Melissa A. Miller

A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumonia ☆

PURPOSE The aim of this study was to determine whether the use of a polyurethane-cuffed endotracheal tube would result in a decrease in ventilator-associated pneumonia rate. MATERIALS AND METHODS We replaced conventional endotracheal tube with a polyurethane-cuff endotracheal tube (Microcuff, Kimberly-Clark Corporation, Rosewell, Ga) in all adult mechanically ventilated patients throughout our large academic hospital from July 2007 to June 2008. We retrospectively compared the rates of ventilator-associated pneumonia before, during, and after the intervention year by interrupted time-series analysis. RESULTS Ventilator-associated pneumonia rates decreased from 5.3 per 1000 ventilator days before the use of the polyurethane-cuffed endotracheal tube to 2.8 per 1000 ventilator days during the intervention year (P = .0138). During the first 3 months after return to conventional tubes, the rate of ventilator-associated pneumonia was 3.5/1000 ventilator days. Use of the polyurethane-cuffed endotracheal tube was associated with an incidence risk ratio of ventilator-associated pneumonia of 0.572 (95% confidence interval, 0.340-0.963). In statistical regression analysis controlling for other possible alterations in the hospital environment, as measured by rate of tracheostomy-ventilator-associated pneumonia, the incidence risk ratio of ventilator-associated pneumonia in patients intubated with polyurethane-cuffed endotracheal tube was 0.565 (P = .032; 95% confidence interval, 0.335-0.953). CONCLUSIONS Use of a polyurethane-cuffed endotracheal tube was associated with a significant decrease in the rate of ventilator-associated pneumonia in our study.

Becoming a high reliability organization

Aircraft carriers, electrical power grids, and wildland firefighting, though seemingly different, are exemplars of high reliability organizations (HROs) - organizations that have the potential for catastrophic failure yet engage in nearly error-free performance. HROs commit to safety at the highest level and adopt a special approach to its pursuit. High reliability organizing has been studied and discussed for some time in other industries and is receiving increasing attention in health care, particularly in high-risk settings like the intensive care unit (ICU). The essence of high reliability organizing is a set of principles that enable organizations to focus attention on emergent problems and to deploy the right set of resources to address those problems. HROs behave in ways that sometimes seem counterintuitive - they do not try to hide failures but rather celebrate them as windows into the health of the system, they seek out problems, they avoid focusing on just one aspect of work and are able to see how all the parts of work fit together, they expect unexpected events and develop the capability to manage them, and they defer decision making to local frontline experts who are empowered to solve problems. Given the complexity of patient care in the ICU, the potential for medical error, and the particular sensitivity of critically ill patients to harm, high reliability organizing principles hold promise for improving ICU patient care.

Implementation challenges in the intensive care unit: The why, who, and how of daily interruption of sedation

PURPOSE Despite strong medical evidence and policy initiatives supporting the use of daily interruption of sedation in mechanically ventilated patients, compliance remains suboptimal. We sought to identify new barriers to daily interruption of sedation. MATERIALS AND METHODS We conducted 5 focus groups of intensive care unit physicians, nurses, and respiratory therapists during a 2-month period to identify attitudes, barriers, and motivations to perform a daily interruption of sedation. Each focus group was audiotaped, and the transcripts were analyzed using qualitative methods to identify recurrent themes. RESULTS There was wide consensus on the importance of daily interruptions of sedation; however, practitioners usually performed sedation interruption for 1 of 5 distinct reasons: minimizing the dose of sedation, performing a neurologic examination, facilitating ventilator weaning, reducing intensive care unit length of stay, and assessing patient pain. Participants rarely espoused more than 1 main reason, and there was no shared understanding of why one might do a daily interruption of sedation. This lack of shared understanding led to different patients being selected and diverse approaches to carrying out the DIS. CONCLUSIONS Despite apparent consensus, lack of shared understanding of the rationale for an intervention may lead to divergent practice patterns and failure to implement standardized, evidence-based practice.

