Critical Care Physicians Research Articles

Gender, Race, and Ethnicity in Critical Care Fellowship Programs in the United States From 2016 to 2021.

The purpose of this study is to determine the trends in gender, race, and ethnicity of U.S. critical care fellowships over the past 6 years (2016-2021). Data on gender, race, and ethnicity of critical care fellows in five Accreditation Council on Graduate Medical Education-accredited training programs (internal medicine, pulmonary and critical care, anesthesiology, surgery, and pediatrics) from 2015 to 2016 to 2020-2021 were obtained from the joint reports of the American Medical Association (AMA) and Association of American Medical Colleges published annually in the Journal of the AMA. From 2016 to 2021, the number of U.S. critical care fellows increased annually, up 23.8%, with the largest number of fellows in pulmonary critical care medicine (60.1%). The percentage of female critical care fellows slightly increased from 38.7% to 39.4% (p = 0.57). White fellows significantly decreased from 57.4% to 49.3% (p = 0.0001); similarly, Asian fellows significantly decreased from 30.8% to 27.5% (p = 0.004). The percentage of Black or African American fellows was not statistically significantly different (4.9% vs 4.4%; p = 0.44). The number of fellows who self-identified as multiracial significantly increased from 52 (1.9%) to 91 (2.7%) (p = 0.043). The percentage of fellows who identified as Hispanic was not significantly different (6.7% vs 7.5%; p = 0.23). The percentage of women and racially and ethnically minoritized fellows (Black and Hispanic) remain underrepresented in critical care fellowship programs. Additional research is needed to better understand these demographic trends in our emerging critical care physician workforce and enhance diversity.

Expert consensus on difficult airway assessment.

Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety. Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts. This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway. This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

URM: Underrepresented or Underrecognized? A Case Study of Black Pediatric Critical Care Physicians.

This study explored Black physicians' experience via an antideficit lens to gain new ideas for advancing minoritized physicians in academic medicine more broadly. Increasingly, systemic racism in academic medicine is intentionally acknowledged and named. However, many solutions to tackle racism and the overall paucity of Black physicians use a deficit framing, painting Black physicians and trainees as lacking preparation, interest, or experience and qualifications. Such solutions aim to help Black people assimilate into the "White Space" of academic medicine, rather than focusing on Black people's strengths. This qualitative study included 15 Black physicians and trainees in pediatric critical care medicine (PCCM) from across the country who participated in semistructured interviews. Through an antideficit lens, the researchers examined the social, cultural, and structural contexts influencing the participants' individual experiences. They analyzed the data combining thematic and narrative qualitative analysis approaches, including restorying. The data help promote understanding of the landscape and context in which Black PCCM physicians become successful. Achievement took on different forms for the participants. Participants described enablers of achievement that supported them through their individual journeys spanning 3 general domains-intrinsic, interpersonal, and systemic. Three additional enablers were tied specifically to participants' Black identities-harnessing Blackness as a superpower, leaning in to lead, and successfully navigating the "unwritten rules." By using an antideficit framework, this study delineates and centers participants' ingenuity in cultivating repertoires of practice that enabled them to succeed, despite challenges rooted in systemic racism. Going forward, rather than focus solely on what is missing, academic medicine should try to shift systems and regularly recognize and value the knowledge, expertise, and merit Black that physicians bring. Perhaps an appropriate framing is not that Black physicians are underrepresented in medicine; maybe instead, it is that they are underrecognized.

Who Is Teaching Residents in the Intensive Care Unit? Perceptions of Interprofessional Teaching at an Academic Medical Center.

Teamwork is essential for high-quality care in the intensive care unit (ICU). Interprofessional education has been widely endorsed as a way of promoting collaborative practice. Interprofessional providers (IPPs), including nurses, pharmacists, and respiratory therapists (RTs), routinely participate in multidisciplinary rounds in the ICU, but their role in teaching residents at academic medical centers has yet to be characterized. To characterize perceptions of interprofessional teaching during and outside of rounds in the ICU. The authors conducted a cross-sectional survey of critical care physicians, internal medicine residents, nurses, pharmacists, and RTs across three ICUs at a tertiary academic medical center from September 2019 to March 2020. The frequency of different types of rounds contributions was rated on a Likert scale. Means and medians were compared across groups. A total of 221 of 285 participants completed the survey (78% response rate). All IPPs described that they report data, provide clinical observations, and make recommendations frequently during ICU rounds, but teaching occurred infrequently (mean values, nurses = 2.9; pharmacists = 3.5; RTs = 3.7; 1 = not at all; 5 = always). Nurses were least likely to report teaching (P = 0.0017). From residents' and attendings' perspectives, pharmacists taught most frequently (mean values, 3.7 and 3.4, respectively). RTs self-report of teaching was higher than physicians' reports of RT teaching (P < 0.0001). Outside of rounds, residents reported a low frequency of teaching by nurses and RTs (means, nurses = 3.1; RTs = 3.1), but they reported a high rate of teaching by pharmacists (mean, 4.4). Nonphysician IPPs routinely participate in ICU rounds but teach medical trainees infrequently. Physicians' perception of IPP teaching frequency was generally lower than self-reports by IPPs. Exploring modifiers of interprofessional teaching may enhance education and collaboration.

