Intensive Care Unit Clinicians Research Articles

The current state of intensive care unit discharge practices - Results of an international survey study.

Increasing pressure on limited intensive care capacities often requires a subjective assessment of a patient's discharge readiness in the absence of established Admission, Discharge, and Transfer (ADT) guidelines. To avoid suboptimal care transitions, it is important to define clear guidelines for the admission and discharge of intensive care patients and to optimize transfer processes between the intensive care unit (ICU) and lower care levels. To achieve these goals, structured insights into usual ICU discharge and transfer practices are essential. This study aimed to generate these insights by focusing on involved stakeholders, established processes, discharge criteria and tools, relevant performance metrics, and current barriers to a timely and safe discharge. In 2022, a structured, web-based, anonymous cross-sectional survey was conducted, aimed at practicing ICU physicians, nurses, and bed coordinators. The survey consisted of 29 questions (open, closed, multiple choice, and scales) that were divided into thematic blocks. The study was supported by several national and international societies for intensive care medicine and nursing. A total of 219 participants from 40 countries (105 from Germany) participated in the survey. An overload of acute care resources with ~90% capacity utilization in the ICU and the general ward (GW) leads to not only premature but also delayed patient transfers due to a lack of available ward and intermediate care (IMC) beds. After multidisciplinary rounds within the intensive care team, the ICU clinician on duty usually makes the final transfer decision, while one-third of the panel coordinates discharge decisions across departmental boundaries. By the end of the COVID-19 pandemic, half of the hospitals had implemented ADT policies. Among these hospitals, nearly one-third of the hospitals had specific transfer criteria established, consisting primarily of vital signs and laboratory data, patient status and autonomy, and organization-specific criteria. Liaison nurses were less common but were ranked right after the required IMC capacities to bridge the care gap between the ICU and normal wards. In this study, 80% of the participants suggested that transfer planning would be easier if there was good transparency regarding the capacity utilization of lower care levels, a standardized transfer process, and improved interdisciplinary communication. To improve care transitions, transfer processes should be managed proactively across departments, and efforts should be made to identify and address care gaps.

Antimicrobial Therapeutic Drug Monitoring in critically ill adult patients -an international perspective on access, utilisation, and barriers.

BackgroundTherapeutic drug monitoring (TDM) is an effective method for individualizing antimicrobial therapy in critically ill patients. The 2021 ADMIN-ICU survey studied a wide range of intensive care unit (ICU) clinicians worldwide to gain their perspectives on antimicrobial TDM. This paper reports the responses from this survey relating to TDM access, utilisation, barriers, and clinical value. MethodsAn online survey consisted of multiple-choice questions and 5-point Likert scales. The survey examined respondent's access to minimum inhibitory concentration (MIC) results, drug assays and dosing software, as well as barriers to TDM. ResultsThe survey included 538 clinicians from 409 hospitals in 45 countries, with 71% physicians and 29% pharmacists. Despite most respondents having access to assays, 21% and 26% of respondents lacked access to vancomycin and aminoglycosides, respectively. In lower-income countries, almost 40% reported no access. Delayed drug assay turnaround time was the most significant barrier to TDM, particularly in lower-income countries. Routine access to MIC results was unavailable for 41% of respondents, with 25% of lower-income country respondents having no access to MIC or susceptibility reports. ConclusionsThis global survey indicated that consistent TDM usage is hindered by assay access in some sites, and timeliness of assay results in others. Addressing barriers to TDM, particularly in low-income countries, should be a priority to ensure equitable access to affordable TDM.

