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1.  Updated systematic review identifies substantial number of retention strategies: Using more strategies retains more study participants 
Journal of clinical epidemiology  2015;68(12):1481-1487.
Background and Objective
The retention of participants in studies is important for the validity of research. We updated our prior systematic review (2005) to assess retention strategies for in-person follow-up in healthcare studies.
Methods
We searched PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Controlled Trials Register (CENTRAL), Cochrane Methodology Register, and Embase (August 2013) for English-language reports of studies that described retention strategies for in-person follow-up in healthcare studies. We abstracted each retention strategy and two authors independently classified each retention strategy with one of the themes developed in our prior review.
Results
We identified 88 studies (67 newly identified studies), six of which were designed to compare retention strategies while the remainder described retention strategies and retention rates. There were 985 strategies abstracted from the descriptive studies (617 from new studies), with a median (interquartile range) number of strategies per study of 10 (7 to 17) and a median (interquartile range) number of themes per study of 6 (4 to 7). Financial incentives were used in 47 (57%) of the descriptive studies. We classified 28% of the strategies under the theme of ‘Contact and Scheduling Methods,’ with 83% of the identified studies using at least one strategy within this theme. The number of strategies used was positively correlated with retention rate (P=0.027), but the number of themes was not associated with retention rate (P=0.469).
Conclusions
The number of studies describing retention strategies has substantially increased since our prior review. However, the lack of comparative studies and the heterogeneity in the types of strategies, participant population and study designs, prohibits synthesis to determine the types of cohort retention strategies that were most effective. However, using a larger number of retention strategies, across 5 or 6 different themes, appears to retain more study participants.
doi:10.1016/j.jclinepi.2015.04.013
PMCID: PMC4658250  PMID: 26186981
retention strategies; follow-up studies; in-person follow-up; systematic review; methods
3.  Patient outcomes after critical illness: a systematic review of qualitative studies following hospital discharge 
Critical Care  2016;20:345.
Background
There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness.
Methods
We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework.
Results
A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability.
Conclusion
ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental, physical, social, and functional sequelae occur after hospital discharge. These findings are important for understanding patient-centered outcomes in critical care and providing focus for future interventional studies aimed at improving outcomes of importance to ICU survivors.
Electronic supplementary material
The online version of this article (doi:10.1186/s13054-016-1516-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s13054-016-1516-x
PMCID: PMC5080744  PMID: 27782830
Critical illness; Qualitative research; Patient outcomes; Quality of life
4.  The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU 
Critical Care  2016;20:261.
Background
Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions.
Method
This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates.
Results
Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96–1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41–0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47–0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40–0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13–0.50, p <0.001).
Conclusions
Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions.
doi:10.1186/s13054-016-1433-z
PMCID: PMC4990875  PMID: 27538536
Sleep; Intensive care unit; Early ambulation; Rehabilitation; Delirium; Sedation
5.  Psychometric evaluation of the Hospital Anxiety and Depression Scale 3 months after acute lung injury 
Journal of critical care  2015;30(4):793-798.
Purpose
To conduct a psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) and to evaluate associations of 2 measures of psychological distress with the HADS Anxiety (HADS-A) and HADS Depression (HADS-D) subscales in acute lung injury (ALI) survivors.
Materials and Methods
We used 3-month post-ALI follow-up data from 151 participants in a multisite prospective cohort study to evaluate the internal consistency and structure of the HADS subscales and items, respectively. We used Spearman ρ correlations and other statistics to relate the 3-level version of the EuroQol-5D (EQ-5D-3L) anxiety/depression item and Medical Outcomes Study Short Form-36 (SF-36) “mental health”–related domains to the HADS subscales.
Results
Internal consistency was good for each of the HADS subscales (α ≥ .70). Exploratory factor analysis revealed a 2-factor structure (anxiety and depression). The EQ-5D-3L item and the SF-36 mental health-related domain scores were associated with HADS-A (ρ = 0.54 and − 0.48 to − 0.70, respectively) and HADS-D (ρ = 0.41 and −0.48 to −0.52, respectively) scores (all P< .01). The relationship between the SF-36 mental health domain score and the HADS-A subscale score was particularly strong (ρ = − 0.70, P < .01).
