Family-Support Intervention in ICUs Increased Patient Comfort and Reduced Costs

MedicalResearch.com Interview with:

Douglas B. White, M.D., M.A.S. Director of the Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center’s Program on  Ethics and Decision Making in  Department of Critical Care Medicine University of Pittsburgh 

Dr. White

Douglas B. White, M.D., M.A.S.
Director of the Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center’s Program on
Ethics and Decision Making in  Department of Critical Care Medicine
University of Pittsburgh 

MedicalResearch.com: What is the background for this study? 

Response: We set out to test the effectiveness of PARTNER (PAiring Re-engineered ICU Teams with Nurse-driven Emotional Support and Relationship-building). PARTNER is delivered by the interprofessional team in the ICU, consisting of nurses, physicians, spiritual care providers, social workers and others who play a part in patient care. The program is overseen by nurse-leaders in each ICU who receive 12 hours of advanced communication skills training to support families. The nurses meet with the families daily and arrange interdisciplinary clinician-family meetings within 48 hours of a patient coming to the ICU. A quality improvement specialist helps to incorporate the family support intervention into the clinicians’ workflow.

PARTNER was rolled out at five UPMC ICUs with different patient populations and staffing. It was implemented in a staggered fashion so that every participating ICU would eventually get PARTNER. Before receiving PARTNER, the ICUs continued their usual methods of supporting families of hospitalized patients. None of the ICUs had a set approach to family communication or required family meetings at regular intervals before receiving PARTNER. A total of 1,420 adult patients were enrolled in the trial, and 1,106 of these patients’ family members agreed to be a part of the study and its six-month follow-up surveys. The patients were very sick, with about 60 percent dying within six months of hospitalization and less than 1 percent living independently at home at that point.

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Reducing Opioids Near End of Hospital Stay May Limit Outpatient Use

MedicalResearch.com Interview with:

Jason Kennedy, MS Research project manager Department of Critical Care Medicine University of Pittsburgh

Jason Kennedy

Jason Kennedy, MS
Research project manager
Department of Critical Care Medicine
University of Pittsburgh

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Most previous studies of opioid use in health care have focused on the outpatient setting. But opioids are often introduced during hospitalization. That’s something clinicians can control, so we looked at inpatient prescription of these drugs to identify targets that may reduce opioid use once patients are out of the hospital.

We analyzed the medical records of 357,413 non-obstetrical adults hospitalized between 2010 and 2014 at 12 University of Pittsburgh Medical Center (UPMC) hospitals in southwestern Pennsylvania. The region is one of the areas of the country where opioid addiction is a major public health problem. We focused on the 192,240 patients who had not received an opioid in the year prior to their hospitalization – otherwise known as “opioid naïve” patients.

Nearly half (48 percent) of these patients received an opioid while hospitalized.  After discharge, those patients receiving hospital opioids were more than twice as likely to report outpatient opioid use within 90-days (8.4 percent vs. 4.1 percent). Patients who receive an opioid for most of their hospital stay and patients who are still taking an opioid within 12 hours of being discharged from the hospital appear more likely to fill a prescription for opioids within 90 days of leaving the hospital.  Continue reading

Pneumonia Patients on Ventilators May Benefit from New Ceftolozane/Tazobactam Antibiotics

MedicalResearch.com Interview with:

Dr. Elizabeth Rhee MD Director, Infectious Disease Clinical Research at Merck

Dr. Rhee

Dr. Elizabeth Rhee MD
Director, Infectious Disease Clinical Research Merck

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: High-risk patients, such as the critically ill, with suspected bacterial infections require prompt treatment with appropriate empiric therapy to improve survival. Given the high prevalence of multidrug-resistant (MDR) Pseudomonas aeruginosa in the ICU setting, new safe and broadly effective treatment options are needed for critically ill patients requiring antipseudomonal agents.

Ceftolozane/tazobactam (C/T) is an antipseudomonal cephalosporin/beta-lactamase inhibitor combination with broad in vitro activity against Gram-negative pathogens, including MDR P. aeruginosa and many extended-spectrum beta-lactamase (ESBL) producers. It is FDA approved for complicated intra-abdominal and urinary tract infections in adults at 1.5g (1g/0.5g) q8h. C/T is currently being studied at 3g (2g/1g) q8h, for the treatment of ventilated nosocomial pneumonia, in the ASPECT-NP Phase 3 trial.

