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Objectives: Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges., Design: Qualitative design-data generation via interviews and data analysis via the framework analysis method., Setting: Patients and caregivers from three continents, identified through the Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups)., Subjects: Patients and caregivers following critical illness., Interventions: Nil., Measurements and Main Results: From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients-interacting with the health system and gaps in care; managing others' expectations of illness and recovery. 2) Challenges for caregivers-health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care-personal attributes, resources, and initiative; receiving support and helping others; and acceptance., Conclusions: Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care., Competing Interests: Drs. Haines’, Boehm’s, Quasim’s, McPeake’s, and Sevin’s institutions received funding from the Society of Critical Care Medicine. Drs. Haines, Boehm, Quasim, McPeake, and Sevin received funding from the Society of Critical Care Medicine to undertake this work. Dr. Boehm is funded by National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) (K12 HL137943) as is Dr. Iwashyna (K12 HL138039). Drs. Boehm’s and Hope’s institutions received funding from the NHLBI. Dr. Boehm’s institution received funding from the American Association of Critical Care Nurses (AACN). Drs. Boehm and Hope received support for article research from the NIH and the AACN Impact Grant. Dr. Hope’s institution received funding from the NIH; he received funding from the AACN. Dr. Netzer received funding from UptoDate. Dr. Hopkins’ institution received funding from the Intermountain Research and Medical Foundation. Dr. Iwashyna received support for article research from the government. Dr. McPeake is funded by a THIS.Institute Post-Doctoral Fellowship (PD-2019-02-16). Dr. McPeake’s institution received funding from the THIS Institute, University of Cambridge. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objective: To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs., Methods: Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine's THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data., Results: Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs-new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU-former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them-clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician's own understanding of patient experience-there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work-this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes., Conclusions: The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area.

Background: The association of family-witnessed cardiopulmonary resuscitation (CPR) and subsequent advance directives in the medical intensive care unit is unknown., Objective: To compare clinical outcomes, including subsequent limitations on care, of family-witnessed vs family-unwitnessed CPR in the inpatient setting., Methods: Analysis of demographics and outcomes pertaining to family presence in a retrospective cohort of consecutive patients receiving first CPR in the medical intensive care unit of a tertiary academic medical center., Results: In 5 years, 323 patients underwent attempted CPR, of which 49 attempts (15.2%) were witnessed by family. In patients with return of spontaneous circulation, 40.9% of those whose first CPR was witnessed by family later had a do not attempt resuscitation order, which did not differ from patients whose first CPR was unwitnessed by family (31.8%). Family-witnessed CPR in the unit was associated with significantly lower rates of return of spontaneous circulation (44.9%) than was family-unwitnessed CPR (62.0%; P = .02). Of all patients with a first CPR, 42 (13.0%) survived to hospital discharge. Only 1 patient with return of spontaneous circulation after first family-witnessed CPR survived to hospital discharge. In-hospital mortality for all patients requiring subsequent CPR was 97.1%., Conclusions: For unclear reasons, family-witnessed CPR in the medical intensive care unit is associated with a similar rate of subsequent CPR efforts and lower rates of return of spontaneous circulation and survival to hospital discharge., (©2017 American Association of Critical-Care Nurses.)

Post-intensive care syndrome, a condition defined by new or worsening impairment in cognition, mental health, and physical function after critical illness, has emerged in the past decade as a common and life-altering consequence of critical illness. New strategies are urgently needed to mitigate the risk of neuropsychological and functional impairment common after critical illness and to prepare and support survivors on their road toward recovery. The present state of critical care survivorship is described, and postdischarge care delivery in the United States and the potential impact of the present-day fragmented model of care delivery are detailed. A novel strategy that uses peer support groups could more effectively meet the needs of survivors of critical illness and mitigate post-intensive care syndrome.

