followed by additional enrollment of patients with COVID-19 from March 20 to December 3, 2020. Clinical adjudication of enrolled participants identified 616 individuals as having bacterial or viral infection. The primary analysis cohort included 334 participants with high-confidence reference adjudications (based on adjudicator concordance and the presence of an identified pathogen confirmed by microbiological testing). A secondary analysis of the entire cohort of 616 participants included cases with low-confidence reference adjudications (based on adjudicator discordance or the absence of an identified pathogen in microbiological testing). Thirty-three participants with COVID-19 were included post hoc. Interventions: The HR-B/V test quantified the expression of 45 host messenger RNAs in approximately 45 minutes to derive a probability of bacterial infection. Main Outcomes and Measures: Performance characteristics for the HR-B/V test compared with clinical adjudication were reported as either bacterial or viral infection or categorized into 4 likelihood groups (viral very likely [probability score <0.19], viral likely [probability score of 0.19-0.40], bacterial likely [probability score of 0.41-0.73], and bacterial very likely [probability score >0.73]) and compared with procalcitonin measurement. Results: Among 755 enrolled participants, the median age was 26 years (IQR, 16-52 years); 360 participants (47.7%) were female, and 395 (52.3%) were male. A total of 13 participants (1.7%) were American Indian, 13 (1.7%) were Asian, 368 (48.7%) were Black, 131 (17.4%) were Hispanic, 3 (0.4%) were Native Hawaiian or Pacific Islander, 297 (39.3%) were White, and 60 (7.9%) were of unspecified race and/or ethnicity. In the primary analysis involving 334 participants, the HR-B/V test had sensitivity of 89.8% (95% CI, 77.8%-96.2%), specificity of 82.1% (95% CI, 77.4%-86.6%), and a negative predictive value (NPV) of 97.9% (95% CI, 95.3%-99.1%) for bacterial infection. In comparison, the sensitivity of procalcitonin measurement was 28.6% (95% CI, 16.2%-40.9%; P < .001), the specificity was 87.0% (95% CI, 82.7%-90.7%; P = .006), and the NPV was 87.6% (95% CI, 85.5%-89.5%; P < .001). When stratified into likelihood groups, the HR-B/V test had an NPV of 98.9% (95% CI, 96.1%-100%) for bacterial infection in the viral very likely group and a positive predictive value of 63.4% (95% CI, 47.2%-77.9%) for bacterial infection in the bacterial very likely group. The HR-B/V test correctly identified 30 of 33 participants (90.9%) with acute COVID-19 as having a viral infection. Conclusions and Relevance: In this study, the HR-B/V test accurately discriminated bacterial from viral infection among patients with febrile ARI and was superior to procalcitonin measurement. The findings suggest that an accurate point-of-need host response test with high NPV may offer an opportunity to improve antibiotic stewardship and patient outcomes.

Accelerated Critical Therapy Now in the Emergency Department Using an Early Intervention Team: The Impact of Early Critical Care Consultation for ICU Boarders.

Evaluate the impact of an emergency department (ED)-based critical care consultation service, hypothesizing early consultation results in shorter hospital length of stay (LOS). DESIGN: Retrospective observational study from February 2018 to 2020. SETTING: An urban academic quaternary referral center. PATIENTS: Adult patients greater than or equal to 18 years admitted to the ICU from the ED. Exclusion criteria included age less than 18 years, do not resuscitate/do not intubate documented prior to arrival, advanced directives outlining limitations of care, and inability to calculate baseline modified Sequential Organ Failure Assessment (mSOFA) score. INTERVENTIONS: ED-based critical care consultation by an early intervention team (EIT) initiated by the primary emergency medicine physician compared with usual practice. MEASUREMENTS: The primary outcome was hospital LOS, and secondary outcomes were hospital mortality, ICU LOS, ventilator-free days, and change in the mSOFA. MAIN RESULTS: A total 1,764 patients met inclusion criteria, of which 492 (27.9%) were evaluated by EIT. Final analysis, excluding those without baseline mSOFA score, limited to 1,699 patients, 476 in EIT consultation group, and 1,223 in usual care group. Baseline mSOFA scores (±sd) were higher in the EIT consultation group at 3.6 (±2.4) versus 2.6 (±2.0) in the usual care group. After propensity score matching, there was no difference in the primary outcome: EIT consultation group had a median (interquartile range [IQR]) LOS of 7.0 days (4.0-13.0 d) compared with the usual care group median (IQR) LOS of 7.0 days (4.0-13.0 d), p = 0.64. The median (IQR) boarding time was twice as long subjects in the EIT consultation group at 8.0 (5.0-15.0) compared with 4.0 (3.0-7.0) usual care, p < 0.001. CONCLUSIONS: An ED-based critical care consultation model did not impact hospital LOS. This model was used in the ED and the EIT cared for critically ill patients with higher severity of illness and longer ED boarding times.