Intensive Care Unit Staffing in the United States

BackgroundThe last national estimates of US intensive care unit (ICU) physician staffing are 25 years old and lack information about interprofessional teams. Research QuestionHow are US adult ICUs currently staffed? Study Design and MethodsWe conducted a cross-sectional survey (05/04/2022-02/02/2023) of adult ICU clinicians (targeting nurse/physician leadership) contacted using 2020 American Hospital Association (AHA) database information and, secondarily, through professional organizations. The survey included questions about interprofessional ICU staffing availability and roles at steady-state (pre-COVID-19). We linked survey data to hospital data in the AHA database to create weighted national estimates by extrapolating ICU staffing data to non-respondent hospitals based on hospital characteristics. ResultsThe cohort consisted of 596 adult ICUs (response rates—AHA contacts: 2.1%; professional organizations: unknown) with geographic diversity and size variability (median [interquartile range]: 20 [12,25] beds); most cared for mixed populations (414 [69.5%]), yet medical (55 [9.2%]), surgical (70 [11.7%]), and specialty (57 [9.6%]) ICUs were well represented. 554 (93.0%) had intensivists available, with intensivists covering all patients in 75.6% of these and onsite 24 hours/day in half (53.3% weekdays; 51.8% weekends). Of all ICUs, 69.8% had physicians-in-training and 77.7% nurse practitioners/physician assistants. For mechanically ventilated patients, nurse:patient ratios were 1:2 in 89.6%. Clinical pharmacists were available in 92.6%, and respiratory therapists in 98.8%. We estimated 85.1% (95% confidence interval: 85.7%, 84.5%) of hospitals nationally had ICUs with intensivists, 51.6% (50.6%, 52.5%) with physicians-in-training, 72.1% (71.3%, 72.9%) with nurse practitioners/physician assistants, 98.5% (98.4%, 98.7%) with respiratory therapists, and 86.9% (86.4%, 87.4%) with clinical pharmacists. For mechanically ventilated patients, 86.4% (85.8%, 87.0%) used 1:2 nurses:patients. InterpretationIntensivist presence in adult US ICUs has greatly increased over 25 years. Intensivists, respiratory therapists, and clinical pharmacists are commonly available, and each nurse usually provides care for two mechanically ventilated patients. However, team composition and workload vary.

A common data model for the standardization of intensive care unit medication features.

Common data models provide a standard means of describing data for artificial intelligence (AI) applications, but this process has never been undertaken for medications used in the intensive care unit (ICU). We sought to develop a common data model (CDM) for ICU medications to standardize the medication features needed to support future ICU AI efforts. A 9-member, multi-professional team of ICU clinicians and AI experts conducted a 5-round modified Delphi process employing conference calls, web-based communication, and electronic surveys to define the most important medication features for AI efforts. Candidate ICU medication features were generated through group discussion and then independently scored by each team member based on relevance to ICU clinical decision-making and feasibility for collection and coding. A key consideration was to ensure the final ontology both distinguished unique medications and met Findable, Accessible, Interoperable, and Reusable (FAIR) guiding principles. Using a list of 889 ICU medications, the team initially generated 106 different medication features, and 71 were ranked as being core features for the CDM. Through this process, 106 medication features were assigned to 2 key feature domains: drug product-related (n = 43) and clinical practice-related (n = 63). Each feature included a standardized definition and suggested response values housed in the electronic data library. This CDM for ICU medications is available online. The CDM for ICU medications represents an important first step for the research community focused on exploring how AI can improve patient outcomes and will require ongoing engagement and refinement.

Centralized Multi-Patient Dashboards' Impact on ICU Clinician Performance and Satisfaction: A Systematic Review.

Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety. This systematic review assesses the impact of centralized multi-patient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes. A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared to the standard practice. We narratively synthesized eligible studies following the SWiM guidelines. Studies were grouped based on dashboard type and outcomes assessed. The search yielded a total of 2407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association. The multi-patient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure and methodological limitations. Designing and evaluating multi-patient tools using robust research methodologies is an important focus for future research.

Impact of COVID-19-related restricted family presence policies on Canadian pediatric intensive care unit clinicians: a qualitative study.

