Search

Objectives: Telecritical care (TCC) refers to the delivery of critical care using telehealth technologies. Despite increasing utilization, significant practice variation exists and literature regarding efficacy remains sparse. The Telecritical Care Collaborative Network sought to provide expert, consensus-based best practice recommendations for the design and delivery of TCC., Design: We used a modified Delphi methodology. Following literature review, an oversight panel identified core domains and developed declarative statements for review by an expert voting panel. During three voting rounds, voters agreed or disagreed with statements and provided open-ended feedback, which the oversight panel used to revise statements. Statements met criteria for consensus when accepted by greater than or equal to 85% of voters., Setting/subjects: The oversight panel included 18 multidisciplinary members of the TCC Collaborative Network, and the voting panel included 32 invited experts in TCC, emphasizing diversity of discipline, care delivery models, and geography., Interventions: None., Measurements and Main Results: We identified ten core domains: definitions/terminology; care delivery models; staffing and coverage models; technological considerations; ergonomics and workplace safety; licensing, credentialing, and certification; trust and relationship building; quality, safety, and efficiency, research agenda; and advocacy, leading to 79 practice statements. Of 79 original statements, 67 were accepted in round 1. After revision, nine were accepted in round 2 and two in round 3 (two statements were merged). In total, 78 practice statements achieved expert consensus., Conclusions: These expert consensus recommendations cover a broad range of topics relevant to delivery of TCC. Experts agreed that TCC is most effective when delivered by care teams with specific expertise and by programs with explicit protocols focusing on effective communication, technical reliability, and real-time availability. Interventions should be tailored to local conditions. Although further research is needed to guide future best practice statements, these results provide valuable and actionable recommendations for the delivery of high-quality TCC., Competing Interests: Dr. Singh received funding from Intuitive Surgical. Dr. Laudanski’s institution received funding from the National Institutes of Health. Dr. Rincon received funding from Blue Cirrus Consulting, Baxter Healthcare, Phillips Health, and Viven Health. Dr. Villanueva received funding from Intercept Telemed, Banner Health, Pasadena Law Center; he disclosed that he is the Chief Medical Officer of Intercept Telemed, a telecritical care medicine physician for Banner Health; and he owns stock in Omnicure and Fruit Street Health, Public Benefit Corporation, and owns stock in Google, Amazon, Apple, Edwards Lifesciences, Eli Lilly, Johnson and Johnson, Microsoft, Oracle, Palantir, UnitedHealth Group, Berkshire Hathaway, Proctor and Gamble, and Walmart. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Purpose of Review: This article summarizes recent developments in the application of telemedicine, specifically tele-critical care (TCC), toward enhancing patient care during various types of emergencies and patient rescue scenarios when there are limited resources in terms of staff expertise (i.e., knowledge, skills, and abilities), staffing numbers, space, and supplies due to patient location (e.g., a non-ICU bed, the emergency department, a rural hospital) or patient volume as in pandemic surges., Recent Findings: The COVID-19 pandemic demonstrated the need for rapidly scalable and agile healthcare delivery systems. During the pandemic, clinicians and hospital systems adopted telemedicine for various applications. Taking advantage of technological improvements in cellular networks and personal mobile devices, and despite the limited outcomes literature to support its use, telemedicine was rapidly adopted to address the fundamental challenge of exposure in outpatient settings, emergency departments, patient follow-up, and home-based monitoring. A critical recognition was that the modality of care (e.g., remote vs. in-person) was less important than access to care, regardless of the patient outcomes. This fundamental shift, facilitated by policies that followed emergency declarations, provided an opportunity to maintain and, in many cases, expand and improve clinical practices and hospital systems by bringing expertise to the patient rather than the patient to the expertise. In addition to using telemedicine to maintain patient access to healthcare, TCC was harnessed to provide local clinicians, forced to manage critically ill patients beyond their normal scope of practice or experience, access to remote expertise (physician, nursing, respiratory therapist, pharmacist). These practices supported decades of literature from the telemedicine community describing the effectiveness of telemedicine in improving patient care and the many challenges defining its value., Summary: In this review, we summarize numerous examples of innovative care delivery systems that have utilized telemedicine, focusing on 'mobile' TCC technology solutions to effectively deliver the best care to the patient regardless of patient location. We emphasize how a 'paradigm of better' can enhance the entirety of the healthcare system., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The potential impact of large-scale combat operations and multidomain operations against peer adversaries poses significant challenges to the Military Health System including large volumes of critically ill and injured casualties, prolonged care times in austere care contexts, limited movement, contested logistics, and denied communications. These challenges contribute to the probability of higher casualty mortality and risk that casualty care hinders commanders' forward momentum or opportunities for overmatch on the battlefield. Novel technical solutions and associated concepts of operation that fundamentally change the delivery of casualty care are necessary to achieve desired medical outcomes that include maximizing Warfighter battle-readiness, minimizing return-to-duty time, optimizing medical evacuation that clears casualties from the battlefield while minimizing casualty morbidity and mortality, and minimizing resource consumption across the care continuum. These novel solutions promise to "automate" certain aspects of casualty care at the level of the individual caregiver and the system level, to unburden our limited number of providers to do more and make better (data-driven) decisions. In this commentary, we describe concepts of casualty digital twins-virtual representations of a casualty's physical journey through the roles of care-and how they, combined with passive data collection about casualty status, caregiver actions, and real-time resource use, can lead to human-machine teaming and increasing automation of casualty care across the care continuum while maintaining or improving outcomes. Our path to combat casualty care automation starts with mapping and modeling the context of casualty care in realistic environments through passive data collection of large amounts of unstructured data to inform machine learning models. These context-aware models will be matched with patient physiology models to create casualty digital twins that better predict casualty needs and resources required and ultimately inform and accelerate decision-making across the continuum of care. We will draw from the experience of the automotive industry as an exemplar for achieving automation in health care and inculcate automation as a mechanism for optimizing the casualty care survival chain., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

The COVID-19 pandemic caused tremendous disruption to the U.S. healthcare system and nearly crippled some hospitals during large patient surges. Limited ICU beds across the country further exacerbated these challenges. Telemedicine, specifically tele-critical care (TCC), can expand a hospital's clinical capabilities through remote expertise and increase capacity by offloading some monitoring to remote teams. Unfortunately, the rapid deployment of telemedicine, especially TCC, is constrained by multiple barriers. In the summer of 2020, to support the National Emergency Tele-Critical Care Network (NETCCN) deployment, more than 50 national leaders in applying telemedicine technologies to critical care assembled to provide their opinions about barriers to NETCCN implementation and strategies to overcome them. Through consensus, these experts developed white papers that formed the basis of this article. Herein, the authors share their experience and propose multiple solutions to barriers presented by laws, local policies and cultures, and individual perspectives according to a minimum, better, best paradigm for TCC delivery in the setting of a national disaster. Cross-state licensure and local privileging of virtual experts were identified as the most significant barriers to rapid deployment of services, whereas refining the model of TCC to achieve the best outcomes and defining the best financial model is the most significant for long-term success. Ultimately, we conclude that a rapidly deployable national telemedicine response system is achievable.

