Several other outcome measures were also assessed. There were no significant differences between the prone and supine patient groups in terms of pulmonary function tests, days of mechanical ventilation (p = 0.22), and intensive care unit length of stay (p=0.15). The mortality rate was 64.1% in the prone group vs. 56.8% in the supine group. Arterial oxygenation, and the percent of well-aerated lung tissue, was slightly higher in the supine group.
There were no statistically significant differences in SF-36 scores between the groups.

While this study consisted of a very small number of patients, only a few studies have examined long-term outcomes for ARDS patients. Importantly, despite recommendations in 1994 suggesting that HRQL be considered for future outcomes studies, this study is one of the few critical care studies attempting to measure it. The results from this study showed that the mortality rate for ARDS was high at one year and that lung function — as well as HRQL — was not statistically different among patients ventilated in the supine vs. prone position. While the results from this study may not be particularly robust based on the small sample size, the methods stand as an example of how future critical care outcomes studies might be conducted.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

There appears to be much room for improvement in terms of better antibiotic stewardship with hospitalized patients. In previous studies, up to 50% of antimicrobial use is believed to be inappropriate. (1,2) In this study, a significant number of patients were both under- and over-treated. Moreover, the class of antibiotics most commonly prescribed – quinolones – is known to have limited activity against enterococci. Misclassification bias and reviewer bias were two potential limitations in this retrospective study. Moreover, co-infection with other bacteria may have partially confounded the results. Both the authors and the invited commentators conclude that, due to the rarity of infectious complications associated with Enterococcus, ABU ought not to be treated.

The results from this study support current efforts to curtail inappropriate antimicrobial use through stewardship programs, focused antimicrobial use campaigns, and mindful practice.

1. Davey P, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev2005; (4): CD003543.

2. Flanders SA & Saint S. Enhancing the safety of hospitalized patients: Who is minding the antimicrobials? Arch Intern Med 2012; 172(1): 38-40.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

The Society joined HQA in 2008, recognizing a unique opportunity to contribute to the rapidly evolving national discussion around hospital quality measurement and public reporting. Using public hospital data can be a little like turning to TripAdvisor for hotel reviews or to Angie’s List for advice on selecting contractors — anecdotal and akin to the characteristics of Lake Wobegon (all the hospitals have great performance, all the patients are highly satisfied, and all the outcomes are above average). However, in the last five years, the HQA has streamlined the process for reviewing and endorsing structure and outcomes measures for impartial public reporting.  These rigorously chosen data are reported on the U.S. Department of Health and Human Services Hospital Compare, now the nation’s broadest compendium of publicly available, widely accessible, comparable quality measures. Hospital Compare reports on more than 50 performance measures for inpatient and outpatient care, allowing the public and healthcare providers to compare the performance of more than 4,500 hospitals across the nation.

HQA also catalyzed adoption of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the first standardized survey for measuring patients’ perceptions of their hospital care. This survey is now routinely included in all patient satisfaction instruments used by public and private hospitals; it provides a level of rigor and consistency long sought as a benchmark for improving quality. Additionally, HQA endorsed the nation’s first measures for surgical site infections; hospitals that publically reported these infections saw improved outcomes.

A consistent challenge (and gripe) from providers and healthcare institutions is that measurement and reporting consume a disproportionate amount of resources and often overlap due to the use of redundant measures. Further, public reporting of some measures has never been rigorously shown to drive performance improvement or better patient outcomes. HQA, with its partners at the Centers for Medicare & Medicare Services and The Joint Commission, has consistently prioritized streamlined reporting to reduce the burden, identifying high-impact measures that drive improvement and discontinuing reporting on measures that are insensitive or “topped-out” (close to 100% compliance).

So why is HQA closing up shop unlike virtually any other Washington, D.C.-based organization?

