Amelia Barwise

Outcomes of surgical treatment for nonfunctioning pituitary adenomas: a systematic review and meta-analysis

Background  Surgery is commonly used in the management of pituitary nonfunctioning adenomas (NFPA). The goal of this systematic review and meta‐analysis is to evaluate the effect of surgery on mortality, surgical complications, pituitary function and vision.

Outcomes of surgical treatment for nonfunctioning pituitary adenomas

Background  Surgery is commonly used in the management of pituitary nonfunctioning adenomas (NFPA). The goal of this systematic review and meta‐analysis is to evaluate the effect of surgery on mortality, surgical complications, pituitary function and vision.

Delayed Rapid Response Team Activation Is Associated With Increased Hospital Mortality, Morbidity, and Length of Stay in a Tertiary Care Institution.

Objective:To identify whether delays in rapid response team activation contributed to worse patient outcomes (mortality and morbidity). Design:Retrospective observational cohort study including all rapid response team activations in 2012. Setting:Tertiary academic medical center. Patients:All those 18 years old or older who had a rapid response team call activated. Vital sign data were abstracted from individual patient electronic medical records for the 24 hours before the rapid response team activation took place. Patients were considered to have a delayed rapid response team activation if more than 1 hour passed between the first appearance in the record of an abnormal vital sign meeting rapid response team criteria and the activation of an rapid response team. Interventions:None. Measurements and Main Results:A total of 1,725 patients were included in the analysis. Data were compared between those who had a delayed rapid response team activation and those who did not. Fifty seven percent patients met the definition of delayed rapid response team activation. Patients in high-frequency physiologic monitored environments were more likely to experience delay than their floor counterparts. In the no-delay group, the most common reasons for rapid response team activation were tachycardia/bradycardia at 29% (217/748), respiratory distress/low SpO2 at 28% (213/748), and altered level of consciousness at 23% (170/748) compared with respiratory distress/low SpO2 at 43% (423/977), tachycardia/bradycardia at 33% (327/977), and hypotension at 27% (261/977) in the delayed group. The group with no delay had a higher proportion of rapid response team calls between 8:00 and 16:00, whereas those with delay had a higher proportion of calls between midnight and 08:00. The delayed group had higher hospital mortality (15% vs 8%; adjusted odds ratio, 1.6; p = 0.005); 30-day mortality (20% vs 13%; adjusted odds ratio, 1.4; p = 0.02); and hospital length of stay (7 vs 6 d; relative prolongation, 1.10; p = 0.02) compared with the no-delay group. Conclusions:Delays in rapid response team activation occur frequently and are independently associated with worse patient mortality and morbidity outcomes.

Long-Term Return to Functional Baseline After Mechanical Ventilation in the ICU

Objective: Predictors of long-term functional impairment in acute respiratory failure of all causes are poorly understood. Our objective was to assess the frequency and predictors of long-term functional impairment or death after invasive mechanical ventilation for acute respiratory failure of all causes. Design: Population-based, observational cohort study. Setting: Eight adult ICUs of a single center. Patients: All adult patients from Olmsted County, Minnesota, without baseline functional impairment who received mechanical ventilation in ICUs for acute respiratory failure of all causes from 2005 through 2009. Interventions: None. Measurements and Main Results: In total, 743 patients without baseline functional impairment received mechanical ventilation in the ICU. At 1- and 5-year follow-up, the rates of survival with return to baseline functional ability were 61% (366/597) and 53% (356/669). Among 71 patients with new functional impairment at 1 year, 55% (39/71) had recovered and were alive without functional impairment at 5 years. Factors predictive of new functional impairment or death at 1 year were age, comorbidities, discharge to other than home, mechanical ventilation of 7 days or longer, and stroke. Of factors known at the time of intubation, the following are predictive of new functional impairment or death: age, comorbidities, nonsurgical condition, Acute Physiology and Chronic Health Evaluation III score, stroke, and sepsis. Post hoc sensitivity analyses revealed no significant change in predictor variables in patient populations when stroke was excluded or who received more than 48 hours of mechanical ventilation. Conclusions: At 1- and 5-year follow-up, many patients who received mechanical ventilation for acute respiratory failure from all causes are no longer alive or have new moderate-to-severe functional impairment. Functional recovery between year 1 and year 5 is possible and common. Sepsis, stroke, illness severity, age, and comorbidities predict long-term functional outcome at intubation.

