Making Diagnostic Uncertainty Visible At Intensive Care Unit Transitions: A Narrative Review Of Diagnostic Pause Strategies, Raha West, Ahmed Elhaddad, Behrad Baharlo, Parind Patel

HCA Healthcare Journal of Medicine

Background

Diagnostic error is a significant patient safety issue in critical care. However, it is often difficult to detect during ongoing care. Patients in the Intensive Care Unit (ICU) often have incomplete histories, overlapping symptoms, changing physiology, and concurrent issues. During ICU transitions, patient diagnoses are often reported without clear information on diagnostic confidence, potential alternative diagnoses, pending results, or triggers needing review.

Methods

This clinical narrative review explored diagnostic uncertainty at ICU transitions, specifically those during ICU-to-ward transfers or unplanned escalations to the ICU. A targeted literature search identified studies of adult ICU diagnostic errors, ICU transition safety, ICU-PAUSE …

Impact Of Palliative Care Consultation On Clinical Interventions And Outcomes In A Medical-Surgical Community-Based Intensive Care Unit, Manjot S. Malhi, Jude Tabba, Aunie M. Danyalian, Michele Iguina, Daniel Zapata, Raiko Diaz, Dionne Morgan, Daniel Heller, Sanaz Kashan, Mauricio Danckers

HCA Healthcare Journal of Medicine

Background

Integrating palliative care into intensive care unit (ICU) practice is an essential component of comprehensive patient management, ensuring that critical interventions are aligned with patient-centered care objectives. This study aims to evaluate the impact of palliative care consultation (PCC) on clinical interventions, patient outcomes, and decision-making processes in a community-based medical-surgical ICUs.

Methods

We conducted a prospective, observational, single-center cohort study of critically ill adult patients in a community-based medical-surgical ICU. Patients were grouped by the presence (PCCP) or absence (PCCA) of palliative care consultation. Primary outcomes included differences in clinical interventions (mechanical ventilation, vasoactive medications, renal replacement therapy, …

Platelet Transfusion Practices In The Icu: A Prospective Multicenter Cohort Study, Van Stefan, Raasveld Jorinde, Andrew Flint, Jimmy Schenk, Claudia Van Den Oord, Merijn Reuland, Sanne De Bruin, Jan Bakker, Maurizio Cecconi,, Marcus Lance

Anaesthesiology, East Africa

Objective: There is a lack of comprehensive international data regarding platelet transfusion practices in the ICU. This study aimed to evaluate the current occurrence rate of platelet transfusion in the ICU and provide an overview of platelet transfusion practices including indications for a platelet transfusion, thresholds, (non-)adherence and geo-economic region variations.

Design: International prospective cohort study.

Setting: Two hundred thirty-three centers in 30 countries worldwide.

Patients: All patients 18 years old and older, admitted to the ICU during a single study week, selected by each site from one of the 16 predefined weeks (March 2019 to …

Using The Observational Medical Outcomes Partnership Common Data Model For A Multi-Registry Intensive Care Unit Benchmarking Federated Analysis: Lessons Learned, Aasiyah Rashan, Daniel P Püttmann, Nicolette F De Keizer, Dave A Dongelmans, Ronald Cornet, Otavio Ranzani, Wangari Siika, Matthew Smith, Steve Harris, Abi Beane

Anaesthesiology, East Africa

Objective: Federated analysis is a method that allows data analysis to be performed on similar datasets without exchanging any data, thus facilitating international research collaboration while adhering to strict privacy laws. This study aimed to evaluate the feasibility of using federated analysis to benchmark mortality in 2 critical care quality registry databases converted to the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM), describing challenges to and recommendations for performing federated analysis on data transformed to OMOP CDM.

