Diana J. Kelm

Fluid Overload in Patients with Severe Sepsis and Septic Shock Treated with Early-Goal Directed Therapy is Associated with Increased Acute Need for Fluid-Related Medical Interventions and Hospital Death

ABSTRACT Early goal-directed therapy (EGDT) consists of early, aggressive fluid resuscitation and is known to improve survival in sepsis. It is unknown how often EGDT leads to subsequent fluid overload and whether post-EGDT fluid overload affects patients’ outcomes. Our hypothesis was that patients with sepsis treated with EGDT were at risk for fluid overload and that fluid overload would be associated with adverse outcomes. We conducted a retrospective cohort of 405 consecutive patients admitted with severe sepsis and septic shock to the medical intensive care unit of a tertiary care academic hospital from January 2008 to December 2009. Baseline demographics, daily weights, fluid status, clinical or radiographic evidence of fluid overload, and medical interventions (thoracentesis, paracentesis, diuretic use, and ultrafiltration) were abstracted, and associations explored using univariate and multivariate logistic and linear regression analyses. At day 1, 67% of patients developed evidence of fluid overload, and in 48%, fluid overload persisted to day 3. Interrater agreement for presence of fluid overload was substantial (&kgr; = 0.7). An increased trend in weight was noted in those with persistent clinical and radiologic evidence of fluid overload, but not with recorded positive fluid balance. When adjusted for baseline severity of illness, fluid overload was associated with increased use of fluid-related medical interventions (thoracentesis and diuretics) and hospital mortality (odds ratio, 1.92; confidence interval, 1.16–3.22). In patients with severe sepsis and septic shock treated with EGDT, clinical evidence of persistent fluid overload is common and is associated with increased use of medical interventions and hospital mortality.

Pre-transplant wasting (as measured by muscle index) is a novel prognostic indicator in lung transplantation

Frailty in non‐transplant populations increases morbidity and mortality. Muscle wasting is an important frailty characteristic. Low body mass index is used to measure wasting, but can over‐ or underestimate muscle mass. Computed tomography (CT) software can directly measure muscle mass. It is unknown if muscle wasting is important in lung transplantation.

Mindfulness Meditation and Interprofessional Cardiopulmonary Resuscitation: A Mixed-Methods Pilot Study

ABSTRACT Problem: Mindfulness training includes mindfulness meditation, which has been shown to improve both attention and self-awareness. Medical providers in the intensive care unit often deal with difficult situations with strong emotions, life-and-death decisions, and both interpersonal and interprofessional conflicts. The effect of mindfulness meditation training on healthcare providers during acute care tasks such as cardiopulmonary resuscitation remains unknown. Mindfulness meditation has the potential to improve provider well-being and reduce stress in individuals involved in resuscitation teams, which could then translate into better team communication and delivery of care under stress. A better understanding of this process could lead to more effective training approaches, improved team performance, and better patient outcomes. Intervention: All participants were instructed to use a mindfulness meditation device (Muse™ headband) at home for 7 min twice a day or 14 min daily over the 4-week training period. This device uses brainwave sensors to monitor active versus relaxing brain activity and provides real-time feedback. Context: We conducted a single-group pretest–posttest convergent mixed-methods study. We enrolled 24 healthcare providers, comprising 4 interprofessional code teams, including physicians, nurses, respiratory therapists, and pharmacists. Each team participated in a simulation session immediately before and after the mindfulness training period. Each session consisted of two simulated cardiopulmonary arrest scenarios. Both quantitative and qualitative outcomes were assessed. Outcome: The median proportion of participants who used the device as prescribed was 85%. Emotional balance, as measured by the critical positivity ratio, improved significantly from pretraining to posttraining (p = .02). Qualitative findings showed that mindfulness meditation changed how participants responded to work-related stress, including stress in real-code situations. Participants described the value of time for self-guided practice with feedback from the device, which then helped them develop individual approaches to meditation not reliant on the technology. Time measures during the simulated scenarios improved, specifically, time to epinephrine in Scenario 1 (p = .03) and time to defibrillation in Scenario 2 (p = .02), improved. In addition, team performance, such as teamwork (p = .04), task management (p = .01), and overall performance (p = .04), improved significantly after mindfulness meditation training. Physiologic stress (skin conductance) improved but did not reach statistical significance (p = .11). Lessons Learned: Mindfulness meditation practice may improve individual well-being and team function in high-stress clinical environments. Our results may represent a foundation to design larger confirmatory studies.