Most major decisions in the intensive care unit (ICU) regarding goals of care are shared by clinicians and someone other than the patient. Multicenter clinical trials focusing on improved communication between clinicians and these surrogate decision makers have not reported consistently improved outcomes. We suggest that acquired maladaptive reasoning may contribute importantly to failure of the intervention strategies tested to date. Surrogate decision makers often suffer significant psychological morbidity in the form of stress, anxiety, depression, and post-traumatic stress disorder. Family members in the ICU also suffer cognitive blunting and sleep deprivation. Their decision-making abilities are eroded by anticipatory grief and cognitive biases, while personal and family conflicts further impact their decision making. We propose recognizing a family ICU syndrome to describe the morbidity and associated decision-making impairment experienced by many family members of patients with acute critical illness (in the ICU) and chronic critical illness (in the long-term, acute care hospital). Research rigorously using models of compromised decision making may help elucidate both mechanisms of impairment and targets for intervention. Better quantifying compromised decision making and its relationship to poor outcomes will allow us to formulate and advance useful techniques. The use of decision aids and improving ICU design may provide benefit now and in the near future. In measuring interventions targeting cognitive barriers, clinically significant outcomes, such as time to decision, should be considered. Statistical approaches, such as survival models and rank statistic testing, will increase our power to detect differences in our interventions.

Purpose: Guidelines for the construction of critical care units require windows in room design to ensure a contribution of natural sunlight to ambient lighting. However, few studies have been published with evidence assessing this recommendation. We investigated the association of ambient light levels with clinical outcomes and sedative/analgesic/neuroleptic use in a medical intensive care unit (MICU)., Methods: This is a retrospective, observational study at a tertiary care facility with a 29-bed MICU. First/single MICU admissions between April 19, 2006, and June 30, 2009 (N = 3577), were analyzed with respect to clinical outcomes and sedation use according to MICU room orientation and corresponding light levels., Results: Light levels were low but varied among the 4 room orientations. There were no significant differences in MICU mortality (north, 14.0%; east, 13.5%; west, 16.2%; south, 15.6%; P = .451), hospital mortality (20.8%, 20.9%, 22.2%, 22.3%; P = .796), 28-day intensive care unit-free days (17.6 ± 10.2, 18.0 ± 10.1, 17.7 ± 10.5, 17.2 ± 10.4; P = .555), 28-day ventilator-free days (16.3 ± 11.1, 16.5 ± 11.1, 15.5 ± 11.5, 15.4 ± 11.4; P = .273). No clinically significant differences in intravenous sedative/analgesic use occurred across room orientations., Conclusions: Despite differing ambient light, room orientation was not associated with critical care outcomes or differences in sedative/analgesic/neuroleptic use. Current guidelines positing that windows alone are necessary or sufficient for MICU room light management may require further investigation and consideration., (Copyright © 2013 Elsevier Inc. All rights reserved.)

A growing number of guidelines and recommendations advocate a restrictive transfusion strategy. Strong evidence exists that a hemoglobin threshold of less than 7 g/dL conserves resources and may improve outcomes in critically ill patients and that platelet counts greater than 10,000/μL are well tolerated. Patients with coronary artery disease can be safely managed with a restrictive transfusion strategy, utilizing a hemoglobin threshold of less than 7 or 8 g/dL; a threshold of less than 8 g/dL can be applied to patients with acute coronary syndromes. In the absence of coagulopathy with bleeding or high risk for bleeding, plasma transfusion should be withheld. Complications from transfusion are significant and previously under-recognized immunologic complications pose a more serious threat than infections. Erythropoietin and iron administration do not reduce transfusion needs in the critically ill. Interventions to reduce blood loss and educate clinicians are successful in reducing transfusion requirements., (Published by Elsevier Inc.)

