ICU Physicians Research Articles

COVID-19 and kidney

At the beginning of COVID-19 pandemic attention of healthcare professionals and scientists were already drawn to the appearance of markers of pathologic changes of the urinary system in SARS-CoV-2-infected patients, signs of acute kidney disease (AKD) (including acute kidney injury (AKI) or development of AKI in patients with chronic kidney disease (CKD). This necessitates verification of pathologic changes markers of the urinary system in SARS-CoV-2-infected patients and clarification of their nosologic relevance.
 The present study aimed to analyze the present information regarding the capacity of SARS-CoV-2 to cause kidney injury (acute kidney disease, including AKI) in patients without such changes before infecting or in patients with CKD, and to verify these changes according to the classification of urinary system disease and Nomenclature for kidney function and disease: report of Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference 2020.
 The presence of the pathologic changes markers of the urinary system in SARS-CoV-2-infected patients necessitates its verification via the use of tools of diagnostics of urinary system disease.
 Infecting with SARS-CoV-2 may cause (isolated) asymptomatic proteinuria, isolated erythrocyturia, hemoglobinuria; AKD (including AKI) in patients without preexisting urinary system injuries, AKI in patients with CKD, and may complicate hemodialysis and peritoneal dialysis. The frequency of AKI and mortality rate in patients with COVID-19 and CKD are much higher than without the last one.
 The AKI frequency is higher in ICU (18 – 37,5%) than in patients with moderate or mild COVID-19 (0,5 – 15%).
 Patients with all CKD stages with moderate or severe COVID-19 must be admitted to the hospital with further determination by a multidisciplinary team (infectionist, nephrologist, ICU physician, etc, according to the clinical situation) of necessary monitoring and treatment capacity for prevention of AKD progression and life-threatening complications or their adequate therapy.
 After confirmation of SARS-CoV-2 absence and release from the hospital, patients with AKD or all stages of CKD should be followed up, and monitoring frequency depends on AKD or CKD stage.

Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan.

We surveyed ICU physician and nurse leaders, assessing their safety culture, ICU team collaboration, and work environment. Using logistic and linear regression models, we compared these organizational characteristics to bundle element implementation, and also compared physician and nurse leaders' perceptions about organizational characteristics and bundle implementation. All (n = 72) acute care hospitals with adult ICUs in Michigan. ICU physician and nurse leader pairs from each hospital's main ICU. We developed, pilot-tested, and deployed an electronic survey to all subjects over a 3 month period in 2016. Results from 73 surveys (28 physicians, 45 nurses, 60% hospital response rate) demonstrated significant variation in hospital and ICU size and type, organizational characteristics, and physician/nurse perceptions of ICU organization and bundle implementation. We found that a robust safety culture and collaborative work environment that uses checklists to facilitate team communication are strongly associated with bundle implementation. There is also a significant dose-response effect between safety culture, a collaborative work environment, and overall bundle implementation. We identified several specific ICU practices that can facilitate ABCDEF Bundle implementation. Our results can be used to develop effective bundle implementation strategies that leverage safety culture, interprofessional collaboration, and routine checklist use in ICUs to improve bundle implementation and performance.

Small Patients and Tiny CAUTI Rates: Sustained CAUTI Reduction in a Children's Hospital

<h3>Background</h3> The pediatric catheter associated urinary tract infection (CAUTI) prevention team was formed in August 2015 to address a patient safety need. CAUTI rates, specifically in the pediatric intensive care unit (PICU), was consistently above national benchmarks, resulting in unnecessary harm to patients. <h3>Methods</h3> The CAUTI prevention team is a multidisciplinary team made up of bedside staff, physicians, and specialists. The team discusses metrics, bundle compliance and new products, and makes recommendations for Foley use and care. Education is provided regularly to bedside staff and physicians, with real time notification of CAUTI events. Since the development in 2015, the team has been able to move from general CAUTI education to specific and targeted reduction tactics. The team provides real-time notification to bedside staff to discuss Foleys in place greater than 2 days in order to facilitate removal. The team also provides weekly personalized utilization rates to ICU physicians for their own trending. Additionally, the team has expanded standardized patient bathing across the hospital, and developed tools for decreased discomfort and anxiety during catheterization processes. <h3>Results</h3> Since the team was formed in 2015, sustained improvement has been seen in CAUTI reduction with a 56% decrease hospital-wide and a 67% decrease specifically in the pediatric intensive care unit (PICU). Additionally, a process shift for Foley utilization in the PICU was seen in August 2016, and has been sustained to date. Prior to committee formation, Foley utilization was as high as 30%. In the last quarter, utilization averaged 10%, a 66% decrease. <h3>Conclusions</h3> The team has established, and more importantly sustained, standards for Foley use and care that have had significant impact on CAUTI rates in our hospital, preventing our patients from harm.

