Short-Term Clinical and Quality Outcomes Have Inconsistent Changes From a Quality Improvement Initiative to Increase Access to Physical Therapy in the Cardiovascular and Surgical ICU Objectives: Studies of mobility during critical illness have mostly examined transitions from immobility (passive activities) or limited mobility to active “early mobility.” Design: Observational analysis of a quality improvement initiative. Setting: Two ICUs (surgical ICU, cardiovascular ICU) at a tertiary academic medical center. Patients: Critically ill surgical and cardiovascular patients. Interventions: Doubling available physical therapy. Measurements and Main Results: We examined the outcomes of therapy time/patient/day, ICU and hospital length of stay, disposition location, and change in functional status. We adjusted for age, sex, illness severity, and number of surgeries. Among 1,515 patients (703 baseline, 812 quality improvement), total therapy time increased from 71,994 to 115,389 minutes and from 42,985 to 93,015 minutes, respectively, in each ICU. In the cardiovascular ICU per patient therapy increased 17% (95% CI, –4.9 to 43.9; p = 0.13), and in the surgical ICU, 26% (95% CI, –1 to 59.4; p = 0.06). In the cardiovascular ICU, there was a 27.4% decrease (95% CI, –52.5 to 10.3; p = 0.13) in ICU length of stay, and a 12.4% decrease (95% CI, –37.9 to 23.3; p = 0.45) in total length of stay, whereas in the surgical ICU, the adjusted ICU length of stay increased 19.9% (95% CI, –31.6 to 108.6; p = 0.52) and total length of stay increased 52.8% (95% CI, 1.0–130.2; p = 0.04). The odds of a lower level of care discharge did not change in either ICU (cardiovascular ICU: 2.6 [95% CI, 0.6–12.2; p = 0.22]); surgical ICU: 3.6 [95% CI, 0.9–15.4; p = 0.08]). Conclusions: Among diverse cardiothoracic and surgical patients, a quality improvement initiative doubling physical therapy shifts is associated with increased total administered therapy time, but when distributed among a greater number of patients during the quality improvement period, the increase is tempered. This was not associated with consistent changes in ICU length of stay or changes in disposition location.

Impact of Increased Intracranial Pressure on Pupillometry: A Replication Study Objectives: In a diverse, multicenter population, to confirm or refute the conclusions that pupillary light reflex changes are associated with increased intracranial pressure. Design: Replication study. Patients: Within the Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care registry there were 273 patients (16,221 pupillary observations) that included both intracranial pressure and pupillometry values. Measurements and Main Results: To evaluate findings by the previous author, we explored for differences among measures of the pulmonary light reflex obtained from automated pupillometry with ICP values dichotomized as < 15 mm Hg (normal) versus ≥ 15 mm Hg (elevated). Analysis of t-test indicates statistically significant differences for all right and left mean pupilometer values, except right latency (p = 0.3000) and repeated measure mixed model (p = 0.0001). In the setting of increased intracranial pressure, mean pupilometer values were lower for both left and right eyes comparing to normal intracranial pressure, except right neurologic pupil index (3.98, 3.92;p = 0.0300) and left latency (0.27, 0.25; p < 0.0001). Conclusions: Our findings confirm and extend those of McNett et al Worsening measures of the pupillary light reflex using automated pupillometry are associated with elevated intracranial pressure.

