Adult Critical Care Research Articles

Arterial cannulation in adult critical care patients: A comparative study between ultrasound guidance and palpation technique

ObjectiveTo compare first attempt success rate for ultrasound-guided (USG) versus direct palpation (DP) for radial, femoral, and dorsalis pedis artery cannulations in adult intensive care unit (ICU) patients. DesignProspective randomized clinical trial. SettingMixed adult ICU of a University Hospital. ParticipantsAdult patients (≥18 years) admitted to the ICU requiring invasive arterial pressure monitoring were included. Exclusion criteria were patients with a pre-existing arterial line and cannulated with other than a 20-gauge cannula for radial and dorsalis pedis artery. InterventionComparison of arterial cannulation by USG versus palpation technique in radial, femoral and dorsalis pedis arteries. Main variables of interestPrimary outcome was first attempt success rate, secondary outcomes were assessing time for cannulations, number of attempts, overall success rate, complications, and comparison of two techniques on patients requiring vasopressor. Results201 patients were enrolled in study, with 99 randomized to DP group and 102 to USG group. Arteries (radial, dorsalis pedis, femoral) cannulated in both groups were comparable (P = .193). Arterial line was placed on first attempt in 85 (83.3%) in USG group versus 55 (55.6%) in DP group (P = .02). Cannulation time in USG group was significantly shorter compared to DP group. ConclusionsIn our study, USG arterial cannulation, compared to palpatory technique, had a higher success rate at first attempt and a shorter cannulation time. Clinical Trial Registry of India numberCTRI/2020/01/022989.

Enhancing Palliative Communication in the Intensive Care Unit Through Simulation: A Quality Improvement Project

BackgroundPalliative communication is a vital aspect of patient and family-centered end-of-life care in the intensive care unit. Despite this, specialty-specific training and education in palliative communication are generally limited for critical care nurses. The purpose of this quality improvement project was to assess the effect of adding a simulation-based learning experience to the existing End of Life Nursing Education Consortium adult critical care course on critical care nurse comfort with palliative communication as a component of end-of-life care. MethodUsing a pretest/post-test design, 11 critical care nurse participants completed a measure of comfort related to end-of-life communication prior to the course and immediately following the simulation experience. ResultA paired-samples t-test showed a statistically increase in comfort with palliative communication from the pretest (M = 56.36, SE = 2.40) to post-test (M = 48.27, SE = 2.97), t (10) = 2.54, p = .30 (two-tailed), The mean decrease in scores was 8.09, 95% CI (0.98, 15.91). Qualitative survey responses indicated that the simulation provided valuable practice of palliative communication techniques. ConclusionA simulation-based learning experience incorporated into an existing palliative care education course is feasible to implement and increased critical care nurse comfort with palliative communication at end-of-life.

U.S. Adult Critical Care Beds Per Capita: A 2021 County-Level Cross-Sectional Study.

Describe the per capita distribution of staffed adult critical care beds across the United States. Cross-sectional epidemiologic assessment of November 2021 hospital data from the Department of Health and Human Services' Protect Public Data Hub. Staffed adult critical care beds per adult population. The percent of hospitals reporting was high and varied by state/territory (median, 98.6% of states' hospitals reporting; interquartile range [IQR], 97.8-100%). There was a total of 4,846 adult hospitals accounting for 79,876 adult critical care beds in the United States and its territories. Crudely aggregated at the national-level, this calculated to 0.31 adult critical care beds per 1,000 adults. The median crude per capita density of adult critical care beds per 1,000 adults across U.S. counties was 0.00 per 1,000 adults (county, IQR 0.00-0.25; range, 0.00-8.65). Spatially smoothed county-level estimates were obtained using Empirical Bayes and Spatial Empirical Bayes approaches, resulting in an estimated 0.18 adult critical care beds per 1,000 adults (range from both methodological estimates, 0.00-8.20). When compared to counties in the lower quartile of adult critical care bed density, counties in the upper quartile had higher average adult population counts (mean 159,000 vs 32,000 adults per county) and a choropleth map demonstrated high densities of beds in urban centers with low density across rural areas. Among U.S. counties, the density of critical care beds per capita was not uniformly distributed, with high densities concentrated in highly populated urban centers and relative scarcity in rural areas. As it is unknown what defines deficiency and surplus in terms of outcomes and costs, this descriptive report serves as an additional methodological benchmark for hypothesis-driven research in this area.

