National Emergency Tele-Critical Care in a Pandemic: Barriers and Solutions.

The COVID-19 pandemic caused tremendous disruption to the U.S. healthcare system and nearly crippled some hospitals during large patient surges. Limited ICU beds across the country further exacerbated these challenges. Telemedicine, specifically tele-critical care (TCC), can expand a hospital's clinical capabilities through remote expertise and increase capacity by offloading some monitoring to remote teams. Unfortunately, the rapid deployment of telemedicine, especially TCC, is constrained by multiple barriers. In the summer of 2020, to support the National Emergency Tele-Critical Care Network (NETCCN) deployment, more than 50 national leaders in applying telemedicine technologies to critical care assembled to provide their opinions about barriers to NETCCN implementation and strategies to overcome them. Through consensus, these experts developed white papers that formed the basis of this article. Herein, the authors share their experience and propose multiple solutions to barriers presented by laws, local policies and cultures, and individual perspectives according to a minimum, better, best paradigm for TCC delivery in the setting of a national disaster. Cross-state licensure and local privileging of virtual experts were identified as the most significant barriers to rapid deployment of services, whereas refining the model of TCC to achieve the best outcomes and defining the best financial model is the most significant for long-term success. Ultimately, we conclude that a rapidly deployable national telemedicine response system is achievable.

Telemedicine for emergency patient rescue.

PURPOSE OF REVIEW: This article summarizes recent developments in the application of telemedicine, specifically tele-critical care (TCC), toward enhancing patient care during various types of emergencies and patient rescue scenarios when there are limited resources in terms of staff expertise (i.e., knowledge, skills, and abilities), staffing numbers, space, and supplies due to patient location (e.g., a non-ICU bed, the emergency department, a rural hospital) or patient volume as in pandemic surges. RECENT FINDINGS: The COVID-19 pandemic demonstrated the need for rapidly scalable and agile healthcare delivery systems. During the pandemic, clinicians and hospital systems adopted telemedicine for various applications. Taking advantage of technological improvements in cellular networks and personal mobile devices, and despite the limited outcomes literature to support its use, telemedicine was rapidly adopted to address the fundamental challenge of exposure in outpatient settings, emergency departments, patient follow-up, and home-based monitoring. A critical recognition was that the modality of care (e.g., remote vs. in-person) was less important than access to care, regardless of the patient outcomes. This fundamental shift, facilitated by policies that followed emergency declarations, provided an opportunity to maintain and, in many cases, expand and improve clinical practices and hospital systems by bringing expertise to the patient rather than the patient to the expertise. In addition to using telemedicine to maintain patient access to healthcare, TCC was harnessed to provide local clinicians, forced to manage critically ill patients beyond their normal scope of practice or experience, access to remote expertise (physician, nursing, respiratory therapist, pharmacist). These practices supported decades of literature from the telemedicine community describing the effectiveness of telemedicine in improving patient care and the many challenges defining its value. SUMMARY: In this review, we summarize numerous examples of innovative care delivery systems that have utilized telemedicine, focusing on 'mobile' TCC technology solutions to effectively deliver the best care to the patient regardless of patient location. We emphasize how a 'paradigm of better' can enhance the entirety of the healthcare system.

Clinical Full-Time Equivalent in PICUs: Survey of the U.S. Pediatric Critical Care Chiefs Network, 2020-2022.