ATS core curriculum 2015 Part I: Adult pulmonary medicine series editor: Carey Thomson

Gaëtane C. Michaud, Colleen L. Channick, Chad R. Marion, Robert M. Tighe, James A. Town, Andrew M. Luks, Jeremy B. Richards, Sucharita Kher, Prerna Mota, Gina Hong, Natalie E. West, Craig Rackley, Luke Neilans, Josanna Rodriguez-Lopez, Hilary DuBrock, Cassie C. Kennedy, Diana J. Kelm, and Carey C. Thomson Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut; Pulmonary and Critical Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts; Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts

Evaluation of TEAM dynamics before and after remote simulation training utilizing CERTAIN platform

ABSTRACT Objective: The current study examines the feasibility and potential effects of long distance, remote simulation training on team dynamics. Design: The study design was a prospective study evaluating team dynamics before and after remote simulation. Subjects: Study subjects consisted of interdisciplinary teams (attending physicians, physicians in training, advanced care practitioners, and/or nurses). Setting: The study was conducted at nine training sites in eight countries. Interventions: Study subjects completed 2–3 simulation scenarios of acute crises before and after training with the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). Measurements and main results: Pre- and post-CERTAIN training simulations were evaluated by two independent reviewers utilizing the Team Emergency Assessment Measure (TEAM), which is a 11-item questionnaire that has been validated for assessing teamwork in the intensive care unit. Any discrepancies of greater than 1 point between the two reviewers on any question on the TEAM assessment were sent to a third reviewer to judge. The score that was deemed discordant by the third judge was eliminated. Pre- and post-CERTAIN training TEAM scores were averaged and compared. Of the nine teams evaluated, six teams demonstrated an overall improvement in global team performance following CERTAIN virtual training. For each of the 11 TEAM assessments, a trend toward improvement following CERTAIN training was noted; however, no assessment had universal improvement. ‘Team composure and control’ had the least absolute score improvement following CERTAIN training. The greatest improvement in the TEAM assessment scores was in the ‘team’s ability to complete tasks in a timely manner’ and in the ‘team leader’s communication to the team’. Conclusion: The assessment of team dynamics using long distance, virtual simulation training appears to be feasible and may result in improved team performance during simulated patient crises; however, language and video quality were the two largest barriers noted during the review process.

Pulmonary manifestations of Q fever: analysis of 38 patients

Background Lung involvement in both acute and chronic Q fever is not well described with only a few reported cases of pseudotumor or pulmonary fibrosis in chronic Q fever. The aim of this study was to better understand the pulmonary manifestations of Q fever. Methods We conducted a retrospective cohort study of patients with diagnosis of Q fever at Mayo Clinic Rochester. A total of 69 patients were initially identified between 2001 and 2014. Thirty-eight patients were included in this study as 3 were pediatric patients, 20 did not meet serologic criteria for Q fever, and 8 did not have imaging available at time of initial diagnosis. Descriptive analysis was conducted using JMP software. Results The median age was 57 years [interquartile range (IQR) 43, 62], 84% from the Midwest, and 13% worked in an occupation involving animals. The most common presentation was fevers (61%). Respiratory symptoms, such as cough, were noted in only 4 patients (11%). Twelve patients (29%) had abnormal imaging studies attributed to Q fever. Three patients (25%) with acute Q fever had findings of consolidation, lymphadenopathy, pleural effusions, and nonspecific pulmonary nodules. Radiographic findings of chronic Q fever were seen in 9 patients (75%) and included consolidation, ground-glass opacities, pleural effusions, lymphadenopathy, pulmonary edema, and lung pseudotumor. Conclusions Our results demonstrate that pulmonary manifestations are uncommon in Q fever but include cough and consolidation for acute Q fever and radiographic findings of pulmonary edema with pleural effusions, consolidation, and pseudotumor in those with chronic Q fever.

