Critical Care Services Research Articles

The Role of Doulas in Addressing Disparities, Barriers, and Potential Solutions to Navigating Reproductive Loss

Reproductive loss can take many forms. Common experiences include abortions, stillbirths, or miscarriages. Especially in a post-Roe time and space, the health disparities and stigmas that exist surrounding reproductive loss and those experiencing pregnancy loss have become even more apparent. Health disparities continue to exist through sociodemographic factors such as ethnicity, gender, race, and socioeconomic status. As found in existing literature on individuals’ experiences with reproductive health care, each person’s experiences strongly correlate with their identities. The level of reproductive care and compassion received vary dramatically as a result, with people of color and lower socioeconomic statuses receiving lower quality of care when seeking it out. Trends in unintended pregnancies and access to support resources also reinforce the idea that health disparities are at play. Additionally, intersectionality, or the overlapping of an individual’s multiple identities, plays an important role in the disparities seen within reproductive healthcare as discrimination and other structural factors are designed to benefit certain groups of individuals while putting others at disadvantages. Studies and surveys of individuals who have experienced pregnancy loss have addressed the existence of these inequalities within reproductive health care. Through a reproductive justice perspective, this literature review aims to bring attention to the disparities present in reproductive healthcare and how the work of reproductive loss doulas, which are full-spectrum doulas who honor all reproductive experiences, may address these disparities with sensitive and compassionate care. While addressing nationwide disparities in pregnancy loss, this literature review uses the state of Michigan to also analyze the current legislative efforts designed to expand access to critical reproductive health care services.

The needs and experiences of critically ill patients and family members in intensive care unit of a tertiary hospital in Malaysia: a qualitative study

BackgroundAdmission to an intensive care unit (ICU) is a stressful experience for patients and their family members. While the focus of management is primarily on medical care, there can be other areas which are overlooked. The purpose of this study was to investigate the needs and experiences of ICU patients and family members.MethodThis qualitative study involved four trained researchers conducting in-depth interviews (IDI) based on a semi-structured interview guide. The participants were ICU patients and family members. All IDIs were audio-recorded and transcribed verbatim. Four researchers independently analyzed the data via thematic analysis with the aid of QDA Miner Lite®. The themes and subthemes were generated and confirmed by literature and expert opinion.ResultsSix IDIs were conducted with three patients and three family members, whose ages ranged from 31 to 64 years old. One pair of participants consisted of a patient and his respective family member, while the other four participants did not have a familial relationship with each other. Three main themes emerged from the analysis: (I) critical care services; (II) physical spaces; and (III) monitoring technology. Medical, psychological, physical, and social needs for critical care services were expressed by both patients and family members. Patients’ needs in clinical spaces were highlighted as a conducive ICU environment with ambient temperature and controlled noise levels. In non-clinical spaces, family members expressed a need for more chairs in the waiting area. Participants expressed the need for call bells as well as patients’ negative perceptions of medical equipment alarms in the ICU when it pertained to monitoring technology.ConclusionThis study provides an in-depth view at the needs and experiences of ICU patients and family members who have a variety of unmet needs. This understanding is critical for guiding ICU personnel and stakeholders in their efforts to humanize ICU care.

Neuroscience Leadership.

Questions or comments about this article may be directed to Julieanne George, MSN MBA RN CNML NE-BC PCCN-K CCRN-K, at [email protected]. J.G. is Senior Clinical Director, Adult Services: Critical Care & Neuroscience Services, and Interim Senior Director, Behavioral Health Services. The author declares no conflicts of interest.

The Maryland (USA) Critical Care Coordination Center (C4): From Pandemic to Permanence.

The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland's (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care. The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation. Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide. The C4 has played an integral role in the State of Maryland's pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

A quality improvement initiative to increase adult ECMO decision-making abilities in a perfusion education program: The use of 3D ECMO simulation.