AI to Mitigate Healthcare Shortages: A Qualitative Analysis of Current and Future Work Conditions to Enhance Job Satisfaction and Wellbeing in Critical Care Nurses and Physicians (Preprint)

AI to Mitigate Healthcare Shortages: A Qualitative Analysis of Current and Future Work Conditions to Enhance Job Satisfaction and Wellbeing in Critical Care Nurses and Physicians (Preprint)

Rapid cycle training for non-critical care physicians to meet intensive care unit staff shortage at an academic training center in a developing country during the COVID-19 pandemic

BackgroundThe sudden unexpected increase in critically ill COVID-19 patients admitted to Intensive Care Units (ICUs), resulted in an urgent need for expanding the physician workforce. A COVID-19 critical care crash (5C) course was implemented to introduce physicians without formal critical care training to care for critically ill COVID-19 patients. Upon successful completion of the course, physicians were recruited to work in a COVID-19 ICU under the supervision of a board-certified critical care physician. The aim of this study is to describe the methods of a novel course designed specifically to teach the management critically ill COVID-19 patients, while assessing change in knowledge, skill competency, and self-reported confidence.MethodsThe blended focused 5C course is composed of both virtual and practical components. Candidates may register for the practical component only after successful completion of the virtual component. We assessed knowledge acquisition using a multiple-choice question test (pre- and post-test assessment), skill competency, and self-reported confidence levels during simulated patient settings. Paired T-test was used to compare before and after course results.ResultsSixty-five physicians/trainees from different specialties were included in the analysis. Knowledge significantly increased from 14.92± 3.20 (out of 20 multiple-choice questions) to 18.81± 1.40 (p< 0.01), skill competence during practical stations had a mean minimum of 2 (out of 3), and self-reported confidence during a simulated patient setting increased significantly from 4.98± 1.15 (out of 10) to 8.76± 1.10 (out of 10) (p< 0.01).ConclusionWe describe our initiative in increasing the ICU physician workforce in the midst of the COVID-19 pandemic. The blended 5C course is a valuable educational program designed by experts from different backgrounds. Future research should be directed at examining outcomes of patients associated with graduates of such program.

An Adjudication Protocol for Severe Pneumonia.

Clinical end points that constitute successful treatment in severe pneumonia are difficult to ascertain and vulnerable to bias. The utility of a protocolized adjudication procedure to determine meaningful end points in severe pneumonia has not been well described. This was a single-center prospective cohort study of patients with severe pneumonia admitted to the medical intensive care unit. The objective was to develop an adjudication protocol for severe bacterial and/or viral pneumonia. Each episode of pneumonia was independently reviewed by 2 pulmonary and critical care physicians. If a discrepancy occurred between the 2 adjudicators, a third adjudicator reviewed the case. If a discrepancy remained after all 3 adjudications, consensus was achieved through committee review. Evaluation of 784 pneumonia episodes during 593 hospitalizations achieved only 48.1% interobserver agreement between the first 2 adjudicators and 78.8% when agreement was defined as concordance between 2 of 3 adjudicators. Multiple episodes of pneumonia and presence of bacterial/viral coinfection in the initial pneumonia episode were associated with lower interobserver agreement. For an initial episode of bacterial pneumonia, patients with an adjudicated day 7-8 clinical impression of cure (compared with alternative impressions) were more likely to be discharged alive (odds ratio, 6.3; 95% CI, 3.5-11.6). A comprehensive adjudication protocol to identify clinical end points in severe pneumonia resulted in only moderate interobserver agreement. An adjudicated end point of clinical cure by day 7-8 was associated with more favorable hospital discharge dispositions, suggesting that clinical cure by day 7-8 may be a valid end point to use in adjudication protocols.

Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review.

Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.