Objectives: To determine the impact of telementoring on caregiver performance during a high-fidelity medical simulation model (HFMSM) of a critically ill patient in a resource-limited setting., Design: A two-center, randomized, controlled study using a HFMSM of a patient with community-acquired pneumonia complicated by acute respiratory distress syndrome., Setting: A notional clinic in a remote location staffed by a single clinician and nonmedical assistant., Participants: Clinicians with limited experience managing critically ill patients., Interventions: Telemedicine (TM) support., Measurements: The primary outcome was clinical performance as measured by accuracy, reliability, and efficiency of care. Secondary outcomes were patient survival, procedural quality, subjective assessment of the HFMSM, and perceived workload., Main Results: TM participants ( N = 11) performed better than non-TM (NTM, N = 12) in providing expected care (accuracy), delivering care more consistently (reliability), and without consistent differences in efficiency (timeliness of care). Accuracy: TM completed 91% and NTM 42% of expected tasks and procedures. Efficiency: groups did not differ in the mean (± sd) minutes it took to obtain an advanced airway successfully (TM 15.2 ± 10.5 vs. NTM 22.8 ± 8.4, p = 0.10) or decompress a tension pneumothorax with a needle (TM 0.7 ± 0.5 vs. NTM 0.6 ± 0.9, p = 0.65). TM was slower than NTM in completing thoracostomy (22.3 ± 10.2 vs. 12.3 ± 4.8, p = 0.03). Reliability: TM performed 13 of 17 (76%) tasks with more consistent timing than NTM. TM completed 68% and NTM 29% of procedural quality metrics. Eighty-two percent of the TM participants versus 17% of the NTM participants simulated patients survived ( p = 0.003). The groups similarly perceived the HFMSM as realistic, managed their patients with personal ownership, and experienced comparable workload and stress., Conclusions: Remote expertise provided with TM to caregivers in resource-limited settings improves caregiver performance, quality of care, and potentially real patient survival. HFMSM can be used to study interventions in ways not possible with real patients.

In 2020, the U.S. Department of Defense officially disclosed a set of ethical principles to guide the use of Artificial Intelligence (AI) technologies on future battlefields. Despite stark differences, there are core similarities between the military and medical service. Warriors on battlefields often face life-altering circumstances that require quick decision-making. Medical providers experience similar challenges in a rapidly changing healthcare environment, such as in the emergency department or during surgery treating a life-threatening condition. Generative AI, an emerging technology designed to efficiently generate valuable information, holds great promise. As computing power becomes more accessible and the abundance of health data, such as electronic health records, electrocardiograms, and medical images, increases, it is inevitable that healthcare will be revolutionized by this technology. Recently, generative AI has garnered a lot of attention in the medical research community, leading to debates about its application in the healthcare sector, mainly due to concerns about transparency and related issues. Meanwhile, questions around the potential exacerbation of health disparities due to modeling biases have raised notable ethical concerns regarding the use of this technology in healthcare. However, the ethical principles for generative AI in healthcare have been understudied. As a result, there are no clear solutions to address ethical concerns, and decision-makers often neglect to consider the significance of ethical principles before implementing generative AI in clinical practice. In an attempt to address these issues, we explore ethical principles from the military perspective and propose the "GREAT PLEA" ethical principles, namely Governability, Reliability, Equity, Accountability, Traceability, Privacy, Lawfulness, Empathy, and Eutonomy, for generative AI in healthcare. Furthermore, we introduce a framework for adopting and expanding these ethical principles in a practical way that has been useful in the military and can be applied to healthcare for generative AI, based on contrasting their ethical concerns and risks. Ultimately, we aim to proactively address the ethical dilemmas and challenges posed by the integration of generative AI into healthcare practice., (© 2023. The Author(s).)