Pediatric Cardiac Intensive Care Distribution, Service Delivery, and Staffing in the United States in 2018.

To assess the distribution, service delivery, and staffing of pediatric cardiac intensive care in the United States. Based on a 2016 national PICU survey, and verified through online searching and clinician networking, medical centers were identified with a separate cardiac ICU or mixed ICU. These centers were sent a structured web-based survey up to four times, with follow-up by mail and phone for nonresponders. Cardiac ICUs were defined as specialized units, specifically for the treatment of children with life-threatening primary cardiac conditions. Mixed ICUs were defined as separate units, specifically for the treatment of children with life-threatening conditions, including primary cardiac disease. Cardiac ICU or mixed ICU physician medical directors or designees. One-hundred twenty ICUs were identified: 61 (51%) were mixed ICUs and 59 (49%) were cardiac ICUs. Seventy five percent of institutions at least sometimes used a neonatal ICU prior to surgery. The most common temporary cardiac support beyond extracorporeal membrane oxygenation was a centrifugal pump such as Centrimag. Durable cardiac support devices were far more common in separate cardiac ICUs (84% vs 20%; p < 0.0001). Significantly less availability of electrophysiology, heart failure, and cardiac anesthesia consultation was available in mixed ICUs (p = 0.0003, p < 0.0001, p = 0.042 respectively). ICU attending physicians were in-house day and night 98% of the time in mixed ICUs and 87% of the time in cardiac ICUs. Nurse practitioners were consistent front-line providers in the ICUs caring for children with primary cardiac disease staffing 88% of cardiac ICUs and 56% of mixed ICUs. Mixed ICUs were more commonly staffed with pediatric residents, and critical care fellows were found in more cardiac ICUs (83% vs 77%; p < 0.0001). Mixed ICUs and cardiac ICUs have statistically different staffing models and available services. More evaluation is needed to understand how this may impact patient outcomes and training programs of physicians and nurses.

Interventions in Post-Intensive Care Syndrome-Family: A Systematic Literature Review.

Data show that family members of ICU patients may have high levels of anxiety, depression, posttraumatic stress disorders, and/or complicated grief. This was previously referred to as post-intensive care syndrome-family. We systematically review randomized controlled trials for post-intensive care syndrome-family. Systematic research in databases (Pubmed, EMBASE, PsycINFO, CINHAL for articles published between January 2000 and October 2019). Interventions in randomized controlled trials for post-intensive care syndrome-family in relatives of adult ICU patients. Review, quality assessment, and risk assessment for bias of eligible publications were performed along recommended guidelines for each investigation. Quality assessment graded studies into "strong" (n = 5), "moderate" (n = 4), and "weak" (n = 2). Out of 2,399 publications, 11 investigations were found eligible (3,183 relatives of ICU patients). Studies addressed interventions during ICU stay (n = 6), during the post-ICU period (n = 4), or both (n = 1). Two studies included relatives of dying/deceased patients. One study implemented end-of-life conferences and showed reduced prevalence of posttraumatic stress disorder (45% vs 69%; p = 0.01), anxiety (45% vs 67%; p = 0.02), and depression (29% vs 56%; p = 0.003). Family conferences with a physician and proactive participation of a nurse reduced anxiety-scores (p = 0.01) without reducing anxiety prevalence (33.3% vs 52.3%; p = 0.08). Other studies failed to improve symptoms or reduce prevalence of post-intensive care syndrome-family. Interestingly, condolence letters may even increase prevalence of posttraumatic stress disorder (52.4% vs 37.1%; p = 0.03). Meetings without the presence of ICU physicians were shown to increase Impact of Event Scale-Revised scores (25.9 vs 21.3; p = 0.0495). Only few data are available on interventions for post-intensive care syndrome-family. It appears that proactive communication and provision of information seems pivotal for post-intensive care syndrome-family treatment. Interestingly, some interventions may even worsen post-intensive care syndrome-family. In the light of the relevance of post-intensive care syndrome-family in daily ICU care, more high-quality data seems urgently needed.

