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Introduction: Tele-Intensive Care Unit (tele-ICU) is care provided to critically ill patients by remote clinicians using audio, and video communications and network resources to access real-time patient information from physiologic monitors and the electronic medical record. Tele-ICU has been demonstrated in civilian healthcare to reduce mortality, improve care quality and safety, decrease intensive care unit (ICU) length of stay (LOS) and ventilator days, and save money. General Leonard Wood Army Community Hospital (GLWACH) is a small medical treatment facility with limited resources with respect to subspecialists and ancillary services., Materials and Methods: In 2012, GLWACH identified the lack of board-certified critical care physicians and limited baseline critical care capabilities as gaps that reduced surgical opportunities, challenged critical skill sustainment, exposed potential patient safety issues, and resulted in costly patient transfers to network hospitals. To address these gaps, GLWACH partnered with the Baptist Health Tele-ICU Service, located in Little Rock, AR, to provide Tele-ICU services to its four-bed intensive care unit. Video Teleconsultation (VTC) equipment was installed in the ICU as was a vendor specific solution for accessing real-time patient vital signs and an "emergency" button. The emergency button functioned by turning on the VTC equipment and calling the Tele-ICU center in Little Rock immediately when pushed. To assess impact, hospital and ICU volume, acuity, case mix index, purchased care costs were monitored before and after implementation of the system. Additionally, a Safety Attitudes Questionnaire (SAQ) was administered before and after implementation., Results: The implementation of the tele-ICU program at GLWACH increased hospital and ICU patient volume, surgical patient volume, and patient complexity. Purchased care costs declined by 30% in the year following implementation and return on investment was $233,311 (19%). All measurements of the SAQ improved following implementation., Conclusions: These findings support the implementation of tele-ICU in the MHS as a cost-effective method to sustain readiness amongst critical care clinicians and improve safety culture in MHS hospitals., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The electronic medical record (EMR) is presumed to support clinician decisions by documenting and retrieving patient information. Research shows that the EMR variably affects patient care and clinical decision making. The way information is presented likely has a significant impact on this variability. Well-designed representations of salient information can make a task easier by integrating information in useful patterns that clinicians use to make improved clinical judgments and decisions. Using Cognitive Systems Engineering methods, our research team developed a novel health information technology (NHIT) that interfaces with the EMR to display salient clinical information and enabled communication with a dedicated text-messaging feature. The software allows clinicians to customize displays according to their role and information needs. Here we present results of usability and validation assessments of the NHIT., Materials and Methods: Our subjects were physicians, nurses, respiratory therapists, and physician trainees. Two arms of this study were conducted, a usability assessment and then a validation assessment. The usability assessment was a computer-based simulation using deceased patient data. After a brief five-minute orientation, the usability assessment measured individual clinician performance of typical tasks in two clinical scenarios using the NHIT. The clinical scenarios included patient admission to the unit and patient readiness for surgery. We evaluated clinician perspective about the NHIT after completing tasks using 7-point Likert scale surveys. In the usability assessment, the primary outcome was participant perceptions about the system's ease of use compared to the legacy system.A subsequent cross-over, validation assessment compared performance of two clinical teams during simulated care scenarios: one using only the legacy IT system and one using the NHIT in addition to the legacy IT system. We oriented both teams to the NHIT during a 1-hour session on the night before the first scenario. Scenarios were conducted using high-fidelity simulation in a real burn intensive care unit room. We used observations, task completion times, semi-structured interviews, and surveys to compare user decisions and perceptions about their performance. The primary outcome for the validation assessment was time to reach accurate (correct) decision points., Results: During the usability assessment, clinicians were able to complete all tasks requested. Clinicians reported the NHIT was easier to use and the novel information display allowed for easier data interpretation compared to subject recollection of the legacy EMR.In the validation assessment, a more junior team of clinicians using the NHIT arrived at accurate diagnoses and decision points at similar times as a more experienced team. Both teams noted improved communication between team members when using the NHIT and overall rated the NHIT as easier to use than the legacy EMR, especially with respect to finding information., Conclusions: The primary findings of these assessments are that clinicians found the NHIT easy to use despite minimal training and experience and that it did not degrade clinician efficiency or decision-making accuracy. These findings are in contrast to common user experiences when introduced to new EMRs in clinical practice., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation.

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.

