Vax the Max, a Gamification Intervention for COVID-19 Vaccination Task Engagement in the Inpatient Setting.

The development of vaccines for SARS-CoV-2 has offered game-changing protection from severe disease and death from COVID-19. Despite efforts to vaccinate individuals in the ambulatory setting, a sizable minority of the US population remains unvaccinated for COVID-19. For unvaccinated patients, hospitalization for non-COVID-19 illness offers another opportunity for vaccination. In the summer of 2021, the authors noted that COVID-19 vaccination rate for medicine inpatients at their hospital had fallen to 5.3 vaccine doses administered per 4-week block. In response, they created Vax the Max, a gamification program of COVID-19 vaccination tasks where internal medicine resident teams were awarded points for completing these tasks. Residents were anonymously surveyed after participation. The hospital demonstrated higher rates of administering the initial COVID-19 vaccine dose and completing the vaccine series in the inpatient setting per 4-week plan-do-study-act cycle after implementation of Vax the Max (5.3 versus 8.8 doses per plan-do-study-act cycle). Among residents, 76.8% reported that Vax the Max spurred their COVID-19 task engagement, and 66% reported that a similar gamification model could be utilized for a different clinical task in the future. An increase was observed in the COVID-19 vaccination rate for medicine inpatients after launching the Vax the Max competition. This occurred in the setting of resident turnover every 4 weeks, which normally makes practice sustainment more challenging. Despite this, a high degree of engagement was produced by itinerant residents. There is potential to explore similar gamification approaches involving resident physicians in areas of quality improvement and patient safety.

"It's Not Just Time Off": A Framework for Understanding Factors Promoting Recovery From Burnout Among Internal Medicine Residents.

BACKGROUND: Burnout rates for internal medicine residents are among the highest of all specialties, yet little is known about how residents recover from burnout. OBJECTIVE: We identified factors promoting recovery from burnout and factors that assist with the subsequent avoidance of burnout among internal medicine residents. METHODS: A purposive sample of postgraduate year 2 (PGY-2), PGY-3, and recent graduates who experienced and recovered from burnout during residency participated in semistructured, 60-minute interviews from June to August 2016. Using qualitative methods derived from grounded theory, saturation of themes occurred after 25 interviews. Coding was performed in an iterative fashion and consensus was reached on major themes. RESULTS: Coding revealed 2 different categories of resident burnout-circumstantial and existential-with differing recovery and avoidance methods. Circumstantial burnout stemmed from self-limited circumstances and environmental triggers. Recovery from, and subsequent avoidance of, circumstantial burnout arose from (1) resolving workplace challenges; (2) nurturing personal lives; and (3) taking time off. In contrast, existential burnout stemmed from a loss of meaning in medicine and an uncertain professional role. These themes were identified around recovery: (1) recognizing burnout and feeling validated; (2) connecting with patients and colleagues; (3) finding meaning in medicine; and (4) redefining a professional identity and role. CONCLUSIONS: Our study suggests that residents experience different types of burnout and have variable methods by which they recover from and avoid further burnout. Categorizing residents' burnout into circumstantial versus existential experiences may serve as a helpful framework for formulating interventions.

Improving Ambulatory Training in Internal Medicine: X + Y (or Why Not?).

The Accreditation Council for Graduate Medical Education (ACGME) requirement that internal medicine residents spend one-third of their training in an ambulatory setting has resulted in programmatic innovation across the country. The traditional weekly half-day clinic model has lost ground to the block or "X + Y" clinic model, which has gained in popularity for many reasons. Several disadvantages of the block model have been reported, however, and residency programs are caught between the threat of old and new challenges. We offer the perspectives of three large residency programs (University of Washington, Emory University, and Massachusetts General Hospital) that have successfully navigated scheduling challenges in our individual settings without implementing the block model. By sharing our innovative non-block models, we hope to demonstrate that programs can and should create the solution that fits their individual needs.

Shortening the Miles to the Milestones: Connecting EPA-Based Evaluations to ACGME Milestone Reports for Internal Medicine Residency Programs.

