Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Using the Hospital Frailty Risk Score to assess mortality risk in older medical patients admitted to the intensive care unit

BACKGROUND

Prognostic information at the time of hospital discharge can help guide goals-of-care discussions for future care. We sought to assess the association between the Hospital Frailty Risk Score (HFRS), which may highlight patients' risk of adverse outcomes at the time of hospital discharge, and in-hospital death among patients admitted to the intensive care unit (ICU) within 12 months of a previous hospital discharge.

METHODS

We conducted a multicentre retrospective cohort study that included patients aged 75 years or older admitted at least twice over a 12-month period to the general medicine service at 7 academic centres and large community-based teaching hospitals in Toronto and Mississauga, Ontario, Canada, from Apr. 1, 2010, to Dec. 31, 2019. The HFRS (categorized as low, moderate or high frailty risk) was calculated at the time of discharge from the first hospital admission. Outcomes included ICU admission and death during the second hospital admission.

RESULTS

The cohort included 22 178 patients, of whom 1767 (8.0%) were categorized as having high frailty risk, 9464 (42.7%) as having moderate frailty risk, and 10 947 (49.4%) as having low frailty risk. One hundred patients (5.7%) with high frailty risk were admitted to the ICU, compared to 566 (6.0%) of those with moderate risk and 790 (7.2%) of those with low risk. After adjustment for age, sex, hospital, day of admission, time of admission and Laboratory-based Acute Physiology Score, the odds of ICU admission were not significantly different for patients with high (adjusted odds ratio [OR] 0.99, 95% confidence interval [CI] 0.78 to 1.23) or moderate (adjusted OR 0.97, 95% CI 0.86 to 1.09) frailty risk compared to those with low frailty risk. Among patients admitted to the ICU, 75 (75.0%) of those with high frailty risk died, compared to 317 (56.0%) of those with moderate risk and 416 (52.7%) of those with low risk. After multivariable adjustment, the risk of death after ICU admission was higher for patients with high frailty risk than for those with low frailty risk (adjusted OR 2.86, 95% CI 1.77 to 4.77).

INTERPRETATION

Among patients readmitted to hospital within 12 months, patients with high frailty risk were similarly likely as those with lower frailty risk to be admitted to the ICU but were more likely to die if admitted to ICU. The HFRS at hospital discharge can inform prognosis, which can help guide discussions for preferences for ICU care during future hospital stays.

Mapping the process of ICU care delivery to improve treatment decisions in acute respiratory failure

Evidence suggests system-level norms and care processes influence individual patients' medical decisions, including end-of-life decisions for patients with critical illnesses like acute respiratory failure. Yet, little is known about how these processes unfold over the course of a patient's critical illness in the intensive care unit (ICU). Our objective was to map current-state ICU care delivery processes for patients with acute respiratory failure and to identify opportunities to improve the process. We conducted a process mapping study at two academic medical centers, using focus groups and semi-structured interviews. The 70 participants represented 17 distinct roles in ICU care, including interprofessional medical ICU and palliative care clinicians, surrogate decision makers, and patient survivors. Participants refined and endorsed a process map of current-state care delivery for all patients admitted to the ICU with acute respiratory failure requiring mechanical ventilation. The process contains four critical periods for active deliberation about the use of life-sustaining treatments. However, active deliberation steps are inconsistently performed and frequently disrupted, leading to prolongation of life-sustaining treatment by default, without consideration of patients' individual goals and priorities. Interventions to standardize active deliberation in the ICU may improve treatment decisions for ICU patients with acute respiratory failure.

The association between nutritional risk index and ICU outcomes across hematologic malignancy patients with acute respiratory failure

Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51-68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9-14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79-99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2-7). Mortality across those at severe malnutrition (NRI < 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04-5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure.

Association between sepsis survivorship and long-term cardiovascular outcomes in adults: a systematic review and meta-analysis

PURPOSE

We aimed to determine the association between sepsis and long-term cardiovascular events.

METHODS

We conducted a systematic review of observational studies evaluating post-sepsis cardiovascular outcomes in adult sepsis survivors. MEDLINE, Embase, and the Cochrane Controlled Trials Register and Database of Systematic Reviews were searched from inception until April 21st, 2021. Two reviewers independently extracted individual study data and evaluated risk of bias. Random-effects models estimated the pooled crude cumulative incidence and adjusted hazard ratios (aHRs) of cardiovascular events compared to either non-septic hospital survivors or population controls. Primary outcomes included myocardial infarction, stroke, and congestive heart failure; outcomes were analysed at maximum reported follow-up (from 30 days to beyond 5 years post-discharge).