Effect of massage therapy on sleep quality in critically ill patients: A systematic review and meta-analysis.

The aim of the study was to compare the effects of massage interventions on sleep quality among patients in the adult critical care unit. Massage interventions have positive effects when applied to manage sleep quality in critical care units. However, research identifying the effect of massage intervention is limited. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five databases were searched from their inception to 15 April 2022 (the last search was conducted on 15 November 2022, but it yielded no additional eligible studies). The literature search was conducted using Embase, MEDLINE, the Cochrane Library, CINAHL, PsycINFO and additional sources such as Google Scholar. The Cochrane risk of bias tool for randomised trials (RoB 2.0) was used to assess the risk of bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system assessed the certainty of evidence and recommendations. In total, ten randomised controlled trials comprising 569 participants were used in the systematic review, and eight trials were included in the meta-analysis. Subgroup analysis revealed significant effects of foot reflexology massage on subjective sleep quality. Massage therapy for a two-night duration in cardiac care unit patients exhibited a significant effect on subjective sleep quality. The overall GRADE certainty of evidence was low. Massage intervention, particularly foot reflexology massage, with a two-night duration showed improvement in subjective sleep quality among critically ill patients. Although evidence quality was low, the results suggest that massage interventions provide a non-invasive, low-cost and effective way to promote sleep quality in critically ill adult patients. Massage interventions can enable nurses to recommend and implement strategies promoting and improving sleep quality among critically ill patients. The review protocol was registered a priori and published online in the PROSPERO database of systematic reviews (www.crd.York.ac.uk/Prospero with the registration number # CRD42022332371). No patient or public contribution if such details are not necessary or do not apply to your work and state why.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects.

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020.With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly.We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU).We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020and June 2020 to determine if they met the inclusion criteria.These subjects were required to be spontaneously ventilating upon admission and eventually required intubation.Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospectiveICU admission analysis.We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects.Our primary outcome of interest was intubation-related mortality.We defined intubation mortality as unexpected death (within 48 hours of intubation).Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress.COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects.COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed therates of intubation survival were no different between the COVID and non-COVID groups.We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.

The use of islamic spiritual care practices among critically ill adult patients: A systematic review

Spiritual care is essential to the healthcare plans of critically ill patients and their families. However, spiritual care remains neglected and requires healthcare institutions and providers’ attention to be incorporated into healthcare management plans, especially for critically ill Muslim patients and their families. To date, no review has been conducted to discuss spiritual care in adult critical care Muslim patients. Spiritual care and Holy Quran recitation have been reported to be practical non-pharmacological interventions for critically ill Muslim patients. However, there is a need for Islamic healthcare institutions and providers to pay further attention to including spiritual care in the healthcare management plans of their patients. Also, future research is recommended to test the effectiveness of incorporating spiritual care in the healthcare plans of critical care patients.

Developing key performance indicators for adult critical care transfer services: Scoping review and Delphi technique.

In 2021 NHS England commissioned regional Adult Critical Care Transfer Services. These services will replace a historically predominant ad hoc approach to adult critical care transfers nationally. It is anticipated that these new formal services will provide a system of robust regional & national governance previously acknowledged to be deficient. As part of this process, it is important that an agreed set of transfer service quality indicators are developed to drive equitable improvement in patient care. We used a Delphi technique to develop a set of key performance indicators through consensus for a recently established London critical care transfer service. We believe this may be the first-time key performance indicators have been developed for adult critical care transfer services using a consensus method. We hope services will consider tracking similar measures to enable benchmarking and drive improvements in patient care.

Implementing Vancomycin Population Pharmacokinetic Models: An App for Individualized Antibiotic Therapy in Critically Ill Patients.

