Objectives: The Sequential Organ Failure Assessment and other severity of illness scales rely on the Glasgow Coma Scale to measure acute neurologic dysfunction, but the Glasgow Coma Scale is unavailable or inconsistently applied in some institutions. The objective of this study was to assess the validity of a modified Sequential Organ Failure Assessment that uses the Richmond Agitation-Sedation Scale instead of Glasgow Coma Scale. Design: Prospective cohort study. Setting: Medical and surgical ICUs within a large, tertiary care hospital. Patients: Critically ill medical/surgical ICU patients. Interventions: We calculated daily Sequential Organ Failure Assessment scores by using electronic medical record-derived data. By using bedside nurse-recorded Glasgow Coma Scale and Richmond Agitation-Sedation Scale measures, we calculated neurologic Sequential Organ Failure Assessment scores using the original Glasgow Coma Scale–based approach and a novel Richmond Agitation-Sedation Scale–based approach, converting the 10-point Richmond Agitation-Sedation Scale to a 4-point neurologic Sequential Organ Failure Assessment score. We assessed construct validity of Richmond Agitation-Sedation Scale–based Sequential Organ Failure Assessment by analyzing correlations with established severity of illness constructs (Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale–based Sequential Organ Failure Assessment) and predictive validity by using logistic regression to determine whether Richmond Agitation-Sedation Scale–based Sequential Organ Failure Assessment predicts ICU, hospital, and 1-year mortality. We assessed discriminative performance with c-statistics. Measurements and Main Results: Among 513 patients (5,199 patient-days), Richmond Agitation-Sedation Scale–based Sequential Organ Failure Assessment was strongly correlated with Acute Physiology and Chronic Health Evaluation II acute physiology score at enrollment (r = 0.583; 95% CI, 0.518–0.642) and daily Glasgow Coma Scale–based Sequential Organ Failure Assessment scores (r = 0.963; 95% CI, 0.956–0.968). Mean Richmond Agitation-Sedation Scale–based Sequential Organ Failure Assessment scores predicted ICU mortality (areas under the curve = 0.814)—as did mean Glasgow Coma Scale–based Sequential Organ Failure Assessment (0.799)—as well as hospital and 1-year mortality. Admission Sequential Organ Failure Assessment scores, whether using Richmond Agitation-Sedation Scale or Glasgow Coma Scale, were less accurate predictors of mortality; areas under the curves for ICU mortality for Richmond Agitation-Sedation Scale–based and Glasgow Coma Scale–based Sequential Organ Failure Assessment, for example, were 0.622 and 0.608, respectively. Conclusion: A modified Sequential Organ Failure Assessment score that uses bedside Richmond Agitation-Sedation Scale when Glasgow Coma Scale data are not available is a valid means of assessing daily severity of illness in the ICU and may be valuable for risk-adjustment and benchmarking purposes.

Objective: The equipment, monitor alarms, and acuity of patients in ICUs make it one of the loudest patient care areas in a hospital. Increased sound levels may contribute to worsened outcomes in these particularly vulnerable patients. Our objective was to determine whether ambient sound levels in surgical ICUs comply with recommendations established by the World Health Organization and Environmental Protection Agency, and whether implementation of an overnight “quiet time” intervention is associated with lower ambient sound levels. Design: Prospective, observational cohort study. Setting: Two comparable 18-bed, surgical ICUs in a large, teaching hospital. Only one ICU had a formal overnight quiet time policy at the start of the study period. Measurements and Main Results: Sound levels were measured in 30-second blocks at preselected locations during the day and night over a period of 6 weeks using a simple, hand-held sound meter. All sound measurements in both units at all times exceeded recommended standards. Median minimum sound levels were lower at night in both units (50.8 and 50.3 vs 53.1 and 51.0 dB, p = 0.0003 and p = 0.009) and were similar between the two units (p = 0.52). The maximum overnight sound levels were statistically lower in the unit with the quiet time intervention implemented (62.5 vs 59.6 dB; p = 0.0040) and decreased overnight immediately after implementation of quiet time in the other unit (62.5 vs 56.1 dB; p < 0.0001). Maximum sound levels were lower inside patient rooms (52.2 vs 55.3 dB; p = 0.004), but minimum sound levels were similar (49.1 vs 49.2 dB; p = 0.23). Linear regression analysis showed that ICU census did not significantly influence sound levels. Conclusions: Ambient sound levels in the surgical ICUs were consistently above levels recommended by the World Health Organization and Environmental Protection Agency at all times. The use of a formal quiet time intervention was associated with a significant, but clinically irrelevant reduction in the median maximum sound level at night. Our results suggest that excessive ambient noise in the ICU is largely attributable to environmental factors, and behavior modifications are unlikely to have a meaningful impact. Future investigations, as well as hospital designs, should target interventions toward ubiquitous noise sources such as ventilation systems, which may not traditionally be associated with patient care.

