Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial

Background To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. Methods The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of “possible sepsis alert” to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. Discussion The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. Trial registration ClinicalTrials.gov NCT04078594. Registered on September 6, 2019

Pediatric intensive care hybrid-style clinical round during COVID-19 pandemic: A pilot study

Background: With the evolving COVID-19 pandemic and the emphasis on social distancing to decrease the spread of SARS-CoV-2 among healthcare workers (HCWs), our pediatric intensive care unit (PICU) piloted utilization of Zoom online into the clinical rounds to enhance communication among the treating team. We aimed to explore the feasibility of these hybrid virtual and physical clinical rounds for PICU patients from the HCWs' perspective. Methods: A mixed quantitative and qualitative deductive thematic content analysis of narrative responses from pediatric intensive care HCWs were analyzed, descriptive statistics were used Results: A total of 31 HCW were included in the analysis; the mean time of the virtual round was 72.45 minutes vs. 34.68 for physical rounds, the most shared component in the virtual round was CXR (93.5%). Some of the HCWs' perceived advantages of the hybrid rounds were enabling the multidisciplinary discussions, lesser round interruptions, and practicality of the virtual discussions. The perceived challenges were the difficulty of the bedside nurse to attend the virtual round, decreased teaching opportunities for the trainees, and decreased interactions among the team members, especially if the video streaming was not utilized. Conclusion: Hybrid virtual and physical clinical rounds in PICU were perceived as feasible by HCWs. The virtual rounds decreased the physical contact between the HCWs, which could decrease the possibility of SARS-CoV-2 spread among the treating team. Still, several components of the hybrid round could be optimized to facilitate the virtual team-members' interactions and enhance the teaching experience.

Electronic early notification of sepsis in hospitalized ward patients: a study protocol for a stepped-wedge cluster randomized controlled trial

Background To examine the effect of screening for sepsis using an electronic sepsis alert versus no alert in hospitalized patients admitted to wards on hospital mortality. Methods This study is conducted in 45 medical-surgical-oncology wards in five hospitals. Based on the quick Sequential Organ Failure Assessment (qSOFA), an electronic alert has been developed in the hospital Electronic Medical Record system. The alert system sends notifications of 'Possible Sepsis Alert' to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. In addition, data on the alert are displayed on management dashboards for each ward. Initially, all wards had a masked alert for 2 months. Hospital wards are then allocated in a randomized fashion to either active or masked alert, such that the alert is activated in five new randomly selected wards every two months until all wards have the active alert. The primary endpoint is in-hospital mortality by 90 days. Discussion The trial has started in October 2019 and is expected to continue for 22 months enrolling more than 62550 hospitalized patients. Trial registration ClinicalTrials.gov NCT04078594. Registered on September 6, 2019, https://clinicaltrials.gov/ct2/show/NCT04078594 Keywords Sepsis, Alert, Screening, qSOFA, mortality, electronic medical records

Personalized delirium sedation goal (PDSG): Balancing comfort and communication in the last days of life.

12033 Background: Management of patients with agitated terminal delirium is challenging as clinicians try to find a balance between adequate sedation to maximize comfort while retaining communication abilities. A novel approach to tailor care is to ask caregivers for a PDSG by setting an individualized target for sedation. In this study, we examined PDSG using (1) clinical vignettes and (2) as a clinical response criteria in patients enrolled onto a randomized clinical trial. Methods: This is a pre-planned secondary analysis of a double-blind randomized clinical trial examining the sedative effect of chlorpromazine and/or haloperidol in patients with agitated terminal delirium refractory to low dose haloperidol (clinicaltrials.gov: NCT03021486; Lancet Oncol 2020 21:7 989-998). At baseline, caregivers and bedside nurses were independently asked to select the PDSG for 6 patient vignettes that differed by level of agitation (high vs. moderate), ability to communicate (yes or no), and survival (days vs. weeks). There were 5 choices for PDSG, corresponding to RASS scores of 0 (no sedation), -1 to -2, -3, -4 and -5 (deep sedation). Respondents were also asked to select the PDSG for the enrolled study patient, which were assessed against actual RASS scores over the first 24 hours to determine a response. We examined the association between PDSG levels and various patient and respondent characteristics with multi-level cumulative logits models. Results: 68 patients were enrolled and 45 received the masked study interventions (median survival 73 h [95% CI 49,106 h]). 42 caregivers and 40 nurses provided PDSG data. For the case vignettes, 7-31% of caregivers and 20-55% of nurses chose RASS -4 or -5 as PDSG. PDSG was significantly lower for patients who were unable to communicate (odds ratio [OR] 3.1-4.4, P < 0.0001), patients with only days of survival vs. weeks (OR 1.7, 95% confidence interval [CI] 1.2-2.5; P = 0.002) and if the respondent was a bedside nurse (OR = 2.5, 95% CI 1.8-3.6; P < 0.0001). For study patients, 12 (29%) of caregivers and 13 (33%) of nurses selected RASS -4 or -5 as PDSG. After the first 2 hours, 40-61% of patients achieved RASS scores that were within ±1 point of caregiver’s PDSG, with no significant difference detected among treatment groups (P = 0.45). PDSG for study patients was significantly lower if the respondent perceived severe distress related to agitation (OR = 4.4, 95% CI 1.1-17.2; P = 0.03), particularly if the respondent was a bedside nurse (OR = 4.8, 95% CI 1.4-16.2; P = 0.01). Conclusions: PDSG represents a novel response criterion to tailor care for patients with agitated terminal delirium. Lighter sedation was preferred by caregivers compared to nurses, particularly for patients with less agitation, ability to communicate, and longer expected survival. These findings may allow clinicians to better tailor the level of sedation for patients with restlessness/agitation in the last days of life. Clinical trial information: NCT03021486.

The Role of “Robotic Assisted Intensivist” As Solution Of Resources Management In Covid-19 Pandemic Era

Providing expertise in the care of critically ill patients is one of the main needs of critical care medicine, especially in the COVID-19 pandemic era. This goal is particularly challenging, given the acknowledged shortage of intensive care specialists. We need the bedside nurse to have real-time access to get continuous reporting monitoring. The intensivist also has access to bed site examination at some time when they are not possible for coming to the intensive care unit (ICU). The big problems during COVID-19 are the limited personal protective equipment, the limited number of intensivist doctors, and the nature of the disease was very contagious and deadly. It is necessary to find a solution so as not to cause new problems, namely the death of medical staff and nurses due to frequent contact with Covid-19 patients. In this article, the author wants to open a view to getting solutions to problems in the field by presenting human replacement technology.