Intensive Care Unit Team Research Articles

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review.

Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU. Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Adults (age 18 and over) undergoing WMV in the ICU. Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients. High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Point-of-care Ultrasound (POCUS) Program for Critical Care Nurse Practitioners and Physician Assistants in an Oncological Intensive Care Unit and Rapid Response Team.

Implementation of a comprehensive point-of-care ultrasound (POCUS) program for nurse practitioners (NPs) and physician assistants (PAs) in an intensive care unit (ICU) setting improves their diagnostic and therapeutic skills and enhances patient care. Overcoming staffing, IT infrastructure, and administrative challenges has allowed our critical care medicine service to develop a successful program that empowers NPs and PAs and boosts their professional growth. Our POCUS program underscores the necessity of institutional support, dedicated mentorship, collaboration with qualified faculty, and creation and maintenance of a curriculum that adheres to accepted national guidelines. Insights gained from our experiences can serve as a valuable resource for institutions aiming to develop their own POCUS programs.

Review article: Emerging and current management of acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) is a clinically and pathophysiologically distinct condition from acutely decompensated cirrhosis and is characterised by systemic inflammation, extrahepatic organ failure, and high short-term mortality. To provide a narrative review of the diagnostic criteria, prognosis, epidemiology, and general management principles of ACLF. Four specific interventions that are explored in detail are intravenous albumin, extracorporeal liver assist devices, granulocyte-colony stimulating factor, and liver transplantation. We searched PubMed and Cochrane databases for articles published up to July 2023. Approximately 35% of hospital inpatients with decompensated cirrhosis have ACLF. There is significant heterogeneity in the criteria used to diagnose ACLF; different definitions identify different phenotypes with varying mortality. Criteria established by the European Association for the Study of the Liver were developed in prospective patient cohorts and are, to-date, the most well validated internationally. Systemic haemodynamic instability, renal dysfunction, coagulopathy, neurological dysfunction, and respiratory failure are key considerations when managing ACLF in the intensive care unit. Apart from liver transplantation, there are no accepted evidence-based treatments for ACLF, but several different approaches are under investigation. The recognition of ACLF as a distinct entity from acutely decompensated cirrhosis has allowed for better patient stratification in clinical settings, facilitating earlier engagement with the intensive care unit and liver transplantation teams. Research priorities over the next decade should focus on exploring novel treatment strategies with a particular focus on which, when, and how patients with ACLF should be treated.

The care of critically ill adults with COVID-19 in Ontario pediatric intensive care units.

To describe and review the experience of two pediatric intensive care units (PICUs) in Ontario, Canada, adapting and providing care to critically ill adults during the COVID-19 pandemic. At a time of extreme pressure to adult intensive care unit (ICU) capacity, two PICUs provided care to critically ill adults with COVID-19 pneumonia. Substantial yet rapid planning was required to facilitate safe delivery of critical care to adult patients while maintaining PICU services, including thoughtful development of care pathways and patient selection. To prepare clinical staff, several communication strategies, knowledge translation, skill consolidation, andsystem-adaptation mechanisms were developed. There was iterative adaptation of operational processes, including staffing models, specialist consultation, and the pharmacy. Care provided by the interprofessional teams was reoriented as appropriate to the needs of critically ill adults in close collaboration with adult ICU teams. Forty-one adults were admitted to the two PICUs over a 12-week period. In total, 36 patients (88%) received invasive ventilation, eight patients (20%) were supported with venovenous extracorporeal membrane oxygenation, and six patients (15%) received continuous renal replacement therapy. Four died in the PICU during this period. Feedback from staff included anxiety around reorienting practice to the care of critically ill adults, physical exhaustion, and psychological distress. Importantly, staff also reported a renewed sense of purpose with participation in the program. Though challenging, the experience has provided opportunity to enhance collaboration with partner institutions and improve the care of older children and adolescents in the PICU.