Pediatric intensive care units (PICUs) worldwide restricted family presence in response to the COVID-19 pandemic. We aimed to explore the experiences and impact of restricted family presence policies on Canadian PICU clinicians. We conducted a qualitative study that followed an interpretive phenomenological design. Participants were PICU clinicians providing direct patient care in Canada during periods of COVID-19-related restricted family presence. We purposively sampled for maximum variation among survey participants who consented to be contacted for further research on the same topic. In-depth interviews were conducted remotely via telephone or video-call, audio-recorded, and transcribed. Interviews were inductively coded and underwent thematic analysis. Proposed themes were member-checked by interviewees. Sixteen PICU clinicians completed interviews. Interviewees practiced across Canada, represented a range of disciplines (eight nurses, two physicians, two respiratory therapists, two child life specialists, two social workers) and years in profession (0-34 years). We identified four themes representing the most meaningful aspects of restricted family presence for participants: 1) balancing infection control and family presence; 2) feeling disempowered by hospital and policy-making hierarchies; 3) empathizing with family trauma; and 4) navigating threats to the therapeutic relationship. Pediatric intensive care unit clinicians were impacted by restricted family presence policies during the COVID-19 pandemic. These policies contributed to feelings of disempowerment and challenged clinicians' perceived ability to provide the best family-centred care possible. Frontline expertise should be incorporated into the design and implementation of policies to best support family-centred care in any context and minimize risks of moral distress for PICU clinicians.

Integrating Social Determinants of Health in Critical Care

BackgroundSocial determinants of health (SDOH) mediate outcomes of critical illness. Increasingly, professional organizations recommend screening for social risks. Yet, how clinicians should identify and then incorporate SDOH into acute care practice is poorly defined. Research QuestionHow do medical intensive care unit (ICU) clinicians currently operationalize SDOH within patient care, given that SDOH are known to mediate outcomes of critical illness? Study Design and MethodsUsing ethnographic methods, we observed clinical work rounds in three urban ICUs within a single academic health system to capture use of SDOH during clinical care. Adults admitted to the medical ICU with respiratory failure were prospectively sequentially enrolled. Observers wrote field notes and narrative excerpts from rounding observations. We also reviewed electronic medical record (EMR) documentation for up to 90 days following ICU admission. We then qualitatively coded and triangulated data using a constructivist grounded theory approach and the Centers for Disease Control Healthy People SDOH framework. ResultsSixty-six patients were enrolled and over 200 observation hours of clinical work rounds were included in the analysis. ICU clinicians infrequently integrated social structures of patients’ lives into their discussions. Social structures were most frequently invoked when related to: 1) etiologies of acute respiratory failure, 2) decisions on life sustaining therapies, and 3) transitions of care. There was no systematic way in which data about common SDOH were collected (e.g., food and housing insecurity) and some SDOH were rarely or never discussed (e.g., access to education, discrimination, incarceration). InterpretationClinicians do not incorporate many areas of known SDOH into ICU rounds. Improvements in integration of SDOH should leverage the multidisciplinary team, identifying who is best suited to collect information of SDOH during different timepoints in critical illness. Next steps include clinician, patient-, and caregiver-focused assessments of feasibility and acceptability of an ICU-based SDOH assessment.

More isn't always better: Technology in the intensive care unit.

Clinical care in modern intensive care units (ICUs) combines multidisciplinary expertise and a complex array of technologies. These technologies have clearly advanced the ability of clinicians to do more for patients, yet so much equipment also presents the possibility for cognitive overload. The aim of this study was to investigate clinicians' experiences with and perceptions of technology in ICUs. We analyzed qualitative data from 30 interviews with ICU clinicians and frontline managers within four ICUs. Our interviews identified three main challenges associated with technology in the ICU: (a) too many technologies and too much data; (b) inconsistent and inaccurate technologies; and (c) not enough integration among technologies, alignment with clinical workflows, and support for clinician identities. To address these challenges, interviewees highlighted mitigation strategies to address both social and technical systems and to achieve joint optimization. When new technologies are added to the ICU, they have potential both to improve and to disrupt patient care. To successfully implement technologies in the ICU, clinicians' perspectives are crucial. Understanding clinicians' perspectives can help limit the disruptive effects of new technologies, so clinicians can focus their time and attention on providing care to patients. As technology and data continue to play an increasingly important role in ICU care, everyone involved in the design, development, approval, implementation, and use of technology should work together to apply a sociotechnical systems approach to reduce possible negative effects on clinical care for critically ill patients.