RESULTS

Of 12,649 screened citations, 27 studies (25 cohort studies, 2 case-crossover studies) were included with a median of 4,289 (IQR 502-68,125) sepsis survivors and 18,399 (IQR 4,028-83,506) controls per study. The pooled cumulative incidence of myocardial infarction, stroke, and heart failure in sepsis survivors ranged from 3 to 9% at longest reported follow-up. Sepsis was associated with a higher long-term risk of myocardial infarction (aHR 1.77 [95% CI 1.26 to 2.48]; low certainty), stroke (aHR 1.67 [95% CI 1.37 to 2.05]; low certainty), and congestive heart failure (aHR 1.65 [95% CI 1.46 to 1.86]; very low certainty) compared to non-sepsis controls.

CONCLUSIONS

Surviving sepsis may be associated with a long-term, excess hazard of late cardiovascular events which may persist for at least 5 years following hospital discharge.

Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?"

BACKGROUND

Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs.

METHODS

This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months.

RESULTS

Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians).

CONCLUSION

Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.

Improving Transitions of Care between the Intensive Care Unit and General Internal Medicine Ward. A Demonstration Study

Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre-post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre-post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre-post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.

A suspected septic transfusion reaction associated with posttransfusion contamination of a platelet pool by vancomycin-resistant Enterococcus faecium

BACKGROUND

Vancomycin-resistant enterococci (VRE) are antibiotic-resistant organisms associated with both colonization and serious life-threatening infection in health care settings. Contamination of platelet concentrates (PCs) with Enterococcus can result in transfusion-transmitted infection.

CASE PRESENTATION

This report describes the investigation of a septic transfusion case involving a 27-year-old male patient with relapsed acute leukemia who was transfused with a 5-day-old buffy coat PC pool and developed fever and rigors.

DISCUSSION

Microbiology testing and pulse-field gel electrophoresis (PFGE) was done on patient blood cultures obtained from peripheral and central lines. Microbiology and molecular testing were also performed on the remaining posttransfusion PC pool, which was refrigerated for 24 hours before microbiology testing. Red blood cell (RBC) and plasma units associated with the implicated PCs were screened for microbial contamination. Patient blood cultures obtained from peripheral and central lines yielded vancomycin-resistant Enterococcus faecium. Gram stain of a sample from the platelet pool was negative but coagulase-negative Staphylococcus (CNST) and VRE were isolated on culture. Antibiotic sensitivity and PFGE profiles of several VRE isolates from the patient before and after transfusion, and the PC pool, revealed that all were closely related. Associated RBC and plasma components tested negative for microbial contamination.

CONCLUSIONS

Microbiological and molecular investigations showed a relationship between VRE isolated from the patient before and after transfusion, and therefore it is postulated that a patient-to-PC retrograde contamination (from either blood or skin) occurred. As the CNST isolated from the PC pool was not isolated from patient samples, its implication in the transfusion event is unknown.

Clinical Interventions to Prevent Tumour Lysis Syndrome in Hematologic Malignancy: A Multisite Retrospective Chart Review

