Ten misconceptions regarding decision-making in critical care.

Diagnostic errors are prevalent in critical care practice and are associated with patient harm and costs for providers and the healthcare system. Patient complexity, illness severity, and the urgency in initiating proper treatment all contribute to decision-making errors. Clinician-related factors such as fatigue, cognitive overload, and inexperience further interfere with effective decision-making. Cognitive science has provided insight into the clinical decision-making process that can be used to reduce error. This evidence-based review discusses ten common misconceptions regarding critical care decision-making. By understanding how practitioners make clinical decisions and examining how errors occur, strategies may be developed and implemented to decrease errors in Decision-making and improve patient outcomes.

Preprocedural fasting policies for patients receiving tube feeding: A national survey.

BACKGROUND: Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures. METHODS: The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated. RESULTS: The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed. CONCLUSIONS: Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

Perioperative Handoff Enhancement Opportunities Through Technology and Artificial Intelligence: A Narrative Review.

BACKGROUND: Perioperative handoffs occur as patients progress through preoperative, intraoperative, and postoperative phases of care. These may occur between clinicians from the same or different role groups, between different care units, for brief breaks during the course of a surgery, or at shift or service changes. Perioperative handoffs occur during a period of increased vulnerability, as teams must convey critical information at a time of high cognitive load, with many potential distractions. METHODS: A search of MEDLINE was conducted for biomedical literature pertaining to perioperative handoffs and technology, electronic tools, and artificial intelligence. The reference lists of identified articles were reviewed, and additional citations were included if relevant. These articles were abstracted to summarize the current literature, and to frame the opportunity for enhanced opportunities to improve perioperative handoffs through technology and artificial intelligence. RESULTS: Several efforts to date have incorporated electronic tools to improve perioperative handoffs but have been limited by imprecision in selecting handoff elements, increased task burden for clinicians, interrupted workflows, physical barriers, and lack of institutional support for their implementation. At the same time, artificial intelligence (AI) and machine learning (ML) are being applied across healthcare, but their use in and integration into handoff workflows have not yet been studied. Use of existing technology including mobile applications, barcode scanners, and radio-frequency identification (RFID) tags to advance perioperative safety has only begun and similarly has not been applied to handoffs. CONCLUSION: In this narrative review, we synthesize prior research on electronic tools for perioperative handoffs, limitations of current tools and barriers to their implementation, and the use of AI and ML in perioperative care. We then discuss potential opportunities to further integrate healthcare technologies and apply AI-derived solutions in the concept of a "smart handoff" with the aim of reducing harm from handoffs and improving patient safety.

Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review.

Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.