Brian Wessman

Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial

Study objective: We evaluated the efficacy of an emergency department (ED)–based lung‐protective mechanical ventilation protocol for the prevention of pulmonary complications. Methods: This was a quasi‐experimental, before‐after study that consisted of a preintervention period, a run‐in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED‐based mechanical ventilator protocol targeting lung‐protective tidal volume, appropriate setting of positive end‐expiratory pressure, rapid oxygen weaning, and head‐of‐bed elevation. A propensity score–matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator‐associated conditions. Results: A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung‐protective ventilation increased by 48.4% in the intervention group. In the propensity score–matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator‐free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU‐free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital‐free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63). Conclusion: Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.

A Quasi-experimental, Before-after Trial Examining the Impact of an Emergency Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-protective Ventilation in Acute Respiratory Distress Syndrome

Objectives: To evaluate the impact of an emergency department mechanical ventilation protocol on clinical outcomes and adherence to lung-protective ventilation in patients with acute respiratory distress syndrome. Design: Quasi-experimental, before-after trial. Setting: Emergency department and ICUs of an academic center. Patients: Mechanically ventilated emergency department patients experiencing acute respiratory distress syndrome while in the emergency department or after admission to the ICU. Interventions: An emergency department ventilator protocol which targeted variables in need of quality improvement, as identified by prior work: 1) lung-protective tidal volume, 2) appropriate setting of positive end-expiratory pressure, 3) oxygen weaning, and 4) head-of-bed elevation. Measurements and Main Results: A total of 229 patients (186 preintervention group, 43 intervention group) were studied. In the emergency department, the intervention was associated with significant changes (p < 0.01 for all) in tidal volume, positive end-expiratory pressure, respiratory rate, oxygen administration, and head-of-bed elevation. There was a reduction in emergency department tidal volume from 8.1 mL/kg predicted body weight (7.0–9.1) to 6.4 mL/kg predicted body weight (6.1–6.7) and an increase in lung-protective ventilation from 11.1% to 61.5%, p value of less than 0.01. The intervention was associated with a reduction in mortality from 54.8% to 39.5% (odds ratio, 0.38; 95% CI, 0.17–0.83; p = 0.02) and a 3.9 day increase in ventilator-free days, p value equals to 0.01. Conclusions: This before-after study of mechanically ventilated patients with acute respiratory distress syndrome demonstrates that implementing a mechanical ventilator protocol in the emergency department is feasible and associated with improved clinical outcomes.

Improving Caregivers’ Perceptions Regarding Patient Goals of Care/End-of-Life Issues for the Multidisciplinary Critical Care Team:

Objective: With population aging and growth, use of critical care medicine at the end of life continues to rise, while many critical care providers are not adequately trained regarding goals of care/end-of-life (GOC/EOL) issues. A multidisciplinary intensive care unit (ICU) team intervention regarding GOC/EOL communication will enhance the clinical abilities of all critical care providers when discussing GOC/EOL issues and increase ICU staff comfort level while improving transitions for patients to a comfort care approach. Design: This study was a preintervention/postintervention survey evaluation. Setting: This study was conducted at an academic tertiary surgical burn trauma ICU. Population: The intervention was provided to nursing, ancillary staff, house staff, and attending physicians. Intervention: An initial survey was circulated among the critical care staff for baseline expectations, satisfaction, and understanding of GOC/EOL care. A robust intervention was begun including the creation of a multidisciplinary GOC/EOL team, communication tools for providers, patient–family pamphlets, standardized EOL order sets, and formalized didactic sessions. Subsequently, the same survey was circulated and compared to baseline data. Measurements: Preintervention/postintervention survey data were reviewed and statistically analyzed. Main Results: Our survey response rate for preintervention/postintervention was 50.4% and 36.1%, respectively. The intervention generated heightened interest in improving family communication and provided focal direction to foster this growth. Based on the serial surveys regarding our intervention, statistically significant staff improvements were seen in “work stress” (P = .04), “EOL information” (P = .006), and “space allotment” (P = .001). Improved congruence of families and health care providers regarding decision over intensity of care was also noted. Conclusion: We created a novel unit-based multidisciplinary program for improved EOL/GOC approaches in the critical care setting. A similarly formatted program could be adapted by other ICUs. Benefits of such a program include improving caregivers’ perceptions regarding EOL/GOC issues and fostering critical care team growth.