Introduction: The Nanosphere Verigene Blood Culture Nucleic Acid Tests allow pathogen and antimicrobial resistance marker identification within 2.5 hours of a positive blood culture. This study assessed the sensitivity of the Verigene among Burn Intensive Care Unit (BICU) isolates and acceleration to targeted antibiotic therapy., Methods: Bacterial identifications from BICU patients with positive blood cultures over 8 months were compared using 2 different platforms, the Verigene Gram-positive and Gram-negative blood culture tests vs. the bioMerieux Vitek2 automated system. Turnaround times were compared, and Verigene sensitivity for identification and resistance marker detection was calculated. Antimicrobial stewardship was assessed by comparing date/time for empiric and targeted therapy to the Verigene result time., Results: Forty-four isolates (29 target and 15 nontarget) from 17 patients were included. The Verigene correctly identified 15 of 17 Gram-negative (sensitivity 88.2%; 95% confidence interval [CI] [87.9, 88.9]) and 8 of 12 Gram-positive target organisms (sensitivity 66.7%; 95% CI [66.3, 67.5]). None of the nontarget isolates were identified. There were no discordant identifications. Resistance marker identification by the Verigene was 100% concordant with confirmatory testing. For 11 isolates with complete laboratory and clinical data, the median time between Verigene and final culture results was 59.3 hours (37.3, 102.2) and from Verigene results to targeted therapy was 62.2 hours (43.6, 66.2)., Discussion: Reasons for lower sensitivity than previously reported are unclear and, on the basis of this limited retrospective review, further study in the BICU population is needed. The Verigene appears useful for antimicrobial stewardship by accelerating the identification of blood isolates., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Hydrocarbons are a wide-ranging group of flammable chemicals and are often used in suicide attempts either by ingestion or as an accelerant in self-immolation. In this case study, we present a 37-year-old female who suffered 6% TBSA partial-thickness burns to her perineum and buttocks, which she claims resulted from diarrhea after ingesting a bottle of lighter fluid. The patient underwent decontamination and medical treatment for her burns and during her inpatient stay, it became apparent that the burns were more likely sustained from an intentional rectal administration of lighter fluid. To our knowledge, this is one of the first reported cases of hydrocarbon enema. We review hydrocarbon poisoning, including both ingestion and dermal exposure, and discuss medical management.

Intensivist physician involvement has been shown to improve outcomes for critically ill patients. Unfortunately, the number of Intensivists nationally is unable to meet the current demand. Similar to the civilian community, the Navy critical care workforce is limited by available resources. Tele-critical care (TCC) has recently been shown to improve outcomes for critically ill patients, and has been suggested as a suitable means of extending Intensivist expertise. Naval Hospital Camp Pendleton (NHCP) is a small community hospital located 41 miles north of Naval Medical Center San Diego (NMCSD). NHCP operates a relatively low-volume six-bed medical-surgical intensive care unit. The Intensivist staffing of NHCP has been variable, ranging from 3 Intensivists to periods of time with no on-site Intensivists. This intermittent staffing has led to (1) network disengagements, (2) unnecessary transfers to NMCSD, and (3) adverse outcomes for critically ill patients cared for at NHCP without Intensivist involvement. In early 2014, NMCSD established a TCC system to address this staffing challenge. Through the TCC program, the tele-Intensivist at NMCSD provides 24/7 coverage for patients located at NHCP using low-cost, off-the-shelf, synchronous high-definition video-teleconferencing equipment, and remote access to electronic medical record, imaging studies, and laboratory data. The tele-Intensivist also participates in multidisciplinary teaching rounds with the NHCP house staff. Several medical protocols have also been developed and implemented as part of the TCC program. When comparing the 12 months before implementation with the 19 months following implementation, we found (1) a trend toward increase volume of admissions per month (22.9 ± 7.5 vs. 27 ± 6.6, p = 0.11), (2) a decrease in total number of avoidable disengagements (12 ± 0.9 vs. 0, p = 0.0008), (3) increased maximum Acute Physiology and Chronic Health Evaluation II score per month (17.22 ± 2.2 vs. 21.8 ± 5.5, p = 0.018), and no adverse outcomes related to the TCC system. This reduction in disengagements correlated with a savings in out-of-network expenditures of $1.3 million over the 19 months of program operation. There was no change in either the patients' length of stay or the number of patients transferred to NMCSD. TCC improves readiness by increasing the volume and acuity of critical care patient encounters at the spoke hospital. TCC can also enhance Graduate Medical Education by providing Intensivist teaching, and supports the concept of "Regionalized Care" by improving the integration of care between hospitals. The quality of care is improved through the more rapid transfer of patients who require a higher level of care, standardization of care through protocols, and the Intensivist expertise that is applied to patients kept at the smaller facility. The value of care increased through both enhanced quality, and the cost savings associated with decreasing network disengagements. Leveraging new technology to provide remote care for our sickest beneficiaries has been proven a successful solution to the dilemma of limited Intensivist staffing. Leadership should consider TCC as a tool to extend Intensivist expertise to all of our small hospitals, and should explore the application of synchronous telehealth within the operational environment where similar staffing challenges exist., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Fluid resuscitation is the foundation of management in burn patients and is the topic of considerable research. One adjunct in burn resuscitation is continuous, high-dose vitamin C (ascorbic acid) infusion, which may reduce fluid requirements and thus decrease the risk for over resuscitation. Research in preclinical studies and clinical trials has shown continuous infusions of high-dose vitamin C to be beneficial with decrease in resuscitative volumes and limited adverse effects. However, high-dose and low-dose vitamin C supplementation has been shown to cause secondary calcium oxalate nephropathy, worsen acute kidney injury, and delay renal recovery in non-burn patients. To the best of our knowledge, the authors present the first case series in burn patients in whom calcium oxalate nephropathy has been identified after high-dose vitamin C therapy.

