Community Hospital Intensive Care Unit Research Articles

EFFECT ON LENGTH OF STAY AND MORTALITY AFTER INITIATION OF EARLY PALLIATIVE CARE CONSULTATION IN A COMMUNITY HOSPITAL ICU: A QUALITY IMPROVEMENT PROJECT

EFFECT ON LENGTH OF STAY AND MORTALITY AFTER INITIATION OF EARLY PALLIATIVE CARE CONSULTATION IN A COMMUNITY HOSPITAL ICU: A QUALITY IMPROVEMENT PROJECT

Risk Factors for Mortality in Mechanically Ventilated Patients with COVID-19 in a Mississippi Community Health System.

To evaluate differences between survivors versus nonsurvivors undergoing mechanical ventilation for coronavirus disease 2019 (COVID-19)-associated respiratory failure at two community medical centers. This was a multicenter, retrospective cohort analysis of all adult patients mechanically ventilated for COVID-19-associated respiratory failure in two community hospital intensive care units in southern Mississippi from March 15, 2020 through October 10, 2020. Among 56 patients requiring mechanical ventilation, the mortality rate was 75% (42/56). Expired patients were intubated later (2 vs 5 days, 95% confidence interval [CI] 6.314-0.8041, P = 0.0983), had lower PaO2:FiO2 ratios (65 vs 77.5 mm Hg, 95% CI 36.08-59.03, P = 0.6305), and tolerated lower levels of positive end-expiratory pressure (7.9 vs 12.6 cm H2O, 95% CI 0.1373-6.722, P = 0.0415) at the time of intubation. Our results suggest that earlier intubation may be associated with reduced mortality in patients with COVID-19-associated respiratory failure and should be further evaluated in the form of a randomized controlled trial.

FEASABILTY, UTILITY, AND SAFETY OF CRITICAL CARE TRANSESOPHAGEAL ECHOCARDIOGRAM PERFORMED IN A COMMUNITY HOSPITAL ICU

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: The Intensivist faces the challenging hemodynamics and complex heart-lung interaction in ventilated patients on daily basis. Critical care transesophageal echocardiogram (TEE) serves as another valuable diagnostic tool for the critical care provider when the transthoracic echocardiogram (TTE) fails to solve the hemodynamic dilemma, most likely because of inadequate window. We want to share our experience at a community hospital intensive care unit (ICU). Most importantly we examined the safety and feasibility of the procedure as well. METHODS: We retrospectively reviewed the charts, TEE reports and images of 16 patients in our ICU. We looked at the rationale behind doing a TEE, weather or not there was any clinically relevant finding from the TEE image acquisition and if that changed clinical management. RESULTS: TEE was feasible and safe in all 16 exams. There were no complications. The most common reason for the TEE was complex hemodynamics in the setting of poor TTE views. 4 exams were done to assess resuscitation during cardiac arrest and to identify any reversible or irreversible causes of the arrest. 1 exam was done to guide ECMO cannula insertion under direct visualization. 1 exam was done to examine the effect of a recruitment maneuver on the right ventricle (RV). We observed a clinically relevant finding in 14 exams. Subsequently these results were conveyed to the medical team taking care of the patient. As a result of the TEE report, a medical decision that changed current management by the primary team was done in 13 exams out of all 16. The most common treatment implemented based of the TEE report was the adjustment of the ventilator settings to improve RV function. Other important decisions included shock differentiation in a complex hemodynamic state, starting an inotrope and even changing LUCAS device position during CPR since initially it was observed via the TEE that the compressions were obstructing the left ventricle outlet (LVOT). CONCLUSIONS: In line with previous data, we found that critical care TEE is feasible, clinically useful and most importantly safely done by intensivists who received adequate training in advanced echocardiography. Our study shows that TEE is another valuable tool that intensivists in north America should be familiar with as it is the case in Europe. CLINICAL IMPLICATIONS: Critical Care TEE is a valuble tool that the intensivist can use to solve hemodynamic dilemmas. It is safe and feasible and has an attractive learning curve.We encourage critical care training programs to consider training their fellows in advanced echocardiography. In the Era of visual medicine, advanced critical care echocardiography is knocking on the doors. DISCLOSURES: No relevant relationships by Mohammad Arabiat, source=Web Response No relevant relationships by Karan Singh, source=Web Response

