Sharon Leung

Barriers to ultrasound training in critical care medicine fellowships: A survey of program directors

Objective:Ultrasonography is an effective tool for making quick diagnoses and guiding therapeutic procedures. National organizations have advocated increasing the use of critical care ultrasonography. The purpose of this study was to investigate the prevalence of teaching of critical care ultrasonography in fellowship programs. In addition, we hoped to identify barriers to establishment of ultrasound training programs. Design:All pulmonary/critical care and critical care medicine (CCM) program directors in the United States were invited to participate in an online survey. We asked respondents for demographic information about their programs and perceived barriers to training, as well as current training opportunities for their fellows in five aspects of critical care ultrasonography. A five-point Likert scale was used for survey answers. Setting:Web-based survey. Subjects:Pulmonary/critical care and CCM program directors in the United States. Interventions:Web-based survey. Measurements and Main Results:Ninety (66%) of 136 program directors responded. Ultrasonography training was offered by fellowship programs in the following areas: vascular access (98%), lung and pleural (74%), cardiac (55%), vascular diagnostic (33%), and abdominal (37%). Ninety-two percent of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting their fellows trained. Forty-one percent indicated that they lacked sufficient faculty trained in ultrasound use. Eighty-four percent agreed or strongly agreed that fellow turnover was an impediment to training. Forty-eight percent believed that cardiac echocardiography required a long training time. Conclusions:Although ultrasound training in vascular access was nearly universal, training in other aspects of ultrasound was less prevalent. We identified several barriers, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.

Statins and outcomes in patients with bloodstream infection: a propensity-matched analysis.

Objective:The pleiotropic effects of statins, 3-hydroxy-3 methylglutaryl coenzyme A reductase inhibitor, have been shown to modify inflammatory cell signaling on the immune response to infection. It was postulated that statins may be a good candidate as novel therapeutic agents for the treatment of sepsis. We investigated whether ongoing statin therapy is associated with mortality in patients with bloodstream infection. Design:A retrospective cohort study. Setting:Two tertiary hospitals in Bronx, NY. Patients:Adult patients in the hospital with bloodstream infection and categorized according to statin therapy as an outpatient or inpatient before bacteremia. Interventions:None. Measurement and Main Results:Of 2,139 bacteremic hospitalized patients, 592 (28%) received statins before blood cultures and 677 (32%) died within 90 days. On multivariate adjustment, the association between statin therapy and 90-day all-cause mortality was statistically significant (hazard ratio, 0.78; 95% confidence interval [CI] 0.65–0.94), but statin users and nonusers differed significantly on many baseline clinical factors. Using the propensity score matched analysis to balance the differences between groups, the association was no longer significant (hazard ratio 0.99; 95% CI 0.77–1.25). Multivariate analysis after stratifying by decile in propensity score for statin use demonstrated similar results (hazard ratio 0.86; 95% CI 0.70–1.06). Statin use was not associated with reduced intensive care unit admission (odds ratio [OR], 0.86; 95% CI 0.59–1.26), hospital length of stay (&bgr; = –0.8 days; 95% CI –2.2 to 1.7 days), intensive care unit length of stay (&bgr; = –0.1 days; 95% CI –3.7 to 3.8 days), or need for mechanical or noninvasive ventilation (OR 1.03; 95% CI 0.70–1.51). Conclusion:After adjusting for the propensity to receive statin therapy, no statistically significant association between statin therapy before bloodstream infection and survival was identified. (Crit Care Med 2012; 40:–1071)

Incidence of Clostridium difficile infection in patients with acute leukemia and lymphoma after allogeneic hematopoietic stem cell transplantation.

after Allogeneic Hematopoietic Stem Cell Transplantation • Author(s): Sharon Leung, MD; Brian S. Metzger, MD, MPH; Brian P. Currie, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 31, No. 3 (March 2010), pp. 313-315 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/651066 . Accessed: 25/03/2013 21:21

Resource-Poor Settings: Infrastructure and Capacity Building: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

BACKGROUND Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. METHODS The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. CONCLUSIONS Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

Bedside Rounding Strategies Used by Bedside Teachers

To the Editors:—We applaud Dr. Gonzalo and colleagues’ efforts to compile reported elements that respected bedside teachers use in preparing and conducting rounds.1 However, we have concerns that the rounds described are not fully engaging patient-centered bedside rounds practices. In comparison to the definition of beside rounds previously published by Gonzalo,2 we were surprised to find that the definition of bedside rounds in the current study did not necessarily require the history presentation in the presence of the patient. We pondered the reasons for the shift and find this current definition unfavorable toward achieving patient-centered care. Without engaging the patient to verify and elaborate history, attending physicians are fully reliant on trainee reports. A thoughtful, focused, and compassionate presentation at the bedside which engages the patient is inherent to an accurate patient-centered approach. Attending physicians are described preparing for rounds; “nearly all attending physicians reviewed written notes, EMR, and if possible, evaluated patients directly…’I look up information…from the previous day. I decide what I am going to focus on…’” Clinicians cannot model patient-centered progressive problem solving if they are anchored to a diagnosis and/or management plan before they have seen the patient. We think the ability to engage with the patient and learners authentically in a collaborative thought process regarding the accurate diagnoses and best patient-centered management is now handicapped by the fact that the attendings have already done the thinking without these other parties. Finally, although it is not completely clear how educational value was defined for patient prioritization and selection, it is inferred that patients who did not have “challenging diagnoses” were considered low educational value and would likely have bedside rounds deferred. The number of patients in the hospital with multiple chronic conditions is staggering.3 Exacerbations of these diagnoses may not be “unfamiliar,” and clinical decision making may not be “challenging” since treatment protocols exist. However, the process of shared decision-making of disease management is vital to these patients. It is clear that patients prefer a less authoritarian and more of a shared decision-making approach to their medical care.4 In fact, patient-centered and value-based care is now written as part of the Affordable Care Act. This cannot be achieved without affirming patients’ values through patient–clinician communication. How can we transform inpatient care to achieve this? While we need additional strategies, bedside rounds, when well defined, prepared, and applied, can move us in the right direction.

Critical Care Organizations: Business of Critical Care and Value/performance Building*

Objective: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. Design: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. Setting: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. Measurements and Main Results: Two phases of critical care organizations care integration are described: “horizontal,” within the system and regionalization of care as an initial phase, and “vertical,” with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. Conclusions: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world.

Advancing into the Community

m 5 c PRESENTATION An infection once almost exclusively acquired in the hospital setting has made its way into a broader population—and for one 56-year-old woman, its course was devastating. She presented after 3 days of diffuse, cramping, abdominal pain, and 6-8 watery, nonbloody, bowel movements per day. Her illness began 4 days prior with the onset of generalized malaise and a low-grade fever that measured up to 100F (37.8° C); she had o cough, chest pain, or shortness of breath. Employed as a epartment store cashier, the patient lived at home with her usband and had no history of hospitalization or travel within he preceding 5 years, no known sick contacts, and no history f antibiotic use in the previous 6 months. She was a cigarette moker with a remote history of heroin addiction. Methadone, 00 mg, was administered daily at a substance abuse clinic, nd she took alprazolam, 2 mg, and clonazepam, 1 mg, muliple times a day for chronic anxiety. She did not take any astric acid suppressants.