ABSTRACTBackground: Tumour lysis syndrome (TLS) occurs when lysis of malignant cells causes electrolyte disturbances and potentially organ dysfunction. Guidelines recommending preventive therapy according to TLS risk are based on low-quality evidence.Objectives: The primary objective was to characterize utilization of TLS preventive strategies through comprehensive description of current practice. Secondary objectives were to determine TLS incidence, to compare use of preventive strategies among intermediate- and high-risk patients, and to describe TLS treatment strategies.Methods: This retrospective chart review examined data for patients with newly diagnosed hematologic malignancy who were admitted to an oncology centre and/or affiliated intensive care unit between October 2015 and September 2016 in Toronto, Ontario, Canada. Results: Fifty-eight patients (29 at intermediate risk, 29 at high risk) were eligible for inclusion. Use of preventive allopurinol, IV bicarbonate, and furosemide was similar between groups. Rasburicase was more frequently used for high-risk patients (3% [1/29] of intermediate-risk patients versus 36% [9/25] of high-risk patients; p = 0.003). In 4 (14%) of the intermediate-risk patients and 2 (8%) of the high-risk patients, TLS developed during the admission. TLS was observed in 10% (1/10) of patients who received preventive rasburicase and 11% (5/44) of those who did not (p > 0.99), and in 9% (4/45) of patients who received preventive IV bicarbonate and 25% (2/8) of those who did not (p = 0.22). Treatment strategies included rasburicase, IV bicarbonate, furosemide, and renal replacement therapy.Conclusions: In this retrospective chart review, rasburicase was more commonly used for high-risk patients, whereas the use of other agents was similar between risk groups. This pattern of use is inconsistent with guidelines, which recommend that all high-risk patients receive rasburicase. There was no difference in TLS incidence between patients who did and did not receive preventive rasburicase or IV bicarbonate. Further prospective studies are needed to inform management of patients with malignancies who are at intermediate or high risk of TLS.RÉSUMÉContexte : Le syndrome de lyse tumorale (SLT) se produit lorsque la lyse de cellules malignes provoque des perturbations électrolytiques et la dysfonction potentielle d’un organe. Les lignes directrices préconisant une thérapie préventive basée sur le risque de SLT se fondent sur des éléments de preuve de piètre qualité.Objectifs : L’objectif principal consistait à décrire l’adoption des stratégies de prévention du SLT en décrivant précisément la pratique actuelle. Les objectifs secondaires consistaient, quant à eux, à déterminer l’incidence du SLT, à comparer l’utilisation des stratégies de prévention pour les patients présentant un risque élevé et moyen et à décrire les stratégies de traitement du SLT.Méthodes : Cet examen rétrospectif a permis d’examiner les données de patients ayant récemment reçu un diagnostic d’hémopathie maligne et ayant été admis dans un centre d’oncologie ou une unité de soins intensifs affiliée, entre octobre 2015 et septembre 2016 à Toronto (Ontario), au Canada.Résultats : Cinquante-huit patients (29 présentant un risque moyen et 29 un risque élevé) étaient admissibles. L’utilisation d’allopurinol à titre préventif, de bicarbonate par voie intraveineuse et de furosémide était similaire d’un groupe à l’autre. Le rasburicase était plus fréquemment utilisé pour les patients présentant un risque élevé (3 % [1/29] de patients présentant un risque moyen contre 36 % [9/25] de patients présentant un risque élevé; p = 0.003). Quatre (14 %) patients présentant un risque moyen et deux (8 %) présentant un risque élevé ont développé un SLT pendant l’admission. Le SLT a été observé chez 10 % (1/10) des patients ayant reçu du rasburicase à titre préventif et chez 11 % (5/44) des patients qui n’en avaient pas reçu (p > 0,99); il a aussi été observé chez 9 % (4/45) des patients ayant reçu du bicarbonate par voie intraveineuse à titre préventif et chez 25 % (2/8) des patients qui n’en avaient pas reçu (p = 0.22). Les stratégies de traitement comprenaient le rasburicase, le bicarbonate par voie intraveineuse, le furosémide et la thérapie de remplacement rénal.Conclusions : Dans cet examen rétrospectif des dossiers, l’usage du rasburicase était plus fréquent pour les patients présentant un risque élevé, tandis que celui d’autres agents était similaire entre les groupes à risque. Ce schéma d’utilisation n’est pas conforme aux lignes directrices, qui recommandent que tous les patients présentant un risque élevé reçoivent du rasburicase. Aucune différence n’est apparue dans l’incidence du SLT parmi les patients ayant reçu du rasburicase ou du bicarbonate par voie intraveineuse à titre préventif et parmi ceux qui n’en avaient pas reçu. Davantage d’études prospectives sont nécessaires pour mieux connaitre la gestion des patients à haut risque ou ceux qui présentent des risques moyens de SLT, mais qui ont des malignités.  

Clinical Interventions to Prevent Tumour Lysis Syndrome in Hematologic Malignancy: A Multisite Retrospective Chart Review

BACKGROUND

Tumour lysis syndrome (TLS) occurs when lysis of malignant cells causes electrolyte disturbances and potentially organ dysfunction. Guidelines recommending preventive therapy according to TLS risk are based on low-quality evidence.

OBJECTIVES

The primary objective was to characterize utilization of TLS preventive strategies through comprehensive description of current practice. Secondary objectives were to determine TLS incidence, to compare use of preventive strategies among intermediate- and high-risk patients, and to describe TLS treatment strategies.

