Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review.

Objectives: To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers.

Design: Data were synthesized from monthly expert consensus and literature review.

Setting: Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force.

Critical Care Organizations: Business of Critical Care and Value/Performance Building.

Objective: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care.

Using Incentives to Improve Resource Utilization: A Quasi-Experimental Evaluation of an ICU Quality Improvement Program.

Objectives: Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing, chest radiographs, and RBC transfusions provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease the avoidable arterial blood gases, chest radiographs, and RBC utilization on utilization of these resources and patient outcomes.

Prevalence and Impact of Unknown Diabetes in the ICU.

Objectives: Many patients with diabetes and their care providers are unaware of the presence of the disease. Dysglycemia encompassing hyperglycemia, hypoglycemia, and glucose variability is common in the ICU in patients with and without diabetes. The purpose of this study was to determine the impact of unknown diabetes on glycemic control in the ICU.

Reduced red blood cell transfusion in cardiothoracic surgery after implementation of a novel clinical decision support tool.

Background: Packed red blood cell (PRBC) transfusion can increase short- and long-term adverse outcomes and health care costs. We compared the transfusion practices in cardiothoracic surgery before and after implementation of a novel clinical decision support (CDS) tool.

Study Design: The transfusion CDS tool was implemented within computerized provider order entry of a multi-institutional urban hospital system in September 2012.

Prescribing patterns of hydrocortisone in septic shock: a single-center experience of how surviving sepsis guidelines are interpreted and translated into bedside practice.

Objectives: The Surviving Sepsis Campaign suggests giving hydrocortisone to septic patients only if their "blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy." Because the definition of "poorly responsive" is not provided, the purpose of this study was to identify prescribing triggers for hydrocortisone in septic shock.

Design: Retrospective chart review of patients with septic shock over 17 months, who received hydrocortisone, followed by a survey of all intensivists who attended in the study ICUs to determine whether provider attitudes matched clinical practice.

Patient-care time allocation by nurse practitioners and physician assistants in the intensive care unit.

Introduction: Use of nurse practitioners and physician assistants ("affiliates") is increasing significantly in the intensive care unit (ICU). Despite this, few data exist on how affiliates allocate their time in the ICU. The purpose of this study was to understand the allocation of affiliate time into patient-care and non-patient-care activity, further dividing the time devoted to patient care into billable service and equally important but nonbillable care.

Patterns and dynamics of subventricular zone neuroblast migration in the ischemic striatum of the adult mouse.

The migratory behavior of neuroblasts after a stroke is poorly understood. Using time-lapse microscopy, we imaged migration of neuroblasts and cerebral vessels in living brain slices of adult doublecortin (DCX, a marker of neuroblasts) enhanced green fluorescent protein (eGFP) transgenic mice that were subjected to 7 days of stroke. Our results show that neuroblasts originating in the subventricular zone (SVZ) of adult mouse brain laterally migrated in chains or individually to reach the ischemic striatum.

Gene profiles and electrophysiology of doublecortin-expressing cells in the subventricular zone after ischemic stroke.

Stroke increases neuroblasts in the subventricular zone (SVZ) of the lateral ventricle and these neuroblasts migrate toward the ischemic boundary to replace damaged neurons. Using brain slices from the nonischemic adult rat and transgenic mice that expressed enhanced green fluorescent protein (EGFP) concomitantly with doublecortin (DCX), a marker for migrating neuroblasts, we recorded electrophysiological characteristics while simultaneously analyzing the gene expression in single SVZ cells. We found that SVZ cells expressing the DCX gene from the nonischemic rat had a mean resting membrane potential (RMP) of -30 mV.

Neural progenitor cells treated with EPO induce angiogenesis through the production of VEGF.

Recombinant human erythropoietin (rhEPO) induces neurogenesis and angiogenesis. Using a coculture system of mouse brain endothelial cells (MBECs) and neural progenitor cells derived from the subventricular zone of adult mouse, we investigated the hypothesis that neural progenitor cells treated with rhEPO promote angiogenesis. Treatment of neural progenitor cells with rhEPO significantly increased their expression and secretion of vascular endothelial growth factor (VEGF) and activated phosphatidylinositol 3-kinase/Akt (PI3K/Akt) and extracellular signal-regulated kinase (ERK1/2).

