Jason Wagner

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

Background:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting Outcomes:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Outcomes among patients discharged from busy intensive care units.

BACKGROUND Strains on the capacities of intensive care units (ICUs) may influence the quality of ICU-to-floor transitions. OBJECTIVE To determine how 3 metrics of ICU capacity strain (ICU census, new admissions, and average acuity) measured on days of patient discharges influence ICU length of stay (LOS) and post-ICU discharge outcomes. DESIGN Retrospective cohort study from 2001 to 2008. SETTING 155 ICUs in the United States. PATIENTS 200 730 adults discharged from ICUs to hospital floors. MEASUREMENTS Associations between ICU capacity strain metrics and discharged patient ICU LOS, 72-hour ICU readmissions, subsequent in-hospital death, post-ICU discharge LOS, and hospital discharge destination. RESULTS Increases in the 3 strain variables on the days of ICU discharge were associated with shorter preceding ICU LOS (all P < 0.001) and increased odds of ICU readmissions (all P < 0.050). Going from the 5th to 95th percentiles of strain was associated with a 6.3-hour reduction in ICU LOS (95% CI, 5.3 to 7.3 hours) and a 1.0% increase in the odds of ICU readmission (CI, 0.6% to 1.5%). No strain variable was associated with increased odds of subsequent death, reduced odds of being discharged home from the hospital, or longer total hospital LOS. LIMITATION Long-term outcomes could not be measured. CONCLUSION When ICUs are strained, triage decisions seem to be affected such that patients are discharged from the ICU more quickly and, perhaps consequentially, have slightly greater odds of being readmitted to the ICU. However, short-term patient outcomes are unaffected. These results suggest that bed availability pressures may encourage physicians to discharge patients from the ICU more efficiently and that ICU readmissions are unlikely to be causally related to patient outcomes. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute; and Society of Critical Care Medicine.

ICU Occupancy and mechanical ventilator use in the United States

Objectives:Detailed data on occupancy and use of mechanical ventilators in U. S. ICU over time and across unit types are lacking. We sought to describe the hourly bed occupancy and use of ventilators in U.S. ICUs to improve future planning of both the routine and disaster provision of intensive care. Design:Retrospective cohort study. We calculated mean hourly bed occupancy in each ICU and hourly bed occupancy for patients on mechanical ventilators. We assessed trends in overall occupancy over the 3 years. We also assessed occupancy and mechanical ventilation rates across different types and sizes of ICUs. Setting:Ninety-seven U.S. ICUs participating in Project IMPACT from 2005 to 2007. Patients:A total of 226,942 consecutive admissions to ICUs. Interventions:None. Measurements and Main Results:Over the 3 years studied, total ICU occupancy ranged from 57.4% to 82.1% and the number of beds filled with mechanically ventilated patients ranged from 20.7% to 38.9%. There was no change in occupancy across years and no increase in occupancy during influenza seasons. Mean hourly occupancy across ICUs was 68.2% ± 21.3% (SD) and was substantially higher in ICUs with fewer beds (mean, 75.8% ± 16.5% for 5–14 beds vs 60.9% ± 22.1% for 20+ beds, p = 0.001) and in academic hospitals (78.7% ± 15.9% vs 65.3% ± 21.3% for community not-for-profit hospitals, p < 0.001). More than half of ICUs (53.6%) had 4+ beds available more than half the time. The mean percentage of ICU patients receiving mechanical ventilation in any given hour was 39.5% (± 15.2%), and a mean of 29.0% (± 15.9%) of ICU beds were filled with a patient on a ventilator. Conclusions:Occupancy of U.S. ICUs was stable over time, but there is uneven distribution across different types and sizes of units. Only three of 10 beds were filled at any time with mechanically ventilated patients, suggesting substantial surge capacity throughout the system to care for acutely critically ill patients.

Outcomes and statistical power in adult critical care randomized trials.