Materials and Methods: To identify as many challenges as possible and to be able to complete the benchmarking phase, …

Outcomes Of Pregnant Icu Patients With Severe Covid-19 Pneumonia In Qatar During The Three Waves Of The Covid-19 Pandemic: A Retrospective Cohort Study, Layla J.M Kily, Sohel M.G Ahmed, Tamam A.K.M Alhusban, Mohammed J. Orompurath, Marcus Lance, Mogahed I.H Hussein, Salwa M. Abuyaqoub, Huda A. Saleh, Eynas Abdalla, Santhosh Gopalakrishnan

Anaesthesiology, East Africa

Introduction: Pregnant women are considered a high-risk group for COVID-19 infection/pneumonia as they are known to be more vulnerable to viral infections. They require close monitoring and appropriate timely intervention to minimize the impact on both the mother and the fetus. Although the more prevalent Omicron variant led to fewer severe infections and fewer intensive care unit (ICU) admissions globally during the third wave, the effect on pregnant women and pregnancy outcomes was unknown. The vaccination campaign was thoroughly established by the third wave of the pandemic in Qatar. This retrospective descriptive cohort study investigates the characteristics, hospital stay, interventions, …

Improving Timely Palliative Care Consultation In The Micu: A Nurse-Driven Quality Improvement Initiative, Sandy Louise Gray

Graduate Theses, Dissertations, and Problem Reports (ETD)

ABSTRACT

Improving Timely Palliative Care Consultation in the MICU: A Nurse-Driven Quality Improvement Initiative

Sandy L Gray

Background: Early palliative care in intensive care units improves outcomes and reduces costs, yet referrals are often delayed. At J.W. Ruby Memorial Hospital’s medical intensive care unit (MICU), baseline median time to consultation was 112 hours (mean=246), exceeding recommended benchmarks and highlighting the need for a standardized process.

Purpose: This quality improvement project evaluated a nurse-driven screening tool to improve timeliness and consistency of palliative care consultations in the MICU.

Intervention: The tool was embedded in the electronic health record (EHR) …

Honoring Veterans’ Wishes: Efficacy Of An Evidence-Based Shared Decision-Making Tool In Va Icu Goals-Of-Care Discussions, Stephanie Alexander, Anna Astashchanka Md, Venktesh Ramnath Md

Doctor of Nursing Practice Final Manuscripts

Abstract

Introduction: This Doctor of Nursing Practice project aimed to enhance the knowledge and confidence of the San Diego Veterans Health Administration’s (VASD) Intensive Care Unit (ICU) medical providers in goals-of-care discussions (GOCD). Additionally, this project aimed to improve the documentation of these discussions.

Background: Delays in GOCD can lead to futile medical and surgical interventions, inappropriate antibiotic use, and higher rates of mental health conditions in patients and their loved ones. Earlier GOCD are associated with lower ventilation and resuscitation rates, earlier hospice enrollment, reduced ICU admissions, lower financial costs, and better patient and caregiver quality of life. However, …

Role Of Midodrine On Vasopressor Duration In Patients With Sepsis, Kamah J. Ellena, Jenna L. Combs, Heather M. Draper, Julie J. Belfer

Journal of Shock and Hemodynamics

Existing literature evaluating the off-label use of midodrine has focused primarily on postoperative hypotensive patients requiring a single vasopressor. This study aimed to evaluate the impact of midodrine on vasopressor duration and length of stay in patients receiving vasopressors for sepsis-related hypotension. This is an institutional review board-approved, single-center, retrospective analysis of critically ill patients with hypotension secondary to sepsis who received midodrine and intravenous vasopressors compared to those who received intravenous vasopressors alone. Patients were matched by Acute Physiology and Chronic Health Evaluation II score, suspected source of infection, and presence of bacteremia. One hundred patients were included in …

Medical Device-Related Pressure Injury (Mdrpi) Prevention In The Intensive Care Unit (Icu): An Evidence Based Practice Quality Improvement Project, Sana Shah

DNP Projects

Introduction: All intensive care unit (ICU) patients utilize various medical devices for care and treatment, placing them at high-risk for medical device-related pressure injuries (MDRPIs), which can lead to life-threatening infections, wounds/scars, and consumption of additional time and products to rectify these issues. Lack of appropriate decompression measures and improper bedside handoff report was recognized in the ICU at a hospital in Connecticut (CT).