EXPERIENCE WITH REMDESIVIR FOR THE TREATMENT OF CRITICAL COVID-19 IN A COMMUNITY-BASED HOSPITAL IN EVANSTON, ILLINOIS

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: In late December 2019, a novel coronavirus named SARS-CoV-2 was discovered in Wuhan, China using deep unbiased sequencing in samples from patients with pneumonia. From its discovery, SARS-CoV-2 has caused global public health emergencies, economic crises, and innumerable deaths. To date, only corticosteroids have been proven to be effective in reducing mortality from COVID-19. From antiviral agents, remdesivir has been recently recognized as a promising therapy against COVID-19, but its mortality benefit is still a matter of controversy. In this study, we analyzed the effect of remdesivir on in-hospital death in our community hospital in the Chicago North Shore. METHODS: We retrospectively reviewed a de-identified dataset of 190 patients with COVID-19 admitted to a community hospital Intensive Care Unit (ICU) in Evanston, Illinois, from March 2020 to December 2020. Only molecularly confirmed COVID-19 cases defined by a positive result on a reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay or nucleic acid amplification test (NAAT) of a specimen collected on a nasopharyngeal swab were included. We performed a Cox proportional hazards model to analyze the effect of remdesivir on the hazard of in-hospital death in our patient population. To minimize confounders, age, qSOFA score, invasive mechanical ventilation, and other targeted COVID-19 therapies used at any given time (including corticosteroids, tocilizumab, hydroxychloroquine, colchicine, azithromycin, and atorvastatin) were forced as covariables into the model. For sensitivity analysis, we calculated the E value (with the lower confidence limit) for the obtained point estimate. The E value is defined as the minimum strength of association on the risk ratio scale that an unmeasured confounder would need to have with both the exposure and the outcome, conditional on the measured covariates, to explain away a specific exposure-outcome association fully. RESULTS: Between 190 patients admitted to the ICU, the median age was 69 years (IQR, 59 – 78 years), 125 (65.8%) were male, 62 (23.6 %) were White, and 84 (44.2%) were admitted from a long-term care facility. Of those patients, 143 (75.3) received corticosteroids, 67 (35.3%) received remdesivir, and 66 (34.7%) received both. Among survivors, 34/90 (37.8%) received remdesivir compared to 33/100 (33%) nonsurvivors. The Cox regression model showed decreased hazard of in-hospital death associated with the administration of remdesivir (Hazard Ratio [HR] 0.55; 95% CI 0.29 – 0.94, p= .028). The E value for the point estimate was 3.04 and the E value for the lower confidence interval was 1.32, meaning that a confounder not included in the multivariable Cox regression model associated with remdesivir use and in-hospital mortality in patients with critical COVID-19 by a hazard ratio of 1.32-fold each could explain away the lower confidence limit, but weaker confounding could not. CONCLUSIONS: According to the data presented above, we concluded that in our patient population, the patients who did not receive remdesivir had a 65% chance of dying sooner compared to the ones who did receive remdesivir (when probability = HR/HR + 1). This could indicate a potential mortality benefit of remdesivir in critically ill patients. CLINICAL IMPLICATIONS: In our patient population, the use of remdesivir was associated with a slower progression to death in critically ill patients with COVID-19. DISCLOSURES: No relevant relationships by Chul Won Chung, source=Web Response No relevant relationships by Goar Egoryan, source=Web Response No relevant relationships by Harvey Friedman, source=Web Response No relevant relationships by Emre Ozcekirdek, source=Web Response No relevant relationships by Ece Ozen, source=Web Response No relevant relationships by Bidhya Poudel, source=Web Response No relevant relationships by Guillermo Rodriguez-Nava, source=Web Response No relevant relationships by Daniela Trelles Garcia, source=Web Response No relevant relationships by Maria Yanez-Bello, source=Web Response No relevant relationships by Qishuo Zhang, source=Web Response

Community implementation of the 3 Wishes Project: an observational study of a compassionate end-of-life care initiative for critically ill patients.