Conclusions
When evaluated in ALI survivors, the HADS has good internal consistency and a 2-factor structure. The HADS subscales were substantially correlated with the EQ-5D-3L anxiety/depression item and SF-36 mental health-related domain scores, suggesting convergent validity for these measures of psychological distress in ALI survivors.
doi:10.1016/j.jcrc.2015.04.006
PMCID: PMC4466136  PMID: 25981443
Acute lung injury; Anxiety; Depression; Critical care; Intensive care unit; Psychometrics
6.  Barriers to Early Mobility of Hospitalized General Medicine Patients 
Objective
Functional status decline commonly accompanies hospitalization making patients vulnerable to complications. Such decline can be mitigated through hospital-based early mobility programs. Success in implementing patient mobility quality improvement processes requires evaluating providers’ knowledge, attitudes, and behaviors.
Design
A cross-sectional, self-administered survey in two different hospital settings was completed by 120 nurses and physical and occupational therapists (rehabilitation therapists, 38; nurses, 82) from six general medicine units. The survey was developed using published guidelines, literature review, and provider meetings and refined through pilot testing. Psychometric properties were assessed, and regression analyses were conducted to examine barriers to early mobility by hospital site, provider discipline, and years of experience.
Results
Internal consistency reliability, item consistency, and discriminant validity psychometric characteristics were acceptable. In multivariable regression analysis, overall perceived barriers were similar between the two hospitals (P = 0.25) and significantly higher for staff with less experience (P = 0.02) and for nurses vs. rehabilitation therapists (P < 0.001). The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific.
Conclusions
This novel survey identified important barriers to mobilizing medical inpatients that were similar across two hospital settings. These results can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility.
doi:10.1097/PHM.0000000000000185
PMCID: PMC4344426  PMID: 25133615
Quality Improvement; Rehabilitation; Surveys; Early Mobility; Provider Practice; Evidence-Based Care; Multidisciplinary
7.  Co-occurrence of and remission from general anxiety, depression, and posttraumatic stress disorder symptoms after acute lung injury: a 2-year longitudinal study 
Critical care medicine  2015;43(3):642-653.
Objective
To evaluate the co-occurrence, and predictors of remission, of general anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms during 2-year follow-up in survivors of acute lung injury (ALI) treated in an intensive care unit (ICU).
Design, Setting, and Patients
This prospective cohort study enrolled 520 patients from 13 medical and surgical ICUs in 4 hospitals, with follow-up at 3, 6, 12, and 24 months post-ALI.
Measurements and Main Results
The outcomes of interest were measured using the Hospital Anxiety and Depression Scale (HADS) anxiety and depression subscales (scores ≥8 indicating substantial symptoms) and the Impact of Event Scale-Revised (IESR, scores ≥1.6 indicating substantial PTSD symptoms). Of the 520 enrolled patients, 274 died before 3-month follow-up; 186/196 consenting survivors (95%) completed at least one HADS and IESR assessment during 2-year follow-up, and most completed multiple assessments. Across follow-up time points, the prevalence of supra-threshold general anxiety, depression, and PTSD symptoms ranged from 38–44%, 26–33%, and 22–24%, respectively; more than half of the patients had supra-threshold symptoms in at least one domain during 2-year follow-up. The majority (59%) of survivors with any supra-threshold symptoms were above threshold for 2 or more types of symptoms (i.e., of general anxiety, depression, and/or PTSD). In fact, the most common pattern involved simultaneous general anxiety, depression, and PTSD symptoms. Most patients with general anxiety, depression, or PTSD symptoms during 2-year follow-up had supra-threshold symptoms at 24-month (last) follow-up. Higher SF-36 physical functioning domain scores at the prior visit were associated with a greater likelihood of remission from general anxiety and PTSD symptoms during follow-up.