Introduction: Future combat environments will be complex, making effective care for multi-domain battlefield injuries more challenging. Technology and resources are essential to reduce provider burden enabling more accurate assessments, decision-making support, expanded treatment, and outcome improvements. Experimentation exercises to evaluate concepts and technologies to incorporate into the Army's future force ensure rapid and continuous integration across air, land, sea, space, and cyberspace domains to overmatch adversaries. A medical lane was first integrated on the communications networks for experimentation in 2022. We describe a project to develop a method for empirically comparing devices intended to support combat casualty care through high-fidelity simulation in preparation for an Army experimentation exercise., Methods: Six medics participated in a series of high-fidelity simulation medical casualty injury scenarios with and without technology devices. The participants provided usability information about their care delivery experiences using the System Usability Scale and Adapted Telehealth Usability Questionnaire-Telemedicine and Advanced Technology Research Command and qualitative feedback., Results: A comparative effectiveness design compared the devices regarding their usability, size, weight, and power with the addition of cost, connectivity, and cyber security, and the qualitative feedback this methodology holistically assessed the technologies as they were applied in the combat casualty care scenario., Conclusions: Results were used by decision makers to determine technology inclusion in experimentation exercise, develop proof of concept methodology to scale for the exercise, and provide technology developers feedback for iterative updates of their devices before participation in experimentation exercise. This project supports the body of simulation studies conducted to understand combat casualty care. It is one of few empirical medical technology assessments with medical personnel end user input that has been reported. The methodology incorporates a user-centered design for rapid technology improvements before fielding., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The ADvanced VIrtual Support for OpeRational Forces (ADVISOR) program is a synchronous telemedicine system developed in 2017 to provide 24/7 remote expert support to U.S. Military and NATO clinicians engaged in medical care in austere locations. Infectious disease (ID) remains the highest consulted service since 2018 and is currently staffed by 10 adult and pediatric ID physicians within the Military Health System. We conducted a retrospective review of the ID ADVISOR calls between 2017 and 2022 to identify trends and better prepare military ID physicians to address urgent ID consultations in overseas settings., Methods: Health records of the ID consultations between July 2017 and January 2022 were reviewed for local caregiver and patient demographics, case descriptions, consultant recommendations, and outcomes. A "not research" determination was made by the Brooke Army Medical Center Human Research Protections Office., Results: ID physicians received 57 calls for 60 urgent patient consultations. Most calls were from countries in the Middle East or in Southwest Asia (United States Central Command (USCENTCOM)), followed by countries in Africa (United States Africa Command (USAFRICOM)). The majority of patients were active duty U.S. Military and were generally male with median age of 25 years. All consults involved an initial phone consultation and 30% continued over email. Ninety percent of the calls were initiated by physicians, and the median time from injury or illness-onset to consult was 3 days. Seventy percent of the consult questions involved treatment and further diagnostics, but one-third of cases required assistance with management of disease prevention. Multidrug-resistant or nosocomial infections, animal or bite exposure, malaria and malaria prevention, febrile illness, and blood-borne pathogen exposure accounted for 63% of the consults. Collaboration with other specialties took place in a minority of cases, and follow-up contact was recommended 20% of the time. Most recommendations involved adjusting drug regimens or further testing. Medical evacuation was only recommended in five of the cases. Although there was limited ability for follow-up, no known deaths occurred., Conclusions: A high proportion of calls to the ID ADVISOR line are relevant to the overlapping content areas of infection prevention, force protection, and outbreak response. Most patients requiring urgent ID consultation were managed successfully without evacuation. The current military-unique ID fellowship curriculum is consistent with the encountered diagnoses per the ID ADVISOR line, and high-yield individual topics have been identified., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: Combat medics are required to perform highly technical medical procedures in austere environments with minimal error. Effective means to quantify medic performance in field and simulated environments are critical to optimize medic training procedures as well as to evaluate the influence of medical equipment and other supportive technologies on medic performance. Human performance evaluation in combat casualty care presents many unique challenges due to the unique environment (battlefields) and population (medics) that must be represented. Recent advances in simulation and measurement technology have presented opportunities to improve simulation fidelity and measurement quality; however, it is currently unclear to what extent these advances have been adopted in this domain., Methodology: In this work, a scoping review of recent (2011-2021) prospective research on Army medic (68 W and Special Operations) performance is presented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines served as the framework for the review. The goal of this work was to summarize recent trends and practices and to illuminate opportunities for future work. Two human factors experts performed an exhaustive review of relevant, peer-reviewed literature and systematically identified articles for inclusion in the final analysis. The articles were examined in detail, and data elements of interest were extracted., Results: Forty-eight articles were identified based on the defined inclusion criteria. Thirty three of the articles focused on technological evaluation, 25 focused on medic training procedures, and 5 focused on evaluating medical techniques. Study contributions were predominantly related to medic training materials/procedures and simulator technology. Supportive medical technologies, including telemedical systems, hemorrhage control devices, and ultrasound devices, also received significant attention. Timing was the most common metric used to quantify medic performance, followed by skill pass/fail ratings. There was a notable lack of neurophysiological data used to examine medic physical/cognitive workload during procedures, a growing practice in many other related domains. The most commonly simulated procedures were hemorrhage control, airway management, and thoracostomy. Notable limitations cited across articles were insufficient simulation fidelity, inadequate sample size or sample representativeness, and poor study design., Conclusions: This work provided a summary of recent peer-reviewed research related to medic simulation and training, and performance evaluation. This article should be used to contextualize existing research and inspire new research questions. Expanding and advancing research on medic simulation and training will help to ensure optimal casualty care at the front lines., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The Military Health System mission is to provide medical care throughout the globe to service members and beneficiaries. To achieve this mission in the most austere of locations, telemedical support is an essential force multiplier when robust in-person medical support is not feasible. This led to the development of a telemedical solution initially known as the Virtual Critical Care Consultation service which provided tele-critical care assistance to downrange providers. The VC3 system then expanded to include multiple medical specialties available for consultation. The current version of this telemedical solution is the ADvanced VIrtual Support for OpeRational Forces (ADVISOR) program which is a synchronous and asynchronous telemedicine system that was developed to provide 24/7 remote expert support to military clinicians engaged in casualty care in austere and operational environments., Materials and Methods: This manuscript reviews the ADVISOR program data collected from 2017 to 2020 and provides a rough order of magnitude for return on investment. We reviewed data collected by Operational Virtual Health Reports and Operational Virtual Health Evaluations following synchronous consultations. Part of the data reviewed was available patient demographic data, local caregiver information, the purpose of the consult, recommendations made during the consult, the technology used during the consult, and the patient disposition. They also recorded the evacuation plan for the patient and whether a medical evacuation was escalated (e.g. changed from routine to urgent, or from urgent to critical care air transport), downgraded (e.g. urgent to routine), or avoided altogether based on the telephonic consultation., Results: There were a total of 156 real-world calls during the evaluation period. The total cost savings for these calls was $1,097,027 (3-year program costs of $909,973 less an average of $87,261+/- $28,633 per call or $2,007,000 total) from downgrading or avoidance of planned evacuations. The unmeasured value associated with ADVISOR consultations should also be commented on. For example, when evacuation plans are escalated based on remote expert consultation, it is probable that the escalation increases patient safety and may avoid medical complications that would result in longer term medical costs to the government., Conclusions: Based on the collected information, the financial return on investment has exceeded costs and the system is perceived as being valued added for both local caregivers and remote experts. The system appears to help optimize evacuation planning, specifically by downgrading or eliminating unnecessary evacuations., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background: The US Central Command (CENTCOM) area of responsibility (AOR) spans 20 nations in the Middle East, Central, and South Asia. Evacuations outside this AOR include all injury types and severities; however, it remains unclear what proportion of evacuations were due to disease and non-battle injuries (DNBI). Understanding these patterns may be useful for defining future medical support requirements for multi domain operations (MDO). We sought to analyze encounters obtained from the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) data for medical evacuations within CENTCOM., Methods: We obtained all encounters within TRAC2ES from February 2009 to November 2018. We analyzed data using entered demographic data and keyword categorization of free text information provided by the medical officer requesting patient movement., Results: There were 50,036 patient movement requests entered into TRAC2ES originating from the CENTCOM AOR for both military and civilian personnel. After removal of ineligible entries (for example, military working dogs), the number of eligible subjects was 49,259, 13 percent combat (n equals 6,389) and 87 percent were noncombat (n equals 42,870). The primary age group requiring evacuation was 18 through 29 (59 percent) and were mostly male (87 percent). Most went by routine status (80 percent), followed by priority (16 percent). Most of the transfers originated from Afghanistan (58 percent) and Iraq (22 percent), with Germany serving as the primary destination (79 percent). Results showed the total number of patient evacuations increased from 2009 to 2010 and then decreased from 2011 to 2017. The most frequent body region associated with the transfer was the extremities for both combat (54 percent) and noncombat (32 percent)., Conclusions: Out of theater disease and non combat injury evacuation rates were nearly 7 times higher than for combat related injuries. Our results highlight the need for additional research and development resources of DNBI related medical care. As we move into future MDO with limited evacuation capabilities, we will need support solutions to cover the full gamut of DNBI.

