scholarly journals Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study

10.2196/16301 ◽  
2019 ◽  
Vol 8 (11) ◽  
pp. e16301 ◽  
Author(s):  
Dong Chang ◽  
Jennifer Parrish ◽  
Nader Kamangar ◽  
Janice Liebler ◽  
May Lee ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Decision Makers ◽  
Care Planning ◽  
Improvement Strategy ◽  
Icu Patients ◽  
Family Meetings ◽  
Planning Approach ◽  
Icu Physicians

Background Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients’ goals of care. Objective The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality. Methods This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization. Results The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020. Conclusions The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses. International Registered Report Identifier (IRRID) DERR1-10.2196/16301

scholarly journals Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study (Preprint)

2019 ◽  
Author(s):  
Dong Chang ◽  
Jennifer Parrish ◽  
Nader Kamangar ◽  
Janice Liebler ◽  
May Lee ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Decision Makers ◽  
Care Planning ◽  
Improvement Strategy ◽  
Icu Patients ◽  
Family Meetings ◽  
Planning Approach ◽  
Icu Physicians

BACKGROUND Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients’ goals of care. OBJECTIVE The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality. METHODS This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization. RESULTS The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020. CONCLUSIONS The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/16301

Abstract 13704: Simulation-based Uptraining Improves Provider Comfort in the Management of Critically Ill Patients With Covid-19

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
James M Horowitz ◽  
Eugene Yuriditsky ◽  
Sunil Nair ◽  
Brian S Kaufman
Keyword(s):  
Critically Ill ◽  
Nurse Practitioners ◽  
Critically Ill Patients ◽  
Simulation Training ◽  
Icu Patients ◽  
Large Numbers ◽  
Simulation Based ◽  
Critical Care Ultrasound ◽  
Simulation Session ◽  
Icu Physicians

Introduction: The COVID-19 surge at our institution required deployment of large numbers of non-intensive care unit (ICU) physicians and advanced practice providers to assist in the management of the critically ill. A 3-hour “uptraining” simulation session was offered to these providers that focused on various aspects of ICU care. Hypothesis: We hypothesized that following a 3-hour simulation session, providers would feel more comfortable in managing critically-ill patients with COVID-19. Methods: One hundred and seventy-five providers underwent a 3-hour simulation-based session focused on management of shock, acute respiratory distress syndrome, and critical care ultrasound. All participants were sent surveys to assess their comfort with various aspects of ICU care following return to their usual work environments. Results: One hundred and eight providers of 175 (62%) completed the surveys. Cardiology fellows and faculty accounted for 36% of the responders, acute care nurse practitioners (NPs) accounted for 16%, while other NPs, residents, and fellows accounted for the remainder. Prior to simulation training, 31% regularly managed patients in the ICU and 28% occasionally managed ICU patients. Following training, 71% of participants were deployed to a COVID-19 ICU as part of their workflow. Overall, 104/108 responders (96%) felt training either significantly or somewhat improved their knowledge in the management of ICU patients. Ninety-four participants (91%) felt training impacted their care of critically ill patients with COVID-19. Table 1 is a display of specific ICU skillsets taught in the session and if the participants felt better equipped to utilize what was covered post deployment. Conclusions: Simulation-based training improved provider comfort in the management of critically ill patients with COVID-19. Table 1: Participants response to “if they felt better equipped to utilize ICU skills following simulation training”

scholarly journals Acinetobacterinfections: a growing threat for critically ill patients

2007 ◽  
Vol 136 (8) ◽  
pp. 1009-1019 ◽  
Author(s):  
M. E. FALAGAS ◽  
E. A. KARVELI ◽  
I. I. SIEMPOS ◽  
K. Z. VARDAKAS
Keyword(s):  
United States ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Relative Frequency ◽  
The United States ◽  
Considerable Proportion ◽  
Southern Europe ◽  
Icu Patients

SUMMARYThere has been increasing concern regarding the rise ofAcinetobacterinfections in critically ill patients. We extracted information regarding the relative frequency ofAcinetobacterpneumonia and bacteraemia in intensive-care-unit (ICU) patients and the antimicrobial resistance ofAcinetobacterisolates from studies identified in electronic databases.Acinetobacterinfections most frequently involve the respiratory tract of intubated patients andAcinetobacterpneumonia has been more common in critically ill patients in Asian (range 4–44%) and European (0–35%) hospitals than in United States hospitals (6–11%). There is also a gradient in Europe regarding the proportion of ICU-acquired pneumonias caused byAcinetobacterwith low numbers in Scandinavia, and gradually rising in Central and Southern Europe. A higher proportion ofAcinetobacterisolates were resistant to aminoglycosides and piperacillin/tazobactam in Asian and European countries than in the United States. The data suggest thatAcinetobacterinfections are a growing threat affecting a considerable proportion of critically ill patients, especially in Asia and Europe.

