Khalid F. Almoosa

Acquired Weakness, Handgrip Strength, and Mortality in Critically Ill Patients

RATIONALE ICU-acquired paresis (ICUAP) is common in survivors of critical illness. There is significant associated morbidity, including prolonged time on the ventilator and longer hospital stay. However, it is unclear whether ICUAP is independently associated with mortality, as sicker patients are more prone and existing studies have not adjusted for this. OBJECTIVES To test the hypothesis that ICUAP is independently associated with increased mortality. Secondarily, to determine if handgrip dynamometry is a concise measure of global strength and is independently associated with mortality. METHODS A prospective multicenter cohort study was conducted in intensive care units (ICU) of five academic medical centers. Adults requiring at least 5 days of mechanical ventilation without evidence of preexisting neuromuscular disease were followed until awakening and were then examined for strength. MEASUREMENTS AND MAIN RESULTS We measured global strength and handgrip dynamometry. The primary outcome was in-hospital mortality and secondary outcomes were hospital and ICU-free days, ICU readmission, and recurrent respiratory failure. Subjects with ICUAP (average MRC score of < 4) had longer hospital stays and required mechanical ventilation longer. Handgrip strength was lower in subjects with ICUAP and had good test performance for diagnosing ICUAP. After adjustment for severity of illness, ICUAP was independently associated with hospital mortality (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.4-25.3; P = 0.001). Separately, handgrip strength was independently associated with hospital mortality (OR, 4.5; 95% CI, 1.5-13.6; P = 0.007). CONCLUSIONS ICUAP is independently associated with increased hospital mortality. Handgrip strength is also independently associated with poor hospital outcome and may serve as a simple test to identify ICUAP. Clinical trial registered with www.clinicaltrials.gov (NCT00106665).

Comparative evaluation of the content and structure of communication using two handoff tools: Implications for patient safety

PURPOSE Handoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format. METHOD A nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns. RESULTS Use of HAND-IT led to fewer communication breakdowns (F1,80 = 45.66: P < .0001), greater number of CEs (t40 = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t40 = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions. CONCLUSION The HAND-ITs body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.

Defining the practice of "no escalation of care" in the ICU.

Objective:Withdrawal or withholding of life-sustaining therapies precedes most deaths in the modern ICU. As goals of care for critically ill patients change from curative to palliative, this transition often occurs abruptly, but a slower more staggered approach may also be used. One such approach is “no escalation of care”, often the first step in this transition at the end-of-life. We aimed to determine the prevalence of no escalation of care designation for ICU decedents and identify which interventions are involved. Design:We performed a retrospective medical record review of all patients who died over a two year period. Records with documentation of no escalation of care in physician orders or progress notes, or other instructions suggesting sequential or selective limitation of interventions were included. Setting:Sixteen bed medical ICU at a single large academic hospital. Interventions:None. Measurements and Main Results:Of a total of 310 ICU decedents, 95 (30%) had a no escalation of care designation before death. Hemodialysis, vasopressors, and blood transfusions were the interventions more likely to be withheld. For ongoing therapies, hemodialysis, blood transfusions, and antibiotics were more likely to be withdrawn. Mechanical ventilation, hydration, and nutrition were less likely to be withheld or withdrawn. A minority had a palliative care consult (15%) or ethics consult (4%) while in the ICU. Time from no escalation of care designation to death averaged 0.8 days (range, 0–5 d). Conclusion:No escalation of care designation occurs in a significant proportion of ICU decedents shortly before death. Some interventions are more likely to be limited than others using a no escalation of care approach.

Accuracy of chest high-resolution computed tomography in diagnosing diffuse cystic lung diseases

The diffuse cystic lung diseases (DCLDs) are a group of pathophysiologically heterogeneous processes characterised by the presence of multiple, thin-walled, air-filled spaces within the pulmonary parenchyma [1]. The differential diagnosis of DCLDs includes lymphangioleiomyomatosis (LAM), follicular bronchiolitis (FB), lymphocytic interstitial pneumonia (LIP), Birt–Hogg–Dubé syndrome (BHD), pulmonary Langerhans cell histiocytosis (PLCH), amyloidosis, light chain deposition disease, cystic metastases, infectious entities such as Pneumocystis, and other aetiologies [2]. Bronchiectasis and bullous changes seen in chronic obstructive pulmonary disease can also produce high-resolution computed tomography (HRCT) patterns that mimic the DCLDs. Correct diagnosis of diffuse cystic lung diseases is established in most cases by critical review of HRCT features http://ow.ly/NvrCc

Characterizing the structure and content of nurse handoffs

Effective communication during nurse handoffs is instrumental in ensuring safe and quality patient care. Much of the prior research on nurse handoffs has utilized retrospective methods such as interviews, surveys and questionnaires. While extremely useful, an in-depth understanding of the structure and content of conversations, and the inherent relationships within the content is paramount to designing effective nurse handoff interventions. In this paper, we present a methodological framework-Sequential Conversational Analysis (SCA)-a mixed-method approach that integrates qualitative conversational analysis with quantitative sequential pattern analysis. We describe the SCA approach and provide a detailed example as a proof of concept of its use for the analysis of nurse handoff communication in a medical intensive care unit. This novel approach allows us to characterize the conversational structure, clinical content, disruptions in the conversation, and the inherently phasic nature of nurse handoff communication. The characterization of communication patterns highlights the relationships underlying the verbal content of nurse handoffs with specific emphasis on: the interactive nature of conversation, relevance of role-based (incoming, outgoing) communication requirements, clinical content focus on critical patient-related events, and discussion of pending patient management tasks. We also discuss the applicability of the SCA approach as a method for providing in-depth understanding of the dynamics of communication in other settings and domains.