METHODS

This retrospective chart review examined data for patients with newly diagnosed hematologic malignancy who were admitted to an oncology centre and/or affiliated intensive care unit between October 2015 and September 2016 in Toronto, Ontario, Canada.

RESULTS

Fifty-eight patients (29 at intermediate risk, 29 at high risk) were eligible for inclusion. Use of preventive allopurinol, IV bicarbonate, and furosemide was similar between groups. Rasburicase was more frequently used for high-risk patients (3% [1/29] of intermediate-risk patients versus 36% [9/25] of high-risk patients; p = 0.003). In 4 (14%) of the intermediate-risk patients and 2 (8%) of the high-risk patients, TLS developed during the admission. TLS was observed in 10% (1/10) of patients who received preventive rasburicase and 11% (5/44) of those who did not (p > 0.99), and in 9% (4/45) of patients who received preventive IV bicarbonate and 25% (2/8) of those who did not (p = 0.22). Treatment strategies included rasburicase, IV bicarbonate, furosemide, and renal replacement therapy.

CONCLUSIONS

In this retrospective chart review, rasburicase was more commonly used for high-risk patients, whereas the use of other agents was similar between risk groups. This pattern of use is inconsistent with guidelines, which recommend that all high-risk patients receive rasburicase. There was no difference in TLS incidence between patients who did and did not receive preventive rasburicase or IV bicarbonate. Further prospective studies are needed to inform management of patients with malignancies who are at intermediate or high risk of TLS.

Factors associated with physicians' predictions of six-month mortality in critically ill patients

Background

Physician's estimates of a patient's prognosis are an important component in shared decision-making. However, the variables influencing physician's judgments are not well understood. We aimed to determine which physician and patient factors are associated with physicians' predictions of critically ill patients' six-month mortality and the accuracy and confidence of these predictions.

Methods

Prospective cohort study evaluating physicians' predictions of six-month mortality. Using univariate and multivariable generalized estimating equations, we assessed the association between baseline physician and patient characteristics with predictions of six-month death, as well as accuracy and confidence of these predictions.

Results

Our cohort was comprised 300 patients and 47 physicians. Physicians were asked to predict if patients would be alive or dead at six months and to report their confidence in these predictions. Physicians predicted that 99 (33%) patients would die. The key factors associated with both the direction and accuracy of prediction were older age of the patient, the presence of malignancy, being in a medical ICU, and higher APACHE III scores. The factors associated with lower confidence included older physician age, being in a medical ICU and higher APACHE III score.

Conclusions

Patient level factors are associated with predictions of mortality at six months. The accuracy and confidence of the predictions are associated with both physician and patients' factors. The influence of these factors should be considered when physicians reflect on how they make predictions for critically ill patients.

Association of Surrogate Decision-making Interventions for Critically Ill Adults With Patient, Family, and Resource Use Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity.

OBJECTIVE

To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use.

DATA SOURCES

A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018.

STUDY SELECTION

Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms included surrogate or substitute decision-maker, critically ill, randomized controlled trials, and their respective related terms.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use).

RESULTS

Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08; P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, -2.11 days; 95% CI, -4.16 to -0.07; P = .04), but not in the overall population (mean difference, -0.79 days; 95% CI, -2.33 to 0.76 days; P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, -0.11; 95% CI, -0.29 to 0.08; P = .26; anxiety: ratio of means, -0.08; 95% CI, -0.25 to 0.08; P = .31; or posttraumatic stress disorder: ratio of means: -0.04; 95% CI, -0.21 to 0.13; P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention; P = .04).

CONCLUSIONS AND RELEVANCE

Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.

What's behind the white coat: Potential mechanisms of physician-attributable variation in critical care

Background

Critical care intensity is known to vary across regions and centers, yet the mechanisms remain unidentified. Physician behaviors have been implicated in the variability of intensive care near the end of life, but physician characteristics that may underlie this association have not been determined.

Purpose

We sought to identify behavioral attributes that vary among intensivists to generate hypotheses for mechanisms of intensivist-attributable variation in critical care delivery.

Methods

We administered a questionnaire to intensivists who participated in a prior cohort study in which intensivists made prognostic estimates. We evaluated the degree to which scores on six attribute measures varied across intensivists. Measures were selected for their relevance to preference-sensitive critical care: a modified End-of-Life Preferences (EOLP) scale, Life Orientation Test–Revised (LOT-R), Jefferson Scale of Empathy (JSE), Physicians' Reactions to Uncertainty (PRU) scale, Collett-Lester Fear of Death (CLFOD) scale, and a test of omission bias. We conducted regression analyses assessing relationships between intensivists’ attribute scores and their prognostic accuracy, as physicians’ prognostic accuracy may influence preference-sensitive decisions.