scholarly journals Study on Intensive Care Unit Nutritional Protocol Based on Timing of National Health Insurance Coverage in Taiwan

2021 ◽  
Vol 5 (Supplement_2) ◽  
pp. 850-850
Author(s):  
Shih-Ching Lo ◽  
Yu-Chin Hsiao ◽  
Ying-Ru Chen ◽  
Hsing-Chun Lin
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Health Insurance ◽  
Critically Ill ◽  
National Health Insurance ◽  
National Health ◽  
Critically Ill Patients ◽  
Nutritional Intervention ◽  
Icu Patients ◽  
Nutritional Care

Abstract Objectives Aggressive nutritional intervention may improve the outcomes of critically ill patients. Therefore, the National Health Insurance Administration (NHIA) in Taiwan revised its relevant fee schedule. On October 1, 2019, nutritional care items for intensive care unit (ICU) patients, covered by the NHIA under the category of nutritional care fees, were introduced to reflect real clinical needs. Methods This retrospective cohort study was conducted in a medical center ICU. The study period was January 1, 2019 to May 31, 2020, before and after the start of national health insurance (NHI) coverage of new nutritional care items for ICU patients. A total of 5292 patients were recruited and divided into two groups based on timing of NHI coverage. There were 1591 patients included in the analysis (751 in the non-NHI group and 840 in the NHI group). In the NHI group, the following nutritional protocol was implemented: First visit was at 48hr following admission to the ICU with 2 follow up visits over the next 5 days, then 3 visits the following week. Patient demographics, daily nutritional data, and outcomes were collected to investigate the impact of this protocol. Results Both groups were given the same nutritional intervention initially. However, there were significant differences in nutritional intervention following the incorporation of this treatment protocol in the ICU. Closely monitored nutritional intervention met critical requirements without overfeeding and led to shorter ICU stays (non-NHI 8.11 ± 6.69 days vs NHI 7.12 ± 7.43 days, p < 0.01). Conclusions Nutritional care plan based on frequent assessments and interventions by dietitians is associated with reduced ICU stays for critically ill patients. Funding Sources None.

scholarly journals Herpes DNAemia and TTV Viraemia in Intensive Care Unit Critically Ill Patients: A Single-Centre Prospective Longitudinal Study

2021 ◽  
Vol 12 ◽  
Author(s):  
François Mallet ◽  
Léa Diouf ◽  
Boris Meunier ◽  
Magali Perret ◽  
Frédéric Reynier ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Clinical Outcomes ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Wilcoxon Test ◽  
Icu Patients ◽  
Prospective Longitudinal Study ◽  
Severity Scores ◽  
Prospective Longitudinal

IntroductionWe analysed blood DNAemia of TTV and four herpesviruses (CMV, EBV, HHV6, and HSV-1) in the REAnimation Low Immune Status Marker (REALISM) cohort of critically ill patients who had presented with either sepsis, burns, severe trauma, or major surgery. The aim was to identify common features related to virus and injury-associated pathologies and specific features linking one or several viruses to a particular pathological context.MethodsOverall and individual viral DNAemia were measured over a month using quantitative PCR assays from the 377 patients in the REALISM cohort. These patients were characterised by clinical outcomes [severity scores, mortality, Intensive Care Unit (ICU)-acquired infection (IAI)] and 48 parameters defining their host response after injury (cell populations, immune functional assays, and biomarkers). Association between viraemic event and clinical outcomes or immune markers was assessed using χ2-test or exact Fisher’s test for qualitative variables and Wilcoxon test for continuous variables.ResultsThe cumulative incidence of viral DNAemia increased from below 4% at ICU admission to 35% for each herpesvirus during the first month. EBV, HSV1, HHV6, and CMV were detected in 18%, 12%, 10%, and 9% of patients, respectively. The incidence of high TTV viraemia (>10,000 copies/ml) increased from 11% to 15% during the same period. Herpesvirus viraemia was associated with severity at admission; CMV and HHV6 viraemia correlated with mortality during the first week and over the month. The presence of individual herpesvirus during the first month was significantly associated (p < 0.001) with the occurrence of IAI, whilst herpesvirus DNAemia coupled with high TTV viraemia during the very first week was associated with IAI. Herpesvirus viraemia was associated with a lasting exacerbated host immune response, with concurrent profound immune suppression and hyper inflammation, and delayed return to immune homeostasis. The percentage of patients presenting with herpesvirus DNAemia was significantly higher in sepsis than in all other groups. Primary infection in the hospital and high IL10 levels might favour EBV and CMV reactivation.ConclusionIn this cohort of ICU patients, phenotypic differences were observed between TTV and herpesviruses DNAemia. The higher prevalence of herpesvirus DNAemia in sepsis hints at further studies that may enable a better in vivo understanding of host determinants of herpesvirus viral reactivation. Furthermore, our data suggest that EBV and TTV may be useful as additional markers to predict clinical deterioration in ICU patients.

