Antibiotic Stewardship in the Medical Intensive Care Unit of an Academic Medical Center: Impact of a Pneumonia Diagnostic Bundle with Pharmacist Intervention

Purpose: Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality. Methods: We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge. Results: Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting rates ranging from 28% to 63%. Patients with family meetings within 72 hours were 30 times more likely to die within 72 hours (32% vs 1%, P < .001). Of the 55 patients who died in the intensive care unit, 27 (49%) had their first family meeting within 1 day of death. Conclusions: Family meetings occur considerably later than 72 hours and are often held in close proximity to a patient’s death. This suggests for some physicians, family meetings may primarily be used to negotiate withdrawal of life support rather than to support the patient and family.

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Obesity as a Predictor of Prolonged Mechanical Ventilation

Otolaryngology ◽

10.1177/0194599820923601 ◽

2020 ◽

Vol 163 (4) ◽

pp. 750-754

Author(s):

Diana Shao ◽

Jeffrey Straub ◽

Laura Matrka

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Medical Intensive Care Unit ◽

Medical Center ◽

Prolonged Mechanical Ventilation ◽

Statistical Significance ◽

Academic Medical Center ◽

Tertiary Care ◽

Medical Intensive Care

Objective To examine the effect of including obesity with parameters of the I-TRACH scale in predicting the need for prolonged mechanical ventilation. Study Design A retrospective cohort study. Setting Tertiary care academic medical center. Subjects and Methods Consecutive patients were identified retrospectively over a 45-month period based on need for mechanical ventilation in the medical intensive care unit. Chart review was performed to collect demographic information as well as clinical data, including duration of mechanical ventilation, body mass index (BMI), and I-TRACH parameters (heart rate >110, serum urea nitrogen >25, serum pH <7.25, serum creatinine >2, serum bicarbonate <20). Statistical analysis was performed to identify any predictors of prolonged mechanical ventilation, defined as ≥14 days and as ≥10 days. Results In total, 455 patients were identified, with an average duration of mechanical ventilation of 10.4 days (range, 0-248 days). On univariate and multivariate regression analysis, only BMI >30 reached statistical significance with respect to prolonged mechanical ventilation ( P < .05). The I-TRACH parameters—either alone or in combination—were not significantly predictive. Conclusion This study challenges previous findings regarding the I-TRACH scale and the relation of its parameters to prolonged mechanical ventilation. Furthermore, BMI >30 alone was predictive of prolonged intubation. Inclusion of BMI in predictive models could assist current decision making in determining the likelihood of prolonged mechanical ventilation in medical intensive care unit patients going forward, and obesity should be considered a predictor of prolonged mechanical ventilation.

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Educational Intervention to Improve Delirium Recognition by Nurses

American Journal of Critical Care ◽

10.4037/ajcc2018851 ◽

2018 ◽

Vol 27 (4) ◽

pp. 270-278 ◽

Cited By ~ 5

Author(s):

Cheri S. Blevins ◽

Regina DeGennaro

Keyword(s):

Health Care ◽

Intensive Care Unit ◽

Intensive Care ◽

Health Care Providers ◽

Educational Intervention ◽

Medical Intensive Care Unit ◽

Medical Center ◽

Academic Medical Center ◽

Care Providers ◽

Medical Intensive Care

Background Delirium poses increased morbidity and mortality risks for hospitalized patients. Underrecognition by health care providers contributes to poor outcomes for patients. Little has been published about methods used to teach health care providers how to screen for delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Objective To evaluate the effectiveness of a multimodal educational intervention for nurses in the medical intensive care unit to improve their knowledge and skills regarding delirium and delirium recognition. Methods An educational intervention was done in the medical intensive care unit of an academic medical center. Effectiveness was evaluated via a quasi-experimental design and using preintervention and postintervention assessments. Procedural correctness of performing the CAM-ICU delirium screening also was measured. Results Nurses participated in 1 small-group session (n = 34). Fifteen sessions were conducted from June to September 2016, and assessments were completed before and after the intervention. The sample consisted of predominantly nurses with a bachelor’s degree (56%) who had 1 to 5 years’ experience (59%). Mean scores overall and on the knowledge subscale differed significantly (P < .001) from before to after the intervention. No correlation was found between demographic groups and score differences. Seventy-nine percent of participants used the tool correctly after the intervention. Conclusions The educational intervention provided for these nurses further validated published reports of the benefits of an educational program about delirium. The content of the educational intervention should be targeted for the setting, the risk factors for the patient population in question, and the specific delirium screening tool used.