OBJECTIVES: To inform workforce planning for pediatric critical care (PCC) physicians, it is important to understand current staffing models and the spectrum of clinical responsibilities of physicians. Our objective was to describe the expected workload associated with a clinical full-time equivalent (cFTE) in PICUs across the U.S. Pediatric Critical Care Chiefs Network (PC3N). DESIGN: Cross-sectional survey. SETTING: PICUs participating in the PC3N. SUBJECTS: PICU division chiefs or designees participating in the PC3N from 2020 to 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A series of three surveys were used to capture unit characteristics and clinical responsibilities for an estimated 1.0 cFTE intensivist. Out of a total of 156 PICUs in the PC3N, the response rate was 46 (30%) to all three distributed surveys. Respondents used one of four models to describe the construction of a cFTE-total clinical hours, total clinical shifts, total weeks of service, or % full-time equivalent. Results were stratified by unit size. The model used for construction of a cFTE did not vary significantly by the total number of faculty nor the total number of beds. The median (interquartile range) of clinical responsibilities annually for a 1.0 cFTE were: total clinical hours 1750 (1483-1858), total clinical shifts 142 (129-177); total weeks of service 13.0 (11.3-16.0); and total night shifts 52 (36-60). When stratified by unit size, larger units had fewer nights or overnight hours, but covered more beds per shift. CONCLUSIONS: This survey of the PC3N (2020-2022) provides the most contemporary description of clinical responsibilities associated with a cFTE physician in PCC. A 1.0 cFTE varies depending on unit size. There is no correlation between the model used to construct a cFTE and the associated clinical responsibilities.

Assessing quality of critical care during an ongoing health emergency-a novel approach to evaluate quality of care at Lebanese public ICUs during COVID-19.

BACKGROUND: Quality of care has been systematically monitored in hospitals in high-income countries to ensure adequate care. However, in low- and middle-income countries, quality indicators are not readily measured. The primary aim of this study was to assess to what extent it was feasible to monitor the quality of intensive care in an ongoing health emergency, and the secondary aim was to assess a quality of care intervention (twinning project) focused on Intensive Care Unit (ICU) quality of care in public hospitals in Lebanon. METHODS: We conducted a retrospective cohort study nested within an intervention implemented by the World Health Organization (WHO) together with partners. To assess the quality of care throughout the project, a monitoring system framed in the Donabedian model and included structure, process, and outcome indicators was developed and implemented. Data collection consisted of a checklist performed by external healthcare workers (HCWs) as well as collection of data from all admitted patients performed by each unit. The association between the number of activities within the interventional project and ICU mortality was evaluated. RESULTS: A total of 1679 patients were admitted to five COVID-19 ICUs during the study period. The project was conducted fully across four out of five hospitals. In these hospitals, a significant reduction in ICU mortality was found (OR: 0.83, P < 0.05, CI: 0.72-0.96). CONCLUSION: We present a feasible way to assess quality of care in ICUs and how it can be used in assessing a quality improvement project during ongoing crises in resource-limited settings. By implementing a quality of care intervention in Lebanon's public hospitals, we have shown that such initiatives might contribute to improvement of ICU care. The observed association between increased numbers of project activities and reduced ICU mortality underscores the potential of quality assurance interventions to improve outcomes for critically ill patients in resource-limited settings. Future research is needed to expand this model to be applicable in similar settings.

[The center for intensive care medicine: a model for interdisciplinary and interprofessional collaboration]. / Das Zentrum für Intensivmedizin: ein Modell für die interdisziplinäre und interprofessionelle Zusammenarbeit.

BACKGROUND: The Federal Joint Committee has established requirements for centers for intensive care medicine which, in cooperation with other clinics, are to take on special tasks for intensive care medicine in a region. High demands are placed on these centers, which it may not be possible to meet without restructuring the existing intensive care structures. OBJECTIVE: In this study, an organizational model for a center for intensive care medicine based on broad interdisciplinary and interprofessional cooperation is presented for discussion. METHODS AND RESULTS: The organizational model contains proposals for integration of the centers for intensive care medicine into the clinic structure, the management team, the staff composition, the areas of clinical activity, and the further tasks of research, teaching, and education and training. CONCLUSION: Establishment of the centers for intensive care medicine provides new and forward-looking impetus for the further development of intensive care medicine in Germany. However, for the new organizational model to be implemented effectively, the necessary restructuring measures must be adequately refinanced and supported by hospital management and medical faculties. In addition, a sustained willingness for interdisciplinary and interprofessional cooperation is required on the part of all those involved, and employees in this model must be offered attractive long-term positions in intensive care medicine.