Method: A literature search using CINAHL, MEDLINE, and the Cochrane Database of Systematic Reviews was conducted, restricting the search to the period between 2018-2022. The keywords searched were: “pressure injuries,” “adult patients,” “intensive care …

Sunsetting Excessive Chest X-Rays In An Intensive Care Unit: A Quality Improvement Project, Cassandra Sweet

Doctors of Nursing Practice (DNP) Final Projects, 2020-current

In the cardiovascular service line at an academic medical center in the southeastern United States, obtaining daily chest x-rays still occurred despite evidence that it is unnecessary and possibly even harmful. This quality improvement project was implemented in a 24-bed Cardiovascular Intensive Care Unit and 20-bed acute care unit, together considered to be the cardiac service line. Using the implementation framework of the Model for Improvement and Plan/Do/Study/Act, a guideline that outlines appropriate times to obtain a chest x-ray based on the American College of Radiology’s appropriateness criteria was created. Daily chest x-rays were eliminated and replaced with an on-demand …

Asking The Question ‘What Matters To You?’ In A London Intensive Care Unit, Harriet Pittaway, Laura White, Karen Turner, Angelique Mcgillivary

Journal of Patient-Centered Research and Reviews

Purpose: At the heart of the paradigm shift in approach to patient care from paternalism toward shared decision-making lies the international “What Matters To You?” (WMTY) movement. However, WMTY principles are not frequently applied to the critical care setting. The aim of this quality improvement project work was to design and integrate a tool for all patients admitted to the intensive care unit (ICU) that helped answer WMTY.

Methods: Using Plan-Do-Study-Act (PDSA) methodology across 8 cycles, a multidisciplinary team designed and integrated a bedside poster into the ICU. Quantitative and qualitative data were collected via a bedside audit process on …

Comprehensive Echocardiographic Findings In Critically Ill Covid-19 Patients With Or Without Prior Cardiac Disease, Renuka Jain, Pedro D. Salinas, Stacie Kroboth, Abigail Kaminski, Sarah Roemer, Ana Cristina Perez Moreno, Bijoy K Khandheria

Journal of Patient-Centered Research and Reviews

Purpose: Coronavirus disease 2019 (COVID-19) presents with a spectrum of disease severity, the most serious cases requiring intensive care. Echocardiography is a front-line tool in evaluating cardiovascular complications of COVID-19 in the intensive care unit (ICU); we analyzed transthoracic echocardiograms obtained from this patient population with state-of-the-art ultrasound technology.

Methods: All patients with COVID-19 requiring ICU admission on whom a transthoracic echocardiogram was obtained were included in the study. Focused transthoracic protocols were performed by experienced sonographers. Echocardiographic variables, including speckle-tracking echocardiography, were collected and analyzed. Clinical information was obtained from the electronic medical record. Patients were followed until discharge. …

Why End-Of-Life Discussion Matters: A Systematic Literature Review, Emily Grandson

All Graduate Theses, Dissertations, and Other Capstone Projects

End-of-life (EOL) discussions are a challenging yet vital topic of conversation in intensive care units (ICU) between healthcare providers, patients, and their families. There is great disparity in where, when, and how EOL discussions take place, but the consequences of neglecting their importance can be devastating physically, psychologically, and financially for all parties involved. Multiple inadequacies in the EOL discussion process have not only contributed to a personal and societal financial burden but an unacceptable quality of death for many ICU patients. A literature review was performed to determine what practice and policy changes could be made to improve EOL …

The Use Of Probiotics To Prevent Ventilator-Associated Pneumonia In Adults, Michael Roper, Paige Douthett

Physician Assistant Capstones, 2016 to 2019

Objective: To assess the efficacy and safety of preventing the acquisition of ventilator- associated pneumonia with the use of probiotic supplementation, as compared to a placebo, among hospitalized adult men and women receiving more than 24 hours of mechanical ventilation. Design: Systematic Literature Review. Methods: Systematic searches were conducted through PubMed and Scopus using the search terms “ventilator”, “probiotics”, and “prevention”. Records were excluded from the analysis if they were published before 2015, full text was not available, studies other than randomized control trial or cohort studies, and if the study population was less than 18 years old. Results: Of …

Cumulative Fluid Balance As A Major Predictor Of Clinical Outcome In Patients Admitted To Surgical Intensive Care Unit, Muhammad Sohaib, Madiha Hashmi, Faisal Shamim, Fazal Hameed Khan

Department of Anaesthesia

Objective: Fluid balance remains a highly controversial topic in the critical care field, and there is no consensus about the amount of fluid required by critically ill patients.In this study, the objective was to find the relationship between fluid balance and in hospital mortality in critically ill surgical patients.Our secondary objective was to identify the association between use of colloid and acute kidney injury and use of blood products and development of ARDS.
Study Design: The medical records of adult patients admitted to a surgical intensive care unit (ICU) >48 hours, from Aug 2014 toFeb 2016 (18 months) were reviewed …