The Next Accreditation System requires internal medicine training programs to provide the Accreditation Council for Graduate Medical Education (ACGME) with semiannual information about each resident's progress in 22 subcompetency domains. Evaluation of resident "trustworthiness" in performing entrustable professional activities (EPAs) may offer a more tangible assessment construct than evaluations based on expectations of usual progression toward competence. However, translating results from EPA-based evaluations into ACGME milestone progress reports has proven to be challenging because the constructs that underlay these two systems differ.The authors describe a process to bridge the gap between rotation-specific EPA-based evaluations and ACGME milestone reporting. Developed at the University of Washington in 2012 and 2013, this method involves mapping EPA-based evaluation responses to "milestone elements," the narrative descriptions within the columns of each of the 22 internal medicine subcompetencies. As faculty members complete EPA-based evaluations, the mapped milestone elements are automatically marked as "confirmed." Programs can maintain a database that tallies the number of times each milestone element is confirmed for a resident; these data can be used to produce graphical displays of resident progress along the internal medicine milestones.Using this count of milestone elements allows programs to bridge the gap between faculty assessments of residents based on rotation-specific observed activities and semiannual ACGME reports based on the internal medicine milestones. Although potentially useful for all programs, this method is especially beneficial to large programs where clinical competency committee members may not have the opportunity for direct observation of all residents.

Intensive care unit-acquired neuromyopathy and corticosteroids in survivors of persistent ARDS.

OBJECTIVES: To determine the incidence and outcomes of intensive care unit-acquired neuromyopathy and to investigate the role of methylprednisolone in survivors of persistent acute lung injury. DESIGN: Secondary analysis of completed randomized placebo-controlled trial. SETTING: Twenty-five hospitals in the NHLBI ARDS Network. PATIENTS AND PARTICIPANTS: Patients enrolled in the ARDS Network study of methylprednisolone versus placebo for persistent ARDS who survived 60 days or to hospital discharge. MEASUREMENTS AND RESULTS: One hundred and twenty-eight study patients survived 60 days. Forty-three (34%) of these patients had evidence by chart review of ICU-acquired neuromyopathy, which was associated with prolonged mechanical ventilation, return to mechanical ventilation, and delayed return to home after critical illness. Treatment with methylprednisolone was not significantly associated with an increase in risk of neuromyopathy (OR 1.5; 95% CI 0.7-3.2). CONCLUSIONS: ICU-acquired-neuromyopathy is common among survivors of persistent ARDS and is associated with poorer clinical outcomes. We did not find a significant association between methylprednisolone treatment and neuromyopathy. Limitations of this study preclude definitive conclusions about the causal relationship between corticosteroids and ICU-acquired neuromuscular dysfunction.

Integrating palliative and critical care: evaluation of a quality-improvement intervention.

RATIONALE: Palliative care in the intensive care unit (ICU) is an important focus for quality improvement. OBJECTIVES: To evaluate the effectiveness of a multi-faceted quality improvement intervention to improve palliative care in the ICU. METHODS: We performed a single-hospital, before-after study of a quality-improvement intervention to improve palliative care in the ICU. The intervention consisted of clinician education, local champions, academic detailing, feedback to clinicians, and system support. Consecutive patients who died in the ICU were identified pre- (n = 253) and postintervention (n = 337). Families completed Family Satisfaction in the Intensive Care Unit (FS-ICU) and Quality of Dying and Death (QODD) surveys. Nurses completed the QODD. The QODD and FS-ICU were scored from 0 to 100. We used Mann-Whitney tests to assess family results and hierarchical linear modeling for nurse results. MEASUREMENTS AND MAIN RESULTS: There were 590 patients who died in the ICU or within 24 hours of transfer; 496 had an identified family member. The response rate for family members was 55% (275 of 496) and for nurses, 89% (523/590). The primary outcome, the family QODD, showed a trend toward improvement (pre, 62.3; post, 67.1), but was not statistically significant (P = 0.09). Family satisfaction increased but not significantly. The nurse QODD showed significant improvement (pre, 63.1; post, 67.1; P < 0.01) and there was a significant reduction in ICU days before death (pre, 7.2; post, 5.8; P < 0.01). CONCLUSIONS: We found no significant improvement in family-assessed quality of dying or in family satisfaction with care, we found but significant improvement in nurse-assessed quality of dying and reduction in ICU length of stay with an intervention to integrate palliative care in the ICU. Improving family ratings may require interventions that have more direct contact with family members.

Intensivist physician staffing and the process of care in academic medical centres.

