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Objectives: To investigate the frequency, types, and implications of complications during intensive care in patients after status epilepticus has been successfully terminated., Design: Retrospective study., Setting: ICUs at a Swiss tertiary academic medical care center., Patients: Data were collected from the digital patient records of all adult patients with status epilepticus from 2012 to 2018., Interventions: None., Methods: Primary outcomes were defined as frequency of complications following status epilepticus termination and return to premorbid functional baseline. Univariable analyses regarding the relative risks of complications occurring after status epilepticus termination for no return to premorbid neurologic function were estimated by Poisson regression with robust error variance., Results: Of 311 patients with status epilepticus, 224 patients (72%) were treated on the ICU for more than 24 hours following status epilepticus termination. Ninety-six percent of patients remained in a prolonged state of altered consciousness for a median of 2 days (interquartile range, 1-3 d) and 80% had complications during their ICU treatment. Fifty-five percent had new-onset delirium with a median duration of 2 days (interquartile range, 1-3 d). Forty-two percent had mechanical ventilation for a median of 4 days (interquartile range, 2-11 d) and 21% had nosocomial infections diagnosed after status epilepticus. Multivariable analyses revealed that mechanical ventilation for more than 24 hours after status epilepticus, and arterial hypotension requiring vasopressors were independently associated with increased risk of no return to premorbid function (RRfor each additional day = 1.01; 95% CI, 1.02-1.03 and RRfor each additional day = 1.03; 95% CI, 1.01-1.05) and death (RRfor each additional day = 1.11; 95% CI, 1.04-1.19 and RRfor each additional day = 1.15; 95% CI, 1.03-1.28). Delirium was independently associated with a decreased relative risk of death (RRfor each additional day = 0.55; 95% CI, 0.37-0.80), but prolonged ICU- and hospital stays., Conclusions: Complications after status epilepticus termination are frequent and associated with no return to premorbid function, death, and prolonged ICU- and hospital stays. These results call for heightened awareness and further studies mainly regarding prediction and preventive strategies in this context.

Objectives: Little is known about the influence of gender on resuscitation performance which may improve future education in resuscitation. The aim of this study was to compare female and male rescuers in regard to cardiopulmonary resuscitation and leadership performance., Design: Prospective, randomized simulator study., Setting: High-fidelity patient simulator center of the medical ICU, University Hospitals Basel (Switzerland)., Subjects: Two hundred sixteen volunteer medical students (108 females and 108 males) of two Swiss universities in teams of three., Interventions: None., Measurements and Main Results: We analyzed data on the group and the individual level separately. The primary outcome on the group level was the hands-on time within the first 180 seconds after the onset of the cardiac arrest. Compared with male-only teams, female-only teams showed less hands-on time (mean ± SD) (87 ± 41 vs 109 ± 33 s; p = 0.037) and a longer delay before the start of chest compressions (109 ± 77 vs 70 ± 56 s; p = 0.038). Additionally, female-only teams showed a lower leadership performance in different domains and fewer unsolicited cardiopulmonary resuscitation measures compared with male-only teams. On the individual level, which was assessed in mixed teams only, female gender was associated with a lower number of secure leadership statements (3 ± 2 vs 5 ± 3; p = 0.027). Results were confirmed in regression analysis adjusted for team composition., Conclusions: We found important gender differences, with female rescuers showing inferior cardiopulmonary resuscitation performance, which can partially be explained by fewer unsolicited cardiopulmonary resuscitation measures and inferior female leadership. Future education of rescuers should take gender differences into account.

Objective: Dissatisfaction is an important threat to high-quality care. The aim of this study was to identify factors independently associated with dissatisfaction with critical care., Design: Prospectively collected observational cohort study., Setting: Nine intensive care units at a tertiary care university hospital in the United States., Participants: Four hundred forty-nine family members of adult intensive care unit patients who completed the Family Satisfaction with Care in the Intensive Care Unit instrument., Intervention: None., Measurements and Main Results: Four family-and patient-related factors ascertainable at intensive care unit admission independently predicted low overall satisfaction: living in the same city as the hospital, disagreement within the family regarding care, having a cardiac comorbidity but being hospitalized in a noncardiac-care intensive care unit, and living in a different household than the patient. When three or more risk factors were present, 63% (95% confidence interval 48%-78%) of families were dissatisfied. Among factors ascertained at the end of the intensive care unit stay, dissatisfaction with six items was independently associated with overall dissatisfaction: 1) perceived competence of nurses (odds ratio for dissatisfaction=5.9, 95% confidence interval 2.3-15.2); 2) concern and caring by intensive care unit staff (odds ratio 5.0, 95% confidence interval 1.9-12.6); 3) completeness of information (odds ratio 4.4, 95% confidence interval 2.4-8.1); 4) dissatisfaction with the decision-making process (odds ratio 3.0, 95% confidence interval 1.6- 5.6); 5) atmosphere of the intensive care unit (odds ratio 2.6, 95% confidence interval 1.4-4.8); and 6) atmosphere of the waiting room (odds ratio 2.7, 95% confidence interval 1.2-6.0)., Conclusion: Specific factors ascertainable at intensive care unit admission identify families at high risk of dissatisfaction with care. Other discrete aspects of the patient/family experience that develop during the intensive care unit stay are also strongly associated with dissatisfaction with the critical care experience. These results may provide insight into the design of future evidence-based strategies to improve satisfaction with the intensive care unit experience.