Safety of Percutaneous Dilatational Tracheotomy in Patients on Dual Antiplatelet Therapy and Anticoagulation Objective: Percutaneous dilatational tracheotomy has become a routine procedure in ICUs. However, given the high and steadily growing number of patients receiving anticoagulation, dual antiplatelet therapy, or even a combination of both (also known as “triple therapy”), there are concerns about the safety of the procedure, in particular for critically ill patients with a high risk of bleeding. In this retrospective study, we investigated whether percutaneous dilatational tracheotomy in this high-risk population was associated with elevated procedural complications. Design: Retrospective single-center study with analysis of all percutaneous dilatational tracheotomies performed in our cardiac ICU from January 2018 to May 2019. Setting: Munich university hospital’s cardiac ICU. Patients and Interventions: A total of 34 patients who underwent percutaneous dilatational tracheotomy according to Ciaglia technique with accompanying bronchoscopy in our cardiac ICU from January 2018 to May 2019 were included. Patients were stratified into clinically relevant risk groups based on anticoagulation and antiplatelet therapy considering standard laboratory coagulation parameters, that is, activated partial thromboplastin time, international normalized ratio, and platelet count with differentiated analysis of procedure-related complications in each risk group until hospital discharge. Measurements and Main Results: A total of 34 patients who underwent percutaneous dilatational tracheotomy were included and assigned to five clinically relevant treatment groups: IV unfractionated heparin (prophylactic dosage) (n = 4), IV unfractionated heparin (therapeutic dosage) (n = 4), aspirin and IV unfractionated heparin (therapeutic dosage) (n = 7), dual antiplatelet therapy with IV unfractionated heparin (prophylactic dosage) (n = 5), and dual antiplatelet therapy with IV unfractionated heparin (therapeutic dosage) (n = 14). Three bleedings without surgical intervention or blood transfusion were documented in the whole cohort, but no single bleeding did occur in the triple therapy group. These were exclusively caused by skin bleedings at the immediate puncture site—each of which could be easily treated with one or two single stitches. There were no severe bleeding complications or potentially life-threatening procedure-related complications. Additionally, the rate of complications in patients with elevated body mass index was not increased. Conclusions: Bronchoscopy-guided percutaneous dilatational tracheotomy according to Ciaglia technique with careful consideration of all potential indications and contraindications may be a safe and low-complication procedure for airway management, even in patients receiving dual antiplatelet therapy and therapeutic anticoagulation simultaneously in our cohort with a high risk of bleeding.

Heterogenous Renal Injury Biomarker Production Reveals Human Sepsis-Associated Acute Kidney Injury Subtypes Objectives: To identify mechanisms associated with sepsis-acute kidney injury based on the expression levels of renal injury biomarkers, neutrophil gelatinase–associated lipocalin, and kidney injury molecule-1 in renal biopsies which may allow the identification of sepsis-acute kidney injury patient subtypes. Design: Prospective, clinical laboratory study using “warm” human postmortem sepsis-acute kidney injury kidney biopsies. Setting: Research laboratory at university teaching hospital. Subjects: Adult patients who died of sepsis in the ICU and control patients undergoing tumor nephrectomy. Measurements and Main Results: Reverse transcription quantitative polymerase chain reaction and immunohistochemical staining were used to quantify messenger RNA and protein expression levels of neutrophil gelatinase–associated lipocalin and kidney injury molecule-1 in the kidney of sepsis-acute kidney injury patients and control subjects. Morphometric analysis was used to quantify renal and glomerular neutrophil gelatinase–associated lipocalin and kidney injury molecule-1 protein levels. Neutrophil gelatinase–associated lipocalin and kidney injury molecule-1 messenger RNA and protein levels were increased in kidneys of sepsis-acute kidney injury patients compared with control kidney tissue. Neutrophil gelatinase–associated lipocalin was localized in the distal tubules, collecting ducts, the adventitia of the renal arterioles, and in the glomerular tufts of renal biopsies from sepsis-acute kidney injury patients. In contrast, kidney injury molecule-1 was localized at the brush border of the proximal tubules. There was no correlation between neutrophil gelatinase–associated lipocalin and kidney injury molecule-1 levels. Furthermore, renal neutrophil gelatinase–associated lipocalin and kidney injury molecule-1 levels were not associated with the extent of renal injury, the severity of critical illness, or serum creatinine levels at either ICU admission or day of expiration. By laser microdissecting glomeruli, followed by reverse transcription quantitative polymerase chain reaction, we identified heterogenous glomerular neutrophil gelatinase–associated lipocalin production in the kidney of sepsis-acute kidney injury patients. Conclusion: We found differences in the expression of neutrophil gelatinase–associated lipocalin and kidney injury molecule-1 in patients with the same syndrome “sepsis-acute kidney injury” meaning there is no single pathway leading to sepsis-acute kidney injury. This underscores the beliefs that there are many/different pathophysiological pathways that can cause sepsis-acute kidney injury. Hence, patients with criteria that meet the definitions of both acute kidney injury and sepsis can be divided into subtypes based on pathophysiological features.

