James R. Rowbottom

Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

BACKGROUND Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. METHODS One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. RESULTS Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. CONCLUSIONS The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Wearable Devices for Sports: New Integrated Technologies Allow Coaches, Physicians, and Trainers to Better Understand the Physical Demands of Athletes in Real time

Elite-level athletes and professional sports teams are continually searching for opportunities to improve athletic performance and gain a competitive advantage on the field. Advances in technology have provided new avenues to maximize player health and safety. Over the last decade, time?motion analysis systems, such as video recording and computer digitization, have been used to measure human locomotion and improve sports performance. While these techniques were state of the art at the time, their usefulness is inhibited by the questionable validity of the acquired data, the labor-intensive nature of collecting data with manual hand-notation techniques, and their inability to track athlete position, movement, displacement, and velocity.

Complexity Analysis of Decision-Making in the Critically Ill:

Rationale: Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life. Objective: To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness. Methods: A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death. Measurements: Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan. Main Results: Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential. Conclusion: Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.

Dose of Early Therapeutic Mobility: Does Frequency or Intensity Matter?

Objective: Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. Design: Randomized interventional study with repeated measures and blinded assessment of outcomes. Setting: Four adult intensive care units (ICUs) in two academic medical centers. Subjects: Fifty-four patients with > 48 hr of mechanical ventilation (MV). Intervention: Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. Measurements: Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. Main Results: Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. Conclusion: Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

A review of wearable technology: Moving beyond the hype: From need through sensor implementation

Wearable devices have garnered increased attention over the past years by the sports industry, military, and general public for everyday use. Technological advancements have enabled athletes, sports teams, soldiers, and physicians to track functional movements, workload, biometric and bio-vital markers to maximize performance and safety while minimizing the potential for injury or accidents. Wearable monitoring systems can provide continuous physiological data thus enabling accurate treatment plans and specific recovery programs. Herein, we present a review of the wearable sensors field in sports and emergency medicine and highlight our current work and collaborations which bridge academia, healthcare professionals, sports team physicians, Life Flight operations, and ED/trauma operations. A key outcome of this work is the identification of crosscutting themes that indicate critical path items for future research.

VINSIA: visual navigator for surgical information access.

Information access at the point of care presents a different set of requirements than those for traditional search engines. Critical care in remote (e.g., battle field) and rural settings not only requires access to clinical guidelines and medical libraries with surgical precision but also with minimal user effort and time. Our development of a graphical, anatomy-driven navigator called Visual Navigator for Surgical Information Access (VINSIA) fulfills the goal for providing evidence-based clinical decision support, specifically in perioperative and critical care settings, to allow rapid and precise information access through a portable stand-alone system. It comes with a set of unique characteristics: (a) a high precision, interactive visual interface driven by human anatomy; (b) direct linkage of anatomical structures to associated content such as clinical guidelines, literature, and medical libraries; and (c) an administrative content management interface allowing only an accredited, expert-level curator to edit and update the clinical content to ensure accuracy and currency. We believe that the deployment of VINSIA will improve quality, safety, and evidence-based standardization of patient care.