Conclusions
The majority of ALI survivors had clinically significant general anxiety, depressive, or PTSD symptoms, and these symptoms tended to co-occur across domains. Better physical functioning during recovery predicted subsequent remission of general anxiety and PTSD symptoms.
doi:10.1097/CCM.0000000000000752
PMCID: PMC4336582  PMID: 25513784
acute lung injury; anxiety; depression; posttraumatic stress disorder; assessments, patient outcomes; epidemiology
8.  Health Care Resource Use and Costs of Two-Year Survivors of Acute Lung Injury. An Observational Cohort Study 
Rationale: Survivors of acute lung injury (ALI) require ongoing health care resources after hospital discharge. The extent of such resource use, and associated costs, are not fully understood.
Objectives: For patients surviving at least 2 years after ALI, we evaluated cumulative 2-year inpatient admissions and related costs, and the association of patient- and intensive care unit–related exposures with these costs.
Methods: Multisite observational cohort study in 13 intensive care units at four academic teaching hospitals evaluating 138 two-year survivors of ALI.
Measurements and Main Results: Two-year inpatient health care use data (i.e., admissions to hospitals, and skilled nursing and rehabilitation facilities) were collected for patients surviving at least 2 years, via (1) one-time retrospective structured interview with patient and/or proxy, (2) systematic medical record review for nonfederal study site hospitals, and (3) inpatient medical record review for non–study site hospitals, as needed for clarifying patient/proxy reports. Costs are reported in 2013 U.S. dollars. A total of 138 of 142 (97%) 2-year survivors completed the interview, with 111 (80%) reporting at least one inpatient admission during follow-up, for median (interquartile range [IQR]) estimated costs of $35,259 ($10,565–$81,166). Hospital readmissions accounted for 76% of costs. Among 12 patient- and intensive care unit–related exposures evaluated, baseline comorbidity and intensive care unit length of stay were associated with increased odds of incurring any follow-up inpatient costs. Having Medicare or Medicaid (vs. private insurance) was associated with median estimated costs that were 85% higher (relative median, 1.85; 95% confidence interval, 1.01–3.45; P = 0.045).
Conclusions: In this multisite study of 138 two-year survivors of ALI, 80% had one or more inpatient admission, representing a median (IQR) estimated cost $35,259 ($10,565–$81,166) per patient and $6,598,766 for the entire cohort. Hospital readmissions represented 76% of total inpatient costs, and having Medicare or Medicaid before ALI was associated with increased costs. With the aging population and increasing comorbidity, these findings have important health policy implications for the care of critically ill patients.
doi:10.1513/AnnalsATS.201409-422OC
PMCID: PMC4418317  PMID: 25594116
acute lung injury; critical care; long-term survivors; patient readmission; health care costs
9.  Neuromuscular electrical stimulation in mechanically ventilated patients: A randomized, sham-controlled pilot trial with blinded outcome assessment 
Journal of critical care  2014;30(1):32-39.
Purpose
To compare neuromuscular electrical stimulation (NMES) versus sham on leg strength at hospital discharge in mechanically ventilated patients.
Materials and Methods
We conducted a randomized pilot study of NMES versus sham applied to 3 bilateral lower extremity muscle groups for 60 minutes daily in ICU. Between 6/2008 and 3/2013, we enrolled adults who were receiving mechanical ventilation within the first week of ICU stay, and who could transfer independently from bed to chair before hospital admission. The primary outcome was lower extremity muscle strength at hospital discharge using Medical Research Council score (maximum = 30). Secondary outcomes at hospital discharge included walking distance and change in lower extremity strength from ICU awakening. Clinicaltrials.gov:NCT00709124.
Results
We stopped enrollment early after 36 patients due to slow patient accrual and the end of research funding. For NMES versus sham, mean (SD) lower extremity strength was 28(2) versus 27(3), p=0.072. Among secondary outcomes, NMES versus sham patients had a greater mean (SD) walking distance (514(389) vs. 251(210) feet, p=0.050) and increase in muscle strength (5.7(5.1) vs. 1.8(2.7), p=0.019).