Continuous Capnography Should Be Used for Every Emergency Department Procedural Sedation

Opposing authors provide succinct, authoritative discussions of controversial issues in emergency medicine. Authors are provided the opportunity to review and comment on opposing presentations. Each topic is accompanied by an Editor’s Note that summarizes important concepts. Participation as at authoritative discussant is by invitation only, but suggestions for topics and potential authors can be submitted to the section editors.

Training emergency physicians to meet the critical care needs in the United States: a consensus of two.

Critical Care Medicine www.ccmjournal.org e677 increased nephrotoxicity and lack of patient-relevant benefit for HES. These results were confirmed by subsequent trials (4, 5). As explained in our article, we prospectively planned in 2006 to assess the impact of the change of volume resuscitation standard on patient outcomes. We did this by looking back on prospectively collected patient data and compared results before and after the changes in practice occurred. Dr. Reinhart lectured for Braun Melsungen and BRAHMS and received royalties from Edwards. Dr. Reinhart and his institution consulted for Adrenomed. His institution received grant support from the German Ministry of Education and Research. Dr. Bayer’s institution received grant support from the Thuringian Ministry of Cultural Affairs (Landesprogramm ProExzellenz; PE 108-2, supported, in part, by an unrestricted grant), The Foundation of Technology, Innovation, and Research Thuringia (STIFT), and The German Sepsis Society (supported, in part, by an unrestricted grant). Dr. Hartog’s institution received support from the German Ministry of Education and Research (grant for the conduct of a clinical study on communication on the ICU [NCT01247792]).

Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study

BACKGROUND: Analgesia and sedation are cornerstone therapies for mechanically ventilated patients. Despite data showing that early deep sedation in the ICU influences outcome, this has not been investigated in the ED. Therefore, ED‐based sedation practices, and their influence on outcome, remain incompletely defined. This studys objectives were to describe ED sedation practices in mechanically ventilated patients and to test the hypothesis that ED sedation depth is associated with worse outcomes. METHODS: This was a cohort study of a prospectively compiled ED registry of adult mechanically ventilated patients at a single academic medical center. Hospital mortality was the primary outcome and hospital‐, ICU‐, and ventilator‐free days were secondary outcomes. A backward stepwise multivariable logistic regression model evaluated the primary outcome as a function of ED sedation depth. Sedation depth was assessed with the Richmond Agitation‐Sedation Scale (RASS). RESULTS: Four hundred fourteen patients were studied. In the ED, 354 patients (85.5%) received fentanyl, 254 (61.3%) received midazolam, and 194 (46.9%) received propofol. Deep sedation was observed in 244 patients (64.0%). After adjusting for confounders, a deeper ED RASS was associated with mortality (adjusted OR, 0.77; 95% CI, 0.63–0.94). CONCLUSIONS: Early deep sedation is common in mechanically ventilated ED patients and is associated with worse mortality. These data suggest that ED‐based sedation is a modifiable variable that could be targeted to improve outcome.

Emergency Medicine: An Integral Component of the Continuum of Critical Care That is Devalued by Fellowship Programs

The need for critical care services is increasing as the gap between supply and demand for Intensivists grows (1,2). The pipeline of practicing Intensivists remains relatively stagnant at about 12,000 U.S. adult critical care medicine (CCM)-certified physicians (3). This discordance between patient need and physician supply has potential to worsen patient outcomes, threaten patient safety, and increase health care costs (1). Therefore, expanding the supply of qualified Intensivists is not only needed, but also makes common sense.

Discrepancies in measuring bladder volumes with bedside ultrasound and bladder scanning in the intensive care unit: A pilot study

Objective Intensive care unit patients are at risk for catheter-associated urinary tract infection. Earlier removal of catheters may be possible with accurate measurement of bladder volume. The purpose was to compare measured bladder volumes with bedside ultrasound, bladder scanner, and urine volume. Design Prospective correlational descriptive study. Setting Surgical/trauma intensive care unit and medical intensive care unit. Patients Renal dialysis patients with less than 100 ml of urine in 24 h prior to urinary catheter removal and patients with suspected catheter obstruction. Measurements and main results A physician trained in ultrasound and an advanced practice registered nurse trained in bladder scanning measured bladder volume; each blinded to the other’s measurement. Device used first (ultrasound or bladder scanner) alternated daily. The intensive care unit team determined need for intermittent catheterization or treatment for suspected obstruction. Fifty-one measurements from 13 patients were obtained with results reported in milliliters. Ultrasound measurements were a mean volume of 72.1 ± 127 (range: 1.7–666) and the bladder scanner measurements were 117 ± 131 (0–529). On six occasions in five dialysis patients, urine volume measurement was available. The mean difference in ultrasound–urine volume mean difference was 0.5 ± 37.8 (range: −68 to 38.2) and the bladder scanner–urine volume was 132 ± 167 (−72 to 397). Two patients with suspected catheter obstructions had ultrasound, bladder scanner, urine volume measurements, respectively: (1) 539, 51, >300 (began voiding before catheter replaced); (2) 666, 68, 1000 with catheter replacement. Conditions leading to greatest differences were obesity, indwelling catheter and ascites. Conclusions These results demonstrate the inaccuracy of the bladder scanner. Ultrasound measurements appear more accurate. To remove urinary catheters in patients with minimal to low urine output, serial ultrasound measurements can be used to monitor bladder volumes and return of renal function.

