Intensive Care Unit Practitioners Research Articles

Prediction of Th17/Treg cell balance on length of stay in intensive care units of patients with sepsis

BackgroundProlonged length of stay (LOS) of sepsis can drain a hospital's material and human resources. This study investigated the correlations between T helper type 17 (Th17) and regulatory T (Treg) balance with LOS in sepsis. MethodsA prospective clinical observational study was designed in Changhai Hospital affiliated to Naval Medical University in Shanghai, China, from January to October 2020. The patients diagnosed with sepsis and who met the inclusion and exclusion criteria were recruited and whether the levels of cytokines, procalcitonin, subtypes, and biomarkers of T cells in the peripheral blood were detected. We analyzed the correlation between these and LOS. ResultsSixty septic patients were classified into two groups according to whether their intensive care unit (ICU) stay exceeded 14 days. The patients with LOS ≥14 days were older ([72.6±7.5] years vs. [63.3±10.4] years, P=0.015) and had higher Sequential Organ Failure Assessment (SOFA) (median [interquartile range]: 6.5 [5.0–11.0] vs. 4.0 [3.0–6.0], P=0.001) and higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (16.0 [13.0–21.0] vs. 8.5 [7.0–14.0], P=0.001). There was no difference in other demographic characteristics and cytokines, interleukin-6, tumor necrosis factor-α, and interleukin-10 between the two groups. The Th17/Treg ratio of sepsis with LOS <14 days was considerably lower (0.48 [0.38–0.56] vs. 0.69 [0.51–0.98], P=0.001). For patients with LOS ≥14 days, the area under the receiver operating characteristic curve for the Th17/Treg ratio was 0.766. It improved to 0.840 and 0.850 when combined with the SOFA and APACHE II scores, respectively. ConclusionsThe Th17/Treg ratio was proportional to septic severity and can be used as a potential predictor of ICU stay in sepsis, presenting a new option for ICU practitioners to better care for patients with sepsis.

Improving environmental sustainability of intensive care units: A mini-review.

The carbon footprint of healthcare is significantly impacted by intensive care units, which has implications for climate change and planetary health. Considering this, it is crucial to implement widespread efforts to promote environmental sustainability in these units. A literature search for publications relevant to environmental sustainability of intensive care units was done using PubMed. This mini-review seeks to equip intensive care unit practitioners and managers with the knowledge necessary to measure and mitigate the carbon cost of healthcare for critically ill patients. It will also provide an overview of the current progress in this field and its future direction.

Comparison of machine learning algorithms to SAPS II in predicting in-hospital mortality of fractures of the pelvis and acetabulum: analyzes based on MIMIC-III database

Fractures of pelvis and acetabulum are at high risk of death worldwide. However, the capability of mortality prediction by the conventional system Simple Acute Physiologic Score (SAPS) II remains limited. Here, we hypothesized that the use of machine learning (ML) algorithms could provide better performance of prediction than SAPS II for traumatic patients in the intensive care unit (ICU). Customized ML models were built including support vector machine, decision tree, logistic regression and random forest based on MIMIC-III clinical database. 307 patients were enrolled with an ICD-9 diagnosis of pelvic, acetabular or combined pelvic and acetabular fractures. Feature expansion method was used for experimental models by extending SAPS II features to the first 72 hours after ICU admission, compared with the traditional first-24-hours ones that were used to build respective control models. A comparison of each model’s performance was made through the area under the receiver-operating characteristic curve (AUROC). All the ML models outperformed SAPS II system (AUROC = 0.73), among which the experimental random forest model had the supreme performance (AUROC of 0.90). The results suggested that ML models could aid in better performance of mortality prediction for pelvic and acetabular injuries and potentially support decision-making for orthopedics and ICU practitioners.