1098: PRELIMINARY ANALYSIS OF PAGER ALERT SYSTEM EFFECT ON PROVIDER BEHAVIOR WITH CHECKLIST USE

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Checklists are simple and effective measures with the potential to reduce errors having a cumulative effect amid dynamic medical environment. However, adoption of checklist in hospital settings is sub-optimal. Various factors like perceived workload and effectiveness contribute to poor compliance. The objective of this study was to identify the effect of a pager alert to the provider on checklist use and compliance. Methods: Single center, retrospective observational study of providers’ use of checklist in a mixed ICU in an academic tertiary care center in Rochester over a period of 8 months. Providers were encouraged to complete a daily rounding checklist for all patients in the ICU using a dashboard accessible on all PCs. In order to enhance compliance, a pager alert was sent to providers for patients identified as high risk using an algorithm calculating prediction scores(APPROVE) for prolonged respiratory failure or death. We compared the checklist compliance rates pre and postimplementation of the pager alert. Results: The unit had a total of 1806 cases during the period (927 pre/879 post.) of which 1114 (492 pre/622 post.) checklists were completed. 45% (419/927) and 33% (288/879) cases during the pre and post period were identified as high risk. The unit compliance changed from 53% (492/927) to 71% (622/879) (p < 0.001). Checklist completion for high risk pool changed from 25% (104/419) to 78% (222/288)(p < 0.001) after the intervention. Checklist compliance for low risk decreased from 76% (388/508) to 68% (400/591)(p = 0.001) Conclusions: A pager alert system introduction was associated with improved checklist completion for high risk patients admitted to the ICU while the checklist compliance for low risk patients decreased. Though simple by design, completion of a checklist is hindered primarily by time restriction during patient care. Sending a pager alert reminder to the providers for high risk cases can be a useful method to help providers identify the cases and use a checklist to improve outcomes.

Coadministration of liposomal amphotericin B and contrast medium does not increase risk of kidney injury

ABSTRACT Intravenous radiographic contrast medium and amphotericin B are commonly required in the care of patients with fungal infections. Both interventions have proposed nephrotoxicity through similar mechanisms. We systematically examined patients who received coadministration of liposomal amphotericin B (AmBisome; GE Healthcare) and intravenous contrast medium within a 24-h period and compared the results for those patients with the results for patients who underwent non-contrast medium studies. We found 114 cases and 85 controls during our study period. Overall, no increased risk of renal injury was seen with coadministration of these 2 agents. Adjustment for age, baseline kidney function, and other clinical factors through propensity score adjustment did not change this result. Our observations suggest that, when clinically indicated, coadministration of contrast medium and liposomal amphotericin B does not present excess risk compared with that from the administration of liposomal amphotericin B alone.

Feasibility of an International Remote Simulation Training Program in Critical Care Delivery: A Pilot Study

Objective To determine the feasibility and effectiveness of a video-enabled remote simulation training program to teach a systematic, standardized approach to the evaluation and management of the critically ill patients as part of an international quality improvement intervention. Patients and Methods In this pilot “train-the-trainer” prospective cohort study, we provided a remote simulation-based educational program for practicing clinicians from intensive care units involved in an international quality improvement project (www.icertain.org). Between February 21, 2014, and August 6, 2015, participants completed a self-guided online curriculum and participated in structured simulation training using web conference software with recording capabilities. The performance was assessed using a matched pair analysis at baseline and using standardized scenarios and a validated assessment tool postintervention. Participants rated their satisfaction with the training experience and confidence in implementing these skills in clinical practice. Results Eighteen local champions from 8 hospitals in 7 countries in Asia, Europe, and South and Central America completed the educational program. Learners exhibited significant improvements in cumulative critical task performance during simulated critical care scenarios with training (60.3%-81.8%; P=.002). Most clinicians (94%) reported that they felt well prepared to manage the common critical care scenarios after training. These local champions have subsequently delivered this educational program to more than 800 international clinicians over a 4-year period. Conclusion Insufficient training is a major barrier to the delivery of cost-effective critical care in many areas of the world. Video-enabled remote simulation training is a low-cost, feasible, and effective method to disseminate clinical skills to critical care practitioners in diverse international settings.