Internationally accepted approaches to the study of functioning and disability can inform critical care practitioners and scholars in their study of functional limitations, disability, and quality of life after critical illness and intensive care. Therefore this article provides an introduction to the World Health Organization's International Classification of Functioning, Disability and Health (ICF). The Institute of Medicine has also recommended this approach for the study of disability. This conceptual framework divides potential problems as follows: problems in body structure and tissue, limitations in activity (i.e., functional limitations as assessed in standardized environments), and restrictions in participation (i.e., the inability to fulfill a social role). The ICF draws attention to effect modifiers that can prevent problems at one level from progressing (or conversely can hasten their progression) to profound decrements in a patient's quality of life. It is particularly relevant for studies of long-term outcomes after critical illness and post-intensive care syndrome (PICS). This article provides a discussion of the ICF specific to the intensive care unit and the disablement process, with particular attention to new opportunities for intervention and their implications for cost and quality of life., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To evaluate whether a multicomponent intervention, particularly increasing staff, can achieve reductions in patient mortality in an already high-intensity, Leapfrog-compliant medical intensive care unit., Design: Retrospective, observational study., Setting: Medical intensive care unit of a tertiary care, academic medical center., Patients: A total of 1,263 patients admitted between April 19, 2004 and April 18, 2006 (before the organizational change) were compared with 2,424 patients admitted between September 5, 2006 and September 4, 2008., Interventions: A multicomponent intervention including the physical move from a 10-bed to a 29-bed medical intensive care unit with larger patient rooms, the initiation of 24-hr critical care specialist coverage in the medical intensive care unit, an increase in the respiratory therapist:patient ratio, and the addition of a clinical pharmacist to the multidisciplinary team., Measurements and Main Results: Measurements were made based on mortality in the intensive care unit and in-hospital. Patient comorbidity as measured by the Charlson score did not change after the intervention (2.7 ± 2.7 vs. 2.8 ± 2.6, p = .62), nor did the acuity of illness as measured by the case mix index (3.0 ± 3.7 vs. 3.1 ± 3.8, p = .69). The unadjusted medical intensive care unit mortality decreased from 18.4% to 14.9% (p = .006), as did in-hospital mortality (from 25.8% to 21.7%, p = .005). The reduction in medical intensive care unit mortality was consistent in the multivariable regression with adjustment for multiple possible confounders (odds ratio = 0.74, 95% confidence interval: 0.61-0.91, p = .003), as was the reduction in hospital mortality (odds ratio = 0.74, 95% confidence interval: 0.62-0.88, p = .001). In mechanically ventilated patients, there was an increase in median 28-day ventilator-free days (21, interquartile range 0-25 vs. 22, interquartile range 0-26, p = .04). An increase in median medical intensive care unit (2.4, interquartile range 1.1-5.2 vs. 2.7, interquartile range 1.3-5.9), p = .009) but not hospital (8.3, interquartile range 4.1-17.0 vs. 8.2, interquartile range 4.0-16.8; p = .851) length of stay in days occurred with the intervention. The mean daily dosing of fentanyl and lorazepam decreased after the intervention., Conclusions: A multicomponent reorganization of medical intensive care unit services was associated with important reductions in mortality for medical intensive care unit patients, as well as an increased number of ventilator-free days. Substantial and sustained changes in clinically important outcomes may be obtained from organizational changes.

Objective: To provide clinicians with evidence-based strategies to optimize support of the family of critically ill patients in the ICU.Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis and family-centered care to revise the 2007 Clinical Practice Guidelines for Support of the Family in the Patient-Centered Intensive Care Unit. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome (PICO) question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with guideline development.Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and PICO question development. The systematic review search yielded 4158 reports after de-duplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Abstract Objectives Anticipatory grief, the experience of grief before the death of a mourned individual, is common among people with seriously ill loved ones and associated with impaired social problem solving. We sought to evaluate anticipatory grief in the Intensive Care Unit setting. Research methodology/design Cross-sectional study of surrogate decision-makers of patients admitted to an intensive care unit, incorporating survey methodology. Setting Intensive care units at a tertiary care centre. Main outcome measures Surrogates completed a 78-question, self-administered questionnaire consisting of demographic and clinical data, as well as three validated instruments: Anticipatory Grief Scale (AGS), Hospital Anxiety and Depression Scale (HADS), and Social Problem Solving Inventory Revised Short Form (SPSI-R:S). Main results Surveys were completed by 50 surrogate decision-makers, among whom anticipatory grief was elevated and associated with anxiety and depression. Anticipatory grief was also significantly associated with worsened overall problem solving (Spearman's Rho −0.32, p value 0.02). Surrogates with loved ones who were older or admitted to a trauma unit experienced anticipatory grief at lower levels. Prior admission and Charlson Comorbidity Index scores were not associated with anticipatory grief. Conclusion Levels of anticipatory grief in the intensive care unit are high and associated with concurrent anxiety and depression. Association of anticipatory grief with worsened social problem solving may worsen decision making ability in surrogates. [ABSTRACT FROM AUTHOR]