859: DEVELOPMENT OF A STANDARDIZED FAMILY COMMUNICATION BUNDLE FOR USE IN AN INTENSIVE CARE UNIT

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Effective communication with the medical team can make the often difficult decisions faced by patients/ families after admission to the ICU less stressful. As part of our participation in the SCCM’s collaborative with the Patient Centered Outcomes Research Institute (PCOR-I), we sought to assess and improve the current state of patient/family communication in our tertiary academic medical center ICU. In response to our assessment, we developed an evidence-based, standardized family communication bundle. Methods: Our multidisciplinary ICU team utilized an SCCMdeveloped survey to perform a needs assessment. Data from our unit regarding family experiences and medical team perceptions of patient/family-centered care were collected using validated surveys. A literature review of best practices for patient/family communication was also performed. Results: Our needs assessment revealed opportunities for improvement in patient/family communication. Only 63.6% (14/22) of family members reported feeling “very included” in the decision making process, and only 32.5% (25/77) of our staff felt we do “very well” in encouraging patients/families to be involved in the decision making process. The use of “bundles” has been found to improve communication in some settings. Using data from these assessments, we developed a standardized bundle consisting of 3 elements: education (multidisciplinary didactics on family care conference best practices and the development/distribution of a reference pocket card), family discussion (creation of an indicator on the patient’s door signifying a discussion had occurred and reminder emails identifying families still in need of a conversation), and documentation (creation of a new standardized template for documenting family discussions in our electronic medical record (EMR) and updating discussed code status in the EMR). Conclusions: Few examples of evidence-based bundles for communication between medical teams and patients/families exist. We assessed the current state of communication within our unit and utilized current literature, guidelines/best practices, and data from our unit to develop a unique 3 element bundle with measureable outcomes. In the future, we plan to examine whether the use of this bundle improves medical team and patient/family perception of communication in our unit.

A Novel ICU Hand-Over Tool The Glass Door of the Patient Room

Background: Poor communication among health-care providers is cited as the most common cause of sentinel events involving patients. Patient care in the critical care setting is incredibly complex. A consistent care plan is necessary between day/night shift teams and among bedside intensive care unit (ICU) nurses, consultants, and physicians. Our goal was to create a novel, easily accessible communication device to improve ICU patient care. Methods: This communication improvement project was done at an academic tertiary surgical/trauma/mixed 36-bed ICU with an average of 214 admissions per month. We created a glass door template embossed on the glass that included 3 columns for daily goals to be written: “day team,” “night team,” and “surgery/consultant team.” Assigned areas for tracking “lines,” “antibiotics,” “ventilator weaning,” and “Deep vein thrombosis (DVT) screening” were included. These doors are filled out/updated throughout the day by all of the ICU providers. All services can review current plans/active issues while evaluating the patient at the bedside. Patient-identifying data are not included. We retrospectively reviewed all ICU safety reported events over a 4-year period (2 years prior/2 years after glass door implementation) for specific handover communication-related errors and compared the 2 cohorts. Results: Information on the glass doors is entered daily on rounds by all services. Prior to implementation, 7.96% of reported errors were related to patient handover communication errors. The post glass-door era had 4.26% of reported errors related to patient handover communication errors with a relative risk reduction of 46.5%. Due to its usefulness, this method of communication was quickly adopted by the other critical care services (cardiothoracic, medical, neurology/neurosurgery, cardiology) at our institution and is now used for over 150 ICU beds. Conclusions: Our glass door patient handover tool is an easily adaptable intervention that has improved communication leading to an overall decrease in the number of handover communication errors.