This Phase 1 pharmacokinetic (PK) study investigated the penetration of a 3g dose of C/T in the epithelial lining fluid (ELF) of ventilated patients with proven or suspected pneumonia. This is the dose and patient population being evaluated in ASPECT-NP. ELF lines the alveoli, and investigators took samples in a group of 26 patients to see what amount of C/T was in the lung and what was circulating in the plasma during the dosing intervals.

In mechanically ventilated critically ill patients, the 3g dose of C/T achieved ≥50% lung penetration (relative to free plasma) and sustained levels in ELF above the target concentrations for the entire dosing interval. These findings support the 3g dose that is included in the ASPECT-NP Phase 3 trial.  Continue reading

Dexmedetomidine Reduced Risk of Delirium

MedicalResearch.com Interview with:

Yoanna Skrobik MD FRCP(c) MSc McGill University Health Centre Canada

Dr. Skrobik

Yoanna Skrobik MD FRCP(c) MSc
McGill University Health Centre
Canada

MedicalResearch.com: What is the background for this study?

Response: My clinical research interests revolve around critical care analgesia, sedation, and delirium. I validated the first delirium screening tool in mechanically ventilated ICU patients (published in 2001), described ICU delirium risk factors, associated outcomes, compared treatment modalities and described pharmacological exposure for the disorder. I was invited to participate in the 2013 Society of Critical Care Medicine Pain, Anxiety, and Delirium management guidelines, and served as the vice-chair for the recently completed Pain, Agitation, Delirium, Early Mobility and Sleep upcoming guidelines.

Until this study, no pharmacological prevention or intervention could convincingly be considered effective in ICU delirium. Although Haloperidol and other antipsychotics are frequently used in practice, their lack of efficacy and possible disadvantages are increasingly being understood.

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Balanced IV Fluids Can Reduce Kidney Damage and Death in Critically Ill Patients

MedicalResearch.com Interview with:

Todd W. Rice, MD, MSc Associate Professor of Medicine Director, Vanderbilt University Hospital Medical Intensive Care Unit Division of Allergy, Pulmonary, and Critical Care Medicine Nashville, TN  

Dr. Rice

Todd W. Rice, MD, MSc
Associate Professor of Medicine
Director, Vanderbilt University Hospital Medical Intensive Care Unit
Division of Allergy, Pulmonary, and Critical Care Medicine
Nashville, TN  

MedicalResearch.com: What is the background for this study?

Response: Our study (called the SMART study) evaluates the effects of different types of intravenous fluids used in practice in critically ill patients.  It is very similar to the companion study (called the SALT-ED study and published in the same issue) which compares the effects of different types of intravenous fluids on non-critically ill patients admitted to the hospital.  Saline is the most commonly used intravenous fluid in critically ill patients.  It contains higher levels of sodium and chloride than are present in the human blood.  Balanced fluids contain levels of sodium and chloride closer to those seen in human blood.

Large observational studies and studies in animals have suggested that the higher sodium and chloride content in saline may cause or worsen damage to the kidney or cause death.  Only a few large studies have been done in humans and the results are a bit inconclusive.

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Standardization and Collaboration Reduced Use of Costly CRRT Treatment for Critically Ill Patients

MedicalResearch.com Interview with:

Rodrigo F. Alban, MD FACS Associate Director Performance Improvement Associate Residency Program Director NSQIP Surgeon Champion Department of Surgery Cedars-Sinai Medical Center

Dr. Alban

Rodrigo F. Alban, MD FACS
Associate Director Performance Improvement
Associate Residency Program Director
NSQIP Surgeon Champion
Department of Surgery
Cedars-Sinai Medical Center 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Continuous Renal Replacement Therapy (CRRT) is a modality of hemodialysis commonly used to manage renal failure in critically ill patients who have significant hemodynamic compromise.  However, it is also resource-intensive and costly and its usage is highly variable and lacks standardization.

Our institution organized a multidisciplinary task force to target high value care in critically ill patients requiring CRRT by standardizing its process flow, promoting cross-disciplinary discussions with patients and family members, and increasing visibility/awareness of CRRT use.  After our interventions, the mean duration of CRRT decreased by 11.3% from 7.43 to 6.59 days per patient.  We also saw a 9.8% decrease in the mean direct cost of CRRT from $11642 to $10506 per patient.  Finally, we also saw a decrease in the proportion of patients expiring on CRRT, and an increase in the proportion of patients transitioning to comfort care.