Adult and pediatric ECMO procedures have been increasingly established as conventional life-saving modalities in critical care services across the world. Since 2017, a multidisciplinary team of program advisors for our perfusion education program have aimed to increase cardiovascular perfusion (CVP) student ECMO exposure and improve clinical decision-making. In this QI intervention, the use of 3D computer-based simulation was assessed in establishing a standardized process to improve the diagnosis and treatment of adult ECMO complications among first year CVP students. The Califia 3D Patient Simulator was incorporated into the curriculum for first year CVP students (n = 26) along with traditional lecture for the adult ECMO complication laboratory session. Pre-class knowledge assessments using de-identified polling software were compared to post-class assessments following the first assigned learning activity. Assessments from students that received simulation before lecture (SIM, n = 15) were compared to students receiving lecture before simulation (LEC, n = 11). User experience questionnaires (UEQ) consisting of 26 questions for six scales of simulation instruction were administered to measure the comprehensive impression of the student experience. Overall median [IQR] pre- and -post knowledge assessment scores were 74% [11] and 84% [11], respectively (p = 0.01). There were no significant differences in pre-class assessment scores between the SIM and LEC groups (74.0% and 74.0%, respectively, p = 0.959). The LEC group achieved higher median post-assessment scores than the SIM group (84% vs 79%, p = 0.032). Among the 26 UEQ survey scales, 23 were positively evaluated (>0.8), and three were a neutral evaluation (-0.8 to 0.8). Cronbach Alpha-Coefficients of >0.78 were measured for attractiveness, perspicuity, efficacy, and stimulation. The coefficient for dependability was 0.37. 25 (96.2%) students indicated that 3D simulation was beneficial to improving ECMO clinical decision-making. In this QI intervention, the implementation of computer-based 3D simulation following lecture was perceived by learners to help improve the diagnosis and treatment of ECMO-related complications.

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.

Revisiting medical neglect concerns in children with life-threatening complex chronic conditions

Background/objectivesLife-Threatening Complex Chronic Conditions (LT-CCCs) increase the complexity of medical neglect concerns. Clinicians' perspectives are central in concerns for medical neglect, yet little is currently known regarding clinicians' understanding of and approach to these situations. We explored how clinicians who care for children with LT-CCCs understand medical neglect. MethodsWe conducted a semi-structured qualitative interview study with 20 clinicians of varying disciplines from critical, palliative, and complex care services about medical neglect in children with LT-CCCs. We used inductive thematic analysis to generate themes. ResultsThree primary themes emerged: Relationship between family and medical community, family overwhelmed with medical demands, and insufficient support. Taken together these themes suggest that concerns for medical neglect are directly related to clinician perception of family inability to meet medical needs. ConclusionClinicians report that concerns for medical neglect in children with LT-CCCs often arise from a mismatch of medical expectations and the perception of familial ability to provide said medical care. Given the complex and delicate medical and psychosocial environments of care for children with LT-CCCs, these medical neglect concerns are more accurately described as Medical Insufficiency, a new term. By reframing this entity, we can reframe the dialogue surrounding this issue, and reconsider approaches to studying, preventing, and resolving it.

Metformin use before COVID-19 vaccination and the risks of COVID-19 incidence, medical utilization, and all-cause mortality in patients with type 2 diabetes mellitus

AimsWe designed this study to determine whether metformin use before COVID-19 vaccination influences the risk of COVID-19 infection, medical utilization, and mortality. MethodsWe used the US collaborative network of TriNetX to identify 123,709 patients with type 2 diabetes mellitus fully vaccinated against COVID-19 between January 1, 2020, and November 22, 2022. The study selected 20,894 pairs of metformin users and nonusers by propensity score matching. The Kaplan-Meier method and Cox proportional hazards models were used to compare the risks of COVID-19 infection, medical utilization, and mortality between the study and control groups. ResultsNo significant difference was noted between metformin users and nonusers in the risk of COVID-19 incidence (aHR = 1.02, 95% CI = 0.94–1.10). Compared to the control cohort, the metformin cohort exhibited a significantly lower risk of hospitalization (aHR = 0.85, 95% CI = 0.81–0.89), critical care services (aHR = 0.81, 95% CI = 0.70–0.94), mechanical ventilation (aHR = 0.75, 95% CI = 0.60–0.95), and mortality (aHR = 0.75, 95% CI = 0.63–0.89). The subgroup analyses and sensitivity analysis showed similar results. ConclusionThe present study showed that metformin use before COVID-19 vaccination could not reduce COVID-19 incidence; however, it was associated with significantly lower risks of hospitalization, intensive care service, mechanical ventilation, and mortality in fully vaccinated type 2 diabetes mellitus patients.