Expansion of around the clock critical care and emergency medicine clinical pharmacy services at a large urban academic medical center

AbstractThe impact of a pharmacist as a dedicated member of multidisciplinary intensive care unit (ICU) and emergency department (ED) teams has repeatedly been described in the literature for over 20 years. A 2020 position paper published by the Society of Critical Care Medicine and the American College of Clinical Pharmacy recommended the optimal practice model include critical care pharmacists providing direct patient care 24 h a day, 7 days a week. The objective of this paper is to describe the expansion and evolution of clinical pharmacy services provided in the ICU and ED at a large academic health center, beginning in 2015 and accelerated in the face of a global pandemic. This was made possible through a combination of creating new positions and reallocating existing positions to substantially increase ICU and ED clinical pharmacy coverage. Over a 7 year period, the emergency medicine and critical care clinical pharmacy team expanded from six full time equivalent (FTE) employees in 2015 to 16 FTEs in early 2022. This allowed for reduced pharmacist to patient ratios, the expansion of clinical pharmacy services from primarily weekday hours to a 24 h per day coverage model, 7 days a week, and to better support clinical pharmacy specialists providing these services. Rapid expansion of around the clock clinical pharmacy services was only possible through collaboration between clinical and operations pharmacy managers and feedback from members of the multidisciplinary team.

The impacts of visual comfort on pediatric oncology intensive care units

Abstract Patient's discomfort in hospital Intensive Care Units (ICUs) regarding infrastructure, the lack of natural light and complementary artificial light, as well as colours found in these environments are important humanization concerns directly affecting the physical and emotional well-being of patients, caregivers and the multidisciplinary team, especially in paediatric oncology ICUS, which are stressful environments. This paper sought to answer relevant questions about visual comfort and traces of stress experienced by caregivers and a multidisciplinary team in a paediatric oncology ICU. For this purpose, a Visual Comfort Questionnaire and a Lipp’s Stress Symptoms Inventory were applied to obtain participants´ feedback at a [hospital] in Brazil. The results showed that caregivers and employees pointed out the need to have more windows in the environment, addressing the importance of natural light for physical and emotional well-being. Based on this, a significant number of employees and companions associate stress to the everyday life in the ICU, which occurred mainly in the intermediate (resistance) or final (exhaustion) phases, according to the Lipp scale. These results showed the importance of a broader approach to hospital humanization.

Exploring collaboration models between geneticists and intensivists for implementing rapid genome sequencing in critical care settings.

The availability of rapid genome sequencing (rGS) for children in a critical-care setting is increasing. This study explored the perspectives of geneticists and intensivists on optimal collaboration and division of roles when implementing rGS in neonatal and pediatric intensive care units (ICUs). We conducted an explanatory mixed methods study involving a survey embedded within an interview with 13 genetics and intensive care providers. Interviews were recorded, transcribed, and coded. Geneticists endorsed higher confidence in performing a physical exam and interpreting/communicating positive results. Intensivists endorsed highest confidence in determining whether genetic testing was appropriate, communicating negative results, and consenting. Major qualitative themes that emerged were: (1) concerns with both "genetics-led" and "intensivist-led" models with workflows and sustainability (2) shift the role of determining rGS eligibility to ICU medical professionals, (3) continued role of geneticists to assess phenotype, and (4) include genetic counselors (GCs) and neonatal nurse practitioners to enhance workflow and care. All geneticists supported shifting decisions regarding eligibility for rGS to the ICU team to minimize time cost for the genetics workforce. Exploring models of geneticist-led phenotyping, intensivist-led phenotyping for some indications, and/or inclusion of a dedicated inpatient GC may help offset the time burden of consenting and other tasks associated withrGS.

#3123 INCREASING THE USE OF REGIONAL CITRATE ANTICOAGULATION FOR CKRT IN A LARGE TERTIARY CENTER: A QUALITY IMPROVEMENT PROJECT