The multi-stakeholder HQA measure review model served as the template for other quality alliances and was incorporated into provisions in the Affordable Care Act. Included as part of that transformative law was the outline for a federally mandated quality improvement focus. Now fully realized as the National Quality Forum’s Measures Application Partnership (MAP), the law requires a multi-stakeholder group to identify quality gaps and then specify, validate and endorse public reporting measures that will be used for accountability, performance review and value-based purchasing.

The MAP has kicked into high gear, and HQA is winding down with a measure of satisfaction in transitioning this important work to the National Quality Forum. SCCM Past-President Mitchell Levy, MD, FCCM, serves as an independent content expert for the MAP, ensuring that a critical care perspective will be considered in the selection and approval of measures.

At the final HQA meeting, Carolyn Clancy, MD, Director of the Agency for Healthcare Research and Quality, reflected on the accomplishments of HQA. She recognized the group’s success in advancing public reporting for hospital care and promoting a national conversation about quality in a serious and informed fashion. She noted that while “much work still remains to be done and quality is still deficient,” the HQA has assured that the patients’ perspective and experience are now truly respected.

The Society has a significant, ongoing role to play in achieving the objectives of high-quality healthcare for all. It is my hope that all SCCM members will participate in our national effort to advance the quality and affordability of care for critically ill and injured patients.

During these last two years, it has also been my privilege to chair the Society’s newest committee: the Quality and Safety Committee.  In the future, I will offer comments on that experience and the work of the committee in advancing quality and safety for our vulnerable, critically ill patients, their families and communities.

Ivor S. Douglas, MD, served as an organizational principal to the Hospital Quality Alliance for the Society of Critical Care Medicine. He serves as chair of the Society’s Quality and Safety Committee.  He is Chief of the Division of Pulmonary and Critical Care Medicine and Director of Medical Intensive Care at the Denver Health Medical Center in Colorado. He is associate professor of medicine at the University of Colorado School of Medicine.

Rates of death or an inability to walk without assistance at 60-day follow-up were not statistically significantly different between the restrictive (35.2%) and liberal strategy group (34.7%, P=0.90).  There were no significant differences between groups regarding functional outcomes, including activities of daily living and fatigue. 

The results from this study are consistent with the Transfusion Requirements in Critical Care trial, although increased rates of myocardial infarction or congestive heart failure were not observed in the liberal strategy group.  It should be noted that before surgery, the restrictive strategy group had more transfusions than the liberal group, but this was not statistically significant (P=0.07), and the mean hemoglobin level was 11.3 in both groups before surgery.  Furthermore, the difference between a hemoglobin level of 8 vs. 10 may or may not be clinically significant. This well-designed and methodologically rigorous study provides additional evidence to support a restrictive transfusion strategy in surgical patients, even when cardiac risk factors are present. 

CarsonJL, et al. for the FOCUS Investigators.  Liberal or restrictive transfusion in high-risk patients after hip surgery.  N Engl J Med 2011; epub ahead of print. 

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

This large observational trial demonstrated that omission of early thromboprophylaxis is associated with a statistically significantly higher risk of mortality in ICU patients.  As with all observational data sets, residual confounding, and other selection biases, might also explain this association; however, the authors appropriately employed robust statistical techniques to control for differences in baseline characteristics and known confounders.  This study adds compelling evidence in support of the recommendation by the National Quality Forum and the Joint Commission International to use thromboprophylaxis in ICU patients as soon as possible after admission. 

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

A number of significant results were found in this large cohort study. Overall, new-onset AF was associated with a 7% increase in the adjusted risk of in-hospital death, and 14% of all hospital-associated new-onset AF occurred in the context of severe sepsis (odds ratio [OR] 6.82; 95% confidence interval [CI], 6.54-7.11; P<0.001). In patients with severe sepsis, 2.6% of patients who also had new-onset AF suffered an ischemic stroke, for an average stroke rate of 0.15% per hospital day for patients with new-onset AF. Those with severe sepsis and new-onset AF had a statistically significant greater stroke risk than those with preexisting AF (OR 3.63; 95% CI, 2.51-5.25; P<0.0001). Various risk factors associated with new-onset AF among patients with severe sepsis were identified.