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Hemodynamic Effects of Ketamine Compared With Propofol or Dexmedetomidine as Continuous ICU Sedation

Annals of Pharmacotherapy ◽

10.1177/10600280211051028 ◽

2021 ◽

pp. 106002802110510

Author(s):

Evan Atchley ◽

Eljim Tesoro ◽

Robert Meyer ◽

Alexia Bauer ◽

Mark Pulver ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Academic Medical Center ◽

Academic Medical ◽

Clinically Significant ◽

Critically Ill Adults ◽

Icu Sedation ◽

Ill Adults ◽

Positive Effect

Background Ketamine has seen increased use for sedation in the intensive care unit. In contrast to propofol or dexmedetomidine, ketamine may provide a positive effect on hemodynamics. Objective The objective of this study was to compare the development of clinically significant hypotension or bradycardia (ie, negative hemodynamic event) between critically ill adults receiving sedation with ketamine and either propofol or dexmedetomidine. Methods This was a retrospective cohort study of adults admitted to an intensive care unit at an academic medical center between January 2016 and January 2021. Results Patients in the ketamine group (n = 78) had significantly less clinically significant hypotension or bradycardia compared with those receiving propofol or dexmedetomidine (n = 156) (34.6% vs 63.5%; P < 0.001). Patients receiving ketamine also experienced smaller degree of hypotension observed by percent decrease in mean arterial pressure (25.3% [17.4] vs 33.8% [14.5]; P < 0.001) and absolute reduction in systolic blood pressure (26.5 [23.8] vs 42.0 [37.8] mm Hg; P < 0.001) and bradycardia (15.5 [24.3] vs 32.0 [23.0] reduction in beats per minute; P < 0.001). In multivariate logistic regression modeling, receipt of propofol or dexmedetomidine was the only independent predictor of a negative hemodynamic event (odds ratio [OR]: 3.3, 95% confidence interval [CI], 1.7 to 6.1; P < 0.001). Conclusion and Relevance Ketamine was associated with less clinically relevant hypotension or bradycardia when compared with propofol or dexmedetomidine, in addition to a smaller absolute decrease in hemodynamic parameters. The clinical significance of these findings requires further investigation.

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A Prediction Rule For Mortality in the Medical Intensive Care Unit Based on Early Acute Organ-System Failure

Journal of Intensive Care Medicine ◽

10.1177/088506669400900402 ◽

1994 ◽

Vol 9 (4) ◽

pp. 172-178 ◽

Cited By ~ 3

Author(s):

Victor Gordan ◽

Roger K. Pitman ◽

Thérese A. Stukel ◽

Daniel Teres ◽

Edward Gillie

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Intensive Care Unit ◽

Medical Center ◽

Prediction Rule ◽

Organ System ◽

System Failure ◽

Classification Rate ◽

Organ System Failure ◽

Medical Intensive Care

We evaluated early acute organ-system failure (AOSF) as a predictor of mortality in medical intensive care unit (MICU) patients. Prospective data were obtained on 825 men admitted to a Veterans Administraion (VA) Medical Center MICU. Clinical criteria were used to diagnose the presence of 7 types of AOSF. Of the 2,364 AOSFs detected, 1,847 (78%) were “early” (i.e., detected within the first 48 hours of MICU stay). A random sample of 550 patients was selected for derivation of a prediction rule for MICU mortality based on age and number of early AOSFs. For each additional early AOSF, the adjusted odds of mortality increased by 3.3 (95% confidence interval: 2.7, 4.0; p < 0.0001). When applied to the cross-validation sample of 275 patients, this rule yielded a sensitivity of 77%, a specificity of 86%, and an overall correct classification rate of 82%. These results suggest that a simple rule based on number of AOSFs detected in the early portion of a patient's MICU stay may be a useful predictor of mortality.

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The Impella 2.5 and 5.0 devices for ST-elevation myocardial infarction patients presenting with severe and profound cardiogenic shock: The Academic Medical Center intensive care unit experience*

Critical Care Medicine ◽

10.1097/ccm.0b013e31821e89b5 ◽

2011 ◽

Vol 39 (9) ◽

pp. 2072-2079 ◽

Cited By ~ 92

Author(s):

Annemarie E. Engström ◽

Ricardo Cocchieri ◽

Antoine H. Driessen ◽

Krischan D. Sjauw ◽

Marije M. Vis ◽

...