Abstract Background and Aims To maintain Continuous Kidney Replacement Therapy (CKRT) circuit patency, KDIGO recommends Regional Citrate Anticoagulation (RCA) as the first-line anticoagulation strategy. In a randomized controlled trial, RCA was associated with increased filter life, reduced circuit downtime, and reduced bleeding, as compared with heparin anticoagulation [1]. RCA-CKRT uptake in our institution, a 1800-bed tertiary center with seven intensive care units (ICU), was low at only 10% of all CKRT sessions. We conducted a Quality Improvement project to increase the uptake of RCA-CKRT in medical and surgical intensive care units in our institution. Method Following established Quality Improvement methodology, we delineated a process map and performed a root-cause analysis. Multiple plan-do-study-act (PDSA) cycles were conducted. A bespoke CKRT audit dashboard was created to automatically compile electronic CKRT prescription records and circuit monitoring data. The primary outcome measure, the percentage of all CKRT sessions that utilise RCA, was monitored monthly. Qualitative and quantitative feedback was monitored. Results Problem analysis (Figure 1) identified that the top root causes contributing to low RCA-CKRT uptake rate were (1) renal physicians defaulting to ‘old habits’ of non-RCA CKRT, (2) nursing staff having inadequate experience and concerns of increased workload, (3) ICU team being uncomfortable with RCA-CKRT, especially fear of citrate toxicity. Multiple PDSA cycles were conducted. In PDSA cycle 1, inclusion and exclusion criteria for default RCA use were standardized. A poster was created to set out these criteria, along with a visual guide explaining how RCA works, and how to identify citrate toxicity. The poster was designed to be eye-catching and easy to understand for non-renal physicians, and was placed prominently in ICU and renal work areas. PDSA cycles 2-4 were educational efforts, including a peer review learning for the renal department, incorporating RCA into ICU resident didactic teaching, and an RCA refresher course for ICU nurses. Through these four PDSA cycles, all three top root causes identified were addressed in turn. Continuous feedback was sought from all stakeholders and acted on in a timely manner. For example, it was identified that some prescribers and nursing staff had the misconception that switching from non-RCA to RCA-CKRT would require changing the entire filter circuit, leading to reluctance to switch to RCA once a CKRT circuit was running. A clarification was promulgated and added to the poster. Over a 12-month period, the percentage of all CKRT sessions utilizing RCA increased from a baseline of 10.5% ± 7.7% (mean ± SD; median 9.8%) to 22.5% ± 14.6% (median 21.5%; p = 0.022) (Figure 2). This included a 3-month period after PDSA cycle 1 during which supplies of RCA-CKRT fluid were disrupted due to COVID-19 supply chain issues. Excluding the months of supply disruption, the uptake of RCA-CKRT would have been 25.3% ± 15.8% (median 25.0%). Conclusion A quality improvement project successfully increased the uptake of RCA-CKRT from 10.5% to 22.5% in a complex tertiary care setting. Understanding key barriers at each stage of a complex process, availability of real-time audit data, and attention to stakeholder feedback were key factors that enabled successful change. Unexpected events (in this case a supply chain disruption) may threaten a loss of momentum for change, but can be overcome with continual stakeholder engagement and additive PDSA cycles.

A confirmed case of macrophage activation syndrome secondary to spotted fever rickettsiosis: Response to immunomodulation in a pediatric patient in northeastern, Mexico

An 8-year-old girl with a rash and high-grade fever for 6 days arrived at the emergency room. She had an erythematous macular rash on the face, trunk, arms, and legs. Further interrogation called attention to the presence of close contact with stray dogs. Her town had been recognized as a site of a rickettsiosis outbreak in the past year. Spotted fever rickettsiosis was suspected, and doxycycline treatment was initiated. Macrophage activation syndrome (MAS) secondary to Rickettsia rickettsii infection was diagnosed according to the Hemophagocytic lymphohistiocytosis and EULAR/PRINTO/PRES 2016 criteria. As there are no clear guidelines on the treatment of MAS secondary to R. rickettsii. the course of action taken by the pediatric intensive care unit team was to avoid disseminated intravascular coagulopathy and treat MAS, both life-threatening conditions. Directed therapy with high doses of methylprednisolone and intravenous immunoglobulin therapy was initiated. The patient recovered, regaining her functional state before the illness. Few articles have described the association between MAS and rickettsiosis, an illness with high mortality, which makes it paramount to detect and treat promptly.

Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease

ObjectivesA quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. MethodsWe performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. ResultsIn-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. ConclusionsBoth in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.

Qualitative Study on Safe and Effective Handover Information during a Rapid Response Team Encounter.