What every intensivist should know about: Trust in the ICU

Trust is an essential element in the relationship between patients and intensive care unit (ICU) clinicians. Without a foundation of trust, communication is difficult, conflict is more likely, and even clinical outcomes can be affected. The ICU is a particularly challenging environment for trust to flourish. Illness occurs suddenly, emotions can be charged, the environment is impersonal, and there is rarely a prior relationship between patients and their caregivers. Therefore, intensivists must have some understanding of the factors that impact patient and family trust, as well as the actions they can take to improve it.

Perspectives on Device-Facilitated Therapy in Management of Pediatric Dysphagia in the Neonatal Intensive Care Unit

Purpose: Most infants born preterm will experience some difficulty with sucking and feeding. As clinicians in the neonatal intensive care unit (NICU), it is important to understand the available technologies so that they may be implemented, when appropriate and accessible, to support these infants in their sucking and feeding performance. The purpose of this review is to highlight devices that are available to assist clinicians in the management of pediatric dysphagia in the NICU. We will review the literature surrounding the use of devices in the management of pediatric dysphagia. This is followed by a clinical perspective from a NICU speech-language pathologist (SLP) who shares important considerations, recommendations, and limitations of device use. Conclusions: By reviewing device-facilitated therapies for the management of pediatric dysphagia and discussing their implementation and effectiveness, we hope that SLPs will gain an understanding of the available technologies and insight into their use in the NICU environment. While the research highlighted shows many benefits of the use of device-facilitated therapies in the NICU, this is an emerging area of the field that is continually evolving and more research is needed to establish the pathway to individualized, developmentally supportive, device-facilitated intervention.

Mobile Application–Based Communication Facilitation Platform for Family Members of Critically Ill Patients

Unmet and racially disparate palliative care needs are common in intensive care unit (ICU) settings. To test the effect of a primary palliative care intervention vs usual care control both overall and by family member race. This cluster randomized clinical trial was conducted at 6 adult medical and surgical ICUs in 2 academic and community hospitals in North Carolina between April 2019 and May 2022 with physician-level randomization and sequential clusters of 2 Black patient-family member dyads and 2 White patient-family member dyads enrolled under each physician. Eligible participants included consecutive patients receiving mechanical ventilation, their family members, and their attending ICU physicians. Data analysis was conducted from June 2022 to May 2023. A mobile application (ICUconnect) that displayed family-reported needs over time and provided ICU attending physicians with automated timeline-driven communication advice on how to address individual needs. The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST; range 0-130, with higher scores reflecting greater need) score between study days 1 and 3. Secondary outcomes included family-reported quality of communication and symptoms of depression, anxiety, and posttraumatic stress disorder at 3 months. A total of 111 (51% of those approached) family members (mean [SD] age, 51 [15] years; 96 women [86%]; 15 men [14%]; 47 Black family members [42%]; 64 White family members [58%]) and 111 patients (mean [SD] age, 55 [16] years; 66 male patients [59%]; 45 Black patients [41%]; 65 White patients [59%]; 1 American Indian or Alaska Native patient [1%]) were enrolled under 37 physicians randomized to intervention (19 physicians and 55 patient-family member dyads) or control (18 physicians and 56 patient-family member dyads). Compared with control, there was greater improvement in NEST scores among intervention recipients between baseline and both day 3 (estimated mean difference, -6.6 points; 95% CI, -11.9 to -1.3 points; P = .01) and day 7 (estimated mean difference, -5.4 points; 95% CI, -10.7 to 0.0 points; P = .05). There were no treatment group differences at 3 months in psychological distress symptoms. White family members experienced a greater reduction in NEST scores compared with Black family members at day 3 (estimated mean difference, -12.5 points; 95% CI, -18.9 to -6.1 points; P < .001 vs estimated mean difference, -0.3 points; 95% CI, -9.3 to 8.8 points; P = .96) and day 7 (estimated mean difference, -9.5 points; 95% CI, -16.1 to -3.0 points; P = .005 vs estimated mean difference, -1.4 points; 95% CI, -10.7 to 7.8; P = .76). In this study of ICU patients and family members, a primary palliative care intervention using a mobile application reduced unmet palliative care needs compared with usual care without an effect on psychological distress symptoms at 3 months; there was a greater intervention effect among White family members compared with Black family members. These findings suggest that a mobile application-based intervention is a promising primary palliative care intervention for ICU clinicians that directly addresses the limited supply of palliative care specialists. ClinicalTrials.gov Identifier: NCT03506438.

