Single Medical Intensive Care Unit Research Articles

Delirium Care by Intensive Care Unit Nurses: Focus Group Studies in a Medical Center of Southern Taiwan.

Studies have identified many nursing interventions that can prevent delirium and fall accidents in clinical patients, detect and treat delirium early to prevent functional decline in the patient, shorten hospitalization duration, and lower the death rate. This study aimed to explore delirium care by intensive care unit (ICU) nurses in a medical center of southern Taiwan. This study conducted 3 semistructured focus group interviews, each for a single medical ICU, involving groups of 6 to 8 nurses each. The nurses were recruited through purposive sampling. This research was approved by an institutional review board in the medical center of southern Taiwan from March 31, 2020, to January 30, 2021. The co-principal investigator described the purpose and process of this study to the participants before they provided their written informed consents. The interviews were conducted in the meeting room and were audiotape recorded. The recordings were transcribed and subject to content analysis to identify the themes of delirium care. For nursing interventions of delirium, satisfying the patient's physical needs: comfort care, massages, and early rehabilitation; and psychological care: being presence, communication, and ensuring familial support were included. In terms of environmental interventions for delirium, providing reorientation, music, light, belongings with sentimental value, and audiovisual equipment were included. However, according to the recruited medical ICU nurses, these nonpharmacological interventions, although effective, do not have long-lasting effects. Finally, nurses reported themselves as having been attacked by patients with delirium. Thus, they all agreed that restraining patients with delirium may be necessary, but restraining is a double-edged sword for ICU delirium patients. Research team suggests for future studies to extend their evidence-based findings of physical, psychological, and environmental care for ICU delirium patients toward integrating the efforts of various health care professionals.

Impact of Clinician Recognition of Acute Respiratory Distress Syndrome on Evidenced-Based Interventions in the Medical ICU.

Observational cohort study. Single medical ICU at an academic tertiary-care hospital. Nine hundred seventy-seven critically ill adults (381 with expert-adjudicated acute respiratory distress syndrome) enrolled from 2006 to 2015. Clinician-recognized-acute respiratory distress syndrome was identified using an electronic keyword search of clinical notes in the electronic health record. We assessed the classification performance of clinician-recognized acute respiratory distress syndrome for identifying expert-adjudicated acute respiratory distress syndrome. We also compared differences in ventilator settings, diuretic prescriptions, and cumulative fluid balance between clinician-recognized acute respiratory distress syndrome and unrecognized acute respiratory distress syndrome. Overall, clinician-recognized-acute respiratory distress syndrome had a sensitivity of 47.5%, specificity 91.1%, positive predictive value 77.4%, and negative predictive value 73.1% for expert-adjudicated acute respiratory distress syndrome. Among the 381 expert-adjudicated acute respiratory distress syndrome cases, we did not observe any differences in ventilator tidal volumes between clinician-recognized-acute respiratory distress syndrome and unrecognized acute respiratory distress syndrome, but clinician-recognized-acute respiratory distress syndrome patients had a more negative cumulative fluid balance (mean difference, -781 mL; 95% CI, [-1,846 to +283]) and were more likely to receive diuretics (49.3% vs 35.7%, p = 0.02). There were no differences in mortality, ICU length of stay, or ventilator-free days. Acute respiratory distress syndrome recognition was low in this single-center study. Although acute respiratory distress syndrome recognition was not associated with lower ventilator volumes, it was associated with differences in behaviors related to fluid management. These findings have implications for the design of future studies promoting evidence-based acute respiratory distress syndrome interventions in the ICU.

Early Mobilization during Extracorporeal Membrane Oxygenation for Cardiopulmonary Failure in Adults: Factors Associated with Intensity of Treatment.