In individualized therapy, the Bayesian approach integrated with population pharmacokinetic models (PopPK) for predictions together with therapeutic drug monitoring (TDM) to maintain adequate objectives is useful to maximize the efficacy and minimize the probability of toxicity of vancomycin in critically ill patients. Although there are limitations to implementation, model-informed precision dosing (MIPD) is an approach to integrate these elements, which has the potential to optimize the TDM process and maximize the success of antibacterial therapy. The objective of this work was to present an app for individualized therapy and perform a validation of the implemented vancomycin PopPK models. A pragmatic approach was used for selecting the models of Llopis, Goti and Revilla for developing a Shiny app with R. Through ordinary differential equation (ODE)-based mixed effects models from the mlxR package, the app simulates the concentrations' behavior, estimates whether the model was simulated without variability and predicts whether the model was simulated with variability. Moreover, we evaluated the predictive performance with retrospective trough concentration data from patients admitted to the adult critical care unit. Although there were no significant differences in the performance of the estimates, the Llopis model showed better accuracy (mean 80.88%; SD 46.5%); however, it had greater bias (mean -34.47%, SD 63.38%) compared to the Revilla et al. (mean 10.61%, SD 66.37%) and Goti et al. (mean of 13.54%, SD 64.93%) models. With respect to the RMSE (root mean square error), the Llopis (mean of 10.69 mg/L, SD 12.23 mg/L) and Revilla models (mean of 10.65 mg/L, SD 12.81 mg/L) were comparable, and the lowest RMSE was found in the Goti model (mean 9.06 mg/L, SD 9 mg/L). Regarding the predictions, this behavior did not change, and the results varied relatively little. Although our results are satisfactory, the predictive performance in recent studies with vancomycin is heterogeneous, and although these three models have proven to be useful for clinical application, further research and adaptation of PopPK models is required, as well as implementation in the clinical practice of MIPD and TDM in real time.

Outgrowing the Pediatric Intensive Care Unit: Adults With a Pediatric Medically Complex Condition.

With more than 20 years of experience as pediatric and adult critical care nurses, we have observed an increase in the number of medically complex children who are living into adulthood and a troubling lack of adult intensive care unit (ICU) systems and processes for these patients.Medical advances have resulted in a significant decline in the mortality rate in the pediatric ICU (PICU), from 15% in 1980 to 4% in 2006. However, an unintended consequence is that more children experience significant morbidity. In fact, more than 50% of all PICU admissions are children with medical complexity.1,2 Families caring for a child who is chronically critically ill have special care requirements. Nurses in the PICU have extensive experience with pediatric-onset conditions such as congenital heart defects, sickle cell disease, neurodegenerative diseases, chromosomal abnormalities, and muscular dystrophies. They are also familiar with growth and development and have expertise in providing developmentally appropriate care. In addition, PICU nurses are trained in the principles of family- and patient-centered care, which include communicating and collaborating with family caregivers about the processes of care to a much greater extent than usually done in an adult ICU. Certified child life specialists are also available in the PICU to provide specific tools to assist in meeting the needs of the family, including siblings. When medically complex children become adults, many of them transition to adult ICUs that may not be ready for them. As a result, approximately 2% of PICU admissions (range 0%-9%) are adults who have had complex medical needs as children.3,4 However, as the number of medically complex children reaching adulthood continues to grow, the “PICU for adults” model is not sustainable.At this time, many adult ICUs are not prepared for patients with pediatric conditions. Creating an environment in which adult and pediatric health care professionals work collaboratively is essential to providing quality care to these patients and families. Systems need to be developed and expanded to provide complex care in the adult ICU. A proactive, interdisciplinary approach including specialized training for the adult ICU team is needed to sustain a high level of quality care and to support the transition to adult care. Staff in the PICU can help to prepare families for the transition as well as provide education and support to the adult ICU team. Issues to consider include differences in anatomy and physiology of pediatric patients, the unique developmental needs of this population, expansion of specialized services (ie, child life specialists), dedicated sleep areas for parents, and involving parents in decisions and patient care.