Entretien en binôme réanimateur et psychologue : la traduction en question

BackgroundDoctors in intensive care units are frequently confronted with the task of announcing upcoming disasters (death, severe disabilities, etc.) to patients’ relatives. Although ICU physicians are accustomed to this difficult exercise, a discrepancy persists between the representations and language of the hospital staff and those of the patients and their relatives. The introduction of joint interviews with the psychologist during these announcements has raised several issues related to translation. ObjectivesThe aim of this article is to identify the different functions of translation that the psychologist can provide and their effects on the interactions between the ICU team and the relatives of patients admitted to intensive care in a critical condition. MethodBased on clinical experience of these multidisciplinary interviews, and on the testimonies gathered informally afterwards from relatives and staff, we propose to identify the effects of language and medical culture, identifying in particular moments of misunderstanding, communication “failures”, and gaps between hospital staff and patients’ relatives. This research makes use of conceptual tools from psychoanalysis and psychology. ResultsDifferences in representations and languages are identified between medical and lay culture, allowing us to identify the psychologist's multiple translation functions in these interactions between family members and caregivers. This function may involve at translating medical jargon for family members, but also translating and making the experience of relatives accessible to medical and paramedical staff. Finally, this study highlights key points concerning the relevance of interviews carried out with several professionals, and in particular those that associate physicians and psychologists. ConclusionsMedical language and culture appears as foreign to relatives of patients hospitalized in intensive care units especially when encountering intensive care doctors during complex moments of catastrophic announcements. The presence of a psychologist during these interviews, who plays the role of translator, makes it possible to grasp the differences that may appear between the two sides, and to calm the violence that this difference may cause for both relatives and hospital staff. This experience highlights the richness of the multidisciplinary approach in the context of announcement interviews.

Program on high value cost-conscious education in intensive care: Educational program on prediction of outcome and cost awareness on Intensive Care admission

BackgroundIntensive Care (ICU) involves extended and long lasting support of vital functions and organs. However, current training programs of ICU residents mainly focus on extended support of vital functions and barely involve training on cost-awareness and outcome. We incorporated an educational program on high-value cost-conscious care for residents and fellows on our ICU and measured the effect of education.MethodsA cohort study with factorial survey design, in which ICU residents and fellows were asked to evaluate clinical vignettes, was performed on the mixed surgical-medical ICU of the Amsterdam University Medical Centre. Residents were offered an educational program focusing on outcome and costs of ICU care. Before and after the program they filled out a questionnaire, which consisted of 23 vignettes, in which known predictors of outcome of community acquired pneumonia (CAP), pancreatitis, acute respiratory distress syndrome (ARDS) and cardiac arrest were presented, together with varying patient factors (age, body mass index (BMI), acute kidney failure (AKI) and haemato-oncological malignancy). Participants were asked to either admit the patient or estimate mortality.ResultsBMI, haemato-oncological malignancy and severity of pancreatitis were discriminative for admission to ICU in clinical vignettes on pancreatitis and CAP. After education, only severity of pancreatitis was judged as discriminative. Before the intervention only location of cardiac arrest (in- vs out of hospital) was distinctive for mortality, afterwards this changed to presence of haemato-oncological malignancy.ConclusionWe incorporated an educational program on high-value cost-conscious care in the training of ICU physicians. Based on our vignette study, we conclude that the improvement of knowledge of costs and prognosis after this program was limited.