Rationale: Early mobilization of extracorporeal membrane oxygenation (ECMO)-supported patients is increasingly common, but it remains unknown whether there are factors predictive of achieving higher intensity mobilization among those able to participate in physical therapy. Additionally, data regarding the safety and feasibility of early mobilization with femoral cannulation, particularly ambulation, are sparse. Objectives: To determine whether there are factors associated with achieving out-of-bed versus in-bed physical therapy in ECMO-supported patients participating in physical therapy, and whether mobilization with femoral cannulation is safe and feasible. Methods: This large, single-center, retrospective study evaluated adult patients who performed active physical therapy while receiving ECMO. Mixed effects modeling was used to identify predictors of out-of-bed versus in-bed activity. Rates of mobilization with femoral cannulation and adverse events were also reported. Results: Between April 2009 and January 2020, 511 patients were supported with ECMO in a single medical intensive care unit, of whom 177 (35%) underwent active physical therapy and were included in the analysis, including 124 of 141 (88%) bridge to lung transplantation and 53 of 370 (14%) bridge to recovery. These 177 patients accounted for 2,706 active physical therapy sessions, with 138 patients (78%) achieving out-of-bed activity. In total, 108 (61%) patients ambulated (1,284 sessions), 34 of whom had femoral cannulae (250 sessions). Bridge-to-transplant (odds ratio [OR], 17.2; 95% confidence interval [CI], 4.12-72.1), venovenous ECMO (OR, 2.83; 95% CI, 1.29-6.22), later cannulation year (OR, 1.65; 95% CI, 1.37-1.98) and higher Charlson comorbidity index (OR, 1.53; 95% CI, 1.07-2.19) were associated with increased odds of achieving out-of-bed versus in-bed physical therapy, whereas invasive mechanical ventilation (OR, 0.11; 95% CI, 0.05-0.25) and femoral cannulation (OR, 0.19; 95% CI, 0.04-0.92) were associated with decreased odds of performing out-of-bed activities. Adverse events occurred in 2% of sessions. Conclusions: Several patient- and ECMO-related factors were associated with achieving higher intensity of early mobilization in patients participating in rehabilitation. Physical therapy with femoral cannulation was safe and feasible, and complications related to mobilization were uncommon.

Predictors and outcomes of sepsis-induced cardiomyopathy in critically ill patients.

BackgroundSepsis-induced cardiomyopathy (SIC) occurs frequently in critically ill patients, but the clinical features and prognostic impact of SIC on sepsis outcome remain controversial. Here, we investigated the predictors and outcomes of SIC.MethodsPatients admitted to a single medical intensive care unit from June 2016 to September 2017 were retrospectively reviewed. SIC was diagnosed by ejection fraction (EF) <50% and ≥10% decrease in baseline EF that recovered within 2 weeks.ResultsIn total, 342 patients with sepsis met the inclusion criteria, and 49 patients (14.3%) were diagnosed with SIC; the latter were compared with 259 patients whose EF was not deteriorated by sepsis (non-SIC). Low systolic blood pressure and increased left ventricular end-diastolic diameter (LVEDD) were identified as predictors of SIC. SIC and non-SIC patients did not differ significantly in terms of 28-day all-cause mortality (24.5% vs. 26.3%, P=0.936). Acute Physiology and Chronic Health Evaluation II (APACHE II; hazard ratio [HR], 1.10; 95% confidential interval [CI], 1.02 to 1.18; P=0.009) and delta neutrophil index (DNI; HR, 1.02; 95% CI, 1.00 to 1.08; P=0.026) were independent risk factors for 28-day mortality with SIC. DNI, APACHE II, and lactate were identified as risk factors for 28-day mortality in sepsis patients as a whole.ConclusionsSIC was not associated with increased mortality compared to non-SIC. Low systolic blood pressure and increased LVEDD were predictors of SIC. High APACHE II score and elevated DNI, which reflect sepsis severity, predict 28-day all-cause mortality.