Boarding in the emergency department: challenges and mitigation strategies.

PURPOSE OF REVIEW: Herein, we conducted a review of the literature to better understand the issue of prolonged emergency department (ED) boarding by providing an overview of the current evidence on the available causes, consequences, and mitigation strategies. RECENT FINDINGS: Severely ill patients awaiting transfer to intensive care units (ICU) imposes additional burdens on the emergency care team from both a clinical and management perspective. The reasons for prolonged ED boarding are multifactorial. ED boarding compromises patients' safety and outcomes, and is associated with increased team burnout and dissatisfaction. Mitigation strategies include the optimization of patients' flow, the establishment of resuscitative care units, deployment of mobile critical care teams, and improvements in training. Staffing adjustments, changes in hospital operations, and quality improvement initiatives are required to improve this situation, while active bed management and implementation of capacity command centers may also help. SUMMARY: Considering the characteristics of healthcare systems, such as funding mechanisms, organizational structures, delivery models, access and quality of care, the challenge of ED boarding of critically ill patients requires a nuanced and adaptable approach. Solutions are complex but must involve the entirety of the hospital system, emergency department, staff adjustment, and education.

Estudo da OPAS sobre mortalidade materna e COVID-19 mostra barreiras no acesso de gestantes a cuidados intensivos

Uma em cada três mulheres grávidas com COVID-19 que deveriam ter tido acesso a uma unidade de terapia intensiva durante os primeiros dois anos da pandemia não recebeu cuidados críticos, de acordo com uma pesquisa colaborativa liderada pelo Organização Pan-Americana da Saúde (OPAS) em oito países da América Latina e recentemente publicada na Lancet Regional Health - Americas.

[Formation and development of discipline system of critical care medicine].

The discipline system of critical care medicine consists of the knowledge system and thinking system. The knowledge system includes a series of interrelated knowledge points. Knowledge points are relatively independent and smallest units in knowledge. In the process of development, critical care medicine has formed its own characteristic knowledge points based on the knowledge of medicine. Thinking system refers to the way of thinking which consists of various thinking modes linked inseparably. Thinking system provides an essential driving force for the formation and continuous development of knowledge system. The actual composition of critical care medicine discipline is the professionals who know well the thinking system and knowledge system of critical care medicine.

Preparing for patients with high-consequence infectious diseases: Example of a high-level isolation unit.

INTRODUCTION: Patients with high-consequence infectious diseases (HCID) are rare in Western Europe. However, high-level isolation units (HLIU) must always be prepared for patient admission. Case fatality rates of HCID can be reduced by providing optimal intensive care management. We here describe a single centre's preparation, its embedding in the national context and the challenges we faced during the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic. METHODS: Ten team leaders organize monthly whole day trainings for a team of doctors and nurses from the HLIU focusing on intensive care medicine. Impact and relevance of training are assessed by a questionnaire and a perception survey, respectively. Furthermore, yearly exercises with several partner institutions are performed to cover different real-life scenarios. Exercises are evaluated by internal and external observers. Both training sessions and exercises are accompanied by intense feedback. RESULTS: From May 2017 monthly training sessions were held with a two-month and a seven-month break due to the first and second wave of the SARS-CoV-2 pandemic, respectively. Agreement with the statements of the questionnaire was higher after training compared to before training indicating a positive effect of training sessions on competence. Participants rated joint trainings for nurses and doctors at regular intervals as important. Numerous issues with potential for improvement were identified during post processing of exercises. Action plans for their improvement were drafted and as of now mostly implemented. The network of the permanent working group of competence and treatment centres for HCID (Ständiger Arbeitskreis der Kompetenz- und Behandlungszentren für Krankheiten durch hochpathogene Erreger (STAKOB)) at the Robert Koch-Institute (RKI) was strengthened throughout the SARS-CoV-2 pandemic. DISCUSSION: Adequate preparation for the admission of patients with HCID is challenging. We show that joint regular trainings of doctors and nurses are appreciated and that training sessions may improve perceived skills. We also show that real-life scenario exercises may reveal additional deficits, which cannot be easily disclosed in training sessions. Although the SARS-CoV-2 pandemic interfered with our activities the enhanced cooperation among German HLIU during the pandemic ensured constant readiness for the admission of HCID patients to our or to collaborating HLIU. This is a single centre's experience, which may not be generalized to other centres. However, we believe that our work may address aspects that should be considered when preparing a unit for the admission of patients with HCID. These may then be adapted to the local situations.

