A novel clinical data acquisition device: Towards real time cardiovascular modelling in the ICU.

A Second Set of Eyes: An Introduction to Tele-ICU

The allocation of intensivists' rounding time under conditions of intensive care unit capacity strain.

Use of Relative Blood Volume Monitoring to Reduce Intradialytic Hypotension in Hospitalized Patients Receiving Dialysis

Are Unselected Risk Scores in the Cardiac Intensive Care Unit Needed?

Critical care and the global burden of critical illness in adults

© 2021 British Association of Critical Care Nurses. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1111/nicc.12726

The number of intensive care unit (ICU) beds in the United Stateshascontinuedto increaseover the last3decades, ashave ICU utilization rates and costs,1,2 and this despite the lack of any federal, regional, or critical care society mandates to justify these increases. Some experts believe that the increase in the number of ICU beds has led to inappropriate use of these beds by patients who are either too healthy or too sick to benefit from intensive care.3,4 This may in part explain the stable national ICU occupancy rate of approximately68%between 1985and2010 and suggests that ICU utilization has simply risen tomeet the increased number of beds.1,2 Furthermore, it hasbeenover adecadeandahalf sincenational societyguidelines for ICUand intermediate careunit admission, discharge, and triagewere published.5,6 In the intervening years, changes have occurred in the demographic and other characteristics of ICUpatientpopulations; the ICUworkforce has evolved; the legislative landscape has altered; and newethical and end-of-life factors have been introduced that affect the appropriate utilization of ICU beds. Ideally, US hospitals and ICUs would follow some consistent and clinically appropriate approaches to the triage of sick patients. At a minimum, we would expect that triage would be similar for day andnight,weekdayandweekendwithin the same hospital or hospital network, andwewould expect it to be independent of ICU and hospital occupancy rates. The reality, however, is far more complex and confusing: ICU triage decisions are based on many factors, some quantifiable and others intangible. These factors can be classified into 2 categories:hospital (institutional)basedandICUrelated.Hospitalbased factors include size (small,medium, or large), teaching or nonteaching status, nurse to patient ratios, rules and regulations of the limits ofward-based care, attitudes toward risk, practice styles of physicians andnurses, availability of nurses andsupport staff (eg,hospitalists, advancepractitioners, rapid response teams), privileging of clinicians for ICU admission, and the presence of step-down units (ie, intermediate or progressive). The ICU-based parameters include ICU to hospital bed ratios, model of care (ie, open, closed, or collaborative), types (ie, multiple-specialty ICUs or single, large ICU), intensivist staffing (ie, high or low intensity, full time or part time), presence of resident trainees and/or advance care practitioners, and coverage (ie, in-house or telemedicine). In this issueofJAMAInternalMedicine,ChangandShapiro7 retrospectively analyze ICU utilization for 4 medical conditions (diabetic ketoacidosis, pulmonary embolism,upper gastrointestinalbleeding,andcongestiveheart failure) in94acutecare nonfederal hospitals in Washington state and Maryland between2010and2012. These common illnessesmaybe classified as “in-between” conditions if they are not presenting at extreme levels of severity. The authors found great variability in the ICU utilization between high and low ICU utilizers. Higher ICUutilizationoccurred in smallerhospitals and teaching hospitals. Of note, the vast majority of hospitals had concordant ICU utilization (high or low) for all 4 conditions, suggesting consistent ICU vs ward triage patterns. The ICU and hospital occupancy did not affect ICU utilization for each of these conditions. Similarly, risk-adjustedhospitalmortality (at 30 days) did not differ between the high and low ICU utilizers;however, onceapatientwasadmitted to the ICU, therewas an increase in the number of invasive procedures (eg, central venous catheters) and higher hospital costs compared with patients cared for on the wards. Although this study showed greater use of standardized care pathways (represented by invasive procedures and increased costs) in the higher ICUutilization centers than in the lower, outcomes were similar. Many factors influence hospiAuthor Audio Interview at jamainternalmedicine.com

© 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows: To identify, appraise and synthesise qualitative research evidence on healthcare stakeholders' perceptions and experiences of factors affecting the implementation of CCT. To identify hypotheses, for subsequent consideration and assessment in effectiveness reviews, about factors that are more likely to ensure successful implementation of CCT.

Healthcare stakeholders' perceptions and experiences of factors affecting the implementation of critical care telemedicine (CCT): qualitative evidence synthesis.

Voices from the ICU: Nursing students' experiences of family involvement in patient care.

Supplemental Digital Content is available in the text.

Using the Systems Engineering Initiative for Patient Safety (SEIPS) model to describe critical care nursing during the SARS-CoV-2 pandemic (2020).

