We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.

Current Management and Prevention Approaches Fall Short The current management approaches for burnout and other forms of psychological distress focus on individual coping, resting

Background The coronavirus disease 2019 (COVID-19) pandemic placed considerable strain on critical care resources. How United States (U.S.) hospitals responded to this crisis is unknown. Research question What actions did U.S. hospitals take to prepare for a potential surge in demand for critical care services in the context of the COVID-19 pandemic? Study design and methods From September to November 2020 we surveyed the chief nursing officers of a representative sample of U.S. hospitals regarding organizational actions taken to increase or maintain critical care capacity during the pandemic. We calculated weighted proportions of hospitals for each potential action in order to create estimates across the entire population of U.S. hospitals, accounting for both the sampling strategy and non-response. We also examined whether the types of actions taken varied by the cumulative regional incidence of COVID-19 cases. Results We received responses from 169 of 540 surveyed U.S. hospitals (response rate: 31.3%). Almost all hospitals canceled or postponed elective surgeries (96.7%) and non-surgical procedures (94.8%). Few hospitals created new medical units in areas not typically dedicated to health care (12.9%), and almost none adopted triage protocols (5.6%) or protocols to connect multiple patients to a single ventilator (4.8%). Actions to increase or preserve intensive care unit (ICU) staff, including use of ICU telemedicine, were highly variable, without any single dominant strategy. Hospitals experiencing higher incidence of COVID-19 did not consistently take different actions compared to hospitals facing lower incidence. Interpretation Responses of hospitals to the mass need for critical care services due to the COVID-19 pandemic were highly variable. Most hospitals canceled procedures to preserve ICU capacity and scaled up ICU capacity using existing clinical space and staffing. Future work linking hospital response to patient outcomes can inform planning for additional surges of this pandemic or other events in the future.

ABCDE implementation was associated with frequent involvement of team members, suggesting a need for role articulation and coordination.

We sought to assess whether HHFNC results in greater production of aerosolized particles than 6 liters per minute nasal cannula, using state-of-the-art techniques of aerosol measurement, in spontaneously breathing human volunteers in a simulated hospital room. For each volunteer, we first measured background aerosol levels in the room immediately prior to testing. We then measured aerosol levels while the healthy volunteer laid in bed - - with the head of bed at 30 degrees - - wearing the following oxygen delivery devices: (a) 6L/min nasal canula (NC) with humidification; (b) non-re-breather mask (NRB) with 15L/min gas flow, non-humidified; (c) HHFNC with 30L/min gas flow; (d) HHFNC with 60L/min gas flow. Two scanning mobility particle sizing (SMPS) systems (TSI 3080/3030, TSI 3080/3750) were used to measure aerosols 10 to 500 nanometer (nm) in size for each of the oxygen delivery devices. There was no variation in aerosol level within patients between room air, 6 L/min NC, 15 L/min NRB, 30 L/min HHFNC, and 60 L/min HHFNC, regardless of coughing.

Objective Daytime intensivist physician staffing is associated with improved outcomes in the intensive care unit (ICU). However, it is unclear whether this association persists in the era of interprofessional, protocol-directed critical care. We sought to reexamine the association between daytime intensivist physician staffing and ICU mortality and determine if interprofessional rounding and protocols for mechanical ventilation in part mediate this relationship. Design Retrospective cohort study of ICUs in the Acute Physiology and Chronic Health Evaluation clinical information system from 2009–2010. Setting 49 ICUs in 25 US hospitals. Patients Adults (17 years and older) admitted to a study ICU. Measurements and Main Results We defined high-intensity daytime intensivist staffing as either a mandatory consult or closed ICU model; interprofessional rounds as rounds that included a respiratory therapist, pharmacist, physician and nurse; and protocol use as having protocols for liberation from mechanical ventilation and lung protective mechanical ventilation. Using multivariable logistic regression, we estimated the independent effect of daytime intensivist physician staffing on in-hospital mortality controlling for interprofessional rounds and protocols for mechanical ventilation, as well as other patient and hospital characteristics. 27 (55%) of ICUs reported high-intensity daytime physician staffing, 42 (85%) of ICUs reported daily interprofessional rounds and 31 (63%) reported having protocols for mechanical ventilation. There was no association between daytime intensivist physician staffing and in-hospital mortality [adjusted OR 0.86, 95% CI (0.65–1.14)]. After adjusting for interprofessional rounds and protocols for mechanical ventilation the effect of daytime intensivist physician staffing remained non-significant [adjusted OR 0.90, 95% (0.70, 1.17)]. Conclusion High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort. This association was not affected by interprofessional rounds or protocols for mechanical ventilation.

Although acute survival from sepsis has improved in recent years, a large fraction of sepsis survivors experience poor long-term outcomes. In particular, sepsis survivors have high rates of weakness, cognitive impairment, hospital readmission, and late death. To improve long-term outcomes, in-hospital care should focus on early, effective treatment of sepsis; minimization of delirium, distress, and immobility; and preparing patients for hospital discharge. In the posthospital setting, medical care should focus on addressing new disability and preventing medical deterioration, providing a sustained period out of the hospital to allow for recovery.

NPs/PAs appear to be a safe adjunct to the ICU team. The findings support NP/PA management of critically ill patients.