CHEST critical care最新文献

英文中文

Innovation and Adaptation in COVID-19 Pandemic Posthospital Discharge Contact and Monitoring in the United States 美国COVID-19大流行患者出院后接触与监测的创新与适应

CHEST critical care

Pub Date : 2024-12-01 DOI: 10.1016/j.chstcc.2024.100101

Katrina E. Hauschildt PhD , Jacquelyn Miller MA , Nathan Wright MA , Amanda Schutz PhD , Lexi Wilhelmsen MPH , Katharine Seagly PhD , Sara E. Golden PhD , Aluko A. Hope MD , Kelly C. Vranas MD , Catherine L. Hough MD , Thomas S. Valley MD

Background

To address unknown risk for readmission among patients with COVID-19 and persistent capacity strain, hospital systems used postdischarge contact and monitoring to facilitate safe discharge and recovery. However, little work has systematically documented how hospitals implemented changes to hospitalization postdischarge contact practices during COVID-19.

Research Question

How did hospitals’ innovate and adapt postdischarge telephone follow-up and remote monitoring strategies to assess discharged patients with COVID-19 for risk of readmission and recovery progress?

Study Design and Methods

Semistructured interviews were conducted (January 2022 to March 2023) with 70 inpatient and outpatient providers and administrators (5-12 per site) in nine health systems that varied by size, region, rurality, proportion of Medicaid patients, and estimated scale of post-COVID-19 care organization. Participants described innovation in and implementation of discharge and postdischarge care processes used to assess patients with COVID-19 for readmission risk and recovery progress. The primary analysis was site-level case comparative analysis.

Results

Respondents described hospital systems’ motivations for adapting preexisting resources and innovating new postdischarge programs, including postdischarge telephone follow-up and remote monitoring programs, to facilitate safe hospital discharge and transitions to ambulatory care for patients with COVID-19. Respondents also explained various factors that influenced the implementation and use of postdischarge contact practices. Participants perceived that these practices mitigated postdischarge risks and alleviated capacity strain. Respondents described retiring or adapting remote monitoring programs for other conditions as COVID-19 demands declined.

Interpretation

Our results show that hospitals implemented and adapted postdischarge practices to help facilitate recovery and address unknown risk for readmission during the pandemic. Some efforts may present opportunities to manage readmission concerns and capacity strain more generally.

背景：为了解决COVID-19患者再入院的未知风险和持续的能力紧张，医院系统采用出院后接触和监测方法，以促进安全出院和康复。然而，很少有工作系统地记录了医院在COVID-19期间如何实施住院出院后接触做法的变化。研究问题：医院如何创新和调整出院后电话随访和远程监测策略来评估出院COVID-19患者的再入院风险和康复进展？研究设计和方法在2022年1月至2023年3月期间，对9个卫生系统的70名住院和门诊提供者和管理人员（每个站点5-12人）进行了半结构化访谈，这些卫生系统因规模、地区、农村、医疗补助患者比例和covid -19后护理组织的估计规模而异。与会者描述了用于评估COVID-19患者再入院风险和康复进展的出院和出院后护理流程的创新和实施情况。主要分析是现场水平的病例比较分析。结果受访者描述了医院系统调整现有资源和创新新的出院后计划（包括出院后电话随访和远程监测计划）的动机，以促进COVID-19患者的安全出院和向门诊护理过渡。受访者还解释了影响出院后接触做法实施和使用的各种因素。与会者认为，这些做法减轻了出院后的风险，减轻了能力紧张。受访者表示，随着COVID-19需求下降，他们将退休或调整远程监测计划以适应其他情况。我们的研究结果表明，医院实施并调整了出院后的做法，以帮助促进康复，并解决大流行期间再入院的未知风险。一些努力可能为更普遍地管理再入院问题和能力紧张提供机会。

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引用次数: 0

Silent Burdens 无声的负担

CHEST critical care

Pub Date : 2024-11-04 DOI: 10.1016/j.chstcc.2024.100106

Cassiano Teixeira MD, PhD

引用次数: 0

Prevalence of Inpatient Pulse Oximetry in Operative and Nonoperative Settings 手术和非手术环境中住院病人脉搏氧饱和度测量的普遍性

CHEST critical care

Pub Date : 2024-10-28 DOI: 10.1016/j.chstcc.2024.100104

Nicholas A. Bosch MD , Anica C. Law MD , Ashraf Fawzy MD, MPH , Theodore J. Iwashyna MD, PhD

引用次数: 0

Operationalizing the New Global Definition of ARDS 落实 ARDS 的新全球定义

CHEST critical care

Pub Date : 2024-10-28 DOI: 10.1016/j.chstcc.2024.100103

George L. Anesi MD, MSCE, MBE , Arisha Ramkillawan MBChB , Jonathan Invernizzi MBBCh, MMed , Stella M. Savarimuthu MD , Robert D. Wise MBChB, MMed , Zane Farina MBChB , Michelle T.D. Smith MBChB, PhD

Background

A proposed new global definition of ARDS seeks to update the Berlin definition and account for nonintubated ARDS and ARDS diagnoses in resource-variable settings.