Who to escalate during a pandemic? A retrospective observational study about decision-making during the COVID-19 pandemic in the UK

BackgroundOptimal decision-making regarding who to admit to critical care in pandemic situations remains unclear. We compared age, Clinical Frailty Score (CFS), 4C Mortality Score and hospital mortality in two separate...

Acute exacerbation of interstitial lung disease in the intensive care unit: Principles of diagnostic evaluation and management.

Interstitial lung disease (ILD) is typically managed on an outpatient basis. Critical care physicians manage patients with ILD in the setting of an acute exacerbation (ILD flare) causing severe hypoxia. The principles of management of acute exacerbation of ILD are different from those used to manage patients with acute respiratory distress syndrome from sepsis, etc. Selected patients may be candidates for aggressive measures like extracorporeal membrane oxygenation and lung transplantation, while almost all patients will benefit from early palliative care. This review focused on the types of ILD, diagnosis, and management pathways for this challenging condition.

The Role of Focused 2-Dimensional Echocardiography in Managing Left Ventricular Outflow Tract Obstruction Mimicking Cardiogenic Shock.

Left ventricular outflow tract obstruction (LVOTO) is a common cardiogenic shock (CS) mimic. We present 3 cases of patients presenting with CS following myocardial infarction, exhibiting a poor response to conventional treatment with inotropy and mechanical circulatory support. This triggered echocardiographic assessment by critical care physicians using focused 2-dimensional (2D) echocardiography. This timely assessment identified anterior mitral valve leaflet entrainment into the left ventricular outflow tract (LVOT), causing LVOTO as the underlying shock mechanism. Echocardiographic findings have led to significant changes in management. The patients underwent fluid administration, weaning from inotropy, and mechanical circulatory support explantation, leading to relief of LVOTO and improved hemodynamics. Critical care basic 2D echocardiography accreditations focus on myocardial function and pericardial effusions. Relevant societies administering these accreditations should consider adding LVOT assessment to enable timely diagnosis of this life-threatening CS mimic.

Microaggressions in anesthesiology and critical care: individual and institutional approaches to change.

Microaggressions are subtle verbal or nonverbal insults that convey derogatory and negative messages to and about people who belong to oppressed groups. Microaggressions reflect structurally and historically perpetuated societal values, which advantage some groups of people by considering them to be inherently more worthy than others, while simultaneously disadvantaging others. While microaggressions may seem innocuous and are often unintentional, they cause tangible harm. Microaggressions are commonly experienced by physicians and learners working in perioperative and critical care contexts and are often not adequately addressed, for a multitude of reasons, including witnesses not knowing how to respond. In this narrative review, we provide examples of microaggressions towards physicians and learners working in anesthesia and critical care, and offer individual and institutional approaches to managing such incidents. Concepts of privilege and power are introduced to ground interpersonal interventions within the larger context of systemic discrimination, and to encourage anesthesia and critical care physicians to contribute to systemic solutions.

Using Two Statewide Medical Operations Coordination Centers to Load Balance in Pediatric Hospitals During a Severe Respiratory Surge in the United States.

Report on the use of two statewide Medical Operations Coordination Centers (MOCCs) to manage a rapid surge in pediatric acute and critical care patient needs. Brief report. The states of Washington and Oregon during the pediatric respiratory surge in November 2022/December 2022 which overwhelmed existing pediatric acute and critical care hospital capacity. Pediatric patients requiring hospitalization in Washington and Oregon. Adaptations to the use of two existing statewide MOCCs to provide pediatric patient load balancing through surveillance, modifications of existing referral agreements, coordinated expansion of resources, activation of regional crisis standards of care, and integration of pediatric critical care physicians from Harborview Medical Center as subject matter experts (SMEs). The Washington and Oregon MOCCs managed 183 pediatric requests from hospitals unable to transfer pediatric patients between November 1, 2022, and December 14, 2022. Sixteen percent of requests were for children younger than 3 months and 37% were for children between 3 months and 1 year; most had acute viral respiratory disease. Requests for children older than 13 years old were primarily intentional drug ingestions. Fifty-eight percent were for critically ill children and 17% originated from critical access hospitals. Washington's SMEs were utilized in nearly a quarter of cases with the disposition changing in 38% of these. Washington and Oregon statewide MOCCs have leveraged centralized coordination to effectively load balance a surge in pediatric patients which has overwhelmed existing pediatric hospital resources. Centralized coordination and surveillance informed pediatric hospitals and policy makers of unmet clinical needs and facilitated rapid expansion of clinical capacity and modifications to referral processes. Integration of pediatric SMEs enabled efficient triage of these resources. MOCCs provide an adaptable centralized resource for addressing surge and have been effective in managing overwhelmed pediatric hospital resources in Washington and Oregon.