Diagnostic Accuracy of Point of Care Ultrasound in Determining Pulmonary Pathology by Acute Care Nurse Practitioners in Critically Ill Patients

SESSION TITLE: Rapid Session: Bedside Imaging SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 07:30 AM - 08:30 AM PURPOSE: Bedside ultrasonography (US) may facilitate rapid diagnosis of thoracic pathology in the Intensive Care Unit (ICU). The feasibility and accuracy of bedside thoracic US performed by acute care nurse practitioners (ACNP) in the ICU are unknown. We hypothesized that bedside thoracic US by ACNPs in the ICU would be feasible and have a high sensitivity and specificity for thoracic pathology visualized on CXR. METHODS: We conducted a prospective observational cohort study in a single medical ICU. Prior to study initiation, all 10 ACNPs staffing the ICU attended a focused, peer-led thoracic US training session, which included didactic instruction, hands-on practice of image acquisition, and image interpretation. During the study, each time a CXR was ordered by treating clinicians, ACNPs were asked to complete a bedside thoracic US prior to interpretation of the CXR. The ACNPs then documented in a secure online database the presence or absence of five key sonographic features in each of the four chest regions scanned. If an US was unable to be performed, the reason was documented. RESULTS: From July 2015- July 2016, 335 portable CXRs were ordered by treating clinicians. In 246 (73%) cases, a thoracic US was completed by the ACNP prior to interpretation of the CXR. In 89 (27%) cases, a thoracic US was not performed, most frequently due to inadequate ACNP time due to other urgent patient care needs. Among the 246 cases with US performed prior to CXR, the CXR identified parenchymal pathology in 141 (57.3%) cases, pleural effusion in 75 (30.6%) cases, and pneumothorax in 3 (1.2%) cases. For parenchymal abnormality on CXR, US demonstrated a sensitivity of 83.7% (95% CI 76.5-89.4%), specificity of 67.6% (95% CI 57.8-76.4%), positive predictive value of 77.6% (95% CI 72.3-82.2%), and negative predictive value of 75.5% (95% CI 67.5-82.1%) (kappa 0.52, P < 0.001). For pleural effusion on CXR, US demonstrated a sensitivity of 68.0% (95% CI 56.2-78.3%), specificity of 85.9% (95% CI 79.7-90.7%), positive predictive value of 68.0% (95% CI 58.7-76.1%), and negative predictive value of 85.9% (95% CI 81.3-89.5%) (kappa 0.54, P < 0.001). The negative predictive value of US for pneumothorax on CXR was 99.6%. The sensitivity and specificity of ultrasound for any pulmonary pathology was 87.7% (95% CI 82.2-92.0%) and 86.3% (95% CI 73.7-94.3%), respectively. The positive predictive value of ultrasound for pulmonary pathology was 96.1% (95% CI 92.5-98.0%). CONCLUSIONS: Bedside thoracic ultrasound demonstrated moderate sensitivity and specificity for pulmonary parenchymal abnormalities and pleural effusions compared to CXR. It demonstrated high sensitivity for pneumothorax and high positive predictive value for any pulmonary pathology. CLINICAL IMPLICATIONS: Bedside thoracic US performed by ACNPs can frequently be completed prior to CXR performance and shows moderate agreement with CXR findings. The primary limitation of bedside thoracic US by ACNPs compared to CXR may be the competing demands of other urgent patient care. DISCLOSURE: The following authors have nothing to disclose: Lisa Flemmons, Sarah Bloom, Todd Rice, Arthur Wheeler No Product/Research Disclosure Information

Safety and Feasibility of a Protocolized Approach to In-Bed Cycling Exercise in the Intensive Care Unit: Quality Improvement Project

In-bed, supine cycle ergometry as a part of early rehabilitation in the intensive care unit (ICU) appears to be safe, feasible, and beneficial, but no standardized protocol exists. A standardized protocol may help guide use of cycle ergometry in the ICU. This study investigated whether a standardized protocol for in-bed cycling is safe and feasible, results in cycling for a longer duration, and achieves a higher resistance. A quality improvement (QI) project was conducted. A 35-minute in-bed cycling protocol was implemented in a single medical intensive care unit (MICU) over a 7-month quality improvement (QI) period compared to pre-existing, prospectively collected data from an 18-month pre-QI period. One hundred and six MICU patients received 260 cycling sessions in the QI period vs. 178 MICU patients receiving 498 sessions in the pre-QI period. The protocol was used in 249 (96%) of cycling sessions. The QI group cycled for longer median (IQR) duration (35 [25-35] vs. 25 [18-30] minutes, P < .001) and more frequently achieved a resistance level greater than gear 0 (47% vs. 17% of sessions, P < .001). There were 4 (1.5%) transient physiologic abnormalities during the QI period, and 1 (0.2%) during the pre-QI period ( P = .031). Patient outcomes were not evaluated to understand if the protocol has clinical benefits. Use of a protocolized approach for in-bed cycling appears safe and feasible, results in cycling for longer duration, and achieved higher resistance.