Research Question

How do ARDS epidemiologic characteristics change with operationalizing the new global definition of ARDS in a resource-limited setting?

Study Design and Methods

We performed a real-use retrospective cohort study among adult patients meeting criteria for the Berlin definition of ARDS or the global definition of ARDS at ICU admission in two public hospitals in the KwaZulu-Natal Department of Health, South Africa, from January 2017 through June 2022.

Results

Among 5,760 adults (aged ≥ 18 years) admitted to the ICU, 2,027 patients (35.2%) met at least one ARDS definition, including 1,218 patients meeting the Berlin definition of ARDS (60.1% of all ARDS diagnoses) and 809 new diagnoses of the global definition of ARDS that were not captured by the Berlin definition alone (39.9% of all ARDS diagnoses and 14.0% of all ICU admissions). After adjustment for hospital-level factors, patients who met only the global definition of ARDS criteria (ie, who would not have been captured by the Berlin definition) showed no statistically significant ICU mortality difference vs patients with ARDS according to the Berlin definition (21.7% [95% CI, 18.9%-24.4%] vs 23.8% [95% CI, 21.5%-26.2%]; OR, 0.88 [95% CI, 0.70-1.10]; P = .25). In prespecified exploratory subgroup analyses, patients without COVID-19 who met only the criteria for the global definition of ARDS showed reduced ICU mortality (14.2% [95% CI, 11.6%-16.9%] vs 22.2% [95% CI, 19.8%-24.6%]; OR, 0.58 [95% CI, 0.45-0.75]; P < .0005) compared with patients without COVID-19 who met the Berlin definition for ARDS.

Interpretation

The new global definition of ARDS captures a significant proportion of patients who would not have been included by the Berlin definition alone. These additional patients with ARDS may have heterogenous patterns of outcomes among diagnostic subgroups, including by COVID-19 status, compared with patients with ARDS according to the Berlin definition.

研究背景ARDS的新全球定义旨在更新柏林定义，并考虑非插管ARDS和资源变化环境中的ARDS诊断。研究问题在资源有限的环境中，ARDS的流行病学特征如何随着ARDS新全球定义的实施而变化？研究设计和方法我们对2017年1月至2022年6月在南非夸祖鲁-纳塔尔省卫生部的两家公立医院ICU入院时符合柏林ARDS定义或全球ARDS定义标准的成年患者进行了实际使用的回顾性队列研究。结果在入住重症监护室的5760名成人（年龄≥18岁）中，有2027名患者（35.2%）符合至少一种ARDS定义，其中1218名患者符合ARDS的柏林定义（占所有ARDS诊断的60.1%），809名新诊断的ARDS全球定义未被柏林定义单独捕获（占所有ARDS诊断的39.9%，占所有ICU入院人数的14.0%）。在对医院层面的因素进行调整后，仅符合ARDS全球定义标准的患者（即柏林定义未涵盖的患者）与根据柏林定义诊断的ARDS患者相比，其ICU死亡率差异无统计学意义（21.7% [95% CI, 18.9%-24.4%] vs 23.8% [95% CI, 21.5%-26.2%]; OR, 0.88 [95% CI, 0.70-1.10]; P = .25）。在预设的探索性亚组分析中，没有 COVID-19 且仅符合 ARDS 整体定义标准的患者 ICU 死亡率降低（14.2% [95% CI, 11.6%-16.9%] vs 22.2% [95% CI, 19.8%-24.6%]; OR, 0.58 [95% CI, 0.45-0.释义ARDS的新全球定义捕获了很大一部分仅按照柏林定义无法纳入的患者。与根据柏林定义的 ARDS 患者相比，这些新增的 ARDS 患者在诊断亚组中可能会有不同的预后模式，包括 COVID-19 状态。

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引用次数: 0

Corrigendum to: Psomiadis JS, Khawaja A, Zimmerman J. CHEST Critical Care. 2023;1(3):100022 Corrigendum to：Psomiadis JS, Khawaja A, Zimmerman J. CHEST Critical Care.2023;1(3):100022

