The surge in critically ill patients has pressured hospitals to expand their intensive care unit capacities and critical care staff. This was difficult given the country’s shortage of intensivists. This paper describes the implementation of a multidisciplinary central line placement team and its impact in reducing the vascular access workload of ICU physicians during the height of the COVID-19 pandemic.

Vascular surgeons, interventionalists, and anesthesiologists were redeployed to the ICU Access team to place central and arterial lines. Nurses with expertise in vascular access were recruited to the team to streamline consultation and assist with line placement.

While 51 central and arterial lines were placed per 100 ICU patients in 2019, there were 87 central and arterial lines placed per 100 COVID-19 ICU patients in the sole month of April 2020. The ICU Access Team placed 107 of the 226 vascular access devices in April 2020, reducing the procedure-related workload of ICU treating teams by 46%.

The ICU Access Team was able to complete a large proportion of vascular access insertions without reported complications. Given another mass casualty event, this ICU Access Team could be reassembled to rapidly meet the increased vascular access needs of patients.

Data regarding preoperative mortality in neonates with critical CHD are sparse and would aid patient care and family counselling. The objective of this study was to utilise a multicentre administrative dataset to report the rate of and identify risk factors for preoperative in-hospital mortality in neonates with critical CHD across US centres.

The Pediatric Health Information System database was utilised to search for newborns ≤30 days old, born 1 January 2009 to 30 June 2018, with an ICD-9/10 code for d-transposition of the great arteries, truncus arteriosus, interrupted aortic arch, or hypoplastic left heart syndrome. Preoperative in-hospital mortality was defined as patients who died prior to discharge without an ICD code for cardiac surgery or interventional catheterisation.

Overall preoperative mortality rate was at least 5.4% (690/12,739) and varied across diagnoses (d-TGA 2.9%, TA 8.3%, IAA 5.5%, and HLHS 7.3%) and centres (0–20.5%). In multivariable analysis, risk factors associated with preoperative mortality included preterm delivery (<37 weeks) (OR 2.3, 95% CI: 1.8–2.9; p < 0.01), low birth weight (<2.5 kg) (OR 3.8, 95% CI: 3.0–4.7; p < 0.01), and genetic abnormality (OR 1.6, 95% CI: 1.2–2.2; p < 0.01). Centre average surgical volume was not a significant risk factor.

Approximately 1 in 20 neonates with critical CHD suffered preoperative in-hospital mortality, and rates varied across diagnoses and centres. Better understanding of the factors that drive the variation (e.g. patient factors, preoperative care models, surgical timing) could help identify patient care improvement opportunities and inform conversations with families.

The Pediatric Cardiac Critical Care Consortium (PC4) is a multi-institutional quality improvement registry focused on the care delivered in the cardiac ICU for patients with CHD and acquired heart disease. To assess data quality, a rigorous procedure of data auditing has been in place since the inception of the consortium.

This report describes the data auditing process and quantifies the audit results for the initial 39 audits that took place after the transition from version one to version two of the registry’s database.

In total, 2219 total encounters were audited for an average of 57 encounters per site. The overall data accuracy rate across all sites was 99.4%, with a major discrepancy rate of 0.52%. A passing score is based on an overall accuracy of >97% (achieved by all sites) and a major discrepancy rate of <1.5% (achieved by 38 of 39 sites, with 35 of 39 sites having a major discrepancy rate of <1%). Fields with the highest discrepancy rates included arrhythmia type, cardiac arrest count, and current surgical status.

The extensive PC4 auditing process, including initial and routinely scheduled follow-up audits of every participating site, demonstrates an extremely high level of accuracy across a broad array of audited fields and supports the continued use of consortium data to identify best practices in paediatric cardiac critical care.

Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center.

A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives’ effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys.

A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff.

Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training.

We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX).

A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed.

Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.

Tracheostomy in the neurocritical care population is associated with poorer outcomes. This study hypothesised that a multidisciplinary approach to tracheostomy care can improve outcomes.

This study was a prospective longitudinal study of all tracheostomised patients in the neurocritical care units of a quaternary centre over 17 years. All patients were managed by a tracheostomy team with a constant core membership of an intensive care consultant, speech and language therapist, and physiotherapist with consultant ENT input.

A total of 51 per cent of patients were decannulated in hospital at an average of 48 (neuromedical) and 57.6 (neurosurgical) days. Of the 42 per cent of patients transferred to another facility with a tracheostomy tube in situ, 37.5 per cent were at an advanced stage of tracheostomy weaning. Complication rates were low at 4.8 per cent with no tracheostomy associated mortalities.

A multidisciplinary approach can enable good outcomes in the neurocritical care population. Consistency of care spanning the step-down from critical to ward-level care is crucial to improving outcomes.

The aim of this study was to report the results of a nationwide critical-care course for non-intensivists to increase staff capacity of intensive care units (ICUs) during the coronavirus disease 2019 (COVID-19) pandemic in Argentina.

Three academic organizations, with special funding from 55 private companies, developed a short virtual course comprised of Web-based videos, virtual tutorials, and a forum chat. Each state assigned scholarships to non-ICU staff from public hospitals. Students received active follow-up for the completion of the course and took a survey upon course completion.

