Physicians could greatly benefit from automated diagnosis and prognosis tools to help address information overload and decision fatigue. Intensive care physicians stand to benefit greatly from such tools as they are at particularly high risk for those factors. Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition affecting >10% of critical care patients and has a mortality rate over 40%.
View Article and Find Full Text PDFIn critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work.
View Article and Find Full Text PDFUnder-recognition of acute respiratory distress syndrome (ARDS) by clinicians is an important barrier to adoption of evidence-based practices such as low tidal volume ventilation. The burden created by the COVID-19 pandemic makes it even more critical to develop scalable data-driven tools to improve ARDS recognition. The objective of this study was to validate a tool for accurately estimating clinician ARDS recognition rates using discrete clinical characteristics easily available in electronic health records.
View Article and Find Full Text PDFBackground: Adoption of innovations in the field of medicine is frequently hindered by a failure to recognize the condition targeted by the innovation. This is particularly true in cases where recognition requires integration of patient information from different sources, or where disease presentation can be heterogeneous and the recognition step may be easier for some patients than for others.
Methods: We propose a general data-driven metric for clinician recognition that accounts for the variability in patient disease severity and for institutional standards.
Unlabelled: Low tidal volume ventilation and prone positioning are recommended therapies yet underused in acute respiratory distress syndrome. We aimed to assess the role of interventions focused on implementation of low tidal volume ventilation and prone positioning in mechanically ventilated adult patients with acute respiratory distress syndrome.
Data Sources: PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials.
Decisions in medicine are made on the basis of knowledge and reasoning, often in shared conversations with patients and families in consideration of clinical practice guideline recommendations, individual preferences, and individual goals. Observational studies can provide valuable knowledge to inform guidelines, decisions, and policy. The American Thoracic Society (ATS) created a multidisciplinary committee to develop a research statement to clarify the role of observational studies-alongside randomized controlled trials (RCTs)-in informing clinical decisions in pulmonary, critical care, and sleep medicine.
View Article and Find Full Text PDFIntensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration.
View Article and Find Full Text PDFEducation in quality improvement (QI) is endorsed by the Association of American Medical Colleges across the spectrum of undergraduate, graduate, and postgraduate training. QI training is also a required component of graduate medical training per the American College of Graduate Medical Education. Despite widespread recognition of the importance of QI education and high levels of trainee involvement in QI as reported by pulmonary and critical care fellowship program directors, significant barriers to the implementation of effective and meaningful QI education during training exist.
View Article and Find Full Text PDFGuideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012.
View Article and Find Full Text PDFImportance: Despite its efficacy, low tidal volume ventilation (LTVV) remains severely underutilized for patients with acute respiratory distress syndrome (ARDS). Physician under-recognition of ARDS is a significant barrier to LTVV use. We propose a computational method that addresses some of the limitations of the current approaches to automated measurement of whether ARDS is recognized by physicians.
View Article and Find Full Text PDFCurr Opin Crit Care
October 2017
Purpose Of Review: The use of evidence-based practices in clinical practice is frequently inadequate. Recent research has uncovered many barriers to the implementation of evidence-based practices in critical care medicine. Using a comprehensive conceptual framework, this review identifies and classifies the barriers to implementation of several major critical care evidence-based practices.
View Article and Find Full Text PDFRationale: Low-Vt ventilation lowers mortality in patients with acute respiratory distress syndrome (ARDS) but is underused. Little is known about clinician attitudes toward and perceived barriers to low-Vt ventilation use and their association with actual low-Vt ventilation use.
Objectives: The objectives of this study were to assess clinicians' attitudes toward and perceived barriers to low-Vt ventilation (Vt <6.
Am J Respir Crit Care Med
February 2017
Background: Studies of nighttime intensivist staffing have yielded mixed results.
Goals: To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients.
Methods: We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay.
Background: Many advances in health care fail to reach patients. Implementation science is the study of novel approaches to mitigate this evidence-to-practice gap.
Methods: The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement on implementation science in pulmonary, critical care, and sleep medicine.
Objective: Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use.
View Article and Find Full Text PDFObjective: The primary aim of this secondary analysis was to determine whether cardiac autonomic neuropathy independently predicted adverse cardiac outcomes in asymptomatic individuals with type 2 diabetes. Additional aims include the determination of the correlation of standard autonomic testing measures and power spectral analysis of heart rate variability, and the association of diabetes-related and cardiac risk factors with cardiac autonomic neuropathy measures.
Methods: Cardiac autonomic neuropathy was assessed at the study entry into the Detection of Ischemia in Asymptomatic Diabetics study, using autonomic heart rate and blood pressure testing, and power spectral analysis of heart rate variability.
To advance implementation research (IR) in respiratory, sleep, and critical care medicine, the American Thoracic Society and the Division of Lung Diseases from the NHLBI cosponsored an Implementation Research Workshop on May 17, 2014. The goals of IR are to understand the barriers and facilitators of integrating new evidence into healthcare practices and to develop and test strategies that systematically target these factors to accelerate the adoption of evidence-based care. Throughout the workshop, presenters provided examples of IR that focused on the rate of adoption of evidence-based practices, the feasibility and acceptability of interventions to patients and other stakeholders who make healthcare decisions, the fidelity with which practitioners use specific interventions, the effects of specific barriers on the sustainability of an intervention, and the implications of their research to inform policies to improve patients' access to high-quality care.
View Article and Find Full Text PDFRationale: Quality improvement (QI) is a required component of fellowship training in pulmonary, critical care, and sleep medicine. However, little is known about how training programs approach QI education.
Objectives: We sought to understand the perceptions of pulmonary, critical care, and sleep medicine training program directors toward QI education.
Adoption of innovations, whether new ideas, technologies, or products, is crucially important to knowledge societies. The landmark studies of adoption dealt with innovations having great societal impact (such as antibiotics or hybrid crops) but where determining the utility of the innovation was straightforward (such as fewer side effects or greater yield). Recent large-scale studies of adoption were conducted within heterogeneous populations and focused on products with little societal impact.
View Article and Find Full Text PDFThe Nationwide Inpatient Sample aggregated data from approximately 20% of US hospital admissions from 1993 to 2011. Prior literature found that pneumonia admissions decreased following the introduction of the pneumococcal vaccine in 2000. The (), codes provide information regarding pneumonia pathogens, but no studies, to our knowledge, have used these codes to analyze longitudinal trends in the pathogens documented during hospitalizations for pneumonia.
View Article and Find Full Text PDFAm J Respir Crit Care Med
September 2013
Curr Opin Crit Care
October 2013
Purpose Of Review: Failed opportunities to reduce morbidity and mortality occur when evidence-based therapies are not fully implemented in clinical practice. We reviewed the recent literature on implementation strategies in the intensive care unit, with particular attention to antibiotic therapy.
Recent Findings: Emphasis in implementation science has shifted to new models that focus more on direct, point-of-care interaction with providers as opposed to an administrative or top-down approach.
Objectives: To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record.
Design: Random allocation design.
Setting: Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center.