Finding New Meaning in the Practice of Medicine: A Quality Improvement Project Evaluating the Remote Communication Liaison Program During the Initial COVID Pandemic Surge.

Background: In spring 2020, the COVID-19 pandemic overwhelmed intensive care teams with severely ill patients. Even at the end of life, families were barred from hospitals, relying solely on remote communication. A Remote Communication Liaison Program (RCLP) was established to ensure daily communication for families, while supporting overstretched intensivists. Objectives: To evaluate the effectiveness and impact of the RCLP on participating liaisons and intensivists. Design: Two quality improvement surveys were developed and administered electronically. Setting/Subjects: Based in the United States, all liaisons and intensivists who participated in this program were invited to take the surveys. Measurements: Descriptive statistics were used to analyze the quantitative Likert-scale data, and qualitative analysis was used to assess themes. Results: Among respondents, all (100%) liaisons and more than 90% of intensivists agreed or strongly agreed that the RCLP provided a valuable service to families. More than 70% of intensivists agreed or strongly agreed that the program lessened their workload. More than 90% of liaisons agreed or strongly agreed that participation in the program improved their confidence and skills in end-of-life decision making, difficult conversations, and comprehension of critical care charts. Themes elicited from the liaisons revealed that participation fostered a renewed sense of purpose as physicians, meaningful connection, and opportunities for growth. Conclusions: RCLP successfully trained and deployed liaisons to rapidly develop skills in communication with beleaguered families during COVID-19 surge. Participation in the program had a profound effect on liaisons, who experienced a renewed sense of meaning and connection to the practice of medicine.

The effect of a tiered provider staffing model on patient outcomes during the coronavirus disease 2019 pandemic: A single-center observational study.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, our hospital experienced a large influx of critically ill patients with acute respiratory failure. In order to increase intensive care unit (ICU) surge capacity, we adopted a "tiered model" for ICU provider staffing where multiple ICUs were staffed by noncritical care providers under the direction of an intensivist. We hypothesized that ICUs staffed with a tiered model would result in similar patient outcomes as ICU staffed with a traditional intensivist model. METHODS: We performed a single-center, observational study in seven ICUs at a tertiary care center. We included consecutive adults admitted to the ICU with acute respiratory distress syndrome (ARDS) due to COVID-19 infection. We collected baseline demographics, treatments, and outcomes of interest in traditionally staffed ICUs versus ICUs staffed with a tiered model. The primary outcome was inpatient mortality. All outcomes were censored at day 28. RESULTS: We included a total of 138 patients in our study: 66 patients were admitted to traditionally staffed ICUs and 52 were admitted to tiered staffing ICUs. Baseline characteristics were similar between groups. ARDS treatments were similar in traditionally staffed ICUs versus tiered staffing model ICUs, including daily mean tidal volume (6.2 mL/kg vs. 6.2 mL/kg, P = 0.95), median daily fluid balance (159 mL vs. 92 mL, P = 0.54), and use of prone ventilation (58% vs. 65%, P = 0.45). There was no difference in inpatient mortality between groups (50% vs. 42%, P = 0.46). We also found no difference in ventilator-free, ICU-free, vasopressor-free, and dialysis-free days between groups. CONCLUSIONS: Our results suggest that patient outcomes are similar in ICUs with traditional staffing models when compared to ICUs with a tiered staffing mode during a pandemic.

Characteristics and outcomes of patients receiving high flow nasal cannula therapy prior to mechanical ventilation in COVID-19 respiratory failure: A prospective observational study.