A rapid response team (RRT) evaluates and manages patients at risk of clinical deterioration. There is limited literature on the structure of the rapid response encounter from the floor to the intensive care unit team. We aimed to define this encounter and examine provider experiences to elucidate what information healthcare staff need to safely manage patients during an RRT evaluation. This phenomenological qualitative study included 6 focus groups (3 in-person and 3 virtually) organized by provider type (nurses, residents, fellows, attendings), which took place until thematic saturation was reached. Two authors inductively coded transcripts and used a quota sampling strategy to ensure that the focus groups represented key stakeholders. Transcripts were then analyzed to identify themes that providers believe influence the RRT's quality, efficacy, and efficiency and their ability to manage and treat the acutely decompensating pediatric patient on the floor. Transcript coding yielded 38 factors organized into 8 themes. These themes are a summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. The principal themes of utmost importance at our institution during an RRT encounter are preparation, a brief and concise handoff from the floor team, and a summary statement from the intensive care unit team with contingency planning at the end of the encounter. Our data suggest that some standardization may be beneficial during the handoff.

Developing and Evaluating a Novel Educational Intensive Care Unit Wall Map

Developing and Evaluating a Novel Educational Intensive Care Unit Wall Map

Rudeness and civility in health care

Rudeness and civility in health care

Impact of critical care pharmacist‐led interventions on pain, agitation, and delirium in mechanically ventilated adults: A systematic review

AbstractBest practices of pain, agitation, and delirium (PAD) management require coordinated, bundled care among an interprofessional intensive care unit (ICU) team. Clinical pharmacists are essential health care team members in optimizing sedation and analgesia management in critically ill patients. The purpose of this systematic review is to summarize the clinical impact of pharmacist‐led interventions targeting PAD in mechanically ventilated adult ICU patients. A literature search was conducted using MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Central Register of Controlled Trials between January 1, 2000 and September 1, 2022. Randomized controlled trials, quasi‐experimental, or observational studies comparing pharmacist‐led interventions aimed at PAD management best practices and usual care in adult (≥18 years) ICU patients were included. Clinical (mechanical ventilation duration, hospital length of stay, and mortality) and economic outcomes as well as sedation and analgesia utilization were evaluated. A total of 1418 citations were identified with 9 studies (n = 3769 patients) meeting eligibility. The types of pharmacist‐led intervention strategies were inconsistent among included studies. Four of the 9 studies showed that pharmacist‐led interventions were associated with a significant reduction in mechanical ventilation duration ranging from 4.0 to 8.5 days compared with approximately 5.6 to 14.0 days in the control groups. Three (50%) of 6 studies evaluating length of stay showed significant reductions with the intervention group compared with controls. No impact on mortality and ICU‐acquired delirium/coma rates was shown. The pharmacist‐led intervention group was also associated with significant reductions in opioid analgesia and sedative utilization. Only two studies evaluated the financial impact of the intervention group with one study finding a positive benefit attributed to decreased drug utilization, while the other report failed to find an impact on total hospital stay costs. Pharmacist‐led interventions promote PAD best practices in the ICU, although the impact on patient‐centered outcomes remains controversial.

ABCDEF Bundle

The ABCDEF bundle was created 10 years ago after new data through clinical practice guidelines emerged via the Society of Critical Care Medicine (SCCM). This bundle provided a novel way for interprofessional teams in intensive care units (ICUs) to work together to focus on pain reduction, appropriate sedation for delirium prevention, increased mobility to reduce ventilator days, and improved sleep hygiene.A lot has happened in the decade since the ABCDEF bundle’s inception. Updated in 2018, the ABCDEF bundle continues to be our driving force and the reference standard around which much of our work is centered in our critical care units. According to data released by SCCM,1 implementing this ICU Liberation Bundle (A-F)2 decreases the likelihood of hospital death within 7 days by 68%, reduces delirium and coma days by 25% to 50%, reduces physical restraint use by more than 60%, cut ICU readmissions in half, and reduces discharges to nursing and rehabilitation facilities by 40%.Quick ways to implement the ABCDEF bundle during your morning rounds:

Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective

ObjectivesThis article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methodsA taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. ResultsThis review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. ConclusionWhile cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.

