Our latest work aims to improve the process of palliative ventilator withdrawal (WMV) in the ICU setting. Distress and patient suffering are common during WMV, yet relatively little research has focused on this topic. Our hope is that our current project will generate needed evidence to inform clinical guidelines.
Observational Study
The first stage of this project characterized the patient experience and provider perspectives in ICUs at both BIDMC and Brigham and Women's Hospital. This observational study enrolled 160 patients, generating data that will aid in determining key factors associated with better symptom management at end of life.
Intervention Development
Modifiable care processes identified in the observational phase of the study were considered in the development of a clinical intervention for palliative ventilator withdrawal.
The intervention development phase also included a comprehensive literature review of evidence guiding the WMV process. Along with the study results, this evidence informed the Comfort Measures Only Time out (CMOT) intervention. A panel of national experts in palliative care, nursing, geriatrics, critical care, and neurocritical care participated in the development process. Similar checklist interventions have been shown to improve surgical outcomes and have been widely adopted in ICUs. However, they have not been used in the setting of palliative ventilator withdrawal.
Feasibility Testing
Our next step in developing the CMOT intervention will be a feasibility study in ICUs at BIDMC. The intervention is designed to be completed by ICU clinicians prior to palliative ventilator withdrawal. This study will assess acceptability and usefulness among ICU participating ICU clinicians. We will also assess levels of patient distress, and we hope to establish a trend toward fewer distressful episodes and better quality of death.
This work is supported by NIH Grant K23AG066929. Read more about this trial here.
Modeling & Outcomes Prediction
Dr. Fehnel also has experience working with large Medicare datasets to assess outcomes in patients receiving neurocritical care. Using the Minimum Data Set, Dr. Fehnel created models of hospital readmission and death following acute ischemic stroke, and worked with collaborator Dr. Vincent Mor to improve the performance of regression models predicting post-stroke 30-day readmission. Other work includes addressing optimum levels of care for acute intracerebral hemorrhage patients and measuring post-acute care outcomes of death and readmission in older subarachnoid hemorrhage patients.
Selected publications:
Walcott BP, Kwon CS, Sheth SA, Fehnel CR, Koffie RM, Asaad WF, et al. Predictors of cranioplasty complications in stroke and trauma patients. J Neurosurg 118:757-762, 2013
Fehnel CR, Ayres AM, Rost NS. Socioeconomic status does not predict cocaine use among ischemic stroke patients: A nested case-control study. JRSM Cardiovasc Dis 3:1-6, 2014
Single Center Case Control Studies
Dr. Fehnel's early work focused on measuring outcomes among stroke and neurocritical care patients. One project examined predictors of cranioplasty infection, a common complication in patients with traumatic brain injuries and severe stroke who receive decompressive surgery to remove part of the skull. A separate study compared ischemic stroke patients with histories of cocaine use to matched controls to detect differences in substance abuse histories.
Our Collaborations
David Y. Hwang, MD, FAAN, FCCM, FNCS
We work with Dr. David Hwang on projects relating to two majors themes: (1) variation in predicting outcomes for patients with severe acute brain injury (SABI); and (2) decision-making and psychosocial support for family members of patients with SABI.
Amit Kumar, MPH, PhD
We also work in collaboration with Dr. Amit Kumar, whose latest project examines racial and Medicare-Medicaid Dual Enrollment disparities in access to quality and intensity of post-acute rehabilitation care and health outcomes in patients with stroke (R01MD017719-01).