Objective: Investigators in France have developed a risk score to predict death or poor neurologic outcome after out-of-hospital cardiac arrest. The aim of this study is to externally validate this score in an independent patient population in the United States., Design: Retrospective, observational, cohort study., Patients: Patients being admitted to the intensive care unit after out-of-hospital cardiac arrest., Setting: Two geographically distinct tertiary care hospitals in the United States., Interventions: None., Measurements and Main Results: The primary end point was poor outcome, defined as either death or a Cerebral Performance Category score of 3-5. The secondary end point was all-cause mortality. Calibration was assessed by comparing the number of expected outcomes based on the logistic model of the French study with observed outcomes within this study using Hosmer-Lemeshow C test (goodness-of-fit). Discrimination was assessed by calculation of the area under the receiver operating characteristic curve. Of a total of 128 patients, 99 (77%) had a poor outcome, including 91 nonsurvivors (71%). The probability of poor neurologic outcome and mortality increased stepwise with increasing out-of-hospital cardiac arrest score. Graphic display of observed against predicted outcomes and goodness-of-fit test indicated good calibration of the score (p = .4). The score showed good discrimination for poor outcome (area under the receiving operating characteristic curve, 0.85; 95% confidence interval, 0.79-0.92) and for mortality (area under the receiving operating characteristic curve, 0.85; 95% confidence interval, 0.78-0.91). In patients with an out-of-hospital cardiac arrest score >40 points and >60 points, the positive predictive value for poor outcome was 97% and 100%, respectively., Conclusions: This study found good calibration and high discrimination of the out-of-hospital cardiac arrest score in two geographically distinct patient populations in the United States. Particularly, this score had a high positive predictive value and performed well in identifying high-risk patients for poor outcomes.

Objective: In an effort to improve upon the traditional sepsis syndrome definitions, the predisposition, infection, response, organ dysfunction (PIRO) model was proposed to better characterize sepsis. The objective of this investigation was to derive and validate a sepsis staging system based on the PIRO concept that risk stratifies patients with suspected infection., Design: Three independent, observational, prospective cohorts were studied. A derivation cohort (n = 2,132) was used to create the PIRO score, identifying independent predictors of mortality. Individual values were assigned to create the weighted integer score for each parameter, yielding the final PIRO score. The prognostic performance was then investigated in independent internal (n = 4,618) and external (n = 1,004) validation cohorts., Setting: Two large U.S. tertiary care centers., Patients: Patients admitted to the hospital from the emergency department with suspected infection., Interventions: None., Measurements and Main Results: The PIRO staging system was created by combining components of predisposition (age, chronic obstructive pulmonary disease, liver disease, nursing home residency, and malignancy with and without metastasis), infection (pneumonia and cellulitis), response (tachypnea, bandemia, and tachycardia), and organ dysfunction (renal, respiratory, cardiac, metabolic, and hematologic). The derived PIRO score showed stepwise increase in mortality with increasing points and high discriminatory ability with an area under the curve of 0.90 in the derivation cohort, 0.86 in internal validation, and 0.83 in external validation., Conclusions: This study provides evidence-based support for the PIRO approach to sepsis staging. Future efforts may utilize this approach with additional parameters (e.g., genetics and novel biochemical markers) to develop further the PIRO stratification system.

Objective: The influence of teaching leadership on the performance of rescuers remains unknown. The aim of this study was to compare leadership instruction with a general technical instruction in a high-fidelity simulated cardiopulmonary resuscitation scenario., Design: Prospective, randomized, controlled superiority trial., Setting: Simulator Center of the University Hospital Basel in Switzerland., Subjects: Two-hundred thirty-seven volunteer medical students in teams of three., Intervention: During a baseline visit, the medical students participated in a video-taped simulated witnessed cardiac arrest. Participants were thereafter randomized to receive instructions focusing either on correct positions of arms and shoulders (technical instruction group) or on leadership and communication to enhance team coordination (leadership instruction group). A follow-up simulation was conducted after 4 mos., Measurements and Main Results: The primary outcome was the amount of hands-on time, defined as duration of uninterrupted cardiopulmonary resuscitation in the first 180 secs after the onset of the cardiac arrest (hands-on time) [corrected]. Secondary outcomes were time to start cardiopulmonary resuscitation, total leadership utterances, and technical skills. Outcomes were compared based on videotapes coded by two independent researchers. After a balanced performance at baseline, the leadership instruction group demonstrated a longer hands-on time (120 secs; interquartile range, 98-135 vs. 87 secs; interquartile range, 61-108; p < .001), a shorter median time to start cardiopulmonary resuscitation (44 secs; interquartile range, 32-62; vs. 67 secs; interquartile range, 43-79; p = .018), and had more leadership utterances (7; interquartile range, 4-10; vs. 5; interquartile range, 2-8; p = .02) in the follow-up visit. The rate of correct arm and shoulder positions was higher in teams with technical instruction (59%; 19 out of 32; vs. 23%; 7 out of 31; p = .003)., Conclusions: Video-assisted leadership and technical instructions after a simulated cardiopulmonary resuscitation scenario showed sustained efficacy after a 4-mo duration. Leadership instructions were superior to technical instructions, with more leadership utterances and better overall cardiopulmonary resuscitation performance.