Publications

OBJECTIVES: ICU-acquired weakness affects 50% of critically ill patients. Early mobility programs have been shown to improve functional status at hospital discharge, shorten duration of mechanical ventilation, prevent delirium, and reduce length of stay. Despite these benefits, early mobility is one of the most difficult parts of the ABCDEF bundle to incorporate into practice. This project sought to use a multidisciplinary intervention to improve mobility in the ICU.

DESIGN: Randomized, pragmatic design quality improvement study.

SETTING: Two ICUs at a large academic medical center between July 2023 and February 2024.

PATIENTS: Five hundred seventy-four ICU patients with 271 in the intervention ICU and 276 in the control ICU.

INTERVENTIONS: A multidisciplinary quality improvement initiative focused on increasing education, raising awareness, and addressing barriers.

MEASUREMENTS AND MAIN RESULTS: Our primary outcome was achievement of an intensity-specific mobility goal with nursing staff on a patient-day level. A difference-in-differences model was used to evaluate the association between the mobility intervention and mobility goal achievement. The percentage of daily mobility goals met increased from 48.6% pre-intervention to 65.4% post-intervention in the intervention ICU (p < 0.001). There was no significant difference in daily mobility goal adherence between the intervention and control ICU pre-intervention, but post-intervention, the intervention ICUs adherence was significantly higher (65.4% vs. 43.0%; p < 0.001). After controlling for demographic, clinical, and ICU characteristics, the intervention ICU was 1.96 times more likely to reach the daily mobility goal on a patient-day level (p = 0.017). There was no significant change in ICU length of stay, inpatient length of stay, discharge to home, or in-hospital mortality between patients treated in the intervention vs. control ICU.

CONCLUSIONS: A multidisciplinary quality improvement initiative can improve adherence to daily mobility goals.

BACKGROUND: Limited evidence exists on the additive risk of bradycardia in children with respiratory syncytial virus (RSV) bronchiolitis receiving dexmedetomidine (DMED). We aim to study the association between RSV bronchiolitis and bradycardia during DMED administration.

METHODS: This retrospective cohort study included 273 children under 2 years old admitted to the intensive care units at Boston Children's Hospital with severe bronchiolitis and sedated with DMED from 2009 to 2022. Children were classified as RSV or non-RSV based on confirmed laboratory results. The primary outcome was a composite measure of clinically significant bradycardia, defined as either a heart rate <60 beats per minute or need for medical intervention(s). The secondary outcome was the minimum heart rate after DMED initiation. Subgroup analyses assessed potential effect modification by age, DMED doses, ventilation mode and pre- versus post-COVID-19.

RESULTS: The median (Q1, Q3) age was 8.0 (4.0, 13.7) months. Of the children studied, 85 (31.1%) had RSV bronchiolitis and 170 (62.3%) underwent invasive mechanical ventilation (IMV) at DMED initiation. Clinically significant bradycardia was observed in 71 (26.0%) patients with no significant difference between the RSV and non-RSV cohorts (OR: 1.80; 95% CI: 0.95 to 3.39; p = 0.07). Subgroup analyses showed effect modification with an increased likelihood of clinically significant bradycardia in the RSV group undergoing IMV (OR: 2.99 vs 0.45; Χ2 1=3.6, p=0.04) or admitted before the COVID-19 pandemic (OR: 2.94 vs 0.51; Χ2 1=4.7, p=0.03). The RSV cohort experienced a significantly greater heart rate reduction after DMED initiation (-8.07 bpm; 95% CI: -13.71 to -2.43; p = 0.005).

CONCLUSIONS: Children with RSV bronchiolitis experienced greater heart rate reduction after DMED initiation, with a higher likelihood of clinically significant bradycardia if IMV is in use at DMED initiation or if admitted before the COVID-19 pandemic. Caution is warranted when treating RSV bronchiolitis patients with DMED.

RATIONALE: Barriers to recognizing and treating acute respiratory distress syndrome (ARDS) exist. Prior studies have not investigated whether these barriers differ between academic and community settings, nor whether there were differences in critical care clinicians' reported ARDS management strategies during the COVID-19 pandemic.

OBJECTIVES: Grounded in the Consolidated Framework for Implementation Research, we sought to determine whether there are differences between academic and community critical care clinicians in their team- and ICU-based culture; interprofessional communication; knowledge, attitudes, and perceived barriers to ARDS recognition and management; and their ICU organization and ARDS management associated with the COVID-19 pandemic.

METHODS: Multidisciplinary survey from September, 2020 to April, 2021 of critical care physicians, nurses, advanced practice providers, and respiratory therapists (RTs) in six academic and nine community hospitals across the United States and Canada. Individual item and cumulative domain scores were compared between academic and community clinicians. Statistical adjustment was performed for multiple comparisons.