Most high-fidelity medical simulation is of limited duration, used for education and training, and rarely intended to study medical technology. U.S. caregivers working in prehospital, resource-limited settings may need to manage patients for extended periods (hours to days). This "prolonged casualty care" occurs during military, wilderness, humanitarian, disaster, and space medicine. We sought to develop a standardized simulation model that accurately reflects prolonged casualty care in order to study caregiver decision-making and performance, training requirements, and technology use in prolonged casualty care., Design: Model development., Setting: High-fidelity simulation laboratory., Subjects: None., Interventions: We interviewed subject matter experts to identify relevant prolonged casualty care medical challenges and selected two casualty types to further develop our model: a large thermal burn model and a severe hypoxia model. We met with a multidisciplinary group of experts in prolonged casualty care, nursing, and critical care to describe how these problems could evolve over time and how to contextualize the problems with a background story and clinical environment with expected resource availability. Following initial scenario drafting, we tested the models with expert clinicians. After multiple tests, we selected the hypoxia model for refinement and testing with inexperienced providers. We tested and refined this model until two research teams could proctor the scenario consistently despite subject performance variability., Measurements and Main Results: We developed a 6-8-hour simulation model that represented a 14-hour scenario. This model of pneumonia evolved from presentation to severe hypoxia necessitating advanced interventions including airway, breathing, and shock management. The model included: context description, caregiver orientation scripts, hourly progressive physiology tracks corresponding to caregiver interventions, intervention/procedure-specific physiology tracks, intervention checklists, equipment lists, prestudy checklists, photographs of setups, procedure, telementor, and role player scripts, business rules, and data collection methods., Conclusions: This is the first standardized, high-fidelity simulation model of prolonged casualty care described in the literature. It may be used to assess caregiver performance and patient outcomes resulting from that performance during a complex, 14-hour prolonged casualty care scenario. Because it is standardized, the model may be used to compare differences in the impact of new technologies upon caregiver performance and simulated patient outcomes.., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Competing Interests: Dr. Pamplin’s institution received funding from the Defense Health Agency, U.S. Army Medical Research and Development Command, and the U.S. Department of Health and Human Services, and he received support for article research from the Defense Health Agency and the Department of Health and Human Services. Drs. Pamplin, Quinn, Little, Goede, Colombo, and Davis disclosed Government work. Dr. Little’s institution received funding from the United States Government—CARES Act. Dr. Colombo disclosed that he is the Principal Investigator for National Emergency Tele-Critical Care Network Team with the Geneva Foundation. Dr. Davis received grant funding for telemedicine research and development work. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Introduction: Tele-critical care (TCC) has improved outcomes in civilian hospitals and military treatment facilities (MTFs). Tele-critical care has the potential to concurrently support MTFs and operational environments and could increase capacity and capability during mass casualty events. TCC services distributed across multiple hub sites may flexibly adapt to rapid changes in patient volume and complexity to fully optimize resources. Given the highly variable census in MTF intensive care units (ICU), the proposed TCC solution offers system resiliency and redundancy for garrison, operational, and mass casualty needs, while also maximizing return on investment for the Defense Health Agency., Materials and Methods: The investigators piloted simultaneous TCC support to the MTF during three field exercises: (1) TCC concurrently monitored the ICU during a remote mass casualty exercise: the TCC physician monitored a high-risk ICU patient while the nurse monitored 24 simulated field casualties; (2) TCC concurrently monitored the garrison ICU and a remote military medical field exercise: the physician provided tele-mentoring during prolonged field care for a simulated casualty, and the nurse provided hospital ICU TCC; (3) the TCC nurse simultaneously monitored the ICU while providing reach-back support to field hospital nurses training in a simulation scenario., Results: TCC proved feasible during multiple exercises with concurrent tele-mentoring to different care environments including physician and nurse alternating operational and hospital support roles, and an ICU nurse managing both simultaneously. ICU staff noted enhanced quality and safety of bedside care. Field exercise participants indicated TCC expanded multipatient monitoring during mass casualties and enhanced novice caregiver procedural capability and scope of patient complexity., Conclusions: Tele-critical care can extend critical care services to anywhere at any time in support of garrison medicine, operational medicine, and mass casualty settings. An interoperable, flexibly staffed, and rapidly expandable TCC network must be further developed given the potential for large casualty volumes to overwhelm a single TCC provider with multiple duties. Lessons learned from development of this capability should have applicability for managing military and civilian mass casualty events., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Coronavirus disease 2019 (COVID-19) has led to a national health care emergency in the United States and exposed resource shortages, particularly of health care providers trained to provide critical or intensive care. This article describes how digital health technologies are being or could be used for COVID-19 mitigation. It then proposes the National Emergency Tele-Critical Care Network (NETCCN), which would combine digital health technologies to address this and future crises. Methods: Subject matter experts from the Society of Critical Care Medicine and the Telemedicine and Advanced Technology Research Center examined the peer-reviewed literature and science/technology news to see what digital health technologies have already been or could be implemented to (1) support patients while limiting COVID-19 transmission, (2) increase health care providers' capability and capacity, and (3) predict/prevent future outbreaks. Results: Major technologies identified included telemedicine and mobile care (for COVID-19 as well as routine care), tiered telementoring, telecritical care, robotics, and artificial intelligence for monitoring. Several of these could be assimilated to form an interoperable scalable NETCCN. NETCCN would assist health care providers, wherever they are located, by obtaining real-time patient and supplies data and disseminating critical care expertise. NETCCN capabilities should be maintained between disasters and regularly tested to ensure continual readiness. Conclusions: COVID-19 has demonstrated the impact of a large-scale health emergency on the existing infrastructures. Short term, an approach to meeting this challenge is to adopt existing digital health technologies. Long term, developing a NETCCN may ensure that the necessary ecosystem is available to respond to future emergencies.

Objectives: To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation., Design: Retrospective review of the literature and expert consensus., Setting: Series of in-person meetings, conference calls, and emails from January 2018 to March 2019., Subjects: A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field., Interventions: A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9., Measurements and Main Results: The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead., Conclusions: The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.