Intensive Care Unit Caregivers Perception of Patient Discomfort: A Qualitative Study

BackgroundBeing hospitalized in an intensive care unit ICU often involves pain and discomfort. While pain is commonly alleviated with analgesics, discomfort is more difficult to diagnose and treat, thus potentially leading to incorrect analgesic administration. AimTo describe intensive care unit practitioners' perceptions of discomfort in the ICU, and their methods to discern between pain and non-pain discomfort. MethodsTwenty-five intensive care unit practitioners (7 doctors and 18 nurses) were interviewed from medical and general intensive care units at one institution in Jerusalem, Israel. Data collection was performed using semi-structured interviews. Interviews were audio-recorded and transcribed. Transcriptions were coded and categorized by two researchers independently. Content analysis identified common themes. ResultsTwo main discomfort themes were identified: unpleasant physical sensations and unpleasant psychologic feelings, with further subcategories. Physiologic and non-physiologic signs such as facial expression and motor activity helped to diagnose discomfort. Trial and error and cause and effect were used to differentiate pain from other sources of discomfort. ConclusionsPractitioners saw pain as a dominant source of discomfort. Treating overall discomfort should focus on improving the quality of the total intensive care unit experience. Strategies to diagnose non-pain discomfort and pain were similar. Differentiating pain from non-pain discomfort is essential in order to provide appropriate treatment for pain and non-pain-related discomfort.

Early mobilization of mechanically ventilated ICU patients in Saudi Arabia: Results of an ICU-wide national survey

BackgroundImproved outcomes for patients on mechanical ventilation may be achieved with early mobilization (EM). However, it is not clear how widely this strategy is adopted into routine intensive care unit (ICU) practice in Saudi Arabia. ObjectivesThis study was conducted to describe the present practices and challenges to providing EM for mechanically ventilated patients, which may drive dissemination and implementation activities. MethodsWe approached 205 ICUs across Saudi Arabia using a validated tool to assess ICU characteristics, the practices of EM for mechanically ventilated patients, and the barriers to providing EM. ResultsWe approached 205 ICU persons in charge and achieved a 65% response rate (133 ICUs). The prevalence of EM for mechanically ventilated patients was 47% (63 ICUs). A total of 85 (64%) of the respondents reported having no previous training in EM. The absence of a written protocol was reported by 55% of the ICU practitioners in charge, 36% started EM within 2 to 5 days of critical illness, and 35% reported that performing EM for mechanically ventilated patients was totally dependent on physicians’ orders. Forty-seven percent of the ICUs that practised EM had at least one coordinator or person in charge of facilitating EM. The highest level of EM with mechanically ventilated patients was 35/63 (55%) with patients remaining in-bed and 28/63 (45%) with patient getting out of bed. A majority of the respondents (39, 64%) performed EM once daily for an interval period of more than 15 min. Previous training in EM and years of experience of the ICU person in charge were significant factors that promoted EM for mechanically ventilated ICU patients (OR: 7.6 (3.37–17.26); p < 0.001 and OR: 1.07 (1.01–1.14), p = 0.004, respectively). Existing protocols increased the odds of starting EM within 2 to 5 days of critical illness by six-fold (OR: 6.03 (1.79–20.30); p = 0.004). No written guidelines/protocols available for EM, medical instability, and limited staff were the most common hospital-, patient- and health care provider-related barriers to EM in the ICUs, respectively. ConclusionThe prevalence of EM for mechanically ventilated patients across Saudi Arabia was 47%, although only 36% of the ICU staff had previous training in EM. Targeting modifiable barriers to EM, including a lack of training, guidelines and protocols, and staffing, will help to promote EM in Saudi Arabian ICUs.

Well-being in the Intensive Care Unit: Looking Beyond COVID-19.

Burnout among critical care personnel has increased due to the additional psychological and physical demands of caring for critically ill patients with limited resources. Factors that increase the risk of burnout include compassion fatigue, lack of control over the work environment, difficult interpersonal relationships, and constant exposure to end-of-life issues. Organizational commitment to physician wellbeing depends on improving workplace efficiency, recognizing stressors in the critical care environment, and providing resources to help manage staffing shortages. Community building, training in communication, and team-building strategies are important steps in building collaboration and camaraderie in the workplace.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey.

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study.

Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center. A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys. A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff. Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

Investigation on the Mental Health Status of ICU Practitioners and Analysis of Influencing Factors During the Stable Stage of COVID-19 Epidemic in China.

