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Incorporating the advanced practice provider (APP) in the delivery of tele critical care medicine (teleCCM) addresses the critical care provider shortage. However, the current literature lacks details of potential workflows, deployment difficulties and implementation outcomes while suggesting that expanding teleCCM service may be difficult. Here, we demonstrate the implementation of a telemedicine APP (eAPP) pilot service within an existing teleCCM program with the objective of determining the feasibility and ease of deployment. The goal is to augment an existing tele-ICU system with a balanced APP service to assess the feasibility and potential impact on the ICU performance in several hospitals affiliated within a large academic center. A REDCap survey was used to assess eAPP workflows, expediency of interventions, duration of tasks, and types of assignments within different service locations. Between 02/01/2021 and 08/31/2021, 204 interventions (across 133 12-h shift) were recorded by eAPP (n routine  = 109 (53.4%); n urgent  = 82 (40.2%); n emergent  = 13 (6.4%). The average task duration was 10.9 ± 6.22 min, but there was a significant difference based on the expediency of the task (F [2; 202] = 3.89; p < 0.022) and type of tasks (F [7; 220] = 6.69; p < 0.001). Furthermore, the eAPP task type and expediency varied depending upon the unit engaged and timeframe since implementation. The eAPP interventions were effectively communicated with bedside staff with only 0.5% of suggestions rejected. Only in 2% cases did the eAPP report distress. In summary, the eAPP can be rapidly deployed in existing teleCCM settings, providing adaptable and valuable care that addresses the specific needs of different ICUs while simultaneously enhancing the delivery of ICU care. Further studies are needed to quantify the input more robustly., (© 2022. The Author(s).)

Background: Intensive care unit telemedicine is an innovative approach to providing critical care services for a broad geographic area, but its success may depend on acceptance by bedside providers., Objectives: To determine critical care nurses' attitudes toward and perceptions about the use of telemedicine in critical care., Methods: A total of 179 nurses in 3 critical care units in 2 university-affiliated academic hospitals that use telemedicine intensivists and nurses were surveyed via the Internet about their practice and perceptions of telemedicine., Results: Among the 93 respondents (response rate, 52%), 72 worked at least 1 night shift and therefore had experience with the telemedicine unit. Reported contact with the telemedicine unit was relatively infrequent: 31% reported being called by the unit 3 or more times in the preceding 6 months. A total of 44% reported regularly incorporating interventions suggested by the telemedicine staff. A majority (72%) thought that telemedicine increases patients' survival, but fewer thought that telemedicine prevents medical errors (47%) or improves the satisfaction of patients' families (42%). Some respondents thought that telemedicine interrupted work flow (9%), was intrusive (11%), or resulted in a feeling of being spied upon (13%). Most nurses thought that personally knowing the telemedicine physician was important (79%), and nurses were more likely to contact the telemedicine unit if they knew the physician on call (61%)., Conclusions: Practicing bedside nurses with experience in telemedicine generally support its use, but concerns about privacy issues and the desire to personally know the telemedicine physician may hinder broader application of the technology.

This prospective study examined whether the integration of acute care nurse practitioners (ACNP) in a "semiclosed" surgical intensive care unit (SICU) model increased compliance with clinical practice guidelines (CPG). Patients were admitted to critical care services with a (a) "semiclosed"/ACNP team or (b) "mandatory consultation"/non-ACNP team. CPG compliance was significantly higher (P < .05) on the "semiclosed"/ACNP team for all 3 CPGs examined in the study.

Objective: To review the history and current applications of artificial intelligence in the intensive care unit., Data Sources: The MEDLINE database, bibliographies of selected articles, and current texts on the subject., Study Selection: The studies that were selected for review used artificial intelligence tools for a variety of intensive care applications, including direct patient care and retrospective database analysis., Data Extraction: All literature relevant to the topic was reviewed., Data Synthesis: Although some of the earliest artificial intelligence (AI) applications were medically oriented, AI has not been widely accepted in medicine. Despite this, patient demographic, clinical, and billing data are increasingly available in an electronic format and therefore susceptible to analysis by intelligent software. Individual AI tools are specifically suited to different tasks, such as waveform analysis or device control., Conclusions: The intensive care environment is particularly suited to the implementation of AI tools because of the wealth of available data and the inherent opportunities for increased efficiency in inpatient care. A variety of new AI tools have become available in recent years that can function as intelligent assistants to clinicians, constantly monitoring electronic data streams for important trends, or adjusting the settings of bedside devices. The integration of these tools into the intensive care unit can be expected to reduce costs and improve patient outcomes.

The cardiothoracic surgery intensive care unit (CTICU) has evolved as a separate entity from the general surgical intensive care unit as management for cardiac surgery patients has become streamlined and algorithm driven. Critical care is best managed when the service is designed for a homogeneous population with a circumscribed set of medical and surgical issues. The repetition involved with the subspecialty care allows health care providers such as primary care nurses, nurse practitioners, physician assistants, and other ancillary services to become appropriately focused on issues pertinent to this population. The goals of the CTICU include the attainment of rapid and safe recovery from surgery and anesthesia despite decreasing resources, increasing patient age and comorbidity, and increasing complexity of the operative procedure. The coordinated and systematic approach to the postoperative cardiac surgery patient under the direction of a staff physician offers the most effective opportunity to achieve these expectations at this time. The traditional model of staffing by a physician with responsibilities that conflict temporally with the immediacy often needed for the postoperative care of cardiac patients may expose patients to unnecessary risks. A responsible physician should be available in the CTICU, especially during the immediate postoperative period when physical assessment and direct hands-on involvement are essential. In an era when the operative team (ie, cardiac surgeon and cardiac anesthesiologist) must return to the surgical suite soon after the patient arrives in the intensive care unit, the presence of a physician dedicated to postoperative medical and surgical management becomes mandatory. According to the Joint Commission on Accreditation of Healthcare Organizations, "Each special care unit is properly directed and staffed according to the nature of the special patient care needs anticipated and scope of services provided." The assignment of staff is designed to match experience with patient acuity., (Copyright 2000 by W.B. Saunders Company)

This article reviews the use of inhalational, intravenous, and epidural agents used in the operating room and ICU. An emphasis is placed on the rationale for their selection. Additionally, the side effects and expected complications are discussed. By developing expertise with one's own repertoire of sedatives, narcotics, and neuromuscular blocking agents, one may decrease postoperative complications and lengths of stay.

Objective: To determine whether the presence of an on-site, organized, supervised critical service improves care and decreases resource utilization., Design: The study compared two patient cohorts admitted to a surgical intensive care unit during the same period of time. The study cohort was cared for by an on-site critical care team supervised by an intensivist. The control cohort was cared for by a team with patient care responsibilities in multiple sites supervised by a general surgeon. The main outcome measures were duration of stay, resource utilization, and complication rate., Setting: Study patients were general surgical patients in an academic medical center., Results: Despite having higher Acute Physiology and Chronic Health Evaluation II scores, patients cared for by the critical care service spent less time in the surgical intensive care unit, used fewer resources, had fewer complications and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst APACHE II score., Conclusions: Critical care interventions are expensive and have a narrow safety margin. It is essential to develop structured and validated approaches to study the delivery of this resource. In this study, the critical care service model performed favorably both in terms of quality and cost.

In critically ill patients, organ function, blood flow, and caregiving personnel change constantly. The risks inherent in paralyzing a patient, such as those of positioning (nerve injuries, stasis injuries) and ventilator disconnection are compounded by the duration of paralysis in the ICU. When used with attention to the pharmacologic properties, patient organ function, and cost, however, muscle relaxants are a useful adjunct to ICU management.