Medical Intensive Care Unit Team Research Articles

The Resident Learning Journey in the Medical Intensive Care Unit.

The medical intensive care unit (MICU) offers rich resident learning opportunities, but traditional teaching strategies can be difficult to employ in this fast-paced, high-acuity environment. Resident perspectives of learning within this environment may improve our understanding of the common challenges residents face and inform novel approaches to transform the MICU educational experience. We conducted a qualitative study of internal medicine residents to better understand their approach to learning the critical care activities that they are entrusted to perform in the MICU. Using a thematic analysis approach, we conducted six focus group interviews with 15 internal medicine residents, separated by postgraduate year. A trained investigator led each interview, which was audio-recorded and transcribed verbatim for analysis. Our diverse research team, representing different career stages across the continuum of learning to minimize interpretive bias, identified codes and subsequent themes inductively. We refined these themes through group discussion and sensitizing social learning theory concepts using Wenger's community of practice and organized them to create learner archetypes and a conceptual framework of resident learning in the MICU. We identified three thematic resident learning categories: learning goals and motivation, clinical engagement, and interprofessional collaboration. We distinguished three learner archetypes, the novice, experiential learner, and practicing member, to describe progressive resident development within the interprofessional MICU team, the challenges they frequently encounter, and potential teaching strategies to facilitate learning. We developed a conceptual framework that describes the resident's journey to becoming a trusted, collaborating member of the interprofessional MICU team. We identified common developmental challenges residents face and offer educational strategies that may support their progress. These findings should inform future efforts to develop novel teaching strategies to promote resident learning in the MICU.

Critical Care Teamwork in the Future: The Role of TeamSTEPPS® in the COVID-19 Pandemic and Implications for the Future

At our institution, we observed inconsistency in the application of structural facilitators for interprofessional teamwork such as handoffs and communication of contingency planning, complete formation and engagement of teams on interprofessional rounds, regular situation monitoring, interprofessional huddles, use of "check back" during code situations, and standard debriefings after codes and procedures (TeamSTEPPS®). To enhance team performance, we piloted TeamSTEPPS® training and reinforcement for all healthcare team members in the medical intensive care unit (MICU), inclusive of trainees, advanced practice providers (APPs), nurses, and respiratory therapists rotating through the unit. Seven months after the training launch, the initial COVID-19 surge interrupted the reinforcement stage of the pilot providing an opportunity to study the retention of TeamSTEPPS® principles and its potential role in response to a crisis. We conducted interprofessional focus groups after a year of crisis management during the pandemic. Themes revealed how TeamSTEPPS® training impacted teamwork and communication, as well as factors that influenced the use of TeamSTEPPS®. This work points to the value of team training in unexpected scenarios. Additional studies at multiple sites are needed to determine scalability for all MICU teams or for onboarding new team members.

Association of care by a non-medical intensive care unit provider team with outcomes of medically critically ill patients.

To determine the association of boarding of critically ill medical patients on non-medical intensive care unit (ICU) provider teams with outcomes. A retrospective cohort study. ICUs in a tertiary academic medical center. Patients with medical critical illness. None. We compared outcomes for critically ill medical patients admitted to a non-medical specialty ICU team (April 1 - August 30, 2020) with those admitted to the medical ICU team (January 1, 2018 - March 31, 2020). The primary outcome was hospital mortality; secondary outcomes were hospital length of stay (LOS) and hospital disposition for survivors. Our cohort consisted of 1241 patients admitted to the medical ICU team and 230 admitted to non-medical ICU teams. Unadjusted hospital mortality (medical ICU, 38.8% vs non-medical ICU, 42.2%, p=0.33) and hospital LOS (7.4 vs 7.4days, p=0.96) were similar between teams. Among survivors, more non-medical ICU team patients were discharged home (72.6% vs 82.0%, p=0.024). After multivariable adjustment, we found no difference in mortality, LOS, or home discharge between teams. However, among hospital survivors, admission to a non-medical ICU team was associated with a longer LOS (regression coefficient [95% CI] for log-transformed hospital LOS: 0.23 [0.05,0.40], p=0.022). Certain subgroups-patients aged 50-64years (odds-ratio [95% CI]: 4.22 [1.84,9.65], p=0.001), with ≤10 comorbidities (0-5: 2.78 (1.11,6.95], p=0.029; 6-10: 6.61 [1.38,31.71], p=0.018), without acute respiratory failure (1.97 [1.20,3.23], p=0.008)-had higher mortality when admitted to non-medical ICU teams. We found no association between admission to non-medical ICU team and mortality for medically critically ill patients. However, survivors experienced longer hospital LOS when admitted to non-medical ICU teams. Middle-aged patients, those with low comorbidity burden, and those without respiratory failure had higher mortality when admitted to non-medical ICU teams.