Background:The 3 Wishes Project (3WP) promotes a personalized dying experience by eliciting and facilitating individualized terminal wishes for patients, families and the clinicians caring for them. We aimed to evaluate the adaptability of the 3WP to a community intensive care unit (ICU), and to describe the patients cared for with this palliative approach, as well as local implementation strategies.Methods:The 3WP was implemented in a 15-bed community hospital ICU in southern Ontario from 2017 to 2019. In this observational, descriptive study, we invited adult patients (≥ 18 yr) whose risk of death was deemed to be 95% or greater by the attending physician, or patients undergoing withdrawal of life-support to participate. We abstracted patient data from medical records, as well as the type, timing and cost of each wish, which person or service made and facilitated each wish, and if and why wishes were completed or not. We summarized data both narratively and quantitatively.Results:The 3WP helped to realize 479 (99.2%) of 483 terminal wishes for 101 dying patients. This initiative was introduced as an interprofessional intervention and championed by nursing staff who were responsible for most patient enrolment and wish facilitation. Wishes included humanizing the ICU environment for the patient with belongings and blankets, musical performances, smudging and bathing ceremonies, and keepsakes. The cost was $5.39 per patient (standard deviation $22.40), with 430 (89.8%) wishes incurring no cost. Wishes made directly by patients accounted for 30 (6.2%) of wishes; those from family members and ICU staff accounted for 236 (48.9%) and 238 (49.3%) of wishes, respectively. The program comforted patients and their loved ones, motivating clinicians to sustain this end-of-life intervention.Interpretation:We documented successful implementation of the 3WP in a community hospital, showing program adaptability and uptake outside of academic centres at relatively low cost. The lack of strict protocolization and personalized design of this intervention underscores its inherent flexibility, with potential to promote individualized end-of-life care in nonacademic hospital wards, homes or hospice.

Initiating and integrating a personalized end of life care project in a community hospital intensive care unit: A qualitative study of clinician and implementation team perspectives.

The end of life (EOL) experience in the intensive care unit (ICU) can be psychologically distressing for patients, families, and clinicians. The 3 Wishes Project (3WP) personalizes the EOL experience by carrying out wishes for dying patients and their families. While the 3WP has been integrated in academic, tertiary care ICUs, implementing this project in a community ICU has yet to be described. To examine facilitators of, and barriers to, implementing the 3WP in a community ICU from the clinician and implementation team perspective. This qualitative descriptive study evaluated the implementation of the 3WP in a 20-bed community ICU in Southern Ontario, Canada. Patients were considered for the 3WP if they had a high likelihood of imminent death or planned withdrawal of life-sustaining therapy. Following the qualitative descriptive approach, semi-structured interviews were conducted with purposively sampled clinicians and implementation team. Data from transcribed interviews were analyzed in triplicate through qualitative content analysis. Interviews with 12 participants indicated that the 3WP personalized and enriched the EOL experience. Interviewees indicated higher intensity education strategies were needed to enable spread as the project grew. Clinicians described many physical resources for the project but suggested more non-clinical project support for orientation, continuing education, and data collection. A majority of wishes focused on physical resources including keepsakes, which helped facilitate project spread when clinician capacity was attenuated by competing duties. In this community hospital, ICU clinicians and implementation team members report perceived improved EOL care for patients, families, and clinicians following 3WP initiation and integration. Implementing individualized and meaningful wishes at EOL for dying patients in a community ICU requires adequate planning and time dedicated to optimizing clinician education. Adapting key features of an intervention to local expertise and capacity may facilitate spread during project initiation and integration.

Surgeons in surge — the versatility of the acute care surgeon: outcomes of COVID-19 ICU patients in a community hospital where all ICU patients are managed by surgical intensivists

BackgroundReported characteristics and outcomes of critically ill patients with COVID-19 admitted to the intensive care unit (ICU) are widely disparate with varying mortality rates. No literature describes outcomes in ICU...

Serum Levels of Vitamin C and Vitamin D in a Cohort of Critically Ill COVID-19 Patients of a North American Community Hospital Intensive Care Unit in May 2020: A Pilot Study

BackgroundThe COVID-19 pandemic has placed an enormous and growing burden on the population and health infrastructure, warranting innovative ways to mitigate risk of contracting and developing severe forms of this disease. A growing body of literature raises the issue of vitamin C and vitamin D as a risk-assessment tool, and therapeutic option, in COVID-19. ObjectiveThe objective of this pilot study was to measure serum vitamin C and vitamin D levels in a cohort of patients with critical COVID-19 illness in our community hospital ICU, correlate with other illness risk factors (age, BMI, HgbA1c, smoking status), generate hypotheses, and suggest further therapeutic intervention studies. MethodThis pilot study included all 21 critically ill COVID-19 patients hospitalized in May 2020 in the ICU of North Suburban Medical Center, Thornton, Colorado, in whose care the principal investigator (C.A.) was involved. We measured patients’ serum vitamin C and vitamin D levels, and standard risk factors like age, BMI, HbA1c, and smoking status. Variables in this study were gauged using descriptive statistics. ResultsOf 21 critically ill COVID-19 patients (15 males and 6 females, 17 Hispanic and 4 Caucasian, of median age 61 years, range 20–94), there were 11 survivors.Serum levels of vitamin C and vitamin D were low in most of our critically ill COVID-19 ICU patients.Older age and low vitamin C level appeared co-dependent risk factors for mortality from COVID-19 in our sample.Insulin resistance and obesity were prevalent in our small cohort, but smoking was not. ConclusionOur pilot study found low serum levels of vitamin C and vitamin D in most of our critically ill COVID-19 ICU patients. Older age and low vitamin C level appeared co-dependent risk factors for mortality. Many were also insulin-resistant or diabetic, overweight or obese, known as independent risk factors for low vitamin C and vitamin D levels, and for COVID-19.These findings suggest the need to further explore whether caring for COVID-19 patients ought to routinely include measuring and correcting serum vitamin C and vitamin D levels, and whether treating critically ill COVID-19 warrants acute parenteral vitamin C and vitamin D replacement.