Predictors of outcomes of patients ≥ 80 years old admitted to intensive care units in Poland - a post-hoc analysis of the VIP2 prospective observational study.

Elderly patients pose a significant challenge to intensive care unit (ICU) clinicians. In this study we attempted to characterise the population of patients over 80 years old admitted to ICUs in Poland and identify associations between clinical features and short-term outcomes. The study is a post-hoc analysis of the Polish cohort of the VIP2 European prospective observational study enrolling patients > 80 years old admitted to ICUs over a 6-month period. Data including clinical features, clinical frailty scale (CFS), geriatric scales, interventions within the ICU, and outcomes (30-day and ICU mortality and length of stay) were gathered. Univariate analyses comparing frail (CFS > 4) to non-frail patients and survivors to non-survivors were performed. Multivariable models with CFS, activities of daily living score (ADL), and the cognitive decline questionnaire IQCODE as predictors and ICU or 30-day mortality as outcomes were formed. A total of 371 patients from 27 ICUs were enrolled. Frail patients had significantly higher ICU (58% vs. 44.45%, P = 0.03) and 30-day (65.61% vs. 54.14%, P = 0.01) mortality compared to non-frail counterparts. The survivors had significantly lower SOFA score, CFS, ADL, and IQCODE than non-survivors. In multivariable analysis CFS (OR 1.15, 95% CI: 1.00-1.34) and SOFA score (OR 1.29, 95% CI: 1.19-1.41) were identified as significant predictors for ICU mortality; however, CFS was not a predictor for 30-day mortality ( P = 0.07). No statistical significance was found for ADL, IQCODE, polypharmacy, or comorbidities. We found a positive correlation between CFS and ICU mortality, which might point to the value of assessing the score for every patient admitted to the ICU. The older Polish ICU patients were characterised by higher mortality compared to the other European countries.

A Usability Survey of a Quality Improvement Data Visualization Tool among Medical Intensive Care Unit Nurses

Abstract Background Cognitive overload is prevalent among intensive care unit (ICU) clinicians. Data visualization may decrease cognitive load by assisting with data interpretation and task prioritization. We developed the Bundle Board to display real-time data from the electronic medical record (EMR), highlighting opportunities for action in standardized ICU patient care. This study evaluates the practical usability of this data visualization tool among nurses in the ICU. Methods The tool is offered as an application separate from the EMR and was available in the medical ICU for 8 months before we surveyed unit nursing staff. To evaluate usability of the tool, we adapted the Health-Information Technology Usability Scale and included an option to provide open-ended feedback. Survey data were analyzed using quantitative and qualitative methods. Results ICU nurses were invited to participate through email and verbal announcements. Of the potential participants, 38% (N = 47) responded. The survey demonstrated that the tool was perceived as usable. For each subscale, mean scores were as follows: Perceived Ease of Use 4.40, Impact 4.14, User Control 4.07, and Perceived Usefulness 3.61. There were no significant differences between core and contracted nurses or after stratifying by duration of Bundle Board use. Fifteen respondents completed the optional free-text portion of the survey. Qualitative analysis revealed six subthemes focusing on perceived impacts on quality and safety, cognitive burden and workload, and emotional impact of the Bundle Board. Conclusion The Bundle Board demonstrated good usability among ICU nurses, who provided substantive feedback for its improvement. These observations may be generalizable to other comparable interventions. Iterative feedback from end users is vital to developing and implementing a digital health intervention. Our study provides a framework for performing a usability analysis within a specific clinician population and environment.

Use of the 3 Wishes Project to Help Individualize End-of-Life Care in a Medical Intensive Care Unit.