Queer(ing) medical spaces: queer theory as a framework for transformative social change in anesthesiology and critical care medicine.

Queer theory is a disruptive lens that can be adopted by researchers, educators, clinicians, and administrators to effect transformative social change. It offers opportunities for anesthesiologists, critical care physicians, and medical practitioners to more broadly understand what it means to think queerly and how queering anesthesiology and critical care medicine spaces improves workplace culture and patient outcomes. This article grapples with the cis-heteronormative medical gaze and queer people's apprehensions of violence in medical settings to offer new ways of thinking about structural changes needed in medicine, medical language, and the dehumanizing application of medical modes of care. Using a series of clinical vignettes, this article outlines the historical context underlying queer peoples' distrust of medicine, a primer in queer theory, and an understanding of how to begin to "queer" medical spaces using this critical framework.

Critical care pharmacy practice advancement recommendations on direct patient care activities: An opinion of the American College of Clinical Pharmacy Critical Care Practice and Research Network

AbstractAn updated position paper on critical care pharmacy services recommends the development of new clinical programs. However, proposed pragmatic strategies for critical care pharmacy practice advancement are lacking. The purpose of this position paper is to develop consensus recommendations aimed at direct patient care activities for the advancement of critical care pharmacy practice. A 24‐member task force of critical care pharmacists, physicians, and nurses participated in a Recommendation Development Phase and Consensus‐building Phase (using a Delphi method) to produce the final critical care practice advancement recommendations. Proposed recommendations of pragmatic medication management opportunities with an advanced scope of practice involving pharmacist prescriptive authority for initiating, modifying, or discontinuing drug therapy and medication monitoring were developed. Task force participants anonymously voted on each proposed recommendation using a five‐point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree). Recommendations failing to achieve consensus (≥70% agreement on “strongly agree”/“agree” votes) were revised for subsequent voting. Task force response rates during the first and second voting rounds were 71% (n = 17) and 79% (n = 19), respectively. A total of 57 (93.4%) of the 61 proposed practice advancement recommendations achieved consensus of which 88.5% (n = 54) met consensus after the first round. Consensus recommendations involved the critical care pharmacist initiating (n = 15), modifying (n = 22), or discontinuing (n = 9) drug therapy, and ordering relevant laboratory values or tests to optimize drug therapy (n = 11). One recommendation failing consensus was not revised for additional voting given the impracticality of achieving agreement. Fifty‐seven of the proposed 61 recommendation statements (93%) achieved the consensus threshold after two rounds of voting by an interprofessional expert panel. These recommendations provide a conceptual framework for promoting novel critical care pharmacist prescriptive authority over specific aspects of direct patient care. Implementation challenges and barriers, further described in this paper, must be explored at the institutional level for acceptance.

Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department.

Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department.

Evaluation of Digital Health Strategy to Support Clinician-Led Critically Ill Patient Population Management: A Randomized Crossover Study.

Single center randomized crossover study. Quaternary care academic hospital. Attending and in-training critical care physicians, and advanced practice providers. AMP. We compared ICU clinician performance in structured clinical task completion using two electronic environments-the standard commercial EMR (Epic) versus the novel AMP in addition to Epic. Twenty subjects (10 pairs of clinicians) participated in the study. During the study session, each participant completed the tasks on two ICUs (7-10 beds each) and eight individual patients. The adjusted time for assessment of the entire ICU and the adjusted total time to task completion were significantly lower using AMP versus standard commercial EMR (-6.11; 95% CI, -7.91 to -4.30 min and -5.38; 95% CI, -7.56 to -3.20 min, respectively; p < 0.001). The adjusted time for assessment of individual patients was similar using both the EMR and AMP (0.73; 95% CI, -0.09 to 1.54 min; p = 0.078). AMP was associated with a significantly lower adjusted task load (National Aeronautics and Space Administration-Task Load Index) among clinicians performing the task versus the standard EMR (22.6; 95% CI, -32.7 to -12.4 points; p < 0.001). There was no statistically significant difference in adjusted total errors when comparing the two environments (0.68; 95% CI, 0.36-1.30; p = 0.078). When compared with the standard EMR, AMP significantly reduced time to assessment of an entire ICU, total time to clinical task completion, and clinician task load. Additional research is needed to assess the clinicians' performance while using AMP in the live ICU setting.