Deciphering the Effects of Performing Ultrasound on Critically Ill Emergency Department Patients No abstract available

Risk Adjustment for Sepsis Mortality to Facilitate Hospital Comparisons Using Centers for Disease Control and Prevention’s Adult Sepsis Event Criteria and Routine Electronic Clinical Data Objectives: Variability in hospital-level sepsis mortality rates may be due to differences in case mix, quality of care, or diagnosis and coding practices. Centers for Disease Control and Prevention’s Adult Sepsis Event definition could facilitate objective comparisons of sepsis mortality rates between hospitals but requires rigorous risk-adjustment tools. We developed risk-adjustment models for Adult Sepsis Events using administrative and electronic health record data. Design: Retrospective cohort study. Setting: One hundred thirty-six U.S. hospitals in Cerner HealthFacts (derivation dataset) and 137 HCA Healthcare hospitals (validation dataset). Patients: A total of 95,154 hospitalized adult patients (derivation) and 201,997 patients (validation) meeting Centers for Disease Control and Prevention Adult Sepsis Event criteria. Interventions: None. Measurements and Main Results: We created logistic regression models of increasing complexity using administrative and electronic health record data to predict in-hospital mortality. An administrative model using demographics, comorbidities, and coded markers of severity of illness at admission achieved an area under the receiver operating curve of 0.776 (95% CI, 0.770–0.783) in the Cerner cohort, with diminishing calibration at higher baseline risk deciles. An electronic health record–based model that integrated administrative data with laboratory results, vasopressors, and mechanical ventilation achieved an area under the receiver operating curve of 0.826 (95% CI, 0.820–0.831) in the derivation cohort and 0.827 (95% CI, 0.824–0.829) in the validation cohort, with better calibration than the administrative model. Adding vital signs and Glasgow Coma Score minimally improved performance. Conclusions: Models incorporating electronic health record data accurately predict hospital mortality for patients with Adult Sepsis Events and outperform models using administrative data alone. Utilizing laboratory test results, vasopressors, and mechanical ventilation without vital signs may achieve a good balance between data collection needs and model performance, but electronic health record–based models must be attentive to potential variability in data quality and availability. With ongoing testing and refinement of these risk-adjustment models, Adult Sepsis Event surveillance may enable more meaningful comparisons of hospital sepsis outcomes and provide an important window into quality of care.

Estimating the Impact of Words Used by Physicians in Advance Care Planning Discussions: The “Do You Want Everything Done?” Effect Objectives: To estimate the probability of a substitute decision maker choosing to withdraw life-sustaining therapy after hearing an affirmative patient response to the phrase “Do you want everything done?” Design: Discrete choice experiment. Setting: Single community hospital in Ontario. Subjects: Nonrandom sampling of healthcare providers and the public. Intervention: Online survey. Measurements and Main Results: Of the 1,621 subjects who entered the survey, 692 consented and 432 completed the survey. Females comprised 73% of subjects. Over 95% of subjects were under 65 years old, and 50% had some intensive care–related exposure. Healthcare providers comprised 29% of the subjects. The relative importance of attributes for determining the probability of withdraw life-sustaining therapy by substitute decision makers was as follows: stated patient preferences equals to 23.4%; patient age equals to 20.6%; physical function prognosis equals to 15.2%; length of ICU stay equals to 14.4%; survival prognosis equals to 13.8%; and prognosis for communication equals to 12.6%. Using attribute level utilities, the probability of an substitute decision maker choosing to withdraw life-sustaining therapy after hearing a patient answer in the affirmative “Do you want everything done?” compared with “I would not want to live if I could not take care of myself” was 18.8% (95% CI, 17.2–20.4%) versus 59.8% (95% CI, 57.6–62.0%) after controlling for all the other five attribute levels in the scenario: age greater than 80 years; survival prognosis less than 1%; length of ICU stay greater than 6 months; communication equals to unresponsive; and physical equals to bed bound. Conclusions: Using a discrete choice experiment survey, we estimated the impact of a commonly employed and poorly understood phrase physicians may use when discussing advance care plans with patients and their substitute decision makers on the subsequent withdraw life-sustaining therapies. This phrase is predicted to dramatically reduce the likelihood of withdraw life-sustaining therapy even in medically nonbeneficial scenarios and potentially contribute to low-value end-of-life care and outcomes. The immediate cessation of this term should be reinforced in medical training for all healthcare providers who participate in advance care planning.

