Standardized Care Is Better Than Individualized Care for the Majority of Critically Ill Patients

Standardized Management of the First Hour of Premature Infants: A Meta-Analysis

CONTEXT

The postnatal management of preterm infants at birth may influence their clinical course in the short, medium, and long term. The concept of the "Golden Hour" (GH) has emerged in neonatology, aiming to standardize this management.

OBJECTIVE

We conducted a meta-analysis to assess GH's impact on early clinical outcomes and on the comorbidities of prematurity.

DATA SOURCES

Pubmed, Embase, Scopus, and Cochrane Library were searched without any restriction.

STUDY SELECTION

We included randomized, prospective, and retrospective studies comparing periods with and without the application of a GH protocol for preterm birth.

DATA EXTRACTION

Two independent reviewers screened titles and abstracts and assessed full texts for eligibility.

RESULTS

Twelve prospective and 6 retrospective studies were included, for a total of 5104 patients. There was a significant reduction in hypothermia both on admission and at 1 hour (odds ratio [OR], 0.40 [95% CI, 0.27-0.60] and OR 0.39 [95% CI, 0.18-0.85]), with increased temperature (mean difference [MD], +0.57 °C [95% CI, 0.07-1.07]). Mean blood glucose and hypoglycemia rates on admission were not statistically affected. However, time to intravenous infusion was reduced (MD, -27.51 minutes [95% CI, -49.40 to -5.56]). There was a significantly lower rate of severe intraventricular hemorrhage (OR, 0.65 [95% CI, 0.47-0.89]) and a trend toward decreased bronchopulmonary dysplasia (OR, 0.69 [95% CI, 0.47-1.02]). Time to administration of surfactant was statistically reduced (MD, -23.6 minutes [95% CI, -42.2 to -5]). Mortality and other comorbidities of prematurity were not different.

LIMITATIONS

Four studies were judged to be of poor quality, and certainty for evidence was graded as low or very low.

CONCLUSIONS

The application of a GH at birth reduced the rate of hypothermia and the time required for intravenous infusion without statistically significant impact on glycemic control.

Variation in Corticosteroid Prescribing Practices for Patients With Septic Shock

OBJECTIVES

Understanding sources of variation in acute care delivery may inform targeted strategies to promote evidence-uptake. We sought to characterize physician-level and ICU-level variation in corticosteroid prescribing for patients with septic shock.

DESIGN

We performed a retrospective cohort study using the electronic health record of a multihospital health system. We identified ICU patients with septic shock admitted between 2018 and 2020. Using medication administration data, we determined which patients received corticosteroids within 2 days of vasopressor initiation. We linked each patient to their attending physician of record using digital signatures from clinical documentation. We then fit a hierarchical mixed-effects logistic regression model to identify factors associated with corticosteroid use and quantify variation in corticosteroid administration across physicians and ICUs.

SETTING

Twenty-six ICUs across nine hospitals in the United States.

PATIENTS

ICU patients with septic shock.

MEASUREMENTS AND MAIN RESULTS

Of 5322 patients with vasopressor dependent septic shock, 1294 (24.3%) were treated with corticosteroids within 2 days of vasopressor initiation. We linked these patients to 174 unique attending physicians across 26 ICUs. At the ICU-level, median corticosteroid use was 21.8% (interquartile range [IQR], 18.5-25.7%). At the physician-level, median corticosteroid use was 22.0% (IQR, 11.9-32.7%). In the mixed-effects regression controlling for patient and physician characteristics, 16.5% of the variation in corticosteroid administration was attributable to the ICUs and 10.1% was attributable to the physicians.

CONCLUSIONS

Both ICUs and physicians contribute to observed variation in the use of corticosteroids for vasopressor dependent septic shock. These findings underscore the need for multilevel interventions to standardize evidence-based practices in critical care.