An integrative review on physical restraint in adult critical care unit

Background: Physical restraints (PRs) are frequently used in adult critical care units to protect staff and prevent self-harm, despite the fact that they represent significant safety risks. Restraint complications may have an impact on the patient's long- and short-term outcomes. This study aims to examine the recent evidence on the use of PR in adult critical care. Method: This integrative review included the studies published between January 2009 and December 2019 and the literature search was conducted in July 2020. The databases searched included EBSCOhost, Ovid, ProQuest, PubMed, Wiley Online Library, SCOPUS, and ScienceDirect. The keywords included in the search were restraint, critical care, intensive care, ICU, mechanical ventilation, intubation, nursing, and experience. A checklist based on the CASP checklist and the JBI Critical Appraisal Tool was used to assess the methodological quality. Results: The findings were evaluated and summarized into seven key topics after twenty-one publications were found to be evaluated. i) High prevalence of PR application in adult critical care unit; ii) determinants of PR applications; iii) types of PR in adult critical care units; iv) decision maker of PR; v) moral and ethical dilemma in PR application; vi) awareness and guidelines for PR applications; vii) common complications and use of sedation, analgesics, antipsychotic drugs in PR application. Conclusion: The number of days PR is used is related to the risk of an adverse event. In order to standardize nursing practice, ICU nurses require greater training on the ideas of PR use. Evidence-based recommendations will assist critical care nurses in making the best judgments possible concerning the use of PR.

The Impact of the Society of Critical Care Medicine's Flagship Journal: Critical Care Medicine: Reflections of Critical Care Pioneers.

On the 50th anniversary of the Society of Critical Care Medicine's journal Critical Care Medicine, critical care pioneers reflect on the importance of the journal to their careers and to the development of the field of adult and pediatric critical care.

P14 Improving adherence to and effectiveness of an adult critical care vancomycin continuous infusion protocol: a pilot quality improvement and administration data accuracy project

Abstract Background Vancomycin treats serious Gram-positive infections. In St George's Hospital (SGH) intensive care unit (ICU) settings, vancomycin is administered intravenously by continuous infusion. Steady-state serum concentrations are monitored daily with a 20–25 mg/L therapeutic target. Non-therapeutic concentrations are associated with patient harm and prolonged stay.1 A service evaluation revealed variable adherence to/effectiveness of the vancomycin prescribing/administration/monitoring protocol. Electronic prescribing and medicine administration (ePMA) system interface issues may have contributed.2 Consequently, multifaceted interventions were devised and piloted on General ICU. Objectives To (i) improve combined protocol prescribing/administration/monitoring adherence; (ii) enhance therapeutic protocol dosing; and (iii) ascertain accuracy of patients’ paper drug administration (PDA) charts compared with the ePMA system. Methods The quality improvement project (QIP) was approved by SGH clinical governance/audit teams. Over a 9 month period (September 2021 to May 2022) system/person-focused interventions were implemented. Protocol dosing2 was revised; introducing a &amp;gt;90 kg patient 2 g loading dose, new renal-function categories and an increased maintenance dose for creatinine clearance (CLCR) &amp;gt;90 mL/min. Protocol accessibility was increased via ePMA and CliniBee/Microguide app integration. Educational protocol presentations were incorporated into medical/nursing induction training. Vancomycin prescribing/administration/monitoring data for non-renal replacement patients during the intervention period, was extracted retrospectively from the ePMA system. This was compared with baseline informing ICU data collected July 2020 to July 2021.2 Patient's drug administration accuracy data (PDA charts/ePMA system) was extracted retrospectively from January to May 2022 and analysed. Results Compared with baseline, the proportion of patients receiving per protocol prescribing/administration of vancomycin loading/maintenance doses with daily monitoring increased [39% (7/18) to 68% (15/22)]. Within 48 h 54% (7/13) of vancomycin serum concentrations in all patients were therapeutic, demonstrating a baseline increase of 21% (3/9 to 7/13). In per protocol treated patients, serum concentrations increased 16% (2/7 to 4/9) therapeutically, decreased 20% (3/7 to 2/9) supra-therapeutically and increased 4% (2/7 to 3/9) sub-therapeutically. Supra-therapeutic concentrations were associated with CLCR &amp;lt;50 mL/min. Sub-therapeutic concentrations were associated with CLCR &amp;gt;90 mL/min and obesity. Compared with the ePMA system, there was 38% (5/13) less PDA charts recording both loading/maintenance doses. Administration time differences &amp;gt;60 min were recorded for 38% (3/8) of loading and 31% (4/13) maintenance doses. Discussion Staff turnover periods were associated with decreased protocol compliance. Further education is required around prescribing/administration of standardized vancomycin infusion bags, with associated rate changes. Integration of pharmacists into daily Microbiology ward rounds may alleviate these issues. Higher 20 mg/kg loading doses for &amp;gt;100 kg patients and maintenance dose revisions may reduce non-therapeutic concentrations.3 Multidirectional variation in vancomycin administration timings recorded between PDA charts/ePMA system, requires further investigation. Infusion-pump data may offer the most accurate administration time for calculating pharmacokinetic variables. Conclusions Multifaceted interventions were successful at improving adherence to/effectiveness of the vancomycin protocol. Findings will inform QIP roll-out across all three SGH ICUs, which will incorporate infusion-pump data collection to facilitate pharmacokinetic modelling. This will inform local dosing strategies and research into patient variability.