Multiple organizations recommend that individualized end-of-life (EOL) care should be standard practice. However, a standardized approach does not exist because EOL care should be individually tailored. The 3 Wishes Project is an EOL intervention that provides direction for individualized care with 3 goals: dignify death, celebrate the patient's life, and support family members and the intensive care unit clinicians caring for the patient. Patients and families are given the opportunity to choose 3 wishes during the dying process. To ascertain if the implementation of the 3 Wishes Project allowed the medical team to provide individualized EOL care. The Iowa Model was used for this evidence-based project. The project was implemented in the medical intensive care unit at an academic medical center. Outcomes were evaluated by the collection and analysis of qualitative and quantitative data. From the 57 patients who died during the 2-month implementation period, 32 wish forms were collected; 31 patients participated and 1 declined. Overall participation among patients was 56%. The top 5 wishes were cloth hearts, blankets, heartbeat printouts, fingerprints and handprints, and music. The total cost was $992, and the average cost per wish was $6.98. Eighty-five percent (33 of 39) of the respondents to the medical team survey indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care. The survey data support the 3 Wishes Project as a method that allowed the medical team to individualize EOL care and as a valuable tool for incorporation at the bedside.

Applying a human factors approach to proning pillows in the ICU: Opportunities for redesign

AbstractProning, or turning a patient face down, is a technique used to manage patients with acute respiratory distress in intensive care units (ICUs). Research suggests that the type of pillow used in proning may have a significant impact on patient outcomes and increase the risk of disfiguring pressure injuries to the face. However, there is little evidence surrounding the usability of these pillows in the ICU. The aim of this study was to identify redesign opportunities by understanding how the tools, tasks, people, environment, and organization all interact during proning in the ICU. Thirty‐six ICU clinicians from two Australian public metropolitan hospitals completed an online questionnaire regarding their opinions and experiences with proned patients and the prevention of pressure injuries. Seven ICU clinicians then completed journey mapping activities to document the key workflows, critical incidents, considerations, and personnel involved in managing proned patients in the ICU. Several barriers and facilitators to pressure injury prevention were identified, including interactions between the various tools (e.g., proning pillows with one opening limits the management of several medical devices), the tasks (e.g., high frequency of repositioning), the people (e.g., clinical inexperience, patient features), the environment (e.g., limited availability of tools), and the organization (e.g., limited number of staff to support tasks). This holistic approach revealed several opportunities for the redesign of proning pillows and associated systems. Key takeaways include the limitations of a one‐size‐fits‐all approach to proning in the ICU context, and the need for flexibility and customization to improve proning pillows, associated medical devices, prophylactic dressings, aids, and processes.

Development of a clinical practice guideline for physiotherapy management of adults invasively ventilated with community-acquired pneumonia

Background and settingPatients hospitalised with community-acquired pneumonia (CAP) are frequently admitted to an intensive care unit (ICU) for invasive mechanical ventilation and receive treatment by physiotherapists. However, clinical physiotherapy practice is variable for this ICU cohort. ObjectivesTo develop a clinical practice guideline for physiotherapy management of adults invasively ventilated with CAP using the best available evidence. MethodsGuideline development using evidence synthesis according to the GRADE and JBI approaches, incorporating findings from four preceding phases of a mixed-methods research program: systematic review and meta-analysis, national survey of Australian ICU physiotherapy practice, e-Delphi study to determine expert consensus, and multidisciplinary peer-review of the expert consensus statements by senior ICU clinicians to determine validity and applicability of the statements for translation into practice. ResultsThe guideline comprises 26 recommendations, encompassing physiotherapy assessment, patient selection and prioritisation, and treatment. Physiotherapy treatment covers domains of humidification, patient positioning, hyperinflation techniques, manual chest wall techniques, normal saline instillation, active treatment, and mobilisation. Recommendations are rated as strong or conditional based on JBI criteria, and certainty of evidence according to GRADE. Considerations for practice are provided within the guideline to enhance clarity and practicality, particularly for conditional recommendations where evidence is limited or conflicting. ConclusionThis guideline, based on the best available evidence for clinical physiotherapy practice for adults invasively ventilated with CAP, is intended to support clinicians with clinical decision making. Further research is required to evaluate guideline implementation into clinical practice, and incorporate the values and preferences of ICU patients and their families. Contribution of paper•This world first clinical practice guideline was developed based on the best available evidence for physiotherapy management of adults invasively ventilated with non-COVID-19 community-acquired pneumonia.•The evidence-based guideline provides 26 recommendations across nine domains of physiotherapy assessment and treatment, to guide best practice for this common ICU cohort.