RATIONALE Intensive care unit (ICU)-based randomized clinical trials (RCTs) among adult critically ill patients commonly fail to detect treatment benefits. OBJECTIVES Appraise the rates of success, outcomes used, statistical power, and design characteristics of published trials. METHODS One hundred forty-six ICU-based RCTs of diagnostic, therapeutic, or process/systems interventions published from January 2007 to May 2013 in 16 high-impact general or critical care journals were studied. MEASUREMENT AND MAIN RESULTS Of 146 RCTs, 54 (37%) were positive (i.e., the a priori hypothesis was found to be statistically significant). The most common primary outcomes were mortality (n = 40 trials), infection-related outcomes (n = 33), and ventilation-related outcomes (n = 30), with positive results found in 10, 58, and 43%, respectively. Statistical power was discussed in 135 RCTs (92%); 92 cited a rationale for their power parameters. Twenty trials failed to achieve at least 95% of their reported target sample size, including 11 that were stopped early due to insufficient accrual/logistical issues. Of 34 superiority RCTs comparing mortality between treatment arms, 13 (38%) accrued a sample size large enough to find an absolute mortality reduction of 10% or less. In 22 of these trials the observed control-arm mortality rate differed from the predicted rate by at least 7.5%. CONCLUSIONS ICU-based RCTs are commonly negative and powered to identify what appear to be unrealistic treatment effects, particularly when using mortality as the primary outcome. Additional concerns include a lack of standardized methods for assessing common outcomes, unclear justifications for statistical power calculations, insufficient patient accrual, and incorrect predictions of baseline event rates.

Reasons underlying interhospital transfers to an academic medical intensive care unit.

PURPOSE Interhospital critical care transfers are common, yet few studies address the underlying reasons for transfers. We examined clinician and patient/surrogate perceptions about interhospital transfers and assessed their agreement on these transfers. MATERIALS AND METHODS This is a mixed-mode survey of 3 major stakeholders in interhospital transfers to an academic medical intensive care unit from August 2007 to April 2008. RESULTS Sixty-two hospitals transferred 138 patients during the study period. Response rates varied among stakeholders (accepting physician, 90%; referring physicians, 20%; patients/surrogates, 33%). All 3 groups frequently endorsed quality of care and need for a specific test/procedure as important. Referring hospital reputation and quality were rarely endorsed. Accepting physicians and patients/surrogates substantially agreed on the need for a specific test (κ = 0.70) and increased survival (κ = 0.78) but, otherwise, had fair to poor agreement. Referring physicians and patients/surrogates rarely agreed and sometimes disagreed greater than expected by chance (κ < 0). Physician pairs strongly agreed on the importance of accepting hospital experience (κ = 0.96) but agreed less on patient satisfaction at the referring hospital (κ = 0.37) and referring hospital reputation (κ = 0.35). CONCLUSIONS Stakeholders do not always agree on the reasons for critical care transfers. Efforts to improve communication are warranted to ensure informed patient choices.

Meeting the Milestones. Strategies for Including High-Value Care Education in Pulmonary and Critical Care Fellowship Training

Physician decision making is partially responsible for the roughly 30% of U.S. healthcare expenditures that are wasted annually on low-value care. In response to both the widespread public demand for higher-quality care and the cost crisis, payers are transitioning toward value-based payment models whereby physicians are rewarded for high-value, cost-conscious care. Furthermore, to target physicians in training to practice with cost awareness, the Accreditation Council for Graduate Medical Education has created both individual objective milestones and institutional requirements to incorporate quality improvement and cost awareness into fellowship training. Subsequently, some professional medical societies have initiated high-value care educational campaigns, but the overwhelming majority target either medical students or residents in training. Currently, there are few resources available to help guide subspecialty fellowship programs to successfully design durable high-value care curricula. The resource-intensive nature of pulmonary and critical care medicine offers unique opportunities for the specialty to lead in modeling and teaching high-value care. To ensure that fellows graduate with the capability to practice high-value care, we recommend that fellowship programs focus on four major educational domains. These include fostering a value-based culture, providing a robust didactic experience, engaging trainees in process improvement projects, and encouraging scholarship. In doing so, pulmonary and critical care educators can strive to train future physicians who are prepared to provide care that is both high quality and informed by cost awareness.

Deferred Admission to the Intensive Care Unit: Rationing Critical Care or Expediting Care Transitions?: Comment on “Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration”

