Academic Intensivists Research Articles

The Role of Professional Organizations in Fostering the Early Career Development of Academic Intensivists.

The Role of Professional Organizations in Fostering the Early Career Development of Academic Intensivists.

A Survey of Academic Intensivists' Use of Neuromuscular Blockade in Subjects With ARDS.

Our Cooling to Help Injured Lungs (CHILL) trial of therapeutic hypothermia in ARDS includes neuromuscular blockade (NMB) as an inclusion criterion to avoid shivering. NMB has been used to facilitate mechanical ventilation in ARDS and was shown to reduce mortality in the ACURASYS trial. To assess the feasibility of a multi-center CHILL trial, we conducted a survey of academic intensivists about their NMB use in patients with ARDS. We distributed via email a 16-question survey about NMB use in patients with ARDS including frequency, indications, and dosing strategy. 212 (24.3%) of 871 respondents completed the survey: 94.7% were board-certified in internal medicine, 88% in pulmonary and critical care; 90.3% practiced in academic medical centers, with 87% working in medical ICUs; 96.6% of respondents who treat ARDS use NMB, and 39.7% use NMB in ≥ 50% of these patients. Of 4 listed indications for initiating NMB in ARDS, allowing adherence with lung-protective ventilator strategies and patient-ventilator synchrony were cited as the most important reasons, followed by the results of the ACURASYS trial and facilitating prone positioning. We conclude that NMB is frequently used by academic intensivists to facilitate mechanical ventilation in patients with moderate to severe ARDS.

The practice of intensive care in Latin America: a survey of academic intensivists

BackgroundIntensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated.ResultsOur study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement.ConclusionsLatin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America.

ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists.

To characterize intensivist handoff practices and expectations and to explore perceptions of the patient safety implications of attending handoffs. Cross-sectional electronic survey administered in 2014. One hundred sixty-nine U.S. hospitals with critical care training programs accredited by the Accreditation Council for Graduate Medical Education. Academic intensivists were recruited via e-mail invitation from a database of 1,712 eligible academic intensivists. None. Six hundred sixty-one intensivists completed the survey (completion rate, 38.6%). Responses were received from at least one individual at 147 of 169 unique hospitals (87.0%) represented in the study database. Five hundred seventy-three (87%) respondents reported participating in handoffs at the end of each ICU rotation. A variety of communication methods were used for end-of-rotation handoffs, including in-person discussion (92.9%), telephone calls (83.9%), e-mail messages (69.0%), computer-generated documents (64.6%), and text messages (23.6%). Mean satisfaction with current handoff process was rated as 68.4 on a scale from 0 to 100 (SD, 22.6). Respondents (55.4%) said that attending handoffs should be standardized, but only 13.3% (76/572) of those participating in end-of-rotation handoffs reported using a standardized process. Specific handoff topics, including active clinical issues and resuscitation status, were reportedly discussed less frequently than would be ideal (p < 0.001 for the difference between reported frequency and ideal frequency). In free-text comments, 76 respondents (11.5%) expressed skepticism that attending handoffs were necessary given the presence of residents and fellows and given a lack of agreement about necessary content. Two hundred respondents (30.8%) reported knowing of an adverse event (inappropriate treatment, cardiac arrest, and death) attributable to inadequate attending handoffs. ICU attending handoffs in the United States exhibit marked heterogeneity, and intensivists do not agree about the value of attending handoffs. In addition, some intensivists perceive a link between suboptimal attending handoffs, inappropriate treatment, and serious adverse events that warrants further study.

Are Attendings Different?. Intensivists Explain Their Handoff Ideals, Perceptions, and Practices

What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care. Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012. Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects' specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The "perfect handoff" was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs. A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.

Surgical Critical Care and Private Practice Surgeons: A Different World Out There!

Few graduating residents seek surgical critical care (SCC) fellowships; fewer than half of positions fill. We hypothesized substantial differences exist in practice patterns and attitudes between SCC surgeons in academic practice (ACs) and in private practice (PVTs). A survey instrument was sent to 1,544 board-certified SCC intensivists in North America. Of those invited, 489 responded (32% response rate). Respondents were mostly men (88%) and Caucasian (86%), with a mean age of 48 years; 60% were ACs, 28% were PVTs, and 12% reported "other;" 94% currently practiced SCC. PVTs (50%) were more likely than ACs (18%) to provide SCC for only their own patients, less likely (24% versus 74%) to function as an "ICU attending," and less likely to work with residents (36% versus 91%) and fellows (4% versus 60%; all p < 0.001). PVTs (48%) spent more time performing elective operations than ACs (27%; p < 0.001). They were more likely than ACs to relinquish management of SCC patients to medical consultants: infectious disease (34% versus 12%), cardiology (31% versus 12%), and pulmonary (23% versus 3%; all p < 0.001). Conflicts with medical specialists were a bigger problem for PVTs (43%) than for ACs (17%; p < 0.001). Private practice surgical intensivists are more likely than academic intensivists to provide critical care for only their own patients and to use consultants to avoid conflicts.