This large observational study is replete with data, and the authors attempted to control for the known limitations involving ICD-9-CD coding. The new-onset AF rate (5.9%) was lower in this study than previously reported rates (6% to 20%), and this may be attributed to the nature of claims data. Furthermore, an immortal-time bias might have falsely lowered the measurable risk for mortality rates associated with new-onset AF. Despite the inherent limitations when using observation data, this study demonstrates significant stroke and mortality risks for patients with severe sepsis and new-onset AF. New-onset AF may be a marker for severity of illness and poor prognosis, or it may directly contribute to mortality. This observational study calls for future investigations to examine the mechanisms responsible for the poor outcomes associated with new-onset AF, as well as possible management options to mitigate the risk for developing AF during severe sepsis.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

Fourteen studies met inclusion criteria.  The studies were moderately heterogeneous (I2=38%), and 36.8% of all included patients came from two reports conducted in cardiac surgery ICUs. Overall, patients treated with chlorhexidine had a statistically significantly lower risk of VAP compared to control subjects (RR 0.72; 95% CI, 0.55-0.94, p=0.02).  A subgroup analysis that included studies using 2% chlorhexidine found a 47% lower risk of VAP compared to controls (RR 0.53; 95% CI, 0.31-0.91, p=0.02). The use of antiseptics appeared to have the greatest benefit in cardiac surgery patients (RR 0.41; 95% CI, 0.17-0.98, p=0.05).

This study was methodologically sound, although over a quarter of the data came from cardiac surgery ICUs.  This might have introduced bias since cardiac surgery patients are often electively admitted and intubated under more controlled conditions than trauma or other types of ICU patients. Only two studies evaluated the use of povidone iodine, and different concentrations of chlorhexidine (0.12-2%) were used. Despite the limitations of this review, this meta-analysis provides strong evidence that the use of antiseptics may be beneficial for ICU patients in the prevention of VAP.  The effect appears to be most pronounced in cardiac surgery patients and with 2% chlorhexidine.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

Significant reductions in the use of chloride-rich solutions were found after the washout period.  The incidence of severe hyperchloremia (2.3% vs. 6.2%, p<0.001) and hypernatremia (0.2% vs. 0.9%, p<0.001) were significantly lower in the intervention group; however, a significantly greater incidence of metabolic alkalosis and alkalemia was found in the intervention group (14.7% vs. 10.5%, p<0.001).    Fluid costs decreased from $15,077 to $3,915.  The time-weighted standard base excess increased from 0.5 (+/- 4.5) to 1.8 (+/- 4.7) in the intervention group.   The authors concluded that restriction of chloride-rich solutions was associated with a significant decease in the incidence of metabolic acidosis, hypernatremia, and severe hyperchloremia; however, the incidence of metabolic alkalosis was increased.

There are a few limitations worth noting.  Not all solutions used in this study are available in the U.S. For example, a gelatin colloid, Gelofusine was used in the control group, and this colloid is not widely used in North America (although it is similar to other colloidal preparations).  No exclusion criteria were applied, thus possibly improving the external validity of the study, but the biochemical effects of chloride restriction may not be the same for all patients.  The implications for the biochemical changes in this study remain unknown.  It is not clear if metabolic alkalosis, versus metabolic acidosis, leads to worse outcomes in the critically ill, and the authors plan to undertake future studies to help answer this question. 

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

The experimental group was reasonably balanced against the control group, although there were some differences.  Patients in the experimental group had higher minute ventilation (p=0.04), greater fluid intake (p=0.09), and higher vasopressor use at the time of enrollment.  Multiple logistic regression was used to control for baseline shock and other mortality-predicting covariates.

