Crit Care Clin
· 2024 Oct · PMID 39218485
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Health disparities persist among minoritized populations. A diverse clinician workforce may help address these disparities and improve patient outcomes; however, diversity in the critical are workforce (particularly amon...Health disparities persist among minoritized populations. A diverse clinician workforce may help address these disparities and improve patient outcomes; however, diversity in the critical are workforce (particularly among women and those historically underrepresented in medicine (URiM)) is lacking. This review describes factors contributing to low respresentation of women and URiM in critical care medicine, and proposes strategies to overcome those barriers.
Crit Care Clin
· 2024 Oct · PMID 39218484
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Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower qua...Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower quality communication from clinicians, and report worse quality of dying than other patients. There are many contributory factors, including system (eg, lack of intensive outpatient symptom management resources), clinician (eg, low-quality serious illness communication), and patient (eg, cultural norms) factors. System and clinician factors contribute to disparities and ought to be remedied, while patient factors simply reflect differences in care and may not be appropriate targets for intervention.
Crit Care Clin
· 2024 Oct · PMID 39218483
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Critical care pathologies are not immune to potential social challenges in both health equity and health disparities. Over the last century, as sepsis physiology and interventions have continued to improve clinical outco...Critical care pathologies are not immune to potential social challenges in both health equity and health disparities. Over the last century, as sepsis physiology and interventions have continued to improve clinical outcomes, recognition that such improvements are not seen in all diverse populations warrants an understanding of this disproportionate success. In this review, the authors evaluate sepsis incidence and outcomes across ethnicity, race, and sex and gender, taking into account social and biological categorization and the association of sepsis-related mortality and morbidity. Further, the authors review how such issues transcend across age groups, with vulnerability to sepsis.
Crit Care Clin
· 2024 Oct · PMID 39218482
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Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in isch...Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.
Bansal M, Mehta A, Balakrishna AM
… +6 more, Saad M, Ventetuolo CE, Roswell RO, Poppas A, Abbott JD, Vallabhajosyula S
Crit Care Clin
· 2024 Oct · PMID 39218481
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Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosi...Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care.
Crit Care Clin
· 2024 Oct · PMID 39218480
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This article reviews the current evidence base for racial and ethnic disparities related to acute respiratory failure. It discusses the prevailing and most studied mechanisms that underlay these disparities, analytical c...This article reviews the current evidence base for racial and ethnic disparities related to acute respiratory failure. It discusses the prevailing and most studied mechanisms that underlay these disparities, analytical challenges that face the field, and then uses this discussion to frame future directions to outline next steps for developing disparities-mitigating solutions.
Crit Care Clin
· 2024 Oct · PMID 39218479
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Despite legal protections guaranteeing care for patients with trauma, disparities exist in patient outcomes. We review disparities in patient management and outcomes related to insurance status, race and ethnicity, and g...Despite legal protections guaranteeing care for patients with trauma, disparities exist in patient outcomes. We review disparities in patient management and outcomes related to insurance status, race and ethnicity, and gender for patients with trauma in the preadmission, in-hospital, and postdischarge settings. We highlight groups understudied and either underrepresented or unrepresented in national trauma databases-including American Indians/Alaska Natives, non-English preferred patients, and patients with disabilities. We call for more study of these groups and of upstream factors affecting the reviewed demographics to measure and improve outcomes for these vulnerable populations.
Reddy AR, Gathers CA, Murosko DC
… +3 more, Rainer T, Naim MY, Fowler J
Crit Care Clin
· 2024 Oct · PMID 39218478
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To date, health disparities in critically ill children have largely been studied within, not across, specific intensive care unit (ICU) settings, thus impeding collaboration which may help advance the care of critically...To date, health disparities in critically ill children have largely been studied within, not across, specific intensive care unit (ICU) settings, thus impeding collaboration which may help advance the care of critically ill children. The aim of this scoping review is to summarize the literature intentionally designed to examine health disparities, across 3 primary ICU settings (neonatal ICU, pediatric ICU, and cardiac ICU) in the United States. We included over 50 studies which describe health disparities across race and/or ethnicity, area-level indices, insurance status, socioeconomic position, language, and distance.
Magee PM, Asp RA, Myers CN
… +3 more, Grunwell JR, Paquette E, Akande MY
Crit Care Clin
· 2024 Oct · PMID 39218477
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A growing body of literature has identified social determinants of health (SDoH) as potential contributors to health disparities in pediatric critical illness. Pediatric critical care providers should use validated scree...A growing body of literature has identified social determinants of health (SDoH) as potential contributors to health disparities in pediatric critical illness. Pediatric critical care providers should use validated screening tools to identify unmet social needs and ensure appropriate referral through multisector partnerships. Pediatric critical care researchers should consider factors outside of race and insurance status and explore the association between neighborhood-level factors and disparate health outcomes during critical illness. Measuring and addressing the SDoH at the individual and neighborhood level are important next steps in mitigating health disparities for critically ill pediatric patients.
Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for...Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for immediate treatment and the inability of patients to provide informed consent. Attempts to obtain consent from surrogate decision-makers can be intrusive and lead to unacceptable delays to treatment. These problems may be overcome by pragmatic approaches to study design and the use of supervised waivers of consent, which is ethical and appropriate in situations where there is high risk of poor outcome and a paucity of proven effective treatment.
Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the aut...Tele-intensive care unit (ICU), or Tele Critical Care (TCC), has been in active use for 25 years and has expanded beyond the original model to support critically ill patients beyond the confines of the ICU. Here, the author reviews the role of TCC in supporting rapid response events, critical care in emergency departments, and disaster and pandemic responses. The ability to rapidly expand critical care services has important capacity and care quality implications. Moreover, as TCC infrastructure becomes less expensive, the opportunities to leverage this care modality also have potentially important financial benefits.
The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospit...The hospital rapid response system (RRS) is a patient safety and quality intervention that responds quickly to clinical deteriorations on general wards with the goal of preventing cardiopulmonary arrests, reducing hospital mortality, and facilitating triage and level of care escalations. The RRS is one of the first organized, and systematic, elements of the "ICU without walls" model. RRSs have been shown to be effective in preventing deterioration to cardiopulmonary arrest on general hospital wards and reducing total and unexpected hospital mortality. Recent studies have demonstrated that this benefit can be enhanced through targeted improvements and modifications of existing RRSs.
Crit Care Clin
· 2024 Jul · PMID 38796228
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Early warning systems (EWSs) are designed and deployed to create a rapid assessment and response for patients with clinical deterioration outside the intensive care unit (ICU). These models incorporate patient-level data...Early warning systems (EWSs) are designed and deployed to create a rapid assessment and response for patients with clinical deterioration outside the intensive care unit (ICU). These models incorporate patient-level data such as vital signs and laboratory values to detect or prevent adverse clinical events, such as vital signs and laboratories to allow detection and prevention of adverse clinical events such as cardiac arrest, intensive care transfer, or sepsis. The applicability, development, clinical utility, and general perception of EWS in clinical practice vary widely. Here, we review the field as it has grown from early vital sign-based scoring systems to contemporary multidimensional algorithms and predictive technologies for clinical decompensation outside the ICU.
Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and...Critical illness is a continuum with different phases and trajectories. The "Intensive Care Unit (ICU) without walls" concept refers to a model whereby care is adjusted in response to the patient's needs, priorities, and preferences at each stage from detection, escalation, early decision making, treatment and organ support, followed by recovery and rehabilitation, within which all healthcare staff, and the patient are equal partners. The rapid response system incorporates monitoring and alerting tools, a multidisciplinary critical care outreach team and care bundles, supported with education and training, analytical and governance functions, which combine to optimise outcomes of critically ill patients, independent of location.
The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain ca...The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.
The intensive care unit (ICU) was born from the postanesthesia care unit (PACU). In today's hospital systems, there remains a lot of overlap in the care missions of each location. The patient populations share many simil...The intensive care unit (ICU) was born from the postanesthesia care unit (PACU). In today's hospital systems, there remains a lot of overlap in the care missions of each location. The patient populations share many similarities and many of the same care, technology, and care protocols apply to patients in both units. As shown by the COVID-19 pandemic, there is immense value in maintaining protocols, processes, and staffing models for the safe care of ICU patients in the PACU when ICU demands exceed capacity.
Crit Care Clin
· 2024 Jul · PMID 38796224
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Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though preva...Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.
Boarding of critically ill patients in the Emergency Department (ED) has increased over the past 20 years, leading hospital systems to explore ED-focused models of critical care delivery. ED-critical care delivery models...Boarding of critically ill patients in the Emergency Department (ED) has increased over the past 20 years, leading hospital systems to explore ED-focused models of critical care delivery. ED-critical care delivery models vary between health systems due to differences in hospital resources and the needs of the critically ill patients boarding in the ED. Three published systems include an ED critical care intensivist consultation model, a hybrid model, and an ED-intensive care unit model. Paraphrasing the Greek philosopher, Plato, "necessity is the mother of invention." This proverb rings true as EDs are facing an increasing challenge of caring for boarding patients, especially those who are critically ill.
Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed...Aeromedical transport (AMT) is an integral part of healthcare systems worldwide. In this article, the personnel and equipment required, associated safety considerations, and evidence supporting the use of AMT is reviewed, with an emphasis on helicopter emergency medical services (HEMS). Indications for HEMS as guideded by the Air Medical Prehospital Triage Score are presented. Lastly, physiologic considerations, which are important to both AMT crews and receiving clinicians, are reviewed.