Trends in Long-Term Ventilation Care in U.K. Children and Young People-Further Consideration Required for Pediatric Critical Care Services.

The objective was to compare specific data from the 2020 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report "Balancing the Pressures" with two previous U.K. studies and to examine changes in the pediatric population requiring long-term ventilation (LTV) as well as the types delivered. We believe that the new data presented will facilitate future service planning. A subset of confidential enquiry data derived from a study by a nationally funded quality improvement organization (NCEPOD: www.ncepod.org.uk ) was compared with two previous U.K. datasets. Healthcare providers across England, Wales, and Northern Ireland-inpatient and community settings. Children and young people (CAYP) 0-16 years old receiving LTV between April 1, 2016, and March 31, 2018. None. When comparing the NCEPOD data with that last published in the United Kingdom, the number of CAYP requiring LTV more than doubled between 2008 and 2018 (933-2,093). There has also been a particular increase in the proportion of children that were under two when they were commenced on LTV (26-39.2%). Children are now more likely than previously to be receiving LTV to manage upper airway obstruction and CNS conditions. There has also been an approximate doubling of those receiving LTV over the whole 24-hour period (9.4-18.4%). The increased numbers and changing characteristics of babies and children requiring LTV over the last 3 decades in the United Kingdom have implications for all healthcare sectors but particularly for providers of critical care services.

Understanding Age Ranges in Current Procedural Terminology®

This article reviews how age ranges are applied for critical care and other services for which code descriptors include an age range.

Effect of Systemic Illness and Comorbidities in the Prognosis of Severe Acute Respiratory Illness Patients: An Observational Study

Background: Globally critically ill COVID-19 (Coronavirus disease-19) patients have stretched critical care services. This study was undertaken to find factors implicated in mortality amongst COVID positive and negative patients presenting with severe acute respiratory illness (SARI) and factors having the probability of indicating COVID positivity.
 Methods: The demographic parameters, comorbid illness, clinical parameters and laboratory values of 327 patients were retrospectively analyzed to find the risk factors for mortality in COVID positive and negative patients and factors predicting COVID positivity amongst SARI patients.
 Results: 58% of SARI patients tested positive by RTPCR. Most common comorbidities were diabetes and hypertension, 35.2% and 33% respectively. Duration of swelling and low haemoglobin were significantly associated with mortality in COVID positive group (p=0.01, 0.005). Acidosis and tachycardia (p=0.003, 0.034) were associated with mortality amongst COVID negative. Creatinine, Sequential Organ Failure Assessment (SOFA) and quick SOFA (qSOFA) were higher in non-survivors of both groups (p<0.001). Age, history of contact or from containment zone, cough, pain abdomen and P/F ratio were significant predictors of COVID positivity (1.020(1.006–1.035); 3.889(1.316–11.495); 2.908(1.182–7.152); 2.147(1.149–4.012); 0.997(0.994-1.000) respectively) by multivariable regression analysis.
 Conclusion: A long duration of swelling and low haemoglobin (<12 g%) were responsible for COVID positive mortality while pain abdomen, raised levels of AST, tachycardia and acidosis were associated with mortality in COVID negative. Deranged creatinine, higher SOFA and qSOFA were associated with mortality in both groups. Age, contact history, residence in containment zone, cough, pain abdomen and poor P/F ratio are predictive factors for COVID positivity.

Women as a Growing Force in Critical Care Medicine-the Journal, Profession, and Society.

Women as a Growing Force in Critical Care Medicine-the Journal, Profession, and Society.