Social distancing as a technique to limit transmission of infectious disease has come into common parlance following the arrival and rapid spread of a novel coronavirus disease around the world in 2019 and 2020. But in the face of an emerging pandemic threat, it is crucial that we start to apply these principles to the clinic, the emergency department, and the hospital ward. We propose that this dynamic situation calls for a parallel "Clinical Distancing" in which we as a medical culture go against many of our fundamental instincts and, at least in the short term, begin to reduce unnecessary patient-care contacts for the benefit of our patients and our ability to continue to provide care to those who need it most. In this commentary, we provide specific recommendations for the rapid implementation of clinical distancing techniques., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objectives: In 2014, the Tele-ICU Committee of the Society of Critical Care Medicine published an article regarding the state of ICU telemedicine, one better defined today as tele-critical care. Given the rapid evolution in the field, the authors now provide an updated review., Data Sources and Study Selection: We searched PubMed and OVID for peer-reviewed literature published between 2010 and 2018 related to significant developments in tele-critical care, including its prevalence, function, activity, and technologies. Search terms included electronic ICU, tele-ICU, critical care telemedicine, and ICU telemedicine with appropriate descriptors relevant to each sub-section. Additionally, information from surveys done by the Society of Critical Care Medicine was included given the relevance to the discussion and was referenced accordingly., Data Extraction and Data Synthesis: Tele-critical care continues to evolve in multiple domains, including organizational structure, technologies, expanded-use case scenarios, and novel applications. Insights have been gained in economic impact and human and organizational factors affecting tele-critical care delivery. Legislation and credentialing continue to significantly influence the pace of tele-critical care growth and adoption., Conclusions: Tele-critical care is an established mechanism to leverage critical care expertise to ICUs and beyond, but systematic research comparing different models, approaches, and technologies is still needed.

Austere clinical environments are those in which limited resources hamper the achievement of optimal patient outcomes. Operational environments are those in which caregivers and resources are at risk for harm. Military and civilian caregivers experience these environments in the context of war, natural disasters, humanitarian assistance missions, and mass casualty events. The military has a particular interest in enhancing local caregiver capabilities within austere and operational environments to improve casualty outcomes when evacuation is delayed or impossible, reduce the cost and the risk of unnecessary evacuations, enhance the medical response during aid missions, and increase combat effectiveness by keeping service members in the fight as long as possible. This article describes military telehealth as it relates to care in austere and operational environments, and it suggests implications for policy, particularly with respect to the current emphasis on telehealth solutions that might not be feasible in those settings.

Objective: Review the application of telemedicine support for managing a patient with possible sepsis, suspected malaria, and unusual musculoskeletal symptoms. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in the Africa Command area of responsibility. Care provided by a small Role I facility on the compound. Organic Medical Expertise: Five 68W combat medics (one is the patient); one SOCM trained 68W combat medic. No US provider present in country. Closest Medical Support: Organic battalion physician assistant (PA) located in the USA; USARAF PA located in Italy; French Role II located in bordering West African country; medical consultation sought via telephone, WhatsApp® (communication with French physician) or over unclassified, encrypted e-mail. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate country clearances and approval to fly from three countries including French forces support approval., (2019.)

Introduction: Critical care is an important component of in-patient and combat casualty care, and it is a major contributor to U.S. healthcare costs. Regular exposure to critically ill and injured patients may directly contribute to wartime skills retention for military caregivers. Data describing critical care services in the Military Health System (MHS), however, is lacking. This study was undertaken to describe MHS critical care services, their resource utilization, and differences in care practices amongst military treatment facilities (MTFs)., Materials and Methods: Twenty-six MTFs representing 38 adult critical care services or intensive care units (ICUs) were surveyed. The survey collected information about organizational structure, resourcing, and unit characteristics at the time of a concurrent 24-h point-prevalence survey designed to describe patient characteristics and staffing in these facilities. The survey was anonymous and protected health information was not collected. We analyzed the data according to high capacity centers (HCCs) (≥200 beds) and low capacity centers (LCCs) (<200 beds). Differences between HCCs and LCCs were compared using Fisher's exact test., Results: Seventeen MTFs (7 HCCs and 10 LCCs), representing 27 ICUs, responded to the survey. This was a 65% response rate for MTFs and a 71% response rate for services/ICUs. HCCs reported more closed vs. open ICUs; more dedicated critical care services (i.e., medical and surgical ICUs vs. mixed ICUs); fewer respiratory therapists available, but more with certification; more total nursing staff and more critical care certified nurses; the use of subjectively more effective protocols (10.5 vs. 6.7 protocols/unit or service); higher utilization of an ICU daily rounds checklist (65% vs. 0%); and less consistency of clinician type participation during multidisciplinary rounds. ICU leadership structure was similar among the institutions. The majority of respondents were unable to provide summary APACHE II scores, but HCCs were more likely to submit this information than LCCs. Most centers perform multidisciplinary rounds daily, but they are more likely to be run by a physician credentialed in critical care at HCCs (85% vs. 59%, p < 0.05). 67% of respondents reported mortality rates <5%. The two services that reported mortality rates greater than 10% were both LCCs., Conclusion: This is the first comprehensive report about MHS critical care services. Despite notable variability in data reporting, an important finding itself, this study highlights notable differences in organizational structure and resourcing between HCCs and LCCs within the MHS. The clinical implication of these differences (i.e., impact on patient outcomes) of these differences require further study. Better understanding of MHS critical care services may improve enterprise decision-making about these services which could ultimately improve care of combat casualties.

Introduction: U.S. military forces have engaged in combat in mature areas of operations (AOs) in Iraq and Afghanistan that allow for casualty evacuation to definitive surgical care within "The Golden Hour." Future combat casualty care will be complex and challenging. Facing the medical demand of the Multi-Domain Battlefield remains an uncertain problem set. What can be anticipated is that a near peer adversary will not allow freedom of movement, air superiority, or uninterrupted communications. Telemedicine is one solution that can aid in this environment because it can reduce the medical footprint in a theater of operation by bringing the remote expert's knowledge and experience to the point of need., Materials and Methods: Telemedicine can augment the capabilities of caregivers in austere, operational settings using synchronous or asynchronous technology to optimize the care of casualties who are delayed in evacuation to higher levels of care. These technologies have been implemented and tested over the past 30 yr. We reviewed the historical literature about military telemedicine and assembled current leaders in military telemedicine to write this review., Results: This manuscript reviews the history of and current capabilities of military telemedicine., Conclusions: Broad implementation of telemedicine in the operational setting is challenged by network limitations and cyber security concerns. Reliable, high bandwidth, low latency, secure communications that is necessary for advanced telemedicine capabilities (i.e., procedural telementoring) will not likely be available at all times during future engagements. The military must develop and train a full spectrum of telemedical support options that include low-to-high bandwidth solutions. Telemedicine is not a substitute for deploying anticipated medical resources or optimizing training: telemedicine is plan B where plan A is training, deployment, and casualty evacuation. Nevertheless, when network and communications resources are sufficient, telemedicine brings advanced expertise to austere, resource-limited contexts when timely evacuation is not possible.