Keyword(s):

Myocardial Infarction ◽

Intensive Care Unit ◽

Intensive Care ◽

Cardiogenic Shock ◽

Medical Center ◽

Academic Medical Center ◽

St Elevation Myocardial Infarction ◽

Academic Medical ◽

St Elevation

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Double Trouble: Patients With Both True and False Arrhythmia Alarms

Critical Care Nurse ◽

10.4037/ccn2020363 ◽

2020 ◽

Vol 40 (2) ◽

pp. 14-23

Author(s):

Stella Chiu Nguyen ◽

Sukardi Suba ◽

Xiao Hu ◽

Michele M. Pelter

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Academic Medical Center ◽

Secondary Analysis ◽

Altered Mental Status ◽

False Alarms ◽

Number Of False Alarms ◽

Academic Medical ◽

Using Data

Background Patients with both true and false arrhythmia alarms pose a challenge because true alarms might be buried among a large number of false alarms, leading to missed true events. Objective To determine (1) the frequency of patients with both true and false arrhythmia alarms; (2) patient, clinical, and electrocardiographic characteristics associated with both true and false alarms; and (3) the frequency and types of true and false arrhythmia alarms. Methods This was a secondary analysis using data from an alarm study conducted at a tertiary academic medical center. Results Of 461 intensive care unit patients, 211 (46%) had no arrhythmia alarms, 12 (3%) had only true alarms, 167 (36%) had only false alarms, and 71 (15%) had both true and false alarms. Ventricular pacemaker, altered mental status, mechanical ventilation, and cardiac intensive care unit admission were present more often in patients with both true and false alarms than among other patients (P < .001). Intensive care unit stays were longer in patients with only false alarms (mean [SD], 106 [162] hours) and those with both true and false alarms (mean [SD], 208 [333] hours) than in other patients. Accelerated ventricular rhythm was the most common alarm type (37%). Conclusions An awareness of factors associated with arrhythmia alarms might aid in developing solutions to decrease alarm fatigue. To improve detection of true alarms, further research is needed to build and test electrocardiographic algorithms that adjust for clinical and electrocardiographic characteristics associated with false alarms.

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Determining Inappropriate Medication Alerts from “Inaccurate Warning” Overrides in the Intensive Care Unit

Applied Clinical Informatics ◽

10.1055/s-0038-1642608 ◽

2018 ◽

Vol 09 (02) ◽

pp. 268-274 ◽

Cited By ~ 4

Author(s):

Christine Rehr ◽

Adrian Wong ◽

Diane Seger ◽

David Bates

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Drug Allergy ◽

Medical Center ◽

Inappropriate Medication ◽

Academic Medical Center ◽

Patient Characteristics ◽

Valuable Resource ◽

Provider Behavior ◽

Academic Medical

Objective This article aims to understand provider behavior around the use of the override reason “Inaccurate warning,” specifically whether it is an effective way of identifying unhelpful medication alerts. Materials and Methods We analyzed alert overrides that occurred in the intensive care units (ICUs) of a major academic medical center between June and November 2016, focused on the following high-significance alert types: dose, drug-allergy alerts, and drug–drug interactions (DDI). Override appropriateness was analyzed by two independent reviewers using predetermined criteria. Results A total of 268 of 26,501 ICU overrides (1.0%) used the reason “Inaccurate warning,” with 93 of these overrides associated with our included alert types. Sixty-one of these overrides (66%) were identified to be appropriate. Twenty-one of 30 (70%) dose alert overrides were appropriate. Forty of 48 drug-allergy alert overrides (83%) were appropriate, for reasons ranging from prior tolerance (n = 30) to inaccurate ingredient matches (n = 5). None of the 15 DDI overrides were appropriate. Conclusion The “Inaccurate warning” reason was selectively used by a small proportion of providers and overrides using this reason identified important opportunities to reduce excess alerts. Potential opportunities include improved evaluation of dosing mechanisms based on patient characteristics, inclusion of institutional dosing protocols to alert logic, and evaluation of a patient's prior tolerance to a medication that they have a documented allergy for. This resource is not yet routinely used for alert tailoring at our institution but may prove to be a valuable resource to evaluate available alerts.

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