Conclusions
In this pilot randomized trial, NMES did not significantly improve leg strength at hospital discharge. Significant improvements in secondary outcomes require investigation in future research.
doi:10.1016/j.jcrc.2014.09.014
PMCID: PMC4268169  PMID: 25307979
randomized controlled trial; electric stimulation; critical illness; intensive care units; respiration; artificial; muscle
10.  Timing of Low Tidal Volume Ventilation and Intensive Care Unit Mortality in Acute Respiratory Distress Syndrome. A Prospective Cohort Study 
Rationale: Reducing tidal volume decreases mortality in acute respiratory distress syndrome (ARDS). However, the effect of the timing of low tidal volume ventilation is not well understood.
Objectives: To evaluate the association of intensive care unit (ICU) mortality with initial tidal volume and with tidal volume change over time.
Methods: Multivariable, time-varying Cox regression analysis of a multisite, prospective study of 482 patients with ARDS with 11,558 twice-daily tidal volume assessments (evaluated in milliliter per kilogram of predicted body weight [PBW]) and daily assessment of other mortality predictors.
Measurements and Main Results: An increase of 1 ml/kg PBW in initial tidal volume was associated with a 23% increase in ICU mortality risk (adjusted hazard ratio, 1.23; 95% confidence interval [CI], 1.06–1.44; P = 0.008). Moreover, a 1 ml/kg PBW increase in subsequent tidal volumes compared with the initial tidal volume was associated with a 15% increase in mortality risk (adjusted hazard ratio, 1.15; 95% CI, 1.02–1.29; P = 0.019). Compared with a prototypical patient receiving 8 days with a tidal volume of 6 ml/kg PBW, the absolute increase in ICU mortality (95% CI) of receiving 10 and 8 ml/kg PBW, respectively, across all 8 days was 7.2% (3.0–13.0%) and 2.7% (1.2–4.6%). In scenarios with variation in tidal volume over the 8-day period, mortality was higher when a larger volume was used earlier.
Conclusions: Higher tidal volumes shortly after ARDS onset were associated with a greater risk of ICU mortality compared with subsequent tidal volumes. Timely recognition of ARDS and adherence to low tidal volume ventilation is important for reducing mortality.
Clinical trial registered with www.clinicaltrials.gov (NCT 00300248).
doi:10.1164/rccm.201409-1598OC
PMCID: PMC4347437  PMID: 25478681
acute lung injury; tidal volume; artificial respiration; prospective studies
11.  Delirium transitions in the medical ICU: exploring the role of sleep quality and other factors 
Critical care medicine  2015;43(1):135-141.
Objective
Disrupted sleep is a common and potentially modifiable risk factor for delirium in the intensive care unit (ICU). As part of a quality improvement (QI) project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium.
Design
Secondary analysis of prospective observational study.
Setting
Medical ICU (MICU) over a 201-day period.
Patients
223 patients with ≥1 night in the MICU in between two consecutive days of delirium assessment.
Interventions
None
Measurements
Daily perceived sleep quality ratings were measured using the Richards Campbell Sleep Questionnaire (RCSQ). Delirium was measured twice-daily using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates evaluated included: age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day’s delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion.
Main Results
Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [IQR] ratings 58 [35-76] vs. 57 [33-78], respectively p=0.71), and perceived sleep quality was unrelated to delirium transition (adjusted OR 1.00, 95% CI 0.99-1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted OR 4.02, 95% CI 2.19-7.38, p<0.001) and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted OR 0.40, 95% CI 0.20-0.80, p=0.01).
Conclusions
We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.
doi:10.1097/CCM.0000000000000610
PMCID: PMC4269569  PMID: 25230376
Sleep; Intensive Care Unit; Delirium; Cognition; Sedation; Outcome Assessment
13.  Factors Associated with Swallowing Assessment after Oral Endotracheal Intubation and Mechanical Ventilation for Acute Lung Injury 
Rationale: Endotracheal intubation is associated with postextubation swallowing dysfunction, but no guidelines exist for postextubation swallowing assessments.
Objectives: We evaluated the prevalence, patient demographic and clinical factors, and intensive care unit (ICU) and hospital organizational factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI).
Methods: We performed a secondary analysis of a prospective cohort study in which investigators evaluated 178 eligible patients with ALI who were mechanically ventilated via oral endotracheal tube. The patients were recruited from 13 ICUs at four teaching hospitals in Baltimore, Maryland. Patient demographic and clinical factors, types of ICU, and hospital study sites were evaluated for their association with completion of a swallowing assessment both in the ICU and after the ICU stay before hospital discharge. Factors significantly associated with a swallow assessment were evaluated in a multivariable logistic regression model.