A Machine Learning Algorithm Predicting Acute Kidney Injury in Intensive Care Unit Patients (NAVOY Acute Kidney Injury): Proof-of-Concept Study.

Acute kidney injury (AKI) represents a significant global health challenge, leading to increased patient distress and financial health care burdens. The development of AKI in intensive care unit (ICU) settings is linked to prolonged ICU stays, a heightened risk of long-term renal dysfunction, and elevated short- and long-term mortality rates. The current diagnostic approach for AKI is based on late indicators, such as elevated serum creatinine and decreased urine output, which can only detect AKI after renal injury has transpired. There are no treatments to reverse or restore renal function once AKI has developed, other than supportive care. Early prediction of AKI enables proactive management and may improve patient outcomes. The primary aim was to develop a machine learning algorithm, NAVOY Acute Kidney Injury, capable of predicting the onset of AKI in ICU patients using data routinely collected in ICU electronic health records. The ultimate goal was to create a clinical decision support tool that empowers ICU clinicians to proactively manage AKI and, consequently, enhance patient outcomes. We developed the NAVOY Acute Kidney Injury algorithm using a hybrid ensemble model, which combines the strengths of both a Random Forest (Leo Breiman and Adele Cutler) and an XGBoost model (Tianqi Chen). To ensure the accuracy of predictions, the algorithm used 22 clinical variables for hourly predictions of AKI as defined by the Kidney Disease: Improving Global Outcomes guidelines. Data for algorithm development were sourced from the Massachusetts Institute of Technology Lab for Computational Physiology Medical Information Mart for Intensive Care IV clinical database, focusing on ICU patients aged 18 years or older. The developed algorithm, NAVOY Acute Kidney Injury, uses 4 hours of input and can, with high accuracy, predict patients with a high risk of developing AKI 12 hours before onset. The prediction performance compares well with previously published prediction algorithms designed to predict AKI onset in accordance with Kidney Disease: Improving Global Outcomes diagnosis criteria, with an impressive area under the receiver operating characteristics curve (AUROC) of 0.91 and an area under the precision-recall curve (AUPRC) of 0.75. The algorithm's predictive performance was externally validated on an independent hold-out test data set, confirming its ability to predict AKI with exceptional accuracy. NAVOY Acute Kidney Injury is an important development in the field of critical care medicine. It offers the ability to predict the onset of AKI with high accuracy using only 4 hours of data routinely collected in ICU electronic health records. This early detection capability has the potential to strengthen patient monitoring and management, ultimately leading to improved patient outcomes. Furthermore, NAVOY Acute Kidney Injury has been granted Conformite Europeenne (CE)-marking, marking a significant milestone as the first CE-marked AKI prediction algorithm for commercial use in European ICUs.

Pediatric Delirium Educational Tool Development With Intensive Care Unit Clinicians and Caregivers in Canada: Focus Group Study.