After 4 m, there were 10,123 students registered from 661 hospitals in 328 cities. Of these, 67.8% passed the course, 29.1% were still ongoing, and 3.1% were inactive. Most students were female (74.2%) with a median of 37 y old (IQR 31-44). The group was composed of 56.5% nurses, 36.2% physicians, and 7.4% physiotherapists, of whom 48.3% did not have any experience in critical care. Mean overall satisfaction was 4.4/5 (standard deviation, 0.9), and 90.7% considered they were able to apply the contents to their practice.

This course was effective for rapid training of non-ICU personnel. The assignment strategy, the educational techniques, and the close follow-up led to low dropout and high success rates and satisfaction.

Differentiation between post-operative inflammation and bacterial infection remains an important issue in infants following congenital heart surgery. We primarily assessed kinetics and predictive value of C-reactive protein for bacterial infection in the early (days 0–4) and late (days 5–28) period after cardiopulmonary bypass surgery. Secondary objectives were frequency, type, and timing of post-operative infection related to the risk adjustment for congenital heart surgery score.

This 3-year single-centre retrospective cohort study in a paediatric cardiac ICU analysed 191 infants accounting for 235 episodes of CPBP surgery. Primary outcome was kinetics of CRP in the first 28 days after CPBP surgery in infected and non-infected patients.

We observed 22 infectious episodes in the early and 34 in the late post-operative period. CRP kinetics in the early post-operative period did not accurately differentiate between infected and non-infected patients. In the late post-operative period, infected infants displayed significantly higher CRP values with a median of 7.91 (1.64–22.02) and 6.92 mg/dl (1.92–19.65) on days 2 and 3 compared to 4.02 (1.99–15.9) and 3.72 mg/dl (1.08–9.72) in the non-infection group. Combining CRP on days 2 and 3 after suspicion of infection revealed a cut-off of 9.47 mg/L with an acceptable predictive accuracy of 76%.

In neonates and infants, CRP kinetics is not useful to predict infection in the first 72 hours after CPBP surgery due to the inflammatory response. However, in the late post-operative period, CRP is a valuable adjunctive diagnostic test in conjunction with clinical presentation and microbiological diagnostics.

The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates’ mental health and patient outcomes.

Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15–20 min modules, totaling 1.5–2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.

Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = −0.41), peritraumatic distress (d = −0.24), and experiential avoidance (d = −0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = −0.94), depression (d = −0.23), anxiety (d = −0.29), and experiential avoidance (d = −0.30).

Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Synchronized cardioversion is an internationally accepted standard therapy for unstable tachyarrhythmias, but it is conventionally an in-hospital physician-led intervention. Increasingly, it is being brought forward into the prehospital setting as part of a specialist paramedic scope of practice; however, very little literature exists regarding the epidemiology or efficacy in this setting.

All patients receiving cardioversion within a United Kingdom (UK) ambulance service were identified using an electronic database. The period of inclusion was March 1, 2017 through October 31, 2020. These data were then interrogated to provide demographic, physiological, and efficacy data, and then a sub-group was created to identify those who presented with a primary arrhythmia (as opposed to post-cardiac arrest).

From a total of 93 patients, prehospital synchronized cardioversion successfully terminated the tachyarrhythmia in 96% of patients presenting with a primary arrhythmia (85% in the allcomers group) with a predominance towards males (82% of patients) and an average age of 67 years. Hypotension and reduced level of consciousness were the most commonly documented unstable features (84.4% and 44.4%).

Cardioversion within a paramedic-led service results in efficacy rates of 96% in patients presenting with a primary tachyarrhythmia. This is a similar efficacy rate to traditional doctor-led therapies. Demographic data show that males make up over 80% of the patient population, in keeping with previously published work across the spectrum of cardiac interventions.

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes.

Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer.

Patients had a median age of 43 years (interquartile range [IQR] 26–59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26–43). Median transportation time was 80 minutes (IQR 40–315). ICU and hospital length of stay were 6 days (IQR 2–12) and 20 days (IQR 7–42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95–1.01). There was also no significant effect on discharge disposition.

No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

To report feasibility, early outcomes and challenges of implementing a 14-day threshold for undertaking surgical tracheostomy in the critically ill coronavirus disease 2019 patient.

Twenty-eight coronavirus disease 2019 patients underwent tracheostomy. Demographics, risk factors, ventilatory assistance, organ support and logistics were assessed.

The mean time from intubation to tracheostomy formation was 17.0 days (standard deviation = 4.4, range 8–26 days). Mean time to decannulation was 15.8 days (standard deviation = 9.4) and mean time to intensive care unit stepdown to a ward was 19.2 days (standard deviation = 6.8). The time from intubation to tracheostomy was strongly positively correlated with: duration of mechanical ventilation (r(23) = 0.66; p < 0.001), time from intubation to decannulation (r(23) = 0.66; p < 0.001) and time from intubation to intensive care unit discharge (r(23) = 0.71; p < 0.001).

Performing a tracheostomy in coronavirus disease 2019 positive patients at 8–14 days following intubation is compatible with favourable outcomes. Multidisciplinary team input is crucial to patient selection.