Skin Preparation and Electrode Replacement to Reduce Alarm Fatigue in a Community Hospital Intensive Care Unit.

Nurses in intensive care units are exposed to hundreds of alarms during a shift, and research shows that most alarms are not clinically relevant. Alarm fatigue can occur when a nurse becomes desensitized to alarms. Alarm fatigue can jeopardize patient safety, and adverse alarm events can lead to patients dying. To evaluate how a process intervention affects the number of alarms during an 8-hour shift in an intensive care unit. A total of 62 patients from an intensive care unit were included in the study; 32 of these patients received the intervention, which included washing the patient's chest with soap and water and applying new electrocardiography electrodes at the start of a shift. The number of alarms, clinical diagnoses, and demographic variables were collected for each patient. A Poisson regression model was used to evaluate the impact of the intervention on the overall number of clinical alarms during the shift, with no adjustments to the alarm settings or other interventions. After relevant covariates are controlled for, the results suggest that patients in the intervention group presented significantly fewer alarms than did patients in the control group. Managing clinical alarms is a main issue in terms of both patient safety and staff workload management. The results of this study demonstrate that a relatively simple process-oriented strategy can decrease the number of alarms.

A real-world assessment of procalcitonin combined with antimicrobial stewardship in a community ICU.

We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU). We implemented daily PCT levels for ICU patients receiving antibiotics. Our protocol recommended stopping antibiotic therapy if PCT met an absolute or relative stopping threshold. We evaluated the adherence to stopping criteria within 48h, antibiotic use [days of therapy (DOT) per 1000 patient-days (PD)], length of stay and ICU-mortality. We performed interrupted time series analysis to compare 24months before and 12months after implementation. A total of 297 antibiotic courses were monitored with PCT in 217 patients. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Antibiotic use pre-PCT was 935 DOTs/1000 PDs and post-PCT was 817 DOTs/1000 PDs (RRadj 0.73, 95% CI: 0.62 to 0.86). No statistically significant changes in clinical outcomes were noted. In the context of an established ASP in a community hospital ICU, PCT monitoring was feasible and associated with an adjusted overall decrease of 27% in antibiotic use with no adverse impact on clinical outcomes. Incorporating PCT testing to guide antibiotic duration can be successful if integrated into workflow and paired with ASP guidance.

Rapid Response Electroencephalography for Urgent Evaluation of Patients in Community Hospital Intensive Care Practice.

Limited access to specialized technicians and trained neurologists results in delayed access to electroencephalography (EEG) and an accurate diagnosis of patients with critical neurological problems. This study evaluated the performance of Ceribell Rapid Response EEG System (RR-EEG), which promises fast EEG acquisition and interpretation without traditional technicians or EEG-trained specialists. The new technology was tested in a community hospital intensive care unit in Northern California. Three physicians (without previous training in EEG) were trained by the manufacturer of the RR-EEG and acquired EEG without the help of any EEG technicians. Time needed from order to EEG acquisition was noted. Quality of EEG and diagnostic information obtained with the new EEG technology were evaluated and compared with the same information from conventional clinical EEG system. Ten patients were tested with this new EEG technology, and 6 of these patients went on to have conventional EEGs when the EEG technicians arrived at the site. In these cases, the conventional EEG was significantly delayed (11.2 ± 3.6 hours) compared with RR-EEG (5.0 ± 2.4 minutes; P < .005). Use of RR-EEG helped clinicians rule out status epilepticus and prevent overtreatment in 4 of 10 cases. RR-EEG and conventional EEG systems yielded similar diagnostic information. RR-EEG can be set up by nurses, and diagnostic information about the presence or absence of seizures can be appreciated by nurses. The RR-EEG system, compared with the conventional EEG, did not require EEG technologists and enabled significantly faster access to diagnostic EEG information. This report confirms the ease of use and speed of acquisition and interpretation of EEG information at a community hospital setting using an RR-EEG device. This new technology has the potential to improve emergent clinical decision making and prevent overtreatment of patients in the intensive care unit setting while empowering nursing staff with useful diagnostic information in real time and at the bedside.