Objective: To characterize ICU nurses’ research experience, work environments, and attitudes toward clinical research in critically ill adults and children. Design: Cross-sectional survey. Setting: Eight (seven adult and one pediatric) academic ICUs affiliated with the Canadian Critical Care Trials Group. Participants: Four hundred eighty-two ICU nurses. Interventions: None. Measurements and Main Results: Response rate was 56%. Most participants had over 6 years of ICU experience (61%) and held a baccalaureate nursing degree (57%). Most participants (63%) had provided care for patients receiving research study procedures more than five times in the past 12 months and agreed that research leads to improved care for the critically ill (78%) and eligible patients should be approached for research participation (78%). Few perceived practicalities of nursing care are considered in study design (20%); 41% agreed that research studies increases nursing workload. Few participants reported receiving adequate information about study progress (24%) or findings (26%). Principal factor analysis identified three factors each in the environmental and attitudinal domains. Linear regression models demonstrated that positive relationships between researchers and clinicians were associated with favorable perceptions of research impact on nursing care (p < 0.001), ICU research acceptability (p < 0.001), and nursing engagement in research (p < 0.05). Nurses with more formal education reported more favorable attitudes toward nursing engagement in research (p < 0.01) and research acceptability (p < 0.01). Lack of experience in study protocol development and/or data analysis was associated with less favorable attitudes about nursing engagement in research (p < 0.01) and impact of research on nursing care (p < 0.01). Conclusion: In these research-intensive ICUs, nurses frequently care for research participants and believe ICU research is important. Inclusion of nurses in study protocol development, improved communication of study progress and findings, and investigation of research-related nursing workload are warranted. Such interventions will support intervention fidelity and data reliability during study conduct and translation of evidence into practice on study completion.

Objectives: Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing, chest radiographs, and RBC transfusions provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease the avoidable arterial blood gases, chest radiographs, and RBC utilization on utilization of these resources and patient outcomes. Design: Prospective pre-post cohort study. Setting: Seven ICUs in an academic healthcare system. Patients: All adult ICU patients admitted to study ICUs during consecutive baseline (n = 7,357), intervention (n = 7,553), and follow-up (n = 7,657) years between September 2010 and August 2013. Interventions: A multifaceted quality improvement program including provider education, audit and feedback, and unit-based provider financial incentives targeting arterial blood gas, chest radiograph, and RBC utilization. Measurements and Main Results: The primary outcome was the number of orders for arterial blood gases, chest radiographs, and RBCs per patient. Compared with the baseline period, unadjusted arterial blood gas, chest radiograph, and RBC utilization in the intervention period was reduced by 42%, 26%, and 17%, respectively (p < 0.01). After adjusting for potentially relevant patient factors, the intervention was associated with 128 fewer arterial blood gases, 73 fewer chest radiographs, and 16 fewer RBCs per 100 patients (p < 0.01). This effect was durable during the follow-up year. This reduction yielded an approximate net savings of $1.5 M in direct costs over the intervention and follow-up years after accounting for the direct costs of the program. Unadjusted hospital mortality decreased from 7% in the baseline period to 5.2% in the intervention period (p < 0.01). This reduction remained significant after adjusting for patient factors (odds ratio = 0.43; p < 0.01). Conclusions: Implementation of a multifaceted quality improvement program including financial incentives was associated with significant improvements in resource utilization. Our findings provide evidence supporting the safety, effectiveness, and sustainability of incentive-based quality improvement interventions.

