Nicholas S. Ward

The compensatory anti-inflammatory response syndrome (CARS) in critically ill patients.

Like the systemic inflammatory response syndrome (SIRS), the compensatory anti-inflammatory response syndrome (CARS) is a complex pattern of immunologic responses to severe infection or injury. The difference is that while SIRS is a proinflammatory response tasked with killing infectious organisms through activation of the immune system, CARS is a global deactivation of the immune system tasked with restoring homeostasis. Much research now suggests that the timing and relative magnitude of this response have a profound impact on patient outcomes.

Bereaved Family Member Perceptions of Quality of End‐of‐Life Care in U.S. Regions with High and Low Usage of Intensive Care Unit Care

Objectives: To compare the quality of end‐of‐life care of persons dying in regions of differing practice intensity.

Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units: results of a national survey.

Objective: To examine cost constraints, resource limitations, and rationing within U.S. intensive care units (ICUs) as perceived by ICU clinicians and the roles of ICU physician and nurse directors in resource allocation decisions. Design: A national survey of hospitals with ICUs. Setting: The study included 447 U.S. hospitals with ICUs. Subjects: ICU nurse and physician directors. Interventions: None. Measurements and Main Results: We randomly selected 447 U.S. hospitals stratified for location and ICU size and contacted them for this survey. The institutional response rate was 63%. When asked to characterize their involvement in budgetary decisions, 55% of nurse directors vs. 3% (p < .001) of physician directors answered “heavy” involvement. Additionally, 91% of nurse vs. 38% of physician directors were given feedback on expenditures (p < .001). Responses to questions about specific situations or practices that may be associated with rationing showed that a substantial minority respondents perceived these practices “sometimes” (occurring 25% to 74% of the time) but the majority perceived it “rarely” (occurring <25% of the time) or not at all. Few perceived rationing as occurring “frequently” (occurring >75% of the time) because of costs or availability. When asked if any rationing occurs in their ICUs (using a prestated definition), only 11% of physician and 6% of nurse directors responded yes. Only 6% of nurses and 5% of physicians said that cost constraints have a significant effect on care. In contrast, when asked how often patients receive “too much” care, 46% of respondents said “sometimes or frequently.” Conclusions: Nurse managers have a larger role in managing ICU costs than physicians. Furthermore, both groups perceive that rationing and other cost-related practices sometimes occur in their ICU, but they more commonly perceived excessive care in ICUs. These data may be helpful for policy makers and administrators and may serve as a benchmark for future studies in critical care or other realms of health care.

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

Objectives:The Accreditation Council for Graduate Medical Education recently released new standards for supervision and duty hours for residency programs. These new standards, which will affect over 100,000 residents, take effect in July 2011. In response to these new guidelines, the Society of Critical Care Medicine convened a task force to develop a white paper on the impact of changes in resident duty hours on the critical care workforce and staffing of intensive care units. Participants:A multidisciplinary group of professionals with expertise in critical care education and clinical practice. Data Sources and Synthesis:Relevant medical literature was accessed through a systematic MEDLINE search and by requesting references from all task force members. Material published by the Accreditation Council for Graduate Medical Education and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force corresponded by electronic mail and held several conference calls to finalize this report. Main Results:The new rules mandate that all first-year residents work no more than 16 hrs continuously, preserving the 80-hr limit on the resident workweek and 10-hr period between duty periods. More senior trainees may work a maximum of 24 hrs continuously, with an additional 4 hrs permitted for handoffs. Strategic napping is strongly suggested for trainees working longer shifts. Conclusions:Compliance with the new Accreditation Council for Graduate Medical Education duty-hour standards will compel workflow restructuring in intensive care units, which depend on residents to provide a substantial portion of care. Potential solutions include expanded utilization of nurse practitioners and physician assistants, telemedicine, offering critical care training positions to emergency medicine residents, and partnerships with hospitalists. Additional research will be necessary to evaluate the impact of the new standards on patient safety, continuity of care, resident learning, and staffing in the intensive care unit.

