Alison S. Clay

One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation: A Cohort Study

BACKGROUND Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. OBJECTIVE To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. DESIGN 1-year prospective cohort study. SETTING 5 intensive care units at Duke University Medical Center, Durham, North Carolina. PARTICIPANTS 126 patients receiving prolonged mechanical ventilation (defined as ventilation for >or=4 days with tracheostomy placement or ventilation for >or=21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. MEASUREMENTS Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care. RESULTS 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was

Expectations and Outcomes of Prolonged Mechanical Ventilation

306,135 (SD,

Debriefing in the intensive care unit: a feedback tool to facilitate bedside teaching.

285,467), and total cohort cost was

Current teaching and evaluation methods in critical care medicine : Has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit?

38.1 million, for an estimated

Multisociety task force recommendations of competencies in Pulmonary and Critical Care Medicine.

3.5 million per independently functioning survivor at 1 year. LIMITATION The results of this single-center study may not be applicable to other centers. CONCLUSION Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. PRIMARY FUNDING SOURCE None.

Management of myxedematous respiratory failure: review of ventilation and weaning principles.

Objective:To compare prolonged mechanical ventilation decision-makers’ expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon. Design:Prospective observational cohort study. Setting:Academic medical center. Patients:A total of 126 patients receiving prolonged mechanical ventilation. Interventions:None. Measurements and Main Results:Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all &kgr; = <0.08), as was their accuracy in outcome prediction (range = 23%–44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients’ likely future survival, general health, and caregiving needs. Conclusions:One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients’ surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates’ unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.

Development of a web-based, specialty specific portfolio

Objective:To develop an assessment tool for bedside teaching in the intensive care unit (ICU) that provides feedback to residents about their performance compared with clinical best practices. Method:We reviewed the literature on the assessment of resident clinical performance in critical care medicine and summarized the strengths and weaknesses of these assessments. Using debriefing after simulation as a model, we created five checklists for different situations encountered in the ICU—areas that encompass different Accreditation Council for Graduate Medical Education core competencies. Checklists were designed to incorporate clinical best practices as defined by the literature and institutional practices as defined by the critical care professionals working in our ICUs. Checklists were used at the beginning of the rotation to explicitly define our expectations to residents and were used during the rotation after a clinical encounter by the resident and supervising physician to review a resident’s performance and to provide feedback to the resident on the accuracy of the resident’s self-assessment of his or her performance. Results:Five “best practice” checklists were developed: central catheter placement, consultation, family discussions, resuscitation of hemorrhagic shock, and resuscitation of septic shock. On average, residents completed 2.6 checklists per rotation. Use of the cards was fairly evenly distributed, with the exception of resuscitation of hemorrhagic shock, which occurs less frequently than the other encounters in the medical ICU. Those who used more debriefing cards had higher fellow and faculty evaluations. Residents felt that debriefing cards were a useful learning tool in the ICU. Conclusions:Debriefing sessions using checklists can be successfully implemented in ICU rotations. Checklists can be used to assess both resident performance and consistency of practice with respect to published standards of care in critical care medicine.

Effects of Respiratory-Therapist Driven Protocols on House-Staff Knowledge and Education of Mechanical Ventilation

Objective:To determine the impact of the Accreditation Council for Graduate Medical Education mandates for duty hours and competencies on instruction, evaluation, and patient care in intensive care units in the United States. Design:A Web-based survey was designed to determine the current methods of teaching and evaluation in the intensive care unit, barriers to changing methods of teaching and evaluation, and the impact of Accreditation Council for Graduate Medical Education regulations on teaching and patient care. Setting:An anonymous Web-based survey was used; cumulative data were analyzed. Subjects:A total of 125 of 380 program directors (33%) for pediatric critical care, pulmonary critical care, anesthesiology critical care, and surgery critical care fellowship programs completed questionnaires. Measurements and Main Results:Bedside case-based teaching and standardized lectures are the most common methods of education in the intensive care unit. Patient safety and resident demands are two factors most likely to result in changes in instruction in the intensive care unit. Barriers to changes in education include clinical workload and lack of protected time and funding. Younger respondents viewed influences to change differently than older respondents. Respondents felt that neither education nor patient care had improved as a result of the Accreditation Council for Graduate Medical Education mandates. Conclusions:Medical education teaching methods and assessment in the intensive care unit have changed little since the initiation of the Accreditation Council for Graduate Medical Education regulations despite respondents’ self-report of a willingness to change. Instead, the Accreditation Council for Graduate Medical Education regulations are thought to have negatively impacted resident attitudes, continuity of care, and even availability for teaching. These concerns, coupled with lack of protected time and funding, serve as barriers toward changes in critical care graduate medical education.

Teaching at the Bedside. Maximal Impact in Minimal Time.

RATIONALE Numerous accrediting organizations are calling for competency-based medical education that would help define specific specialties and serve as a foundation for ongoing assessment throughout a practitioners career. Pulmonary Medicine and Critical Care Medicine are two distinct subspecialties, yet many individual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties identifies educational goals for trainees and guides practitioners through their lifelong learning. OBJECTIVES To define specific competencies for graduates of fellowships in Pulmonary Medicine and Internal Medicine-based Critical Care. METHODS A Task Force composed of representatives from key stakeholder societies convened to identify and define specific competencies for both disciplines. Beginning with a detailed list of existing competencies from diverse sources, the Task Force categorized each item into one of six core competency headings. Each individual item was reviewed by committee members individually, in group meetings, and conference calls. Nominal group methods were used for most items to retain the views and opinions of the minority perspective. Controversial items underwent additional whole group discussions with iterative modified-Delphi techniques. Consensus was ultimately determined by a simple majority vote. MEASUREMENTS AND MAIN RESULTS The Task Force identified and defined 327 specific competencies for Internal Medicine-based Critical Care and 276 for Pulmonary Medicine, each with a designation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty. CONCLUSIONS Specific competencies in Pulmonary and Critical Care Medicine can be identified and defined using a multisociety collaborative approach. These recommendations serve as a starting point and set the stage for future modification to facilitate maximum quality of care as the specialties evolve.

It Takes a Village”: An Interprofessional Patient Safety Experience for Nursing and Medical Students

Respiratory failure in myxedema is a complex medical emergency and may require prolonged ventilatory assistance. Appropriate management of this medical problem requires an understanding of its effects on the central nervous system and peripheral neuromusculoskeletal system. Weaning of these patients can be very protracted and requires a diligent multidisciplinary approach. Because of its infrequency, ventilatory management of severe hypothyroidism has not been studied in a controlled fashion. The first part of this review discusses the mechanisms of respiratory failure in myxedema. The second part explores strategies in mechanical ventilation and weaning of myxedematous patients.