The clinical use of urinary mitochondrial DNA in adult surgical critical care patients with acute kidney injury.

Acute kidney injury (AKI) affects 47% of adult surgical critical care patients (ASCCPs). AKI is induced through a common oxidative stress pathway resulting in mitochondrial and tubular cell injury with increased urinary mitochondrial DNA (UmtDNA) excretion. UmtDNA is an emerging and readily sampled novel biomarker for varied surgical critical care cohorts. This review aimed to determine the clinical use of UmtDNA genes (ND1 and COX3) in AKI in ASCCPs. PubMed, MEDLINE and Web of Science databases were searched. Eligibility criteria were based on the patient/problem, intervention, comparison and outcome framework. Methodological quality of studies was assessed with the Newcastle-Ottawa Quality Assessment Scale. WebPlot Digitizer version 4.4 was used to extract UmtDNA data from graphs and UmtDNA ratios were statistically analysed with PRISM version 9.1.0 (GraphPad Software). Six human studies (n=391) with three translational murine models (n=112) satisfied inclusion criteria. One sample t test suggested significantly high UmtDNA-ND1 ratios in progressive/severe AKI (or delayed renal transplant graft function) to no AKI (or immediate renal transplant graft function) and increased UmtDNA-COX3 ratios approached significance. Sensitivities and specificities for UmtDNA ranged from 68% to 85% and 52% to 83.6%, respectively, comparable with new biomarkers, neutrophil gelatinase-associated lipocalin and kidney injury molecule-1. Weak correlation was observed with serum creatinine. These findings were complemented in translational murine AKI experiments with significantly elevated ND1 and COX3. From bench to clinical practice, UmtDNA appears to be a promising novel biomarker of progressive/severe AKI (or delayed graft function). Large prospective, multi-centre studies reporting standardised UmtDNA findings should clarify use of UmtDNA in ASCCP-AKI management.

A Multifaceted Educational Intervention to Reduce Plasma Utilization

Blood transfusion services maintain quality practice through adherence to guidelines but are faced with blood component wastage due to multiple factors. One factor, in particular, is poor ordering and utilization practices followed by physicians who may not be familiar with the indications and the optimal conditions for the handling of blood products. This study evaluates whether an educational intervention would help reduce ordering of plasma and improve wastage rates after thawing. The study followed a quasi-experimental pre-test post-test design. A multifaceted educational intervention was introduced at a tertiary hospital-based combining predisposing, enabling, and reinforcing activities, based on the literature of effective continuous professional development. The activities included a brief survey to evaluate participant knowledge about indications of plasma and its storage condition, a lecture, and periodic reports and reminders sent to all department heads in the hospital. Respondents to the survey and lecture attendees included physicians in adult critical care and anesthesia departments. Monthly plasma utilization and wastage rates were compared before and after introducing the intervention. Sixty physicians participated in the survey. The questions were answered correctly by less than half. After introducing the intervention, monthly plasma transfusion rates decreased; however, wastage rates did not improve. There is a knowledge gap among physicians who order plasma. The educational intervention resulted in lower plasma transfusion rates but did not affect wastage rates. Future interventions would benefit from including physicians in other departments as well as nurses.