“Fellow of the Day”: A Novel Trainee Role to Improve Fellows’ Outpatient Continuity Clinics

Rationale: The implementation of team‐based care models in residency programs is one method to improve patient and provider outpatient satisfaction. However, to our knowledge, this has not yet been studied in fellowship programs. Objectives: We instituted a pilot project to test a team‐based model of care in our pulmonary and critical care medicine (PCCM) fellows’ clinic by creating a new outpatient role called the “Fellow of the Day,” with the goal of reducing clinical disruption for the fellows, providing more educational value for medical students, and improving patient care. Methods: Data were collected over a 4‐month time period from electronic surveys from medical students, fellows, and supervising faculty. We also used timestamp data to determine fellows’ response times to patient messages. Results: After implementation of the Fellow of the Day designation, (1) fellows were more engaged in teaching the medical student (P = 0.007); (2) fellows spent less of their personal time (P = 0.04) or time away from critically ill patients to focus on patient care‐related messages (P = 0.04) and paperwork (P = 0.02); and (3) medical students had improved experience with more enjoyment (P = 0.03) and active engagement in clinic (P = 0.03). The Fellow of the Day role did not affect faculty workflow. Patients received responses to their postvisit messages in a more timely manner (P = 0.003). Conclusions: The Fellow of the Day role was successfully implemented at our institution with multiple benefits, not only to fellows but also to patients, medical students, and supervising faculty. Our education committee has recommended continuation of the role in our fellowship program.

Education Considerations: Communication Curricula, Simulated Resuscitation, and Duty Hour Restrictions.

In routine practice, an intensivist must convey intricate and often devastating information to patients and surrogates, guiding them through complex decisions with life-and-death implications. Although the Accreditation Council for Graduate Medical Education (ACGME) and the American Thoracic Society have called for pulmonary and critical care medicine (PCCM) trainees to receive formal communication skills training, few curricula have been developed, implemented, and published. Focusing on the family meeting as a prototypical intensive care unit (ICU) encounter, McCallister and colleagues (1) developed a year-long communication skills educational program. Beginning with a 3-hour didactic workshop incorporating role plays, the program was interwoven into the first year of PCCM fellowship. The authors created a checklist-based assessment derived from available literature on ICU communication, the Family Meeting Behavioral Skills Checklist, to facilitate feedback and monitor evolution of fellows’ skills. This tool was used for self-evaluation, to provide structured feedback from palliative medicine faculty observing fellows conducting family meetings, and by two blinded psychologists who scored digital recordings of simulated family meetings performed before and after the intervention. In a pre–post analysis, trainees demonstrated a significant increase in total observed Family Meeting Behavioral Skills Checklist skills from 51 to 65% (P, 0.01; Cohen’s D effect size, 1.13) and improved self-confidence (from 77 to 89%, P, 0.01; effect size, 0.87). In the same issue of AnnalsATS, Hope and colleagues (2) describe a communication skills program implemented in their medical ICU. This 1-month curriculum incorporated didactic sessions focused on palliative care, ethics, and end-of-life care, as well as several family conference simulations. Key communication concepts were emphasized through repetition and reinforcement. In unblinded pre–post faculty evaluations fellows demonstrated a statistically significant improvement in three skills: setting an agenda (64% vs. 41%; chi-square, 5.27; P = 0.02); summarizing the care the patient would receive (64% vs. 39%; chi-square, 6.21; P = 0.01); and outlining the follow-up plan (60% vs. 37%; chi-square, 5.2; P = 0.02). Both fellowships created a didactic series, an original checklist evaluation, and used both self-assessments and simulations to judge trainees’ progress. Whereas one was interwoven throughout the year, the other occurred in a single medical ICU rotation. These studies demonstrate the feasibility of embedding communication training in PCCM fellowship, thereby improving trainees’ observable skills and self-confidence. Further study is required to validate these novel assessment tools and measure impact of the educational interventions on patient-centered outcomes, including attention to emotion and to assess optimal structure and duration of curriculum. n

Predictors of Disseminated Intravascular Coagulation in Patients with Septic Shock

Purpose. The goal of this study was to identify potential clinical predictors for the development of disseminated intravascular coagulation (DIC) in patients with septic shock. Material and Methods. We performed a retrospective analysis of a cohort of adult (>18 years of age) patients with septic shock admitted to a medical ICU in a tertiary care hospital from July 2005 until September 2007. A multivariate logistic regression model was used to determine the association of risk factors with overt DIC. Results. In this study, a total of 390 patients with septic shock were analyzed, of whom 66 (17%) developed overt DIC. Hospital mortality was significantly greater in patients who developed overt DIC (68% versus 38%, ). A delay in the timing of antibiotics was associated with an increased risk of the development of overt DIC (). Patients on antiplatelet therapy prior to hospital admission and who that received adequate early goal-directed therapy (EGDT) were associated with a decreased risk of overt DIC (). Conclusions. In our cohort of patients with septic shock, there was a risk reduction for overt DIC in patients on antiplatelet therapy and adequate EGDT, while there was an increased risk of DIC with antibiotic delay.