Ventilator-associated events prevention, learning lessons from the past: A systematic review

BACKGROUND Preventing Ventilator-associated events (VAE) is a major challenge. Strictly monitoring for ventilator-associated pneumonia (VAP) is not sufficient to ensure positive outcomes. Therefore, the surveillance definition was updated and a change to the broader VAE was advocated. OBJECTIVE This paper summarizes the scientific efforts assessing VAP preventive bundles and the recent transition in surveillance methods. METHODS We conducted a systematic review to identify lessons from past clinical studies assessing VAP prevention bundles. We then performed a thorough literature review on the recent VAE surveillance algorithm, highlighting its advantages and limitations. CONCLUSION VAP prevention bundles have historically proven their efficacy and the introduction of the new VAE definition aimed at refining and objectivizing surveillance methods. Randomized controlled trials remain vital to determine the effect of VAE prevention on patient outcomes. We recommend expanding beyond limited VAP prevention strategies towards VAE prevention bundles.

Value of the PaO2:FiO2 ratio and Rapid Shallow Breathing Index in predicting successful extubation in hypoxemic respiratory failure

PURPOSE We sought to determine the predictive value of the PaO₂:FiO₂ ratio (PFR), both independently and in combination with the standard Rapid Shallow Breathing Index (RSBI), for successful extubations in patients with primary hypoxemic respiratory failure (HRF). MATERIALS AND METHODS A retrospective chart review of 154 patients with HRF requiring mechanical ventilation for ≥24 hours was performed. The primary outcome was reintubation within 48 hours. RESULTS 142 (92%) patients were successfully extubated. Pre-extubation PFR and RSBI values among reintubated and successfully extubated patients were similar. The areas under the curve of the receiver operating characteristic curves using RSBI and PFR were .5 and .62, respectively. A PFR < 200 or RSBI ≥ 70 when the PFR was ≥200 indicated a higher risk of reintubation, with .7 sensitivity and .56 specificity (area under the curve, .69), using a classification and regression tree model. CONCLUSIONS Neither the PFR independently nor the PFR in combination with the RSBI in a classification and regression tree model accurately predicted successful extubation in patients with HRF.

Error Recovery in the Wilderness of ICU

Our previous investigations of error detection and correction in a laboratory setting (in-vitro) using error-embedded tasks show that individual physicians identified less than 50 % of the errors [1]. Experts corrected the errors as soon as they detected them and were better able to detect errors requiring integration of multiple elements in the case. Residents were more cautious in making decisions showing a slower error recovery pattern, and the detected errors were more procedural in nature with specific patient outcomes. In this study, error detection and correction are shown to be dependent on expertise, and on the nature of the everyday tasks of the clinicians, given that experts make top level decisions, while residents take care of patient-related problems on day-to-day basis.

Low Testosterone Levels are Frequent in Patients with Acute Respiratory Failure and are Associated with Poor Outcomes

OBJECTIVE Low testosterone level is a common finding in critically ill patients with trauma, shock, and sepsis. However, its prevalence and outcomes in patients with primary acute respiratory failure is unknown; low testosterone could contribute to respiratory muscle weakness and further compromise ventilation in these patients. METHODS We aimed to determine the prevalence, severity, and effects of hypotestosteronemia in patients with acute respiratory failure in a 16-bed single academic center medical intensive care unit (ICU). We studied 30 men who required mechanical ventilation for ≥24 hours for a primary diagnosis of acute respiratory failure. Blood samples were drawn on ICU day 1 and day 3 to measure serum levels of total and free testosterone. RESULTS Hypotestosteronemia (level below the lower reference limit) was present on day 1 in 93.1% (total testosterone) and 76.7% (free testosterone) of patients and on day 3 in 94.4% (total testosterone) and 100% (free testosterone) of patients. Sex hormone-binding globulin, dehydroepiandrosterone sulfate, follicle-stimulating hormone, luteinizing hormone, and thyroid function levels were all within stated reference ranges. Total and free testosterone levels correlated inversely with ventilator days and ICU length of stay. CONCLUSION Hypotestosteronemia is common in mechanically ventilated patients with primary acute respiratory failure and may contribute to longer ICU stay. Further studies are needed to determine the effect of testosterone replacement on short- and long-term outcomes in these patients.

Applying the New Institute for Healthcare Improvement Inpatient Waste Tool to Identify "Waste" in the Intensive Care Unit.

Abstract:Healthcare waste—the inappropriate use of healthcare resources that provides no benefit to patients yet contributes to cost and even harm—is a potentially significant contributor to high healthcare costs. This project aimed to apply a new locally modified Institute for Healthcare Improvement (IHI)–developed waste identification tool to measure the prevalence of and reason for the inappropriate use of intensive care unit (ICU) beds, one type of potential waste. Unnecessary days (i.e., waste) and their causes in a 16-bed “closed” medical ICU (MICU) and a 10-bed “semi-closed” transplant surgical ICU (TSICU) were identified by physicians over a 3-month period. Data on 513 patients admitted to both ICUs for a total of 1,631 patient-days demonstrated that 15% of MICU days and 25.8% of TSICU days were unnecessary. Although causes of waste in each ICU differed, delays in transfer of patients out of the ICU, end-of-life decision-making, and delays in procedures were among the commonest. Determination of waste also varied among physicians, ranging from 4.5% to 27.7% in the MICU and 0%–37.5% in the TSICU. This study found that the IHI waste tool can be effectively used to identify waste in the ICU, which is common and varies based on the ICU type and physician perceptions.