Objective: To understand the impact of COVID-19 epidemic on the mental health status of intensive care unit (ICU) practitioners in China, and to explore the relevant factors that may affect the mental health status of front-line medical workers so as to adopt efficient and comprehensive measures in a timely manner to protect the mental health of medical staff.Methods: The study covered most of the provinces in China, and a questionnaire survey was conducted based on the WeChat platform and the Wenjuanxing online survey tool. With the method of anonymous investigation, we chose ICU practitioners to participate in the investigation from April 5, 2020 to April 7, 2020. The respondents were divided into two groups according to strict criteria of inclusion and exclusion, those who participated in the rescue work of COVID-19 (COVID-19 group) and those who did not (non-COVID-19 group). The SCL-90 self-evaluation scale was used for the evaluation of mental health status of the subjects.Results: A total of 3,851 respondents completed the questionnaire. First, the overall mental health status of the targeted population, compared with the Chinese norm (n = 1,388), was reflected in nine related factor groups of the SCL-90 scale, and significant differences were found in every factor in both men and women, except for the interpersonal sensitivity in men. Second, the overall mental health of the non-COVID-19 group was worse than that of the COVID-19 group by the SCL-90 scale (OR = 1.98, 95% CI, 1.682–2.331). Third, we have revealed several influencing factors for their mental health in the COVID-19 group, current working status (P < 0.001), satisfaction of diet and accommodation (P < 0.05), occupational exposure (P = 0.005), views on the risk of infection (P = 0.034), and support of training (P = 0.01).Conclusion: The mental health status of the ICU practitioners in the COVID-19 group is better than that of the non-COVID-19 group, which could be attributed to a strengthened mentality and awareness of risks related to occupational exposure and enforced education on preventive measures for infectious diseases, before being on duty.

M-BLUE protocol for coronavirus disease-19 (COVID-19) patients: interobserver variability and correlation with disease severity

AIMTo retrospectively evaluate the interobserver variability of intensive care unit (ICU) practitioners and radiologists who used the M-BLUE (modified bedside lung ultrasound in emergency) protocol to assess coronavirus disease-19 (COVID-19) patients, and to determine the correlation between total M-BLUE protocol score and three different scoring systems reflecting disease severity.MATERIALS AND METHODSInstitutional review board approval was obtained and informed consent was not required. Ninety-six lung ultrasonography (LUS) examinations were performed using the M-BLUE protocol in 79 consecutive COVID-19 patients. Two ICU practitioners and three radiologists reviewed video clips of the LUS of eight different regions in each lung retrospectively. Each observer, who was blind to the patient information, described each clip with M-BLUE terminology and assigned a corresponding score. Interobserver variability was assessed using intraclass correlation coefficient. Spearman's correlation coefficient analysis (R-value) was used to assess the correlation between the total score of the eight video clips and disease severity.RESULTSFor different LUS signs, fair to good agreement was obtained (ICC = 0.601, 0.339, 0.334, and 0.557 for 0–3 points respectively). The overall interobserver variability was good for both the five different readers and consensus opinions (ICC = 0.618 and 0.607, respectively). There were good correlations between total LUS score and scores from three systems reflecting disease severity (R=0.394–0.660, p<0.01).CONCLUSIONIn conclusion, interobserver agreement for different signs and total scores in LUS is good and justifies its use in patients with COVID-19. The total scores of LUS are useful to indicate disease severity.

Active Breaks Initiative During Hospital Rounds in the Surgical ICU to Improve Wellness of Healthcare Providers: An Observational Descriptive Study.

Healthcare professionals in the intensive care unit (ICU) confront stressful working conditions. Morning rounds involve several hours of prolonged standing and uninterrupted concentration each day and require both mental and physical endurance from the entire care team. There is concern that work-related fatigue among ICU practitioners will compromise their ability to safely and effectively care for their patients. To address this concern, the surgical intensive care unit (SICU) at Long Island Jewish Medical Center implemented an initiative to promote provider wellness through "active breaks" during rounds. Between October and December 2019, 30 physicians, physician assistants, nurses, and students collectively engaged in active breaks during SICU rounds and then completed a 7-question, post-test survey to assess their experience. The survey consisted of both closed-end and open-ended questions. The data were then analyzed using simple statistics. In response to closed-ended questioning, the majority of participants agreed that active breaks relieved stress (27/30; 90%), promoted wellness (29/30; 96.7%), and improved team morale (29/30; 93.1%). When given the options of tricep dips, squats or push-ups, squats were the favored activity during breaks (17/30; 56.7%). Most of the participants (27/30; 90%) considered the active breaks to be appropriate for the working environment; two participants had no opinion on this matter. Approximately 90% of the respondents were interested in maintaining active breaks as part of the routine of morning rounds. Our assessment suggests active breaks during rounds are a healthy outlet to address the inherent stress associated with critical care. This initiative also potentially protects healthcare providers from burnout and, consequentially, improves the quality of patient care.