BACKGROUND: Treatment strategies for acute hypoxic respiratory failure secondary to coronavirus 2019 disease (COVID-19) had significant variation early in the pandemic. We sought to determine if patients treated with high flow nasal cannula (HFNC) prior to mechanical ventilation had differing outcomes compared to those treated only with conventional oxygen. METHODS: This was a prospective, observational study of patients with COVID-19 admitted to a tertiary care medical center with a diagnosis of acute hypoxic respiratory failure. Adult patients with a positive polymerase chain reaction test for COVID-19 who required mechanical ventilation were included. RESULTS: A total of 91 patients met the inclusion criteria for our study. The mean age was 68.4 years (standard deviation [SD] ± 12) and 58% were male. The mean initial partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio was 152 (SD ± 65) and was not significantly different between the HFNC group and the conventional oxygen strategy group (P = 0.95). The observed mortality rate was 30% in the HFNC group versus 52% in the conventional oxygen strategy group (P = 0.05). The multivariate odds ratio of mortality for patients on HFNC was 0.375 compared to a conventional oxygen strategy (95% confidence interval 0.122-1.151, P = 0.09). CONCLUSIONS: While HFNC appears to be safe as the initial treatment strategy for COVID-19 associated respiratory failure, HFNC did not result in a statistically significant difference in mortality compared to a conventional oxygen strategy. Further studies are needed to confirm these findings.

Impact of antibiotic choice on readmission in adults experiencing an acute COPD exacerbation.

PURPOSE: The impact of antibiotic therapy in managing acute chronic obstructive pulmonary disease (COPD) exacerbations requiring hospitalization remains unclear. We conducted a study to assess the impact of antibiotic therapy on the rate of 30-day readmission after discharge from a hospital stay for an acute COPD exacerbation. Additional study outcomes analyzed included the effects of antibiotic therapy on hospital length of stay, in-hospital mortality, 90-day and 12-month readmission rates, and time to next COPD exacerbation. METHODS: The study was an institutional review board-approved, retrospective, observational review of adult patients at a tertiary academic medical center. The medical records of patients 18 years of age or older who were hospitalized for an acute COPD exacerbation between January 2008 and December 2014 were evaluated. Included patients were stratified by receipt of guideline-appropriate, guideline-inappropriate, or no antibiotic therapy. Nonparametric data were analyzed using the Kruskal-Wallis test (nonparametric) and categorical data via χ 2 test, respectively. RESULTS: Three hundred twenty-five subjects were included; there were no significant differences in baseline characteristics in the 3 study groups. Sixty-eight percent of patients (n = 223) received antibiotics. The percentage of patients readmitted within 30 days did not differ between cohorts: 11.9% (appropriate therapy) vs 13.2% (nonappropriate therapy) vs 12.2% (no antibiotics) (P = 0.95 for all comparisons). Additionally, no detectable differences in 90-day or 12-month readmission rate, length of hospital day, or in-hospital mortality were found. However, a trend toward increased time to next COPD exacerbation was noted in those receiving antibiotics vs no antibiotics (352 days vs 192 days, P = 0.07). CONCLUSION: Treatment of COPD exacerbations with antibiotics did not impact readmission rates, length of hospital stay, in-hospital mortality, or time to next exacerbation. More investigation is warranted to assess the effect of antibiotics on time to next exacerbation, as well as comparative effectiveness between antibiotic classes.

Identification of risk factors for hypertension and tachycardia upon dexmedetomidine discontinuation.

PURPOSE: Dexmedetomidine may cause hypertension and tachycardia upon discontinuation. Risk factors are poorly described but may include prolonged infusion, higher doses, a history of hypertension, and abrupt cessation. This study aims to identify risk factors for hypertension and tachycardia upon dexmedetomidine discontinuation. MATERIALS/METHODS: In this single-center, case-control study, critically ill patients requiring dexmedetomidine for 6 h or more were screened for hypertension or tachycardia within 24 h of discontinuation. We compared baseline and dexmedetomidine-specific data between patients who developed hypertension or tachycardia (cases) and those who did not (controls) and used logistic regression to identify independent risk factors. RESULTS: Of 110 patients, 35 (31.8%) experienced hypertension or tachycardia. When comparing cases to controls, the maximum dexmedetomidine dose was 0.7 and 0.75 µg/kg/h (p = .54), cumulative dose was 1174.5 and 1063.5 µg/kg/h (p = .43), and duration was 31and 23.25 h (p = .22), respectively. Only a past medical history of hypertension was an independent predictor of hypertension or tachycardia upon dexmedetomidine discontinuation. CONCLUSIONS: Approximately one third of patients experienced hypertension or tachycardia upon dexmedetomidine discontinuation. A past medical history of hypertension was the only independent risk factor identified in this study based on the clinical data collected.