Measurements and Main Results: Before hospital discharge, 79 (44%) patients completed a swallowing assessment, among whom 59 (75%) had their assessments initiated in ICU and 20 (25%) had their assessments initiated on the hospital ward. Female sex (odds ratio [OR] = 2.01; 95% confidence interval [95% CI] = 1.03–3.97), orotracheal intubation duration (OR = 1.13 per day; 95% CI = 1.05–1.22), and hospital study site (Site 3: OR = 2.41; 95% CI = 1.00–5.78) were independently associated with swallowing assessment. Although Site 3 had a twofold increase in swallowing assessments in the ICU, there was no significant difference between hospitals in the frequency of swallowing assessments completed after ICU discharge (P = 0.287) or in the proportion of patients who failed a swallowing assessment conducted in the ICU (P = 0.468) or on the ward (P = 0.746).
Conclusions: In this multisite prospective study, female sex, intubation duration, and hospital site were associated with postextubation swallowing assessment. These results demonstrate variability in practice patterns between institutions and highlight the need to determine the appropriate timing and indications for swallowing assessment and to more fully understand swallowing dysfunction after intubation.
doi:10.1513/AnnalsATS.201406-274OC
PMCID: PMC4298980  PMID: 25387319
deglutition; deglutition disorders; intubation; referral and consultation; acute lung injury
14.  Variable-Domain Functional Regression for Modeling ICU Data 
We introduce a class of scalar-on-function regression models with subject-specific functional predictor domains. The fundamental idea is to consider a bivariate functional parameter that depends both on the functional argument and on the width of the functional predictor domain. Both parametric and nonparametric models are introduced to fit the functional coefficient. The nonparametric model is theoretically and practically invariant to functional support transformation, or support registration. Methods were motivated by and applied to a study of association between daily measures of the Intensive Care Unit (ICU) Sequential Organ Failure Assessment (SOFA) score and two outcomes: in-hospital mortality, and physical impairment at hospital discharge among survivors. Methods are generally applicable to a large number of new studies that record a continuous variables over unequal domains.
doi:10.1080/01621459.2014.940044
PMCID: PMC4315944  PMID: 25663725
Variable-domain functional regression; Functional data analysis; Nonparametric statistics; Scalar-on-function regression; Varying-coeffcient model; Longitudinal data
15.  Cox Regression Models with Functional Covariates for Survival Data 
Statistical modelling  2015;15(3):256-278.
We extend the Cox proportional hazards model to cases when the exposure is a densely sampled functional process, measured at baseline. The fundamental idea is to combine penalized signal regression with methods developed for mixed effects proportional hazards models. The model is fit by maximizing the penalized partial likelihood, with smoothing parameters estimated by a likelihood-based criterion such as AIC or EPIC. The model may be extended to allow for multiple functional predictors, time varying coefficients, and missing or unequally-spaced data. Methods were inspired by and applied to a study of the association between time to death after hospital discharge and daily measures of disease severity collected in the intensive care unit, among survivors of acute respiratory distress syndrome.
doi:10.1177/1471082X14565526
PMCID: PMC4591554  PMID: 26441487
functional data analysis; survival analysis; Cox proportional hazards model; nonparametric statistics; intensive care unit
16.  Delirium, Steroids, and Cardiac Surgery 
Anesthesia and analgesia  2014;119(5):1011-1013.
doi:10.1213/ANE.0000000000000412
PMCID: PMC4204108  PMID: 25329015
17.  RBC Transfusion Practices in Two Surgical ICUs: a Mixed Methods Assessment of Barriers to Evidence-based Practice 
Transfusion  2014;54(10 0 2):2658-2667.
BACKGROUND
Despite evidence supporting the restrictive red blood cell (RBC) transfusion thresholds and associated clinical practice guidelines, clinical practice has been slow to change in the ICU. Our aim was to identify barriers to conservative transfusion practice adherence.
