Clinicians’ Perceptions of Telemedicine for Conducting Family Conferences Prior to Transfer to a Tertiary Care Center Intensive Care Unit

Objectives: Critically ill patients are often transferred from rural to tertiary care medical centres for further higher levels of care. The transportation process may delay family conferences during which prognosis and goals of care are discussed. These conferences typically occur when family members meet the treating physicians for the first time in person after transport. Telemedicine is a tool that may be used to bridge this gap in communication by enabling these family conferences before transport. There are no data on perceptions of telemedicine used in this setting. We conducted a qualitative study assessing provider perceptions regarding the use of telemedicine for conducting family conferences prior to transport. Methods: Critical care physicians and nurses were invited to view an educational video demonstrating the process of conducting a family conference via telemedicine. Immediately following viewing of the video, physicians and nurses filled out an open-ended questionnaire regarding their thoughts and perceptions of the video and the telemedicine family conference approach. Results: There was a 68% response rate to the surveys. Responses were categorised into two major themes: benefits and barriers. Within the theme of benefits, three sub-themes were identified: satisfaction, knowledge and quality of care. We identified four domains within the theme of barriers: time, perception, technology and logistics. Conclusions: Respondents believe that there may be several benefits including increased satisfaction, improved communication and empowerment of families by dissemination of knowledge. Barriers to the use of this intervention identified include costs, time, technology and negative perceptions of the telemedicine conference

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570