Cases and Review of the Literature : Three * Lactic Acidosis in Status Asthmaticus

found online on the World Wide Web at: The online version of this article, along with updated information and services can be ) ISSN:0012-3692 http://chestjournal.chestpubs.org/site/misc/reprints.xhtm

Antimicrobial stewardship for sepsis in the intensive care unit: Survey of critical care and infectious diseases physicians

OBJECTIVE: To evaluate the attitudes of infectious diseases (ID) and critical care physicians toward antimicrobial stewardship in the intensive care unit (ICU). DESIGN: Anonymous, cross-sectional, web-based surveys. SETTING: Surveys were completed in March-November 2017, and data were analyzed from December 2017 to December 2019. PARTICIPANTS: ID and critical care fellows and attending physicians. METHODS: We included 10 demographic and 17 newly developed, 5-point, Likert-scaled items measuring attitudes toward ICU antimicrobial stewardship and transdisciplinary collaboration. Exploratory principal components analysis (PCA) was used for data reduction. Multivariable linear regression models explored demographic and attitudinal variables. RESULTS: Of 372 respondents, 315 physicians had complete data (72% attendings, 28% fellows; 63% ID specialists, and 37% critical care specialists). Our PCA yielded a 3-item factor measuring which specialty should assume ICU antimicrobial stewardship (Cronbach standardized α = 0.71; higher scores indicate that ID physicians should be stewards), and a 4-item factor measuring value of ICU transdisciplinary collaborations (α = 0.62; higher scores indicate higher value). In regression models, ID physicians (vs critical care physicians), placed higher value on ICU collaborations and expressed discomfort with uncertain diagnoses. These factors were independently associated with stronger agreement that ID physicians should be ICU antimicrobial stewards. The following factors were independently associated with higher value of transdisciplinary collaboration: female sex, less discomfort with uncertain diagnoses, and stronger agreement with ID physicians as ICU antimicrobial stewards. CONCLUSIONS: ID and critical care physicians endorsed their own group for antimicrobial stewardship, but both groups placed high value on ICU transdisciplinary collaborations. Physicians who were more uncomfortable with uncertain diagnoses reported preference for ID physicians to coordinate ICU antimicrobial stewardship; however, physicians who were less uncomfortable with uncertain diagnoses placed greater value on ICU collaborations

A practical approach to adult acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a common disease encountered in hospitalized adult patients that, historically, has carried a very high mortality. This article reviews the clinical features and how pathophysiology informs the evidence-based management of ARDS

A practical approach to adult acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a common disease encountered in hospitalized adult patients that, historically, has carried a very high mortality. This article reviews the clinical features and how pathophysiology informs the evidence-based management of ARDS

Will My Job Be Safe if I Defend My Patients?: When Patient Advocacy Collides with Employment Law

Physicians are moving increasingly from self-employed, private practices to at-will employment relationships. This historic change in the organizational administration of medical services is likely to accelerate as the Affordable Care Act is implemented and as accountable care organizations permeate the medical marketplace. Physicians vow an ascendant oath to safeguard patients\u27 welfare, but as they become employees, they may sign legal contracts that also oblige obedience to the institutions that hire them. What happens when an employer makes a decision that is not in the best interests of patients and the physicians fulfill their Hippocratic obligation to voice dissent on their patients\u27 behalf rather than abiding by their contractual obligation to obey their employer? This article explores the philosophical and legal ramifications of this potential collision of obligations to patients and to employers. As health-care spending is reined in, hospitals will face the ever-increasing challenge of balancing financial considerations with ethical responsibilities to patients. In efforts to control costs, providers might make decisions that endanger patient health, provoking dissent from clinician-employees who are ethically obligated to advocate for their patients. Hospitals might implement cost-saving measures that inadvertently negatively affect health because they deem such measures to be the lesser of evils when the alternative is financial distress. But when that happens, could a clinician be fired for speaking against corporate policy, or does he or she have a right to speak without fear of retribution? As more clinicians become employees rather than independent contractors, the protections available for employee speech become highly relevant to health care, and particularly to patient safety. Current understanding is that there are \u3e 100,000 preventable deaths each year in American hospitals, and only clinicians\u27 empowered participation through speech aimed at defining and repairing unsafe systems can curb this unacceptable statistic. The law in most states, however, does not provide clear protection from retaliation for health-care professionals engaged in patient advocacy. This article, therefore, urges reform to provide such protection as well as urges health-care professionals within and beyond corporate entities to work toward construction of just cultures in which every member of the health-care team is empowered and encouraged to report problems