Background: Burn Intensive Care Unit (BICU) work is necessarily complex and depends on clinician actions, resources, and variable patient responses to interventions. Clinicians use large volumes of data that are condensed in time, but separated across resources, to care for patients. Correctly designed health information technology (IT) systems may help clinicians to treat these patients more efficiently, accurately, and reliably. We report on a 3-year project to design and develop an ecologically valid IT system for use in a military BICU., Methods: We use a mixed methods Cognitive Systems Engineering approach for research and development. Observations, interviews, artifact analysis, survey, and thematic analysis methods were used to reveal underlying factors that mold the work environment and affect clinician decisions that may affect patient outcomes. Participatory design and prototyping methods have been used to develop solutions., Results: We developed 39 requirements for the IT system and used them to create three use cases to help developers better understand how the system might support clinician work to develop interface prototypes. We also incorporated data mining functions that offer the potential to aid clinicians by recognizing patterns recognition of clinically significant events, such as incipient sepsis. The gaps between information sources and accurate, reliable, and efficient clinical decision that we have identified will enable us to create scenarios to evaluate prototype systems with BICU clinicians, to develop increasingly improved designs, and to measure outcomes., Conclusion: The link from data to analyses, requirements, prototypes, and their evaluation ensures that the solution will reflect and support work in the BICU as it actually occurs, improving staff efficiency and patient care quality., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Efforts to expand Medicaid while controlling spending must be informed by a deeper understanding of the extent to which the high medical costs associated with severe obesity (having a body mass index of [Formula: see text] or higher) determine spending at the state level. Our analysis of population-representative data indicates that in 2013, severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. Approximately 11 percent of the cost of severe obesity was paid for by Medicaid, 30 percent by Medicare and other federal health programs, 27 percent by private health plans, and 30 percent out of pocket. Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations' access to cost-effective treatment for severe obesity should be part of each state's strategy to mitigate rising obesity-related health care costs., (Project HOPE—The People-to-People Health Foundation, Inc.)

Purpose: The Surviving Sepsis Guidelines established recommendations for early recognition and rapid treatment of patients with sepsis. Recognizing systemic difficulties that delayed the application of early goal-directed therapy, the Emergency Department and Critical Care leadership instituted a sepsis protocol to identify patients with sepsis and expedite antibiotic delivery. We aimed to determine if the sepsis protocol improved the time to first dose of antibiotics in patients diagnosed with sepsis., Materials and Methods: We performed a retrospective chart review of patients with sepsis comparing the time from antibiotic order placement to the first dose of antibiotic therapy over a 3-year period. Patients who received vancomycin and ciprofloxacin underwent additional subgroup analysis, as these antibiotics were made available by protocol for use without infectious disease consultation., Results: The average time to first dose of antibiotics for the presepsis protocol group was 160 minutes, and the average time for the sepsis protocol group was 99 minutes. Fifty-eight patients received vancomycin, and 30 received ciprofloxacin, with a decrease in time of 65 minutes and 41 minutes, respectively., Conclusions: Initiation of a sepsis protocol, which emphasizes early goal-directed therapy, can improve time to administration of first dose of antibiotics., (Published by Elsevier Inc.)