1995. Serial Procalcitonin Measurement in a Community Intensive Care Unit: Is There Value in the Setting of an Established Antibiotic Stewardship Program?

BackgroundProcalcitonin (PCT) monitoring has been shown to result in reduced antibiotic use without an impact on patient outcomes. However, the real-world value of this biomarker has yet to be determined, particularly when efforts to optimize antibiotic use are already in place. We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU) in Toronto, Canada.MethodsWe conducted a quality improvement initiative in our ICU from November 2017 to October 2018 measuring daily PCT levels for immunocompetent patients receiving antibiotic therapy for suspected or proven bacterial infection with an expected duration between 48 hours and 21 days. Our protocol recommended stopping antibiotic therapy if PCT fell below 0.5 μg/L (absolute threshold) or if it dropped more than 80% from its peak value (relative threshold). ASP rounds took place twice weekly since 2013, integrating a regular discussion about PCT levels once this initiative was implemented. We evaluated the adherence to stopping criteria within 48h, antibiotic use (days of therapy per 1,000 patient-days), length of stay, 48h re-admission, and ICU-mortality. Interrupted time series with segmented regression was performed to evaluate pre-post intervention differences compared with the 12-months prior to implementation.ResultsA total of 297 antibiotic courses were monitored with PCT in 217 patients. Respiratory (62%), unknown infection (11%), and intra-abdominal infection (7%) were the most common reasons for antibiotics. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Adherence by ICU physician varied widely between 24% and 52%. Antibiotic use pre-PCT was 1,002 DOTs/1,000 PDs and post-PCT was 817 DOTs/1,000 PDs (adjusted change −15%, 95% CI: −28% to +8%) (Figure 1). No statistically significant changes in clinical outcomes were noted.ConclusionIn the context of an active ASP in a community hospital ICU, PCT monitoring was associated with a non-significant decrease in antibiotic use. Further evaluation of reasons for inter-physician variability in adherence and opportunities for improved and sustained overall adherence should be explored. Disclosures All authors: No reported disclosures.

Qualitative descriptive study to explore nurses’ perceptions and experience on pain, agitation and delirium management in a community intensive care unit

ObjectivesThe purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically...

Nurse-Initiated Mobilization Practices in 2 Community Intensive Care Units: A Pilot Study.

Critical-care nurses play a vital role in promoting safe early mobilization in intensive care unit (ICU) settings to reduce the risks associated with immobility in ICUs, including the risk of delirium, ICU-acquired weakness, and functional decline. The purposes of this study were to describe nurse-led mobilization practices in 2 community hospital ICUs and to report differences and similarities between the 2 settings. This was a cross-sectional exploratory study of 18 nurses (ICU A: n = 12, ICU B: n = 6) and 124 patients (ICU A: n = 50, ICU B: n = 74). Patient-specific therapeutic intervention needs and nurse-initiated mobilization practices were tracked over a 1-month period. Differences in patient characteristics and nurse-led mobilization activities were observed between ICUs. After controlling for patient characteristics, we found statistically significant differences in nurse-led mobilization activities between the 2 units, suggesting that factors other than patient characteristics may explain differences in nurse-led mobilization practices.

Optimising non-invasive mechanical ventilation: Which unit should care for these patients? A cohort study