The study was terminated early by the data safety monitoring board after an interim analysis indicated worse outcomes in the experimental group.  Patients in the experimental group had fewer ventilator-free days than the placebo group (14.0 [SD 11.1] vs. 17.2 [10.2], p=0.02).  The experimental group also had fewer ICU-free days (14.0 vs 16.7, p=0.04), and higher unadjusted mortality (26.6% vs 16.3 %, p=0.054).  When mortality was adjusted for baseline covariates, no statistically significant different was observed between groups (p=0.11). The experimental group had fewer organ failure-free days (12.3 vs 15.5, p=0.02).

The findings in this study are incongruent with prior work in this area, and this may be attributed to a lower overall ALI mortality (21.7%) than observed in previous n-3 fatty acid studies, a slight imbalance in baseline covariates that might have benefitted the control group, and the use of low tidal volumes in both study groups.  Additionally, the use of different enteral preparations and ventilator protocols in earlier studies might have biased results in favor of n-3 fatty acids.

The authors concluded that enteral supplementation of fatty acids, GLA, and antioxidants in patients with ALI does not improve outcomes and may be harmful.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

These results suggest that trainees from hospitals with high- intensity ventilation protocols do not demonstrate knowledge deficits regarding mechanical ventilation as compared to trainees from hospitals with low-intensity protocols.

Potential limitations to this work include the use of examination questions to test knowledge exclusively about mechanical ventilation and the fact that the study population consisted of examinees trained in internal medicine, not surgery, anesthesiology or emergency medicine. Nevertheless, this study has important implications for physician-educators, because the unintended consequences of protocols on education have not been evaluated broadly. Clinical protocols, which are designed to enhance and standardize patient care, may have an impact on medical education, especially in an era where work-hours are limited and care has become compartmentalized.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

A total of 396,380 patients were included, with 47% hospitalized and 16,474 (4%) with an ICU stay.  Over 97% of all patients in the three groups had a primary care physician visit within one year of discharge.   Among all patients with an ICU stay, the incidence of medication discontinuation ranged from 22.8% for antiplatelet/anticoagulant medications to 5.4% for respiratory inhalers. Patients with an ICU stay were 1.48 times more likely to have discontinuation of a statin (95% confidence interval [CI], 1.39-1.57) and 2.31 times more likely to have discontinuation of antiplatelet/anticoagulant medications (95% CI, 2.07-2.57). Compared to controls, the adjusted odds ratio for medication discontinuation after an ICU stay varied from 1.11 for statins (95% CI, 1.05-1.18) to 1.29 for levothyroxine (95% CI, 1.17-1.41). In a preplanned secondary outcome analysis, the risk of death, emergent hospitalization or emergency department visit was significantly increased when statins or antiplatelet/anticoagulant medications were discontinued following hospitalization. The authors concluded that treatment in an ICU places patients at greater risk for unintentional discontinuation of long-term medications.

The high incidence of medication discontinuation in this study may not be caused solely by acts of omission.  ICU or hospital admission may lead to deliberate discontinuation of chronic medications for a wide variety of reasons.  Nonetheless, the authors selected 5 drug classes that have been associated with adverse consequences when discontinued.  Different levels of care provided during the admission, varying ICU and hospital lengths of stay, and lack of other clinical details may also explain the findings in this study.

An accompanying editorial by Jeremy M. Kahn, MD, MS, and Derek C. Angus, MD, MPH, FCCM, notes that solutions to better administer the complexities of medication management are much needed, and this study highlights the potential threats to patient welfare during transition through different levels of care within the health system.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

Consecutive patients with confirmed or suspected infection, and two or more systemic inflammatory response syndrome criteria, were enrolled. Of the 291 patients assigned to one of two quantitative resuscitation protocols, the median time from triage to initial antibiotic administration was 115 minutes (interquartile range, 65-175).  A multivariate logistic regression model did not reveal any evidence for confounding since adjusted odds ratios were not significantly different from unadjusted odds ratios when multiple independent variables were evaluated. No association was found between in-hospital mortality rates when antibiotics were given within six hours of initial triage in the emergency department (ED). However, patients who received antibiotics after recognition of shock (n = 172) had a higher mortality rate (n = 119, odds ratio 2.35; 95% CI, 1.12-4.53).