Severe maternal morbidity: admission shift from intensive care unit to obstetric high-dependency unit.

BACKGROUND: To study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU). METHODS: This is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend. RESULTS: A total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications. CONCLUSIONS: The introduction of HDU helps to reduce ICU utilization in obstetric population.

Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care.

BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans.

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine.

OBJECTIVES: The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION: Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS: The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS: Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.

Human factors in ECLS - A keystone for safety and quality - A narrative review for ECLS providers.

INTRODUCTION: Although the technology used for extracorporeal life support (ECLS) has improved greatly in recent years, the application of these devices to the patient is quite complex and requires extensive training of team members both individually and together. Human factors is an area that addresses the activities, contexts, environments, and tools which interact with human behavior in determining overall system performance. HYPOTHESIS: Analyses of the cognitive behavior of ECLS teams and individual members of these teams with respect to the occurrence of human errors may identify additional opportunities to enhance safety in delivery of ECLS. RESULTS: The aim of this article is to support health-care practitioners who perform ECLS, or who are starting an ECLS program, by establishing standards for the safe and efficient use of ECLS with a focus on human factor issues. Other key concepts include the importance of ECLS team leadership and management, as well as controlling the environment and the system to optimize patient care. CONCLUSION: Expertise from other industries is extrapolated to improve patient safety through the application of simulation training to reduce error propagation and improve outcomes.

Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study.

OBJECTIVES: Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center. METHODS: A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys. RESULTS: A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff. SIGNIFICANCE OF RESULTS: Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

Comparison of two strategies for managing in-hospital cardiac arrest.

In-hospital cardiac arrest (IHCA) is associated with poor outcomes. There are currently no standards for cardiac arrest teams in terms of member composition and task allocation. Here we aimed to compare two different cardiac arrest team concepts to cover IHCA management in terms of survival and neurological outcomes. This prospective study enrolled 412 patients with IHCA from general medical wards. From May 2014 to April 2016, 228 patients were directly transferred to the intensive care unit (ICU) for ongoing resuscitation. In the ICU, resuscitation was extended to advanced cardiac life support (ACLS) (Load-and-Go [LaG] group). By May 2016, a dedicated cardiac arrest team provided by the ICU provided ACLS in the ward. After return of spontaneous circulation (ROSC), the patients (n = 184) were transferred to the ICU (Stay-and-Treat [SaT] group). Overall, baseline characteristics, aetiologies, and characteristics of cardiac arrest were similar between groups. The time to endotracheal intubation was longer in the LaG group than in the SaT group (6 [5, 8] min versus 4 [2, 5] min, p = 0.001). In the LaG group, 96% of the patients were transferred to the ICU regardless of ROSC achievement. In the SaT group, 83% of patients were transferred to the ICU (p = 0.001). Survival to discharge did not differ between the LaG (33%) and the SaT (35%) groups (p = 0.758). Ultimately, 22% of patients in the LaG group versus 21% in the SaT group were discharged with good neurological outcomes (p = 0.857). In conclusion, we demonstrated that the cardiac arrest team concepts for the management of IHCA did not differ in terms of survival and neurological outcomes. However, a dedicated (intensive care) cardiac arrest team could take some load off the ICU.