scholarly journals Prediction Scores Do Not Correlate with Clinically Adjudicated Categories of Pulmonary Embolism in Critically Ill Patients

2014 ◽  
Vol 21 (1) ◽  
pp. 36-42 ◽  
Author(s):  
CM Katsios ◽  
M Donadini ◽  
M Meade ◽  
S Mehta ◽  
R Hall ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Pulmonary Embolism ◽  
Intensive Care ◽  
Randomized Trial ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Pretest Probability ◽  
Icu Patients ◽  
Outpatient Settings ◽  
Diagnostic Scores

BACKGROUND: Prediction scores for pretest probability of pulmonary embolism (PE) validated in outpatient settings are occasionally used in the intensive care unit (ICU).OBJECTIVE: To evaluate the correlation of Geneva and Wells scores with adjudicated categories of PE in ICU patients.METHODS: In a randomized trial of thromboprophylaxis, patients with suspected PE were adjudicated as possible, probable or definite PE. Data were then retrospectively abstracted for the Geneva Diagnostic PE score, Wells, Modified Wells and Simplified Wells Diagnostic scores. The chance-corrected agreement between adjudicated categories and each score was calculated. ANOVA was used to compare values across the three adjudicated PE categories.RESULTS: Among 70 patients with suspected PE, agreement was poor between adjudicated categories and Geneva pretest probabilities (kappa 0.01 [95% CI −0.0643 to 0.0941]) or Wells pretest probabilities (kappa −0.03 [95% CI −0.1462 to 0.0914]). Among four possible, 16 probable and 50 definite PEs, there were no significant differences in Geneva scores (possible = 4.0, probable = 4.7, definite = 4.5; P=0.90), Wells scores (possible = 2.8, probable = 4.9, definite = 4.1; P=0.37), Modified Wells (possible = 2.0, probable = 3.4, definite = 2.9; P=0.34) or Simplified Wells (possible = 1.8, probable = 2.8, definite = 2.4; P=0.30).CONCLUSIONS: Pretest probability scores developed outside the ICU do not correlate with adjudicated PE categories in critically ill patients. Research is needed to develop prediction scores for this population.

scholarly journals Might Confounding Factors Have an Effect on Suboptimal Dosing of Fluconazole in Critically Ill Patients?

2020 ◽  
Author(s):  
Emre Kara ◽  
Aygin Bayraktar Ekincioglu ◽  
Gokhan Metan
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Antimicrobial Agents ◽  
Confounding Factors ◽  
Recent Issue ◽  
Icu Patients ◽  
Wide Variability

In a recent issue of Antimicrobial Agents and Chemotherapy, Muilwijk et al. evaluated the fluconazole pharmacokinetics (PK) and dosing in critically ill patients and concluded that there is wide variability in pharmacokinetic characteristics among intensive care unit (ICU) patients (1).…

scholarly journals Baseline characteristics, level of disease severity and outcomes of patients with COVID-19 admitted to intensive care unit in COVID-19 dedicated Mugda Medical College and Hospital, Dhaka, Bangladesh

2020 ◽  
Vol 7 (10) ◽  
pp. 3837
Author(s):  
Irin Hossain ◽  
Manzurul H. Khan ◽  
Shah G. Tuhin ◽  
M. M. Aktaruzzaman ◽  
Shafiur Rahman ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Clinical Characteristics ◽  
Icu Patients ◽  
Ventilator Support ◽  
Medical College ◽  
Central Oxygen ◽  
Novel Coronavirus