RESULTS: 1,906 clinicians responded to at least one survey item (53% response rate). Mean (SD) culture scores were higher for community physicians vs. academic physicians (5.3 [1.8] vs. 4.4 [2.0], P<0.001) and community nurses vs. academic nurses (4.4 [2.2] vs. 3.8 [2.1], P=0.007). Academic nurses and RTs had higher knowledge scores compared to community nurses and RTs (P<0.001 for each comparison). Community physicians, nurses, and RTs reported higher mean (SD) number of changes in ICU organization and practice during the COVID-19 pandemic compared to academic clinicians (e.g., community physicians: 13.7 [2.7] changes vs. academic physicians: 11.8 [4.3] changes, P=0.001). While academic physicians, nurses, and RTs were approximately twice as likely to care for ARDS patients daily or several days per week compared to community clinicians, ARDS management, attitudes, and belief in evidence was similar between academic and community clinicians in most respects.

CONCLUSIONS: A large, multidisciplinary survey identified differences between academic and community critical care clinicians' culture and knowledge in the care of ARDS patients. The COVID-19 pandemic had a greater impact on community ICU organization and ARDS management. Multifaceted implementation strategies should target implementation barriers differently in academic and community settings.

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.

BACKGROUND: Emergence agitation is a complex syndrome of altered consciousness after emergence from anesthesia. It can result in injury to patients and staff and is associated with other postoperative complications. Sevoflurane has been associated with emergence agitation, potentially due to low tissue solubility and therefore speed of emergence. Prior meta-analyses comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics did not demonstrate a statistically significant difference. Given the publication of additional relevant studies not included in prior meta-analyses as well as improved diagnosis of emergence agitation, we aim to perform an updated, comprehensive meta-analysis comparing emergence agitation incidence between sevoflurane and isoflurane anesthetics in children.

METHODS: We conducted an updated systematic review and meta-analysis of clinical trials comparing sevoflurane to isoflurane in children <18 years of age, reporting emergence agitation as an outcome, published before July 2023 using databases and registers. Our primary outcome was the incidence of emergence agitation. Secondary outcomes were time to extubation, awakening time, and length of stay in the postanesthetic care unit. We assessed the risk of bias using the Cochrane Risk of Bias tool version 2. We pooled the effect size for the outcomes using the fixed effects model if we had low heterogeneity, otherwise, we used a random-effects model.

RESULTS: Eight randomized controlled trials (523 children) were included in the final analysis. The incidence of emergence agitation after isoflurane was significantly lower compared to sevoflurane (risk ratio: 0.62 (95% CI: [0.46-0.83]; I2  = 40.01%, p < .001)). Time to extubation, awakening times, and postanesthetic care unit duration were not significantly different. The protective effect of isoflurane compared to sevoflurane remained significant in subgroups of patients who received premedication or intraoperative systemic analgesics (risk ratios: (0.48 [0.28-0.82]; I2  = 60.78%, p = .01), (0.52 [0.37-0.75]; I2  = 0.00%, p < .001), respectively).

CONCLUSION: The risk of emergence agitation in children after maintenance anesthesia with sevoflurane is significantly greater than with isoflurane; we did not find evidence of prolonged emergence or postanesthetic length of stay. When possible, isoflurane should be considered for maintenance anesthesia over sevoflurane in patients at high risk of emergence agitation.

BACKGROUND: Timely primary care follow-up after acute care discharge may improve outcomes.

OBJECTIVE: To evaluate whether post-discharge follow-up rates differ among patients discharged from hospitals directly affiliated with their primary care clinic (same-site), other hospitals within their health system (same-system), and hospitals outside their health system (outside-system).

DESIGN: Retrospective cohort study.

PATIENTS: Adult patients of five primary care clinics within a 14-hospital health system who were discharged home after a hospitalization or emergency department (ED) stay.

MAIN MEASURES: Primary care visit within 14 days of discharge. A multivariable Poisson regression model was used to estimate adjusted rate ratios (aRRs) and risk differences (aRDs), controlling for sociodemographics, acute visit characteristics, and clinic characteristics.

KEY RESULTS: The study included 14,310 discharges (mean age 58.4 [SD 19.0], 59.5% female, 59.5% White, 30.3% Black), of which 57.7% were from the same-site, 14.3% same-system, and 27.9% outside-system. By 14 days, 34.5% of patients discharged from the same-site hospital received primary care follow-up compared to 27.7% of same-system discharges (aRR 0.88, 95% CI 0.79 to 0.98; aRD - 6.5 percentage points (pp), 95% CI - 11.6 to - 1.5) and 20.9% of outside-system discharges (aRR 0.77, 95% CI [0.70 to 0.85]; aRD - 11.9 pp, 95% CI - 16.2 to - 7.7). Differences were greater for hospital discharges than ED discharges (e.g., aRD between same-site and outside-system - 13.5 pp [95% CI, - 20.8 to - 8.3] for hospital discharges and - 10.1 pp [95% CI, - 15.2 to - 5.0] for ED discharges).

CONCLUSIONS: Patients discharged from a hospital closely affiliated with their primary care clinic were more likely to receive timely follow-up than those discharged from other hospitals within and outside their health system. Improving care transitions requires coordination across both care settings and health systems.