The Burden Of Diarrhea: A Survey Of The Caregivers’ Opinions And Perceptions Of Workload In The Intensive Care Unit

In the literature, the prevalence of diarrhea in the Intensive Care Unit (ICU) has been reported to be 3.3-78%. The problem is significant to patients and also increases workload burden for ICU staff. Unfortunately, research on this topic is very limited; we found one single study on the impact that diarrhea has on nursing staff workload. Therefore, we conducted a retrospective chart review to describe the prevalence and impact of diarrhea in our organization. For the purposes of this study, we equated diarrhea with type 7 stools as defined in the Bristol Stool Form Scale. In January of 2018, we developed a bowel management guideline and rolled out the associated protocol in a multifaceted implementation process which included a variety of educational strategies. Toward promoting the use of the tool in practice, we sought to assess staff perceptions of the resources and time needed to manage diarrhea and bowel function with a survey that was administered to ICU staff in a 600 bed, level one trauma center. The purpose of this poster is to describe the findings from a survey to assess perceptions of workload after the implementation of the new bowel management guidelines

Implementation of a COPD inpatient clinical pathway with a dedicated respiratory therapist team.

Background: In 2014 our facility admitted 325 patients diagnosed with acute exacerbation of COPD (AE COPD), 14% of which required readmission within 30 days. Although below the Centers for Medicare and Medicaid penalty threshold, we hypothesized that significant variations in care in our system resulted in inefficient care, suboptimal clinical outcomes, and increased cost. We created a COPD clinical pathway and a dedicated respiratory therapist (RT) team to provide patient and family education and medication management. Baseline metrics showed an average LOS of 3.76 days, and patient satisfaction scores of 53% regarding care transitions, 84% for discharge medications, and 80% for communication about medications. Method: A multidisciplinary task force, led by a pulmonologist and a hospitalist, created a COPD inpatient pathway. The Acute Exacerbation COPD order set was revised to include standardized medication and consultation orders. A new policy allows the RTs to modify and enter inhaled medications based on the COPD gold guidelines. With our parent health system, Maine Health, COPD educational materials where created to be shared throughout the system. RTs on the education team were trained with gold guidelines and attended the AARC\u27s Chronic Disease Educator program. The COPD program provides daily evaluation, patient and family education, and communication with the primary team and case managers. Discharge teaching and patient instructions regarding inhaled medications, airway clearance, and oxygen conserving techniques are all provided by the RT. Results: The program was initiated January 2016. A 10 week evaluation of the program reveals that the order set has been used 61 times, 22 of which were for non-AE COPD patients. The RTs saw 98% of those patients on the pathway, with average LOS of 4 days and a 15% readmission rate. Patient satisfaction data is unavailable at this time. Conclusions: Review of order set usage identifies a culture of unwillingness of the primary medical team to order specialty service consults. Evaluation of readmission data indicates that along with barriers to best practice care identified in the area of medication access and patient compliance, patients felt they were discharged too early from a previous admission. The RTs on the team will be instituting use of the IHI State Action on Avoidable Hospital Admissions (STARR) tool to evaluate discrete readmission data

Hemodynamic, Biochemical, and Ventilatory Parameters are Independently Associated with Outcome after Cardiac Arrest.

BACKGROUND: Hypotension, hyperglycemia, dysoxia, and dyscarbia may contribute to reperfusion injury, and each is independently associated with poor outcome (PO) after cardiac arrest. We investigated whether the combined effects of these physiological derangements are associated with cardiac arrest outcomes. METHODS: This institutional review board-approved retrospective cohort study included consecutive resuscitated cardiac arrest patients that received targeted temperature management at Maine Medical Center from 2013 to 2015. We abstracted demographics, intra-arrest factors, and physiological parameters. The primary outcome was dichotomized cerebral performance category (CPC 1-2 vs 3-5) at hospital discharge. After comparing demographics, clinical factors, and persistent post-arrest physiological derangements in patients with good and PO, we constructed a logistic regression model comprised of clinical and demographic factors separately associated with severity, and physiology variables, attempting to evaluate the independent effects of persistent physiological derangements on outcome. RESULTS: Sixty-eight of 222 (31%) patients had CPC 1-2 (good outcome [GO]) at discharge. In bivariate analysis, factors associated with PO included increased time from collapse to resuscitation, non-shockable rhythm, and age-combined Charlson comorbidity index. In multivariate analysis, each persistent physiological derangement incrementally decreased the likelihood of GO [OR GO per derangement 0.71 (interquartile range [IQR] 0.51-0.99), p = 0.042, area under the curve (AUC) for final model 0.769]. CONCLUSIONS: Uncorrected physiological derangements in the first 24 h after cardiac arrest are independently associated with PO. Although causality cannot be established, these findings support preclinical models suggesting that aggressive normalization of physiology after resuscitation may be a reasonable strategy to decrease reperfusion injury

