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Acute respiratory distress syndrome (ARDS) has a high mortality and is associated with significant morbidity. Prior outcome studies have focused predominant on short-term outcomes (6-12 months). We assessed longitudinal neurocognitive, emotional, and quality of life in ARDS survivors at hospital discharge, and 1 and 2 years after hospital discharge using neuropsychologic tests and emotional and quality-of-life questionnaires. Neurocognitive sequelae occurred in 73% (54 of 74) of ARDS survivors at hospital discharge, 46% (30 of 66) at 1 year, and 47% (29 of 62) at 2 years. ARDS survivors report moderate to severe depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. The ARDS survivors had decreased quality of life, with the physical domains improving at 1 year, with no additional change at 2 years. Role emotional, pain, and general health did not change from hospital discharge to 2 years. Mental health improved during the first year and declined at 2 years. ARDS results in significant neurocognitive and emotional morbidity and decreased quality of life that persists at least 2 years after hospital discharge. ARDS can cause significant long-term, brain-related morbidity manifest by neurocognitive impairments and decreased quality of life.

Cognitive sequelae often occur after acute carbon monoxide poisoning. This double-blind, randomized trial assigned subjects either to three sessions in a hyperbaric-oxygen chamber or to one normobaric-oxygen treatment plus two sessions of exposure to normobaric room air, all administered within 24 hours after the end of exposure to carbon monoxide. Cognitive sequelae six weeks later were less frequent among persons who received hyperbaric-oxygen therapy (25.0 percent) than among those who received normobaric-oxygen treatment (46.1 percent, P=0.007). Differences were sustained 12 months after the episode of acute carbon monoxide poisoning. The results of this double-blind trial support the use of hyperbaric oxygen. Carbon monoxide poisoning is a serious health problem 1 , 2 resulting in approximately 40,000 visits to the emergency department annually in the United States. 2 , 3 Unfavorable cognitive sequelae (problems with memory, attention or concentration, and affect) can occur immediately after exposure and persist or can be delayed, but they generally occur within 20 days after carbon monoxide poisoning. 1 – 6 Cognitive sequelae lasting one month 5 , 7 – 9 or more 2 , 4 appear to occur in 25 to 50 percent of patients with loss of consciousness or with carboxyhemoglobin levels greater than 25 percent. 2 , 7 , 8 The recommended treatment for acute carbon monoxide poisoning . . .

Objective: The Sequential Organ Failure Assessment (SOFA) score has been recommended for triage during a mass influx of critically ill patients, but it requires laboratory measurement of 4 parameters, which may be impractical with constrained resources. We hypothesized that a modified SOFA (MSOFA) score that requires only 1 laboratory measurement would predict patient outcome as effectively as the SOFA score. Methods: After a retrospective derivation in a prospective observational study in a 24-bed medical, surgical, and trauma intensive care unit, we determined serial SOFA and MSOFA scores on all patients admitted during the 2008 calendar year and compared the ability to predict mortality and the need for mechanical ventilation. Results: A total of 1770 patients (56% male patients) with a 30-day mortality of 10.5% were included in the study. Day 1 SOFA and MSOFA scores performed equally well at predicting mortality with an area under the receiver operating curve (AUC) of 0.83 (95% confidence interval 0.81-.85) and 0.84 (95% confidence interval 0.82-.85), respectively ( P = .33 for comparison). Day 3 SOFA and MSOFA predicted mortality for the 828 patients remaining in the intensive care unit with an AUC of 0.78 and 0.79, respectively. Day 5 scores performed less well at predicting mortality. Day 1 SOFA and MSOFA predicted the need for mechanical ventilation on day 3, with an AUC of 0.83 and 0.82, respectively. Mortality for the highest category of SOFA and MSOFA score (>11 points) was 53% and 58%, respectively. Conclusions: The MSOFA predicts mortality as well as the SOFA and is easier to implement in resource-constrained settings, but using either score as a triage tool would exclude many patients who would otherwise survive. ( Disaster Med Public Health Preparedness . 2010;4:277-284)

The Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience. Participants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual's ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU. Three hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile. Distinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.

Objective To determine whether heart rate variability (HRV; a physiological measure of acute stress) is associated with persistent psychological distress among family members of adult intensive care unit (ICU) patients. Methods This prospective study investigated family members of patients admitted to a study ICU. Participants’ variability in heart rate tracings were measured by low frequency (LF)/high frequency (HF) ratio and detrended fluctuation analysis (DFA). Questionnaires were completed 3 months after enrollment to ascertain outcome rates of anxiety, depression, and post-traumatic stress disorder (PTSD). Results Ninety-nine participants were enrolled (median LF/HF ratio, 0.92 [interquartile range, 0.64–1.38]). Of 92 participants who completed the 3-month follow-up, 29 (32%) had persistent anxiety. Logistic regression showed that LF/HF ratio (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.43, 1.53) was not associated with 3-month outcomes. In an exploratory analysis, DFA α (OR 0.93, 95% CI 0.87, 0.99), α1 (OR 0.97, 95% CI 0.94, 0.99), and α2 (OR 0.94, 95% CI 0.88, 0.99) scaling components were associated with PTSD development. Conclusion Almost one-third of family members experienced anxiety at three months after enrollment. HRV, measured by LF/HF ratio, was not a predictor of psychologic distress, however, exploratory analyses indicated that DFA may be associated with PTSD outcomes.