Objectives: Hospital readmission is common after sepsis, yet the relationship between the index admission and readmission remains poorly understood. We sought to examine the relationship between infection during the index acute care hospitalization and readmission and to identify potentially modifiable factors during the index sepsis hospitalization associated with readmission.Design: In a retrospective cohort study, we evaluated 444 sepsis survivors at risk of an unplanned hospital readmission in 2012. The primary outcome was 30-day unplanned hospital readmission.Setting: Three hospitals within an academic healthcare system.Subjects: Four hundred forty-four sepsis survivors.Measurements and Main Results: Of 444 sepsis survivors, 23.4% (95% CI, 19.6-27.6%) experienced an unplanned 30-day readmission compared with 10.1% (95% CI, 9.6-10.7%) among 11,364 nonsepsis survivors over the same time period. The most common cause for readmission after sepsis was infection (69.2%, 72 of 104). Among infection-related readmissions, 51.4% were categorized as recurrent/unresolved. Patients with sepsis present on their index admission who also developed a hospital-acquired infection ("second hit") were nearly twice as likely to have an unplanned 30-day readmission compared with those who presented with sepsis at admission and did not develop a hospital-acquired infection or those who presented without infection and then developed hospital-acquired sepsis (38.6% vs 22.2% vs 20.0%, p = 0.04). Infection-related hospital readmissions, specifically, were more likely in patients with a "second hit" and patients receiving a longer duration of antibiotics. The use of total parenteral nutrition (p = 0.03), longer duration of antibiotics (p = 0.047), prior hospitalizations, and lower discharge hemoglobin (p = 0.04) were independently associated with hospital readmission.Conclusions: We confirmed that the majority of unplanned hospital readmissions after sepsis are due to an infection. We found that patients with sepsis at admission who developed a hospital-acquired infection, and those who received a longer duration of antibiotics, appear to be high-risk groups for unplanned, all-cause 30-day readmissions and infection-related 30-day readmissions. [ABSTRACT FROM AUTHOR]

BACKGROUND: The effect of the respiratory therapist (RT)/patient ratio and RT organizational factors on respiratory resource utilization is unknown. We describe the impact of a multi-component intervention that called for an increase in RT/patient ratio (1:14 to 1:10), improved RT orientation, and formation of a core staffing model on best practice, including spontaneous breathing trials (SBTs) and catheter and bronchoscopically directed lower respiratory tract cultures, or bronchoalveolar lavage (BAL), in both ventilated and non-ventilated patients in the ICU. METHODS: We conducted a single center, quasi-experimental study comparing 651 patients with single and first admissions between April 19, 2005 and April 18, 2006 before the RT services reorganization with 1,073 patients with single and first admissions between September 16, 2007 and September 4, 2008. Baseline characteristics were compared, along with SBTs, BAL use, lower respiratory tract cultures, and chest physiotherapy. RESULTS: Patients in the 2 groups were similar in terms of age (52.9 ± 15.8 y vs 53.9 ± 16.4 y, P ± .23), comorbidity as measured by Charlson score (2.8 ± 2.6 vs 2.8 ± 2.7, P ± .56), and acuity of illness as measured by the Case Mix Index (3.2 ± 3.9 vs 3.3 ± 4.1, P ± .47). Mechanically ventilated patients had similar prevalences of respiratory diseases (24.2% vs 25.1%, P ± .61). There was an increase in SBTs (0.5% vs 73.1%, P < .001), chest physiotherapy (7.4% vs 21.6%, P < .001), BALs (24.0% vs 41.4%, P < .001), and lower respiratory tract cultures (21.5% vs 38.0%, P < .001) in mechanically ventilated patients post-intervention. CONCLUSIONS: A multi-component intervention, including an increase in RT/ patient ratio, improved RT orientation, and establishment of a core staffing model, was associated with increased respiratory resource utilization and evidence-based practice, specifically BALs and SBTs. [ABSTRACT FROM AUTHOR]

The article discusses the important role played by systematic reviews and meta-analyses as common ways to seek the answer to specific research questions using published data. The significant function of such methods in providing systematic ways to perform literature search, appraise data, and draw conclusion is discussed. The advantage of the approaches which help develop comprehensive and systematic literature search strategy, yet, differ in several ways is also mentioned.