Objective: Cerebral edema is common in severe hepatic encephalopathy and may be life threatening. Bolus 23.4% hypertonic saline improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established. We investigated the hypothesis that bolus hypertonic saline decreases cerebral edema in severe hepatic encephalopathy utilizing a quantitative technique to measure brain and cerebrospinal fluid volume changes. Design: Retrospective analysis of serial CT scans, and clinical data for a case-control series were performed. Setting: ICUs of a tertiary care hospital. Patients: Patients with severe hepatic encephalopathy treated with 23.4% hypertonic saline and control patients who did not receive 23.4% hypertonic saline. Interventions: 23.4% hypertonic saline bolus administration. Measurements and Main Results: We used clinically obtained CT scans to measure volumes of the ventricles, intracranial cerebrospinal fluid, and brain using a previously validated semiautomated technique (Analyze Direct, Overland Park, KS). Volumes before and after 23.4% hypertonic saline were compared with Wilcoxon signed rank test. Associations among total cerebrospinal fluid volume, ventricular volume, serum sodium, and Glasgow Coma Scale scores were assessed using Spearman rank correlation test. Eleven patients with 18 administrations of 23.4% hypertonic saline met inclusion criteria. Total cerebrospinal fluid (median, 47.6?mL [35.1–69.4 mL] to 61.9?mL [47.7–87.0 mL]; p < 0.001) and ventricular volumes (median, 8.0?mL [6.9–9.5 mL] to 9.2?mL [7.8–11.9 mL]; p = 0.002) increased and Glasgow Coma Scale scores improved (median, 4 [3–6] to 7 [6–9]; p = 0.008) after 23.4% hypertonic saline. In contrast, total cerebrospinal fluid and ventricular volumes decreased in untreated control patients. Serum sodium increase was associated with increase in total cerebrospinal fluid volume (r = 0.83, p < 0.001), and change in total cerebrospinal fluid volume was associated with ventricular volume change (r = 0.86; p < 0.001). Conclusions: Total cerebrospinal fluid and ventricular volumes increased after 23.4% hypertonic saline, consistent with a reduction in brain tissue volume. Total cerebrospinal fluid and ventricular volume change may be useful quantitative measures to assess cerebral edema in severe hepatic encephalopathy.

Objective: To determine the relation between high arterial oxygen tension levels (PaO2) and long-term mortality in patients with spontaneous intracerebral hemorrhage treated in the ICU. Design: National observational multicenter cohort study. Setting: Twenty-one ICUs in Finland. Patients: A total of 3,033 adult patients. Interventions: None. Measurements and Main Results: Patients were divided into high (> 150?mm Hg), intermediate (97.5–150?mm Hg), and low (< 97.5?mm Hg) PaO2 groups based on the lowest measured PaO2/FIO2 ratio during the first 24 hours after ICU admission: 63% (n = 1,923) were in the low group, 29% (n = 892) were in the intermediate group, and 7% (n = 218) were in the high group; 80% were mechanically ventilated. The primary outcome was 6-month mortality, which occurred in 49% of patients and was significantly more frequent in the high PaO2 group than in the intermediate and low PaO2 groups (61% vs 52% and 46%, respectively, p < 0.001). In univariate analysis, patients in the high PaO2 group had a significantly increased risk of 6-month mortality compared with the low PaO2 group (odds ratio, 1.82; 95% CIs, 1.36–2.42; p < 0.001), but this statistically significant relation was lost after adjusting for markers of severity of illness in a logistic mixed-effects regression model (odds ratio, 1.10; 95% CI, 0.76–1.60; p = 0.598). Conclusions: No significant relation between PaO2 levels and long-term mortality was found. The clinical role of hyperoxemia in patients with intracerebral hemorrhage treated in the ICU remains controversial and warrants further studies.