Changes in antimicrobial utilization during the coronavirus disease 2019 (COVID-19) pandemic after implementation of a multispecialty clinical guidance team.

Evaluate changes in antimicrobial use during COVID-19 and after implementation of a multispecialty COVID-19 clinical guidance team compared to pre-COVID-19 antimicrobial use. Retrospective observational study. Tertiary-care academic medical center. Internal medicine and medical intensive care unit (MICU) provider teams and hospitalized COVID-19 patients. Difference-in-differences analyses of antibiotic days of therapy per 1,000 patient days present (DOT) for internal medicine and MICU teams treating COVID-19 patients versus teams that did not were performed for 3 periods: before COVID-19, initial COVID-19 period, and after implementation of a multispecialty COVID-19 clinical guidance team which included daily, patient-specific antimicrobial stewardship recommendations. Patient characteristics associated with antibiotic DOT were evaluated using multivariable Poisson regression. In the initial COVID-19 period, compared to the pre-COVID-19 period, internal medicine and MICU teams increased weekly antimicrobial use by 145.3 DOT (95% CI, 35.1-255.5) and 204.0 DOT (95% CI, -16.9 to 424.8), respectively, compared to non-COVID-19 teams. In the intervention period, internal medicine and MICU COVID-19 teams both had significant weekly decreases of 362.3 DOT (95% CI, -443.3 to -281.2) and 226.3 DOT (95% CI, -381.2 to -71.3). Of 131 patients hospitalized with COVID-19, 86 (65.6%) received antibiotics; no specific patient factors were significantly associated with an expected change in antibiotic days. Antimicrobial use initially increased for COVID-19 patient care teams compared to pre-COVID-19 levels but significantly decreased after implementation of a multispecialty clinical guidance team, which may be an effective strategy to reduce unnecessary antimicrobial use.

Interventions of a clinical pharmacist in a medical intensive care unit – a retrospective analysis

Several studies demonstrated a significant decrease in prescription errors, adverse drug events, treatment costs and improved patient outcomes, when a clinical pharmacist (CP) was a full member of a multidisciplinary team in the intensive care unit (ICU). Our aim was to evaluate the activities of a CP, included in a 12-bed medical ICU team of a university hospital in the course of several months. We conducted a retrospective analysis of all the CP’s interventions from March 2017 to November 2017, carried out and documented after reviewing and discussing patients’ medical data with the treating ICU physicians. We identified four main categories of CP’s interventions: pharmacotherapy adjustments to kidney function (PAKF category), drug-drug interactions (DDIs category), therapeutic monitoring of drugs with narrow therapeutic index (TDM category), and drug administration by the nasogastric tube (NGT category). During the study period, 533 patients were admitted to the medical ICU. The CP reviewed the medical data of 321 patients and suggested 307 interventions in 95 patients. There were 147 interventions of the PAKF category, 57 interventions of the TDM category, 30 interventions of the NGT category, and 22 interventions of the DDIs category. Fifty-one interventions were unspecified. The majority of all interventions (203/307) were related to antimicrobial drugs. ICU physicians completely accepted 80.2% of the CP’s suggestions. We observed that regular participation of the CP in the medical ICU team contributed to more individualized and improved pharmacological treatment of patients. Therefore, ICU teams should be encouraged to include CPs as regular team members.

Incorporating Retrieval Practice Into Intensive Care Unit Teaching Rounds: A Feasibility Study.