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Study Finds No Benefit To Prophylactic Haldol For Delirium in ICU

MedicalResearch.com Interview with:
“hospital.” by Bethany Satterfield is licensed under CC BY 2.0
Mark van den Boogaard, PhD, RN, CCRN
Assistant Professor
Department of Intensive Care Medicine
Radboud University Medical Center
Nijmegen Netherlands 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response:  Delirium is affecting many of our intensive care unit (ICU) patients which is impacting their recovery on the short-term as well as on the long-term. Therefore we were very interested to investigate if the use prophylactic haloperidol would be beneficial for the ICU patients. Especially because there were indications that it would be effective in ICU delirium prevention and also because this drug is being used in daily practice to prevent ICU delirium although there is no clear evidence. The overall finding of our large-scale well designed study is that we didn’t find any beneficial effect of prophylactic haloperidol in ICU patients. Moreover, this finding is very consistent over all groups of patients.  Continue reading

Resistance to Carbapenem Antibiotics Doubled in Intensive Care Units

MedicalResearch.com Interview with:

Eilish McCann, PhD</strong> Director, Outcomes Research (Center for Observational and Real-World Evidence) Merck

Dr. Eilish McCann

Eilish McCann, PhD
Director, Outcomes Research (Center for Observational and Real-World Evidence)
Merck

MedicalResearch.com: What is the background for this study?

Response: One of the most pressing challenges facing medicine today is the emergence of bacterial resistance to antibiotics. One area of high concern is the increasing prevalence of resistance to powerful antibiotics like carbapenems, as patients with infections due to carbapenem-resistant bacteria have very few alternate effective treatment options.

In this study we used real-world data from a Becton, Dickinson and Company electronic research data set to analyze over 140,000 bacterial isolates from patients at 342 hospitals across the United States, so that we could investigate where the burden of carbapenem resistance is most acute. Importantly analysis of real-world data in this way allows us to gain insights from a large number of hospitals, giving a broad and nationally representative picture of the resistance burden.

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Risk Factors for Unplanned Transfer to the ICU after ED Admission

MedicalResearch.com Interview with:
Marleen Boerma MD
Department of Emergency Medicine
Elisabeth-Tweesteden Hospital
Tilburg, The Netherlands

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Unplanned Intensive Care Unit (ICU) admission has been used as a surrogate marker of adverse events, and is used by the Australian Council of Healthcare Accreditation as a reportable quality indicator. If we can identify independent variables predicting deterioration which require ICU transfer within 24 hours after emergency department (ED) admission, direct ICU admission should be considered. This may improve patient safety and reduce adverse events by appropriate disposition of patients presenting to the ED.

This study shows that there were significantly more hypercapnia patients in the ICU admission group (n=17) compared to the non-ICU group (n=5)(p=0.028). There were significantly greater rates of tachypnea in septic patients (p=0.022) and low oxygen saturation for patients with pneumonia (p=0.045). The level of documentation of respiratory rate was poor.

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In-Bed Cycling Feasible for ICU Patients on Ventilation

MedicalResearch.com Interview with:

Michelle Kho, PT, PhD</strong> Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation Assistant Professor School of Rehabilitation Science McMaster University

Dr. Michelle Kho

Michelle Kho, PT, PhD
Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation
Assistant Professor
School of Rehabilitation Science
McMaster University

MedicalResearch.com: What is the background for this study?

Response: Patients who survive the ICU are at risk for muscle weakness and can experience physical functional disability lasting 5 to 8 years after the ICU. From a study conducted in Belgium, patients who were randomized to receive cycling after being in ICU for 2 weeks walked farther at ICU discharge than those who did not. Other research supported physiotherapy starting within days of starting mechanical ventilation to improve functional outcomes. Our CYCLE research program combines these 2 concepts – Can we start cycling very early in a patient’s ICU stay, and will this improve functional outcomes post-ICU?

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Expensive Intensive Care Units Often Overutilized

MedicalResearch.com Interview with:

Dr. Dong W. Chang, MD MS</strong> Division of Respiratory and Critical Care Physiology and Medicine Los Angeles Biomed Research Institute at Harbor-University of California Los Angeles, Medical Center Torrance California

Dr. Dong Chang

Dr. Dong W. Chang, MD MS
Division of Respiratory and Critical Care Physiology and Medicine
Los Angeles Biomed Research Institute at Harbor-University of California
Los Angeles, Medical Center
Torrance California

MedicalResearch.com: What is the background for this study?