Identification of Major Adverse Kidney Events Within the Electronic Health Record.

Acute kidney injury is common among critically ill adults and is associated with increased mortality and morbidity. The Major Adverse Kidney Events by 30days (MAKE30) composite of death, new renal replacement therapy, or persistent renal dysfunction is recommended as a patient-centered outcome for pragmatic trials involving acute kidney injury. Accurate electronic detection of the MAKE30 endpoint using data within the electronic health record (EHR) could facilitate the use of the EHR in large-scale kidney injury research. In an observational study using prospectively collected data from 200 admissions to a single medical intensive care unit, we tested the performance of electronically-extracted data in identifying the MAKE30 composite compared to the reference standard of two-physician manual chart review. The incidence of MAKE30 on manual-review was 16%, which included 8.5% for in-hospital mortality, 3.5% for new renal replacement therapy, and 8.5% for persistent renal dysfunction. There was strong agreement between the electronic and manual assessment of MAKE30 (98.5% agreement [95% CI 96.5-100.0%]; kappa 0.95 [95% CI 0.87-1.00]; P < 0.001), with only three patients misclassified by electronic assessment. Performance of the electronic MAKE30 assessment was similar among patients with and without CKD and with and without a measured serum creatinine in the 12months prior to hospital admission. In summary, accurately identifying the MAKE30 composite outcome using EHR data collected as a part of routine care appears feasible.

Education Considerations: Communication Curricula, Simulated Resuscitation, and Duty Hour Restrictions.

In routine practice, an intensivist must convey intricate and often devastating information to patients and surrogates, guiding them through complex decisions with life-and-death implications. Although the Accreditation Council for Graduate Medical Education (ACGME) and the American Thoracic Society have called for pulmonary and critical care medicine (PCCM) trainees to receive formal communication skills training, few curricula have been developed, implemented, and published. Focusing on the family meeting as a prototypical intensive care unit (ICU) encounter, McCallister and colleagues (1) developed a year-long communication skills educational program. Beginning with a 3-hour didactic workshop incorporating role plays, the program was interwoven into the first year of PCCM fellowship. The authors created a checklist-based assessment derived from available literature on ICU communication, the Family Meeting Behavioral Skills Checklist, to facilitate feedback and monitor evolution of fellows’ skills. This tool was used for self-evaluation, to provide structured feedback from palliative medicine faculty observing fellows conducting family meetings, and by two blinded psychologists who scored digital recordings of simulated family meetings performed before and after the intervention. In a pre–post analysis, trainees demonstrated a significant increase in total observed Family Meeting Behavioral Skills Checklist skills from 51 to 65% (P, 0.01; Cohen’s D effect size, 1.13) and improved self-confidence (from 77 to 89%, P, 0.01; effect size, 0.87). In the same issue of AnnalsATS, Hope and colleagues (2) describe a communication skills program implemented in their medical ICU. This 1-month curriculum incorporated didactic sessions focused on palliative care, ethics, and end-of-life care, as well as several family conference simulations. Key communication concepts were emphasized through repetition and reinforcement. In unblinded pre–post faculty evaluations fellows demonstrated a statistically significant improvement in three skills: setting an agenda (64% vs. 41%; chi-square, 5.27; P = 0.02); summarizing the care the patient would receive (64% vs. 39%; chi-square, 6.21; P = 0.01); and outlining the follow-up plan (60% vs. 37%; chi-square, 5.2; P = 0.02). Both fellowships created a didactic series, an original checklist evaluation, and used both self-assessments and simulations to judge trainees’ progress. Whereas one was interwoven throughout the year, the other occurred in a single medical ICU rotation. These studies demonstrate the feasibility of embedding communication training in PCCM fellowship, thereby improving trainees’ observable skills and self-confidence. Further study is required to validate these novel assessment tools and measure impact of the educational interventions on patient-centered outcomes, including attention to emotion and to assess optimal structure and duration of curriculum. n

Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study.