While You Don't See Color, I See Bias: Identifying Barriers in Access to Graduate Medical Education Training.

There is a need to acknowledge and address issues of implicit and explicit bias within medical education. These biases can impact standardized test questions and scores, evaluations of clinical performance, and subsequent letters of recommendation, all of which can affect the selection of diverse candidates advancing through medical training. Biased behavior toward trainees can negatively impact their learning environment and career trajectory. This article outlines key definitions related to bias and discusses the ways in which bias potentially impacts selection and entry into Pulmonary and Critical Care Medicine fellowship training. Finally, we will describe some ways to mitigate bias within the fellowship selection process and training programs.

Racial Differences in a Detroit, MI, ICU Population of Coronavirus Disease 2019 Patients.

OBJECTIVES: To investigate the potential influence of racial differences in outcomes of patients infected by coronavirus disease 2019-positive patients who require intensive care in an urban hospital. DESIGN: Retrospective cohort study. SETTING: Henry Ford Health System Multidisciplinary ICU, a total of 156 beds spread throughout the hospital in Detroit, MI. PATIENTS: We obtained data from the electronic medical record of all adult severe acute respiratory syndrome coronavirus-2-positive patients managed in the ICU of Henry Ford Hospital in Detroit, MI, between March 13, 2020, and July 31, 2020. Included patients were divided into two groups: people of color (including Black, Asian, Hispanic/Latino, and Arab) and White. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 365 patients were evaluated: 219 were Black (60.0%), 129 were White (35.3%), two were Asian (0.6%), eight were Hispanic/Latino (2.2%), and seven were Arab (1.9%). People of color were younger (62.8 vs 67.1; p = 0.007), with equal distribution of sex. People of color had less coronary artery disease (34 [14.4%] vs 35 [27.1%]; p =0.003) and less self-reported use of regular alcohol consumption (50 [21.2%] vs 12 [9.3%]; p = 0.004) than Whites, with no differences in diabetes (125 [53.0%] vs 66 [51.2%]; p = 0.742), hypertension (188 [79.7%] vs 99 [76.8%]; p = 0.516), congestive heart failure (41 [17.4%] vs 32 [24.8%]; p = 0.090), or chronic kidney disease (123 [54.1%] vs 55 [42.6%]; p = 0.083).There was no difference in ICU length of stay between people of color (18 d [CI, 7-47 d]) and Whites (18 d [CI, 6-48 d]; p = 0. 0.979). Neither frequency (72.5% vs 71.3%; p = ns) nor median time to mechanical ventilation between people of color (9 d [CI, 6-15 d]) and Whites (10 d [CI, 5-16 d]; p = 0.733) was different. Overall, 188 patients (51.5 %) died in the hospital. The 28-day mortality was lower in people of color (107/236; 45.3%) versus Whites (73/129; 56.6%) (adjusted odds ratio 0.60; p = 0.034), and there was an increased median survival time in people of color (20 d) versus Whites (13.5 d; hazard ratio 0.62; p = 0.002). The inhospital mortality was lower in people of color versus White, but the difference was not statistically significant (113 [47.9%] vs 75 [58.1%], respectively; p = 0.061). Finally, there was no significant difference in days of symptoms prior to admission, frequency of presenting symptoms, or frequency or severity of acute respiratory distress syndrome between the two groups. CONCLUSIONS: In critically ill patients infected with coronavirus disease 2019, people of color had a lower 28-day mortality than Whites with no difference in hospital mortality, ICU length of stay, or rates of intubation. These findings are contrary to previously held beliefs surrounding the pandemic.

Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders.

The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation.

The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients.

OBJECTIVES: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. DESIGN: Multicenter, prospective cohort study. SETTING: The emergency department and ICUs of 15 medical centers. PATIENTS: Mechanically ventilated adult emergency department patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73). CONCLUSIONS: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.

Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE.

Prior to 2001 there was no standard for early management of severe sepsis and septic shock in the emergency department. In the presence of standard or usual care, the prevailing mortality was over 40-50 %. In response, a systems-based approach, similar to that in acute myocardial infarction, stroke and trauma, called early goal-directed therapy was compared to standard care and this clinical trial resulted in a significant mortality reduction. Since the publication of that trial, similar outcome benefits have been reported in over 70 observational and randomized controlled studies comprising over 70,000 patients. As a result, early goal-directed therapy was largely incorporated into the first 6 hours of sepsis management (resuscitation bundle) adopted by the Surviving Sepsis Campaign and disseminated internationally as the standard of care for early sepsis management. Recently a trio of trials (ProCESS, ARISE, and ProMISe), while reporting an all-time low sepsis mortality, question the continued need for all of the elements of early goal-directed therapy or the need for protocolized care for patients with severe and septic shock. A review of the early hemodynamic pathogenesis, historical development, and definition of early goal-directed therapy, comparing trial conduction methodology and the changing landscape of sepsis mortality, are essential for an appropriate interpretation of these trials and their conclusions.

Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review.

BACKGROUND: A significant population of elderly Americans on warfarin is at risk for immediate and delayed intracranial hemorrhage. This qualitative systematic review ascertains the delayed intracranial hemorrhage risk associated with minor head injury and preinjury warfarin use. METHODS: A systematic review using MEDLINE, EMBASE, and the Cochrane Library was performed in August 2014. Cohort studies evaluating delayed intracranial hemorrhage in patients with minor head injuries on warfarin were eligible for inclusion. The definition of delayed hemorrhage was any intracranial bleeding detected subsequent to initial negative brain imaging result following the head injury. Three authors screened and abstracted the data and evaluated methodological quality. Data abstraction also included clinical characteristics that could identify risk factors for delayed intracranial hemorrhage. RESULTS: The search retrieved 294 unique articles, of which 5 studies constituted the final review. The studies included data on 1,257 patients. Among higher-quality studies, the incidence of delayed intracranial hemorrhage ranged from 5.8 to 72 per 1,000 cases of patients on warfarin with minor head injury. Population age was an influential factor in this range of incident rates. International normalized ratio levels had no clear association with individual risk for delayed intracranial hemorrhage. CONCLUSION: The incidence of delayed intracranial hemorrhage is low among patients on warfarin with minor head injury. Trauma centers should consider the characteristics of the population they serve compared with the published studies when determining management strategies for these patients. LEVEL OF EVIDENCE: Systematic review, level III.

Novel Use of Glidescope Indirect Laryngoscopy for Insertion of a Minnesota Tube for Variceal Bleeding.

BACKGROUND: With improvements in endoscopic and interventional radiologic therapies, insertion of gastroesophageal balloon tamponade catheters, commonly known as Sengstaken-Blakemore or Minnesota tubes, is a rarely performed procedure for esophageal or gastric variceal bleeding. In small hospitals or freestanding emergency departments, endoscopic or interventional radiology (IR) therapies might not be available, so patients with exsanguinating variceal bleeding must be stabilized or temporized for transport to larger hospitals. Occasionally, tamponade devices are necessary as a rescue therapy for failed endoscopic or IR therapies or can be used as definitive therapy in select cases. In addition to being rarely performed, there are multiple technical complications associated with blind insertion of tamponade catheters. DISCUSSION: We describe a novel use of indirect laryngoscopy using a Glidescope for assisting in placement of a Minnesota tube in 4 patients with exsanguinating esophageal bleeding. CONCLUSIONS: Insertion of a Minnesota tube for bleeding esophageal or gastric varices is an uncommon, technically challenging procedure that can be lifesaving, and is something emergency physicians, intensivists, and gastroenterologists should be capable of performing. Addition of indirect laryngoscopy may help to improve rapid, safe, and successful placement of these devices.