CHEST critical care

Pub Date : 2024-10-25 DOI: 10.1016/j.chstcc.2024.100105

引用次数: 0

Transitions of Care Between Community to Hospital and Back Again 从社区到医院再到医院的护理过渡

CHEST critical care

Pub Date : 2024-10-19 DOI: 10.1016/j.chstcc.2024.100102

Kimberley J. Haines PhD , Yasmine Ali Abdelhamid PhD

引用次数: 0

Association Between Sex and Race and Ethnicity and IV Sedation Use in Patients Receiving Invasive Ventilation 接受有创通气患者的性别、种族和民族与静脉镇静剂使用之间的关系

CHEST critical care

Pub Date : 2024-10-09 DOI: 10.1016/j.chstcc.2024.100100

Sarah L. Walker , Federico Angriman MD, PhD , Lisa Burry PharmD, PhD , Leo Anthony Celi MD, MPH , Kirsten M. Fiest PhD , Judy Gichoya MD , Alistair Johnson PhD , Kuan Liu PhD , Sangeeta Mehta MD , Georgiana Roman-Sarita RRT , Laleh Seyyed-Kalantari PhD , Thanh-Giang T. Vu MD , Elizabeth L. Whitlock MD , George Tomlinson PhD , Christopher J. Yarnell MD, PhD

Background

IV sedation is an important tool for managing patients receiving invasive ventilation, yet excess sedation is harmful, and dosing could be influenced by implicit bias.

Research Question

What are the associations between sex or race and ethnicity and sedation practices?

Study Design and Methods

We performed a retrospective single-center cohort study of adults receiving invasive ventilation for ≥ 24 hours using the Medical Information Mart for Intensive Care Version IV (2008-2019) database from Boston, Massachusetts. We used a repeated-measures design (4-hour intervals) to study the association between sex (female or male) or race and ethnicity (Asian, Black, Hispanic, White) and sedation outcomes. Sedation outcomes included sedative use (propofol, benzodiazepine, dexmedetomidine) and minimum sedation score. We categorized sedative use as follows: no sedative and then lowest, second, third, and highest quartiles of sedative dose. We adjusted for covariates with multilevel Bayesian proportional odds modeling and reported ORs with 95% credible intervals (CrIs).

Results

We studied 6,764 patients: 43% female; 3.5% Asian, 12% Black, 4.5% Hispanic, and 80% White. Benzodiazepines were administered to 2,334 patients (36%). Black patients received benzodiazepines less often and at lower doses than White patients (more benzodiazepine: OR, 0.66; 95% CrI, 0.49-0.92). Propofol was administered to 3,865 patients (57%). Female patients received propofol less often and at lower doses than male patients (more propofol: OR, 0.72; 95% CrI, 0.61-0.86). Dexmedetomidine was administered to 1,439 patients (21%), and use was similar across sex or race and ethnicity. Female patients were less sedated than male patients (deeper sedation: OR, 0.71; 95% CrI, 0.62-0.81), and Black patients were more sedated than White patients (more sedated: OR, 1.28; 95% CrI, 1.05-1.55).

Interpretation

Among patients receiving invasive ventilation for at least 24 hours, IV sedation and attained sedation levels varied by sex and by race and ethnicity. Adherence to sedation guidelines may improve equity in sedation management for critically ill patients.

研究背景IV镇静是管理接受有创通气患者的重要工具，但过度镇静是有害的，而且剂量可能会受到隐性偏见的影响。研究问题性别或种族和民族与镇静方法之间存在哪些关联？研究设计和方法我们使用马萨诸塞州波士顿市的重症监护医疗信息市场第四版（2008-2019 年）数据库，对接受有创通气时间≥ 24 小时的成人进行了一项回顾性单中心队列研究。我们采用重复测量设计（4 小时间隔）来研究性别（女性或男性）或种族和民族（亚洲人、黑人、西班牙裔、白人）与镇静结果之间的关系。镇静结果包括镇静剂使用（异丙酚、苯二氮卓、右美托咪定）和最低镇静评分。我们对镇静剂的使用进行了如下分类：无镇静剂，然后是镇静剂剂量的最低、第二、第三和最高四分位数。我们采用多层次贝叶斯比例几率模型对协变量进行了调整，并报告了ORs及95%可信区间（CrIs）：女性占 43%，亚裔占 3.5%，黑人占 12%，西班牙裔占 4.5%，白人占 80%。2,334 名患者（36%）服用了苯二氮卓类药物。黑人患者使用苯二氮卓的频率和剂量低于白人患者（更多苯二氮卓：OR，0.66；95% CrI，0.49-0.92）。3865名患者（57%）使用了异丙酚。与男性患者相比，女性患者接受异丙酚的频率和剂量较低（异丙酚用量更多：OR，0.72；95% CrI，0.61-0.86）。1,439名患者（21%）使用了右美托咪定，不同性别、种族和民族的使用情况相似。女性患者的镇静程度低于男性患者（镇静程度更深：OR，0.71；95% CrI，0.62-0.81），黑人患者的镇静程度高于白人患者（镇静程度更高：OR，1.28；95% CrI，1.05-1.55）。遵守镇静指南可提高重症患者镇静管理的公平性。

