Multidisciplinary Prerounding Meeting as a Continuous Quality Improvement Tool: Leveraging to Reduce Continuous Benzodiazepine Use at an Academic Medical Center.

BACKGROUND: Evidence-based medicine often has many barriers to overcome prior to implementation in practice, hence the importance of continuous quality improvement. We report on a brief (≤10 minutes) multidisciplinary meeting prior to rounds to establish a dashboard for continuous quality improvement and studied the success of this meeting on a particular area of focus: continuous infusion benzodiazepine minimization. METHODS: This was a prospective observational study of patients admitted to the medical intensive care unit (MICU) of a large academic medical center over a 4-month period. A morning multidisciplinary prerounding meeting was implemented to report on metrics required to establish a dashboard for MICU care for the previous 24 hours. Fellows and nurse practitioners on respective teams reported on key quality metrics and other important data related to patient census. Continuous benzodiazepines were tracked daily as the number of patients per team who had orders for a continuous benzodiazepine infusion. The aim of this report is to describe the development of the morning multidisciplinary prerounding meeting and its impact on continuous benzodiazepine use, along with associated clinical outcomes. RESULTS: The median number of patients prescribed a continuous benzodiazepine daily decreased over this time period and demonstrated a sustained reduction at 1 year. Furthermore, sedation scores improved, corresponding to a reduction in median duration of mechanical ventilation. The effectiveness of this intervention was mapped post hoc to conceptual models used in implementation science. CONCLUSIONS: A brief multidisciplinary meeting to review select data points prior to morning rounds establishes mechanisms for continuous quality improvement and may serve as a mediating factor for successful implementation when initiating and monitoring practice change in the ICU.

Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial.

Importance: Experimental data suggest that intravenous vitamin C may attenuate inflammation and vascular injury associated with sepsis and acute respiratory distress syndrome (ARDS). Objective: To determine the effect of intravenous vitamin C infusion on organ failure scores and biological markers of inflammation and vascular injury in patients with sepsis and ARDS. Design, Setting, and Participants: The CITRIS-ALI trial was a randomized, double-blind, placebo-controlled, multicenter trial conducted in 7 medical intensive care units in the United States, enrolling patients (N = 167) with sepsis and ARDS present for less than 24 hours. The study was conducted from September 2014 to November 2017, and final follow-up was January 2018. Interventions: Patients were randomly assigned to receive intravenous infusion of vitamin C (50 mg/kg in dextrose 5% in water, n = 84) or placebo (dextrose 5% in water only, n = 83) every 6 hours for 96 hours. Main Outcomes and Measures: The primary outcomes were change in organ failure as assessed by a modified Sequential Organ Failure Assessment score (range, 0-20, with higher scores indicating more dysfunction) from baseline to 96 hours, and plasma biomarkers of inflammation (C-reactive protein levels) and vascular injury (thrombomodulin levels) measured at 0, 48, 96, and 168 hours. Results: Among 167 randomized patients (mean [SD] age, 54.8 years [16.7]; 90 men [54%]), 103 (62%) completed the study to day 60. There were no significant differences between the vitamin C and placebo groups in the primary end points of change in mean modified Sequential Organ Failure Assessment score from baseline to 96 hours (from 9.8 to 6.8 in the vitamin C group [3 points] and from 10.3 to 6.8 in the placebo group [3.5 points]; difference, -0.10; 95% CI, -1.23 to 1.03; P = .86) or in C-reactive protein levels (54.1 vs 46.1 µg/mL; difference, 7.94 µg/mL; 95% CI, -8.2 to 24.11; P = .33) and thrombomodulin levels (14.5 vs 13.8 ng/mL; difference, 0.69 ng/mL; 95% CI, -2.8 to 4.2; P = .70) at 168 hours. Conclusions and Relevance: In this preliminary study of patients with sepsis and ARDS, a 96-hour infusion of vitamin C compared with placebo did not significantly improve organ dysfunction scores or alter markers of inflammation and vascular injury. Further research is needed to evaluate the potential role of vitamin C for other outcomes in sepsis and ARDS. Trial Registration: ClinicalTrials.gov Identifier: NCT02106975.

Feasibility of Contrasting Brain Connectivity Patterns in Cognitive and Motor Cerebral Networks to Clinical Outcomes in Patients Surviving Acute Respiratory Failure: A Pilot Study.