Procedures in COVID-19 Patients: Part-I.

The number of cases with novel coronavirus disease-2019 (COVID-19) infection is increasing every day in the world, and India contributes a substantial proportion of this burden. Critical care specialists have accepted the challenges associated with the COVID-19 pandemic and are frontline warriors in this war. They have worked hard in streamlining workflow isolation of positive patients, clinical management of critically ill patients, and infection prevention practices. With no end in sight for this pandemic, intensive care unit (ICU) practitioners, hospital administrators, and policy makers have to join hands to prepare for the surge in critical care bed capacity. In this position article, we offer several suggestions on important interventions to the ICU practitioners for better management of critically ill patients. This position article highlights key interventions for COVID-19 treatment and covers several important issues such as endotracheal intubation and tracheostomy (surgical vs PCT), nebulization, bronchoscopy, and invasive procedures such as central venous catheters, arterial lines, and HD catheters.How to cite this article: Pande RK, Bhalla A, SN Myatra, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-I. Indian J Crit Care Med 2020;24(Suppl 5):S263–S271.

Intensive care and anesthetic management of patients with Brugada syndrome and COVID-19 infection.

Coronavirus disease 2019 (COVID‐19) spreads across the world, and the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic viral infection. Rapid diagnosis, isolation, and intensive clinical management are very important for all patients with COVID‐19, especially for those with cardiac diseases as Brugada syndrome (BrS). BrS is an arrhythmogenic disease reported to be one among the leading causes of sudden cardiac death. In these patients, episodes of lethal arrhythmias may be induced by several factors or situations, and for this reason management during ICU permanence or anesthesia must provide some precautions, avoiding factors that are known to have the potential to worsen the probability to induce arrhythmias. For ICU practitioners, management of acute respiratory failure, hemodynamics, and cardiovascular complications certainly are the key for the best treatment of these patients but to date specific data on supportive ICU care for these patients are lacking, and current recommendations are based on existing evidence from other viral infections and general intensive care management. We want to focus on some general rules, resulted from cases series and clinical practice, to be followed during the ICU management of patients with BrS and concomitant COVID‐19 infection.

Glucose Control

Patients with diabetes mellitus routinely require management in the adult intensive care unit (ICU). These patients have increased morbidity, mortality, hospital length of stay, cost of care, and frequency of hospital and ICU admission. Glucose control in these patients presents challenges for the clinician. In the critically ill, hyperglycemia does not occur exclusively in patients with diabetes or prediabetes but may be related to stress-induced hyperglycemia or iatrogenic causes. Hyperglycemia can contribute to decreased wound healing and immune function and a host of cellular and molecular dysfunctions and has been linked to increased hospital mortality. Hypoglycemia in the ICU is associated with patients with preexisting diabetes, those receiving insulin and other medications, and septic individuals, among others. Insulin therapy is the mainstay of glucose management in the critically ill. ICU practitioners should be aware that point-of-care glucose meters are not as accurate as core laboratory results. Finally, both hypoglycemia and wide fluctuations in blood glucose during critical illness are also associated with increased mortality, although clear cause-and-effect relationships have not been established. This review contains 1 figure, 8 tables, and 71 references. Key words: Diabetes mellitus, glucose measurement, glucose targets, hyperglycemia, hypoglycemia, insulin

Sedation with ketamine and fentanyl combination improves patient outcomes in intensive care units

Psychological manifestations such as depression and suicidal ideation are commonly caused by poorly controlled pain, anxiety, and sleep deprivation in intensive care unit (ICU) patients. We are concerned that previous analgesic and sedative techniques administered as single-medication approaches are outdated and inadequate. It is imperative that ICU practitioners are knowledgeable in multimodal approaches to pain and sedation in high acuity settings. We have shown that appropriate combinations of ketamine and fentanyl are effective, and if further supplementation is needed, we utilize additional pharmacological agents in low doses and regional techniques that ultimately lower the overall opioid consumption. We acknowledge that a variety of medication supplementations tailored to the patient’s clinical needs and nature of surgery improves a patient’s outcome in ICU and overall quality of life.

