Leapfrog Group: a prince in disguise or just another frog?

Executive directors, presidents, chief executive officers of some of the principal nursing organizations, and other nurse leaders in the United States were interviewed to ascertain their reactions to the recommendations of the Leapfrog Group, a coalition of more than 90 companies that employ large numbers of workers in the United States. The Leapfrog Group is concerned with patient safety and was formed in response to the Institute of Medicine's report on health care errors. Three recommendations for urban hospitals focus on computerized physician order entry, evidence-based hospital referral, and the use of intensivists.     

Patient safety: is it just another bandwagon?

In this paper, the author questions the focus of the patient safety movement, speculating that it might be just another "bandwagon" that health executives and some health professionals are eager to join. The history of this current emphasis on patient safety is briefly sketched, including current activities in Canada, and questions are raised about whether the movement aids or avoids pressing healthcare issues, many of which are supported by good evidence. These include the relationship between nursing staffing and patient outcomes, the way in which a "cult of efficiency" has operated to make errors more likely and how the silencing of nurses and other staff leads to error. Whether or not one considers the current focus on patient safety a bandwagon, it is important to reflect critically upon the activities undertaken to address the issue and to determine whether one should jump on this bandwagon.     

Pulmonary versus extrapulmonary acute respiratory distress syndrome: different diseases or just a useful concept?

The acute respiratory distress syndrome may complicate both pulmonary and extrapulmonary conditions. There is a growing belief that the predisposition to, and clinical course of, the syndrome may be influenced by the extent to which the lung is directly involved in the precipitating pathologic changes. Several studies have highlighted differences in morphology and respiratory physiology between the two subgroups in the early stages of acute respiratory distress syndrome. Further, preliminary reports have suggested that the effects of therapeutic interventions such as alterations in positive end-expiratory pressure, prone ventilation, and the use of inhaled vasoactive agents may differ between pulmonary and extrapulmonary acute respiratory distress syndrome. There are, however, inconsistencies between various studies addressing these issues, which may relate in part to differences in etiologic case mix. There are also practical difficulties in assigning certain cases to one of these two groups. Finally, there are as yet no outcome data to support any modification of clinical management on the basis of this distinction.     

Automated detection of patient-ventilator asynchrony: new tool or new toy?

Although severe patient-ventilator asynchrony is frequent during invasive and non-invasive mechanical ventilation, diagnosing such asynchronies usually requires the presence at the bedside of an experienced clinician to assess the tracings displayed on the ventilator screen, thus explaining why evaluating patient-ventilator interaction remains a challenge in daily clinical practice. In the previous issue of Critical Care, Sinderby and colleagues present a new automated method to detect, quantify, and display patient-ventilator interaction. In this validation study, the automatic method is as efficient as experts in mechanical ventilation. This promising system could help clinicians extend their knowledge about patient-ventilator interaction and further improve assisted mechanical ventilation.In the previous issue of Critical Care, Sinderby and colleagues [1] compare the analyses by experts and by an innovative automated method to detect and quantify patient-ventilator interaction in ventilator tracings from a previously published study. There is very good agreement between the two approaches and this opens up some exciting prospects.Indeed, even if we have successfully used patient-triggered assisted ventilation for more than 20 years and even if (compared with controlled ventilation) this allows a reduction in sedation needs [2] and a decrease in ventilator-induced diaphragmatic dysfunction [3], we still have not solved the problem of patients ‘fighting’ against their ventilators. This phenomenon, commonly called patient-ventilator asynchrony [4], is related mainly to the fact that during assisted ventilation, especially during pressure support, ventilator-delivered pressurization does not exactly match the characteristics of patients’ inspiratory demand [5]. As a consequence, severe patient-ventilator asynchrony occurs in one fourth of invasively ventilated patients [6] and in more than 40% of non-invasively ventilated patients [7].Even if patient-ventilator asynchrony is very common, studying this phenomenon remains a challenge in daily clinical practice [8]. Indeed, its correct diagnosis usually requires the presence at the bedside of an experienced clinician to assess the tracings displayed on the ventilator screen, which is not possible 24 hours a day. Additionally, up to now, a really sensitive and reliable detection of patient-ventilator asynchronies could only be performed offline by an expert using the simultaneous recording of diaphragmatic electrical activity (Eadi) flow and pressure–time curves [8], an option clearly limited to research purposes.Only an efficient and easy-to-use automated system could help in the real-time diagnosis of patient-ventilator asynchronies at the bedside. As the automated system introduced by Sinderby and colleagues [1] assesses patient-ventilator interaction by automatically comparing ventilator pressure and Eadi waveforms as efficiently as experienced clinicians, it provides, for the first time, a true opportunity of continuously monitoring patient-ventilator interaction in routine clinical practice. Given that a high number of asynchronies have been associated with suboptimal ventilator settings such as excessive levels of pressure support or poorly adapted expiratory trigger setting [9,10], this new monitoring tool also offers the opportunity to better adapt ventilator settings during assisted ventilation by providing real-time feedback to intensive care clinicians. Furthermore, improved closed-loop systems using the automated detection of patient-ventilator asynchronies to continuously and automatically adapt ventilator settings could be implemented in ventilators to further improve the standard of care during mechanical ventilation.Perhaps more importantly, poor patient-ventilator asynchrony has been associated with increased respiratory muscle workload [11], prolonged mechanical ventilation duration [6,12], and poorer outcome in difficult-to-wean patients [13]. However, whether patient-ventilator asynchronies simply occur more frequently in more severely ill patients or whether the occurrence of patient-ventilator asynchronies is by itself responsible for the poor prognosis is still unknown. Answering this important question requires large-scale clinical studies to assess the impact on patients’ outcome of using ventilator strategies which can improve patient-ventilator synchrony, as, for instance, new ventilatory modes such as neurally adjusted ventilatory assist or proportional assist ventilation [14,15] or Eadi-based algorithms to adapt the ventilator settings during pressure support. However, given that, until now, analyzing patient-ventilator synchrony required manual cycle-by-cycle analysis of the ventilator tracings, such large-scale studies could never be performed. By allowing an automated detection, quantification, and display of patient-ventilator asynchronies, the system introduced by Sinderby and colleagues [1] could provide the opportunity to conduct large-scale outcome studies on the impact of correcting patient-ventilator asynchrony. Finally, this system gives the possibility of diagnosing timing errors between Eadi and pressure curves with increased sensitivity compared with standard manual analysis. This, in turn, provides an interesting new tool to further assess patient-ventilator synchrony and maybe to define a cutoff between acceptable and unacceptable synchrony.In summary, the automated system presented by Sinderby and colleagues [1] to automatically detect, quantify, and display patient-ventilator asynchrony is a promising monitoring tool that should help intensive care clinicians extend their knowledge of patient-ventilator interaction and further improve assisted mechanical ventilation.     