Enteric tube placement in patients with esophageal varices: Risks and predictors of postinsertion gastrointestinal bleeding.

BACKGROUND AND AIM: Enteric tube (ET) placement is approached with caution in patients with esophageal varices (EV) due to concern of causing variceal bleeding. Data are limited on rates and predictors of gastrointestinal bleeding (GIB) in these patients. This study aims to assess the rate and predictors of bleeding from EV after ET placement. METHODS: We performed a retrospective chart review on patients requiring ET access with known EV. Inclusion criteria were age >18 with endoscopically proven EV who required ET placement. Patients who were admitted with, or developed a GIB prior to placement of ET were excluded, as were patients admitted for liver transplantation. Primary outcome was incidence of GIB within 48 h of tube placement. Secondary outcome was a >2 g/dL drop in hemoglobin within 48 h of placement without evidence of bleed. Statistical analysis was performed using Fischer's exact test, Mann-Whitney U test, and univariate logistic regression model. RESULTS: A total of 75 patients were included in the analysis. The most common etiology of cirrhosis was alcohol (44%). The most common location of EV was in the lower third of the esophagus (61%). The primary outcome was observed in 11 (14.6%) patients. The secondary outcome was found in eight (10.6%) patients. On univariate analysis, GIB was associated with higher MELD-Na (P = 0.026) and EV located in the lower third of the esophagus (P = 0.048). CONCLUSION: ET placement in patients with EV is associated with low risk of bleeding. Elevated MELD-Na and lower EV location conferred a higher risk of bleeding after ET placement.

Efficacy of Oscillation and Lung Expansion in Reducing Postoperative Pulmonary Complication.

BACKGROUND: Postoperative pulmonary complications (PPCs) cause high morbidity and mortality. Targeted treatment for patients at risk for PPCs can improve outcomes. This multicenter prospective trial examined the impact of oscillation and lung expansion (OLE) therapy, using continuous high-frequency oscillation and continuous positive expiratory pressure on PPCs in high-risk patients. METHODS: In stage I, CPT and ICD codes were queried for patients (n = 210) undergoing thoracic, upper abdominal, or aortic open procedures at 3 institutions from December 2014 to April 2016. Patients were selected randomly. Age, comorbidities, American Society of Anesthesiologists physical status classification scores, and PPC rates were determined. In stage II, 209 subjects were enrolled prospectively from October 2016 to July 2017 using the same criteria. Stage II subjects received OLE treatment and standard respiratory care. The PPCs rate (prolonged ventilation, high-level respiratory support, pneumonia, ICU readmission) were compared. We also compared ICU length of stay (LOS), hospital LOS, and mortality using t-tests and analysis of covariance. Data are mean ± SD. RESULTS: There were 419 subjects. Stage II patients were older (61.1 ± 13.7 years vs 57.4 ± 15.5 years; p < 0.05) and had higher American Society of Anesthesiologists scores. Treatment with OLE decreased PPCs from 22.9% (stage I) to 15.8% (stage II) (p < 0.01 adjusted for age, American Society of Anesthesiologists score, and operation time). Similarly, OLE treatment reduced ventilator time (23.7 ± 107.5 hours to 8.5 ± 27.5 hours; p < 0.05) and hospital LOS (8.4 ± 7.9 days to 6.8 ± 5.0 days; p < 0.05). No differences in ICU LOS, pneumonia, or mortality were observed. CONCLUSIONS: Aggressive treatment with OLE reduces PPCs and resource use in high-risk surgical patients.

The impact of smoking on patient outcomes in severe sepsis and septic shock.