Results

20 of 25 eligible intensivists (80%) completed the questionnaire. Intensivists’ scores on the EOLP, LOT-R, PRU, CLFOD, and omission bias measures varied considerably, while their responses on the JSE scale did not. There were no consistent associations between attribute scores and prognostic accuracy.

Conclusions

Intensivists vary in feasibly measurable attributes relevant to preference-sensitive critical care delivery. These attributes represent candidates for future research aimed at identifying mechanisms of clinician-attributable variation in critical care and developing effective interventions to reduce undue variation.

Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review

IMPORTANCE

Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.

OBJECTIVE

To identify risk factors and physical findings that predict difficult intubation.

DATA SOURCES

The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.

STUDY SELECTION

Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.

DATA EXTRACTION AND SYNTHESIS

Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.

RESULTS

Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).

CONCLUSIONS AND RELEVANCE

Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.

Contributors to Intensive Care Unit Clinicians' Predictions of Patient Outcomes: A Qualitative Analysis

BACKGROUND

Information about a critically ill patient's prognosis is important to the shared decision-making process. The factors that physicians and nurses consider when generating their prognoses are not well understood.

OBJECTIVE

To explore the factors that intensive care unit clinicians consider when prognosticating for their patients.

METHODS

Intensive care unit clinicians (physicians and nurses) were asked to predict 6-month survival and describe the patient-related factors that they considered in their prognoses. The reported factors were tallied and compared with predictions of 6-month survival or death and with correct and incorrect predictions.

RESULTS

Physicians and nurses completed 254 and 286 surveys, respectively, for 303 patients. Of 23 factors identified, the 3 most frequently reported were acute conditions, medical history and comorbid conditions, and trajectory. For patients predicted to be alive at 6 months, physicians commonly mentioned the factors procedures and age; nurses mentioned behavior patterns, previous experiences, and social support. For patients predicted to be dead at 6 months, both groups commonly mentioned cancer. Factors with the highest ratios of correct to incorrect predictions reported by physicians were procedures and definitive treatment; those reported by nurses were procedures, behavior patterns, and current functional status.

CONCLUSIONS

Intensive care unit clinicians use various patient factors to inform their prognoses. Clinicians use different factors when predicting survival than when predicting death. Some factors are reported more frequently for correct predictions than for incorrect predictions.

Patients' perceptions and ICU clinicians predictions of quality of life following critical illness

PURPOSE

To determine how patients perceive their quality of life (QOL) six months following critical illness and to measure clinicians' discriminative accuracy of predicting this outcome.

MATERIALS AND METHODS

This prospective cohort study of intensive care unit (ICU) survivors asked patients to report their QOL strictly at six months compared to one month before their critical illness as better, the same, or worse. ICU physicians and nurses made six-month QOL predictions for these patients.

RESULTS

Of 162 critical illness survivors, 33% (n = 53) of patients reported six-month QOL as better, 33% (n = 54) the same, and 34% (n = 55) worse. Abnormal cognition and inability to return to primary pastime or original place of residence (p < .05 for all) were associated with worse self-reported QOL at six months in multivariable regression. Predictions of patient perceptions of QOL at six months were pessimistic and had low discriminative accuracy for both physicians (sensitivity 56%, specificity 53%) and nurses (sensitivity 49%, specificity 57%).

CONCLUSIONS

Among survivors of critical illness, one-third each reported their six-month post-ICU QOL as better, the same, or worse. Self-reported six-month QOL was associated with six-month function. ICU clinicians should use caution in predicting self-reported QOL, as discriminative accuracy was poor in this cohort.

7 versus 14 days of antibiotic treatment for critically ill patients with bloodstream infection: a pilot randomized clinical trial

Background

Shorter-duration antibiotic treatment is sufficient for a range of bacterial infections, but has not been adequately studied for bloodstream infections. Our systematic review, survey, and observational study indicated equipoise for a trial of 7 versus 14 days of antibiotic treatment for bloodstream infections; a pilot randomized clinical trial (RCT) was a necessary next step to assess feasibility of a larger trial.