The recommendation for administering antibiotics within one hour for severe sepsis and septic shock is based on expert opinion and a previous large retrospective study that demonstrated higher survival rates when antibiotics were given within one hour. In this most recent study, investigators were unable to show increased mortality rates for each hour’s delay to administration of antibiotics after emergency department triage; although, when antibiotics were delayed for patients in shock, mortality rates increased. These findings, which showed no difference in mortality rates when antibiotics were delayed after triage (but not shock), may be partly attributed to a relatively small sample size, the fact that each participating institution had robust resuscitation protocols, and a lower overall mortality rate for septic shock than described in previous studies. The findings in this study may also be credited to the effect of an early goal-directed resuscitation protocol, in which antibiotics are one of several crucial elements of current evidence-based support for patients with severe sepsis and septic shock.
Jing Tao, MD, senior resident in the Department of Anesthesiology at the University of Maryland, contributed to this installment of Concise Critical Appraisal.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

1. Dellinger RP, et al.  Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008.  Crit Care Med 2008; 36: 296-327.
2. Jones AE, et al.  Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: A randomized clinical trial.  JAMA 2010; 303: 739-746.
3. Kumar A, et al.  Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.  Crit Care Med 2006; 34: 1589-1596.

Forty-two mechanically ventilated patients in a mixed medical-surgical ICU were prospectively enrolled in this blinded, non-randomized trial. Enrollment in the trial was triggered by the need for thoracic computed tomography (CT), which was used as the gold standard for all patients.  All patients had a CXR, CT, and ultrasound examination. The primary author performed all ultrasound exams and was blinded to the CT findings; the exams were not reviewed by a blinded radiologist.

Ultrasound had superior sensitivity and specificity for the detection of consolidation, pleural effusion, and interstitial edema when compared to CXR. A positive likelihood ratio of 14.29 was reported for detecting consolidation with ultrasound (100% sensitivity, 78% specificity); a likelihood ratio of 13.4 was reported for diagnosing interstitial edema (94% sensitivity, 93% specificity). Alternatively, CXR had a sensitivity of only 38% for consolidation and a sensitivity of 46% for interstitial edema. Ultrasound identified six of eight pneumothoraces with a sensitivity of 75%. None of the pneumothoraces were clinically significant. The authors concluded that lung ultrasound demonstrated superior diagnostic performance compared to CXR, and may be considered as an alternative to computed tomography (CT) in some instances.

Since patient selection was based on a predefined need for a CT, the study was subject to considerable verification bias.  Moreover, all exams were performed by one investigator, and none of the exams were confirmed by a blinded radiologist or second ultrasonographer.  All patients were positioned laterally for the exam, and this positioning might have changed the localization for some abnormalities, and may not always be feasible or safe for many ICU patients in other settings.  The case mix, plagued by the limitation of a small sample size, was heavily skewed towards trauma patients (n=11) and patients with sepsis (n=18), further limiting the generalizability across diverse ICU patient populations.

Notwithstanding the significant limitations, this work stands as yet another example of how ultrasound might be used in the ICU as a safer and cheaper alternative to other diagnostic modalities. Training, equipment acquisition and quality control remain significant concerns that must be addressed before ultrasound can be reliably used in place of an established “gold standard” such as chest CT.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

After a limited search involving PubMed, EMBASE, and the Cochrane registry, six randomized controlled trials were identified. These studies reported the type of arrest (in-hospital versus out-of-hospital), a comparison group (placebo or another drug) and survival. Primary outcomes were return of spontaneous circulation (ROSC), 30-day survival and functional neurological status as defined by a Glasgow-Pittsburgh Cerebral Performance Category (CPC) score of 1 or 2. The authors did not report so-called gray literature (i.e., research not found through conventional publishing channels), abstracts from recent conferences, references from included studies, or other bibliographic databases. Moreover, formal assessments for risk of bias were not described in the methods section of the paper. Validity criteria were unclear, but the authors reported assessing methodological quality in an eSupplement that was not available at the time of this appraisal.