Clinical and immunological features of post-resuscitation care

Background Patients treated after resuscitation from cardiac arrest (CA) have different levels of neurological, circulatory, and systemic ischemia?reperfusion injuries, as well as variable immune-inflammatory profiles; in some patients, inflammation may be a treatment target. Clinical and immune-inflammatory phenotypes are poorly characterized; our preliminary data show that CD73+ lymphocytes are anti-inflammatory by downregulating neutrophil activation status. We hypothesized that after resuscitation from CA, different profiles of circulating neutrophils, CD73+ lymphocytes and neutrophil/CD73+ lymphocyte ratios would correspond to recognizable clinical phenotypes. The aim of this study was to evaluate how the clinical features differ among groups of patients with different immunological profiles after resuscitation from CA. Methods We reexamined existing data included in the Post Cardiac Arrest Syndrome (PCAS) study (NCT02664831, MMC IRB#4684) and in Maine Medical Center’s cardiac arrest database. Patients ? 18 years admitted to the intensive care unit after cardiopulmonary arrest, and treated with targeted temperature management were enrolled in the PCAS study after informed consent. Blood samples were collected from enrolled individuals at predetermined intervals over a week after return of spontaneous circulation (ROSC), and analyzed for numbers of white blood cell subtypes. Clinical data were also collected: time to ROSC, initial rhythm, no flow interval, low flow interval, shock, outcomes, and other clinical features. Neutrophils, CD73+ lymphocytes, and the neutrophil/CD73+ lymphocyte ratio at 24 hours after ROSC were measured and tertiles developed. We then evaluated the clinical features of patients within each tertile by calculating the median (IQR), or number (percent) of each. Differences across groups were analyzed using Kruskal-Wallis, Fisher’s exact, or Chi-square tests of independence. All statistical analyses were conducted in R, and p-values ?0.05 considered statistically significant. Results Forty-eight patients were sorted into tertiles of 16 each. Age, gender, and most elements of the past medical history were not associated with neutrophil levels, CD73+ lymphocytes, or the neutrophil/CD73+ ratio at 24 hours after resuscitation. However, high neutrophils were associated with an increased duration of ischemia, especially prolonged low-flow time (with CPR), a non-shockable rhythm, smoking, and pre-existing renal disease. Low CD73+ lymphocytes were associated with worse outcomes, as was a high neutrophil/CD73+ ratio. Conclusions Although limited by sample size, we found significant differences in clinical features of patients with different levels of neutrophils, CD73+ lymphocytes and neutrophil/CD73+ ratio. The CD73+ lymphocyte count and the neutrophil to CD73+ ratio may be independent risk factors for poor outcome after resuscitation, unrelated to clinical features like duration of the arrest or an initial shockable rhythm; these classifications may facilitate immunomodulatory therapies for cardiac arrest. In order to gain a better understanding of how clinical features in CA patients differ depending on immunological profiles, further studies with larger study populations are needed

Surface cooling after cardiac arrest: effectiveness, skin safety, and adverse events in routine clinical practice.

BACKGROUND: Effectiveness of cooling and adverse events (AEs) involving skin have not been intensively evaluated in cardiac arrest survivors treated with therapeutic hypothermia (TH) when induced and maintained with a servomechanism-regulated surface cooling system. METHODS: Retrospective review of sixty-nine cardiac arrest survivor-events admitted from April 2006-September 2008 who underwent TH using the Medivance Arctic Sun Temperature Management System. A TH database and medical records were reviewed, and nursing interviews conducted. Primary endpoint was time from initiation to target temperature (TT; 32-34 °C). Secondary endpoints were cooling rate, percentage of hypothermia maintenance phase at TT, effect of body-mass index (BMI) on rate of cooling, and AEs. RESULTS: Mean time to the target temperature (TT) was 2.78 h; 80% of patients achieved TT within 4 h; all did within 8 h. Patients were at TT for 96.7% of hypothermia maintenance; 17% of patients had \u3e1 hourly temperature measurement outside TT range. Mean cooling rate during induction phase was 1.1 °C/h, and was not associated with BMI. Minor skin injury occurred in 14 (20%) patients; 4 (6%) were device-related. Skin injuries were associated with shock (P = 0.04), and decubitus ulcers were associated with left ventricular ejection fraction CONCLUSIONS: The Arctic Sun Temperature Management System was an effective means of performing therapeutic hypothermia after cardiac arrest. Infrequent skin injuries were associated with vasopressor use and low ejection fraction

Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006-2011: interplay of age, do-not-resuscitate order, and outcomes.

OBJECTIVES: It is not known if aggressive postresuscitation care, including therapeutic hypothermia and percutaneous coronary intervention, benefits cardiac arrest survivors more than 75 years old. We compared treatments and outcomes of patients at six regional percutaneous coronary intervention centers in the United States to determine if aggressive care of elderly patients was warranted. DESIGN: Retrospective evaluation of registry data. SETTING: Six interventional cardiology centers in the United States. PATIENTS: Six hundred and twenty-five unresponsive cardiac arrest survivors aged 18-75 were compared with 129 similar patients aged more than 75. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cardiac arrest survivors aged more than 75 had more comorbidities (3.0 ± 1.6 vs 2.0 ± 1.6, p \u3c 0.001), but were matched to younger patients in initial heart rhythm, witnessed arrests, bystander cardiopulmonary resuscitation, and total ischemic time. Patients aged more than 75 frequently underwent therapeutic hypothermia (97.7%), urgent coronary angiography (44.2%), and urgent percutaneous coronary intervention (24%). They had more sustained hyperglycemia (70.5% vs 59%, p = 0.015), less postcooling fever (25.2% vs 35.2%, p = 0.03), were more likely to have do-not-resuscitate orders (65.9% vs 48.2%, p \u3c 0.001), and undergo withdrawal of life support (61.2% vs 47.5%, p = 0.005). Good functional outcome at 6 months (Cerebral Performance Category 1-2) was seen in 27.9% elderly versus 40.4% younger patients overall (p = 0.01) and in 44% versus 55% (p = 0.13) of patients with an initial shockable rhythm. Of 35 survivors more than 75 years old, 33 (94.8%) were classified as Cerebral Performance Category 1 or 2 at (mean) 6.5-month follow-up. In multivariable logistic regression modeling, age more than 75 was significantly associated with outcome only when the presence of a do-not-resuscitate order was excluded from the model. CONCLUSIONS: Elderly patients were more likely to have do-not-resuscitate orders and to undergo withdrawal of life support. Age was independently associated with outcome only when correction for do-not-resuscitate status was excluded, and functional outcomes of elderly survivors were similar to younger patients. Exclusion of patients more than 75 years old from aggressive care is not warranted on the basis of age alone

Feasibility of bispectral index monitoring to guide early post-resuscitation cardiac arrest triage.

INTRODUCTION: Triage after resuscitation from cardiac arrest is hindered by reliable early estimation of brain injury. We evaluated the performance of a triage model based on early bispectral index (BIS) findings and cardiac risk classes. METHODS: Retrospective evaluation of serial patients resuscitated from cardiac arrest, unable to follow commands, and undergoing hypothermia. Patients were assigned to a cardiac risk group: STEMI, VT/VF shock, VT/VF no shock, or PEA/asystole, and to a neurological dysfunction group, based on the BIS score following first neuromuscular blockade (BISi), and classified as BISi\u3e20, BISi 10-20, or BISi RESULTS: BISi in 171 patients was measured at 267(±177)min after resuscitation and 35(±1.7)°C. BISi82% neurological-cause and 91% overall mortality, BISi 10-20 35% neurological and 55% overall mortality, and BISi\u3e20 12% neurological and 36% overall mortality. 33 patients presented with STEMI, 15 VT/VF-shock, 41 VT/VF-no shock, and 80 PEA/asystole. Among BISi\u3e20 patients, 75% with STEMI underwent urgent cardiac catheterization (cath) and 94% had good outcome. When BISi\u3e20 with VT/VF and shock, urgent cath was infrequent (33%), and 4 deaths (44%) were uniformly of circulatory etiology. Of 56 VT/VF patients without STEMI, 24 were BISi\u3e20 but did not undergo urgent cath - 5(20.8%) of these had circulatory-etiology death. Circulatory-etiology death also occurred in 26.5% BIS\u3e20 patients with PEA/asystole. When BISi CONCLUSIONS: Neurocardiac triage based on very early processed EEG (BIS) is feasible, and may identify patients appropriate for individualized post-resuscitation care. This and other triage models warrant further study

Neurologic outcomes and postresuscitation care of patients with myoclonus following cardiac arrest.