BACKGROUND: To assess, in the setting of severe sepsis and septic shock, whether current smokers have worse outcomes compared to non-smokers. METHODS: This is a retrospective analysis of immunocompetent adult patients with severe sepsis and septic shock at a tertiary medical center. The primary outcome was the effect of active smoking on hospital mortality. Chi-square test and logistic regression were used to assess categorical outcomes. Wilcoxon rank-sum was utilized to test the differences in continuous outcomes among the varied smoking histories. Multivariable logistic regression was used to evaluate the association of smoking and mortality, need for vasopressors, mechanical ventilation, and ICU admission. RESULTS: Of the 1437 charts reviewed, 562 patients were included. Current smokers accounted for 19% (107/562) of patients, while 81% (455/562) were non-smokers. The median hospital length of stay in survivors was significantly longer in current smokers versus non-smokers (8 vs 7 days, p = 0.03). There was a trend towards a higher mortality among current smokers, but this failed to meet statistical significance (OR 1.81, 95% CI 0.92-3.54, p = 0.08). On multivariable analysis, current smoking was associated with the need for mechanical ventilation (OR 2.38, 95% CI 1.06-5.34, p = 0.04), but that association was not observed with the need for vasopressors (OR 2.10, 95% CI 1.01-4.36, p = 0.58) nor ICU admission (OR 0.93, 95% CI 0.41-2.13, p = 0.86). CONCLUSIONS: In patients with severe sepsis or septic shock, current smoking was associated with a longer hospital stay, the need for mechanical ventilation, and trended towards a higher mortality. Larger multicenter prospective case-control studies are needed to confirm these findings.

Utility and diagnostic accuracy of bedside lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration.

PURPOSE: We investigated the feasibility and diagnostic accuracy of lung ultrasonography during medical emergency team (MET) activations for respiratory deterioration. MATERIAL AND METHODS: We performed a prospective study of inpatients requiring MET evaluation for respiratory decompensation. A blinded investigator recorded videos of lung and lower extremity ultrasonography. The videos were reviewed by blinded investigators to determine a ultrasonography diagnosis. The accuracy of MET diagnosis and ultrasonography diagnosis were compared to the final diagnosis determined by retrospective chart review. RESULTS: The ultrasound exam was completed in 49/50 (98%) patients enrolled in the study with a mean duration of 13±4min. When excluding six cases that were not amenable to diagnosis by our algorithm, we report a lung ultrasonography diagnostic accuracy of 84% (37/44) which is similar to the accuracy of the MET clinical diagnosis of 75% (33/44) (p=0.29). Furthermore, we report in 28/37 (76%) of cases where the lung ultrasonography diagnosis was correct, patients may have received inappropriate therapies. CONCLUSIONS: Lung ultrasonography can be rapidly performed in the majority of patients with MET activation for respiratory deterioration. As an independent diagnostic test, lung ultrasonography is non-inferior to the MET clinical assessment and may prevent unnecessary treatments if used simultaneously.

Efficacy of High-Flow Nasal Cannula Therapy in Intensive Care Units.