Objectives: Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. Design: The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement. Main Results: Six recommendations were endorsed: 1) Definition: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their “default” approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. Conclusions: Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.

Objective: Excellence is an important goal for all physicians. Unfortunately, it is hard to define, evaluate, and achieve. To provide a concise interpretive review of excellence in intensive care medicine, with a focus on those key characteristics that excellent physicians possess but are seldom discussed. Data Sources: Electronic search of the PubMed database using the search terms “excellence,” “role models,” “compassion,” “commitment,” “dedication,” and “passion.” Study Selection: Publications or studies of excellence, role models, compassion, commitment, dedication, and passion. Two reviewers evaluated each term. Data Extraction: Publications or studies were abstracted independently and in duplicate. Data Synthesis: Excellence in critical care can be achieved through deliberate practice, feedback, and effective evaluation. Excellence embodies numerous characteristics, which include compassion, commitment, and passion. Conclusions: Awareness of the fundamental characteristics of excellence can help young students and doctors determine what they should strive for to become excellent physicians as well as encourage experienced doctors to rekindle the spark that initially motivated them to become physicians.

Objectives: Circadian rhythms are severely disrupted among the critically ill. These circadian arrhythmias impair mentation, immunity, autonomic function, endocrine activity, hormonal signaling, and ultimately healing. In this review, we present a modern model of circadian disruption among the critically ill, discuss causes of these circadian arrhythmias, review observational and intervention studies of the effects of circadian-rhythm–restoring factors on medical outcomes, and identify needed key trials of circadian interventions in the critically ill. Data Sources: MEDLINE, EMBASE, PsychINFO, Google Scholar through December 2014. Study Selection: Articles relevant to circadian rhythms, melatonin, and light in the critically ill were selected. Data Extraction and Data Synthesis: Articles were synthesized for this review of circadian arrhythmia and the use of circadian-rhythm–restoring interventions among the critically ill. Conclusions: Circadian disruption often demonstrates serial degradation: initially, the amplitude attenuates along with delayed circadian phase. With increasing acuity of illness, circadian rhythmicity may be lost entirely. Causes of chronodisruption may be environmental or internal to the patient. In particular, inadequate daytime illumination and nocturnal light pollution disrupt healthy circadian periodicity. Internal causes of circadian arrhythmia include critical illness itself and subjective experience of distress and pain. Observational studies of windowed rooms and real-time ambient lighting have found that physiologic light-dark patterns may support recovery from critical illness. Studies of early morning bright light or evening melatonin agonists have found improved rates of delirium, enhanced sleep, and lower arrhythmia prevalence. The current evidence base emphasizes that lighting and melatoninergic interventions deserve to be tested in full-scale trials.

Objective: Alterations in neutrophil morphology (size, shape, and composition), mechanics (deformability), and motility (chemotaxis and migration) have been observed during sepsis. We combine summarizing features of neutrophil morphology, mechanics, and motility that change during sepsis with an investigation into their clinical utility as markers for sepsis through measurement with novel technologies. Data Sources: We performed an initial literature search in MEDLINE using search terms “neutrophil,” “morphology,” “mechanics,” “dynamics,” “motility,” “mobility,” “spreading,” “polarization,” “migration,” and “chemotaxis.” We then combined the results with “sepsis” and “septic shock.” We scanned bibliographies of included articles to identify additional articles. Study Selection and Data Extraction: Final selection was done after the authors reviewed recovered articles. We included articles based on their relevance for our review topic. Data Synthesis: When compared with resting conditions, sepsis causes an increase in circulating numbers of larger, more rigid neutrophils that show diminished granularity, migration, and chemotaxis. Combined measurement of these variables could provide a more complete view on neutrophil phenotype manifestation. For that purpose, sophisticated automated hematology analyzers, microscopy, and bedside microfluidic devices provide clinically feasible, high-throughput, and cost-limiting means. Conclusions: We propose that integration of features of neutrophil morphology, mechanics, and motility with these new analytical methods can be useful as markers for diagnosis, prognosis, and monitoring of sepsis and may even contribute to basic understanding of its pathophysiology.

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