The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit

Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections

BACKGROUND

Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections.

OBJECTIVE

The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions.

METHODS

A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models.

RESULTS

Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use.

CONCLUSIONS

Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.

Appropriate use criteria for endotracheal suction interventions in mechanically ventilated children: The RAND/UCLA development process

OBJECTIVES

Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness.

CONCLUSIONS

The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients.

Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making

In the last years, new trends on patient diagnosis for admission in cardiac intensive care unit (CICU) have been observed, shifting from acute myocardial infarction or acute heart failure to non-cardiac diseases such as sepsis, acute respiratory failure or acute kidney injury. Moreover, thanks to the advances in scientific knowledge and higher availability, there has been increasing use of positive pressure mechanical ventilation which has its implications on the heart. Therefore, there is a growing need for Cardiac intensivists to quickly, noninvasively and repeatedly evaluate various hemodynamic conditions and the response to therapy. Transthoracic critical care echocardiography (CCE) currently represents an essential tool in CICU, as it is used to evaluate biventricular function and complications following acute coronary syndromes, identify the mechanisms of circulatory failure, acute valvular pathologies, tailoring and titrating intravenous treatment or mechanical circulatory support. This could be completed with trans-esophageal echocardiography (TOE), advanced echocardiography and lung ultrasound to provide a thorough evaluation and monitoring of CICU patients. However, CCE could sometimes be challenging as the acquisition of good-quality images is limited by mechanical ventilation, suboptimal patient position or recent surgery with drains on the chest. Moreover, there are some technical caveats that one should bear in mind while performing CCE in order to optimize its use and avoid misleading findings. The aim of this review is to highlight the key role of CCE, providing an updated overview of its main applications and possible pitfalls in order to facilitate its use in CICU for clinical decision-making.

COVID-19 and Disruptive Modifications to Cardiac Critical Care Delivery: JACC Review Topic of the Week

The COVID-19 pandemic has presented a major unanticipated stress on the workforce, organizational structure, systems of care, and critical resource supplies. To ensure provider safety, to maximize efficiency, and to optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This review draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe, as well as lessons learned from military mass casualty medicine. This review offers pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies (e.g., telemedicine) to enable effective collaboration despite social distancing imperatives.

Diagnostic and treatment utility of echocardiography in the management of the cardiac patient

BACKGROUND

Echocardiograms are an incredibly useful diagnostic tool due to their lack of harmful radiation, the relative ease and speed with which they can be performed, and their almost ubiquitous availability. Unfortunately, the advantages that support the use of echocardiography can also lead to the overuse of this technology. We sought to evaluate the physician perceived impact echocardiography has on patient management.

AIM

To evaluate the physician perceived impact echocardiography has on patient management.

METHODS

Surveys were distributed to the ordering physician for echocardiograms performed at our institution over a 10-wk period. Only transthoracic echocardiograms performed on the inpatient service were included. Surveys were distributed to either the attending physician or the resident physician listed on the echocardiogram order. The information requested in the survey focused on the indication for the study and the perceived importance and effect of the study. Observational statistical analysis was performed on all of the answers from the collected surveys.

RESULTS

A total of 103 surveys were obtained and analyzed. The internal medicine (57%) and cardiology (37%) specialties ordered the most echocardiograms. The most common reason for ordering an echocardiogram was to rule out a diagnosis (38.2%). Only 27.5% of physicians reported that the echocardiogram significantly affected patient care, with 18.6% reporting a moderate effect, and 30.4% reporting a mild effect. A total of 19.6% of physicians stated that there was no effect on patient management. Additionally, 43.1% of physicians reported that they made changes in patient management due to no change having occurred in the disease, 11.8% reported that changes in management were based on the recommendation of a specialist, and only 9.8% reported that further imaging was ordered due to the results of the echocardiogram. The majority of physicians (67.6%) considered an echocardiogram to be “somewhat essential” in the management of adult inpatients, with only 15.7% considering it “essential”.

CONCLUSION

The majority of physicians surveyed report the echocardiogram had only a mild effect on management with only 27.5% reporting a significant effect. However, the majority of physicians (83.3%) perceived an echocardiogram to be somewhat or entirely essential for management. Only 9.8% reported the echo led to further imaging. These insights into ordering physician reasoning should help guide better definition of the optimal and ideal use of echocardiography.