Nonconsented Human Immunodeficiency Virus Testing Among Critically Ill Patients

Human immunodeficiency virus (HIV) testing can improve care for many critically ill patients, but state laws and institutional policies may impede such testing when patients cannot provide consent. We electronically surveyed all US academic intensivists in 2006 to determine how state laws influence intensivists' decisions to perform nonconsented HIV testing and to assess intensivists' reliance on surrogate markers of HIV infection when unable to obtain HIV tests. We used multivariate logistic regression, clustered by state, to identify factors associated with intensivists' decisions to pursue nonconsented HIV testing. Of 1,026 responding intensivists, 765 (74.6%) had encountered decisionally incapacitated patients for whom HIV testing was wanted. Of these intensivists, 168 pursued testing without consent and 476 first obtained surrogate consent to testing. Intensivists who believed nonconsented HIV testing was ethical (odds ratio, 3.8; 95% confidence interval, 2.2-6.5) and those who believed their states allowed nonconsented testing when medically necessary (odds ratio, 2.3; 95% confidence interval, 1.6-3.4) were more likely to pursue nonconsented HIV tests; actual state laws were unrelated to testing practices. Of the intensivists, 72.7% had ordered tests for perceived surrogate markers of HIV infection in lieu of HIV tests; more than 90% believed these tests were sufficiently valid to base clinical decisions on. Most US intensivists have encountered decisionally incapacitated patients for whom HIV testing may improve care. Intensivists' decisions to pursue nonconsented testing are associated with their personal ethics and often erroneous perceptions of state laws, but not with the laws themselves. Uniform standards enabling nonconsented HIV testing may minimize inappropriate influences on intensivists' decisions and reduce intensivists' reliance on perceived surrogate markers of immunodeficiency.

Development of an e-mail database of US intensive care physicians

Purpose Although surveying critical care physicians regarding their behaviors and attitudes may usefully inform clinical, ethical, and policy questions, few resources exist for surveying intensivists electronically. We sought to develop an e-mail database for all intensivists associated with US training programs in critical care medicine (academic intensivists) and to determine the feasibility of using this database to survey intensivists. Materials and Methods We obtained e-mail addresses for academic intensivists by consulting each training program's institutional Web site or contacting program directors directly. We sent presumed intensivists up to 3 e-mail invitations to participate in an initial survey. Results We identified 2858 potential intensivists and obtained operative e-mail addresses for 2494 (87%). Only 31 (9%) of the remaining intensivists were members of the Society of Critical Care Medicine, suggesting that most of those without identified addresses were not intensivists. During the conduct of an initial survey, 161 physicians self-identified themselves as nonintensivists; of the remaining 2333 presumed intensivists, 1026 (44%) responded and 44 (2%) opted out. The response rate of 44% is based on the conservative assumptions that the remaining 1263 physicians were intensivists and saw the e-mail invitation. Conclusions This database provides a unique resource for investigators wishing to efficiently identify the views and practice patterns of US academic intensivists and provides a benchmark response rate of approximately 44% for electronic surveys of intensivists.

Attitudes and preferences of intensivists regarding the role of family interests in medical decision making for incompetent patients.

The role of family interests in medical decision making is controversial. Physicians who routinely treat incompetent patients may have preferred strategies for addressing family interests as they are encountered in surrogate medical decision making. We sought to determine how physicians view the role of family interests in surrogate medical decision making. Cross-sectional mail survey. Remote study. Surveyed were neonatologists, pediatric intensivists, and medical intensivists affiliated with American medical schools. A total of 327 (55%) of 596 surveys were returned; 35% of respondents were pediatric intensivists, 39% were neonatologists, and 26% were medical intensivists. The majority of respondents believed that family interests should be considered in decisions for incompetent patients, even if those interests are not necessarily important interests of the patient. Less than 10% preferred the traditional model in which the physician-patient relationship is exclusive and family interests are excluded. Medical intensivists, and those who described themselves as more religious, more opposed to healthcare rationing, and more protective of patients, tended to prefer patient-centered surrogate decision-making models. Physicians who treat children, especially neonatologists, were more accepting of family-centered surrogate decision-making models than were physicians who exclusively treat adults. A majority of the academic intensivists in our study believed that family interests should play an important role in medical decision making for incompetent patients. Our findings suggest that the traditional view of the physician-patient relationship may represent an overly simplistic model for medical decision making.

Evaluation of right heart catheterization in critically ill patients. Ontario Intensive Care Study Group.

To determine physicians' assessment of the therapeutic effect and patient benefit of data obtained from right heart catheterization. Before/after study. One medical and one surgical academic ICU in two medical centers. A total of 107 critically ill patients with uncertain hemodynamic status. Physicians looking after the patients were asked to evaluate the extent to which results of right heart catheterization resulted in changes in therapy and outcome. The same questions were asked of academic intensivists, two of whom reviewed each chart. Agreement regarding whether right heart catheterization had changed therapy was poor (chance corrected agreement [kappas] of -0.02 to 0.33). Treating physicians were more inclined than chart reviewers to conclude that management changes based on right heart catheterization improved outcome. Agreement on which patients benefited was poor (kappas of 0.03 to 0.32). Physicians' assessment of the effect of right heart catheterization on treatment decisions and patient outcomes is not reliable. Credible information regarding the benefits of right heart catheterization will require randomized trials.