Performance, Knowledge, and Barrier Awareness of Medical Staff Regarding the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Critical Care Patients: A Cross-Sectional Study

Performance, Knowledge, and Barrier Awareness of Medical Staff Regarding the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Critical Care Patients: A Cross-Sectional Study

BACCN position statement on non‐medical prescribing in critical care

AbstractBackgroundThe British Association of Critical Care Nurses (BACCN) published its first position statement on non‐medical prescribing (NMP) in critical care in 2009 (Bray et al., Nurs Crit Care. 2009;14:224‐234). Over the years, more nurses and other health care professionals have become non‐medical prescribers, and the BACCN have thus revisited and updated the statement.AimTo update the 2009 position statement on NMP in critical care to reflect contemporary guidance and practice.Study designA working group was established following an expression of interest to BACCN members, and the original BACCN position statement and literature review were updated using key databases. An electronic questionnaire was developed by the working group to describe current NMP practises and the authorization and prescribing of blood and blood components. It was distributed via email to 1861 BACCN members and on BACCN social media in October and November 2021.ResultsTwo hundred and fifty nine health care professionals from the four countries of the United Kingdom completed the survey, and of these 136 (52.5%) respondents were BACCN members. One hundred and five (40.4%) of the respondents described themselves as non‐medical prescribers, and of these, 57 (54.8%) were independent prescribers and 47 (45.2%) were supplementary and independent prescribers, with one respondent not revealing. The remaining 154 (59.4%) respondents were not registered as non‐medical prescribers. Ninety‐one (86.7%) of the respondents who were non‐medical prescribers reported making prescribing decisions on every clinical shift, and 67 (64.4%) of these audited their prescribing practises. Of the 105 who described themselves as non‐medical prescribers, 71 (67.6%) had been in their area of practice for more than 5 years before they became non‐medical prescribers, with 3 (2.8%) being in the practise area for less than 1 year.All seven statements from Bray et al's (2009) position statement were revised and updated following the survey results and review of the literature search.ConclusionsThe updated position statement is based upon new policy documents from a range of sources, including the Nursing and Midwifery Council, the Faculty of Intensive Care Medicine, the Royal College of Emergency Medicine and the Royal Pharmaceutical Society. It takes account of the adult critical care patient pathway before, during and after an admission to critical care.Relevance to clinical practiceNon‐medical prescribing (NMP) should only be implemented to improve the safety and quality of care for the critically ill or deteriorating patient. The requirement for NMP needs to be determined locally by organizations, ensuring that the care of the critically ill and deteriorating patient is the main reason. NMP must not be used as a substitute for unsafe medical practice or poor medical prescribing practice. Non‐medical prescribers must adhere to the current Royal Pharmaceutical Society's Prescribing Competency Framework and must be registered with their professional regulatory body. Non‐medical prescribers must audit and evaluate their practice as well as ensuring continuing professional development. Non‐medical prescribers in critical care must consider how their own professional codes of conduct, scope of practice, standards and guidelines impact their prescribing decisions. Non‐medical prescribers must work collaboratively to ensure that continuity and transfer of care between care settings consider deprescribing and medicines reconciliation.

577: ADDRESSING PATIENT AND FAMILY SPIRITUAL NEEDS: A NATIONAL NEEDS ASSESSMENT OF PEDIATRIC FELLOWS

Introduction: Spiritual care is an essential component of whole-person healthcare and becomes increasingly important in critical situations. Despite practice guidelines from the American College of Critical Care Medicine, studies have shown that adult critical care physicians rarely initiate conversations about patients’ and families’ spiritual needs and cite lack of training as a significant barrier. Little is known about the perspectives of pediatric physicians working in critical care settings as they relate to spiritual care. Methods: An IRB-approved survey was sent to 720 pediatric fellows training in critical care settings (165 Cardiology, 259 Critical Care, 296 Neonatology). Categorical data was compared using chi-squared test or Fisher’s exact tests. The Wilcoxon rank sum test was used to compare the percentage correct on ten multiple-choice questions about world religions. Written free text responses were independently reviewed and coded using inductive analysis by two research investigators. Results: 245 surveys were completed yielding a 34% response rate. 83% of fellows had never received prior spiritual care training and 72% of fellows indicated that they would be somewhat or very likely to incorporate spiritual care into their practice if they received training. Prior training was significantly associated with increased knowledge of a framework for taking a spiritual history (p < 0.001), the spiritual care resources at the fellow’s institution (p < 0.004), and spiritual practices that could influence medical care (p < 0.029). Prior training was significantly associated with frequency of taking a spiritual history (p < 0.0001), comfort taking a spiritual history (p < 0.0001), and referring patients/families to spiritual care resources (p < 0.016). Lack of time and training were the most commonly reported barriers to providing spiritual care in qualitative responses. Conclusions: Providing spiritual care for families is important in critical care. Pediatric fellows are open to incorporating spiritual care into their practice but lack the training to do so. Prior training is significantly associated with improved knowledge and skills in providing spiritual care. An opportunity exists to implement spiritual care training into pediatric training programs.