OBJECTIVES: To evaluate the outcomes of cardiac arrest survivors with myoclonus receiving modern postresuscitation care. DESIGN: Retrospective review of registry data. SETTING: Cardiac arrest receiving centers in Europe and the United States from 2002 to 2012. PATIENTS: Two thousand five hundred thirty-two cardiac arrest survivors 18 years or older enrolled in the International Cardiac Arrest Registry. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eighty-eight percent of patients underwent therapeutic hypothermia and 471 (18%) exhibited myoclonus. Patients with myoclonus had longer time to professional cardiopulmonary resuscitation (8.6 vs 7.0 min; p \u3c 0.001) and total ischemic time (25.6 vs 22.3 min; p \u3c 0.001) and less often presented with ventricular tachycardia/ventricular fibrillation, a witnessed arrest, or had bystander cardiopulmonary resuscitation. Electroencephalography demonstrated myoclonus with epileptiform activity in 209 of 374 (55%), including status epilepticus in 102 of 374 (27%). Good outcome (Cerebral Performance Category 1-2) at hospital discharge was noted in 9% of patients with myoclonus, less frequently in myoclonus with epileptiform activity (2% vs 15%; p \u3c 0.001). Patients with myoclonus with good outcome were younger (53.7 vs 62.7 yr; p \u3c 0.001), had more ventricular tachycardia/ventricular fibrillation (81% vs 46%; p \u3c 0.001), shorter ischemic time (18.9 vs 26.4 min; p = 0.003), more witnessed arrests (91% vs 77%; p = 0.02), and fewer do-not-resuscitate orders (7% vs 78%; p \u3c 0.001). Life support was withdrawn in 330 of 427 patients (78%) with myoclonus and poor outcome, due to neurological futility in 293 of 330 (89%), at 5 days (3-8 d) after resuscitation. With myoclonus and good outcome, median ICU length of stay was 8 days (5-11 d) and hospital length of stay was 14.5 days (9-22 d). CONCLUSIONS: Nine percent of cardiac arrest survivors with myoclonus after cardiac arrest had good functional outcomes, usually in patients without associated epileptiform activity and after prolonged hospitalization. Deaths occurred early and primarily after withdrawal of life support. It is uncertain whether prolonged care would yield a higher percentage of good outcomes, but myoclonus of itself should not be considered a sign of futility

Derivation and validation of the CREST model for very early prediction of circulatory etiology death in patients without ST-segment-elevation myocardial infarction after cardiac arrest.

BACKGROUND: No practical tool quantitates the risk of circulatory-etiology death (CED) immediately after successful cardiopulmonary resuscitation in patients without ST-segment-elevation myocardial infarction. We developed and validated a prediction model to rapidly determine that risk and facilitate triage to individualized treatment pathways. METHODS: With the use of INTCAR (International Cardiac Arrest Registry), an 87-question data set representing 44 centers in the United States and Europe, patients were classified as having had CED or a combined end point of neurological-etiology death or survival. Demographics and clinical factors were modeled in a derivation cohort, and backward stepwise logistic regression was used to identify factors independently associated with CED. We demonstrated model performance using area under the curve and the Hosmer-Lemeshow test in the derivation and validation cohorts, and assigned a simplified point-scoring system. RESULTS: Among 638 patients in the derivation cohort, 121 (18.9%) had CED. The final model included preexisting coronary artery disease (odds ratio [OR], 2.86; confidence interval [CI], 1.83-4.49; CONCLUSIONS: The CREST model stratified patients immediately after resuscitation according to risk of a circulatory-etiology death. The tool may allow for estimation of circulatory risk and improve the triage of survivors of cardiac arrest without ST-segment-elevation myocardial infarction at the point of care