USE OF LEAN SIX SIGMA METHOD TO IMPROVE PROCESS OF ELECTROLYTE REPLACEMENT PROTOCOL IN ICU

TYPE: Abstract Publication TOPIC: Education, Research, and Quality Improvement PURPOSE: Electrolyte imbalance is a common and potentially life threatening phenomenon in critically ill patients. Our data analysis found failure to implement the ICU protocol leads to inadequacy, inconsistency and delay in correcting electrolytes in critically ill patients that can cause life threaterning complications. METHODS: The team utilized a Lean Six Sigma approach to identify the root causes of delays in treatment. This project specifically utilized: affinity diagram, regression analysis and Failure Mode Effects Analysis. Team composition included the Chief Nursing Officer, ICU physicians, nursing director, nurse manager, ICU nurses and a pharmacist. Initial cycle of improvement focused on nurse education and awareness of the impact of a lack of adherence to the protocol. Lab initiated a secondary cycle focused around rapid provision of the lab results to assist in this process. Quality improvement impacts virtually every level of healthcare, from supply chain management to patient safety. RESULTS: Process changes demonstrated a 44% improvement in potassium replacement and 71% improvement in magnesium replacement in the ICU. Significant improvement was demonstrated in the time from lab available to start of electrolyte replacement. CONCLUSIONS: Lean Six Sigma methodology can be used successfully to reduce variation in ICU protocol like electrolytes replacement. CLINICAL IMPLICATIONS: Process variation improvement 71% for Magnesium and 44% for potassium replacement protocol leads to reduction in morbidilty and mortality from arrythmia in ICU. DISCLOSURE: No significant relationships. KEYWORDS: Lean six sigma, process improvement, ICU protocol

Knowledge acquisition and retention after a high flow training programme in Peru: a quasi-experimental single group pre–post design

ObjectiveRespiratory infections remain the leading infectious cause of death in children under 5 and disproportionately affect children in resource-limited settings. Implementing non-invasive respiratory support can reduce respiratory-related mortality. However, maintaining...

Survey of COVID-19 Preparedness among Lebanese ICU Physicians

Survey of COVID-19 Preparedness among Lebanese ICU Physicians

Adverse Events After Transition From ICU to Hospital Ward: A Multicenter Cohort Study.

To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). Multicenter cohort study. Ten adult medical-surgical Canadian ICUs. Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. None. Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.

Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study.

To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries. A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review. Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers. Not applicable. Not applicable. In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals. Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.

Smart Mode of Mechanical Lung Ventilation During Early Activation of Cardiosurgical Patients

Purpose of the study: a comparative assessment of safety and quality of respiratory support carried out using the ASV mode vs. conventional protocol, in which ventilation parameters are set by an ICU physician during early postoperative period in cardiosurgical patients.Materials and methods. The modes of a respiratory support included automated ASV ventilation (40 patients) versus conventional ventilation (38 patients) managed by 8 ICU physicians were compared in a cohort of cardiosurgical patients in a randomized controlled study.The comparison included ventilation parameters, all efforts of physicians to adjust ventilator settings and time it took, duration of respiratory support in ICU, incidence of adverse events in the course of weaning, total time in ICU and hospital, postoperative complications and mortality.Results. There was no reliable difference in the duration of postoperative trachea intubation, which was equal to 267±76 minutes (the ASV group) and 271±80 minutes (the control group).The number of manual adjustments, which was 2 vs. 4 (P&lt;0.00001), and the time spent by a clinical physician near a ventilator, which was 99±35 seconds vs. 166±70 seconds, were reliably lower in the ASV group (P=0.00001).The time between restoration of patient’s own respiratory activity and transfer to the assisted breathing mode was longer in the control group and amounted to 30 (0–90) min. while in the smart mode, the transfer took place immediately after restoration (P=0.004969).When ASV was used, the driving pressure was reliably lower during all phases of respiratory support: ΔP 7.2±1.6 vs. 9.3±2.1 cm H2O, (P=0.000001); there was no reliable difference in the tidal volume: 7.0 (6–8.5) (ASV) vs. 7 (6–10) ml/kg/ideal body mass (the control group).Conclusion. ASV represents a lung-protective ventilation that reduces physician’s time cost and medical staff efforts in ALV management without compromising patient’s safety and respiratory support quality.