STUDY DESIGN AND METHODS
A mixed methods study involving observation of prescriber (i.e. physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, MD.
RESULTS
Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87% and 90%, respectively) indicated the ideal pre-transfusion hemoglobin (HgB) to be ≤7g/dL in non-bleeding/non-ischemic patients compared to a minority of nurses (8% [p=0.002] and 42% [p=0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pre-transfusion HgB in their units (CSICU: p<0.001, SICU: p=0.019). During rounds, providers infrequently explicitly discussed HgB monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.
CONCLUSIONS
Our study identified several provider and system barriers to evidence based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.
doi:10.1111/trf.12718
PMCID: PMC4197098  PMID: 24846447
blood transfusion; intensive care units; evidence-based medicine; critical care; quality assurance; healthcare; patient care team
18.  Timing of Limitations of Life Support in the Intensive Care Unit and Sequential Organ Failure Assessment (SOFA) scores: The Authors Reply 
Critical care medicine  2014;42(8):e596.
doi:10.1097/CCM.0000000000000447
PMCID: PMC4234114  PMID: 25029150
Decision Making; Intensive Care; Resuscitation Orders; Prognosis; Withholding Treatment; Life Support Care
19.  Allowing Physicians to Choose the Value of Compensation for Participation in a Web-Based Survey: Randomized Controlled Trial 
Background
Survey response rates among physicians are declining, and determining an appropriate level of compensation to motivate participation poses a major challenge.
Objective
To estimate the effect of permitting intensive care physicians to select their preferred level of compensation for completing a short Web-based survey on physician (1) response rate, (2) survey completion rate, (3) time to response, and (4) time spent completing the survey.
Methods
A total of 1850 US intensivists from an existing database were randomized to receive a survey invitation email with or without an Amazon.com incentive available to the first 100 respondents. The incentive could be instantly redeemed for an amount chosen by the respondent, up to a maximum of US $50.
Results
The overall response rate was 35.90% (630/1755). Among the 35.4% (111/314) of eligible participants choosing the incentive, 80.2% (89/111) selected the maximum value. Among intensivists offered an incentive, the response was 6.0% higher (95% CI 1.5-10.5, P=.01), survey completion was marginally greater (807/859, 94.0% vs 892/991, 90.0%; P=.06), and the median number of days to survey response was shorter (0.8, interquartile range [IQR] 0.2-14.4 vs 6.6, IQR 0.3-22.3; P=.001), with no difference in time spent completing the survey.
Conclusions
Permitting intensive care physicians to determine compensation level for completing a short Web-based survey modestly increased response rate and substantially decreased response time without decreasing the time spent on survey completion.
doi:10.2196/jmir.3898
PMCID: PMC4705363  PMID: 26223821
data collection; monetary incentives; cash; physicians; electronic questionnaire; survey design; response rate
20.  Corticosteroids and transition to delirium in patients with acute lung injury 
Critical care medicine  2014;42(6):1480-1486.
Objective
Delirium is common in mechanically ventilated patients in the intensive care unit (ICU) and associated with short- and long-term morbidity and mortality. The use of systemic corticosteroids is also common in the ICU. Outside of the ICU setting, corticosteroids are a recognized risk factor for delirium, but their relationship with delirium in critically ill patients has not been fully evaluated. We hypothesized that systemic corticosteroid administration would be associated with a transition to delirium in mechanically ventilated patients with acute lung injury (ALI).
Design
Prospective cohort study
Setting
Thirteen ICUs in 4 hospitals in Baltimore, MD
Patients
520 mechanically ventilated adult patients with ALI
Measurements and Main Results
Delirium evaluation was performed by trained research staff using the validated CAM-ICU screening tool. A total of 330 (64%) of the 520 patients had at least two consecutive ICU days of observation in which delirium was assessable (e.g., patient was non-comatose), with a total of 2286 days of observation and a median (inter-quartile range [IQR]) of 15 (9, 28) observation days per patient. These 330 patients had 99 transitions into delirium from a prior non-delirious, non-comatose state. The probability of transitioning into delirium on any given day was 14%. Using multivariable Markov models with robust variance estimates, the following factors (adjusted odds ratio, 95% confidence interval) were independently associated with transition to delirium: older age (compared to <40 years old, 40-60 years (1.81, 1.26 to 2.62) and >=60 years (2.52, 1.65 to 3.87)) and administration of any systemic corticosteroid in the prior 24 hours (1.52, 1.05 to 2.21).