Orofacial pain: just another chronic pain? Results from a population-based survey

Features of somatisation have been shown to predict the onset of widespread body pain. This study aims to determine to what extent persons with orofacial pain syndromes share these features and to what extent they are uniquely related to oral mechanical factors. We have conducted a population-based cross-sectional survey in the South-East Cheshire area of the United Kingdom involving 2504 individuals aged 18-65 years. All participants completed a postal questionnaire which enquired about the occurrence of both orofacial pain and widespread body pain. It also enquired about potential risk factors for one or both conditions. In total, 473 subjects (23%) reported orofacial pain only, 123 (6%) widespread pain only, while 85 (4%) reported both. The number reporting both was significantly higher than would be expected if the symptoms were independent (P<0.001). Several oral mechanical factors were significantly associated with both orofacial pain and widespread body pain (grinding teeth, clicking jaw, missing teeth), while two (facial trauma, locking jaw) were specifically related to orofacial pain. Both pain syndromes were associated equally with high levels of psychological distress, indicators of somatisation and maladaptive response to illness. These results suggest that orofacial pain syndromes may commonly be a manifestation of the process of somatisation and the excess reporting of some local mechanical factors amongst persons with these symptoms, may not be uniquely associated with pain in the orofacial region.     

Neurally adjusted ventilatory assist: a ventilation tool or a ventilation toy?

Mechanical ventilation has, since its introduction into clinical practice, undergone a major evolution from controlled ventilation to various modes of assisted ventilation. Neurally adjusted ventilatory assist (NAVA) is the newest development. The implementation of NAVA requires the introduction of a catheter to measure the electrical activity of the diaphragm (EA(di)). NAVA relies, opposite to conventional assisted ventilation modes, on the EA(di) to trigger the ventilator breath and to adjust the ventilatory assist to the neural drive. The amplitude of the ventilator assist is determined by the instantaneous EA(di) and the NAVA level set by the clinician. The NAVA level amplifies the EA(di) signal and determines instantaneous ventilator assist on a breath-to-breath basis. Experimental and clinical data suggest superior patient-ventilator synchrony with NAVA. Patient-ventilator asynchrony is present in 25% of mechanically ventilated patients in the intensive care unit and may contribute to patient discomfort, sleep fragmentation, higher use of sedation, development of delirium, ventilator-induced lung injury, prolonged mechanical ventilation, and ultimately mortality. With NAVA, the reliance on the EA(di) signal, together with an intact ventilatory drive and intact breathing reflexes, allows integration of the ventilator in the neuro-ventilatory coupling on a higher level than conventional ventilation modes. The simple monitoring of the EA(di) signal alone may provide the clinician with important information to guide ventilator management, especially during the weaning process. Although, until now, little evidence proves the superiority of NAVA on clinically relevant end points, it seems evident that patient populations (eg, COPD and small children) with major patient-ventilator asynchrony may benefit from this new ventilatory tool.