Publications by Year: 2025

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.