ObjectiveTo investigate: (1) patient and family experiences with healthcare and the intensive care unit (ICU); (2) experiences during their critical illness; (3) communication and decision making during critical illness; (4) feelings about the ICU experience; (5) impact of the critical illness on their lives; and (6) concerns about their future after the ICU.DesignFour semistructured focus group interviews with former ICU patients and family members.SettingsMulticultural community group and local hospitals containing medical/surgical ICUs.ParticipantsPatients and family who experienced a critical illness within the previous 10 years.InterventionsNone.Measurements and main resultsFour separate focus groups each lasting a maximum of 150 min and consisting of a total of 21 participants were held. Focus groups were conducted using a semistructured script including six topics relating to the experience of critical illness that facilitated deduction and the sorting of data by thematic analysis into five predominant themes. The five main themes that emerged from the data were: (1) personalised stories of the critical illness; (2) communication and shared decision making, (3) adjustment to life after critical illness, (4) trust towards clinical team and relevance of cultural beliefs and (5) end-of-life decision making. Across themes, we observed a misalignment between the medical system and patient and family values and priorities.ConclusionsThe experience of critical illness of a diverse group of patients and families can remain vivid for years after ICU discharge. The identified themes reflect the strength of memory of such pivotal experiences and the importance of a narrative around those experiences. Clinicians need to be aware of the lasting effects of critical illness has on patients and families.

Acute Respiratory Distress Syndrome (ARDS) is characterized by lung injury and hypoxemia, has a high mortality rate, and is associated with significant morbidity including cognitive and emotional sequelae and decreased quality of life. There is limited information regarding which of these factors are associated with decreased quality of life. This study assessed the relationships between quality of life, cognitive and emotional function in ARDS survivors at 1-year post-hospital discharge. Sixty-six ARDS survivors were administered a battery of neuropsychological tests, measures of emotional function and quality of life 1 year post-hospital discharge. At 1 year 45% of the ARDS patients had cognitive sequelae and 29% had mild to moderate symptoms of depression and anxiety. Depression, anxiety, and intensive care unit length of stay were significantly correlated with decreased quality of life. Cognitive impairments did not correlate with decreased quality of life. Illness severity and emotional function, but not cognitive sequelae, are associated with decreased quality of life 1 year following ARDS. ARDS is common and may result in significant cognitive and emotional morbidity and decreased quality of life. (JINS, 2004, 10, 1005–1017.)

Faced with an increasing loss of autonomy in the managed care marketplace, physicians often view the debate about the quality of care as simply about finding ways to reward them for doing less for patients and to control costs by the use of arbitrary rules for clinical care. 1 Skeptics view quality-of-care projects as a disguised form of marketing; this skepticism will not disappear until physicians can see quality-of-care efforts that make difficult decisions easier and more accurate. 2 , 3 Establishing systems for improving care is difficult, at best, for groups of specialist physicians, but it is next to impossible for physicians . . .

To study morbidity and mortality in ARDS patients from 1987 to 1999. Review of a prospectively collected database of ARDS patients. Large, community hospital located in Salt Lake City, UT. ARDS patients identified for the years 1987 to 1999. We prospectively identified ARDS patients at LDS Hospital in Salt Lake City, UT, using Pao2/fraction of inspired oxygen ratio (P/F) criteria, the presence of bilateral chest radiograph infiltrates, and the absence of left atrial hypertension. We assigned a primary risk factor for ARDS and identified the presence of organ failure before and after ARDS. We compared two temporal groups (ie, 1987 to 1990 vs 1994 to 1999) and used two criteria of arterial hypoxemia (P/F: patients from 1994 to 1999, ≤ 105 and ≤ 173; patients from 1987 to 1990, ≤ 0.2) At 1,500 m (the altitude of Salt Lake City), a Pao2 of ≤ 173 corresponds to an alveolar-arterial oxygen pressure difference of ≤ 200 at sea level. We used death at hospital discharge as an end point. We identified 516 ARDS patients with a P/F of ≤ 105 (1987 to 1990, 256 patients; 1994 to 1999, 260 patients). Patients who had ARDS between 1994 and 1999 with a P/F of ≤ 105 had a lower mortality rate than patients between 1987 and 1990 with a P/F of ≤ 105 (44% vs 54%, respectively; p < .05). There were 288 patients with a P/F range of 106 to 173 during 1994 to 1999. Patients from 1994 to 1999 with a P/F of ≤ 173 had a lower mortality rate compared to patients from 1987 to 1990 (35% vs 54%, respectively; p < .01). Patients from 1994 to 1999 (for both P/F groups) had statistically fewer total nonpulmonary organ failures (ie, more patients had zero organ failures or single organ failures) and fewer specific organ failures (ie, sepsis, cardiovascular failures, and CNS failures). There were statistically fewer cases of cardiovascular failure, sepsis, and in both periods (ie, prior to ARDS and after the onset of ARDS) for 1994-to-1999 patients with a P/F of ≤ 105 compared to 1987-to-1990 patients with a P/F of ≤ 105. Mortality from ARDS has decreased and is associated with decreased organ failure prior to and during the course of ARDS.

Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation. Our eProtocols have progressed from a locally developed mainframe computer application in one clinical site (LDS Hospital) to web-based applications available in multiple languages and used internationally. We use eProtocol-insulin as an example to illustrate this evolution. We initially developed eProtocol-insulin as a local quality improvement effort to manage stress hyperglycemia in the adult intensive care unit (ICU). We extended eProtocol-insulin use to translate our quality improvement results into usual clinical care at Intermountain Healthcare ICUs. We exported eProtocol-insulin to support research in other US and international institutions, and extended our work to the pediatric ICU. We iteratively refined eProtocol-insulin throughout these transitions, and incorporated new knowledge about managing stress hyperglycemia in the ICU. Based on our experience in the development and clinical use of eProtocols, we outline remaining challenges to eProtocol development, widespread distribution and use, and suggest a process for eProtocol development. Technical and regulatory issues, as well as standardization of protocol development, validation and maintenance, need to be addressed. Resolution of these issues should facilitate general use of eProtocols to improve patient care.