Telehealth Challenges for California Rural Hospitals in Reaching Latino Populations During COVID-19

Background Rural and remote communities were especially vulnerable to the COVID-19 pandemic due to the availability and capacity of rural health services. Research has found that key issues surrounded (1) the lack of staff, (2) the need for coordinated health services, and (3) operational and facility issues. Similarly, research also confirms that irrespective of hospital capacity issues existing during crisis, compared to urban communities, rural communities typically face poorer access to health services. Telehealth programs have long held promise for addressing health disparities perpetuated by inadequate health care access. In response to the current COVID-19 pandemic, Adventist Health Saint Helena Hospital, a rural hospital in northern California, urgently worked to expand telehealth services. However, as Adventist Health Saint Helena Hospital is the longest-serving rural hospital in the state of California, administrators were also able to draw on experiences from the pandemic of 1918/1919. Understanding their historically rural and heavily Latino populations, their telehealth approach was coupled with cultural approaches for prioritizing socially responsive and equitable access to health services. Objective This study aimed to present one rural community’s holistic sociotechnical response to COVID-19 in redesigning their health care delivery approach. Redesign efforts included the expansion of digital health services coupled with county-wide collaborations for nondigital mobile health centers, testing, and vaccination clinics to meet the needs of those with limited digital access and language barriers. Methods We present data on telehealth services for maintaining critical care services and a framework on the feasibility of private-public partnerships to address COVID-19 challenges. Results In this paper, we provide a critical review of how a rural hospital adapted its health care approach to incorporate telehealth services and distance services to meet the needs of a diverse population. Conclusions This paper contributes empirical data on how rural communities can use telehealth technologies and community partnerships for a holistic community approach to meet health needs during a natural disaster. Conflicts of Interest None declared.

A comparison of clinical profile and outcomes among different age groups of critically ill elderly patients in a tertiary level hospital in Nepal: A retrospective study

Background: Ageing population has increased the rate of hospitalizations and demand for critical care services. The data on the clinical profile and outcomes of different groups of elderly admitted to the intensive care units (ICU) are however sparse. Aims and Objectives: The aim of this study was to evaluate and compare the clinical profile and outcomes among different age groups of critically ill elderly patients admitted to the ICU of a tertiary level hospital. Materials and Methods: This retrospective and observational study reviewed all the elderly patients aged 60 years and above, admitted to the ICU of a tertiary hospital over a period of 1 year. The patients were divided into three groups, 60–69 years, 70–79 years, and 80 years and above. Non-probability sampling was done. Kruskal–Wallis H test was performed to compare the median values of the variables between the three groups. Results: Among 173 patients analyzed, the three groups did not differ in clinical characteristics, requirement of renal replacement therapy and cardiovascular support, length of stay (LOS) in ICU, LOS in mechanical ventilator, and patients who improved and transferred out of ICU. Acute physiology and chronic health evaluation II (APACHE) II score was significantly higher in 70–79 years compared to the other two groups (P=0.01) as was the in-hospital mortality (P=0.03). Conclusion: APACHE II score rather than age is a good predictor of adverse outcomes in ICU. Age should not be used to preclude the utilization of resources in ICU.

Epidemiology of Intensive Care Admissions for Children in the US From 2001 to 2019

Estimates of the number of US children receiving intensive care unit (ICU) care and ICU admission patterns over time are lacking. To determine how ICU admission patterns, use of critical care services, and the characteristics and outcomes of critically ill children have changed from 2001 to 2019. This population-based retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient databases from a total of 21 US states in 2001, 2004, 2010, 2016, and 2019. Hospitalized children aged 0 to 17 years, excluding newborns (during birth hospitalization), were included. Patients admitted to rehabilitation institutions or psychiatric hospitals were also excluded. Data were analyzed from July 2021 to December 2022. Care in a nonneonatal ICU. From extracted patient data, International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision, Clinical Modification, codes were used to identify diagnoses, comorbid conditions, organ failures, and mechanical ventilation. Generalized linear Poisson regression and the Cuzick test were used to evaluate trends. US Census data were used to generate age- and sex-adjusted national estimates of ICU admissions and costs. Of 2 157 991 pediatric admissions, 275 656 (12.8%) included ICU care. The mean (SD) age was 6.43 (6.10) years; 121 894 individuals were female (44.2%), and 153 731 were male (55.8%). From 2001 to 2019, the prevalence of ICU care among hospitalized children increased from 10.6% to 15.5%. The percentage of ICU admissions in children's hospitals rose from 51.2% to 85.1% (relative risk [RR], 1.66; 95% CI, 1.64-1.68). The percentage of children admitted to an ICU with an underlying comorbidity increased from 46.2% to 57.0% (RR, 1.23; 95% CI, 1.22-1.25), and the percentage with preadmission technology dependence increased from 16.4% to 23.5% (RR, 1.44; 95% CI, 1.40-1.48). The prevalence of multiple organ dysfunction syndrome increased from 6.8% to 21.0% (RR, 3.12; 95% CI, 2.98-3.26), while mortality decreased from 2.5% to 1.8% (RR, 0.72; 95% CI, 0.66-0.79). Hospital length of stay increased by 0.96 days (95% CI, 0.73-1.18) for ICU admissions from 2001 to 2019. After inflation adjustment, total costs for a pediatric admission involving ICU care nearly doubled between 2001 and 2019. Nationally, an estimated 239 000 children were admitted to a US ICU in 2019, corresponding to $11.6 billion in hospital costs. In this study, the prevalence of children receiving ICU care in the US increased, as did length of stay, technology use, and associated costs. The US health care system must be equipped to care for these children in the future.