Pilot Randomized Trial of a Recovery Navigator Program for Survivors of Critical Illness With Problematic Alcohol Use Objective: Many survivors of critical illness have problematic alcohol use, associated with risk of death and hospital readmission. We tested the feasibility, acceptability, treatment fidelity, and potential efficacy of a customized alcohol intervention for patients in ICUs. The intervention was delivered by a Recovery Navigator using principles of motivational interviewing and shared decision-making. Design: Pilot randomized trial. Setting: Two urban ICUs in Denver, CO. Patients: Patients with problematic alcohol use were enrolled prior to hospital discharge. Interventions: Patients were randomly assigned to usual care, single-session motivational interviewing and shared decision-making, or multisession motivational interviewing and shared decision-making. Measurements and Main Results: We assessed feasibility via enrollment and attrition, acceptability via patient satisfaction (Client Satisfaction Questionnaire-8), fidelity via observation and questionnaires, and potential efficacy via group means and CIs on measures of alcohol use, psychiatric symptoms, cognition, and other alcohol-related problems. Over 18 months, we offered the study to 111 patients, enrolled 47, and randomized 36; refusals were mainly due to stigma or patients' desire to handle problems on their own. Groups were similar at baseline, and 67% of patients met criteria for alcohol use disorder. Average patient satisfaction was high (mean = 28/32) regardless of group assignment. Sessions were delivered with 98% adherence to motivational interviewing principles and excellent motivational interviewing spirit; patients perceived the intervention to be more autonomy supportive than usual care. Group means after 6 months suggested that patients receiving the intervention might improve on measures such as alcohol use, psychiatric symptoms, legal problems, and days of paid work; however, they did not receive more substance use treatment. All results were nonsignificant due to small sample size. Conclusions: A Recovery Navigator intervention was feasible and acceptable for delivering high-fidelity brief interventions to ICU patients. Changes in alcohol-related problems with motivational interviewing and shared decision-making were nonsignificant but clinically meaningful in size. A full-scale randomized trial of motivational interviewing and shared decision-making is warranted.

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study Objectives: Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation. Design: Multi-ICU proof-of-concept study and a single ICU before-after study. Setting: University hospital ICUs. Patients: Adult patients receiving mechanical ventilation. Interventions: An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers. Measurements and Main Results: We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01–1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03–1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09–4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13–5.16 d; p = 0.040) shorter, compared with the expected durations without the application. Conclusions: Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

Comparison of Automated Sepsis Identification Methods and Electronic Health Record–based Sepsis Phenotyping: Improving Case Identification Accuracy by Accounting for Confounding Comorbid Conditions Objective: To develop and evaluate a novel strategy that automates the retrospective identification of sepsis using electronic health record data. Design: Retrospective cohort study of emergency department and in-hospital patient encounters from 2014 to 2018. Setting: One community and two academic hospitals in Maryland. Patients: All patients 18 years old or older presenting to the emergency department or admitted to any acute inpatient medical or surgical unit including patients discharged from the emergency department. Interventions: None. Measurements and Main Results: From the electronic health record, 233,252 emergency department and inpatient encounters were identified. Patient data were used to develop and validate electronic health record–based sepsis phenotyping, an adaptation of “the Centers for Disease Control Adult Sepsis Event toolkit” that accounts for comorbid conditions when identifying sepsis patients. The performance of this novel system was then compared with 1) physician case review and 2) three other commonly used strategies using metrics of sensitivity and precision relative to sepsis billing codes, termed “billing code sensitivity” and “billing code predictive value.” Physician review of electronic health record–based sepsis phenotyping identified cases confirmed 79% as having sepsis; 88% were confirmed or had a billing code for sepsis; and 99% were confirmed, had a billing code, or received at least 4 days of antibiotics. At comparable billing code sensitivity (0.91; 95% CI, 0.88–0.93), electronic health record–based sepsis phenotyping had a higher billing code predictive value (0.32; 95% CI, 0.30–0.34) than either the Centers for Medicare and Medicaid Services Sepsis Core Measure (SEP-1) definition or the Sepsis-3 consensus definition (0.12; 95% CI, 0.11–0.13; and 0.07; 95% CI, 0.07–0.08, respectively). When compared with electronic health record–based sepsis phenotyping, Adult Sepsis Event had a lower billing code sensitivity (0.75; 95% CI, 0.72–0.78) and similar billing code predictive value (0.29; 95% CI, 0.26–0.31). Electronic health record–based sepsis phenotyping identified patients with higher in-hospital mortality and nearly one-half as many false-positive cases when compared with SEP-1 and Sepsis-3. Conclusions: By accounting for comorbid conditions, electronic health record–based sepsis phenotyping exhibited better performance when compared with other automated definitions of sepsis.