Despite moderate to high degrees of heterogeneity (I2 46-71%), the authors completed a meta-analysis. Neither ROSC, long-term survival or favorable neurological outcomes were statistically significantly associated with the use of vasopressin. In a subgroup analysis of studies reporting long-term survival after asystole and administration of the drug within 20 minutes of arrest, vasopressin was associated with higher odds of survival (odds ratio [OR] 2.84; 95% confidence interval [CI] 1.19, 6.79; p=0.02). ROSC was also higher in two studies reporting the use of vasopressin in asystole when given within 20 minutes of arrest (OR 1.70; 95% CI 1.17, 2.47; p=0.005).

To date, none of the four core advanced cardiac life support drugs (lidocaine, amiodarone, epinephrine, vasopressin) have been shown to affect long-term survival, even though ROSC rates may be increased in both human and animal models. Although these drugs have not been shown to advance long-term outcomes, most experts believe there is little harm and potential short-term benefits. Notwithstanding the methodological limitations of this meta-analysis, the results support a possible role for vasopressin in asystole when the drug is given promptly as a one-time substitution for epinephrine. Whether there is enough equipoise to pursue this finding with additional placebo-controlled studies remains to be seen.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

Dr. Weil received his medical degree from the State University of New York and completed training in cardiology and cardiovascular physiology at the Mayo Clinic in Rochester, Minnesota. His research focused on the mechanism of shock, the hemodynamic effects of endotoxin, and the relationship of endotoxic shock with other types of shock. His contributions are too numerous to name, so I will mention but a few of them.

He established the first “shock ward” to provide continuous monitoring of seriously ill cardiology and postsurgical patients. He also developed a cardiac catheterization laboratory and monitoring facility for surgical patients, as well as a clinical physiology unit for hemodynamic and metabolic patient studies. Dr. Weil’s research further advanced the care of critically ill patients with the introduction of computer techniques for patient monitoring. His inquisitive mind never stopped wondering how he could make the lives of his patients better.

Dr. Weil was an innovator and a great leader in medicine. His dream of saving lives advanced the field of critical care. Dr. Weil was one of the critical care titans, and he will be deeply missed.

Sincerely,

Pamela A. Lipsett, MD, MHPE, FCCM
President

A total of 4,640 patients underwent randomization: 2,328 in the late PN group, and 2,312 in the early PN group. Total energy levels were not statistically different between groups by day 15 of the study. Both groups had similar rates of ICU and hospital mortality at 90 days. Patients in the late PN group had a median ICU length of stay that was 1 day shorter (hazard ratio, 1.06; 95% confidence interval, 1.00 to 1.13; P=0.04), and a median hospital length of stay that was 2 days shorter. The late PN group also had fewer infections, shorter duration of mechanical ventilation and shorter duration for renal-replacement therapy. Healthcare costs were decreased for the late PN group by approximately $1,600 USD per patient. The late PN group had higher levels of inflammation, as assessed by C-reactive protein levels.