BackgroundEarly mobilization (EM) of patients on mechanical ventilation (MV) is shown to improve outcomes after critical illness. Little is known regarding clinician knowledge of EM or multi-disciplinary barriers to use of EM in the intensive care unit (ICU). The goal of this study was to assess clinician knowledge regarding EM and identify barriers to its provision.MethodsSimultaneous cross-sectional surveys of medical ICU (MICU) nurses (RN)/physical therapists (PT) respondents and physician (MD) respondents in a single MICU at an academic hospital in Seattle, WA in 2010–2011. Responses were indicated on a 5 point Likert scale and reported as proportion of respondents agreeing or disagreeing. Chi-square testing and Fisher’s exact testing was performed to determine whether responses differed by duration of employment or prior EM experience.ResultsA total of 120 clinicians responded to the survey (91 MDs (response rate 82% (91/111)), 17 RNs (response rate 22%, (17/78)), and 12 PTs (response rate 86%, (12/14)), overall response rate 86%). Most clinicians indicated knowledge regarding benefits of EM. More attending physicians reported knowledge of EM benefits, but also that risks of EM outweigh the benefits compared to trainees (p = 0.02 and 0.01). Clinicians across disciplines reported near universal agreement to use of EM for patients on MV, while the minority reported agreement to EM for patients on vasoactive agents. The most frequently reported cross-disciplinary barriers to EM were staffing and time. Risk of self-injury and excess work stress were indicated as barriers by RN and PT respondents.ConclusionsMICU clinicians, at our institution, reported knowledge of EM in the ICU. Staffing and clinician time were frequently identified cross-disciplinary barriers. Risk of self-injury and excess work stress were frequently reported RN and PT barriers.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2253-14-84) contains supplementary material, which is available to authorized users.

New Onset of Atrial Fibrillation in a Medical ICU: Prevalence and Risk Factors

Objectives: To evaluate the prevalence and the risk factors of new onset atrial fibrillation (AF) in a single medical ICU. Methods: A prospective observational study was conducted in a 10 bed single medical ICU over a period of 18 months. All patients with sinus rhythm admitted in the medical ICU were included. Those presenting with any arrhythmia on admission, having a PACEMAKER or having undergone a recent cardiothoracic surgery were excluded. Results: Of the 377 patients included on the study, atrial fibrillation occurred in 26 patients (7%). Patients who developed AF were older, had higher severity scores on admission, and required significantly more fluids, catecholamine, and mechanical ventilation. They had a longer ICU and hospital LOS. ICU mortality was significantly higher in AF patients. Five inde- pendent risk factors of AF were identified by multivariate analysis: advanced age, the presence of COPD, sepsis, car- diogenic shock, and hypoxemia. Conclusion: AF occurs in approximately 7% of medical critically ill patients and is associated with age, a history of COPD, the presence of sepsis, cardiogenic shock and hypoxemia. AF occurs in more critically ill patients and is associated with increased morbidity and mortality.