Methods

We conducted an open, pilot RCT of antibiotic treatment duration among critically ill patients with bloodstream infection across 11 intensive care units (ICUs). Antibiotic selection, dosing and route were at the discretion of the treating team; patients were randomized 1:1 to intervention arms consisting of two fixed durations of treatment – 7 versus 14 days. We recruited adults with a positive blood culture yielding pathogenic bacteria identified while in ICU. We excluded patients with severe immunosuppression, foci of infection with an established requirement for prolonged treatment, single cultures with potential contaminants, or cultures yielding Staphylococcus aureus or fungi. The primary feasibility outcomes were recruitment rate and adherence to treatment duration protocol. Secondary outcomes included 90-day, ICU and hospital mortality, relapse of bacteremia, lengths of stay, mechanical ventilation and vasopressor duration, antibiotic-free days, Clostridium difficile, antibiotic adverse events, and secondary infection with antimicrobial-resistant organisms.

Results

We successfully achieved our target sample size (n = 115) and average recruitment rate of 1 (interquartile range (IQR) 0.3–1.5) patient/ICU/month. Adherence to treatment duration was achieved in 89/115 (77%) patients. Adherence differed by underlying source of infection: 26/31 (84%) lung; 18/29 (62%) intra-abdominal; 20/26 (77%) urinary tract; 8/9 (89%) vascular-catheter; 4/4 (100%) skin/soft tissue; 2/4 (50%) other; and 11/12 (92%) unknown sources. Patients experienced a median (IQR) 14 (8–17) antibiotic-free days (of the 28 days after blood culture collection). Antimicrobial-related adverse events included hepatitis in 1 (1%) patient, Clostridium difficile infection in 4 (4%), and secondary infection with highly resistant microorganisms in 10 (9%). Ascertainment was complete for all study outcomes in ICU, in hospital and at 90 days.

Conclusion

It is feasible to conduct a RCT to determine whether 7 versus 14 days of antibiotic treatment is associated with comparable 90-day survival.

Trial registration

ClinicalTrials.gov, identifier: NCT02261506. Registered on 26 September 2014.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2474-1) contains supplementary material, which is available to authorized users.

An unexpected but underestimated case of disseminated toxoplasmosis

Toxoplasma gondii is a ubiquitous intracellular parasite that can cause disseminated infection following reactivation in immunocompromised hosts. We describe a 58-year-old man who died of refractory shock because of disseminated toxoplasmosis. The diagnosis was only made postmortem on autopsy. We discuss the importance of considering toxoplasmosis on the differential diagnosis in high-risk patients, and review the role of screening and chemoprophylaxis in preventing infection.

Discriminative Accuracy of Physician and Nurse Predictions for Survival and Functional Outcomes 6 Months After an ICU Admission

IMPORTANCE

Predictions of long-term survival and functional outcomes influence decision making for critically ill patients, yet little is known regarding their accuracy.

OBJECTIVE

To determine the discriminative accuracy of intensive care unit (ICU) physicians and nurses in predicting 6-month patient mortality and morbidity, including ambulation, toileting, and cognition.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study conducted in 5 ICUs in 3 hospitals in Philadelphia, Pennsylvania, and enrolling patients who spent at least 3 days in the ICU from October 2013 until May 2014 and required mechanical ventilation, vasopressors, or both. These patients' attending physicians and bedside nurses were also enrolled. Follow-up was completed in December 2014.

MAIN OUTCOMES AND MEASURES

ICU physicians' and nurses' binary predictions of in-hospital mortality and 6-month outcomes, including mortality, return to original residence, ability to toilet independently, ability to ambulate up 10 stairs independently, and ability to remember most things, think clearly, and solve day-to-day problems (ie, normal cognition). For each outcome, physicians and nurses provided a dichotomous prediction and rated their confidence in that prediction on a 5-point Likert scale. Outcomes were assessed via interviews with surviving patients or their surrogates at 6 months. Discriminative accuracy was measured using positive and negative likelihood ratios (LRs), C statistics, and other operating characteristics.