BACKGROUND: Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation. OBJECTIVE: To determine the relationship between intensivist staffing and select process-based quality indicators in the intensive care unit. RESEARCH DESIGN: Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project. PATIENTS: 861 adult patients receiving prolonged mechanical ventilation in an intensive care unit. RESULTS: Patient-level information on physician staffing and process-of-care quality indicators were collected on day 4 of mechanical ventilation. By day 4, 668 patients received care under a high intensity staffing model (primary intensivist care or mandatory consult) and 193 patients received care under a low intensity staffing model (optional consultation or no intensivist). Among eligible patients, those receiving care under a high intensity staffing model were more likely to receive prophylaxis for deep vein thrombosis (risk ratio 1.08, 95% CI 1.00 to 1.17), stress ulcer prophylaxis (risk ratio 1.10, 95% CI 1.03 to 1.18), a spontaneous breathing trial (risk ratio 1.37, 95% CI 0.97 to 1.94), interruption of sedation (risk ratio 1.64, 95% CI 1.13 to 2.38) and intensive insulin treatment (risk ratio 1.40, 95% CI 1.18 to 1.79) on day 4 of mechanical ventilation. Models accounting for clustering by hospital produced similar estimates of the staffing effect, except for prophylaxis against thrombosis and stress ulcers. CONCLUSIONS: High intensity physician staffing is associated with increased use of evidence-based quality indicators in patients receiving mechanical ventilation.

Respiratory controversies in the critical care setting. Should tidal volume be 6 mL/kg predicted body weight in virtually all patients with acute respiratory failure?

Over the last 2 decades, it has become clear that mechanical ventilation itself can cause lung injury and affect outcome. The development of ventilator-induced lung injury is strongly associated with overdistension of lung parenchyma, and limiting lung stretch saves lives in patients with acute lung injury. The debate in this paper is whether all patients on mechanical ventilation should be managed with a tidal volume (V(T)) of 6 mL/kg predicted body weight. Current data indicate that reducing lung stretch should be the standard for all patients with acute lung injury and acute respiratory distress syndrome who require ventilatory support. However, insufficient data exist to indicate that a V(T) of 6 mL/kg predicted body weight should be the standard for all patients who require mechanical ventilation. Whether V(T) is the correct target for therapeutic interventions is debatable. Plateau pressure may be a better target for assessing and preventing alveolar over-distension. As the data evolve, it is conceivable that the actual V(T) used should be based on the individual patient's lung mechanics rather than assuming that one V(T) will suit all patients. Consensus at this time is not possible, and this paper presents the arguments on both sides of the controversy.

Respiratory controversies in the critical care setting. When caring for critically ill patients, do clinicians have a responsibility to be innovative and try unproven approaches when accepted approaches are failing?

As the first paper in this Journal Conference on intensive care unit controversies, the editors wished us to set the tone for the debate by discussing the ethics of medical "adventurism" in the intensive care unit. More life-or-death decisions are made in the intensive care unit than elsewhere in the hospital, and the critical care specialist often sees himself or herself as a warrior in a battle with death. This adrenaline-charged calling attracts highly intelligent, hard-working, and compassionate caregivers, as well as fiercely independent clinicians. The result of this is that critical care specialists passionately debate about the meaning and application of published "evidence" and this leads to thoughtful debate, as exemplified by the papers in this and the next issue of Respiratory Care, as well as thoughtless and often dangerous disregard for evidence-based medicine. Physicians are morally obligated to provide the best and most appropriate care possible for their patients, but when accepted approaches are failing and a critically ill patient is getting worse, the critical care physician must make a decision regarding innovative therapy, based on the patient's prognosis, the available evidence, the resources on hand, the expertise of the physicians, and the values of the patient and the physician. This decision may lead, at times, to trying unproven and innovative strategies to achieve a clinical goal. In such cases, it is to be hoped that this can be done in such a way that data are formally and prospectively collected to increase our knowledge.

The association between body mass index and clinical outcomes in acute lung injury.

BACKGROUND: The association between body mass index (BMI) and outcomes in critically ill patients is unclear. Our objective was to determine the association between BMI and outcomes in a population-based cohort of patients with acute lung injury (ALI). METHODS: In a prospective cohort study of all ICU patients in King County, Washington, with ALI in 1 year (1999 to 2000), 825 patients had a BMI recorded. Using multivariate analysis, patients in the abnormal BMI groups were compared to normal patients in the following areas: mortality, hospital length of stay (LOS), ICU LOS, duration of mechanical ventilation, and discharge disposition. RESULTS: There was no mortality difference in any of the abnormal BMI groups compared to normal-weight patients. Severely obese patients had longer hospital LOS than normal-weight patients (mean increase, 10.5 days; 95% confidence interval [CI], 4.8 to 16.2 days; p < 0.001); this was accentuated when analysis was restricted to survivors (mean increase, 14.3 days; 95% CI, 7.1 to 21.6 days; p < 0.001). ICU LOS and duration of mechanical ventilation were also longer in the severely obese group when analysis was restricted to survivors (mean increase, 5.6 days; 95% CI, 1.3 to 9.8 days; p = 0.01; and mean increase, 4.1 days; 95% CI, 0.4 to 7.7 days, respectively; p = 0.03). Severely obese patients were more likely to be discharged to a rehabilitation or skilled nursing facility than to home. CONCLUSIONS: BMI is not associated with mortality in patients with ALI, but severe obesity is associated with increased morbidity and resource utilization in the hospital and after discharge.