Smartphone to-do list application to improve workflow in an intensive care unit: A superiority quasi-experimental study

BackgroundSmartphone to-do list app was hypothesized to be more efficient than a paper-based list in the management of workflow and to provide additional benefits. PurposeTo analyze the impact of a mobile task-management application on the workflow of an ICU medical staff. MethodsSuperiority by a margin test, quasi-experimental study comparing the use of a smartphone application versus standard practice regarding tasks management in an academic ICU. Superiority margin was set at 8 % based on a pilot study. During two periods of 20 working days each (October 2018 and January 2019), medical staff managed tasks with both methods on a weekly rotation basis. Primary outcome was the proportion of daily tasks completed. Secondary outcomes assessed users’ satisfaction and the impact of the app in terms of changes in clinical practice. Results25 ICU physicians were enrolled. A total of 1983 tasks were recorded. The proportion of completed tasks per day was higher when using the smartphone app (99 % [96–100] versus 95 % [93–98] for the standard group, p = 0.006), but did not reach the superiority margin. Smartphone application was perceived as positive experience, as participants felt that they forgot fewer tasks (p = 0.02), were more aware of their progress on ongoing or remaining tasks (p = 0.03) and observed an improvement in communication among the medical staff (p = 0.03). ConclusionThis study failed to demonstrate the superiority of a smartphone app over paper-based lists regarding the proportion of daily tasks completed. However, positive feedback regarding the application was received from the medical staff.

The first experience of application of “full outline of unresponsiveness” (FOUR SCALE) in patients with acute cerebral insufficiency. Two-center research “FOUR-Rus”. Two-center trial

Background. Analysis of distribution of Full Outline of UnResponsiveness (FOUR) Scale provided by F. M. Wijdicks at the Mayo Clinic in 2005 served as the basis for the initiation of the Federation of anesthesiologists of Russia study “FOUR-Rus” (NCT04018989 ClinicalTrails.gov). Objectives. To assess reproducibility and consistency when using the Russian-language version of the FOUR scale. Materials and methods. 260 patients were selected, aged 37 to 90 years with acute head injury, including: I60 — 39 (15 %), I61 — 86 (33 %), I63 — 130 (51 %), I67 — 4 (0,15 %) patients. Center № 1/2 — 159/101 patients. Age — sex composition, level of sedation and pain in the groups did not differ. For examinations in the centers, 2 ICU physicians and 1 neurologist were selected. Reproducibility and interdisciplinary consistency were assessed in pairs with Cronbach’s alpha (α) internal consistency. Statistical analysis was performed using IBM SPSS Statistics Subscription. Conclusions. There are no differences in consistency and reproducibility between FOUR and GSC in stroke patients when used by resuscitators and neurologists in non-specialized ICU. The FOUR scale has maximum reproducibility and wider possibilities for assessing the level of consciousness.

Developing the family support tool: An interactive, web-based tool to help families navigate the complexities of surrogate decision making in ICUs

IntroductionAlthough family members of incapacitated, critically ill patients often struggle in the role of surrogate decision maker, there are no low-cost, easily-scaled interventions to address this problem. Aim of the studyTo develop and pilot-test the Family Support Tool, an interactive, web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs. Material and methodsWe used a mixed methods, user-centered process to create the Family Support Tool, including: 1) creation of a preliminary design by an expert panel; 2) engagement of a key stakeholder panel to iteratively refine the preliminary design; 3) user testing of a low-fidelity prototype of the tool by 6 former ICU surrogates; 4) creation of a web-based prototype; and 5) user testing of the web-based prototype with 14 surrogates and ICU physicians, including semi-structured interviews and quantitative measurement of usability, acceptability, and perceived effectiveness. ResultsThe initial design contained a collection of videos and exercises designed to help individuals understand the surrogate's role and think through the patient's values and preferences. Based on family stakeholders' feedback about the emotional overwhelm they experience early in an ICU stay, we redesigned the tool to be viewed in sections, with the first section focused on decreasing surrogates' emotional distress, and later sections focused on helping surrogates prepare for family meetings. Surrogates actively making decisions in the ICU judged the final tool to be highly usable (mean summary score 83.5, correlating to 95th percentile when normalized to devices of its type), acceptable (mean 4.2 +/− 0.5 out of 5), and effective (mean 4.3 +/− 0.6 out of 5). All surrogates reported the tool helped them consider goals of care and all indicated they would recommend the tool to a friend. ConclusionsWe successfully developed a web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs that has high potential for scalability. Surrogates judged the tool to be usable, acceptable, and effective. These data support proceeding to test the tool in a pilot randomized clinical trial.