Pediatric intensive care unit (PICU)-associated delirium contributes to a decline in postdischarge quality of life, with worse outcomes for individuals with delayed identification. As delirium screening rates remain low within PICUs, caregivers may be able to assist with early detection, for which they need more education, as awareness of pediatric delirium among caregivers remains limited. This study aimed to develop an educational tool for caregivers to identify potential delirium symptoms during their child's PICU stay, educate them on how to best support their child if they experience delirium, and guide them to relevant family resources. Web-based focus groups were conducted at a tertiary pediatric hospital with expected end users of the tool (ie, PICU health care professionals and caregivers of children with an expected PICU length of stay of over 48 h) to identify potential educational information for inclusion in a family resource guide and to identify strategies for effective implementation. Data were analyzed thematically to generate requirements to inform prototype development. Participants then provided critical feedback on the initial prototype, which guided the final design. In all, 24 participants (18 health care professionals and 6 caregivers) attended 7 focus groups. Participants identified five informational sections for inclusion: (1) delirium definition, (2) key features of delirium (signs and symptoms), (3) postdischarge outcomes associated with delirium, (4) tips to inform family-centered care, and (5) education or supportive resources. Participants identified seven design requirements: information should (1) be presented in an order that resembles the structure of the clinical discussion around delirium; (2) increase accessibility, recall, and preparedness by providing multiple formats; (3) aim to reduce stress by implementing positive framing; (4) minimize cognitive load to ensure adequate information processing; (5) provide supplemental electronic resources via QR codes; (6) emphasize collaboration between caregivers and the health care team; and (7) use prompting questions to act as a call to action for caregivers. Key design requirements derived from end-user feedback were established and guided the development of a novel pediatric delirium education tool. Implementing this tool into regular practice has the potential to reduce distress and assist in the early recognition and treatment of delirium in the PICU domain. Future evaluation of its clinical utility is necessary.

Severe infections requiring intensive care unit admission in patients receiving ibrutinib for hematological malignancies: a groupe de recherche respiratoire en réanimation onco-hématologique (GRRR-OH) study

BackgroundIn the last decade, Ibrutinib has become the standard of care in the treatment of several lymphoproliferative diseases such as chronic lymphocytic leukemia (CLL) and several non-Hodgkin lymphoma. Beyond Bruton tyrosine kinase inhibition, Ibrutinib shows broad immunomodulatory effects that may promote the occurrence of infectious complications, including opportunistic infections. The infectious burden has been shown to vary by disease status, neutropenia, and prior therapy but data focusing on severe infections requiring intensive care unit (ICU) admission remain scarce. We sought to investigate features and outcomes of severe infections in a multicenter cohort of 69 patients receiving ibrutinib admitted to 10 French intensive care units (ICU) from 1 January 2015 to 31 December 2020.ResultsMedian time from ibrutinib initiation was 6.6 [3–18] months. Invasive fungal infections (IFI) accounted for 19% (n = 13/69) of severe infections, including 9 (69%; n = 9/13) invasive aspergillosis, 3 (23%; n = 3/13) Pneumocystis pneumonia, and 1 (8%; n = 1/13) cryptococcosis. Most common organ injury was acute respiratory failure (ARF) (71%; n = 49/69) and 41% (n = 28/69) of patients required mechanical ventilation. Twenty (29%; n = 20/69) patients died in the ICU while day-90 mortality reached 55% (n = 35/64). In comparison with survivors, decedents displayed more severe organ dysfunctions (SOFA 7 [5–11] vs. 4 [3–7], p = 0.004) and were more likely to undergo mechanical ventilation (68% vs. 31%, p = 0.010). Sixty-three ibrutinib-treated patients were matched based on age and underlying malignancy with 63 controls receiving conventional chemotherapy from an historic cohort. Despite a higher median number of prior chemotherapy lines (2 [1–2] vs. 0 [0–2]; p < 0.001) and higher rates of fungal [21% vs. 8%, p = 0.001] and viral [17% vs. 5%, p = 0.027] infections in patients receiving ibrutinib, ICU (27% vs. 38%, p = 0.254) and day-90 mortality (52% vs. 48%, p = 0.785) were similar between the two groups.ConclusionIn ibrutinib-treated patients, severe infections requiring ICU admission were associated with a dismal prognosis, mostly impacted by initial organ failures. Opportunistic agents should be systematically screened by ICU clinicians in this immunocompromised population.

Designing a Behaviour Change Wheel guided implementation strategy for a hypoxaemic respiratory failure and ARDS care pathway that targets barriers

BackgroundA significant gap exists between ideal evidence-based practice and real-world application of evidence-informed therapies for patients with hypoxaemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS). Pathways can improve...