Nephrology in the Academic Intensive Care Unit: A Qualitative Study of Interdisciplinary Collaboration

Collaboration between nephrology consultants and intensive care unit (ICU) teams is important in light of the high incidence of acute kidney injury in today's ICUs. Although there is considerable debate about hownephrology consultants and ICU teams shouldcollaborate, communicative dynamics betweenthe 2 parties remain poorly understood. Thisarticle describes interactions between nephrology consultants and ICU teams in the academic medical setting. Focused ethnography using semi-structured interviews and participant observation. Purposive sampling was used to enroll nephrologists, nephrology fellows, and ICU practitioners across several roles collaborating in 3 ICUs (a medical ICU, a surgical ICU, and a cardiothoracic surgical ICU) of a large urban US academic medical center. Participant observation (150 hours) and semi-structured interviews (35) continued until theoretical saturation. Interview and fieldnote transcripts were coded in an iterative team-based process. Explanation was developed using an abductive approach. Nephrology consultants and surgical ICU teams exhibited discordant preferences about the aggressiveness of renal replacement therapy based on different understandings of physiology, goals of care, and acuity. Collaborative difficulties resulting from this discordance led to nephrology consultants often serving as dialysis proceduralists rather than diagnosticians in surgical ICUs and to consultants sometimes choosing not to express disagreements about clinical care because of the belief that doing so would not lead to changes in the course of care. Aspects of this single-site study of an academic medical center may not be generalizable to other clinical settings and samples. Surgical team perspectives would provide further detail about nephrology consultation in surgical ICUs. The effects of findings on patient care were not examined. Differences in approach between internal medicine-trained nephrologists and anesthesia- and surgery-trained intensivists and surgeons led to collaborative difficulties in surgical ICUs. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing rooted in long-term socialization to different disciplinary practices.

Commencing Out-of-Bed Rehabilitation in Critical Care—What Influences Clinical Decision-Making?

ObjectivesTo develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. DesignA prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. SettingFour tertiary metropolitan ICUs. ParticipantsPractitioners (ICU medical, nursing, and physiotherapy staff) (N=507). InterventionsNot applicable. Main Outcome MeasuresA decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners. ResultsThere were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. ConclusionThese results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.

Aspects on Patient Safety in Critical Care Unit

Safety culture is a complex phenomenon that is not clearly understood by hospital leaders, thus making it difficult to operationalize. We found senior leadership accountability key to an organization-wide culture of safety. Ensuring patient safety is becoming increasingly important for intensive care unit practitioners. The intensive care unit is particularly prone to medical errors because of the complexity of the patients, interdependence of the practitioners, and dependence on team functioning. Workload, emotional stability, following safety precautions and lack of drug availability problems were found that lead to lack of the patients‟ safety in the ICU.

An Advanced Practice Provider-Led Initiative for Delirium Screening and Management in an Oncologic ICU