Integrating palliative and critical care: description of an intervention.

A large proportion of deaths in the United States occur in the intensive care unit (ICU) or after a stay in the ICU, and there is evidence of problems in the quality of care these patients and their families receive. In an effort to respond to this problem, we developed a multifaceted, nurse-focused, quality improvement intervention that is based on self-efficacy theory applied to changing clinician behavior. We have called the intervention "Integrating Palliative and Critical Care." This five-component intervention includes: 1) critical care clinician education to increase knowledge and awareness of the principles and practice of palliative care in the ICU, 2) critical care clinician local champions to provide role modeling and promote attitudinal change concerning end-of-life care, 3) academic detailing of nurse and physician ICU directors to identify and address local barriers to improving end-of-life care in each ICU, 4) feedback of local quality improvement data, and 5) system supports including implementation of palliative care order forms, family information pamphlets, and other system supports for providing palliative care in the ICU. The goal of this report is to describe the conceptual model that led to the development of the intervention, and for each of the five components, we describe the theoretical and empirical support for each component, the content of the component, and the lessons we have learned in implementing the component. Future reports will need to examine the ability of the interventions to improve outcomes of palliative care in the ICU.

Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome.

BACKGROUND: Persistent acute respiratory distress syndrome (ARDS) is characterized by excessive fibroproliferation, ongoing inflammation, prolonged mechanical ventilation, and a substantial risk of death. Because previous reports suggested that corticosteroids may improve survival, we performed a multicenter, randomized controlled trial of corticosteroids in patients with persistent ARDS. METHODS: We randomly assigned 180 patients with ARDS of at least seven days' duration to receive either methylprednisolone or placebo in a double-blind fashion. The primary end point was mortality at 60 days. Secondary end points included the number of ventilator-free days and organ-failure-free days, biochemical markers of inflammation and fibroproliferation, and infectious complications. RESULTS: At 60 days, the hospital mortality rate was 28.6 percent in the placebo group (95 percent confidence interval, 20.3 to 38.6 percent) and 29.2 percent in the methylprednisolone group (95 percent confidence interval, 20.8 to 39.4 percent; P=1.0); at 180 days, the rates were 31.9 percent (95 percent confidence interval, 23.2 to 42.0 percent) and 31.5 percent (95 percent confidence interval, 22.8 to 41.7 percent; P=1.0), respectively. Methylprednisolone was associated with significantly increased 60- and 180-day mortality rates among patients enrolled at least 14 days after the onset of ARDS. Methylprednisolone increased the number of ventilator-free and shock-free days during the first 28 days in association with an improvement in oxygenation, respiratory-system compliance, and blood pressure with fewer days of vasopressor therapy. As compared with placebo, methylprednisolone did not increase the rate of infectious complications but was associated with a higher rate of neuromuscular weakness. CONCLUSIONS: These results do not support the routine use of methylprednisolone for persistent ARDS despite the improvement in cardiopulmonary physiology. In addition, starting methylprednisolone therapy more than two weeks after the onset of ARDS may increase the risk of death. (ClinicalTrials.gov number, NCT00295269.).

Causes and timing of death in patients with ARDS.