Continuous Control of Tracheal Cuff Pressure and Microaspiration of Gastric Contents in Critically Ill Patients

Underinflation of the tracheal cuff frequently occurs in critically ill patients and represents a risk factor for microaspiration of contaminated oropharyngeal secretions and gastric contents that plays a major role in the pathogenesis of ventilator-associated pneumonia (VAP). To determine the impact of continuous control of tracheal cuff pressure (P(cuff)) on microaspiration of gastric contents. Prospective randomized controlled trial performed in a single medical intensive care unit. A total of 122 patients expected to receive mechanical ventilation for at least 48 hours through a tracheal tube were randomized to receive continuous control of P(cuff) using a pneumatic device (intervention group, n = 61) or routine care of P(cuff) (control group, n = 61). The primary outcome was microaspiration of gastric contents as defined by the presence of pepsin at a significant level in tracheal secretions collected during the 48 hours after randomization. Secondary outcomes included incidence of VAP, tracheobronchial bacterial concentration, and tracheal ischemic lesions. The pneumatic device was efficient in controlling P(cuff). Pepsin was measured in 1,205 tracheal aspirates. Percentage of patients with abundant microaspiration (18 vs. 46%; P = 0.002; OR [95% confidence interval], 0.25 [0.11-0.59]), bacterial concentration in tracheal aspirates (mean ± SD 1.6 ± 2.4 vs. 3.1 ± 3.7 log(10) cfu/ml, P = 0.014), and VAP rate (9.8 vs. 26.2%; P = 0.032; 0.30 [0.11-0.84]) were significantly lower in the intervention group compared with the control group. However, no significant difference was found in tracheal ischemia score between the two groups. Continuous control of P(cuff) is associated with significantly decreased microaspiration of gastric contents in critically ill patients.

Rehabilitation therapy and outcomes in acute respiratory failure: An observational pilot project

Purpose The aim of this study was to describe the frequency, physiologic effects, safety, and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation. Materials and Methods Prospective observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit (ICU) during a 13-week period was conducted. Results Of the 32 patients who met the inclusion criteria, only 21 (66%) received physician orders for evaluation by rehabilitation services (physical and/or occupational therapy). Fifty rehabilitation treatments were provided to 19 patients on a median of 12% of medical ICU days per patient, with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment. Physiologic changes during rehabilitation therapy were minimal. Joint contractures were frequent in the lower extremities and did not improve during hospitalization. In 53% and 79% of initial ICU assessments, muscle weakness was present in upper and lower extremities, respectively, with a decreased prevalence of 19% and 43% at hospital discharge, respectively. New impairments in physical function were common at hospital discharge. Conclusions This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength, range of motion, and functional outcomes at hospital discharge.

The role of "colonization pressure" in the spread of vancomycin-resistant enterococci: an important infection control variable.

The spread of nosocomial multiresistant microorganisms is affected by compliance with infection control measures and antibiotic use. We hypothesized that "colonization pressure" (ie, the proportion of other patients colonized) also is an important variable. We studied the effect of colonization pressure, compliance with infection control measures, antibiotic use, and other previously identified risk factors on acquisition of colonization with vancomycin-resistant enterococci (VRE). Rectal colonization was studied daily for 19 weeks in 181 consecutive patients who were admitted to a single medical intensive care unit. A statistical model was created using a Cox proportional hazards regression model including length of stay in the medical intensive care unit until acquisition of VRE, colonization pressure, personnel compliance with infection control measures (hand washing and glove use), APACHE (Acute Physiology and Chronic Health Evaluation) 11 scores, and the proportion of days that a patient received vancomycin or third-generation cephalosporins, sucralfate, and enteral feeding. With survival until colonization with VRE as the end point, colonization pressure was the most important variable affecting acquisition of VRE (hazard ratio [HR], 1.032; 95% confidence interval [C1], 1.012-1.052; P=.002). In addition, enteral feeding was associated with acquisition of VRE (HR, 1.009; 95% CI, 1.000-1.017; P=.05), and there was a trend toward association of third-generation cephalosporin use with acquisition (HR, 1.007; 95% CI, 0.999-1.015; P=.11). The effects of enteral feeding and third-generation cephalosporin use were more important when colonization pressure was less than 50%. Once colonization pressure was 50% or higher, these other variables hardly affected acquisition of VRE. Acquisition of VRE was affected by colonization pressure, the use of antibiotics, and the use of enteral feeding. However, once colonization pressure was high, it became the major variable affecting acquisition of VRE.