PURPOSE: We conducted a meta-analysis to compare the physiological and clinical outcomes of high-flow nasal cannula (HFNC) with standard oxygen (O2) or conventional noninvasive ventilation (NIV) in intensive care units (ICUs). PROCEDURES: We selected the full-text prospective studies comparing HFNC with standard O2 or NIV in ICU. The continuous variables were analyzed with sample size-adjusted pooled t test. The categorical variables were extracted and combined for recalculating odds ratio. FINDINGS: We included 18 articles with 2004 patients. No difference was observed in the below outcomes comparing HFNC with standard O2: oxygen saturation (95.0% vs 93.8%, P = .27), Pao2/Fio2 (217.7 vs 161.9 mm Hg, P = .29), Paco2 (38.3 vs 39.3 mm Hg, P = .33), pH (7.416 vs 7.419, P = .90), discomfort (1.19 vs 1.44, P = .44), intubation or reintubation rate (odds ratio = 0.79, 95% confidence interval [CI]: 0.39-1.21, P = .27), and ICU stay (4.0 vs 4.5 days, P = .90). Below outcomes were modestly improved with HFNC compared to standard O2: respiratory rate (21.6 vs 24.7, P = .06) and ICU mortality (odds ratio = 0.69, 95% CI: 0.43-1.11, P = .13). Below outcomes were significantly improved with HFNC compared to standard O2: heart rate (89.1 vs 98.4, P = .03), Pao2 (104.5 vs 90.0 mm Hg, P = .04), and dyspnea (2.7 vs 4.3, P = .05). When comparing HFNC to NIV, below outcomes were significantly lower: Pao2 (106.9 vs 134.2 mm Hg, P = .02), Pao2/Fio2 (178.4 vs 220.0 mm Hg, P = .02), Paco2 (37.7 vs 39.2 mm Hg, P = .04), and ICU mortality (odds ratio = 0.39, 95% CI: 0.19-0.82, P = .01). CONCLUSION: When comparing to standard O2, the most effective outcomes from HFNC are reduced heart rate and dyspnea in both ICU and critical care unit patients. The HFNC modestly reduced intubation rate and ICU mortality. Patients with pneumonia may benefit from HFNC in reduced respiratory rate, heart rate, dyspnea, discomfort, intubation rate, ICU mortality, ICU stay, and improved Pao2. When comparing to NIV, HFNC group did not do as good in Pao2 and Pao2/Fio2 but had a slightly lower intubation rate and ICU mortality.

A Symptom-Triggered Benzodiazepine Protocol Utilizing SAS and CIWA-Ar Scoring for the Treatment of Alcohol Withdrawal Syndrome in the Critically Ill.

BACKGROUND: There are limited data on the efficacy of symptom-triggered therapy for alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU). OBJECTIVE: To evaluate the safety and efficacy of a symptom-triggered benzodiazepine protocol utilizing Riker Sedation Agitation Scale (SAS) scoring for the treatment of AWS in the ICU. METHODS: We performed a before-and-after study in a medical ICU. A protocol incorporating SAS scoring and symptom-triggered benzodiazepine dosing was implemented in place of a protocol that utilized the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale and fixed benzodiazepine dosing. RESULTS: We enrolled 167 patients (135 in the preintervention and 32 in the postintervention group). The median duration of AWS was shorter in the postintervention (5, interquartile range [IQR] = 4-8 days) than in the preintervention group (8, IQR = 5-12 days; P < 0.01). Need for mechanical ventilation (31% vs 57%, P = 0.01), median ICU length of stay (LOS; 4, IQR = 2-7, vs 7, IQR = 4-11 days, P = 0.02), and hospital LOS (9, IQR = 6-13, vs 13, IQR = 9-18 days; P = 0.01) were less in the postintervention group. There was a reduction in mean total benzodiazepine exposure (74 ± 159 vs 450 ± 701 mg lorazepam; P < 0.01) in the postintervention group. CONCLUSION: A symptom-triggered benzodiazepine protocol utilizing SAS in critically ill patients is associated with a reduction in the duration of AWS treatment, benzodiazepine exposure, need for mechanical ventilation, and ICU and hospital LOS compared with a CIWA-Ar-based protocol using fixed benzodiazepine dosing.

Pre-emptive antibiotic therapy to reduce ventilator-associated pneumonia: "thinking outside the box".

Mechanically ventilated, intubated patients are at increased risk for tracheal colonization with bacterial pathogens that may progress to heavy bacterial colonization, ventilator-associated tracheobronchitis (VAT), and/or ventilator-associated pneumonia (VAP). Previous studies report that 10 to 30 % of patients with VAT progress to VAP, resulting in increased morbidity and significant acute and chronic healthcare costs. Several natural history studies, randomized, controlled trials, and a meta-analysis have reported antibiotic treatment for VAT can reduce VAP, ventilator days, length of intensive care unit (ICU) stay, and patient morbidity and mortality. We discuss early diagnostic criteria, etiologic agents, and benefits of initiating, early, appropriate intravenous or aerosolized antibiotic(s) to treat VAT and reduce VAP, to improve patient outcomes by reducing lung damage, length of ICU stay, and healthcare costs.