Intensive Care Unit Palliative Care Shortens Hospital Stays

Resident education rarely includes training in the hands-on mechanics of care delivery; however, these bedside skills and knowledge are necessary for patient care and crucial when time and resources are limited. Nurses and respiratory therapists are content experts in this arena yet are rarely asked to provide formal education to resident physicians. Leveraging their bedside experience to enhance resident instruction represents a unique opportunity to address this area of need while working to improve interprofessional collaborative practice through interprofessional education (IPE).1At Children's Hospital of Philadelphia, an intensive care unit (ICU) hospitalist, nurse, and respiratory therapist developed a bedside care curriculum to deliver to pediatric and emergency medicine residents during their 1-month ICU rotation using nurses and respiratory therapists as educators. The primary aim of the PICU Overnight INTerprofessional Education of Residents (POINTER) program was to improve resident bedside care knowledge. Secondary aims were to increase resident comfort with and participation in bedside care and promote interprofessional collaboration.An informal needs assessment identified content areas of interest which were formulated into 4 hands-on sessions by the team: code cart and push-pull fluid delivery system (CCPP), arterial lines (AL), central and peripheral venous access (CPVA), and tracheostomy and respiratory management (TR). Thirty-minute sessions were delivered Monday through Thursday nights (content rotated weekly) to align with resident Q4 call schedule and to avoid conflicts with daytime educational opportunities; timing was flexible to accommodate unit acuity as well as educator and resident availability. Sessions were conducted in-unit using available materials and at bedside when feasible (eg, to demonstrate arterial line setup). Educators signed up to teach during regularly scheduled shifts using a shared calendar. The curriculum had no associated developmental or ongoing costs, and maintenance required less than 1 hour of administrative work per week.The POINTER program was prospectively evaluated using pre- and post-surveys to measure resident knowledge, comfort, and participation in bedside care. The curriculum and interprofessional collaboration were assessed using open-ended questions and a modified Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration survey.Ninety-eight residents and 27 respiratory therapists and nurse educators participated over 10 months (August 2020-May 2021), and residents attended a median of 3 sessions. Survey completion rate (pre- and post-curriculum) was 51% (50 of 98) for residents and 43% (10 of 23) for educators.Residents demonstrated increased bedside care knowledge and comfort overall (both P<.001; Table). Residents who attended the CCPP, AL, or TR session showed improved comfort with these skills (P<.001, P<.001, P=.018, respectively), and residents who attended the AL session increased knowledge (P=.004) and participation (P<.001) compared to those who did not attend. Residents self-reported that POINTER improved their knowledge (84%, 42 of 50), made them better clinicians/residents (72%, 36 of 50 unique residents), increased their pre-post understanding of the nurse/respiratory therapist knowledge base (60%, 30 of 50, P<.001), and the program should continue (76%, 38 of 50). Residents' attitudes toward physician-nurse collaboration did not change, though they were high at baseline (median score 39/40). Educators enjoyed participating (90%, 9 of 10 educators) and felt they became better teachers (80%, 8 of 10).Resident comments included: “Practical,” “Unique way to learn hands-on skills,” “It filled a gap in our knowledge,” and “I loved...to learn from RTs and RNs! They have a lot of knowledge, and we rarely have formalized time for education with them.”Educator comments included: “I enjoyed helping the residents learn…and get hands-on training,” and “I had taken for granted what the residents know.... They don't have as much experience or understanding as I thought, and they need that to help make medical decisions.”In conclusion, we successfully developed and deployed a novel IPE-based resident overnight curriculum utilizing bedside nurses and respiratory therapists as educators at low cost. Participants appreciated its practical, interdisciplinary nature and increased their knowledge, comfort with, and participation in bedside care. Given its flexibility and customizability, POINTER is likely generalizable to any field with bedside care provided by non-physicians willing to educate learners.

To study the potential beneficial role of furosemide in resolving renal failure after hemofiltration in mechanically ventilated critically ill patients. Single-center randomized, double blind, placebo-controlled study. A 13-bed mixed intensive care unit (ICU) in a teaching hospital. Patients who had been treated with continuous venovenous hemofiltration were included. After the end of continuous venovenous hemofiltration, the urine of the first 4 hours was collected for measuring creatinine clearance. Patients were subsequently randomized for furosemide (0.5 mg/kg/hr) or placebo by continuous infusion. To prevent hypovolemia, the rate of fluid infusion was adapted every hour and was set as the urinary production of the previous hour. End points were renal recovery (creatinine clearance more than 30 mL/min or stable serum creatinine without renal replacement therapy) in the ICU and in the hospital. Seventy-two patients were included and 71 were eligible for the analysis. The 36 furosemide-treated patients had a significantly increased urinary volume compared with the 35 placebo-treated patients (median 247 mL/hr (interquartile range [IQR] 774 mL/hr) vs. 117 mL/hr (IQR 158 mL/hr), p = 0.003) and greater sodium excretion (median 73 mmol/L (IQR 48) vs. 37 (IQR 48) mmol/L, p = 0.001). In the furosemide group 25 patients and in the placebo group 27 patients showed recovery of renal function at ICU discharge (p = 0.46). Two patients of the furosemide group needed long-term dialysis dependency (p = 0.23). Furosemide by continuous infusion in the recovery phase of hemofiltration-dependent acute kidney failure did increase urinary volume and sodium excretion but did not lead to a shorter duration of renal failure or more frequent renal recovery.