BACKGROUND: There is a paucity of research regarding the feasibility and association of cerebral cortex function to patient outcomes after acute respiratory failure (ARF). PURPOSE: To determine the feasibility of functional connectivity measures and examine the association of functional connectivity to a multifaceted battery of outcomes in survivors of ARF. METHODS: Eight ARF patients (age:58±3.7, ICU days:10.4±8.6) completed functional magnetic resonance imaging (fMRI), cognitive, physical-function, anxiety, depression, and driving simulator tests at one month post-hospital discharge. Pearson's correlations assessed the relationship between functional connectivity within the default mode network (FPN), sensorimotor network (SMN), and frontoparietal network (FPN) to outcomes. RESULTS: Low physical-function (r=0.75, p=0.03) and divided-attention (r=-0.86, p=0.03) during the driving simulator task correlated with low FPN connectivity. Low SMN connectivity demonstrated relationships to slower gait speed (r=0.82, p=0.01) and low short physical performance battery (SPPB) scores (r=0.81, p=0.01). CONCLUSIONS: fMRI is feasible to assess ARF patients' post-ICU limitations, as low post-ARF brain connectivity may be linked to low physical function, providing potential development of therapeutic interventions.

Mechanical Power: A New Concept in Mechanical Ventilation.

Mechanical ventilation is a potentially life-saving therapy for patients with acute lung injury, but the ventilator itself may cause lung injury. Ventilator-induced lung injury (VILI) is sometimes an unfortunate consequence of mechanical ventilation. It is not clear however how best to minimize VILI through adjustment of various parameters including tidal volume, plateau pressure, driving pressure, and positive end expiratory pressure (PEEP). No single parameter provides a clear indication for onset of lung injury attributable exclusively to the ventilator. There is currently interest in quantifying how static and dynamic parameters contribute to VILI. One concept that has emerged is the consideration of the amount of energy transferred from the ventilator to the respiratory system per unit time, which can be quantified as mechanical power. This review article reports on recent literature in this emerging field and future roles for mechanical power assessments in prospective studies.

Physical Function Measured Prior to Lung Transplantation Is Associated With Posttransplant Patient Outcomes.

INTRODUCTION: The primary objective of this study was to determine whether pretransplant physical function is correlated with posttransplantation outcomes. METHODS: We performed a retrospective study of patients that participated in pretransplantation screening and subsequently underwent lung transplantation. Pretransplant variables of interest included demographics, muscle mass, body composition, physical function, and physical frailty. Correlation tests were performed to assess relationships with significance set at 0.05. RESULTS: Twenty-five patients with a mean age of 57 ± 13 years (68% male) with pretransplant lung allocation score of 45 ± 14 were included. This cohort had a 3-year mortality rate of 32% (n = 8). Pretransplant 4-m gait speed was significantly related to performance on the Short Physical Performance Battery (r = 0.74, P = .02) and distance ambulated on the 6-minute walk test (r = 0.62, P = .07) at hospital discharge. Older age was associated with slower gait speed and worse performance on sit-to-stand testing at hospital discharge (r = -0.76, P = .01 and r = -0.75, P = .01, respectively). Statistically, only diagnosis of cystic fibrosis was associated with 3-year mortality. DISCUSSION: Our study demonstrates that demographic, clinical, and physical function assessed prior to lung transplantation may be indicators of functional recovery.

Low Yield of Thyroid-Function Tests in Adult Hospitalized Patients - A Retrospective Analysis.