Background: Healthcare expenditures are a significant economic cost with critical care services constituting one of its largest components. The Military Health System (MHS) is the largest, global healthcare system of its kind. In this project, we sought to describe critical care services and the patients who receive them in the MHS., Methods: We surveyed 26 military treatment facilities (MTFs) representing 38 critical care services or intensive care units (ICUs). MTFs with multiple ICUs and critical care services responded to the survey as services (e.g., surgical or medical ICU service), whereas MTFs with only one ICU responded as a unit and gave information about all types of patients (i.e., medical and surgical). Our survey was divided into an administrative portion and a 24-h point prevalence survey of patients and patient care. The administrative portion is reported separately in this journal. The 24-h point prevalence survey collected information about all patients present in, admitted to, or discharged from participating services/units during the same 24-h period in December 2014. The survey was anonymous and protected health information was not collected., Findings: Sixteen MTFs (69%) and 27 ICU services/units (71%) returned the point prevalence survey. MTFs with >200 beds (n = 3, 22%) were categorized as "high capacity centers" (HCCs) whereas those with ≤200 beds (n = 13, 78%) were characterized as low capacity centers (LCCs). Two MTFs (one HCC and one LCC) returned only administrative data. The remaining 16 MTFs reported data about 151 patients. In all, 100 (67%) of the patients were at three HCCs during this study period. One HCC accounted for 39% (59 patients) of all patient care during this study. Most patients were cared for in mixed medical/surgical ICUs (34.4%), followed by medical (21.2%), surgical (18.5%), trauma (11.9%), cardiac (7.9%), and burn (6.0%) ICUs. The most common medical indication for admission was cardiac followed by general medical. The most common surgical indications for admission were trauma, other, and cardiothoracic surgery. The average APACHE II score of all patients across both LCCs and HCCs was 11 ± 8.1 (8 ± 7.8 vs. 13 ± 7.7 p = 0.008). The lower acuity of patients in this study is reflected in a high turnover rate, low rate of arterial and central line placements (33%), and low rates of life support (all types, 30%; mechanical ventilation only, 21.2%; noninvasive mechanic ventilation only, 7.9%; and vasoactive medications, 6.6%). Thirty-five (23.2%) patients within the study were affected by a total of 57 complications. The three most common complications experienced were acute kidney injury, bleeding, and sepsis., Discussion: This is the first detailed report about MHS critical care services and the patients receiving care. It describes a low acuity ICU patient population, concentrated at larger MTFs. This study highlights the need for the establishment of a system that allows for the continuous collection of high priority information about clinical care in the MHS in order to facilitate implementation of standardized protocols and process improvements.

Management of wartime burn casualties can be very challenging. Burns frequently occur in the setting of other blunt and penetrating injuries. This clinical practice guideline provides a manual for burn injury assessment, resuscitation, wound care, and specific scenarios including chemical and electrical injuries in the deployed or austere setting. The clinical practice guideline also reviews considerations for the definitive care of local national patients, including pediatric patients, who are unable to be evacuated from theater. Medical providers are encouraged to contact the US Army Institute of Surgical Research (USAISR) Burn Center when caring for a burn casualty in the deployed setting.

Toxic industrial chemicals include chlorine, phosgene, hydrogen sulfide, and ammonia have variable effects on the respiratory tract, and maybe seen alone or in combination, secondary to inhalation injury. Other considerations include the effects of cyanide, carbon monoxide, and fire suppressants. This Clinical Practice Guideline (CPG) will provide the reader with a brief overview of these important topics and general management strategies for each as well as for inhalation injury. Chlorine, phosgene, hydrogen sulfide, and ammonia are either of intermediate or high water solubility leading to immediate reactions with mucous membranes of the face, throat, and lungs and rapid symptoms onset after exposure. The exception to rapid symptom onset is phosgene which may take up to a day to develop severe acute respiratory distress syndrome. Management of these patients includes early airway management, lung-protective ventilator strategies, aggressive pulmonary toilet, and avoidance of volume overload.

Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. In the austere or hostile environment, the challenges to deliver care to this patient population are magnified. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.

Objective: Review clinical thought process and key principles for diagnosing weaponized chemical and biologic injuries. Clinical Context: Special Operation Forces (SOF) team deployed in an undisclosed, austere environment. Organic Expertise: Two SOF Soldiers with civilian EMT-Basic certification. Closest Medical Support: Mobile Forward Surgical Team (2 hours away); medical consults available by e-mail, phone, or video-teleconsultation. Earliest Evacuation: Earliest military evacuation from country 12-24 hours. With teleconsultation, patients departed to Germany as originally scheduled without need for Medical Evacuation., (2018.)

Objective: Review the management of a patient with acute patella fracture supported by telemedical consultation. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in Africa Command area of responsibility. Care was provided by a Role I facility on the compound. Organic Expertise: Three 68W combat medics; one Special Operations Combat Medic (SOCM). Closest Medical Support: Organic battalion physician assistant (PA) located in the United States; USARAF PA located in a European country; French Role II located in nearby West African country; telemedical consults via e-mail, phone, or videoteleconsultation. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate clearances., (2018.)

Portable pulsed xenon ultraviolet disinfection (PPX-UVD) may reduce healthcare associated infections (HAI). There is limited data to inform use in burn intensive care units (BICU), where multidrug-resistant organisms (MDRO), especially gram negative rods (GNR), commonly cause disease. We evaluated PPX-UVD effects on environmental bioburden and rates of HAI and MDRO acquisition in a BICU. PPX-UVD was used for 3 months after standard cleaning of patient and operating rooms (ORs). Settle and touch plates in patient rooms and ORs were obtained after standard cleaning, pre-and post-PPX-UVD. HAI and MDRO acquisition were evaluated 1year prior to and for 3 month periods before, during, and after PPX-UVD. 110 touch and settle plates (33 pre- and 30 post-PPX-UVD) were obtained after standard cleaning, pre- and post-PPX-UVD. After PPX-UVD, environmental samples with any growth decreased (48% vs 31%, p=0.02), as did mean colony count/sample (2.8 pre- vs 1.6 post-, p=0.03). The 379 colonies largely represented skin commensals, without identified MDRO. Following PPX-UVD, no changes in device-associated infections, overall MDRO, or MDR GNR were seen, though a prolonged interval without healthcare-associated Clostridium difficile infection was observed. PPX-UVD in a BICU reduced overall environmental bioburden, without a statistically significant impact on HAI or MDRO., (Published by Elsevier Ltd.)