When do confounding by indication and inadequate risk adjustment bias critical care studies? A simulation study

IntroductionIn critical care observational studies, when clinicians administer different treatments to sicker patients, any treatment comparisons will be confounded by differences in severity of illness between patients. We sought to investigate the extent that observational studies assessing treatments are at risk of incorrectly concluding such treatments are ineffective or even harmful due to inadequate risk adjustment.MethodsWe performed Monte Carlo simulations of observational studies evaluating the effect of a hypothetical treatment on mortality in critically ill patients. We set the treatment to have either no association with mortality or to have a truly beneficial effect, but more often administered to sicker patients. We varied the strength of the treatment’s true effect, strength of confounding, study size, patient population, and accuracy of the severity of illness risk-adjustment (area under the receiver operator characteristics curve, AUROC). We measured rates in which studies made inaccurate conclusions about the treatment’s true effect due to confounding, and the measured odds ratios for mortality for such false associations.ResultsSimulated observational studies employing adequate risk-adjustment were generally able to measure a treatment’s true effect. As risk-adjustment worsened, rates of studies incorrectly concluding the treatment provided no benefit or harm increased, especially when sample size was large (n = 10,000). Even in scenarios of only low confounding, studies using the lower accuracy risk-adjustors (AUROC < 0.66) falsely concluded that a beneficial treatment was harmful. Measured odds ratios for mortality of 1.4 or higher were possible when the treatment’s true beneficial effect was an odds ratio for mortality of 0.6 or 0.8.ConclusionsLarge observational studies confounded by severity of illness have a high likelihood of obtaining incorrect results even after employing conventionally “acceptable” levels of risk-adjustment, with large effect sizes that may be construed as true associations. Reporting the AUROC of the risk-adjustment used in the analysis may facilitate an evaluation of a study’s risk for confounding.

Diverse attitudes to and understandings of spontaneous awakening trials: Results from a statewide quality improvement collaborative

Objectives:Spontaneous awakening trials (SATs) improve outcomes in mechanically ventilated patients, but implementation remains erratic. We examined variation in reported practice, prevalence of attitudes and fears regarding spontaneous awakening trials, and organizational practices associated with routine implementation of spontaneous awakening trials in an ICU quality improvement collaborative. Design:Written survey. Setting:Michigan Health and Hospital Association’s Keystone ICU, a quality improvement collaborative of 73 hospitals. Subjects:Attendees of the yearly Keystone ICU meeting, January 2011, including nurses, physicians, hospital administrators, and other healthcare professionals. Intervention:Respondents were asked about institutional characteristics, spontaneous awakening trial practice, attitudes and barriers regarding spontaneous awakening trials, and organizational cultural characteristics that might influence SAT practice. The association of organizational cultural characteristics and attitudes with reported spontaneous awakening trial use was evaluated using logistic regression. Measurements and Main Results:Three hundred nineteen participants attended the meeting. The survey response rate was 83.4%. Respondents reported wide variation in approach to spontaneous awakening trial performance and patient selection. 48.6% of respondents reported regular spontaneous awakening trial use, defined as greater than 75% of mechanically ventilated patients undergoing spontaneous awakening trials each day. In bivariable analysis, addressing sedation goals routinely in rounds and having spontaneous awakening trials as part of unit culture were positively associated with regular spontaneous awakening trial use, whereas the perception that spontaneous awakening trials increased short-term adverse effects, staff fears of spontaneous awakening trials, and the perception that spontaneous awakening trials are hard work were negatively associated with regular spontaneous awakening trial use. In multivariable analysis, only addressing sedation in rounds (odds ratio, 2.85 [95% CI, 1.55–5.23]), incorporation of spontaneous awakening trials into unit culture (odds ratio, 3.36 [95% CI, 1.75–6.43]), and the perception that spontaneous awakening trials are hard work (odds ratio, 0.53 [95% CI, 0.30–0.96]) remained statistically significantly associated with regular spontaneous awakening trial use. Respondents in managerial positions were less likely to perceive spontaneous awakening trials as hard work (odds ratio, 0.44 [95% CI, 0.22–0.85]). Conclusions:Even in a motivated statewide quality improvement collaborative, spontaneous awakening trial practice varies widely and concerns persist regarding spontaneous awakening trials. Cultural practices may counteract the effect of concerns regarding spontaneous awakening trials and are associated with increased performance of this beneficial intervention. Patient selection should be a focus for continuing medical education. Differences in perception of work between management and staff may also be a focus for improved communication.

Organisational characteristics associated with the use of daily interruption of sedation in US hospitals: a national study