Perceptions of Ethical Decision-Making Climate Among Clinicians Working in European and U.S. ICUs: Differences Between Nurses and Physicians*

To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses. Prospective observational study. A total of 68 adult ICUs in 13 European countries and the United States. ICU physicians and nurses. None. Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions. Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.

Abstract 405: A Machine Learning-Based Prediction of Cardiac Arrest Outcome Using a Large Multi-Center Database

Background: Cardiac arrest (CA) poses a significant risk of death and long-term neurological disability yet there remains a lack of accurate and reliable methods to prognosticate post-CA outcome, indicating a major unmet need. Additionally, no existing CA outcome prediction model utilizes physiological time series (PTS) data, which captures transitions in a patient’s health state at high temporal resolution. Materials and Methods: We screened the Philips eICU database, which includes over 200,000 patients in 200 hospitals, extracting data on CA patients within 24 hours of ICU admission. We first extracted PTS and Electronic Health Record (HER) features and selected our features using nested Random Forest. The outcome labels were neurological state or mortality at ICU discharge. We tested various individual and ensemble machine learning algorithms (GLM, Random Forest, Gradient Boosting, Support Vector Machine, Neural Networks) and optimization techniques (hyperparameter tuning, model stacking, and transfer learning) to maximize the accuracy of outcome prediction. Results: For prediction of neurological outcome, our model combining EHR and PTS features achieved a higher sensitivity (0.78), specificity (0.88), and AUC (0.87±0.01) compared to the APACHE baseline standard model (AUC: 0.74±0.01, sensitivity: 0.77, specificity: 0.63). Also, for prediction of mortality our model (AUC: 0.81±0.01, sensitivity: 0.78, specificity: 0.71) outperformed the APACHE clinical baseline (AUC: 0.75±0.01, sensitivity: 0.86, specificity: 0.56) by 7%. The integration of PTS with EHR data increased mean AUC by 4% for neurological outcome and 2% for mortality. Conclusion: Results demonstrate that for both neurological outcome and mortality prediction, our ensemble model was significantly more effective compared to the baseline APACHE model. Additionally, we find that PTS data adds to the discriminative power of clinical models. With appropriate validation in prospective cohorts, these findings could be used as point-of-care references to aid ICU physicians in clinical decision-making.

CD19 CAR T-Cell Therapy in Patients with Relapse/Refractory DLBCL: Retrospective Analysis of the Eligibility Criteria

CD19 CAR T-Cell Therapy in Patients with Relapse/Refractory DLBCL: Retrospective Analysis of the Eligibility Criteria

Interprofessional collaboration during medical emergencies among doctors, nurses, and respiratory therapists in the intensive care unit: A phenomenological study protocol.

The aim of this study was to explore the lived experiences of interprofessional collaboration among nurses, doctors, and respiratory therapists during medical emergencies in the intensive care unit. Descriptive phenomenological study. Participants will be recruited through purposive sampling with maximum variation across the ICUs in a tertiary hospital in Singapore. Guided by data saturation, data collection will include individual semi-structured interviews with ICU nurses, physicians, and respiratory therapist who have attended to medical emergencies such as cardiopulmonary arrest or difficult airway management in the ICUs. Interviews will be audio recorded, transcribed verbatim, and analysed via Colaizzi's descriptive phenomenology method. Research Ethics Committee approval was sought from the National Healthcare Group, Domain Specific Review Board (April 2019). The study is funded by the National Healthcare Group - Health Outcomes and Medical Education Research Grant (April 2019). The study is expected to be concluded by April 2020. Whilst interprofessional collaboration remains a major interest among nursing research, there is a paucity of evidence surrounding interprofessional collaboration in the specific context of medical emergencies in the ICUs. This is especially crucial as the failure of interprofessional collaboration during medical emergencies can be catastrophic to patient safety. Hence, this study will adopt a qualitative approach to contribute to the evidence base surrounding this lesser known phenomenon. The findings generated from this study will inform future team training initiatives, advance nursing leadership initiatives, and identify barriers and facilitators towards fostering greater interprofessional collaboration during medical emergencies. The evidence gained from this study contributes to the limited knowledge base of interprofessional collaboration during medical emergencies. Findings will have vast impact on nursing and interprofessional programs such as crisis leadership and management. The findings could also inform practice frameworks during medical emergencies to support interprofessional collaboration and optimize patient care.