BACKGROUND: In the US, serum thyroid-stimulating hormone (TSH) and thyroxine measurements are the fourth- and tenth-commonest laboratory tests ordered, respectively. Diagnosis of thyroid disorder requires clinical suspicion supported by laboratory values. However, in the setting of acute illness, both the clinical and laboratory pictures can be confounded. OBJECTIVE: To study clinical outcomes and derangement patterns of inpatient thyroid-function tests. DESIGN: This retrospective study was conducted at an academic center on admissions aged ≥18 years and TSH tests performed over a 1-year period. Admissions with active pregnancy and/or prior thyroid-related diagnosis were excluded. MAIN OUTCOMES: Clinical outcomes were divided based on new diagnosis of thyroid-related disorder, newly prescribed thyroxine replacement, or antithyroid drugs/ endocrinology referrals, or both. In order to analyze the derangement patterns of abnormal TSH, only the results of the first test ordered were considered (as some admissions had multiple TSH tests ordered). RESULTS: A total of 7,204 admissions aged ≥18 years had TSH tests done. Of these, 1,912 were excluded. Of the 5,292 admissions with no prior thyroid disorder or active pregnancy, 183 (3.46%) were assigned a new diagnosis of thyroid-related disorder, 54 (1.02%) received treatment/referral, and 46 (0.87%) received both a new diagnosis and treatment/referral. Based on the TSH results (reference range 0.42-4.0 mIU/L) of the 5,292 admissions, 4,312 (81.5%) and 980 (18.5%) admissions were flagged normal and abnormal, respectively. Of the 980 admissions with one or more abnormal TSH results, 21 (2.14%) had first ordered TSH <0.05 mIU/L, 855 (87.25%) admissions had first TSH result between 0.05-10 mIU/L, and lastly 104 (10.61%) were >10 mIU/L. CONCLUSION: There is low value in testing inpatients for thyroid disorders, and testing comes at significant expense to the health-care system.

ICU Recovery Clinic Attendance, Attrition, and Patient Outcomes: The Impact of Severity of Illness, Gender, and Rurality.

OBJECTIVES: The primary purpose is to characterize patients attending ICU recovery clinic and then describe their trajectory of cognitive and emotional health in 1 year. DESIGN: Retrospective observational study to assess attendance, attrition, and patient outcomes. SETTING: ICU Recovery Clinic. PATIENTS: Adult patients recently admitted to ICU for sepsis or acute respiratory failure and who were referred to clinic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-eight patients (63%) attended ICU recovery clinic with a mean age of 53.2 ± 16 years (range, 20-82 yr), 42% female and mean Sequential Organ Failure Assessment scores at an ICU admission of 9.4 ± 2.9 participated in outcomes. Twelve patients (32%) were lost to follow up and 12 patients (32%) were transferred to different providers before the end of 1 year. Sequential Organ Failure Assessment scores were negatively associated with health-related quality of life at baseline (r = -0.41; p = 0.033; n = 28) and short term (r = -0.40; p = 0.037; n = 27). Male patients had higher Sequential Organ Failure Assessment scores (mean difference = 2.4; t = 2.779; p = 0.008) and longer hospital length of stay (mean difference = 9.3; t = 2.27; p = 0.029). Female patients had higher scores on Hospital Anxiety and Depression Scale (mean difference = 7.2; t = 2.74; p = 0.01) and Impact of Events Scale-Revised (mean difference = 18.9; t = 2.74; p = 0.011) at the initial follow-up visit. Patients never attending clinic were more likely to live further away, have a tracheotomy, and spent longer time in the ICU. CONCLUSIONS: Attendance and attrition in ICU recovery clinic are related to patient factors (living in rural area) and ICU factors. Data suggest different recovery trajectories exist based on gender, severity of illness, and self-reported outcomes.

Interrater Reliability of Muscle Ultrasonography Image Acquisition by Physical Therapists in Patients Who Have or Who Survived Critical Illness.

OBJECTIVE: Previous studies have demonstrated that muscle ultrasound (US) can be reliably performed at the patient bedside by novice assessors with minimal training. The primary objective of this study was to determine the interrater reliability of muscle US image acquisition by physical therapists and physical therapist students. Secondarily, this study was designed to elucidate the process for training physical therapists to perform peripheral skeletal muscle US. METHODS: This was a cross-sectional observational study. Four novices and 1 expert participated in the study. Novice sonographers engaged in a structured training program prior to implementation. US images were obtained on the biceps brachii, quadriceps femoris, and tibialis anterior muscles in 3 groups: patients in the intensive care unit, patients on the hospital ward, and participants in the outpatient gym who were healthy. Reliability of image acquisition was analyzed compared with the expert sonographer. RESULTS: Intraclass correlation coefficient values ranged from 0.76 to 0.97 with an average for all raters and all muscles of 0.903, indicating excellent reliability of image acquisition. In general, the experienced physical therapist had higher or similar intraclass correlation coefficient values compared with the physical therapist students in relation to the expert sonographer. CONCLUSIONS: Excellent interrater reliability for US was observed regardless of the level of experience, severity of patient illness, or patient setting. These findings indicate that the use of muscle US by physical therapists can accurately capture reliable images in patients with a range of illness severity and different clinical practice settings across the continuum of care. IMPACT: Physical therapists can utilize US to obtain images to assess muscle morphology. LAY SUMMARY: Physical therapists can use noninvasive US as an imaging tool to assess the size and quality of peripheral skeletal muscle. This study demonstrates that physical therapists can receive training to reliably obtain muscle images in patients admitted to the intensive care unit who may be at risk for muscle wasting and may benefit from early rehabilitation.

