Sarah J. Beesley

Let Them In: Family Presence during Intensive Care Unit Procedures

Families have for decades advocated for full access to intensive care units (ICUs) and meaningful partnership with clinicians, resulting in gradual improvements in family access and collaboration with ICU clinicians. Despite such advances, family members in adult ICUs are still commonly asked to leave the patients room during invasive bedside procedures, regardless of whether the patient would prefer family to be present. Physicians may be resistant to having family members at the bedside due to concerns about trainee education, medicolegal implications, possible effects on the technical quality of procedures due to distractions, and procedural sterility. Limited evidence from parallel settings does not support these concerns. Family presence during ICU procedures, when the patient and family member both desire it, fulfills the mandates of patient-centered care. We anticipate that such inclusion will increase family engagement, improve patient and family satisfaction, and may, on the basis of studies of open visitation, pediatric ICU experience, and family presence during cardiopulmonary resuscitation, decrease psychological distress in patients and family members. We believe these goals can be achieved without compromising the quality of patient care, increasing provider burden significantly, or increasing risks of litigation. In this article, we weigh current evidence, consider historical objections to family presence at ICU procedures, and report our clinical experience with the practice. An outline for implementing family procedural presence in the ICU is also presented.

Relative Bradycardia in Patients With Septic Shock Requiring Vasopressor Therapy

Objectives: Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia (heart rate, < 80 beats/min) in septic shock are unknown. To determine mortality associated with patients who are relatively bradycardic while in septic shock. Design: Retrospective study of patients admitted for septic shock to study ICUs during 2005–2013. Setting: One large academic referral hospital and two community hospitals. Patients: Adult patients with septic shock requiring vasopressors. Intervention: None. Measurements: Primary outcome was 28-day mortality. We used multivariate logistic regression to evaluate the association between relative bradycardia and mortality, controlling for confounding with inverse probability treatment weighting using a propensity score. Results: We identified 1,554 patients with septic shock, of whom 686 (44%) met criteria for relative bradycardia at some time. Twenty-eight-day mortality in this group was 21% compared to 34% in the never-bradycardic group (p < 0.001). Relatively bradycardic patients were older (65 vs 60 yr; p < 0.001) and had slightly lower illness severity (Sequential Organ Failure Assessment, 10 vs 11; p = 0.004; and Acute Physiology and Chronic Health Evaluation II, 27 vs 28; p = 0.008). After inverse probability treatment weighting, covariates were balanced, and the association between relative bradycardia and survival persisted (p < 0.001). Conclusions: Relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding. Our data support expanded investigation into whether inducing relative bradycardia will benefit patients with septic shock.

Humanizing Intensive Care: Theory, Evidence, and Possibilities

Intensive care units (ICUs) are showcases for many of the most stunning technological advances in medicine. Survival from once routinely fatal diseases is rapidly increasing [1]. Unfortunately, the severity of illness and the invasiveness of intensive therapies can make the ICU a brutal place for all involved [2, 3]. Patients report violations of their dignity and most survivors and family members experience symptoms of anxiety, depression, or posttraumatic stress disorder (PTSD) [4]. For patients who die in or shortly after the ICU stay, many of the deaths will have been deformed by an overemphasis on medical technology [5]. ICU admission may threaten the individual’s sense of self, both from the threat of annihilation through death and the dehumanization attendant to critical illness, its treatments, and clinician behaviors [2]. The sometimes brutal realities of contemporary ICU care are generating appropriate debates about how to humanize the ICU. Several possible solutions have been proposed [6], but the topic has often been associated with a lack of clear thinking, particularly in the ICU.

Preliminary Identification of Coping Profiles Relevant to Surrogate Decision Making in the ICU

Objective The Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience. Methods Participants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual’s ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU. Results Three hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile. Conclusion Distinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.

Association of hospice utilization and publicly reported outcomes following hospitalization for pneumonia or heart failure: a retrospective cohort study

BackgroundThe Center for Medicare and Medicaid Services (CMS) and the Hospital Quality Alliance began collecting and reporting United States hospital performance in the treatment of pneumonia and heart failure in 2008. Whether the utilization of hospice might affect CMS-reported mortality and readmission rates is not known.MethodsHospice utilization (mean days on hospice per decedent) for 2012 from the Dartmouth Atlas (a project of the Dartmouth Institute that reports a variety of public health and policy-related statistics) was merged with hospital-level 30-day mortality and readmission rates for pneumonia and heart failure from CMS. The association between hospice use and outcomes was analyzed with multivariate quantile regression controlling for quality of care metrics, acute care bed availability, regional variability and other measures.Results2196 hospitals reported data to both CMS and the Dartmouth Atlas in 2012. Higher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia but not for heart failure. Higher quality of care was associated with lower rates of mortality for both pneumonia and heart failure. Greater acute care bed availability was associated with increased readmission rates for both conditions (p < 0.05 for all).ConclusionsHigher rates of hospice utilization were associated with lower rates of 30-day mortality and readmission for pneumonia as reported by CMS. While causality is not established, it is possible that hospice referrals might directly affect CMS outcome metrics. Further clarification of the relationship between hospice referral patterns and publicly reported CMS outcomes appears warranted.

Echocardiography in the Intensive Care Unit

Purpose of ReviewThis review provides an overview of the evidence for and current practices incorporating the use of echocardiography in the intensive care setting. We describe training and certification for critical care echocardiography and the use of echocardiography for the assessment of hemodynamics, fluid responsiveness, diagnosis of shock, procedural guidance, and cardiac arrest.Recent FindingsRecent advances have been made in multiple aspects of critical care echocardiography, including training and certification, assessment of fluid responsiveness in spontaneously breathing patients, and evaluation of undifferentiated shock.SummaryEchocardiography is increasingly used in the intensive care setting. Its applications and evidence base continue to expand. Randomized controlled trials are needed to demonstrate that the use of echocardiography improves patient outcomes.

345: BARRIERS TO PROVIDING QUALITY END OF LIFE CARE IN THE ICU RESULTS OF A MULTICENTER SURVEY

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) quality and 3 of poor quality. The patients who had a PC consultation in the ICU, when compared to the ones who did not, showed a trend towards reduction in ICU and hospital LOS. This was statistically significant in the high quality studies. Mortality outcomes were similar in both patient groups. PC consultations also lead to a significant reduction in ICU and total hospital costs in 5 of the 8 eligible trials. Using weighted means, ICU costs were (control vs PC)

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

7533 vs

Esmolol infusion in patients with septic shock and tachycardia: a prospective, single-arm, feasibility study

6406 (p<0.001) and hospital costs were

Peer Support in Critical Care: A Systematic Review

9518 vs