BackgroundUse of noninvasive ventilation (NIV) has extended beyond intensive care units (ICUs), becoming usual practice in emergency departments (EDs) and general wards. ObjectiveTo analyse the relationship between nursing care and NIV outcome in different hospital units. Design and settingsThree university hospitals and one community hospital participated in a prospective observational cohort study. ParticipantsTen units participated: 4 ICUs (1 surgical, 3 medical-surgical), 3 recovery (1 postsurgical, 2 EDs, 3 general wards). MethodTreatment success/failure, interface intolerance and complications were evaluated according to patient characteristics, nursing care provided, and procedures used. Complications analysed included bronchoaspiration, pneumothorax, skin lesions, inability to manage secretions, eye irritations, deteriorating level of consciousness, gastric distension, and excessive air losses around the mask. ResultsOf 387 patients, 194 (50.1%) were treated in ICU, 121 (31.3%) in ED, 38 (9.8%) postsurgery, and 34 (8.8%) in general wards. Regression analysis, adjusted for APACHE score and NIV indication, showed 3.3 times greater risk of NIV failure (95% CI [1.2–9.2]) in a university-hospital ICU with <50 NIV cases/year, compared to a community hospital ICU. In ICUs and general wards, NIV was suspended in 12% of patients due to interface intolerance. Acute-on-chronic lung diseases (ACLD) had lower risk of NIV failure (OR 0.2 [95% CI 0.06–0.69]) and lack of humidification was not associated with treatment failure (OR 0.2 [95% CI 0.1–0.4]). Poor secretion management was linked to pneumonia (OR 2.5 [95% CI 1.1–5.9]) and early weaning/extubation (OR 3.3 [95% CI 1.2–8.9]). Interface intolerance was associated with conventional ICU ventilators (OR 4.4 [95% CI 2.1–9.2]) and nasal skin lesions with excessive air losses (OR 2.4 [95% CI 1.1–5.3]), especially with oronasal masks (OR 3.5 [95% CI 1.1–11.3]). ConclusionsAcute respiratory failure patients with pneumonia admitted to general wards had increased interface intolerance and NIV failure. Rotating mask types could improve NIV success in any unit administering this therapy.

Using Fresh Frozen Plasma for Acute Airway Angioedema to Prevent Intubation in the Emergency Department: A Retrospective Cohort Study.

Background. Angioedema (AE) is a common condition which can be complicated by laryngeal edema, having up to 40% mortality. Although sporadic case reports attest to the benefits of fresh frozen plasma (FFP) in treating severe acute bouts of AE, little evidence-based support for this practice is available at present. Study Objectives. To compare the frequency, duration of intubation, and length of intensive care unit (ICU) stay in patients with acute airway AE, with and without the use of FFP. Methods. A retrospective cohort study was conducted, investigating adults admitted to large community hospital ICU with a diagnosis of AE during the years of 2007–2012. Altogether, 128 charts were reviewed for demographics, comorbidities, hospital courses, and outcomes. A total of 20 patients received FFP (108 did not). Results. Demographics and comorbidities did not differ by treatment group. However, nontreated controls did worse in terms of intubation frequency (60% versus 35%; p = 0.05) and ICU stay (3.5 days versus 1.5 days; p < 0.001). Group outcomes were otherwise similar. Conclusion. In an emergency department setting, the use of FFP should be considered in managing acute airway nonhereditary AE (refractory to steroid, antihistamine, and epinephrine). Larger prospective, better controlled studies are needed to devise appropriate treatment guidelines.

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Bathing in Community Hospital Intensive Care Units

A Multicenter Pragmatic Interrupted Time Series Analysis of Chlorhexidine Bathing in Community Hospital Intensive Care Units

Intensivist Staffing: Evolving Challenges and Solutions.

Increases in critical care utilization related to aging of our population, static supplies of critical care specialists, and reduced availability of physicians in training to staff intensive care units (ICUs) have led many institutions to reevaluate their ICU prescribing provider staffing plans. The epidemiology of critical care staffing needs, regulations, requirements, standards, and professional society staffing recommendations are reviewed and the components of a prescribing provider staffing plan are described along with their costs. Factors that impact staffing costs including the availability of intensivist extenders, electronic support, and telemedicine tools that impact the efficiency of care delivery are evaluated in the context of staffing plan evaluation. Financial modeling is used to compare the costs of common prescribing provider staffing plans for typical referral medical center ICUs, community hospital ICUs, and rural health centers that care for the critically ill.

The relationship of outpatient prescription narcotic use to the early implementation and manner of assisted ventilation in a community hospital intensive care unit

The use of prescription opioids has increased in the United States during the past twenty years. The relationship of outpatient opioid use to early assisted ventilation needs in patients admitted to a community hospital intensive care unit was examined.

The Prevalence of Outpatient Prescription Narcotic Use and Its Impact on Ventilatory and Pressor Requirements in a Community Hospital Intensive Care Unit

The Prevalence of Outpatient Prescription Narcotic Use and Its Impact on Ventilatory and Pressor Requirements in a Community Hospital Intensive Care Unit