Teaching rounds are an important component of the learning environment for residents in the intensive care unit (ICU). Retrieval practice is a cognitive learning tool that helps learners consolidate information and might improve the quality and culture of teaching rounds. We performed a feasibility study from October 2018 to June 2019 to investigate the incorporation of retrieval practice into ICU rounds. Participants included internal medicine and family medicine residents and pulmonary and critical care medicine fellows and faculty on medical ICU (MICU) teams at a tertiary care academic medical center. For 1-week periods, residents were asked to use retrieval practice after rounds, sharing one learning point. Participants were anonymously surveyed about the feasibility and acceptability of this strategy and perceptions of the educational value of ICU rounds before and after incorporating retrieval practice. We enrolled 9 MICU teams, including 31 residents, 8 fellows, and 8 attendings. Pre- and postsurvey response rates were 89% and 91% (42 and 43 of 47, respectively). Sixty-nine percent of respondents (30 of 43) reported sharing learning points on at least 3 days of the intervention week. Eighty-six percent of respondents (37 of 43) said retrieval practice did not adversely affect the workflow at the end of rounds. The perception that teaching on rounds was a priority increased after the intervention (3.93 versus 4.28 on 1-5 Likert scale, P = .047). Using retrieval practice on MICU rounds was feasible and acceptable and was associated with an increase in the perceived priority given to teaching on rounds.

Cost avoidance associated with clinical pharmacist presence in a medical intensive care unit

ObjectiveTo determine the clinical pharmacist‐generated cost avoidance and benefit‐cost ratio in a medical intensive care unit (MICU).MethodsAll accepted clinical pharmacist recommendations on a multidisciplinary, rounding service at an academic medical center over a 12‐month period were evaluated. Cost avoidance values from each intervention were determined using a systematic framework. Total cost avoidance was calculated by summing the cost avoidance for each general category. Average rates of cost avoidance per day and hour were calculated by dividing total cost avoidance by number of days and hours the clinical pharmacist provided care. Average interventions and cost avoidance per day and hour were calculated for weekday and call status. Differences between months, day of the week, and call status were evaluated using chi‐square goodness of fit tests.ResultsOver 12 months, 8866 clinical pharmacist‐recommended interventions were implemented, averaging 38.9 interventions per workday. The four most commonly accepted interventions were minor adverse drug event prevention (n = 4023, 45%), dosage adjustment: no continuous renal replacement therapy (n = 1162, 13%), antimicrobial therapy initiation and streamlining (n = 966, 11%), and antimicrobial pharmacokinetic evaluation (n = 777, 9%). All interventions resulted in a total cost avoidance of $3 270 178, averaging $14 731 per workday. Interventions per hour (P < 0.001) and average cost avoidance per hour (P < 0.001) differed significantly across workdays. For on‐call days compared with postcall days, there were a similar average number of interventions per hour (10.2 vs 9.8, P = 0.28) and average cost avoidance per hour ($3741 vs $3622, P = 0.47); the benefit‐cost ratio was 24.5:1.ConclusionsThe clinical pharmacist‐generated cost avoidance over a 12‐month period in the MICU was $3 270 178 and the benefit‐cost ratio was 24.5:1. Day of the week but no call status affected average cost avoidance. Employing a clinical pharmacist to be part of the multidisciplinary MICU team can reduce health care expenditures through cost avoidance.

PMU28 - Economic Impact of Pharmacy Resident's Interventions in Medical Intensive Care Unit of University Hospital in Thailand

To quantify the impact of pharmacy resident on hospital cost while performing clinical services to the Medical Intensive Care Unit (MICU) from a hospital perspective. The documented clinical interventions of MICU residency pharmacist were reviewed retrospectively from October 2016 to January 2017. In the reviewing process, the Drug Related Problems (DRPs) which were screened, detected, and managed by the pharmacy resident were classified by senior pharmacy resident. These classified DRPs were also judged for the potential impacts to patients if there were no intervention made by the pharmacist and these potential impacts were calculated into cost avoidance. Cost of DRPs treatment including drug costs were collected from hospital database. There were 35 DRPs from 304 patients in MICU which were detected and managed by pharmacy resident. Most of DRPs were occurred in the prescribing process (94%). Over-therapeutic and sub-therapeutic level was the main reason of DRPs in MICU (37%). Vancomycin and Colistin had the highest frequency causing DRPs (11%). The acceptance rate of pharmacist’s intervention was 91%. The estimated cost avoidance from all interventions made by pharmacy resident in four months was 3,375.45 USD. The result of one-way sensitivity analysis demonstrated the potential impact in cost of medication and laboratory-test which ranged the hospital cost saving from 3,076.62 USD to 5,581.31 USD. Pharmacy resident had the potential impact in reducing hospital unnecessary healthcare cost due to medication errors or preventable DRPs. Moreover, including pharmacist as a member of MICU team could provide potential benefit to other healthcare members such as dosage recommendation and adjustments, medication recommendation or any pharmacy services which could facilitate team member for better treatment outcomes.

