Faculty Bibliography

OBJECTIVES/OBJECTIVE:To characterise the variation in composition, leadership, and activation criteria of rapid response and cardiac arrest teams in five north-eastern states of the USA. DESIGN/METHODS:Cross-sectional study consisting of a voluntary 46-question survey of acute care hospitals in north-eastern USA. SETTING/METHODS:Acute care hospitals in New York, New Jersey, Rhode Island, Vermont, and Pennsylvania. PARTICIPANTS/METHODS:Surveys were completed by any member of the rapid response team (RRT) with a working knowledge of team composition and function. Participants were all Medicare-participating acute care hospitals, including teaching and community hospitals as well as hospitals from rural, urban and suburban areas. RESULTS:Out of 378 hospitals, contacts were identified for 303, and 107 surveys were completed. All but two hospitals had an RRT, 70% of which changed members daily. The most common activation criteria were clinical concern (95%), single vital sign abnormalities (77%) and early warning score (59%). Eighty one per cent of hospitals had a dedicated cardiac arrest team.RRT composition varied widely, with respiratory therapists, critical care nurses, physicians and nurse managers being the most likely to attend (89%, 78%, 64% and 51%, respectively). Consistent presence of critical care physicians was uncommon and both cardiac arrest teams and teams were frequently led by trainee physicians, often without senior supervision. CONCLUSIONS:As the largest study to date in the USA, we have demonstrated wide heterogeneity, rapid team turnover and a lack of senior supervision of RRT and cardiac arrest teams. These factors likely contribute to the mixed results seen in studies of RRTs.

During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small handful of expatriate patients were evacuated to specialized high-level containment care units, or biocontainment units, in the United States and Western Europe. Given the lower mortality rate (18% versus 40% for those treated in Africa) among these patients, it is likely that high-level containment care will be used in the future with increasing frequency. It is also likely that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients. We report here the results of those discussions.

BACKGROUND:Trustworthy clinical practice guidelines (CPGs) require identification and careful management of conflicts of interest (COIs) among all participants in the guideline development. Furthermore, COIs are more common than anticipated. However, there are no universally accepted methods to identify and manage COIs. OBJECTIVE:To describe and summarize the current COI disclosure forms and management policies in selected critical care professional societies that develop high-impact CPGs. In addition, we aim to provide suggestions to guideline developers on how to identify and manage different types of COIs. METHODS:We searched PubMed and MEDLINE for CPGs published between 2013 and 2018 in English language and addressed general critical care topics. We then ranked the CPGs according to the numbers of citations and selected the first five critical care professional societies that sponsored the guidelines. We obtained the most recent COI declaration forms and management policies. Two reviewers abstracted data on different types of COI in each of the disclosure forms and management policies. RESULTS:All selected professional critical care societies require that members declare direct financial COIs; four societies inquire specifically about intellectual COIs (involvement in primary research). Three out of five societies require members to disclose indirect institutional financial COIs; however, none inquire about other forms of institutional COI. We developed, by consensus, a streamlined framework to classify and manage different types of COIs. CONCLUSION/CONCLUSIONS:The current COI disclosure forms of selected professional societies provide more attention to financial disclosures and COIs and less attention to detecting and managing intellectual COIs, while rarely addressing institutional COIs. We provide some suggestions for guideline developers on the classification and management of different COIs in the context of CPGs.

OBJECTIVE:To identify research priorities in the management, epidemiology, outcome and underlying causes of sepsis and septic shock. DESIGN/METHODS:A consensus committee of 16 international experts representing the European Society of Intensive Care Medicine and Society of Critical Care Medicine was convened at the annual meetings of both societies. Subgroups had teleconference and electronic-based discussion. The entire committee iteratively developed the entire document and recommendations. METHODS:Each committee member independently gave their top five priorities for sepsis research. A total of 88 suggestions (ESM 1 - supplemental table 1) were grouped into categories by the committee co-chairs, leading to the formation of seven subgroups: infection, fluids and vasoactive agents, adjunctive therapy, administration/epidemiology, scoring/identification, post-intensive care unit, and basic/translational science. Each subgroup had teleconferences to go over each priority followed by formal voting within each subgroup. The entire committee also voted on top priorities across all subgroups except for basic/translational science. RESULTS:The Surviving Sepsis Research Committee provides 26 priorities for sepsis and septic shock. Of these, the top six clinical priorities were identified and include the following questions: (1) can targeted/personalized/precision medicine approaches determine which therapies will work for which patients at which times?; (2) what are ideal endpoints for volume resuscitation and how should volume resuscitation be titrated?; (3) should rapid diagnostic tests be implemented in clinical practice?; (4) should empiric antibiotic combination therapy be used in sepsis or septic shock?; (5) what are the predictors of sepsis long-term morbidity and mortality?; and (6) what information identifies organ dysfunction? CONCLUSIONS:While the Surviving Sepsis Campaign guidelines give multiple recommendations on the treatment of sepsis, significant knowledge gaps remain, both in bedside issues directly applicable to clinicians, as well as understanding the fundamental mechanisms underlying the development and progression of sepsis. The priorities identified represent a roadmap for research in sepsis and septic shock.