Multisociety task force for critical care research: key issues and recommendations.

BACKGROUND: Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. OBJECTIVE: To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. METHODS: The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the U.S. Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. RESULTS: The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: (1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; (2) an approach that more effectively links areas of research (i.e., basic and translational research, or clinical research and implementation) should be embraced; (3) future approaches to human research should account for disease complexity and patient heterogeneity; and (4) an enhanced infrastructure for critical care research is essential for future success. CONCLUSIONS: This document contains the themes/recommendations developed by a large, multiprofessional cross-section of critical care scientists, clinicians, and educators. It provides a unique framework for future research in critical care medicine.

Multisociety Task Force for Critical Care Research: key issues and recommendations.

BACKGROUND: Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. OBJECTIVE: To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. METHODS: The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. RESULTS: The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (i.e., basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. CONCLUSIONS: This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists, clinicians, and educators. It provides a unique framework for future research in critical care medicine.

Nursing considerations to complement the Surviving Sepsis Campaign guidelines.

OBJECTIVES: To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. DESIGN: Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. METHODS: We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. RESULTS: Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. CONCLUSION: Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.

Improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation.

Sepsis is a significant problem, and septicemia is the 10th leading cause of death in the United States. Sepsis incidence is increasing, and the mortality rate is 20% to 50% for patients with severe sepsis. This article identifies methods for improving outcomes of severe sepsis and septic shock. Included are recommendations for diagnosis and treatment. Case studies are included.

Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use.

BACKGROUND: Inadequate communication persists between healthcare professionals and patients and patients' families in intensive care units. Unwanted or ineffective treatments can occur when patients' goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients' outcomes and resource utilization. OBJECTIVES: To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit. METHODS: During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician. RESULTS: Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15,559 vs $24,080) and variable ($5087 vs $8035) costs. CONCLUSIONS: Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients' families reduced lengths of stay and resource utilization.

Severe sepsis management are we doing enough?

For the first time in medical history, a drug has been shown to reduce the mortality associated with sepsis, the leading cause of death in many ICUs. Optimal use by appropriate selection of patients and early recognition of sepsis could save thousands of lives. Nurses play a major role in recognizing severe sepsis. By using the concepts introduced here, nurses can play a direct role in saving the lives of patients with sepsis.

Monitoring carbon dioxide in critical care: the newest vital sign?

Carbon dioxide (CO(2)) monitoring can yield substantial information about cardiac and pulmonary function. Because capnography is not complicated, it is relatively easy to apply in a wide variety of clinical settings. A new area of CO(2) measurement is sublingual CO(2). Although outcomes data are as yet unavailable for this technology, its ease of use makes it an attractive monitoring tool to assess severity of illness and predict patients' responses to therapy. This article describes the pathophysiology and clinical applications of the technologies and describes why they may well be "the newest vital signs."

Will my patient survive this cardiac arrest?

The authors describe how capnography is used to predict patient outcomes during cardiopulmonary resuscitation.

Multisociety task force for critical care research: key issues and recommendations.

BACKGROUND: Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. OBJECTIVE: To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. METHODS: The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. RESULTS: The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (ie, basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. CONCLUSIONS: This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists, clinicians, and educators. It provides a unique framework for future research in critical care medicine.

Multisociety task force for critical care research: key issues and recommendations.

BACKGROUND: Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. OBJECTIVE: To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. METHODS: The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. RESULTS: The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (ie, basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. CONCLUSIONS: This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists, clinicians, and educators. It provides a unique framework for future research in critical care medicine.

Hemodynamics in sepsis.

Hemodynamics in sepsis change as sepsis develops. Initial hemodynamics of sepsis often are much different from later stages of sepsis, shifting from low cardiac output states to high cardiac output states. Tissue oxygenation also changes with initial mixed venous oxyhemoglobin (Svo2) or central venous oxyhemoglobin (Scvo2) levels below normal, with later stages reflecting high values. These changes occur as sepsis progresses, producing a marked disturbance in capillary flow and tissue oxygenation. Treatments for these changes in sepsis are different, making the identification of the hemodynamic state essential to optimally treat the patient. Fortunately, hemodynamic monitoring techniques are markedly improved from older techniques such as the pulmonary artery catheter. With noninvasive techniques such as esophageal and external Doppler for measuring hemodynamics, clinicians beyond the intensive care unit can make hemodynamic assessments that were not possible until just recently. This improved assessment should make it much easier to properly identify sepsis and initiate appropriate treatments in a timely manner.

Evidenced-based practice: priorities and implementation strategies.

Evidenced-based practice (EBP) should be a driving force behind establishing optimal clinical practices. Recently, clinicians and hospitals have started efforts to introduce key EBP. These efforts hold the potential to improve patient outcomes and reduce costs. However, many practices need updating with EBP. Which ones should be chosen? While practices often vary in terms of importance for each hospital, some changes in practice are likely to have a better return on the investment (ROI). Two key areas affecting most hospitals are practices associated with high costs and increased mortality. In critical care areas, these two key areas often involve addressing outlier management and severe sepsis. In addition, the recognition of the need for the change is only one step in ensuring EBP. To ensure EBP is implemented, clinical leaders who will ensure that the new practice standards are being utilized are necessary. Fortunately, many hospitals have strong leaders. The advanced practice nurse (APN) is one such leader. The APN is often in a unique position to help recognize, prioritize, and implement EBP into the hospitals culture. This article illustrates steps in making EBP a reality by highlighting the management of outliers and severe sepsis and the implementation strategies for these conditions.

Capnography application in acute and critical care.

The use of capnography has expanded over recent years. Currently, capnography is used in a variety of acute care settings. This article describes what capnography is and how it is used. The normal and abnormal capnogram or waveforms are described to assist in identifying various clinical situations. The multiplicity of clinical indications include detection of pulmonary embolism as well as malpositioned endotracheal/tracheal, gastric, and small bowel tubes. Capnography also provides clinicians with information regarding expiratory breathing patterns and assists in perfusion assessments such as those for cardiopulmonary resuscitation. Finally, case studies are provided to help the reader apply the concepts of capnography to a variety of acute care settings.

Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update.

OBJECTIVE: To provide the American College of Critical Care Medicine with updated guidelines for hemodynamic support of adult patients with sepsis. DATA SOURCE: Publications relevant to hemodynamic support of septic patients were obtained from the medical literature, supplemented by the expertise and experience of members of an international task force convened from the membership of the Society of Critical Care Medicine. STUDY SELECTION: Both human studies and relevant animal studies were considered. DATA SYNTHESIS: The experts articles reviewed the literature and classified the strength of evidence of human studies according to study design and scientific value. Recommendations were drafted and graded levels based on an evidence-based rating system described in the text. The recommendations were debated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. CONCLUSIONS: An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated.