Publications by Year: 2019

BACKGROUND: The emotional toll of critical illness on patients and their families can be profound and is emerging as an important target for value improvement. One source of emotional harm to patients and families may be care perceived as inadequately respectful. The prevalence and risk factors for types of emotional harms is under-studied.

METHODS: This prospective cohort study was conducted in nine ICUs at a tertiary care academic medical center in the United States. Prevalence of inadequate respect for (a) the patient and (b) the family, as well as prevalence of perceived lack of control over the care of their loved ones, was assessed by the Family Satisfaction with Care in the Intensive Care Unit instrument. The relationship between these outcomes with demographic and clinical covariates was assessed. Stratification by patient survivorship was performed in sensitivity analysis.

RESULTS: Of more than 1,500 respondents, 16.9% and 21.8% reported that the patient or the family member, respectively, received inadequate respect. No clinical characteristics of the patients were associated with inadequate respect for either the patient or the family member. By comparison, more than half of respondents reported a lack of control over their loved one's care; this finding was associated with multiple clinical factors. Prevalence and associated factors differed by patient survivorship status.

CONCLUSION: Care that is inadequately respectful to patients and families in the setting of critical illness is prevalent but does not appear to be associated with clinical characteristics. The incidence of such emotional harms is nuanced, difficult to predict, and deserves further investigation.

Rationale: Although gastrostomy tubes have shown to be of limited benefit in patients with advanced dementia, they continue to be used to deliver nutritional support in critically ill patients. The epidemiology and short-term outcomes are unclear. Objectives: To quantify national practice patterns and short-term outcomes of gastrostomy tube placement among the critically ill over the last two decades in the United States. Methods: Using the U.S. Agency for Healthcare and Research Quality's Healthcare Cost and Utilization Project's National Inpatient Sample, we evaluated trends in annual population-standardized rates of gastrostomy tube placement among critically ill adults from 1994 to 2014; we also quantified trends in length of stay, in-hospital mortality, and discharge location. We conducted sensitivity analyses among mechanically ventilated patients, survivors, and decedents of critical illness, and in a critically ill population excluding patients with dementia. Results: From 1994 to 2014, population-based rates of gastrostomy tube use in critically ill patients increased from 11.9 to 28.8 gastrostomies per 100,000 U.S. adults (peak in incidence in 2010), an increase of 142% (31,392-91,990 gastrostomy tubes in critically ill patients; P < 0.001). Patients receiving gastrostomy tubes during critical illness occupied a growing proportion of all gastrostomy tube placements, accounting for 19.6% of all gastrostomy tubes placed in 1994 and 50.8% in 2014. The rate of gastrostomies in critically ill patients remained roughly stable, from 2.5% of critically ill patients in 1994 to a peak of 3.7% in 2002 before declining again to 2.4% in 2014. Hospital length of stay and in-hospital mortality decreased among gastrostomy tube recipients (28.7 d to 20.5 d, P < 0.001; 25.9-11.3%, P < 0.001; respectively), whereas discharges to long-term facilities increased significantly (49.6-70.6%; P < 0.001). Sensitivity analyses among mechanically ventilated patients revealed similar increases in population-based estimates of gastrostomy tube placement. Conclusions: The incidence of gastrostomy tube placement among critically ill patients more than doubled between 1994 and 2014, with most patients being discharged to long-term care facilities. Critically ill patients are now the primary utilizer of gastrostomy tubes placed in the United States. Additional research is needed to better characterize the long-term risk and benefits of gastrostomy tube use in critically ill patients.

RATIONALE: Critically ill patients in the intensive care unit (ICU) often require the care of specialist physicians for clinical or procedural expertise. The current state of communication between specialist physicians and families and nurses has not been explored.

OBJECTIVES: To document the receipt of communication by nurses and family members regarding consultations performed on their patient or loved one, and to quantify how this impacts their overall perceptions of the quality of specialty care.

METHODS: Prospective survey of 60 adult family members and 90 nurses of 189 ICU patients who received a specialist consultation between March and October of 2015 in a single academic medical center in the United States. Surveys measured the prevalence of direct communication-defined as communication conducted in person, via telephone, or via text-page in which the specialist team gathered information about the patient from the nurse/family member and/or shared recommendations for care-and perceived quality of care.

RESULTS: In about two-thirds of family surveys (40/60) and one-half of nurse surveys (75/160), respondents had no direct communication with the specialist team that performed the consultation. Compared to nurses who had no direct communication with the specialists, those who did were 1.5 times more likely to rate the consultation as "excellent" (RR 1.48, 95% CI 1.2-1.8, p<0.001). Nearly 40% (22/60) of families knew so little about the consultation that they felt incapable of evaluating it.

CONCLUSIONS: Most ICU families and nurses have no interaction with specialist providers. Nurses' frequent exclusion from conversations about specialty care may pose safety risks and increase the likelihood of mixed messages for patients and families, most of whom desire some interaction with specialists. Future research is needed to identify effective mechanisms for information sharing that keep nurses and families aware of consultation requests, delivery, and outcomes without increasing the risk of mixed messages.

OBJECTIVES: A bundled consent process, where patients or surrogates provide consent for all commonly performed procedures on a single form at the time of ICU admission, has been advocated as a method for improving both rates of documented consent and patient/family satisfaction, but there has been little published literature about the use of bundled consent. We sought to determine how residents in an academic medical center with a required bundled consent process actually obtain consent and how they perceive the overall value, efficacy, and effects on families of this approach.

DESIGN: Single-center survey study.

SETTING: Medical ICUs in an urban academic medical center.

SUBJECTS: Internal medicine residents.