BACKGROUND: Since the early 1980s, case fatality of patients with ARDS has decreased, and explanations are unclear. DESIGN AND METHODS: Using identical definitions of ARDS and organ failure, we analyzed consecutive cohorts of patients meeting syndrome criteria at our institution in 1982 (n = 46), 1990 (n = 112), 1994 (n = 99), and 1998 (n = 205) to determine causes and timing of death. RESULTS: Overall case fatality has decreased from 68% in 1981-1982 to a low of 29% in 1996, plateauing since the mid-1990s (p = 0.001 for trend). Sepsis syndrome with multiple organ failure remains the most common cause of death (30 to 50%), while respiratory failure causes a small percentage (13 to 19%) of deaths. The distribution of causes of death has not changed over time. There was no change in the timing of death during the study periods: 26 to 44% of deaths occurred early (< 72 h after ARDS onset), and 56 to 74% occurred late (> 72 h after ARDS onset). However, the increased survival over the past 2 decades is entirely accounted for by patients who present with trauma and other risk factors for their ARDS, while survival for those patients whose risk factor is sepsis has not changed. Additionally, withdrawal of life support in these patients is now occurring at our institution significantly more frequently than in the past, and median time until death has decreased in patients who have support withdrawn. CONCLUSIONS: While these results do not explain the overall case fatality decline in ARDS, they do indicate that sepsis syndrome remains the leading cause of death and suggest that future therapies to improve survival be targeted at reducing the complications of sepsis.

Factors associated with nurse assessment of the quality of dying and death in the intensive care unit.

OBJECTIVE: To determine the feasibility of using nurse ratings of quality of dying and death to assess quality of end-of-life care in the intensive care unit and to determine factors associated with nurse assessment of the quality of dying and death for patients dying in the intensive care unit. DESIGN: Prospective cohort study. SETTING: Hospital intensive care unit. PATIENTS: 178 patients who died in an intensive care unit during a 10-month period at one hospital. INTERVENTIONS: Nurses completed a 14-item questionnaire measuring the quality of dying and death in the intensive care unit (QODD); standardized chart reviews were also completed. MEASUREMENTS AND MAIN RESULTS: Five variables were found to be associated with QODD scores. Higher (better) scores were significantly associated with having someone present at the time of death (p <.001), having life support withdrawn (p =.006), having an acute diagnosis such as intracranial hemorrhage or trauma (p =.007), not having cardiopulmonary resuscitation in the last 8 hrs of life (p <.001), and being cared for by the neurosurgery or neurology services (p =.002). Patient age, chronic disease, and Glasgow Coma Scale scores were not associated with the 14-item QODD. Using multivariate analyses, we identified three variables as independent predictors of the QODD score: a) not having cardiopulmonary resuscitation performed in the last 8 hrs of life; b) having someone present at the moment of death; and c) being cared for by neurosurgery or neurology services. CONCLUSIONS: Intensive care unit nurse assessment of quality of dying and death is a feasible method for obtaining quality ratings. Based on nurse assessments, this study provides evidence of some potential targets for interventions to improve the quality of dying for some patients: having someone present at the moment of death and not having cardiopulmonary resuscitation in the last 8 hrs of life. If nurse-assessed quality of dying is to be a useful tool for measuring and improving quality of end-of-life care, it is important to understand the factors associated with nurse ratings.

Narcotic and benzodiazepine use after withdrawal of life support: association with time to death?

OBJECTIVE: To determine whether the dose of narcotics and benzodiazepines is associated with length of time from mechanical ventilation withdrawal to death in the setting of withdrawal of life-sustaining treatment in the ICU. DESIGN: Retrospective chart review. SETTING: University-affiliated, level I trauma center. PATIENTS: Consecutive critically ill patients who had mechanical ventilation withdrawn and subsequently died in the ICU during two study time periods. RESULTS: There were 75 eligible patients with a mean age of 59 years. The primary ICU admission diagnoses included intracranial hemorrhage (37%), trauma (27%), acute respiratory failure (27%), and acute renal failure (20%). Patients died during a median of 35 min (range, 1 to 890 min) after ventilator withdrawal. On average, 16.2 mg/h opiates in morphine equivalents and 7.5 mg/h benzodiazepine in lorazepam equivalents were administered during the time period starting 1 h before ventilator withdrawal and ending at death. There was no statistically significant relationship between the average hourly narcotic and benzodiazepine use during the 1-h period prior to ventilator withdrawal until death, and the time from ventilator withdrawal to death. The restriction of medication assessment in the last 2 h of life showed an inverse association between the use of benzodiazepines and time to death. For every 1 mg/h increase in benzodiazepine use, time to death was increased by 13 min (p = 0.015). There was no relationship between narcotic dose and time to death during the last 2 h of life (p = 0.11). CONCLUSIONS: We found no evidence that the use of narcotics or benzodiazepines to treat discomfort after the withdrawal of life support hastens death in critically ill patients at our center. Clinicians should strive to control patient symptoms in this setting and should document the rationale for escalating drug doses.

Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit.