Interprofessional Collaborative Practice in the Medical Intensive Care Unit: a Survey of Caregivers' Perspectives.

Research on caregivers, defined as designated family members or support persons, in the medical intensive care unit (MICU) has primarily focused on their emotional needs and experiences, thus leaving a gap in knowledge related to their perceptions of team dynamics. To examine caregivers' perceptions of team interactions and competencies for interprofessional collaborative practice (IPCP) and overall satisfaction with the MICU team. The Support Person Jefferson Teamwork Observation Guide (JTOG)™ was administered to a convenience sample of caregivers in the MICU at a large urban academic medical center between May 2016 and December 2016. One hundred sixty-one JTOG surveys were completed. Caregivers agreed on the importance of healthcare professionals working together as a team to provide patient care (3.97 out of 4.0 on Likert response scale where 1 is "Not at all important" and 4 is 'Extremely important") and were satisfied with the MICU team (3.74 out of 4.0), positively evaluating the four core competencies for IPCP (3.55 for values/ethics, 3.58 for interprofessional communication, 3.61 for roles/responsibilities, and 3.64 for teams/teamwork) and the patient/family-centeredness sub-competency (3.58 out of 4.0). There was a strong positive correlation between caregivers' Global JTOG scores and overall satisfaction with the MICU team (r = 0.596, p < 0.01). Caregivers' comments about factors that affected their experience focused on aspects of interprofessional communication and patient/family-centeredness. Findings underscore the importance of interprofessional communication and providing patient/family-centered care. Assessing caregivers' perceptions of IPCP can provide a critical lens into team functioning and, thus, be used to identify teams' strengths as well as opportunities for improvement.

Hospital Length of Stay With a Proactive Psychiatric Consultation Model in the Medical Intensive Care Unit: A Prospective Cohort Analysis

Previous studies have demonstrated that proactive psychiatric consultation reduces hospital length of stay (LOS) in the general medical setting; however this model has not been studied in the intensive care unit (ICU). To compare outcomes between a conventional consultation model and a proactive psychiatric consultation model. Two medical ICUs (MICUs) were randomized to proactive psychiatric consultation vs conventional consultation psychiatric models. Proactive consultation included embedding a psychiatrist into daily MICU team rounds on all patients. In the conventional consultation MICU, psychiatric consultations were activated when deemed necessary. Primary outcomes were hospital LOS and MICU LOS. Secondary outcomes included delirium-coma-free hours and ventilator-free hours. A total of 429 patients were admitted to the proactive consultation MICU; 393 patients were admitted to the conventional consultation MICU. The consultation rate for the intervention group was 24.2% vs 6.1% in the control group (p < 0.001). Time to psychiatric consultation was shorter in the intervention group. Median hospital LOS was 6.92 days, interquartile range 3.70-14.31 in the intervention group vs 7.69 days, interquartile range 3.95-16.21 in the control group (p = 0.113). MICU LOS, delirium-coma-free hours, and ventilator-free hours were not significantly different between the 2 groups. Among the respiratory failure subgroup, hospital LOS was shorter in the intervention vs control group (median 9.46 days, interquartile range 4.95-17.56 vs 12.29 days, interquartile range 6.58-21.10, p = 0.011). Proactive psychiatric consultation in a MICU was associated with decreased time to consultation among all patients and shorter hospital LOS among patients with respiratory failure.

A 24-Hour Postintensive Care Unit Transition-of-Care Model Shortens Hospital Stay.