Response: The study was based on our overall impression that ICU care is often delivered to patients who are unlikely to derive long-term benefit (based on their co-morbidities/severity of illness, etc.). However, what surprised us was the magnitude of this problem. Our study found more than half the patients in ICU at a major metropolitan acute-care hospital could have been cared for in less expensive and invasive settings.

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Mechanical Ventilation Doubles For Persons With Advanced Dementia

MedicalResearch.com Interview with:

Joan M. Teno, MD, MS Department of Gerontology and Geriatrics, Cambia Palliative Care Center of Excellence University of Washington Medicine Seattle, Washington

Dr. Joan Teno

Joan M. Teno, MD, MS
Department of Gerontology and Geriatrics,
Cambia Palliative Care Center of Excellence
University of Washington Medicine
Seattle, Washington

MedicalResearch.com: What is the background for this study?

Response: An important challenge for our health care system is effectively caring for persons that high-need, high-cost — persons afflicted with advanced dementia and severe functional impairment are among these persons, with substantial need and if hospitalized in the ICU and mechanically ventilated are high cost patients, who are unlikely to benefit from this level of care and our best evidence suggest the vast majority of persons would not want this care. In a previous study, we interviewed families of advance dementia with 96% starting the goals of care are to focus comfort. Mechanical ventilation in some cases may be life saving, but in cases such as those with advanced dementia and severe functional impairment, they may result in suffering without an improvement in survival.

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Extubating Patients From Ventilators At Night Linked To Higher Mortality

MedicalResearch.com Interview with:

Hayley B. Gershengorn, MD Associate Professor, Albert Einstein College of Medicine Attending Physician, Montefiore Medical Center Bronx, NY 10467

Dr. Hayley Gershengorn

Hayley B. Gershengorn, MD
Associate Professor, Albert Einstein College of Medicine
Attending Physician, Montefiore Medical Center
Bronx, NY 10467

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Little was previously known about the timing of extubations for mechanically ventilated intensive care unit patients or whether extubating patients overnight is safe. In this retrospective cohort study of mechanically ventilated intensive care unit adult patients in the United States, 20.1% were extubated overnight. Overnight extubation was associated with significantly higher hospital mortality.

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Antibacterial Gloves May Reduce Cross Contamination In ICU Setting

Ojan Assadian, M.D., DTMH Professor for Skin Integrity and Infection Prevention Institute for Skin Integrity and Infection Prevention School of Human & Health Sciences University of Huddersfield Queensgate, Huddersfield UKMedicalResearch.com Interview with:
Ojan Assadian, M.D., DTMH
Professor for Skin Integrity and Infection Prevention
Institute for Skin Integrity and Infection Prevention
School of Human & Health Sciences
University of Huddersfield
Queensgate, Huddersfield UK

MedicalResearch: What is the background for this study? What are the main findings?

Prof. Assadian: Although medical gloves serve as an important mechanical barrier to prevent healthcare workers’ hands from getting contaminated with potentially pathogenic microorganisms, their inappropriate and incorrect use may support microbial transmission, eventually resulting in indirect horizontal cross-contamination of other patients.

We conducted a clinical study designed to determine the efficacy of a newly developed synthetic antibacterial nitrile medical glove coated with an antiseptic, polyhexamethylen-biguanid hydrochloride (PHMB), on its external surface, and compared this antibacterial glove to an identical non-antibacterial glove in reducing surface contamination after common patient care measures in an intensive care unit.

We found significantly lower numbers of bacteria on surfaces after performing typical clinical activities such as intravenous fluid handling, oral toilet, or physiotherapy, if touched with antibacterial gloves.

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Benzodiazepines May Adversely Affect ICU Patients On Ventilators

Nick Lonardo, PharmD Pharmacy, Clinical Coordinator Department of Pharmacy Services Salt Lake City, Utah 84132MedicalResearch.com Interview with:
Nick Lonardo, PharmD
Pharmacy, Clinical Coordinator
Department of Pharmacy Services
Salt Lake City, Utah 84132

Medical Research: What are the main findings of the study?

Dr. Lonardo: To our knowledge, this is the first, large, multicenter, retrospective cohort study to show that continuous infusion benzodiazepines are independently associated with increased mortality in mechanically ventilated ICU patients. In addition, benzodiazepines were associated with an increased time of mechanical ventilation and ICU length of stay.

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