Background: Novel coronavirus disease is associated with highly intensive care unit (ICU) mortality. With the dramatic increase of confirmed cases as well as death toll in Bangladesh, timely and effective management of severely and critically ill patients appears to be particularly important. This includes streamlining workflows for rapid diagnosis and isolation, clinical management, and infection prevention. The main objective of this study was identification of the demographic, clinical characteristics, severity and outcome of patients admitted into ICU.  Methods: We aimed to describe the demographic and clinical characteristics, severity of disease, management patterns and outcomes of critically ill patients with coronavirus disease 2019 admitted to ICU in a Bangladeshi setting and for this purpose a retro-prospective study of conveniently selected 63 ICU admitted patients with COVID-19 was conducted from May 1 to June 30, 2020. Data were obtained from patient charts and the hospitals’ records using a structured questionnaire.  Results: Most of the ICU patients were older male (30, 65.3%) and most of them were 70 or above years of age group (17, 37.0%). ICU patients more likely suffered from comorbidities like hypertension (938, 60.3%); diabetes             (36, 57.1%); chronic kidney disease (21, 33.3%). In most cases treatment in ICU included the administration of antibiotics (100.0%) (Meropenem, 20, 31.7%). Forty-Eight patients died (discharge mortality, 76.2%), and fourteen patients were discharged alive from the ICU with a rate of 22.2%. One patient transferred (Palliative discharge, 1.6%) to other facilities for palliative care purpose.Conclusions: Our findings also highlight the importance of planning for mass critical care along with central oxygen supply system as the need for ICU care and ventilator support to treat patients with COVID-19 grows rapidly in Bangladesh.  

scholarly journals Heparin-Induced Thrombocytopenia in Critically Ill Patients

2015 ◽  
Vol 41 (01) ◽  
pp. 049-060 ◽  
Author(s):  
Theodore Warkentin
Keyword(s):  
Intensive Care Unit ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Low Molecular Weight Heparin ◽  
Low Molecular Weight ◽  
Liver Necrosis ◽  
Icu Patients ◽  
Heparin Induced Thrombocytopenia ◽  
Background Frequency ◽  
Intravascular Catheters

Many critically ill patients receive heparin, either before intensive care unit (ICU) admission (e.g., postcardiac surgery), for prophylaxis/treatment of thrombosis, for hemodialysis/filtration, or even incidentally (e.g., flushing of intravascular catheters), and are therefore at risk for developing immune heparin-induced thrombocytopenia (HIT), a prothrombotic drug reaction caused by platelet-activating antiplatelet factor 4 (PF4)/heparin antibodies. However, HIT explains at most 1 in 100 thrombocytopenic ICU patients (HIT frequency 0.3–0.5% vs. 30–50% background frequency of ICU-associated thrombocytopenia), and most patients who form anti-PF4/heparin antibodies do not develop HIT; hence, HIT overdiagnosis often occurs. This review discusses HIT-related issues relevant to ICU patients, including how to (1) distinguish HIT both clinically and serologically from non-HIT–related thrombocytopenia; (2) recognize HIT-mimicking disorders, such as the acute disseminated intravascular coagulation (DIC)/liver necrosis-limb necrosis syndrome; (3) prevent HIT in the ICU through use of low-molecular-weight heparin; and (4) treat HIT, including awareness of “PTT confounding” when anticoagulating patients with DIC.

Association of neurogranin with delirium among critically ill patients

2020 ◽  
Vol 14 (17) ◽  
pp. 1613-1617
Author(s):  
Márcia LZ Wanderlind ◽  
Renata Gonçalves ◽  
Cristiane D Tomasi ◽  
Felipe Dal-Pizzol ◽  
Cristiane Ritter
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Alzheimer Disease ◽  
Critically Ill ◽  
Dendritic Spines ◽  
Critically Ill Patients ◽  
Icu Patients ◽  
Icu Admission

Background: Neurogranin (Ng) concentrates at dendritic spines. In patients with Alzheimer disease Ng levels are elevated. The role of Ng in delirium development has not been assessed, therefore we hypothesized that Ng levels are associated with delirium in critically ill patients. Materials & methods: From 94 critically ill patients, 47 developed delirium and 47 controls were included. Blood was collected during the first 24 h of intensive care unit (ICU) admission, and on the day of delirium diagnoses. Ng and IL-1β were determined. Results: Ng and IL-1β levels were higher in the delirium group at ICU admission and on the day of delirium diagnoses. IL-1β and Ng were independently associated with delirium occurrence. Conclusion: Ng levels are associated with delirium development in ICU patients.

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