Role Of Echocardiography In The Intensive Care Unit: Overview Of The Most Common Clinical Scenarios, Luca Longobardo, Concetta Zito, Scipione Carerj, Giuseppe Caracciolo, Bijoy K. Khandheria

Journal of Patient-Centered Research and Reviews

The intensive care unit (ICU) is among the more important settings in which echocardiography plays a pivotal role. The ease of use, speed of execution, and completeness of information on heart anatomy and function that echocardiography is able to provide makes this tool the perfect diagnostic technique in patients for whom exhaustive information must be quickly obtained by physicians who sometimes lack specific skills in cardiovascular imaging. However, the clinical entities encountered by ICU clinicians are often difficult to distinguish and patient symptoms may not be obvious. This brief review describes three common clinical scenarios that benefit from echocardiography in …

Meta-Regression: Prognostic Models As Objective Predictors Of Mortality Among Icu Cancer Patients, Sheila Donnell

Nursing Theses and Dissertations

Cancer patients admitted to the intensive care unit (ICU) may be experiencing complications of disease or treatment-related effects. While acute complications related to disease and/or its therapeutic management vary in severity, the approach to ICU-centered care is complicated by actual versus perceived risks of poor outcomes. Prognostic models that inform clinical judgment of nurses and physicians may prove helpful in this population. The Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) are ICU-based models predicting 30-day mortality among the general ICU population. Although studies have been …

Sepsis In Patients With Ventilator Associated Pneumonia Due To Methicillin- Resistant Staphylococcus Aureus: Incidence And Impact On Clinical Outcomes, Anupama Raghuram, Martin Gnoni, Timothy Lee Wiemken, Leslie Beavin, Julio A. Ramirez, Forest W. Arnold, Marcus J. Zervos, Daniel H. Kett, Thomas M. File Jr., Gary Stein, Kimbal D. Ford, Paula Peyrani, The Impact-Hap Investigators

The University of Louisville Journal of Respiratory Infections

Background: Sepsis is a clinical syndrome associated with organ dysfunction due to a dysregulated host response to infection. Methicillin-resistant Staphylococcus aureus (MRSA) Ventilator-associated pneumonia (VAP) is a serious infection frequently associated with sepsis. The objectives of this study were to define the incidence of sepsis and clinical failure in patients with MRSA VAP.

Methods: This was a secondary analysis of the Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study database. VAP was defined according to CDC criteria. MRSA VAP was considered when MRSA was isolated from a tracheal aspirate or bronchoalveolar lavage. We …

Intensive Care In Oncology: Admission And Outcomes In Adult Patients With Cancer, Surya John

Honors Undergraduate Theses

Background: Historically, patients with cancer have been perceived as poor candidates for ICU admission. General ICU admission criteria lists cancer patients as low priority in ICU admission depriving them of the care they rightfully deserve. The purpose of this literary synthesis was to examine ICU admission criteria, risk factors, and outcomes of ICU admission in relation to hematological and solid tumor cancers and discuss ways that practitioners and nurses can educate patients with cancer and their families on appropriateness of ICU care.

Methods: A total of 768 articles were found in a literature search including all literature from 2005 to …

Cardiac Tamponade After Removal Of Temporary Pace Maker In Multidiscipinary Intensive Care Unit, Muhammad Faisal Khan, Ali Bin Sarwar Zubairi

Department of Anaesthesia

Cardiac tamponade is a medical and surgical emergency, which needs early recognition and treatment. Myocardial perforation leading to cardiac tamponade is a rare complication after pace maker insertion. We are reporting a case of cardiac tamponade after removal of temporary pace maker in a multidisciplinary intensive care unit.

Cardiac Tamponade After Removal Of Temporary Pace Maker In Multidiscipinary Intensive Care Unit, Muhammad Faisal Khan, Ali Bin Sarwar Zubairi

Department of Medicine

Cardiac tamponade is a medical and surgical emergency, which needs early recognition and treatment. Myocardial perforation leading to cardiac tamponade is a rare complication after pace maker insertion. We are reporting a case of cardiac tamponade after removal of temporary pace maker in a multidisciplinary intensive care unit.