Patients discharged early from the medical intensive care unit (MICU) are at risk of deterioration, MICU readmission, and increased mortality. An earlier discharge to a medical ward is desirable to reduce costs but it may adversely affect outcomes. To address this problem, a new model for the MICU transition of care was implemented at our academic center: The MICU team continued to manage all patients transferred from the MICU to the medical ward for at least 24 hours. Data were collected for all MICU patients admitted 1 year before and 1 year after the intervention. Hospital length of stay (LOS) after transfer from the MICU, readmission rate, and mortality rate were compared before and after the intervention. A nonparsimonious propensity model based on 30 factors was used to identify matched preintervention and postintervention cohorts. A total of 618 of the 848 patients admitted to the MICU were transferred to medical ward during the year prior to the implementation of the new model, and 600 of the 883 patients were transferred during the following year. Pre- and postintervention cohorts were well matched (n = 483 patients in each group). Poisson regression analysis showed a decrease in the hospital LOS after MICU transfer by 1.17 days (P < .001) without a significant change in adjusted mortality (lower by 1.9%, P = .181) and MICU readmission rates (lower by 2%, P = .264). A new model for the post-MICU transition of care, with the MICU team continuing to manage all patients transferred to the medical ward for at least 24 hours, significantly decreased duration of hospital stay after MICU transfer without affecting MICU readmission and mortality rate. The implementation of this model may lower medical costs and make transition of care safer without adverse outcomes.

Expanding Continuous Quality Improvement Capacity in the Medical Intensive Care Unit: Prehealth Volunteers as a Solution.

Health care delivery systems are challenged to support the increasing demands for improving patient safety, satisfaction, and outcomes. Limited resources and staffing are common barriers for making significant and sustained improvements. At Oregon Health & Science University, the medical intensive care unit (MICU) leadership team faced internal capacity limitations for conducting continuous quality improvement, specifically for the implementation and evaluation of the mobility portion of an evidence-based care bundle. The MICU team successfully addressed this capacity challenge using the person power of prehealth volunteers. In the first year of the project, 52 trained volunteers executed an evidence-based mobility intervention for 305 critically ill patients, conducting more than 200 000 exercise repetitions. The volunteers contributed to real-time evaluation of the project, with the collection of approximately 26 950 process measure data points. Prehealth volunteers are an untapped resource for effectively expanding internal continuous quality improvement capacity in the MICU and beyond.

Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals

Purpose: Technological advances in intensive care unit may lead physicians to question or omit portions of the physical exam. Our goal is to assess the opinions of intensive care unit physicians about physical examination in modern day medicine. Methods: Subjects included physicians on medical intensive care unit teams at one university hospital and two university-affiliated teaching hospitals. Participants responded to an interview divided into two sections: (1) A semistructured interview including open-ended questions on the management of four critical care scenarios and on the utility of physical exam; (2) Multiple-choice questions about physical exam. Main Results: The response rate was 100%. A total of 122 individuals, 16(13%) attendings, 24(20%) fellows and 82(67%) residents, responded. Half 61 (50%) considered physical examination to be of limited utility in the intensive care unit. Fifteen percent of answers to the clinical scenarios were reasoned based on physical examination. Most extended the definition of physical examination to include data derived from monitoring 119(97%), life support 121(99%) and bedside imaging devices 112(92%). Residents 45(37%), students 35(29%) and nurses 35(29%) were recognized as the team members who examine patients the most. Conclusion: Physical examination was considered useful by half of the

Empiric antibiotic, mechanical ventilation, and central venous catheter duration as potential factors mediating the effect of a checklist prompting intervention on mortality: an exploratory analysis

BackgroundChecklists are clinical decision support tools that improve process of care and patient outcomes. We previously demonstrated that prompting critical care physicians to address issues on a daily rounding checklist that were being overlooked reduced utilization of empiric antibiotics and mechanical ventilation, and reduced risk-adjusted mortality and length of stay. We sought to examine the degree to which these process of care improvements explained the observed difference in hospital mortality between the group that received prompting and an unprompted control group.MethodsIn the medical intensive care unit (MICU) of a tertiary care hospital, we conducted face-to-face prompting of critical care physicians if processes of care on a checklist were being overlooked. A control MICU team used the checklist without prompting. We performed exploratory analyses of the mediating effect of empiric antibiotic, mechanical ventilation, and central venous catheter (CVC)duration on risk-adjusted mortality.ResultsOne hundred forty prompted group and 125 control group patients were included. One hundred eighty-three patients were exposed to at least one day of empiric antibiotics during MICU admission. Hospital mortality increased as empiric antibiotic duration increased (P<0.001). Prompting was associated with shorter empiric antibiotic duration and lower risk-adjusted mortality in patients receiving empiric antibiotics (OR 0.41, 95% CI 0.18-0.92, P=0.032). When empiric antibiotic duration was added to mortality models, the adjusted OR for the intervention was attenuated from 0.41 to 0.50, suggesting that shorter duration of empiric antibiotics explained 15.2% of the overall benefit of prompting. Evaluation of mechanical ventilation was limited by study size. Accounting for CVC duration changed the intervention effect slightly.ConclusionsIn this analysis, some improvement in mortality associated with prompting was explained by shorter empiric antibiotic duration. However, most of the mortality benefit of prompting was unexplained.