Clinical concise review : Mechanical ventilation of patients with chronic obstructive pulmonary disease

Objective:To summarize the current literature on mechanical ventilation of patients with chronic obstructive pulmonary disease (COPD) using published data to augment commonly accepted principles of clinical practice. Data Source:A MEDLINE/PubMed search from 1966 to November 2006 using the search terms mechanical ventilation, respiratory failure, noninvasive positive pressure ventilation (NIPPV), and COPD, and weaning. Subsequent searches were done on more specific issues such as heliox. Additionally, prominent researchers in this field were interviewed for knowledge of ongoing or unpublished data and their clinical practice. Data Extraction and Synthesis:COPD is very common cause of respiratory failure and admission to the intensive care unit. Mechanical ventilation of patients with COPD presents a unique set of challenges compared with other patients. Care must be taken to avoid augmenting dynamic hyperinflation and acid/base disturbances resulting from chronic hypercapnic respiratory failure. Modalities such as NIPPV and helium/oxygen gas mixtures are increasingly being recognized for their ability to help prevent invasive ventilation and aid in getting patients off invasive ventilation. Conclusions:Despite decades of study, most of the principles of safe mechanical ventilation for patients with COPD such as low respiratory rates that maximize expiratory time and careful attention to air-trapping still hold true to this day. NIPPV appears to be the most important new modality in reducing the mortality, morbidity and incidence of invasive mechanical ventilation.

Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors.

Background: Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. Methods: We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. Results: Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was “too many” and 71% felt the maximum size was “too many.” The median (interquartile range) patient-to-attending physician ratio was 13 (10–16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. Conclusions: Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

Successful determination of lower inflection point and maximal compliance in a population of patients with acute respiratory distress syndrome.

ObjectiveTo compare the ease and efficacy of two commonly used methods for choosing optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome: a static pressure-volume curve to determine the lower inflection point (Pflex) and the “best PEEP” (PEEPbest) as determined by the maximal compliance curve. DesignProspective study. SettingMedical and respiratory intensive care units of university-associated tertiary care hospital. PatientsTwenty-eight patients on mechanical ventilation with acute respiratory distress syndrome. InterventionsA critical care attending physician or fellow and an experienced respiratory therapist attempted to obtain both static pressure-volume curves and maximal compliance curves on 28 patients with acute respiratory distress syndrome by using established methods that were practical to everyday use. The curves then were used to determine both Pflex and PEEPbest, and the results were compared. Measurement and Main resultsOur results showed at least one value for optimal PEEP was obtained in 26 of 28 patients (93%). Pflex was determined in 19 (68%), a PEEPbest in 24 (86%), and both values in 17 (61%). In patients who had both Pflex and PEEPbest determined, there was a close concordance (±3 cm H2O) in 60%. When the values of Pflex and PEEPbest were interpreted by two additional investigators, there was unanimous agreement on the Pflex (±3) only 64% of the time. There was agreement on the value of PEEPbest 93% of the time. ConclusionsOur data show that optimal PEEP, as determined by a pressure-volume curve and a maximal compliance curve, are sometimes unobtainable by practical means but, when obtained, often correspond. A maximal compliance is more often identified, has less interobserver variability, and poses less risk to the patient. We conclude that determining optimal PEEP by maximal static compliance may be easier to measure and more frequently obtained at the bedside than by using a static pressure-volume curve.

Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing.

Objectives:Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios. Data Sources:A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference. Data Extraction:A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a “closed” model where the intensivists control triage and patient care. Data Synthesis and Conclusions:The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

Effects of prone position ventilation in ARDS. An evidence-based review of the literature.

In summary, the many studies done on PPV show that the technique improves oxygenation most of the time. The mechanisms behind this effect are probably numerous and have yet to be elucidated completely. In addition, PPV is a safe procedure that rarely worsens a patients respiratory status or causes other complications and is thus a welcome additional therapeutic option when treating patients with ARDS. Despite the recent large, randomized, controlled trial showing no improvement in mortality rate or organ dysfunction overall, there is evidence suggesting that PPV may be of most benefit in more severely ill patients. Further studies will be useful.

Rationing and critical care medicine

As healthcare expenditures have continued to grow in the United States and elsewhere, the demand for cost-cutting measures has increased. This has led many to wonder if we are, in fact, rationing health care. Critical care is characterized by very high expenditures on a relatively few number of patients, many of whom do not survive, and it is therefore a likely place where rationing could occur. Although much has been written about the concept of rationing, there are few data about the practice, with the exception of studies that examined triaging in the intensive care unit. Research in this area is greatly hampered by the fact that identifying rationing can be very subjective given the relatively inconsistent methods by which critical care is actually practiced and the lack of a clear definition of rationing. This article reviews the concept of healthcare rationing by exploring the many different definitions and methods by which it could occur and the ethical principles underlying these methods. In addition, we review the pertinent literature on resource allocation and rationing in intensive care units.