Previous observational trials demonstrated improved outcomes for critically ill patients who reached nutritional targets earlier with PN. In this study, early initiation of PN was not beneficial when compared to late initiation. Although the effects of other co-interventions (such as immunonutrition) were not studied, all primary and secondary endpoints indicated that early PN was not beneficial, and that adherence to North American PN guidelines, which advocate late PN initiation in ICU patients, is likely more judicious.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

The US group had a statistically significantly higher success rate (100% vs. 87.5%, p< 0.05), shorter access time (26.8 minutes vs. 44.8 minutes, p< 0.05), and fewer complications. There were no pneumothoraces or hemothoraces in the US group; the number needed to treat to prevent one pneumothorax or inadvertent arterial puncture was 20 (0% in US group vs. 4.9% in landmark group). The mean number of attempts was lower in the US group (1.1 ± .3 vs. 1.9 ± .7). Catheter misplacement was not significantly different between the two groups.

Limitations to this work include a limited sample size and no description of a priori power calculations for each of the outcome measures. The incidence of pneumothorax with SCV cannulation using landmark techniques varies in the literature and was observed to be 4.9% in this study, which many would consider to be moderately high. The US approach may have been associated with fewer complications since the insertion site was more lateral, and the axillary vein, rather than the SCV, might have been the initial insertion site for some of the patients. Although all cannulations were performed by physicians with at least six years of ICU experience, US-guided SCV cannulation was deemed to be technically difficult as assessed by a postprocedural semiquantitative scale.

While US-guided internal jugular cannulation has become a standard of care in many ICUs, US-guided SCV cannulation has yet to be validated and accepted as a routine technique. Results of this study suggest that US-guided SCV cannulation is feasible (although technically difficult), and it may help prevent complications, including pneumothorax.

Concise Critical Appraisal is a regular feature in the Society of Critical Care Medicine’s eNewsletter. Authored by Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

Authors employed a stepped-wedge design for 6,290 adult patients admitted to seven ICUs (three medical, three surgical and one mixed cardiovascular) between April 26, 2005, and September 30, 2007. The primary outcome was adjusted hospital mortality. Other outcomes included shorter hospital and ICU lengths of stay, best practice adherence and lower complication rates.

The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the pre-intervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio, 0.40 [95% CI, 0.31-0.52]). Telemedicine was associated with lower mortality rates both within ICUs over time and across ICUs during the same periods, emphasizing that the results could not be solely attributed to time trends. The tele-ICU intervention period, compared with the pre-intervention period, was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis, prevention of stress ulcers, cardiovascular protection and prevention of ventilator-associated pneumonia. Lower rates of ventilator-associated pneumonia, catheter-related bloodstream infections and shorter hospital lengths of stay were also reported in the tele-ICU group. Telemedicine physicians worked in conjunction with local clinicians to enforce daily goals, respond to bedside alarms and review care and adherence to evidence-based practices.

Limitations worth noting include the non-randomized, unblinded nature of the study design, as well as the fact that the study was conducted in a single academic medical center. The positive results from this study, as opposed to those of previous tele-ICU studies, may indicate a higher degree of mandatory collaboration between on-site intensivists and telemedicine physicians; participation was mandatory in all ICUs included in this study, and on-site clinical staff could not “opt out.” Additionally, all of the telemedicine physicians in the study worked in the same ICUs; hence, these results may not be replicated in settings where the telemedicine unit and hospital unit do not share ICU providers. Moreover, these results may not be replicated in hospitals that do not have existing robust quality improvement processes.

This studyby Lilly and colleagues examined a tele-ICU closely linked to specific quality improvement activities, providing the first convincing evidence that ICU telemedicine can be an effective complement to bedside care in some settings. Future large randomized multi-institutional studies will be required to confirm the external generalizability of these results.

Dragos M. Galusca, MD, a fellow at Johns Hopkins Hospital, contributed to this installment of Concise Critical Appraisal.

Concise Critical Appraisal is a regular feature in the Society of Critical Care Medicine’s eNewsletter. Authored by Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

The Advocacy Committee is charged with keeping SCCM Council and membership informed of policy issues that may influence critical care medicine providers and by educating policymakers, government agency leaders, healthcare providers, business groups, payors, the public, and other interested and concerned parties about the mission of SCCM and issues of importance to the care of critically ill patients. This blog is another tool to provide information on issues that affect the care of the critically ill and to provide education related to those issues.