PO-03-153 POST-OPERATIVE ATRIAL FIBRILLATION STANDARIZATION OF CARE THROUGH CLINICAL CARE PATHWAYS FOR CARDIAC SURGICAL PATIENTS

Post-operative atrial fibrillation (POAF) occurs commonly in cardiac surgical patients up to 55% of the time leading to an increase risk of thromboembolic events, stroke, renal and respiratory failure, and an increase in all-cause 30-day and 6-month mortality. Standardization of care through guideline-directed clinical pathways may decrease occurrence of POAF and morbidity associated with it in the post-operative period. A multidisciplinary team including cardiac electrophysiologist, cardiac surgeons, and pulmonary critical care physicians developed a guideline-directed clinical AF pathway for patients with POAF. Patients were consecutively enrolled with the use of the AF pathway. The data of interest has been collected in a REDCap database. A retrospective review was performed of 327 cardiac surgery patients in 2020 as well as 301 cardiac surgery patients in 2021 after the POAF pathway implementation. Baseline characteristics of both groups in addition to the length of stay (LOS), hospitalization from admit to discharge, readmissions recurrent of AF post discharge were collected for both cohorts of patients. Baseline characteristics of patients that utilized the POAF pathway compared to ones in the retrospective review prior to implementation of the POAF pathway demonstrated no no statistical difference in cardiovascular comorbidities including baseline existence of hypertension, diabetes, left atrial size, age and obesity. There was however a significant reduction in LOS in patients that utilized the POAF pathway. The average LOS for patients that were included in the POAF pathway was reduced by 8 days (6 to 14 days) with a p-value of < 0.0001 compared to the conventional cohort. This resulted in an estimated > 2400 hospital days avoided which equates to approximately $1.36M total cost savings based on the calendar year 2021 estimated cost per opportunity day. Additionally, there is was a decrease in hospital readmissions, occurrence of AF during hospitalization and post discharge. POAF clinical pathway utilization for cardiac surgical patients significantly reduced LOS and reduced hospital readmissions for AF as well as recurrence of AF during and after hospitalizations therefore improving overall cardiac surgical outcomes.

POCUS for Diastolic Dysfunction: A Review of the Literature.

Emergency and critical care physicians frequently encounter patients presenting with dyspnea and normal left ventricular systolic function who may benefit from early diastolic evaluation to determine acute patient management. The current American Society of Echocardiography Guidelines approach to diastolic evaluation is often impractical for point of care ultrasound (POCUS) evaluation, and few studies have evaluated the potential use of a simplified approach. This article reviews the literature on the use of a simplified diastolic evaluation to assist in determining acute patient management.

Standardized Curriculum Improves Physician and Nurse Confidence and Competence in Brain Death (P12-2.005)

<h3>Objective:</h3> To study the impact of a standardized brain death curriculum on physician and nurse competence, confidence, and comfort. <h3>Background:</h3> There is decreased familiarity with and exposure to brain death amongst medical professionals when compared with cardiac death. Therefore, targeted education should be offered to multidisciplinary healthcare providers to impact competence and familiarity with this entity. <h3>Design/Methods:</h3> Brain death educational curricula were developed for and offered to (A) neurosciences and critical care physicians to effect accurate declaration and discussion of brain death, and (B) critical care nursing to improve confidence and competence in answering family questions about brain death at the bedside. Trainees and attending physicians underwent a formal didactic followed by simulation-based training incorporating examination and communication skills. Critical care nurses underwent formalized didactic followed by peer-based simulated conversations of frequently asked questions. All participants submitted pre-curriculum and post-curriculum surveys that included a combination of Likert, fill-in, and multiple-choice questions as well as a knowledge test. Wilcoxon signed-rank test and Kruskal-Wallis test were used for statistical analysis (P&lt;0.05). <h3>Results:</h3> 46 neurosciences and critical care physicians and 21 critical care nurses participated in their respective brain death curriculum. Mean scores on knowledge test improved from 5.3 to 6.9 out of 10 for physicians (p&lt;0.001) and from 4.2 to 6.2 out of 8 for nurses (p&lt;0.001). Mean physician confidence in performing independent brain death declaration increased from 3.6 to 7.7, out of 10 (p&lt;0.001). Mean physician comfort documenting a brain death assessment increased from 3.7 to 7.9, out of 10 (p&lt;0.001). Mean comfort in discussing brain death with patients’ family increased from 5.0 to 8.1 for physicians and from 5.3 to 7.8 for nurses (both out of 10, both p&lt;0.001). <h3>Conclusions:</h3> Formalized education on brain death improves confidence, comfort, and competence in brain death among physicians and nurses. <b>Disclosure:</b> Dr. Hodosevich has nothing to disclose. Dr. LaBuzetta has nothing to disclose.