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引用次数: 0

Association of Hyperinflammatory Subphenotype With Code Status De-Escalation in Patients With Acute Respiratory Failure 急性呼吸衰竭患者的高炎症亚表型与代码状态解除的关系

CHEST critical care

Pub Date : 2024-09-10 DOI: 10.1016/j.chstcc.2024.100098

Amanda C. Moale MD , S. Mehdi Nouraie MD, PhD , Haris Zia MD , Caitlin Schaefer MPH , Ian J. Barbash MD, MS , Douglas B. White MD, MAS , Bryan J. McVerry MD , Georgios D. Kitsios MD, PhD

引用次数: 0

Interpreting Clinical Trial Results 解读临床试验结果

CHEST critical care

Pub Date : 2024-09-06 DOI: 10.1016/j.chstcc.2024.100097

Christopher Kearney MD , Brooke Barlow PharmD , Brandon Pang MD , Nicholas A. Bosch MD

Randomized clinical trials (RCTs) are the gold standard to evaluate intervention efficacy and effectiveness. To apply current, evidence-based interventions to daily practice, it is imperative that practicing intensivists be able to interpret the results of individual RCTs in the context of their patients. In this article, we outline an approach to interpreting critical care RCTs from the perspective of the clinician that focuses on answering four questions: (1) Would my patient have been enrolled and represented in the RCT? (2) Is the intervention feasible? (3) Are there threats to the internal validity of the RCT results? (4) Are the RCT results meaningful? Answers to these four questions can be used to assist intensivists in deciding whether to apply RCT evidence to their patients at the bedside and to avoid common pitfalls of RCT interpretation.

随机临床试验（RCT）是评估干预效果和有效性的黄金标准。要将当前的循证干预措施应用到日常实践中，执业的重症监护医生必须能够根据患者的情况解读单个 RCT 的结果。在本文中，我们概述了从临床医生的角度解读重症监护 RCT 的方法，重点回答四个问题：(1) 我的病人是否会被纳入 RCT 并在 RCT 中得到体现？(2）干预措施是否可行？(3) RCT 结果的内部有效性是否受到威胁？(4) RCT 结果是否有意义？这四个问题的答案可用于帮助重症监护医生决定是否在床边将 RCT 证据应用于患者，并避免 RCT 解释的常见误区。

引用次数: 0

Time Is Brain 时间就是大脑

CHEST critical care

Pub Date : 2024-09-06 DOI: 10.1016/j.chstcc.2024.100099

Giulia M. Benedetti MD , Lindsey A. Morgan MD , Dana B. Harrar MD, PhD

Status epilepticus (SE) is a life-threatening emergency that requires prompt recognition and treatment and is common in the ICU. The definition of SE has evolved, with a shift toward highlighting the potential for permanent neurologic injury and prioritizing early termination. Although EEG serves a confirmatory role in the diagnosis of convulsive SE, SE in the ICU often is nonconvulsive, making EEG essential for diagnosis and management. In this review, we characterize the neurobiology of SE and provide clinically applicable strategies for timely recognition and effective treatment of SE, highlighting ICU-level therapies and integration of continuous EEG. We also discuss the simultaneous etiologic evaluation that must take place to identify the cause of SE.

癫痫状态（SE）是一种危及生命的急症，需要及时识别和治疗，在重症监护病房很常见。癫痫状态的定义也在不断演变，目前已转向强调永久性神经损伤的可能性和优先考虑早期终止治疗。虽然脑电图在惊厥性 SE 的诊断中起着确诊作用，但 ICU 中的 SE 通常是非惊厥性的，因此脑电图对诊断和管理至关重要。在这篇综述中，我们描述了 SE 的神经生物学特征，并提供了及时识别和有效治疗 SE 的临床适用策略，重点介绍了 ICU 级别疗法和连续脑电图的整合。我们还讨论了为确定 SE 病因而必须同时进行的病因学评估。

引用次数: 0

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