In the ongoing effort to improve quality care for hospitalized patients and to align Medicare payments with quality outcomes, the Centers for Medicare and Medicaid Services (CMS) have released their latest proposed list of value-based purchasing (VBP) quality measures, to become effective in FY 2013. The proposed measures include 17 processes of care measures and eight Hospital Consumer Assessment of Healthcare Providers & Systems Survey (HCAHPS) measures. Additionally in FY 2014, CMS proposes to adopt three mortality measures, eight HAC measures, nine AHRQ measures and six HAI measures.  Find a complete description of the proposed list of VBP quality measures for FY 2013 and FY 2014.

CMS will accept public comments on the proposed rule through March 8, 2011, and expects to respond to them in a final VBP rule in 2011.  Additionally, The Joint Commission is seeking input on two newly proposed NPSGs for its Hospital Accreditation program addressing two HAIs: VAP and CAUTI. These standards for consideration are a result of The Joint Commission’s involvement with the HAI-Allied Task Force, which seeks strategies to prevent the six highest morbidity and mortality HAIs across the continuum of care. SCCM is reviewing the proposal. Public comment is due to The Joint Commission by January 27, 2011.

For the first time this year, the MCCKAP exam will be offered online, providing almost immediate feedback to participants on their level of critical care knowledge. In addition, since the exam is now paperless, mailing and administrative costs are reduced. Programs will still receive the same advanced statistical analysis of their fellows as a group, but this year that comprehensive feedback will be provided more quickly.  The 2010 exam will take place March 1-5 and sales have been comparable to prior years.  We are preparing to provide extra support this year to handle technical and other calls which may be caused by the transition to the online platform.

The HHS sponsored Critical Care Cross-Training for Hospital-Based non-ICU Health Care Professionals (CCXT) Course is being received very positively.  Since the initial posting of the course in December 2009, 793 healthcare professionals have registered for the course.  This number represents 582 individuals from the US States, District of Columbia and Territories and 207 international participants from 45 countries. The majority of participants are physicians and nurses who practice in academic medical centers or community hospitals.  Even as H1N1 and seasonal influenza incidence decline, interest in the course continues with approximately 50 participants registering so far this February.  Ongoing monitoring of the course reveals that a number of participants complete the course over an extended period of time.  Participants often complete the skill station modules (mechanical ventilation) early in their course progress and then return to complete the didactic modules.

Based on customer and committee feedback, we continue to make changes to the adult and pediatric resident education program (RICU).  While minor corrections and bug fixes have occurred since Congress, an improved test reporting system is planned for release this summer.  A conference call with the committee leadership, Council staff liaison, support staff and me is planned in March to further work on developing this important online learning tool.  Look for major improvements in the next iteration of the program planned for this summer.

The web-based, peer-review platform for Critical Care Medicine and Pediatric Critical Care Medicineis transitioning from ScholarOne to Editorial Manager.  The conversion began in January 2010 and full integration is expected by July 2010. Currently, all new journal submissions are being entered into Editorial Manager while revisions of 2009 submissions are being maintained through completion in ScholarOne. Use of Editorial Manager will facilitate post-acceptance production processes, reducing costs and labor needs and will allow for eventual single sign-on through MySCCM. 

In addition to all of this recent activity, the new version of LearnICU (a more comprehensive and interactive learning website) is in development.  I had the plesaure of attending several design meetings and the plans look most impressive and comprehensive.  The Society’s Accreditation and Online Learning Committee is already gearing up to provide topic editors and staff are working on new online learning activities which will be incorporated into the new site.  Most notably all presentations from meetings will be made available here, as well as the ability to take a variety of online self-assessment exams.

These are just some of the highlights of SCCM’s growing online capabilities and I’m pleased to be a part of this exciting activity.