Multidisciplinary rounds (MDRs) in the burn intensive care unit serve as an efficient means for clinicians to assess patient status and establish patient care priorities. Both tasks require significant cognitive work, the magnitude of which is relevant because increased cognitive work of task completion has been associated with increased error rates. We sought to quantify this workload during MDR using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). Research staff at three academic regional referral burn centers administered the NASA-TLX to clinicians during MDR. Clinicians assessed their workload associated with 1) "Identify(ing) if the patient is better, same, or worse than yesterday" and 2) "Identify(ing) the most important objectives of care for the patient today." Data were collected on clinician type, years of experience, and hours of direct patient care. Surveys were administered to 116 total clinicians, 41 physicians, 25 nurses, 13 medical students, and 37 clinicians in other roles. Clinicians with less experience reported more cognitive work when completing both tasks (P < .005). Clinicians in the "others" group (respiratory therapists, dieticians, pharmacists, etc.) reported less cognitive work than all other groups for both tasks (P < .05). The NASA-TLX was an effective tool for collecting perceptions of cognitive workload associated with MDR. Perceived cognitive work varied by clinician type and experience level when completing two key tasks. Less experience was associated with increased perceived work, potentially increasing mental error rates, and increasing risk to patients. Creating tools or work processes to reduce cognitive work may improve clinician performance.

Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients., (© The Author(s) 2015.)

Objective: Review application of telemedicine support for penetrating trauma. Clinical context: Special Operations Resuscitation Team (SORT) deployed in Africa Area of Responsibility (AOR) Organic expertise: Internal Medicine physician, two Special Operations Combat medics (SOCMs), and one radiology technician Closest surgical support: Non-US surgical support 20km away; a nonsurgeon who will perform surgeries; neighboring country partner-force surgeon 2 hours by fixedwing flight. Earliest evacuation: Evacuated 4 days after presentation to a neighboring country with surgical capability., (2016.)

Objective: Review application of telemedicine support for removal of fragment and wound management. Clinical context: Special Forces Operational Detachment- Alpha deployed in Central Command area of responsibility operating out of a small aid station ("house" phase of prolonged field care) Organic expertise: 18D Special Operations Combat medic Closest medical support: Combined Joint Special Operations Task Force (CJSOTF) surgeon located in another country; thus, all consults were either via telephone or over Secret Internet Protocol Router e-mail. Earliest evacuation: NA., (2016.)

One of the core capabilities of prolonged field care is telemedicine. We developed the Virtual Critical Care Consult (VC3) Service to provide Special Operations Forces (SOF) medics with on-demand, virtual consultation with experienced critical care physicians to optimize management and improve outcomes of complicated, critically injured or ill patients. Intensive-care doctors staff VC3 continuously. SOF medics access this service via phone or e-mail. A single phone call reaches an intensivist immediately. An e-mail distribution list is used to share information such as casualty images, vital signs flowsheet data, and short video clips, and helps maintain situational awareness among the VC3 critical care providers and other key SOF medical leaders. This real-time support enables direct communication between the remote provider and the clinical subject matter expert, thus facilitating expert management from near the point of injury until definitive care can be administered. The VC3 pilot program has been extensively tested in field training exercises and validated in several real-world encounters. It is an immediately available capability that can reduce medical risk and is scalable to all Special Operations Command forces., (2016.)

Background: Recently, automated alerts have been used to identify patients with respiratory failure based on set criteria, which can be gleaned from the electronic medical record (EMR). Such an approach may also be useful for identifying patients with severe adult respiratory distress syndrome (ARDS) who may benefit from extracorporeal membrane oxygenation (ECMO). Inhaled nitric oxide (iNO) is a common rescue therapy for severe ARDS which can be easily tracked in the EMR, and some patients started on iNO may have indications for initiating ECMO. This case series summarizes our experience with using automated electronic alerts for ECMO team activation focused particularly on an alert triggered by the initiation of iNO., Methods: After a brief trial evaluation, our Smart Alert system generated an automated page and e-mail alert to ECMO team members whenever a nonzero value for iNO appeared in the respiratory care section of our EMR. If iNO was initiated for severe respiratory failure, a detailed evaluation by the ECMO team determined if ECMO was indicated. For those patients managed with ECMO, we tabulated baseline characteristics, indication for ECMO, and outcomes., Results: From September 2012 to July 2013, 45 iNO alerts were generated on 42 unique patients. Six patients (14%) met criteria for ECMO. Of these, four were identified exclusively by the iNO alert. At the time of the alert, the median PaO₂-to-FIO₂ ratio was 64 mm Hg (range, 55-107 mm Hg), the median age-adjusted oxygenation index was 73 (range, 51-96), and the median Murray score was 3.4 (range, 3-3.75), indicating severe respiratory failure. Median time from iNO alert to ECMO initiation was 81 hours (range, -2-292 hours). Survival to hospital discharge was 83% in those managed with ECMO., Conclusion: Automated alerts may be useful for identifying patients with severe ARDS who may be ECMO candidates., Level of Evidence: Diagnostic test, level V.

Purpose: Establishing well-understood daily patient care goals should improve healthcare team (HCT) communication, reduce errors, and improve patient outcomes. The purpose of this study was to test the hypothesis that implementation of a daily goals "Door Communication Card" (DCC) would improve goal alignment between members of the HCT., Methods: As part of a process improvement project, HCT members listed their top care goals for a patient on a given day. After initial data collection, DCCs were placed on patients' doors. Anyone was allowed to write on the card, but the "official" daily goals were recorded during multidisciplinary rounds. One month after introduction of the DCC, HCT members were re-queried about their patients' care goals. Three reviewers independently compared goals and assessed their alignment before and after implementation of the DCC. We collected goals over a 4-month period and selected 5 random days before and after intervention for assessment., Results: The goal alignment among HCT members was low before and did not improve after intervention (Attending-to-Nurse 55% vs 38%, P = .02; Attending-to-Resident 60% vs 54%, P = .43; Attending-to-Primary 35% vs 28%, P = .45; Nurse-to-Attending 52% vs 36%, P = .03; Nurse-to-Resident 55% vs 38%, P = .04; Nurse-to-Primary 37% vs 27%, P = .36; Resident-to-Attending 59% vs 54%, P = .4; Resident-to-Nurse 56% vs 40%, P = .05; Resident-to-Primary 36% vs 24%, P = .16; Primary-to-Attending 34% vs 42%, P = .44; Primary-to-Nurse 42% vs 35%, P = .6; Primary-to-Resident 32% vs 34%, P = .8)., Conclusions: Alignment of daily patient care goals among HCT members is low overall and did not improve after implementing a DCC available to all team members. Further study to elucidate the mechanism by which daily goals forms improve patient care is required., (Published by Elsevier Inc.)

