Adult Medical Intensive Care Unit Patients Research Articles

Comparison of intensive care unit liberation bundle adherence prior to and during the COVID‐19 pandemic: A retrospective cohort study

AbstractThe intensive care unit (ICU) liberation (A–F) bundle is recommended by the Society of Critical Care Medicine guidelines as standard supportive care. Significant deviations were made to providing bundled care during the coronavirus disease 2019 (COVID‐19) pandemic. The objective of the study is to describe how COVID‐19 affected bundle adherence at a single academic medical center. This is a retrospective cohort study of adult medical ICU patients on mechanical ventilation (MV) for at least 48 h and an ICU stay of at least 7 days. Patients were separated into three cohorts based on ICU admission date and COVID‐19 status from April 2019 to March 2021; pre‐pandemic (pre‐COV), pandemic COVID‐19 negative (COV‐neg), and pandemic COVID‐19 positive (COV‐pos). Primary outcomes were median average daily bundle adherence over 7 days and daily complete bundle adherence. Secondary outcomes were individual bundle component adherence rates and patient outcomes. A total of 67 patients were included. Median average daily bundle adherence (pre‐COV 68.6% vs. COV‐neg 51.4% vs. COV‐pos 32.6%; p < 0.001), median number of days with complete adherence (pre‐COV 1 [interquartile range (IQR) 0–1] vs. COV‐neg 0 [IQR 0–0] vs. COV‐pos 0 [IQR 0–0]; p < 0.001), and percentage of patients with any day of complete bundle adherence (pre‐COV 78.6% vs. COV‐neg 14.3% vs. COV‐pos 7.1%) were different among groups and individual bundle component adherence varied. Also, median duration of MV (pre‐COV: 6.3 days [IQR 5.6–9], COV‐neg: 8.9 days [IQR 7.6–14], COV‐pos: 11.6 days [IQR 8.4–21], p = 0.01) and median days alive and free from MV up to Day 30 (pre‐COV: 23 [IQR 21–24], COV‐neg: 20 [IQR 15–22], COV‐pos: 18 [IQR 7–21], p = 0.015) were significantly different between groups. ICU A–F bundle adherence was significantly reduced during the COVID‐19 pandemic in patients with and without COVID‐19 infection.

THE EFFECT OF PHYSICAL REHABILITATION ON REPEATED SUSTAINED ATTENTION TESTS IN CRITICALLY ILL PATIENTS

Introduction Delirium, a clinical syndrome defined as an acute and fluctuating disturbance of consciousness and impaired attention (American Psychiatry Association, 2013), affects up to 90% of mechanically ventilated patients in the intensive care unit (ICU) and is associated with long-term cognitive impairment (Pandharipande, et al., 2013). While evidence for pharmacological therapy for delirium is limited, several non-pharmacological interventions, including physical rehabilitation, reduce delirium incidence and duration (Alvarez et al., 2009; Schweickert et al., 2009). This study evaluates the effects of physical rehabilitation on attention - a fundamental cognitive domain disrupted in delirium. Methods Adult medical ICU patients without neurological pathology, dementia, or coma, receiving physical rehabilitation as part of routine care were included in this study. All patients were assessed for delirium at approximately 8 am, and then completed two standardized tests of attention, separated by about 3 hours, using the Edinburgh Delirium Test Box for the ICU (EDTB-ICU) (Green et al., 2017). The EDTB-ICU is a non-invasive, computerized neuropsychological testing device that quantitatively measures attention via a method that is suitable for non-verbal ICU patients, including those who are mechanically ventilated. The EDTC-ICU includes 3 levels of increasing difficulty, consisting of 3 trials each, with a total score range of 0-9. Patients were randomized in a 1:1 ratio to complete the second attention test either before vs. after the routine care physical therapy session (referred to as the control vs. study group, respectively) using computer-generated permuted block randomization created using STATA 14. The allocation sequence was concealed from the researcher, but assessors were not blinded to treatment condition. Baseline data regarding patients’ cognitive and functional status were collected from direct testing and informant interview. Delirium was assessed via the Confusion Assessment Method (CAM) (Inouye et al., 1990) and Delirium Rating Scale-Revised-98 (DRS-R98) (Trzepacz et al., 2001). Each instrument was rated after direct standardized cognitive function testing and patient examination, medical record review, and collateral informant interview by trained personnel. Patient performance on the EDTB-ICU did not contribute to these ratings and was evaluated separately. Group differences in baseline data were compared using Mann-Whitney U tests for continuous variables and Fisher's exact tests for dichotomous variables. Within-subject change in sustained attention performance was calculated using the Wilcoxon signed-rank test. To compare the effect of intervening physical rehabilitation (study group) vs. no physical rehabilitation (control group) on change in attention, a mixed effects model with a random intercept was fitted. Significance was defined as p Results Of 1,711 patients screened, 31 were eligible, consented and completed the study protocol (Fig. 1). Table 1 reports baseline characteristics of the cohort (n=31), study group (n=15), and control group (n=16). The two groups were similar at baseline. Table 2 reports median initial and repeat EDTB-ICU scores. The control group declined by an average of 1.0 point (95% CI: -1.9, -0.1; p=0.02) while the study group declined by an average of 0.3 points (95% CI: -2.4, 1.9; p=0.2). This difference in change over time between the study vs. control group was not significantly different (p=0.25). Conclusions This pilot study did not demonstrate a significant difference in sustained attention for critically ill patients who were randomized to receive repeated attention testing with vs. without intervening physical rehabilitation. Given prior randomized controlled trials demonstrating reductions in delirium in ICU patients receiving vs. not receiving physical rehabilitation, larger-sized studies evaluating the impact of physical rehabilitation on attention, a critical domain in assessing delirium, are needed to further investigate these findings. This research was funded by Research Funding Source: Hitachi Ltd.