Objective Daily interruption of sedation (DIS) has multiple proven benefits, but implementation is erratic. Past research on sedative interruption utilisation focused on individual clinicians, ignoring the role of organisations in shaping practice. The authors test the hypothesis that specific hospital organisational characteristics are associated with routine use of DIS. Design and setting National, mailed survey to a stratified random sample of US hospitals in 2009. Respondents were the lead infection control professionals at each institution. Methods Survey items enquired about DIS use, institutional structure, and organisational culture. Multivariable analysis was used to evaluate the independent association of these factors with DIS use. Results A total of 386 hospitals formed our final analytic sample; the response rate was 69.4%. Hospitals ranged in size from 25 to 1359 beds. 26% of hospitals were associated with a medical school. Almost 80% reported regular use of DIS for ventilated patients. While 75.4% of hospitals reported having leadership focus on safety culture, only 42.7% reported that their staff were receptive to changes in practice. In a multivariable logistic regression model, structural characteristics such as size and academic affiliation were not associated with use of DIS. However, leadership emphasis on safety culture (p=0.04), staff receptivity to change (p=0.02) and involvement in an infection prevention collaborative (p=0.04) were significantly associated with regular DIS use. Conclusions Several elements of hospital organisational culture were associated with regular use of DIS in US hospitals. These findings emphasise the importance of combining specific administrative approaches with strategies to encourage receptivity to change among bedside clinicians in order to successfully implement complex evidence-based practices in the intensive care setting.

Issues of Survivorship Are Rarely Addressed during Intensive Care Unit Stays. Baseline Results from a Statewide Quality Improvement Collaborative

UNLABELLED RATIONALE/OBJECTIVE: In the context of increasing survivorship from critical illness, many studies have documented persistent sequelae among survivors. However, few evidence-based therapies exist for these problems. Support groups have proven efficacy in other populations, but little is known about their use after an intensive care unit (ICU) stay. Therefore, we surveyed critical care practitioners regarding their hospitals practice regarding discussing post-ICU problems for survivors with patients and their loved ones, communicating with primary care physicians, and providing support groups for current or former patients and families. METHODS A written survey was administered to 263 representatives of 73 hospitals attending the January 2013 annual meeting of the Michigan Health and Hospitals Association Keystone ICU initiative, a quality improvement collaborative focused on enhancing outcomes across Michigan ICUs. RESULTS There were 174 completed surveys, a 66% response rate. Representatives included staff nurses, nursing leadership, physicians, hospital administrators, respiratory therapists, and pharmacists. Sixty-nine percent of respondents identified at least one issue facing ICU survivors after discharge. The concerns most commonly identified by these ICU practitioners were weakness, psychiatric pathologies, cognitive dysfunction, and transitions of care. However, most respondents did not routinely discuss post-ICU problems with patients and families, and only 20% had a mechanism to formally communicate discharge information to primary care providers. Five percent reported having or being in the process of creating a support group for ICU survivors after discharge. CONCLUSIONS Despite growing awareness of the problems faced by ICU survivors, in this statewide quality improvement collaborative, hospital-based support groups are rarely available, and deficiencies in transitions of care exist. Practice innovations and formal research are needed to provide ways to translate awareness of the problems of survivorship into improved outcomes for patients.

Implementing Antimicrobial Stewardship in Long-term Care Settings: An Integrative Review Using a Human Factors Approach

Implementing effective antimicrobial stewardship in long-term care facilities (LTCFs) is associated with challenges distinct from those faced by hospitals. LTCFs generally care for elderly populations who are vulnerable to infection, have prescribers who are often off-site, and have limited access to timely diagnostic testing. Identification of feasible interventions in LTCFs is important, particularly given the new requirement for stewardship programs by the Centers for Medicare and Medicaid Services (CMS). In this integrative review, we analyzed published evidence in the context of a human factors engineering approach as well as educational interventions to understand aspects of multimodal interventions associated with the implementation of successful stewardship programs in LTCFs. The outcomes indicate that effective antimicrobial stewardship in long-term care is supported by incorporating multidisciplinary education, tools integrated into the workflow of nurses and prescribers that facilitate review of antibiotic use, and involvement of infectious disease consultants.

Management of Strongyloides Hyperinfection Syndrome

Strongyloides stercoralis is an infectious helminth endemic to the tropics and subtropics, and can be seen in immigrants and returning travelers. Symptoms of acute infection involve organs of the typical life cycle of the nematode. In milder forms of chronic infections, strongyloides is capable of persisting in a host for years to decades. Severe strongyloidiasis includes the hyperinfection syndrome and disseminated infection, and occurs most frequently in the immunocompromised and immunosuppressed populations. We illustrate a case of severe strongyloidiasis, discuss clinical manifestations and diagnosis of infection, and present the evidence for treatment options. The key to successful therapy is early recognition of disease, and prompt diagnosis in high risk patients.

Use of Daily Interruption of Sedation and Early Mobility in US Hospitals

Although the Awakening and Breathing Coordination, Delirium assessment, and Early exercise/mobility (ABCDE) bundle may be effective, individual components of ABCDE may not be implemented as intended. We examined the use of daily interruption of sedation (DIS) and early mobility, looking for an association between these bundle elements. Despite the growing use of DIS and early mobility, the two do not seem to be adopted together, with serious implications for the effectiveness of the ABCDE bundle.