RESULTS

Among 340 patients approached, 303 (89%) consented (median age, 62 years [interquartile range, 53-71]; 57% men; 32% African American); 6-month follow-up was completed for 299 (99%), of whom 169 (57%) were alive. Predictions were made by 47 physicians and 128 nurses. Physicians most accurately predicted 6-month mortality (positive LR, 5.91 [95% CI, 3.74-9.32]; negative LR, 0.41 [95% CI, 0.33-0.52]; C statistic, 0.76 [95% CI, 0.72-0.81]) and least accurately predicted cognition (positive LR, 2.36 [95% CI, 1.36-4.12]; negative LR, 0.75 [95% CI, 0.61-0.92]; C statistic, 0.61 [95% CI, 0.54-0.68]). Nurses most accurately predicted in-hospital mortality (positive LR, 4.71 [95% CI, 2.94-7.56]; negative LR, 0.61 [95% CI, 0.49-0.75]; C statistic, 0.68 [95% CI, 0.62-0.74]) and least accurately predicted cognition (positive LR, 1.50 [95% CI, 0.86-2.60]; negative LR, 0.88 [95% CI, 0.73-1.06]; C statistic, 0.55 [95% CI, 0.48-0.62]). Discriminative accuracy was higher when physicians and nurses were confident about their predictions (eg, for physicians' confident predictions of 6-month mortality: positive LR, 33.00 [95% CI, 8.34-130.63]; negative LR, 0.18 [95% CI, 0.09-0.35]; C statistic, 0.90 [95% CI, 0.84-0.96]). Compared with a predictive model including objective clinical variables, a model that also included physician and nurse predictions had significantly higher discriminative accuracy for in-hospital mortality, 6-month mortality, and return to original residence (P < .01 for all).

CONCLUSIONS AND RELEVANCE

ICU physicians' and nurses' discriminative accuracy in predicting 6-month outcomes of critically ill patients varied depending on the outcome being predicted and confidence of the predictors. Further research is needed to better understand how clinicians derive prognostic estimates of long-term outcomes.

Long-term outcomes of patients after acute respiratory distress syndrome: hard work for nothing?

Acute respiratory distress syndrome (ARDS) is a common syndrome that can impose significant health burdens on individuals and the health care systems that serve them. Patients who are treated for this condition in the acute setting often face long-term physical and psychological complications that result from their prolonged hospitalization. While there is reasonable evidence for the use of conventional ventilation strategies, little is known about the effectiveness of unconventional treatment strategies; moreover, the existing literature does not support routine use of these often expensive interventions. It is difficult to prognosticate the long-term function of an individual patient in the acute setting, and thus it is too early to say that some of the unconventional treatments should be abandoned merely because the existing studies do not demonstrate efficacy. This is complicated by the fact that ARDS is a heterogeneous syndrome with a heterogeneous patient population. Experts in ARDS can reasonably continue to use these interventions (with caution, based on their clinical experience) and should continually evaluate their physiologic effect; however, we must keep in mind that there is no clear evidence as to whether these treatments provide benefit or harm and that continuous, rigorous evaluation is required.

Clinical utility of abnormal opacity overlying the vertebral column on lateral chest radiography

BACKGROUND

Chest radiography is an important component of the evaluation of patients with complaints referable to the chest. We sought to investigate the clinical utility of one particular finding on the lateral chest radiograph (CXR), namely, radioopacity obscuring the normal superior to inferior progression of vertebral radiolucency. A review of the literature yielded little published evidence to characterize the clinical utility of this finding to date.

METHODS

We retrospectively identified 370 patients from a hospital database who underwent both computed tomography (CT) imaging of the chest and lateral chest radiography within 24 hours. We calculated the sensitivity, specificity, and likelihood ratios (LRs) associated with the presence or absence of an abnormal opacity overlying the vertebral column on lateral chest radiography using CT imaging of the chest as the reference standard. We also estimated interobserver and intraobserver reliability of this finding.

RESULTS

Abnormal opacity overlying the vertebral column had a sensitivity of 86.9% (95% confidence interval [CI], 82.5%-90.3%) and specificity of 70.4% (95% CI, 59.7%-79.2%) for relevant CT-documented lower lobe and associated structural pathology. The associated summary positive LR (LR+) was 2.9 (95% CI, 2.1-4.1) and summary negative LR (LR-) was 0.19 (95% CI, 0.13-0.26). Kappa statistics were indicative of moderate intraobserver and interobserver agreement.

CONCLUSIONS

The presence of abnormal opacity overlying the vertebral column on lateral chest radiography increases the probability of lower lobe and associated structural pathology somewhat. The absence of this finding decreased the probability of such pathology to a greater degree. Thus, this finding is useful in differentiating those patients with pathology from those without.

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents

OBJECTIVE

We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal.

DESIGN

Cross-sectional postal survey.

SETTING

Canadian internal medicine training programs.

PARTICIPANTS

Internal medicine residents attending Canadian English-speaking medical schools.