Analysis of Rothman Index Data to Predict Postdischarge Adverse Events in a Medical Intensive Care Unit.

Currently, there are no objective metrics included in the intensive care unit (ICU) discharge decision making process. In this study, we evaluate Rothman Index(RI) data for a possible metric as part of a quality improvement project. Our objectives were to determine whether RI could predict adverse events occurring within 72 hours of ICU discharge decision, the optimal clinical cutoff value for this metric, and to determine whether there is a relation between the RI warning alert 24 hours prior to discharge and adverse events postdischarge. Retrospective observational study. Single center tertiary hospital. Adult medical ICU patients discharged from the ICU between January 20, 2015 and March 14, 2015. None. A total of 194 patients were studied with mean age of 62.74 (18.37) years. Data collection included RI at the time of decision-making for ICU discharge and the presence of any warning signals in the previous 24 hours. A 72-hour follow-up chart review recorded any adverse events, including readmission to a higher level of care, discontinuation of discharge due to clinical status change, emergency department visit if discharged home, rapid response activation, or cardiopulmonary arrest postdischarge. Adverse events after ICU discharge were observed in 31 (16%) patients with 9 events being ICU readmission (4.6%). Based on an age-adjusted multivariate model, a higher RI was associated with lower odds of an adverse event (odds ratio [OR] = 0.969, P = .006, confidence interval [CI]: 0.9487-0.9911). An RI value ≥ 50 was associated with 72% lower odds of an adverse event (OR = 0.2887, 95% CI = 0.1278-0.6517 and P = .003) compared to RI < 50. This RI cutoff value was associated with the largest decrease in odds of events. As expected, patients with a very high-risk warning alert had a higher proportion of adverse events compared to patients who did not. (31.75% vs 12.65%, P = < .02). Patients who have an RI < 50 or a very high-risk warning alert have a higher risk of adverse events postdischarge from the ICU. Rothman Index may be a useful metric for ICU discharge decision-making.

Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia

BACKGROUND AND OBJECTIVESAntimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile–associated diarrhea (CDAD), physicians’ acceptance rate, patient’s intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics.DESIGN AND SETTINGSThis is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh.METHODSAdult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback.RESULTSA total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value <.05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm.CONCLUSIONA proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region.

Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study

Background The inability to speak during mechanical ventilation is recognized as a terrifying and isolating experience that is related to feelings of panic, insecurity, anger, worry, fear, sleep disturbances, and stress among critically ill patients. Alternative methods of communicating with temporarily nonspeaking patients in the intensive care unit (ICU) have received little study. Although electronic voice output communication aids (VOCAs) are available for disabled children and adults, the effectiveness of VOCA systems with adult medical ICU patients who may have multisystem illness, prolonged intubation, and longer ICU stays has not been explored. Objectives The purpose of this pilot study was to describe (1) the characteristics of intubated MICU patients who use VOCAs, (2) the usage patterns (message categories, frequency, assistance required), (3) communication quality (ease, user satisfaction), and (4) barriers to communication with VOCAs. Methods This pilot study used participant observation, semi-structured interviews, questionnaires, and clinical record review in a complementary design to obtain data on communication events and VOCA use with 11 critically ill adults. Results Study participants, 45.5 ± 16.0 years of age with 13 ± 1.9 years of education and moderately severe illness (APACHE III = 27.5 ± 16.1), used the VOCA for 5.7 ± 4.6 days. Ease of Communication Scale measurements showed significantly less difficulty with communication after device use (t > 2.62; P = .047). Almost half ( n = 5) of the participants demonstrated some independent use of the device. VOCAS were used in one quarter of observed communication events. Patients used VOCAs most often to communicate with family visitors and initiated communication interactions more often when VOCAs were used than when communicating by other nonvocal methods. Poor device positioning, deterioration in patient condition, staff time constraints, staff unfamiliarity with device, and complex message screens were primary barriers to VOCA use. Conclusions This study showed that use of VOCAs is possible with selected critically ill adults and may contribute to greater ease of communication during respiratory tract intubation particularly with family members. Further clinical research using control or comparison groups is needed.