There are several reasons to doubt that we can expand the supply of high-quality critical care to meet the expected surge in demand brought on by an aging population. First, critical care expenditures already strain nations’ abilities to meet other socially desirable goals.1 Second, most critically ill patients are cared for by physicians who lack specific training in critical care medicine,2 a staffing model that has been associated with worse outcomes in most studies.3 Third, severe shortages are projected in critical care workforces.4,5 Therefore, if the capacity of critical care is relatively fixed, we must instead try to improve the efficiency of care.6 Although these observations have spawned conceptual analyses about how critical care ought to be allocated, relatively little empirical work has documented how critical care is allocated. Therefore, the cohort study reported by Stelfox et al7 in this issue of the Archives is a welcome addition. To examine the influence of intensive care unit (ICU) bed scarcity on processes of care and patient outcomes, the authors evaluated 3494 consecutive episodes of sudden clinical deterioration leading to the activation of a medical emergency team (MET) at all 3 hospitals in Calgary, Canada, between January 1, 2007, and December 31, 2009. After adjusting for patient- and hospital-level covariates, the authors found that when fewer ICU beds were available at the time of MET activation, patients were less likely to be admitted to the ICU (or were admitted later) and that transitions of care were more common from resuscitative to either medical (no ICU transfer) or comfort care. Despite relatively large differences in these intermediate outcomes, in-hospital mortality was not affected by ICU bed availability. What does this seeming paradox tell us about decisions to admit patients to ICUs? Decisions to admit patients to the ICU should ideally be based on their severity of illness or other objective markers. However, this study adds to an evidence base8,9 showing that bed availability and other nonpatient-centered factors affect triage. Indeed, the present study suggests that decision making is directly affected by “nonnormative” factors such as the time of day and day of week of MET activation and the training level of the MET provider who happens to be on call. The influence of these factors on decision making, without corresponding differences in mortality, suggests that many ICU admissions are unnecessary because the patient is either too well or too sick to benefit. Furthermore, it appears that clinicians can allocate beds efficiently by eliminating nonbeneficial admissions when scarcity forces them to do so. This conclusion differs from a multicenter European study suggesting that ICU admission confers a survival advantage when beds are scarce9 but agrees with a Seattle-based study that was published a quarter of a century ago showing that although bed scarcity commonly caused clinicians to discharge patients “prematurely,” survival was unaffected.10 Such uncertainty regarding whether ICU admission could benefit some patients from whom it is denied defies efforts to label such decisions as rationing (withholding of potentially beneficial services) vs elimination of waste. Regardless, the most provocative suggestion of the present study is that clinicians may reduce ICU admissions that are not overtly beneficial by addressing patients’ goals of care in a more timely and determinative manner when they exhibit physiologic deterioration on the floor. If this mechanistic explanation is true, then scarcity may in fact motivate more patient-centered care near life’s end. Nonetheless, before we conclude that we can get better care at lower cost by closing existing ICU beds, several limitations of the study merit consideration. First, Stelfox and colleagues7 show that ICU bed availability is correlated with delayed or deferred ICU admission and with changes in goals of care, but causality remains uncertain. It is plausible that bed scarcity could cause these outcomes, and the observed “dose-response” relationships between the degree of bed scarcity and the frequency of these outcomes lend further causal support. However, there are also several alternate explanations for the results. If bed availability were truly a random variable, then residual confounding would be unlikely. However, the relationships identified, for example, between ICU bed availability and the type of MET provider, suggest degrees of nonrandomness. Furthermore, although the authors suggest that floor teams were unaware of ICU bed availability, this suggestion is uncertain and unlikely to generalize to the many hospitals in which electronic patient flow software is available at every computer terminal. Might the threshold for MET activation have been influenced by ICU bed availability? If floor teams activated METs slightly less often during times of ICU bed surplus because they were able to transfer their sickest patients directly to the ICU, then a bias against showing a mortality difference might arise. Second, the authors report that more patients are transferred to another hospital or facility if they clinically deteriorate when ICU beds are plentiful. Presumably, patients who are transferred are both sufficiently stable for transfer and invested in curative goals of care, and their exclusion potentially biases the results toward higher mortality during times of bed availability. Third, more patients were discharged home with support services when they experienced sudden declines during times of bed scarcity. If home hospice were included among these services, even greater changes toward comfort goals of care might occur when beds are scarce. However, because the ensuing deaths at home were excluded from analyses, this too would bias the relationship between hospital mortality and bed availability toward the null. Much work remains to be done before we can fully appreciate whether strained ICU capacity6 ultimately leads to more or less appropriate use of ICU resources. The study by Stelfox and colleagues7 highlights a new potential benefit of ICU bed scarcity: that it may expedite transitions of care toward palliation among patients who are likely to die with or without ICU admission. Therefore, this study’s greatest legacy may be to provide the impetus that is needed for efforts to better understand the conditions that promote clinicians’ willingness to do the difficult but important work of considering and frankly discussing all therapeutic options that may be appropriate for critically ill patients who are decompensating before their eyes.