INTERVENTIONS: We administered an online survey about bundled consent use to all residents. Quantitative and qualitative data were analyzed.

MEASUREMENTS AND MAIN RESULTS: One-hundred two of 164 internal medicine residents (62%) completed the survey. A majority of residents (55%) reported grouping procedures and discussing general risks and benefits; 11% reported conducting a complete informed consent discussion for each procedure. Respondents were divided in their perception of the value of bundled consent, but most (78%) felt it scared or stressed families. A minority (26%) felt confident that they obtained valid informed consent for critical care procedures with the use of bundled consent. An additional theme that emerged from qualitative data was concern regarding the validity of anticipatory consent.

CONCLUSIONS: Resident physicians experienced with the use of bundled consent in the ICU held variable perceptions of its value but raised concerns about the effect on families and the validity of consent obtained with this strategy. Further studies are necessary to further explore what constitutes best practice for informed consent in critical care.

BACKGROUND: Dyspnea is prevalent among hospitalized patients but little is known about the experience of dyspnea among inpatients. We sought to characterize the multiple sensations and associated emotions of dyspnea in patients admitted with dyspnea to a tertiary care hospital.

METHODS: We selected patients who reported breathing discomfort of at least 4/10 on admission (10 = unbearable). Research staff recruited 156 patients within 24 hours of admission and evaluated daily patients' current and worst dyspnea with the Multidimensional Dyspnea Profile; patients participated in the study 2.6 days on average. The Multidimensional Dyspnea Profile assesses overall breathing discomfort (A1), intensity of five sensory qualities of dyspnea, and 5 negative emotional responses to dyspnea. Patients were also asked to rate whether current levels of dyspnea were "acceptable."

RESULTS: At the time of the first research interview, patients reported slight to moderate dyspnea (A1 median 4); however, most patients reported experiencing severe dyspnea in the 24 hours before the interview (A1 mean 7.8). A total of 54% of patients with dyspnea ≥4 on day 1 found the symptom unacceptable. The worst dyspnea each day in the prior 24 hours usually occurred at rest. Dyspnea declined but persisted through hospitalization for most patients. "Air hunger" was the dominant sensation, especially when dyspnea was strong (>4). Anxiety and frustration were the dominant emotions associated with dyspnea.

CONCLUSIONS: This first multidimensional portrait of dyspnea in a general inpatient population characterizes the sensations and emotions dyspneic patients endure. The finding that air hunger is the dominant sensation of severe dyspnea has implications for design of laboratory models of these sensations and may have implications for targets of palliation of symptoms.

OBJECTIVES: To assess trends in timing of mortality among patients with septic shock.

DESIGN: Retrospective cohort study.

SETTING: Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project's National Inpatient Sample, 1994-2014.

PATIENTS: Hospitalized adults (≥ 18 yr) with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with septic shock; secondary analysis: adults with International Classification of Diseases, 9th Edition, Clinical Modification codes consistent with acute respiratory failure receiving invasive mechanical ventilation and patients with both septic shock and acute respiratory failure receiving invasive mechanical ventilation.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: From 1994 to 2014, 48-hour mortality rates decreased among patients with septic shock (21.2% to 10.8%) and septic shock with acute respiratory failure receiving invasive mechanical ventilation (19.1% to 13.4%) but increased among patients with acute respiratory failure receiving invasive mechanical ventilation (7.9% to 9.8%; p value for all trends, < 0.001). Three-to-14-day mortality decreased among patients with septic shock (22.1% to 15.5%), septic shock with acute respiratory failure receiving invasive mechanical ventilation (28.7% to 22.4%) and acute respiratory failure receiving invasive mechanical ventilation (16.8% to 15.0%; p value for all trends, < 0.001). Mortality after 14 days decreased among all groups (septic shock: 12.6% to 6.7%; septic shock with acute respiratory failure receiving invasive mechanical ventilation: 20.3% to 11.3%; and acute respiratory failure receiving invasive mechanical ventilation: 12.7% to 5.8%; p value for all trends, < 0.001). Cox proportional hazard ratio for declining risk in mortality per year (adjusted for patient and hospital characteristics) was 0.96 (95% CI, 0.96-0.96) for septic shock, 0.97 (0.97-0.97) for acute respiratory failure receiving invasive mechanical ventilation and septic shock, and 0.99 (0.99-0.99) for acute respiratory failure receiving invasive mechanical ventilation.

CONCLUSIONS: Septic shock 48-hour, 3-14-day and greater than 14-day mortality declined markedly over two decades; in contrast, patients with acute respiratory failure only experienced marked decreases in greater than 14-day in-hospital mortality rates.

PURPOSE: Opioid associated admissions to the Intensive Care Unit (ICU) are increasing, but how institutions manage the care of these patients is unknown. We studied the availability of protocols and guidelines in Intensive Care Units (ICUs) for the management of the critically ill patient with opioid use disorder.

MATERIALS AND METHODS: A survey was sent to a random sampling of ICU clinicians at acute care hospitals in the United States.

RESULTS: Of the 300 hospitals contacted, 118 agreed to participate and 58 submitted surveys (49%, 58/118 response rate). While a majority of ICUs has a guideline to titrate sedative analgesics, only 7% reported a guideline that addresses the sedation needs of patients with opioid use disorder. Only one respondent identified a guideline for the continuation of medication-assisted treatment such as methadone. Most respondents did not have, or were unaware of, a guideline to manage opioid withdrawal or to prevent over-reversal with naloxone. Outpatient resources were offered to patients by 36% of institutions, while even fewer reported the use of a dedicated addiction care team.

CONCLUSIONS: Few institutional guidelines exist to provide clinicians with the tools necessary to prevent harm and promote recovery for this growing and vulnerable ICU population.