A Model for Increasing Palliative Care in the Intensive Care Unit: Enhancing Interprofessional Consultation Rates and Communication

Background Only a minority of patients who die in the medical intensive care unit (MICU) receive palliative care services. At the South Texas Veterans Health Care System Audie L. Murphy Hospital, only 5% of patients who died in the MICU from May to August 2010 received a palliative care consultation. Measures We measured the percentage of MICU patients for which there was a palliative care consultation during the intervention period. Intervention Starting October 1, 2010 and ending April 30, 2011, the palliative care and MICU teams participated in daily “pre-rounds” to identify patients at risk for poor outcomes, who may benefit from a palliative care consultation. Outcomes Palliative care consultation increased significantly from 5% to 59% for patients who died in the MICU during the intervention period. Additionally, palliative care consultation increased from 5% to 21% for all patients admitted to the MICU during the intervention period. Conclusions/Lessons Learned Daily pre-rounds between the palliative care and MICU teams increased palliative care services for MICU patients at risk for poor outcomes, who may benefit from a palliative care consultation.

Prompting Physicians to Address a Daily Checklist and Process of Care and Clinical Outcomes

Checklists may reduce errors of omission for critically ill patients. To determine whether prompting to use a checklist improves process of care and clinical outcomes. We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting. One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients. In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.

A Program to Improve the Quality of Emergency Endotracheal Intubation

To assess the results of a quality improvement (QI) project designed to improve safety of emergency endotracheal intubation (EEI). Single center prospective observational. 16-bed intensive care unit. Nine pulmonary/critical care fellows. For 3 years, EEI performed by the medical intensive care unit team were analyzed to identify interventions that would improve quality of the procedure. By segmental process analysis, the procedure of EEI was subjected to iterative change. Major components of process improvement were development of a combined team approach, a mandatory checklist, use of crew resource management (CRM) tactics, and postevent debriefing. Quality analysis and improvement included training of fellows using scenario-based training (SBT) with computerized patient simulator (CPS) to improve mechanical skills of intubation and team leadership. Fellows received 15 sessions of SBT with CPS using a combined checklist and team approach before assuming team leadership position during real-life EEI. For a 10-month period, fellows carried digital voice recorders to EEI; which, when combined with recording of continuous oximetry and BP monitoring were used to assess the quality of EEI. 128 EEI were performed of which 101 had full data recorded. Complications were 14% severe hypoxemia (<80% saturation), 6% severe hypotension (SBP<70 mm Hg), 1% death, 20% difficult EEI (≥ 3 attempts), 11% esophageal intubations, 2% aspiration, and 1% dental injury; 62% EEI were successfully achieved on first attempt, 11% required >3 attempts. EEI may be performed by pulmonary/critical medicine (PCCM) fellows with safety comparable to that described in other studies on EEI. Important parts of the program included the use of formal iterative QI approach, the use of intensive SBT with CPS, basic CRM, a comprehensive checklist, and a combined team approach. A key benefit of the program was to make the process of EEI fully transparent for ongoing quality and safety improvement.

Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients.

In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay. Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known. Blinded, retrospective chart review. University-based hospital in Chicago, IL. One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. None. We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs. sedation as directed by the medical intensive care unit team without this strategy. Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention. The incidence of complications was evaluated for each patient's hospital course. One hundred twenty-six of 128 charts were available for review. Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs. 26 (6.2%) in those subjected to conventional sedation techniques (p =.04). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.