Does Robotic Telerounding Enhance Nurse-Physician Collaboration Satisfaction About Care Decisions?

BACKGROUND: Delivering healthcare using remote robotic telepresence is an evolving practice in medical and surgical intensive critical care units and will likely have varied implications for work practices and working relationships in intensive care units. Our study assessed the nurse-physician collaboration satisfaction about care decisions from surgical intensive critical care nurses during remote robotic telepresence night rounds in comparison with conventional telephone night rounds. MATERIALS AND METHODS: This study used a randomized trial to test whether robotic telerounding enhances the nurse-physician collaboration satisfaction about care decisions. A physician randomly used either the conventional telephone or the RP-7 robot (InTouch(®) Health, Santa Barbara, CA) to perform nighttime rounding in a surgical intensive care unit. The Collaboration and Satisfaction About Care Decisions (CSACD) survey instrument was used to measure the nurse-physician collaboration. The CSACD scores were compared using the signed-rank test with a significant p value of ≤0.05. RESULTS: From December 1, 2011 to December 13, 2012, 20 off-shift nurses submitted 106 surveys during telephone rounds and 108 surveys during robot rounds. The median score of surveys during robot rounds was slightly but not significantly higher than telephone rounds (51.3 versus 50.5; p=0.3). However, the CSACD score was significantly increased from baseline with robot rounds (51.3 versus 43.0; p=0.01), in comparison with telephone rounds (50.5 versus 43.0; p=0.09). The mediators, including age, working experience, and robot acceptance, were not significantly (p>0.1) correlated with the CSACD score difference (robot versus telephone). CONCLUSIONS: Robot rounding in the intensive care unit was comparable but not superior to the telephone in regard to the nurse-physician collaboration and satisfaction about care decision. The working experience and technology acceptance of intensive care nurses did not contribute to the preference of night shift rounding method from the aspect of collaboration with the physician about care decision-making.

Antibiotic treatment of ventilator-associated tracheobronchitis: to treat or not to treat?

PURPOSE OF REVIEW: To evaluate the data on antimicrobial therapy for ventilator-associated tracheobronchitis (VAT) to prevent ventilator-associated pneumonia (VAP), and its impact on patient outcomes. RECENT FINDINGS: Mechanically ventilated patients are at increased risk for tracheal colonization with bacterial pathogens that may progress to VAT and/or VAP. Previous studies suggest that 10-30% of patients with VAT progress to VAP, which results in increased morbidity but not mortality. Several natural history studies and small randomized controlled trials and a meta-analysis reported that appropriate, pre-emptive antibiotic treatment for VAT reduces VAP, duration of intubation and length of ICU stay. SUMMARY: This review focuses on diagnostic criteria for VAT and VAP, etiologic agents, rationale and benefits of initiating pre-emptive, appropriate antibiotic treatment for VAT to prevent VAP, improve patient outcomes and associated acute and chronic healthcare costs.

Resource utilization and end-of-life care in a US hospital following medical emergency team-implemented do not resuscitate orders.

BACKGROUND: Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE: To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN: Retrospective review. SETTING: Single, tertiary care center. PATIENTS: Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS: Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS: None. RESULTS: We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS: Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.

Ventilator-associated tracheobronchitis: pre-emptive, appropriate antibiotic therapy recommended.

Nseir and colleagues presented data from a large multicenter study of patients with ventilator-associated tracheobronchitis (VAT), demonstrating that appropriate antibiotic therapy for VAT was an independent predictor for reducing transition to pneumonia (ventilator-associated pneumonia, or VAP). These data added to the growing evidence supporting the use of appropriate antibiotic therapy for VAT as a standard of care to prevent VAP and improve patient outcomes.