The article presents a retrospective study about the readmissions in the Intensive Care Units (ICU) and the hospital mortality based on the same hospital admission. Topics discussed include the evaluation of limited treatment disorder patients, the problem with do not resuscitate (DNR) orders for quality metrics and the effort among critical care outreach teams.

Purpose The primary objective was to evaluate the impact of an analgosedation protocol in a cardiac intensive care unit (CICU) on daily doses and costs of analgesic, sedative, and antipsychotic medications. Methods We conducted a single-center quasi-experimental study in 363 mechanically ventilated patients admitted to our CICU from March 1, 2011, to April 13, 2013. On March 1, 2012, an analgosedation protocol was implemented. Patients in the pre-implementation group were managed at the cardiologist's discretion, which consisted of a continuous sedative-hypnotic approach and opioids as needed. Patients in the implementation group were managed using this protocol. Results The mean ± S.D. per-patient doses (mg/day) of propofol, lorazepam, and clonazepam decreased with the use of an analgosedation protocol (propofol 132,265.7 ± 12,951 versus 87,980.5 ± 10,564 [ p = 0.03]; lorazepam 10.5 ± 7.3 versus 3.3 ± 4.0 [ p < 0.001]; clonazepam 9.9 ± 8.3 versus 1.1 ± 0.5 [ p = 0.03]). The mean daily cost of propofol and lorazepam also significantly decreased (33.5% reduction in propofol cost [ p = 0.03]; 69.0% reduction in lorazepam cost [ p < 0.001]). The per-patient dose and cost of fentanyl (mcg/day) declined with analgosedation protocol use (fentanyl 2,274.2 ± 2317.4 versus 1,026.7 ± 981.4 [ p < 0.001]; 54.8% decrease in fentanyl cost [ p < 0.001]). Conclusion The implementation of an analgosedation protocol significantly decreased both the use and cost of propofol, lorazepam, and fentanyl. Further investigation of the clinical impact and cost-effectiveness of a critical care consultation service with implementation of an analgosedation protocol is warranted in the CICU. [ABSTRACT FROM AUTHOR]

Background A myriad of trauma indices has been validated to predict probability of trauma survival. We aimed to compare the performance of commonly used indices for the development of the acute respiratory distress syndrome (ARDS). Materials and methods Historic, observational cohort study of 27,385 consecutive patients admitted to a statewide referral trauma center between July 11, 2003 and October 31, 2011. A validated algorithm was adapted to identify patients with ARDS. Each trauma index was evaluated in logistic regression using the area under the receiver operating characteristic curve. Results The case rate for ARDS development was 5.8% (1594). The receiver operating characteristics for injury severity score (ISS) had the best discrimination and had an area under the curve of 0.88 (95% confidence interval [CI] = 0.87–0.89). Glasgow coma score (0.71, 95% CI = 0.70–0.73), A Severity Characterization of Trauma (0.86, 95% CI = 0.85–0.87), Revised Trauma Score (0.71, 95% CI = 0.70–0.72) and thorax Abbreviated Injury Score (0.73, 95% CI = 0.72–0.74) performed worse ( P < 0.001) and Trauma and Injury Severity Score (0.88, 95% CI = 0.87–0.88) performed equivocally ( P = 0.51) in comparison to ISS. Using a cutoff point ISS ≥16, sensitivity and specificity were 84.9% (95% CI = 83.0%–86.6%) and 75.6% (95% CI = 75.1%–76.2%), respectively. Conclusions Among commonly used trauma indices, ISS has superior or equivocal discriminative ability for development of ARDS. A cutoff point of ISS ≥16 provided good sensitivity and specificity. The use of ISS ≥16 is a simple method to evaluate ARDS in trauma epidemiology and outcomes research. [ABSTRACT FROM AUTHOR]