Meghan B. Lane-Fall

Insurance and racial differences in long-term acute care utilization after critical illness.

Objectives:To determine whether insurance coverage and race are associated with long-term acute care hospital utilization in critically ill patients requiring mechanical ventilation. Design:Retrospective cohort study. Setting:Nonfederal Pennsylvania hospital discharges from 2004 to 2006. Patients:Eligible patients were aged 18 yrs or older, of white or black race, and underwent mechanical ventilation in an intensive care unit during their hospital stay. Interventions:None. Measurements and Main Results:We used multivariable logistic regression with hospital-level random effects to determine the independent association between discharge to long-term acute care hospital, insurance status, and race after appropriate controls, including a chart-based measure of severity of illness. The primary outcome measure was discharge to long-term acute care hospital. Of 66,233 eligible patients, 84.7% were white and 15.3% were black. More white patients than black patients had commercial insurance (23.4% vs. 14.9%) compared to Medicaid (10.6% vs. 29.7%) or no insurance (1.3% vs. 2.2%). Long-term acute care hospital transfer occurred in 5.0% of patients. On multivariable analysis in patients aged younger than 65 yrs, black patients were significantly less likely to undergo long-term acute care hospital transfer (odds ratio, 0.71; p = .003), as were patients with Medicaid vs. commercial insurance (odds ratio, 0.17; p < .001). Analyzing race and insurance together and accounting for hospital-level effects, patients with Medicaid were still less likely to undergo long-term acute care hospital transfer (odds ratio, 0.18; p < .001), but race effects were no longer present (odds ratio, 1.06; p = .615). No significant race effects were seen in the Medicare-eligible population aged 65 yrs or older (odds ratio for transfer to long-term acute care hospital, 0.93; p = .359). Conclusions:Differences in long-term acute care hospital utilization after critical illness appear driven by insurance status and hospital-level effects. Racial variation in long-term acute care hospital use is not seen after controlling for insurance status and is not seen in a group with uniform insurance coverage. Differential access to postacute care may be minimized by expanding commercial or Medicare insurance availability and standardizing long-term acute care admission criteria across hospitals. (Crit Care Med 2012; 40:–1149)

Addressing the mandate for hand-off education: a focused review and recommendations for anesthesia resident curriculum development and evaluation.

The Accreditation Council for Graduate Medical Education requires that residency programs teach residents about handoffs and ensure their competence in this communication skill. Development of hand-off curricula for anesthesia residency programs is hindered by the paucity of evidence regarding how to conduct, teach, and evaluate handoffs in the various settings where anesthesia practitioners work. This narrative review draws from literature in anesthesia and other disciplines to provide recommendations for anesthesia resident hand-off curriculum development and evaluation.

Handoffs and transitions in critical care (HATRICC): protocol for a mixed methods study of operating room to intensive care unit handoffs

BackgroundOperating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process.Methods/DesignThe Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment: We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants’ impressions about the current process. Adaptation and implementation: We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process’ feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units. Evaluation: Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process. Data analysis: The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability.DiscussionThe HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients.Trial registrationClinicalTrials.gov identifier: NCT02267174. Date of registration October 16, 2014.

Outcomes measures and risk adjustment.

This paper reviews the field of outcomes measurement in anesthesia and surgery, emphasizing those outcomes that may be influenced by perioperative care. Data sources for outcomes measurement are described, and the concept of risk adjustment is introduced. The basic mechanics of outcomes measurement and its pitfalls are explained. Finally, specific perioperative outcomes - mortality, readmission and composite outcomes - are described and their limitations are considered.

Decreased urine output and acute kidney injury in the postanesthesia care unit.

Decreased urine output and acute kidney injury (also known as acute renal failure) are among the most important complications that may develop in the postanesthetic period. In this article, the authors present definitions of decreased urine output, oliguria, and acute kidney injury. They review the epidemiology, pathophysiology, and prevention of postoperative acute kidney injury. Finally, the article offers approaches to diagnosis and management of the postsurgical patient with decreased urine output or acute kidney injury.

An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients

Background: Studies of nighttime intensivist staffing have yielded mixed results. Goals: To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients. Methods: We searched five databases (2000‐2016) for studies comparing in‐hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta‐analyses used random effects models. Results: Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta‐analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75‐1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes. Conclusions: Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta‐analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.

ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists

Objectives:To characterize intensivist handoff practices and expectations and to explore perceptions of the patient safety implications of attending handoffs. Design:Cross-sectional electronic survey administered in 2014. Setting:One hundred sixty-nine U.S. hospitals with critical care training programs accredited by the Accreditation Council for Graduate Medical Education. Subjects:Academic intensivists were recruited via e-mail invitation from a database of 1,712 eligible academic intensivists. Interventions:None. Measurements and Main Results:Six hundred sixty-one intensivists completed the survey (completion rate, 38.6%). Responses were received from at least one individual at 147 of 169 unique hospitals (87.0%) represented in the study database. Five hundred seventy-three (87%) respondents reported participating in handoffs at the end of each ICU rotation. A variety of communication methods were used for end-of-rotation handoffs, including in-person discussion (92.9%), telephone calls (83.9%), e-mail messages (69.0%), computer-generated documents (64.6%), and text messages (23.6%). Mean satisfaction with current handoff process was rated as 68.4 on a scale from 0 to 100 (SD, 22.6). Respondents (55.4%) said that attending handoffs should be standardized, but only 13.3% (76/572) of those participating in end-of-rotation handoffs reported using a standardized process. Specific handoff topics, including active clinical issues and resuscitation status, were reportedly discussed less frequently than would be ideal (p < 0.001 for the difference between reported frequency and ideal frequency). In free-text comments, 76 respondents (11.5%) expressed skepticism that attending handoffs were necessary given the presence of residents and fellows and given a lack of agreement about necessary content. Two hundred respondents (30.8%) reported knowing of an adverse event (inappropriate treatment, cardiac arrest, and death) attributable to inadequate attending handoffs. Conclusions:ICU attending handoffs in the United States exhibit marked heterogeneity, and intensivists do not agree about the value of attending handoffs. In addition, some intensivists perceive a link between suboptimal attending handoffs, inappropriate treatment, and serious adverse events that warrants further study.

A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications

Background: There is a need for robust, clearly defined, patient‐relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research. Methods: A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three‐stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials. Results: From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions); (ii) pneumonia (12 definitions); and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition. Conclusions: A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.

Veno-Venous Extracorporeal Life Support in Hemodynamically Unstable Patients With ARDS.

When clinicians consider extracorporeal life support (ECLS) for acute respiratory distress syndrome (ARDS) patients with hemodynamic instability, both veno-arterial (VA) and veno-venous (VV) ECLS are therapeutic possibilities. We analyzed 17 patients with ARDS on inotropic or vasopressor support requiring ECLS for refractory hypoxemia. After implementing VV ECLS, pressor requirements (based on norepinephrine equivalents) were significantly lower in all patients (P = .0001 for overall comparison across time points). None of the 17 patients required conversion from VV ECLS to VA ECLS (95% confidence interval 0%–20.0%). In this sample of 17 patients with substantial baseline vasopressor support and hypoxemic respiratory failure, initiation of VV ECLS was associated with reduced pressor requirements. Such a strategy may help avoid complications of VA ECLS in patients with both respiratory and hemodynamic failure.

Clinician Perception of the Effectiveness of an Automated Early Warning and Response System for Sepsis in an Academic Medical Center

RATIONALE We implemented an electronic early warning and response system (EWRS) to improve detection of and response to severe sepsis. Sustainability of such a system requires stakeholder acceptance. We hypothesized that clinicians receiving such alerts perceive them to be useful and effective. OBJECTIVES To survey clinicians after EWRS notification about perceptions of the system. METHODS For a 6-week study period 1 month after EWRS implementation in a large tertiary referral medical center, bedside clinicians, including providers (physicians, advanced practice providers) and registered nurses (RNs), were surveyed confidentially within 2 hours of an alert. MEASUREMENTS AND MAIN RESULTS For the 247 alerts that triggered, 127 providers (51%) and 105 RNs (43%) completed the survey. Clinicians perceived most patients as stable before and after the alert. Approximately half (39% providers, 48% RNs) felt the alert provided new information, and about half (44% providers, 56% RNs) reported changes in management as a result of the alert, including closer monitoring and additional interventions. Over half (54% providers, 65% RNs) felt the alert was appropriately timed. Approximately one-third found the alert helpful (33% providers, 40% RNs) and fewer felt it improved patient care (24% providers, 35% RNs). CONCLUSIONS A minority of responders perceived the EWRS to be useful, likely related to the perception that most patients identified were stable. However, management was altered half the time after an alert. These results suggest further improvements to the system are needed to enhance clinician perception of the systems utility.