We recently reported the first part of a study testing the impact of data literacy training on "assessing pain, spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium ...monitoring/management, early exercise/mobility, and family and patient empowerment" ABCDEF A-F) compliance. The purpose of the current study, part 2, was to evaluate the effectiveness of the implementation approach by surveying clinical staff to examine staff knowledge, skill, motivation, and organizational resources.
The Clark and Estes Gap Analysis framework was used to study knowledge, motivation, and organization (KMO) influences. Assumed influences identified in the literature were used to design the A-F bundle implementation strategies. The influences were validated against a survey distributed to the ICU interprofessional team.
Single-center study was conducted in eight adult ICUs in a quaternary academic medical center.
Interprofessional ICU clinical team.
A quantitative survey was sent to 386 participants to evaluate the implementation design postimplementation. An exploratory factor analysis was performed to understand the relationship between the KMO influences and the questions posed to validate the influence. Descriptive statistics were used to identify strengths needed to sustain performance and weaknesses that required improvement to increase A-F bundle adherence.
The survey received an 83% response rate. The exploratory factor analysis confirmed that 38 of 42 questions had a strong relationship to the KMO influences, validating the survey's utility in evaluating the effectiveness of implementation design. A total of 12 KMO influences were identified, 8 were categorized as a strength and 4 as a weakness of the implementation.
Our study used an evidence-based gap analysis framework to demonstrate key implementation approaches needed to increase A-F bundle compliance. The following drivers were recommended as essential methods required for successful protocol implementation: data literacy training and performance monitoring, organizational support, value proposition, multidisciplinary collaboration, and interprofessional teamwork activities. We believe the learning generated in this two-part study is applicable to implementation design beyond the A-F bundle.
Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in ...center management practices on ARDS mortality rates remains unknown.
What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States?
We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed.
A total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.
Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes.
ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov
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The COVID-19 pandemic caused tremendous disruption to the U.S. healthcare system and nearly crippled some hospitals during large patient surges. Limited ICU beds across the country further ...exacerbated these challenges. Telemedicine, specifically tele-critical care (TCC), can expand a hospital's clinical capabilities through remote expertise and increase capacity by offloading some monitoring to remote teams. Unfortunately, the rapid deployment of telemedicine, especially TCC, is constrained by multiple barriers. In the summer of 2020, to support the National Emergency Tele-Critical Care Network (NETCCN) deployment, more than 50 national leaders in applying telemedicine technologies to critical care assembled to provide their opinions about barriers to NETCCN implementation and strategies to overcome them. Through consensus, these experts developed white papers that formed the basis of this article. Herein, the authors share their experience and propose multiple solutions to barriers presented by laws, local policies and cultures, and individual perspectives according to a minimum, better, best paradigm for TCC delivery in the setting of a national disaster. Cross-state licensure and local privileging of virtual experts were identified as the most significant barriers to rapid deployment of services, whereas refining the model of TCC to achieve the best outcomes and defining the best financial model is the most significant for long-term success. Ultimately, we conclude that a rapidly deployable national telemedicine response system is achievable.
This study compared the sensitivity of three methods: staphyloccocal clumping test, SCT (Sigma and Calbiochem-Behring, CBC, reagents); Thrombo-Wellcotest (TWT); and Dade fibrinogen degradation ...products detection set, to quantify fibrinogen/fibrin split products (FSP) in blood samples from 696 patients and 124 normal donors using fibrinogen as the reference value. The Dade method gave quantitative results closely approaching the stated amount of fibrinogen. The SCT using Sigma reagents gave higher "fibrinogen" values, while the CBC reagents gave markedly lower "fibrinogen" values. The TWT detected only 25% of the fibrinogen standard. Detection of FSP following plasmin digestion of fibrinogen varied considerably for each test. The TWT, insensitive to most of the native fibrinogen, detected most of the FSP following only 15 minutes of plasmin digestion. In contrast, both assays relying on the SCT were completely negative after 24 hours of plasmin digestion. All four methods yielded FSP titers of less than 10 micrograms/mL in 97 (78.2%) of 124 blood samples from normal donors. The SCT Sigma reagents consistently gave results of less than 10 micrograms/mL in all normal donors. No instance of an FSP value greater than 40 micrograms/mL was noted for the 124 normal donors. Of the 696 patient blood samples tested, the Dade assay gave the highest or equally highest (with respect to another FSP method) value in 604 (87%) cases; the Sigma SCT did so in 360 (52%); the TWT in 316 (45%); and the CBC assay in 184 (26%) cases. The Dade test classified the largest number of blood samples, 328 (47.1%), in the greater than 10 less than 40 micrograms/mL titer category; however, the proportion of cases (32.2%) in which this test yielded values greater than 40 micrograms/mL was about the same as those produced by the Sigma SCT (29.9%) and TWT products (25.8%). Thus, with the exception of the normal (less than 10 micrograms/mL) and the suspicious (10-40 micrograms/mL) range, all three methods (Dade, Sigma, and TWT) are comparable in their abilities to detect abnormal levels of FSP. In the normal range, the Dade method will yield results that are frequently in the suspicious range. The CBC was noticeably inferior in detecting both suspicious and frankly abnormal values of FSP. Eight patients with acute leukemia were monitored sequentially with FSP and fibrinopeptide A (FpA) assays during their first course of chemotherapy. In all instances, elevated FpA levels correlated with elevated FSP values, as determined by the Dade, Sigma, or TWT assays.
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