SESSION TITLE: ICU Management SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: Delirium occurs in 30-80% of patients admitted to the Intensive Care Unit (ICU) and is associated with increased morbidity and mortality, mechanical ventilator-days, hospital and ICU length of stay (LOS), costs, and long term cognitive impairment. Most cases of delirium are missed by ICU clinicians. The Confusion Assessment Method for the ICU (CAM-ICU) is one of the few validated tools for the assessment of delirium in the critically-ill population. However, routine use of CAM-ICU by nurses alone does not improve delirium recognition and management. We hypothesize that an Advanced Practice Provider (APP) led initiative can close additional gaps in knowledge and improve accuracy of and compliance to CAM-ICU screening and overall delirium management. METHODS: As part of a larger multidisciplinary delirium quality improvement project, a small group of APPs created a comprehensive training program that targeted nurse practitioners (NPs), physician assistants (PAs) and critical care fellows working in the ICU at Memorial Sloan Kettering Cancer Center. The educational sessions included formal didactic lectures, open discussions, and a multi-item questionnaire to capture participants’ demographics, knowledge, and comfort level with the use of CAM-ICU and with delirium management. CAM-ICU administration and delirium pathophysiology, assessment, management and impact were discussed. All participants were provided electronic tablets and completed the questionnaire before and after each educational session. Delirium rates and both compliance to and accuracy of CAM-ICU were recorded before and after the intervention. Survey responses were compared between pre- and post-training using McNemar’s test for categorical variables and Wilcoxon Signed Rank test for continuous variables. Data are presented as absolute numbers, percentages, and medians with first and third interquartile ranges. A p value of < 0.05 was statistically significant. RESULTS: Thirty one ICU practitioners participated in the training program: 8 critical care fellows, 20 board-certified NPs and 3 board-certified PAs with a median of 6 (2.5-10) years ICU experience. Of the 31 practitioners, 5 (16%) had participated in a delirium screening and treatment program prior to our intervention and 13 (41%) had never used CAM-ICU in practice. Scores on the 15-item questionnaire improved from a baseline of 76% to 86% (p < 0.0001). Comfort level with CAM-ICU administration increased from 16% to 61% (p < 0.0001) while comfort level with delirium management increased from 35% to 68% (p = 0.0001). Finally, post-intervention audits revealed compliance to CAM-ICU screening of 99% from a baseline of 60%, accuracy of CAM-ICU results of 90-95% from a pre-training rate of 50-60%, and an increase in ICU delirium rates from 18.3% in the fourth quarter of 2015 to 30% in the fourth quarter of 2016. CONCLUSIONS: An APP-led initiative successfully improved knowledge of delirium prevention and management by physicians, NPs and PAs working in a medical-surgical ICU. The post-training adherence to CAM-ICU screening increased. CLINICAL IMPLICATIONS: Our intervention supports the need for identification of APP delirium champions to lead educational programs for their colleagues in the ICU. DISCLOSURE: The following authors have nothing to disclose: Sarah Rebal, Caroline Shirzadi, Jennifer Agatep, Konstantina Matsoukas, Kate Tayban, Heidi Yulico, Kay See Tan, Kenneth Seier, Yesne Alici, Beatriz Korc-Grodzicki, Louis Voigt No Product/Research Disclosure Information

Perceived safety and efficacy of neuromuscular blockers for acute respiratory distress syndrome among medical intensive care unit practitioners: A multicenter survey

PurposeNeuromuscular blocking agents (NMBAs) are frequently used in patients with acute respiratory distress syndrome (ARDS). The purpose of this survey is to describe providers' knowledge and perceived efficacy and safety of NMBAs in patients with ARDS. Materials and methodsWe performed a prospective, multicenter survey of medical intensive care unit intensivists, fellows, nurse practitioners (NPs), physician's assistants (PAs), and pharmacists at 5 tertiary care centers between July 2012 and May 2013. ResultsA total of 335 surveys were sent to providers, with a 47% response rate. Ninety-eight percent of providers correctly identified that NMBAs lack anxiolytic and analgesic properties. The effect of end-organ damage on NMBA clearance was less commonly identified by NPs/PAs for both hepatic (P=.0077) and renal (P=.0272) dysfunction compared with physicians. More NP/PAs identified the association of consciousness with the use of NMBAs than physicians (P=.047). Forty-two percent of prescribers reported always or frequently using continuous-infusion NMBAs in patients with severe ARDS, with 89% initiating NMBAs because of ventilator dyssynchrony. Prescribers perceived continuous NMBAs to be more effective than inhaled prostaglandins (74% vs 56%) in severe ARDS but less safe (45% vs 84%). Train of 4 was identified by 54% of prescribers as their primary method for titration. ConclusionProviders are knowledgeable about NMBAs, but educational opportunities exist. Perceptions about the efficacy and safety of NMBAs varied among prescribers, and inconsistencies existed in the prioritization of management strategies for ARDS.