Recovery from COVID-19 and acute respiratory distress syndrome: the potential role of an intensive care unit recovery clinic: a case report.

BACKGROUND: In this case report, we describe the trajectory of recovery of a young, healthy patient diagnosed with coronavirus disease 2019 who developed acute respiratory distress syndrome. The purpose of this case report is to highlight the potential role of intensive care unit recovery or follow-up clinics for patients surviving acute hospitalization for coronavirus disease 2019. CASE PRESENTATION: Our patient was a 27-year-old Caucasian woman with a past medical history of asthma transferred from a community hospital to our medical intensive care unit for acute hypoxic respiratory failure due to bilateral pneumonia requiring mechanical ventilation (ratio of arterial oxygen partial pressure to fraction of inspired oxygen, 180). On day 2 of her intensive care unit admission, reverse transcription-polymerase chain reaction confirmed coronavirus disease 2019. Her clinical status gradually improved, and she was extubated on intensive care unit day 5. She had a negative test result for coronavirus disease 2019 twice with repeated reverse transcription-polymerase chain reaction before being discharged to home after 10 days in the intensive care unit. Two weeks after intensive care unit discharge, the patient returned to our outpatient intensive care unit recovery clinic. At follow-up, the patient endorsed significant fatigue and exhaustion with difficulty walking, minor issues with sleep disruption, and periods of memory loss. She scored 10/12 on the short performance physical battery, indicating good physical function. She did not have signs of anxiety, depression, or post-traumatic stress disorder through self-report questionnaires. Clinically, she was considered at low risk of developing post-intensive care syndrome, but she required follow-up services to assist in navigating the healthcare system, addressing remaining symptoms, and promoting return to her pre-coronavirus disease 2019 societal role. CONCLUSION: We present this case report to suggest that patients surviving coronavirus disease 2019 with subsequent development of acute respiratory distress syndrome will require more intense intensive care unit recovery follow-up. Patients with a higher degree of acute illness who also have pre-existing comorbidities and those of older age who survive mechanical ventilation for coronavirus disease 2019 will require substantial post-intensive care unit care to mitigate and treat post-intensive care syndrome, promote reintegration into the community, and improve quality of life.

The effect of body composition and BMI on 25(OH)D response in vitamin D-supplemented athletes.

Fat mass is inversely associated with vitamin D status, and athletes with the most adipose tissue may have the greatest risk for insufficient (25(OH)D 20-32 ng mL(-1)) or deficient (25(OH)D < 20 ng ml(-1)) status. The effects of fat and lean mass on 25(OH)D change in response to vitamin D supplementation have yet to be elucidated in athletes. In addition, vitamin D has a known role in bone health yet a link between short-term changes in 25(OH)D and bone turnover in indoor athletes have not yet been described. Thirty-two collegiate swimmers and divers (19 male, 13 female; 19 (1) years) participated in a 6-month randomized controlled trial and consumed either 4000 IU d(-1) of vitamin D3 (n = 19) or placebo (PLA; n = 13). Anthropometry and blood collection of 25(OH)D, bone-specific alkaline phosphatase (B-ALP) and N-terminal telopeptide (NTx) occurred at three time points. Dual-energy X-ray absorptiometry measured body composition analysis at baseline and endpoint. In the vitamin D group, BMI was negatively correlated with 6-month 25(OH)D change (R = -0.496; P = .03) and a stronger predictor of 25(OH)D change (P = .04) than ultraviolet B exposure and fat mass change. Athletes in the high bone turnover group showed significantly greater losses of 25(OH)D over 6-months compared to athletes in the low bone turnover group (P = .03). These results suggest athletes within the normal BMI category experience a diminished response to 4000 IU d(-1) of vitamin D3 supplementation, and periods of high bone turnover may be an additional risk factor for developing compromised vitamin D status in athletes.