Critical Care Reviews Newsletter 338 3rd June 2018

Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.  “The highlights of this week’s edition are the publication of the protocols and statistical analyses of the ICU-ROX and TARGET trials, two of the major multi-centre studies being discussed at #CCR19.  The are also many other great articles to read, including observational studies on ICU admissions for sepsis or pneumonia in Australia and New Zealand in 2017, outcomes in patients perceived as receiving excessive care, and community-acquired sepsis in European pediatric intensive care units; guidelines on Takotsubo syndrome, & cardiac and vascular surgery–associated acute kidney injury; narrative reviews on acute heart failure, the evidence base for fluid resuscitation, and mechanical CPR; plus a series of three editorials arguing the place of the Swan–Ganz catheter in contemporary critical care.”
The full text of newsletter 338 can be found via this link

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A Randomized Trial of a Family-Support Intervention in Intensive Care Units.

This article was published online by the New England Journal of Medicine during May 2018.
Background:  Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences.
Methods:  We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates’ mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates’ mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.
Results:   A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates’ mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates’ mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).
Conclusions:  Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates’ burden of psychological symptoms, but the surrogates’ ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care.
The print copy of this issue of “The New England Journal of Medicine” is available in the Healthcare Library on D Level of Rotherham General Hospital.

Predicting Intensive Care Unit Readmission with Machine Learning Using Electronic Health Record Data

This article by Rojas and colleagues was published in Annals of the American Thoracic Society during May 2018.
Rationale:  Patients transferred from the intensive care unit (ICU) to the wards who are later readmitted to the ICU have increased length of stay, healthcare expenditure, and mortality compared to those who are never readmitted. Improving risk-stratification for patients transferred to the wards could have important benefits for critically ill hospitalized patients.
Objective:  We aimed to use a machine-learning technique to derive and validate an ICU readmission prediction model with variables available in the electronic health record (EHR) in real-time and compare it to previously published algorithms.
Methods:  This observational cohort study was conducted at an academic hospital in the United States with approximately 600 inpatient beds. A total of 24,885 ICU transfers to the wards were included, with 14,962 transfers (60%) in the training cohort and 9,923 transfers (40%) in the internal validation cohort. Patient characteristics, nursing assessments, ICD-9 codes from prior admissions, medications, ICU interventions, diagnostic tests, vital signs, and laboratory results were extracted from the EHR and used as predictor variables in a gradient boosted machine model. Accuracy for predicting ICU readmission was compared to the Stability and Workload Index for Transfer (SWIFT) score and Modified Early Warning Score (MEWS) in the internal validation cohort and also externally using the Medical Information Mart for Intensive Care (MIMIC-III) database (n=42,303 ICU transfers).
Results:  Eleven percent (2,834) of discharges to the wards were later readmitted to the ICU. The machine-learning derived model had significantly better performance (AUC 0.76) than either the SWIFT score (AUC 0.65), or MEWS (AUC 0.58); p value < 0.0001 for all comparisons. At a specificity of 95%, the derived model had a sensitivity of 28% compared to 15% for SWIFT score and 7% for the MEWS. Accuracy improvements with the derived model over MEWS and SWIFT were similar in the MIMIC III cohort.
Conclusions:  A machine learning approach to predicting ICU readmission was significantly more accurate than previously published algorithms in both our internal validation and the MIMIC-III cohort. Implementation of this approach could target patients who may benefit from additional time in the ICU or more frequent monitoring after transfer to the hospital ward.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 337 27th May 2018

Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.  “The big news this week is the long-awaited results of the EOLIA trial, investigating ECMO in severe ARDS.  The other highlights of this edition are randomised controlled trials on family-support critcal care reviewsin the ICU & discontinuation order of vasopressors in the management of septic shock; systematic reviews and meta analyses on aldosterone antagonists in STEMI without heart failure & REBOA for exsanguination; and observational studies on withholding or withdrawing life-sustaining therapies in older adults in ICU & qSOAF in low- and middle-income countries.”

The full text of newsletter 337 can be found via this link

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models

This article by Toft-Petersen and colleagues was published on-line in Anaesthesia in May 2018.
In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units.
The physical copy of Anaesthesia is available in the Healthcare Library on Level D of Rotherham Hospital.  However, this article has not yet been published in a physical issue and is only available on-line.  The full text of the article can be accessed by personal subscribers using this link.

Implementing an educational program to improve critical care nurses’ enteral nutritional support

This research by Kim and Chang was published in “Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses” in May 2018.
Background:  Although international nutrition societies recommend enteral nutrition guidelines for patients in intensive care units (ICUs), large gaps exist between these recommendations and actual clinical practice. Education programs designed to improve nurses’ knowledge about enteral nutrition are therefore required. In Korea, there are no educational intervention studies about evidence-based guidelines of enteral nutrition for critically ill patients.
Objectives:  We aimed to evaluate the effects of an education program to improve critical care nurses’ perceptions, knowledge, and practices towards providing enteral nutritional support for ICU patients.
Methods:  A quasi-experimental, one-group study with a pre- and post-test design was conducted from March to April 2015. Nurses (N = 205) were recruited from nine ICUs from four tertiary hospitals in South Korea. The education program comprised two sessions of didactic lectures. Data were collected before (pre-test) and 1 month after (post-test) the education program using questionnaires that addressed nurses’ perceptions, knowledge, and practices relating to providing enteral nutritional support for ICU patients.
Results:  After the program, nurses showed a significant improvement in their perceptions and knowledge of enteral nutrition for ICU patients. There was a significant improvement in inspecting nostrils daily, flushing the feeding tube before administration, providing medication that needs to be crushed correctly, changing feeding sets, and adjusting feeding schedules.
Conclusions:  The findings indicate that an enteral nutrition education program could be an effective strategy to increase critical care nurses’ support for the critically ill. This education program can be incorporated into hospital education or in-service training for critical care nurses to strengthen their perceptions and knowledge of nutritional support in the ICU. This may improve the clinical outcomes of ICU patients.
To access the full text of these articles via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 336 20th May 2018

critcal care reviewsCritical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.  “The highlights of this edition are randomised controlled trials comparing bougie with stylet for first-pass emergency intubation, tranexamic acid for hyperacute primary intracerebral haemorrhage, and standardized handoff curriculum for ICU handover; systematic reviews on low-dose corticosteroids for septic shock, and therapeutic hypothermia for patients following traumatic brain injury; and observational studies on sedation intensity, withholding or withdrawing of life-sustaining therapy in older adults, and frailty and failure to rescue after low-risk and high-risk inpatient surgery.”  The full text of newsletter 336 can be found via this link