1199. Implementation of a Nasal Antiseptic Decolonization Program Reduces the Occurrence of Healthcare-Associated Infections in the Adult Intensive Care Unit Setting

Abstract Background Universal decolonization programs effectively reduce methicillin-resistant Staphylococcus aureus (MRSA) infections, bloodstream infections, and healthcare costs. However, universal decolonization programs that utilize mupirocin may promote antimicrobial resistance. Non-antibiotic interventions, such as nasal antiseptic decolonization, can contribute to the prevention of healthcare-associated infections (HAIs). A large hospital system sought to evaluate the impact of a universal nasal antiseptic program on HAIs in the adult intensive care unit (ICU) setting. Methods A nasal antisepsis decolonization quality improvement project (QIP) was implemented to reduce ICU HAIs by applying a 62% nasal antiseptic swab with emollients bilaterally to the nares every 12 hours for all adult ICU patients. The program was piloted across nine ICUs at three large hospitals from November 2021 to January 2022 and captured data from 12,404 patient days and 4,058 treatment days. Central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and MRSA bacteremia rates were compared a) between treated and non-treated patients during the QIP period and b) to rates during a three-month period prior to the QIP. Results The results of the pilot program indicated that patients who received treatment with the 62% nasal swab developed fewer HAIs than patients who did not receive the treatment. Two HAIs occurred in the treatment group (two CAUTIs) compared to 14 HAIs in the non-treatment group (three CAUTIs, nine CLABSIs, and two MRSA bacteremia). Figures 1 and 2 below demonstrate HAI rates in the non-treatment and the treatment groups. Figure 1Figure 2 Conclusion Based on pilot results, the system approved implementation of a universal nasal antisepsis program using the 62% alcohol based nasal swab with emollients for expansion to all adult critical care units. Considerations for the future implementation of the program include broadening patient inclusion and performing ongoing HAI surveillance of treated and untreated patient groups. Disclosures All Authors: No reported disclosures.

Fifty Years of Critical Care Medicine: The Editors' Perspective.

Fifty Years of Critical Care Medicine: The Editors' Perspective.

Major Publications in the Critical Care Pharmacotherapy Literature: 2021.

PubMed/MEDLINE. Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critical care patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2021, and December 31, 2021. Candidate articles were organized by clinical domain based on the emerging themes from all studies. A modified Delphi process was applied to obtain consensus on the most impactful publication within each clinical domain based on overall contribution to scientific knowledge and novelty to the literature. The search revealed 830 articles, of which 766 were excluded leaving 64 candidate articles for the Delphi process. These 64 articles were organized by clinical domain including: emergency/neurology, cardiopulmonary, nephrology/fluids, infectious diseases, metabolic, immunomodulation, and nutrition/gastroenterology. Each domain required the a priori defined three Delphi rounds. The resultant most impactful articles from each domain included five randomized controlled trials and two systematic review/meta-analyses. Topics studied included sedation during mechanical ventilation, anticoagulation in COVID-19, extended infusion beta-lactams, interleukin-6 antagonists in COVID-19, balanced crystalloid resuscitation, vitamin C/thiamine/hydrocortisone in sepsis, and promotility agents during enteral feeding. This synoptic review provides a summary and perspective of the most impactful articles relevant to the pharmacotherapy of critically ill adults published in 2021.