Conclusions
After adjusting for other risk factors, systemic corticosteroid administration is significantly associated with transitioning to delirium from a non-delirious state. The risk of delirium should be considered when deciding about the use of systemic corticosteroids in critically ill patients with ALI.
doi:10.1097/CCM.0000000000000247
PMCID: PMC4028387  PMID: 24589640
Delirium; Steroids; Intensive Care; Markov Chains; Treatment Outcome; Acute Lung Injury
21.  A scenario-based, randomized trial of patient values and functional prognosis on intensivist intent to discuss withdrawing life support 
Critical care medicine  2014;42(6):1455-1462.
Objective
To evaluate the effect of (1) patient values as expressed by family members, and (2) a requirement to document patients’ functional prognosis on intensivists’ intention to discuss withdrawal of life support in a hypothetical family meeting.
Design
A 3-armed, randomized trial
Setting
179 U.S. hospitals with training programs in critical care accredited by the Accreditation Council for Graduate Medical Education
Subjects
630 intensivists recruited via e-mail invitation from a database of 1,850 eligible academic intensivists
Interventions
Each intensivist was randomized to review ten, on-line, clinical scenarios with a range of illness severities involving a hypothetical patient (Mrs. X). In control-group scenarios, the patient did not want continued life support without a reasonable chance of independent living. In the first experimental arm, the patient wanted life support regardless of functional outcome. In the second experimental arm, patient values were identical to the control group, but intensivists were required to record the patient’s estimated three-month functional prognosis
Measurements and Main Results
Response to the question: “Would you bring up the possibility of withdrawing life support with Mrs. X’s family?” answered using a five-point Likert scale. There was no effect of patient values on whether intensivists intended to discuss withdrawal of life support (P = 0.81), but intensivists randomized to record functional prognosis were 49% more likely (95% confidence interval: 20%–85%) to discuss withdrawal.
Conclusions
In this national, scenario-based, randomized trial, patient values had no effect on intensivists’ decisions to discuss withdrawal of life support with family. However, requiring intensivists to record patients’ estimated 3-month functional outcome substantially increased their intention to discuss withdrawal.
doi:10.1097/CCM.0000000000000227
PMCID: PMC4128685  PMID: 24584065
Decision Making; Intensive Care; Resuscitation Orders; Prognosis; Withholding Treatment; Life Support Care
22.  Risk Factors for Physical Impairment after Acute Lung Injury in a National, Multicenter Study 
Rationale: Existing studies of risk factors for physical impairments in acute lung injury (ALI) survivors were potentially limited by single-center design or relatively small sample size.
Objectives: To evaluate risk factors for three measures of physical impairments commonly experienced by survivors of ALI in the first year after hospitalization.
Methods: A prospective, longitudinal study of 6- and 12-month physical outcomes (muscle strength, 6-minute-walk distance, and Short Form [SF]-36 Physical Function score) for 203 survivors of ALI enrolled from 12 hospitals participating in the ARDS Network randomized trials. Multivariable regression analyses evaluated the independent association of critical illness–related variables and intensive care interventions with impairments in each physical outcome measure, after adjusting for patient demographics, comorbidities, and baseline functional status.
Measurements and Main Results: At 6 and 12 months, respectively, mean (± SD) values for strength (presented as proportion of maximum strength score evaluated using manual muscle testing) was 92% (± 8%) and 93% (± 9%), 6-minute-walk distance (as percent-predicted) was 64% (± 22%) and 67% (± 26%), and SF-36 Physical Function score (as percent-predicted) was 61% (± 36%) and 67% (± 37%). After accounting for patient baseline status, there was significant association and statistical interaction of mean daily dose of corticosteroids and intensive care unit length of stay with impairments in physical outcomes.