INTERVENTIONS

A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools.

MEASUREMENTS AND MAIN RESULTS

Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence.

CONCLUSIONS

The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.

Does this patient with headache have a migraine or need neuroimaging?

CONTEXT

In assessing the patient with headache, clinicians are often faced with 2 important questions: Is this headache a migraine? Does this patient require neuroimaging? The diagnosis of migraine can direct therapy, and information obtained from the history and physical examination is used by physicians to determine which patients require neuroimaging.

OBJECTIVE

To determine the usefulness of the history and physical examination that distinguish patients with migraine from those with other headache types and that identify those patients who should undergo neuroimaging.

DATA SOURCES AND STUDY SELECTION

A systematic review was performed using articles from MEDLINE (1966-November 2005) that assessed the performance characteristics of screening questions in diagnosing migraine (with the International Headache Society diagnostic criteria as a gold standard) and addressed the accuracy of the clinical examination in predicting the presence of underlying intracranial pathology (with computed tomography/magnetic resonance imaging as the reference standard).

DATA EXTRACTION

Two authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality using predetermined criteria. Disagreement was resolved by consensus with a third author.

DATA SYNTHESIS

Four studies of screening questions for migraine (n = 1745 patients) and 11 neuroimaging studies (n = 3725 patients) met inclusion criteria. All 4 of the migraine studies illustrated high sensitivity and specificity if 3 or 4 criteria were met. The best predictors can be summarized by the mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling). If 4 of the 5 criteria are met, the likelihood ratio (LR) for definite or possible migraine is 24 (95% confidence interval [CI], 1.5-388); if 3 are met, the LR is 3.5 (95% CI, 1.3-9.2), and if 2 or fewer are met, the LR is 0.41 (95% CI, 0.32-0.52). For the neuroimaging question, several clinical features were found on pooled analysis to predict the presence of a serious intracranial abnormality: cluster-type headache (LR, 10.7; 95% CI, 2.2-52); abnormal findings on neurologic examination (LR, 5.3; 95% CI, 2.4-12); undefined headache (ie, not cluster-, migraine-, or tension-type) (LR, 3.8; 95% CI, 2.0-7.1); headache with aura (LR, 3.2; 95% CI, 1.6-6.6); headache aggravated by exertion or a valsalva-like maneuver (LR, 2.3; 95% CI, 1.4-3.8); and headache with vomiting (LR, 1.8; 95% CI, 1.2-2.6). No clinical features were useful in ruling out significant pathologic conditions.

CONCLUSIONS

The presence of 4 simple historical features can accurately diagnose migraine. Several individual clinical features were found to be associated with a significant intracranial abnormality, and patients with these features should undergo neuroimaging.

Left ventricular isovolumic relaxation is a predictor of left ventricular end-diastolic pressure

BACKGROUND

The relationship between isovolumic left ventricular (LV) relaxation and LV filling pressures remains incompletely explored. If there is a relationship between the rate of early diastolic LV relaxation and LV end-diastolic pressure, this would have important implications concerning both our understanding and, potentially, our treatment of LV diastolic dysfunction.

OBJECTIVE

To examine the baseline hemodynamic correlates of LV end-diastolic pressure in patients with both normal and abnormal LV function.

METHODS

The relationships between LV end-diastolic pressure, a variety of hemodynamic parameters (tau, the rate of LV isovolumic relaxation, LV peak positive+dP/dt, LV peak systolic pressure and heart rate), measures of LV end-systolic and end-diastolic volume, and age were determined using regression analysis techniques in 104 patients with normal LV systolic function and 90 patients with an LV ejection fraction of less than 40%.

RESULTS

Univariate analysis demonstrated a correlation between tau and LV end-diastolic pressure (r=0.743, P<0.001). There were significant univariate relationships between a number of other hemodynamic variables and LV end-diastolic pressure. A multiple regression model demonstrated that tau made the most important contribution to a model where LV end-diastolic pressure is the dependent variable. LV peak systolic pressure and heart rate also made significant contributions to the model. In 33 of these patients, when LV end-diastolic pressure was reduced using an inferior vena cava occlusion balloon, tau did not change. The acute administration of clonidine (n=11) caused an increase in LV end-diastolic pressure that was closely correlated with an observed increase in tau (r=0.843, P<0.001).

CONCLUSIONS

These observations suggest that the rate of LV isovolumic relaxation is a predictor of LV end-diastolic pressure.