Efficiency of a psychiatric support for PTSD on a cohort of relatives of patients hospitalized in intensive care unit during the French lockdown – the OLAF (Opération Liaison et Aide aux Familles in French) dispositive

IntroductionHaving a family member admitted in Intensive Care Unit (ICU) can cause a severe psychological stress, and various psychological disorders gathered into the notion of Post intensive care syndrome-family (PICS-F). In this way, Family-centered care in ICU represents the aim of international accepted recommendations focusing on a partnership approach to health care decision-making between the family and health care provider to prevent PICS-F. During the first SARS-CoV-2 linked lockdown, social restrictions impaired the right application of these recommendations, increasing risk of PICS-F, particularly Post-Traumatic Stress Disorder (PTSD).ObjectivesThe main objective was to compare the PTSD prevalence at 6 months in a group of relatives including during OLAF implementation with a control group in a cohort of ICU-patient relatives.MethodsConsidering this, the psychiatric team and the ICU team of the Toulouse University, France, proposed the creation of a temporary device called OLAF (Opération de Liaison et d’Aide aux Familles in French), aiming to bring a psychological phone support to ICU-patient relatives. Besides this operational approach we designed a research approach that aimed to investigate the impact of OLAF device on PICS-F.ResultsWe noted that 12 participants (11.5 %) presented a PTSD at 6 months without statistically significant differences between the groups (p=0.8). Considering that OLAF group presented higher PDI (Peritraumatric Distress Inventory) score at screening we also considered a mediation model suggesting that OLAF could have played a role to diminish the PCL-5 score as a covariable. In the multinomial logistic regression analysis, we found that the only factor associated with the PTSD diagnosis was the level of Anxiety and Depression Signs measured with HADS (Hospital Anxiety and Depression Scale) at screening (OR= 1.2, p<0.001).ConclusionsWe found no difference in PTSD prevalence according to OLAF intervention. Nevertheless, our result suggested that the intervention could have play a role in reducing PTSD by acting on anxiety and peri traumatic distress in a mediated model. We found that anxiety score could serve as a risk marker to predict PTSD and should probably be precociously screened and treated in this population.Disclosure of InterestNone Declared

EVALUATING THE MATERNAL OUTCOME IN OBSTETRIC ICU A STUDY FROM A TERITIARY CARE HOSPITAL IN SOUTH INDIA

Background : Critically ill obstetric patients pose challenges to the intensive care unit team due to their altered physiology as well as due the presence of the foetus and safety of both the mother and the foetus is of most important. A better knowledge of the spectrum, characteristics and outcomes of the diseases involving this group of patients is the first step towards achieving prevention and the current study is done to supplement the present knowledge on obstetric emergencies requiring ICU care. Aims and Objectives :The objective is to study the profile of cases admitted to obstetric ICU and to evaluate maternal outcome and prognosis. Materials and Methods :This is observational study was conducted at Andhra Medical College ,visakhapatnam a teritiary care hospital from January 2022 to June 2022 . 1. All antenatal women irrespective of the period of gestation and postnatal women within 42 days of delivery requiring ICU admission for obstetric, non-obstetric reasons,irrespective of age, parity, mode of delivery, and co-morbid conditions were included . 2. Results were subjected to statistical analysis and conclusions drawn. Results : During the study period of 6 months, a total number of 82 obstetric patients were admitted to ICU. Specific interventions that had been undertaken at the ICU (such as the use of intubation, mechanical ventilation, and intensive monitoring )were recorded. The complications that were encountered at the ICU, such as disseminated intravascular coagulation (DIC) and multiorgan failure, were recorded. Majority were of obstetric reasons (n=58, 70.7%).Non-obstetric reasons (n=24, 29.3%) 28 maternal deaths occurred during the study period.Most common cause of death in our study was MODS followed by complications of hypertensive disorders of pregnancy. Discussion : Present centre being a tertiary care hospital majority of the women had severe complications and many were referred after a significant amount of delay .This stresses the idea that, in cases involving obstetric patients, there could not be much time for transfer to an intensive care unit and that things could swiftly deteriorate. Lack of antenatal care, poor socio economic background, delay in referral from the peripheral health centres predicted poor outcomes. Conclusion : The findings of the present study reinforce the statement by WHO that There is a story behind every maternal death or life-threatening complication. Understanding the lessons to be learned can help to avoid such outcomes. A multidisciplinary team approach is required in ICU. All residents of obstetrics and gynaecology should have short mandatory training phase in critical care.

Logistic Regression and Machine Learning Models for Predicting Whether Intensive Care Patients Who Are Alert and Without Delirium Remain As Such for at Least Two More Days.