Alex's notebook: The Eastern Association for the Surgery of Trauma 2023 Presidential Address.

Professor of Surgery, University of Maryland School of Medicine, Director Adult Critical Care Services, University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, 410 328-3495. [email protected]

Modernizing payment to critical access hospitals: A proposal for the next iteration of the Flex Program.

Modernizing payment to critical access hospitals: A proposal for the next iteration of the Flex Program.

Canadian Pediatric Intensive Care Adaptations for Critically Ill Adults During the COVID-19 Pandemic: Survey Study

The COVID-19 pandemic overwhelmed Canadian hospitals with adult admissions. A large number of adult patients required critical care therapies, placing significant strain on hospital resources. In order to decompress adult intensive care units, pediatric intensive care units (PICUs) introduced adapted models of traditional care to lessen these burdens. We aimed to evaluate how PICUs across Canada adapted care for the high volumes of critically ill adults. A survey containing 40 questions was sent to the medical directors of 14 Canadian PICUs where English was the primary clinical language. The survey was designed to gain perspective on the various adaptations that PICUs instituted during the COVID-19 pandemic. Of the 13 PICUs that returned survey responses (response rate: 13/14, 93%), 10 (77%) participated in at least one adaptation to support the influx of admitted adults with COVID-19. The key challenges included disorganization, loss of autonomy, and compromised patient care. The significant advantages of these adaptations included a sense of learning and comradery. Our study highlighted an unpreparedness in critical care surge capacity. During the COVID-19 pandemic, adaptations rapidly emerged in Canada that involved PICUs with adult care. In the future, preplanned adaptations for optimizing robust critical care services should be developed based on what has been learned from the COVID-19 pandemic.

Impact of Alcohol Misuse on Requirements for Critical Care Services and Development of Hospital Delirium in Patients With COVID-19 pneumonia.

Retrospective cohort study. Twelve University of Colorado hospitals between March 2020 and April 2021. Adults with a COVID-19 diagnosis. None. The primary outcome was admission to the ICU. Secondary outcomes included need for mechanical ventilation, development of delirium, and in-hospital mortality. Alcohol misuse was defined by International Classification of Diseases, 10th Revision codes. Of 5,979 patients hospitalized with COVID-19, 26% required ICU admission and 15.4% required mechanical ventilation. Delirium developed in 4.5% and 10.5% died during hospitalization. Alcohol misuse was identified in 4%. In analyses adjusted for age, sex, body mass index, diabetes, and liver disease, alcohol misuse was associated with increased odds of ICU admission (adjusted odds ratio [aOR], 1.46; p < 0.01), mechanical ventilation (aOR, 1.43; p = 0.03), and delirium (aOR, 5.55; p < 0.01) compared with patients without misuse. Mortality rates were not associated with alcohol misuse alone, although the presence of both alcohol misuse and in-hospital delirium significantly increased odds of in-hospital death (aOR, 2.60; p = 0.04). Among patients hospitalized with COVID-19, alcohol misuse was associated with increased utilization of critical care resources including ICU admission and mechanical ventilation. Delirium was an important modifiable risk factor associated with worse outcomes in hospitalized patients with alcohol misuse, including increased odds of death.

Implications of the current economic crisis on anaesthesia and critical care services in Sri Lanka: observations of a junior anaesthetist

No abstract available