Coupling of angiogenesis and neurogenesis in cultured endothelial cells and neural progenitor cells after stroke.

Angiogenesis and neurogenesis are coupled processes. Using a coculture system, we tested the hypothesis that cerebral endothelial cells activated by ischemia enhance neural progenitor cell proliferation and differentiation, while neural progenitor cells isolated from the ischemic subventricular zone promote angiogenesis. Coculture of neural progenitor cells isolated from the subventricular zone of the adult normal rat with cerebral endothelial cells isolated from the stroke boundary substantially increased neural progenitor cell proliferation and neuronal differentiation and reduced astrocytic differentiation.

The Sonic hedgehog pathway mediates carbamylated erythropoietin-enhanced proliferation and differentiation of adult neural progenitor cells.

Carbamylated erythropoietin (CEPO), a well characterized erythropoietin (EPO) derivative, does not bind to the classical EPO receptor and does not stimulate erythropoiesis. Using neural progenitor cells derived from the subventricular zone of the adult mouse, we investigated the effect of CEPO on neurogenesis and the associated signaling pathways in vitro. We found that CEPO significantly increased neural progenitor cell proliferation and promoted neural progenitor cell differentiation into neurons, which was associated with up-regulation of Sonic hedgehog (Shh), its receptor ptc, and mammalian achaete-scute homolog 1 (Mash1), a pro-neuron basic helix-loop-helix protein transcription factor.

Chemokine ligand 2 (CCL2) induces migration and differentiation of subventricular zone cells after stroke.

Ischemic stroke stimulates neurogenesis in the adult rodent brain. The molecules that mediate stroke-induced neurogenesis have not been fully investigated. Using a microarray containing 113 known genes associated with angiogenesis, we analyzed transcriptional profiles in subventricular zone (SVZ) tissue and in cultured neural progenitor cells isolated from the SVZ of adult mice subjected to middle cerebral artery occlusion (MCAo).

Neuroblast division during migration toward the ischemic striatum: a study of dynamic migratory and proliferative characteristics of neuroblasts from the subventricular zone.

Ischemic stroke induces neurogenesis in the subventricular zone (SVZ), and newly generated neurons in the SVZ migrate toward the ischemic boundary. However, the characteristics of migrating SVZ cells have not been investigated after stroke. Using time-lapse imaging in both SVZ cells and organotypic brain slice cultures, we measured the dynamics of SVZ cell division and migration of adult rats subjected to stroke.

Stroke induces ependymal cell transformation into radial glia in the subventricular zone of the adult rodent brain.

Adult ependymal cells are postmitotic and highly differentiated. Radial glial cells are neurogenic precursors. Here, we show that stroke acutely stimulated adult ependymal cell proliferation, and dividing ependymal cells of the lateral ventricle had genotype, phenotype, and morphology of radial glial cells in the rat.

Matrix metalloproteinase 2 (MMP2) and MMP9 secreted by erythropoietin-activated endothelial cells promote neural progenitor cell migration.

We investigated the hypothesis that endothelial cells activated by erythropoietin (EPO) promote the migration of neuroblasts. This hypothesis is based on observations in vivo that treatment of focal cerebral ischemia with EPO enhances the migration of neuroblasts to the ischemic boundary, a site containing activated endothelial cells and angiogenic microvasculature. To model the microenvironment within the ischemic boundary zone, we used a coculture system of mouse brain endothelial cells (MBECs) and neural progenitor cells derived from the subventricular zone of the adult mouse.

Neurogenin 1 mediates erythropoietin enhanced differentiation of adult neural progenitor cells.

Proneuronal basic helix-loop-helix (bHLH) transcription factor, neurogenin 1 (Ngn1), regulates neuronal differentiation during development of the cerebral cortex. Akt mediates proneuronal bHLH protein function to promote neuronal differentiation. Here, we show that recombinant human erythropoietin (rhEPO) significantly increased Akt activity and Ngn1 mRNA levels in neural progenitor cells derived from the subventricular zone (SVZ) of adult rat, which was coincident with increases of neural progenitor cell proliferation, differentiation, and neurite outgrowth.