Background: Combat casualty care is distributed across professions and echelons of care. Communication within it is fragmented, inconsistent, and prone to failure. Daily checklists used during intensive care unit (ICU) rounds have been shown to improve compliance with evidence-based practices, enhance communication, promote consistency of care, and improve outcomes. Checklists are criticized because it is difficult to establish a causal link between them and their effect on outcomes. We investigated how checklists used during ICU rounds affect communication., Methods: We conducted this project in two military ICUs (burn and surgical/trauma). Checklists contained up to 21 questions grouped according to patient population. We recorded which checklist items were discussed during rounds before and after implementation of a "must address" checklist and compared the frequency of discussing items before checklist prompting., Results: Patient discussions addressed more checklist items before prompting at the end of the 2-week evaluation compared with the 2-week preimplementation period (surgical trauma ICU, 36% vs. 77%, p < 0.0001; burn ICU, 47% vs. 72 %, p < 0.001). Most items were addressed more frequently in both ICUs after implementation. Key items such as central line removal, reduction of laboratory testing, medication reconciliation, medication interactions, bowel movements, sedation holidays, breathing trials, and lung protective ventilation showed significant improvements., Conclusion: Checklists modify communication patterns. Improved communication facilitated by checklists may be one mechanism behind their effectiveness. Checklists are powerful tools that can rapidly alter patient care delivery. Implementing checklists could facilitate the rapid dissemination of clinical practice changes, improve communication between echelons of care and between individuals involved in patient care, and reduce missed information.

Early detection and management of shock are important in optimizing clinical outcomes. One regional marker, sublingual capnography (SLCO2), is particularly appealing as redistribution of blood flow away from the sublingual mucosa can happen very early in the compensatory phase of hypovolemic shock. Our objective was to test the hypothesis that SLCO2 would detect early hypovolemia in a human laboratory model of hemorrhage: progressive lower body negative pressure until onset of cardiovascular collapse. Eighteen healthy nonsmoking subjects (10 males, 8 females) with mean age of 28 (SD, 8) years, body weight of 72 (SD, 13) kg, and height of 172 (SD, 9) cm were recruited to participate, of whom 17 completed the experiment. Average time to presyncope was 1,579 ± 72 s (mean ± SE). At the time of cardiovascular collapse, lower body negative pressure altered (P < 0.001) systolic blood pressure (mean ± SE: 130 ± 3 vs. 98 ± 2 mm Hg), pulse pressure (mean ± SE: 58 ± 2 vs. 33 ± 2 mm Hg), and heart rate (mean ± SE: 63 ± 3 vs. 102 ± 6 beats/min) when compared with baseline, whereas SLCO2 did not change (49.1 ± 1.0 vs. 48.6 ± 1.5 mm Hg, P = 0.624). In a model of progressive central hypovolemia in humans, we did not detect metabolic derangements in the sublingual mucosa as measured by SLCO2.

Communication failures are a significant contributor to medical errors that harm patients. Critical care delivery is a complex system of inter-professional work that is distributed across time, space, and multiple disciplines. Because health-care education and delivery remain siloed by profession, we lack a shared framework within which we discuss and subsequently optimize patient care. Furthermore, our disparate professional perspectives and interests often interfere with our ability to effectively prioritize individual care. It is important, therefore, to develop a cognitively shared framework for understanding a patient's severity of illness and plan of care across multiple, traditionally poorly communicating disciplines. We suggest that the 'phases-of-illness paradigm' will facilitate communication about critically ill patients and create a shared mental model for interdisciplinary patient care. In so doing, this paradigm may reduce communication errors, complications, and costs while improving resource utilization and trainee education. Additional research applications are feasible.

Background: Acute lung injury (ALI) is a syndrome consisting of noncardiogenic acute hypoxemic respiratory failure with the presence of bilateral pulmonary infiltrates and occurs in up to 33% of critically ill trauma patients. Retrospective and observational studies have suggested that a blood component resuscitation strategy using equal ratios of packed red blood cells (PRBCs) and fresh frozen plasma (FFP) may have a survival benefit in combat casualties. The purpose of this study was to determine whether this strategy is associated with an increased incidence of ALI., Methods: We performed a prospective observational study of all injured patients admitted to an intensive care unit (ICU) at a combat support hospital who required >5 units of blood transfusion within the first 24 hours of admission. Baseline demographic data along with Injury Severity Score (ISS), pulmonary injury, presence of long bone fracture, blood products transfused, mechanical ventilation data, and arterial blood gas analysis were collected. The primary endpoint of the study was the development of ALI at 48 hours after injury. Those who did not survive to ICU admission were excluded from analysis. Follow-up (including mortality) longer than 48 hours was unavailable secondary to rapid transfer out of our facility. A multivariate logistic regression was performed to determine the independent effects of variables on the incidence of early ALI., Results: During a 12-month period (from January 2008 to December 2008), 87 subjects were studied; of these, 66 patients met inclusion criteria, and 22 patients developed ALI at 48 hours (33%). Overall, the ratio of FFP to PRBC was 1:1.1. Those who developed ALI had a higher ISS (32 +/- 15 vs. 26 +/- 11; p = 0.04) and received more units of FFP (22 +/- 15 vs. 12 +/- 7; p < 0.001), PRBCs (22 +/- 16 vs. 13 +/- 7; p = 0.008), and platelets (5 +/- 11 vs. 1 +/- 2; p = 0.004) compared with those who did not develop ALI. Multivariate logistic regression analysis revealed that presence of pulmonary injury (odds ratio, 5.4; 95% confidence interval, 1.3-21.9) and volume of FFP transfused (odds ratio, 1.2; 95% confidence interval, 1.1-1.3) had independent effects on ALI at 48 hours., Conclusion: On the basis of this small, prospective, descriptive study of severely injured patients admitted to the ICU, we determined that the presence of pulmonary injury had the greatest impact on the incidence of early ALI. There was also an independent relationship between the amount of FFP transfused and the incidence of early ALI. Further studies are required to determine the effects of the development of early ALI from FFP transfusion on short- and long-term survival.