OBJECTIVE: The intensive care unit remains a setting where death is common, and a large proportion of these deaths are preceded by withdrawal of life support. We describe a quality improvement project implementing and evaluating a "withdrawal of life support order form" to improve quality of end-of-life care in the intensive care unit. DESIGN: Before-after evaluation. SETTING: County-owned, university-operated, tertiary, level I trauma center. SUBJECTS: Subjects were 143 nurses and 61 physicians. INTERVENTIONS: We conducted a before-after evaluation of the order form's implementation. The order form has sections on preparations, sedation/analgesia, withdrawal of mechanical ventilation, and the principles of life support withdrawal. To evaluate the form, we surveyed intensive care unit clinicians regarding satisfaction with the form, measured nurse-assessed quality of dying and death with a 14-item survey (scored 0 for worst possible death to 100 for best possible), and performed chart review to assess narcotic and benzodiazepine use and time from ventilator withdrawal to death. MEASUREMENTS AND MAIN RESULTS: We surveyed 143 nurses and 61 physicians about satisfaction with the form. Among nurses reporting that the form was used (n = 73), most (84%) reported that the order form was helpful and they were most satisfied with the sedation and mechanical ventilation sections. Almost all physicians found the form helpful (95%), and > 70% of physicians found three of the four sections helpful (sedation, mechanical ventilation, and preparations). We obtained quality of dying and death scores for 41 patient deaths before and 76 deaths after the intervention. These scores did not significantly change (mean preintervention score, 78.3; mean postintervention score, 74.2; p = .54) before and after the intervention. Total doses of narcotics and benzodiazepines increased after implementation of the order form in the hour before ventilator withdrawal, the hour after ventilator withdrawal, and the hour before death (p < or = .03). There was no change in the median time from ventilator withdrawal to death (preintervention 37 mins, postintervention 39 mins; p = .49). CONCLUSIONS: Nurses and physicians found the withdrawal of life support order form helpful. The order form did not improve nurses' assessment of patients' dying experience. Medications for sedation increased during the postorder form period without evidence of significantly hastening death. Although the order form was helpful to clinicians and changed medication delivery, demonstrating clear improvements in quality of dying may require larger sample sizes, more sensitive measures, or more effective interventions.

Chronic alcohol abuse is associated with an increased incidence of acute respiratory distress syndrome and severity of multiple organ dysfunction in patients with septic shock.

OBJECTIVE: Alcohol is one of the most commonly used drugs in the world and causes dysfunction in many vital organs. However, the effects of chronic alcohol abuse on acute lung injury and nonpulmonary organ dysfunction are relatively unexplored. The goal of this study was to determine the effects of chronic alcohol abuse on the incidence and severity of the acute respiratory distress syndrome and multiple organ dysfunction syndrome in patients with septic shock. DESIGN: Multicenter prospective epidemiologic study. SETTING: Intensive care units of four university urban hospitals. PATIENTS A total of 220 critically ill patients with septic shock. MEASUREMENTS AND MAIN FINDINGS: Thirty percent of the patients (66 of 220) were identified as having a history of chronic alcohol abuse based on a positive response to an alcohol screening questionnaire. The incidence of acute respiratory distress syndrome in patients with a positive history of chronic alcohol abuse was 70% (46 of 66), compared with 31% (47 of 154) in individuals without a history of chronic alcohol abuse (p < .001). After adjusting for differences in the source of infection, sex, age, chronic hepatic dysfunction, diabetes, severity of illness, nutritional status, and smoking status, the effects of chronic alcohol abuse on the incidence of acute respiratory distress syndrome remained significant (p < .001; odds ratio, 3.70; 95% confidence interval, 1.83-7.71). The effect of the source of infection (pulmonary vs. nonpulmonary) on the development of acute respiratory distress syndrome also remained significant in this multivariable analysis (p < .001; odds ratio, 3.68; 95% confidence interval, 1.95-7.18). Based on the highest daily Sequential Organ Failure Assessment score, patients with a history of chronic alcohol abuse had more severe nonpulmonary organ dysfunction when compared with nonalcoholics (9.42 +/- 3.89 vs. 8.05 +/- 4.10, p = .01). After adjusting for source of infection, sex, age, nutritional status, history of diabetes, and smoking status, the effects of chronic alcohol abuse on the incidence of nonpulmonary organ dysfunction also remained significant (p = .03; odds ratio, 2.07; 95% confidence interval, 1.09-3.97). CONCLUSIONS: We conclude that chronic alcohol abuse is an independent risk factor for acute respiratory distress syndrome and increases the severity of nonpulmonary organ dysfunction in patients with septic shock.