Background Some intensive care unit patients are alert and without delirium for atleast two consecutive days. These patients, like other critically ill individuals, are at risk for dignity-related distress. An interval ofat least two days would provide for apalliative care multidisciplinary team to be consulted in the late morning or afternoon of day one and visit the next day. An assessment would include the administration of the validated Patient Dignity Inventory in a reflective manner. To determine whether dignity-related distress can be identified and treated during patients' intensive care unit stay, we evaluated whether asubstantive fraction of such patients (≥5%) have asubstantial (>90%) probability ofremaining alert and without delirium in the intensive care unit for at least four consecutive days. Methods The retrospective cohort study used data from one large teaching hospital in the United States of America, from 2012 to June 2022. The inclusion criteria were: a)adults, b)present in an intensive care unit at 12 PM one day and continually sofor the next 48 hours, c)during those two days had every Riker sedation-agitation scale score "4, calm and cooperative," and d) during those two days had all Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scores negative (i.e., no delirium) and all Delirium Observation Screening Scale (DOS) scores less than three (i.e., no delirium). Results Among the 10,314 patients alert and without delirium in an intensive care unit over two-day periods that included threesuccessive 12PMs, 3,826 (37%) maintained this status for at least two successive 12PMs. Six patient characteristics (e.g., hemodynamic infusion or ventilatory support) had value in predicting those 37% ofpatients. However, logistic regression and classification models each predicted a few (≈0.2%) patients with >90% probability of maintaining these criteria. Forecasts were inaccurate for nearly all patients remaining alert and without delirium in the intensive care unit (≈37%) because the models predicted no patient alert, without delirium, and in the intensive care unit for twodays would remain so for at least four days. That ≈63% accuracy was improved upon by random forest machine learning, but only with ≈3% improvement. Conclusion Although many intensive care unit patients remain alert and without delirium for several consecutive days, each patient has a high daily probability of intensive care unit discharge or deterioration in medical condition. Therefore, the results of our prediction modeling show that care models for the assessment and treatment of patients with intensive care unit-associated dignity-related distress should not rely solely on the intensive care unit team but instead should be taken from the perspective ofthe entire hospitalization.

Outgrowing the Pediatric Intensive Care Unit: Adults With a Pediatric Medically Complex Condition.

With more than 20 years of experience as pediatric and adult critical care nurses, we have observed an increase in the number of medically complex children who are living into adulthood and a troubling lack of adult intensive care unit (ICU) systems and processes for these patients.Medical advances have resulted in a significant decline in the mortality rate in the pediatric ICU (PICU), from 15% in 1980 to 4% in 2006. However, an unintended consequence is that more children experience significant morbidity. In fact, more than 50% of all PICU admissions are children with medical complexity.1,2 Families caring for a child who is chronically critically ill have special care requirements. Nurses in the PICU have extensive experience with pediatric-onset conditions such as congenital heart defects, sickle cell disease, neurodegenerative diseases, chromosomal abnormalities, and muscular dystrophies. They are also familiar with growth and development and have expertise in providing developmentally appropriate care. In addition, PICU nurses are trained in the principles of family- and patient-centered care, which include communicating and collaborating with family caregivers about the processes of care to a much greater extent than usually done in an adult ICU. Certified child life specialists are also available in the PICU to provide specific tools to assist in meeting the needs of the family, including siblings. When medically complex children become adults, many of them transition to adult ICUs that may not be ready for them. As a result, approximately 2% of PICU admissions (range 0%-9%) are adults who have had complex medical needs as children.3,4 However, as the number of medically complex children reaching adulthood continues to grow, the “PICU for adults” model is not sustainable.At this time, many adult ICUs are not prepared for patients with pediatric conditions. Creating an environment in which adult and pediatric health care professionals work collaboratively is essential to providing quality care to these patients and families. Systems need to be developed and expanded to provide complex care in the adult ICU. A proactive, interdisciplinary approach including specialized training for the adult ICU team is needed to sustain a high level of quality care and to support the transition to adult care. Staff in the PICU can help to prepare families for the transition as well as provide education and support to the adult ICU team. Issues to consider include differences in anatomy and physiology of pediatric patients, the unique developmental needs of this population, expansion of specialized services (ie, child life specialists), dedicated sleep areas for parents, and involving parents in decisions and patient care.