Commentary on "preoperative cardiology consultations for geriatric patients with hip fractures rarely provide additional recommendations and are associated with prolonged hospital stays and delayed surgery: a retrospective case control study"

This letter discusses the recent study by Vahabi et al., which examined the role of preoperative cardiology consultations in geriatric patients undergoing hip fracture surgery. While the study highlights the limited impact of these consultations on treatment modifications and the associated delays in surgical intervention, this letter suggests areas for further exploration. Specifically, it proposes extending outcome monitoring to include long-term cardiovascular events and incorporating cost-effectiveness analysis to better assess the value of preoperative consultations. Moreover, the letter advocates for the use of blinding in future studies to minimize selection bias and enhance the reliability of results.

Timely delivery of care in neurological emergencies: can standardized management protocols help?

PURPOSE OF REVIEW

To review the evidence that supports the implementation of goal-directed care bundle protocols to improve outcomes from neurocritical conditions, and of the possible advantage of specific over generalized protocols.

RECENT FINDINGS

Articles from January 1, 2023 to July 31, 2024 were searched to evaluate the effectiveness of standardized management in neurological emergencies. The use of care bundles and standardized protocols with time- and target-related metrics has shown benefit in patients with acute stroke and traumatic brain injury.

SUMMARY

A goal-directed care protocol to guide standard management implemented by a multidisciplinary team can improve outcomes from neurological emergencies. However, implementation challenges need to be addressed before wide adoption of protocolized care for maximum benefit to populations.

Antibiotic Diversity Index: A novel metric to assess antibiotic variation among hospitalized children

BACKGROUND

Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate.

OBJECTIVE

The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes.

METHODS

We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs.

RESULTS

A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs.

CONCLUSIONS

We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions.

Improving Function in Older Adults With Hospital-Associated Deconditioning: Lessons Learned Comparing a Randomized Controlled Trial to Real World Practice

OBJECTIVE

The optimal approach for improving physical function following acute hospitalization is unknown. A recent clinical trial of home health physical therapy compared a high-intensity, progressive, multi-component (PMC) intervention to enhanced usual care (EUC). While both groups improved in physical function, no between-group differences were observed. However, the EUC group received care that differed from real world practice due to standardized treatments and a higher frequency of visits. This study compared a non-randomized true usual care (TUC) group to the EUC and PMC groups.

METHODS

Participants in the parent trial were randomly assigned to the EUC group (n = 100) and PMC group (n = 100) following hospital discharge. A subset of eligible patients (n = 55) were concurrently enrolled in the TUC group. Both the PMC and EUC groups received strength, activities of daily living, and gait training that differed in intensity but were matched in frequency and duration. TUC group care was determined by the home health agency. The primary outcome at 60-days was the Short Physical Performance Battery (SPPB).

RESULTS

In comparison to the TUC group, the EUC and PMC groups had significantly greater improvements in SPPB score (EUC: +1.04 points [CI = 0.18-1.90]; PMC: +1.12 points [CI = 0.23-2.00]).

CONCLUSION

While participants in the EUC and PMC groups experienced greater functional recovery compared to those in the TUC group, it cannot be determined whether these differences are due to the interventions received or confounding factors associated with the addition of a third, non-randomized, study group during the trial period.

IMPACT

This study illustrates the importance of design and interpretation of control groups for clinical trials. Further, the differences between the TUC group and the enhanced intervention groups warrant future research exploring whether increasing visits and standardizing care improve function in older adults receiving home health physical therapy after hospital associated deconditioning.

LAY SUMMARY

Participants in the intervention groups received standardized and more therapy than usual care, and experienced greater functional improvements. However, these differences may be due to factors associated with the addition of a non-randomized group during an ongoing clinical trial.

Policy Proposals for Mitigating Intensive Care Unit Strain: Insights from the COVID-19 Pandemic

