The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives.

BACKGROUND: High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE: This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD: An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS: A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION: A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Bypassing the Brick-and-Mortar Hospital: Increasing Direct Admissions from the Emergency Department to Inpatient Hospital-at-Home.

Home hospital programs continue to grow across the United States. There are limited studies around the process of patient selection and successful acquisition from the emergency department. The article describes how an interdisciplinary team used quality improvement methodology to significantly increase the number of admissions directly from the emergency department to the Advanced Care at Home program.

A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis.

Background: The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients. Method: We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups. Results: Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing. Conclusion: In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.

REadmission PREvention in SepSis: Development and Validation of a Prediction Model.

ABSTRACT: Hospital 30-day readmissions remain a major quality and cost indicator. Traditional readmission risk scores, such as LACE (length of stay, acuity of admission, Charlson comorbidity index, and emergency department visits), may be suboptimal in special patient populations, such as those with sepsis. As sepsis survivorship improves, there is a need to determine which variables might be associated with a decrease in 30-day readmission. We completed a retrospective analysis reviewing patients with sepsis who had unplanned 30-day readmissions. Multivariate regression analysis was performed for the REadmission PREvention in SepSis (REPRESS) model, which evaluated age, length of stay, Charlson disease count, Richmond Agitation-Sedation Scale score, discharge to a skilled nursing facility, and mobility for predictive significance in hospital readmission. Our REPRESS model performed better when compared with LACE for predicting readmission risk in a sepsis population.

Surviving Sepsis Guideline-Directed Fluid Resuscitation: An Assessment of Practice Patterns and Impact on Patient Outcomes.

IMPORTANCE: Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage. OBJECTIVES: Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation. DESIGN: Large, multisite retrospective cohort study. SETTING AND PARTICIPANTS: The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis. MAIN OUTCOMES AND MEASURES: Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0-29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay. RESULTS: We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight). CONCLUSIONS AND RELEVANCE: IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.

C19TM: A nurse practitioner and physician assistant-led telemonitoring initiative ensures timely transfer of critically ill coronavirus disease 2019 patients.

ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic has required swift implementation of innovative practices in health care across the globe. We describe a nurse practitioner (NP) and physician assistant (PA)-led initiative to implement telemonitoring (TM) of noncritical patients with COVID-19 by critical care NPs and PAs (C19TM) for early detection of decompensation and early transfer to the intensive care unit (ICU). Every hospitalized patient with suspected or confirmed COVID-19 received an initial telemedicine consult with a critical care NP or PA. Patients were subsequently monitored via electronic health record once every 12-hour shift for the following indicators: oxygen modality and flow, increase in oxygen requirements, sustained tachypnea, and hemodynamic instability. If signs of decompensation were noted, the NP/PA would remotely reassess the patient, provide recommendations to the hospital internal medicine team, and transfer the patient to the ICU. The primary goal was to avoid cardiopulmonary deterioration requiring aerosol-generating procedures outside of the ICU. Over 65 days, 113 patients (86 suspected and 27 confirmed) were enrolled in C19TM. As a result, there were 13 transfers to the ICU, none of which required an aerosol-generating procedure outside of the ICU.

Neuro R2 score: Predicting high-risk neurologic readmissions within 30 days.

OBJECTIVE: To evaluate clinical and demographic factors of patients with neurologic disorders to determine which patient characteristics are significant for predicting 30-day hospital readmissions to develop a readmission risk predictor specific to patients with neurologic disorders. METHODS: We performed a retrospective single-center chart review for all patients admitted to the Department of Neurology or neurologic intensive care unit from January 1, 2013, to December 31, 2017. Clinical and demographic factors were analyzed to determine the association with readmission. Multivariable logistic regression analysis was performed and validated to develop a simple tool (Neuro R2 score) for predicting patients with neurologic disorders at high risk for hospital readmission. RESULTS: After removal of planned readmissions and patients who died in the hospital, the records of 4,876 patients with 314 (6.4%) readmission events were analyzed. The strongest predictors for readmission were Charlson disease count (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.06-1.35, p = 0.005), urgent or emergent admission (OR 1.50, 95% CI 1.04-2.17, p = 0.031), discharge to rehabilitation (OR 1.66, 95% CI 1.16-2.35, p = 0.005), cancer (OR 1.70, 95% CI 1.15-2.50, p = 0.007), brain tumor (OR 1.82, 95% CI 1.08-3.09, p < 0.03), cerebrovascular disease (OR 2.18, 95% CI 1.53-3.11, p < 0.001), and discharge to skilled nursing facility (OR 2.43, 95% CI 1.65-3.57, p < 0.001). CONCLUSIONS: The Neuro R2 score was developed to predict readmission risk, specifically in patients with neurologic disorders. Future research could include further validation of this readmission risk tool and strategies to reduce readmission in patients with the highest risk.

Focused transthoracic echocardiography curriculum for advanced practice providers assures good concordance with intensivists at echocardiography.

OBJECTIVE: To describe a focused transthoracic echocardiography (FoTE) curriculum for advanced practice providers (APPs) for echocardiography-driven diagnosis of shock in critically ill patients. METHODS: Twelve APPs in 4 intensive care units at an academic medical center received didactic sessions on FoTE, including 1-on-1 proctorship with a registered cardiac sonographer. For a period of 6 months the trainees performed individual studies, then they performed FoTE examinations on critically ill patients; their diagnoses were compared with those of experienced intensivists for the same patients. RESULTS: After 6 months of multiple steps of training, APPs could acquire good echocardiographic views, achieving a good inter-rater agreement (Cohen's κ of 0.745 [95% CI, 0.385-1.0; P < .01]) in the diagnosis of shock when compared to experienced intensivists. CONCLUSIONS: Structured FoTE curriculum enables APPs to have reasonably good diagnostic concordance with intensivists in an echocardiography-driven diagnosis of shock in critically ill patients.

Sepsis and Shock Response Team: Impact of a Multidisciplinary Approach to Implementing Surviving Sepsis Campaign Guidelines and Surviving the Process.

The Surviving Sepsis Campaign guidelines are designed to decrease mortality through consistent application of a 7-element bundle. This study evaluated the impact of improvement in bundle adherence using a time-series analysis of compliance with the bundle elements before and after interventions intended to improve the process, while also looking at hospital mortality. This article describes interventions used to improve bundle compliance and hospital mortality in patients admitted through the emergency department with sepsis, severe sepsis, or septic shock. Quality improvement methodology was used to develop high-impact interventions that led to dramatically improved adherence to the Surviving Sepsis Campaign guidelines bundle. Improved performance was associated with a significant decrease in the in-hospital mortality of severe sepsis patients presenting to the emergency department.

Acute Liver Failure.

Acute liver failure, also known as fulminant hepatic failure, is a rare life-threatening disease that has a high mortality rate and affects many organ systems. Causes of acute liver failure vary-it can be attributed to drugs, viruses, and other uncommon sources. Complications of liver failure can include encephalopathy, cerebral edema, sepsis, renal failure, gastrointestinal bleeding, and respiratory failure. Fortunately, with advances in critical care medicine and emergent liver transplant, mortality rates have decreased in the past decade. This article reviews acute liver failure, its manifestations in different organ systems, and its treatment.