Conclusions: Patients had substantial impairments, from predicted values, for 6-minute-walk distance and SF-36 Physical Function outcome measures. Minimizing corticosteroid dose and implementing existing evidence-based methods to reduce duration of intensive care unit stay and associated patient immobilization may be important interventions for improving ALI survivors’ physical outcomes.
doi:10.1164/rccm.201401-0158OC
PMCID: PMC4061900  PMID: 24716641
acute lung injury; exercise test; muscle strength; risk factors; follow-up studies
23.  Cognitive screening among acute respiratory failure survivors: a cross-sectional evaluation of the Mini-Mental State Examination 
Critical Care  2015;19(1):220.
Introduction
The Mini-Mental State Examination (MMSE) is a common cognitive screening test, but its utility in identifying impairments in survivors of acute respiratory failure is unclear. The purpose of this study was to evaluate MMSE performance versus a concurrently administered detailed neuropsychological test battery in survivors of acute respiratory failure.
Methods
This cross-sectional analysis used data from the ARDSNet Long Term Outcomes Study (ALTOS) and Awakening and Breathing Controlled Trial (ABC). Participants were 242 survivors of acute respiratory failure. The MMSE and detailed neuropsychological tests were administered at 6 and 12 months post-hospital discharge for the ALTOS study, and at hospital discharge, 3 and 12 months for the ABC study. Overall cognitive impairment identified by the MMSE (score <24) was compared to impairments identified by the neuropsychological tests. We also matched orientation, registration, attention, memory and language domains on the MMSE to the corresponding neuropsychological test. Pairwise correlations, sensitivity, specificity, positive and negative predictive values, and agreement were assessed.
Results
Agreement between MMSE and neuropsychological tests for overall cognitive impairment was fair (42 to 80%). Specificity was excellent (≥93%), but sensitivity was poor (19 to 37%). Correlations between MMSE domains and corresponding neuropsychological tests were weak to moderate (6 months: r = 0.11 to 0.28; 12 months: r = 0.09 to 0.34). The highest correlation between the MMSE and neuropsychological domains was for attention at 6 months (r = 0.28) and language at 12 months (r = 0.34).
Conclusions
In acute respiratory failure survivors, the MMSE has poor sensitivity in detecting cognitive impairment compared with concurrently administered detailed neuropsychological tests. MMSE results in this population should be interpreted with caution.
doi:10.1186/s13054-015-0934-5
PMCID: PMC4480909  PMID: 25939482
24.  Association of Impaired Functional Status at Hospital Discharge and Subsequent Rehospitalization 
Journal of hospital medicine  2014;9(5):277-282.
OBJECTIVE
To determine whether functional status near the time of discharge from acute care hospitalization is associated with acute care readmission.
PATIENTS AND METHODS
Retrospective cohort study of 9405 consecutive patients admitted from an acute care hospital to an inpatient rehabilitation facility between July 1, 2006 and December 31, 2012. Patients’ functional status at admission to the rehabilitation facility was assessed by the Functional Independence Measure (FIM) score, and divided into low, middle, or high functional status. The main outcome was readmission to an acute care hospital within 30 days of acute care discharge (for all patients and by subgroup according to diagnostic group: medical, orthopedic, or neurologic).
RESULTS
There were 1182 (13%) readmissions. FIM score was significantly associated with readmission, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for low and middle versus high FIM score category of 3.0 (2.5-3.6; P < 0.001) and 1.5 (95% CI: 1.3-1.8; P < 0.001), respectively. This relationship between FIM score and read-mission held across diagnostic category. Medical patients with low functional status had the highest readmission rate (OR: 29%; 95% CI: 25%-32%) and an adjusted OR for readmission of 3.2 (95% CI: 2.4-4.3, P < 0.001) compared to medical patients with high FIM scores.
CONCLUSIONS AND RELEVANCE
For patients admitted to an acute inpatient rehabilitation facility, functional status near the time of discharge from an acute care hospital is strongly associated with acute care readmission, particularly for medical patients with greater functional impairments. Reducing functional status decline during acute care hospitalization may be an important strategy to lower readmissions.
doi:10.1002/jhm.2152
PMCID: PMC4347875  PMID: 24616216

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