Intensive care unit (ICU) strain, characterized by a discrepancy between perceived or actual intensive care resources and demand, significantly impacts patient outcomes and healthcare worker well-being. The coronavirus disease (COVID-19) pandemic exacerbated ICU strain, leading to increased mortality and extended hospital stays, affecting both critically ill patients with and without COVID-19. A systematic review identified 16 leading and lagging indicators of ICU capacity strain, including queuing, premature and after-hours ICU discharge, use of temporary space, length of stay, burnout, staffing and nurse-to-patient ratio, ICU census, acuity and turnover, standardized mortality ratio, readmissions, availability of critical supplies, ventilator use, and surgery cancellation. However, variability in operational definitions and limited evidence regarding the reliability, validity, usability, and feasibility limit the value of single indicators for informed strategic planning and policy guidance. Regional and national policies and programs are essential to enhance real-time monitoring for effective management of critical care resources, and they mitigate the impact of ICU strain, facilitating complex interhospital transfers to reduce strain and ensuring comprehensive strategies for enhancing ICU resilience. Proactive regional cooperation is advocated for policy formulation, knowledge exchange, and resource allocation to anticipate and mitigate ICU strain, ensuring equitable healthcare access during global health crises. The policy implications for future preparedness emphasize the importance of evidence-based triage and adaptable patient management strategies alongside ethical considerations in resource allocation and the role of behavioral economic insights in optimizing resource utilization and collaborative healthcare practices. This multifaceted approach for addressing ICU strain comprehensively and effectively during a pandemic would promote health equity and enhance healthcare system resilience under both routine operations and crisis conditions.

Two big bones, one big decision: When to fix bilateral femur fractures

PURPOSE

For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates.

METHODS

The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups.

RESULTS

1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h.

CONCLUSION

Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

2022 Year in Review: Ventilator Liberation

Mechanical ventilation is ubiquitous in critical care, and duration of ventilator liberation is variable and multifactorial. While ICU survival has increased over the last two decades, positive-pressure ventilation can cause harm to patients. Weaning and discontinuation of ventilatory support is the first step in ventilator liberation. Clinicians have a wealth of evidence-based literature at their disposal; however, more high-quality research is needed to describe outcomes. Additionally, this knowledge must be distilled into evidence-based practice and applied at the bedside. A proliferation of research on the subject of ventilator liberation has been published in the last 12 months. Whereas some authors have reconsidered the value of applying the rapid shallow breathing index in weaning protocols, others have begun to investigate new indices to predict liberation outcomes. New tools such as diaphragmatic ultrasonography have begun to appear in the literature as a tool for outcome prediction. A number of systematic reviews with both meta-analysis and network meta-analysis that synthesize the literature on ventilator liberation have also been published in the last year. This review describes changes in performance, monitoring of spontaneous breathing trials, and evaluations of successful ventilator liberation.

Reducing Surgical Complications in Spine Patients Through a Medication Management Support Program

STUDY DESIGN

A hospital-wide medication management program was implemented to ensure that high-risk patients would systematically pause antiplatelet and anticoagulant medications. We analyzed complications before and during the implementation of this program.

OBJECTIVE

The goal of the study was to determine if a medication management support program was effective for reducing perioperative complications, including hemorrhage, myocardial infarction, stroke, pulmonary embolism, and deep vein thrombosis.

DATA AND METHODS

Using data from the National Surgical Quality Improvement Program database, we examined the presence of 5 complications before and during the implementation of a medication management support program. There were 9732 patients in the clinic population who underwent elective spine surgery between 2011 and 2020 and were included in this analysis. Of those 9732 patients, 7205 had surgery before the introduction of the program, whereas 2527 had surgery at some point after the program was introduced. We conducted a series of Pearson's χ 2 tests to determine the relative frequencies of the complications before and during the program.

RESULTS

Results showed that during the implementation of the program, patients were relatively less likely to experience hemorrhage (3.16% vs. 1.11%; P <0.001). The reductions in thrombotic complications were clinically significant: myocardial infarction (0.12% vs. 0.00%), stroke (0.10% vs. 0.04%), pulmonary embolism (0.33% vs. 0.28%), and deep vein thrombosis (0.36% vs. 0.28%). These P values ranged from P =0.08 for myocardial infarction to P =0.67 for pulmonary embolism.

CONCLUSIONS

The use of this medication management support program appears effective for reducing the need for blood transfusions and thrombotic complications. While promising, the results should be interpreted with caution as we do not know whether this type of program will be effective for other hospital systems.

Nursing Skill Assessment of Hospital Nurses in Management of Critically Ill Patients

Objective

To analyze the application of standardized nursing procedures in critically ill patients' nursing evaluation.

Methods

90 cases of critically ill patients aged from 18 to 65 who were treated in our hospital from April 2020 to April 2021 were selected and divided into the control group and observation group, respectively, with 45 cases according to the drawing method. The rescue time, blood pressure, heart rate before and after nursing, adverse mood, length of stay, incidence of adverse events, ICU transfer and death, and satisfaction of 2 groups were statistically analyzed and compared.

Results

The rescue time of cardiopulmonary resuscitation, oxygen inhalation, venous opening, and endotracheal resuscitation in the observation group was 3.24 ± 1.01, which is lower than that in the control group, 6.65 ± 2.11, with statistical significance (P < 0.05). Similarly, the vital signs in the observation group were 2.45 ± 0.44, which is also significantly lower than that in the control group, 5.67 ± 1.56. After nursing, the blood pressure and heart rate in the observation group were lower than those in control group, with statistical significance (P < 0.05). The adverse mood of the observation group after nursing was lower than that of the control group, with statistical significance (P < 0.05). The length of stay, incidence of adverse events, intensive care unit (ICU) transfer, and death in the observation group were lower than those in the control group, with statistical significance (P < 0.05). The length of stay in the observation group was 8.87 ± 2.11, while 11.34 ± 2.45 in the observation group. The incidence of adverse events in the observation group was 1, while 8 in the observation group. The length of stay in the observation group was 8.87 ± 2.11, while 11.34 ± 2.45 in the observation group. The ICU transfer in the observation group were 2, while 9 in the observation group. There was no death in the observation group, however, 4 in the observation group. Nursing satisfaction in the observation group was higher than that in the control group, with statistical significance (P < 0.05). The number of patients that are very satisfied in the observation group was 28, while 20 in the control group. The number of patients that are satisfied in the observation group was the same as in the control group, both 15. However, the number of patients that are dissatisfied in the observation group was 2, while 10 in the control group.

Conclusion

The application of the standardized nursing process in the nursing of critically ill patients can not only effectively reduce the self-rating anxiety scale (SAS) and sarcoidosis diagnostic score (SDS) of patients but also reduce the incidence of complications and improve the nursing satisfaction of patients.

Unsuccessful and Successful Clinical Trials in Acute Respiratory Distress Syndrome: Addressing Physiology-Based Gaps

The acute respiratory distress syndrome (ARDS) is a severe form of acute hypoxemic respiratory failure caused by an insult to the alveolar-capillary membrane, resulting in a marked reduction of aerated alveoli, increased vascular permeability and subsequent interstitial and alveolar pulmonary edema, reduced lung compliance, increase of physiological dead space, and hypoxemia. Most ARDS patients improve their systemic oxygenation, as assessed by the ratio between arterial partial pressure of oxygen and inspired oxygen fraction, with conventional intensive care and the application of moderate-to-high levels of positive end-expiratory pressure. However, in some patients hypoxemia persisted because the lungs are markedly injured, remaining unresponsive to increasing the inspiratory fraction of oxygen and positive end-expiratory pressure. For decades, mechanical ventilation was the only standard support technique to provide acceptable oxygenation and carbon dioxide removal. Mechanical ventilation provides time for the specific therapy to reverse the disease-causing lung injury and for the recovery of the respiratory function. The adverse effects of mechanical ventilation are direct consequences of the changes in pulmonary airway pressures and intrathoracic volume changes induced by the repetitive mechanical cycles in a diseased lung. In this article, we review 14 major successful and unsuccessful randomized controlled trials conducted in patients with ARDS on a series of techniques to improve oxygenation and ventilation published since 2010. Those trials tested the effects of adjunctive therapies (neuromuscular blocking agents, prone positioning), methods for selecting the optimum positive end-expiratory pressure (after recruitment maneuvers, or guided by esophageal pressure), high-frequency oscillatory ventilation, extracorporeal oxygenation, and pharmacologic immune modulators of the pulmonary and systemic inflammatory responses in patients affected by ARDS. We will briefly comment physiology-based gaps of negative trials and highlight the possible needs to address in future clinical trials in ARDS.