The Incremental Burden of Acute Respiratory Distress Syndrome: Long-term Follow-up of a Population-Based Nested Case-Control Study

Objective: To evaluate the long‐term survival of patients at similar risk for hospital‐acquired acute respiratory distress syndrome (ARDS) who did and did not develop ARDS. Methods: We conducted long‐term follow‐up of a population‐based nested case‐control study in a consecutive cohort of adult Olmsted County, Minnesota, patients admitted from January 1, 2001, through December 31, 2010. Patients in whom ARDS developed during their hospital stay (cases) were matched to similar‐risk patients without ARDS (controls) by 6 characteristics: age, sex, sepsis, high‐risk surgery, ratio of oxygen saturation to fraction of inspired oxygen, and ARDS risk according to the Lung Injury Prediction Score. Hospital mortality, discharge disposition, and long‐term survival were compared. Results: Patients who developed hospital‐acquired ARDS (n=400) had higher hospital mortality than at‐risk controls (n=400) (35% vs 5%; P<.001). Among hospital survivors (252 matched pairs), ARDS cases were more likely to be discharged to rehabilitation (13% vs 4%) and long‐term care (30% vs 15%) facilities, whereas more controls were discharged home (71% vs 41%). After discharge, differences in survival persisted beyond 90 days (adjusted hazard ratio [HR], 1.76; 95% CI, 1.2‐2.5; P=.002) and 6 months (adjusted HR, 1.73; 95% CI, 1.2‐2.6; P<.001). Conclusion: These results suggest that in a population‐based matched case‐control study of patients with similar characteristics at the time of hospital admission, those who developed hospital‐acquired ARDS had worse long‐term survival.

Differences in Code Status and End-of-Life Decision Making in Patients With Limited English Proficiency in the Intensive Care Unit

Objective: To determine whether code status, advance directives, and decisions to limit life support were different for patients with limited English proficiency (LEP) in the intensive care unit (ICU) as compared with patients whose primary language was English. Patients and Methods: We conducted a retrospective cohort study in adult patients admitted to 7 ICUs in a single tertiary academic medical center from May 31, 2011, through June 1, 2014. Results: Of the 27,523 patients admitted to the ICU, 779 (2.8%) had LEP. When adjusted for severity of illness, sex, education level, and insurance status, patients with LEP were less likely to change their code status from full code to do not resuscitate during ICU admission (odds ratio [OR], 0.62; 95% CI, 0.46‐0.82; P<.001) and took 3.8 days (95% CI, 1.9‐5.6 days; P<.001) longer to change to do not resuscitate. Patients with LEP who died in the ICU were less likely to receive a comfort measures order set (OR, 0.38; 95% CI, 0.16‐0.91; P=.03) and took 19.1 days (95% CI, 13.2‐25.1 days; P<.001) longer to transition to comfort measures only. Patients with LEP were less likely to have an advance directive (OR, 0.23; 95% CI, 0.18‐0.29; P<.001), more likely to receive mechanical ventilation (OR, 1.26; 95% CI, 1.07‐1.48; P=.005), and more likely to have restraints used (OR, 1.36; 95% CI, 1.11‐1.65; P=.003). The hospital length of stay was 2.7 days longer for patients with LEP. Additional adjustment for religion, race, and age yielded similar results. Conclusion: There are important differences in end‐of‐life care and decision making for patients with LEP.

Information needs for the rapid response team electronic clinical tool

BackgroundInformation overload in healthcare is dangerous. It can lead to critical errors and delays. During Rapid Response Team (RRT) activations providers must make decisions quickly to rescue patients from physiological deterioration. In order to understand the clinical data required and how best to present that information in electronic systems we aimed to better assess the data needs of providers on the RRT when they respond to an event.MethodsA web based survey to evaluate clinical data requirements was created and distributed to all RRT providers at our institution. Participants were asked to rate the importance of each data item in guiding clinical decisions during a RRT event response.ResultsThere were 96 surveys completed (24.5% response rate) with fairly even distribution throughout all clinical roles on the RRT. Physiological data including heart rate, respiratory rate, and blood pressure were ranked by more than 80% of responders as being critical information. Resuscitation status was also considered critically useful by more than 85% of providers.ConclusionThere is a limited dataset that is considered important during an RRT. The data is widely available in EMR. The findings from this study could be used to improve user-centered EMR interfaces.