Alejandro C. Arroliga M.D.

Tatham, K. C., N. D. Ferguson, Q. Zhou, L. Hand, P. Austin, R. Taneja, A. C. Arroliga, J. F. Sanchez, E. J. Jimenez, B. P. Staub, M. E. Kho, J. G. Domínguez-Cherit, A. Mullaly, Y. M. Arabi and M. O. Meade (2021). “Evolution of practice patterns in the management of acute respiratory distress syndrome: A secondary analysis of two successive randomized controlled trials.” J Crit Care 65: 274-281.

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PURPOSE: We sought to examine changes in acute respiratory distress syndrome (ARDS) management over a 12-year period of two successive randomized trials. METHODS: Analyses included baseline data, from eligible patients, prior to influence of trial protocols, and daily study data, from randomized patients, of variables not determined by trial protocols. Mixed linear regressions examined changes in practice year-on-year. RESULTS: A total of 2376 patients met the inclusion criteria. Over the 12-year period, baseline tidal volume index decreased (9.0 to 7.0 ml/kg, p < 0.001), plateau pressures decreased (30.8 to 29.0 cmH(2)O, p < 0.05), and baseline positive end-expiratory pressures increased (10.8 to 13.2 cmH(2)O, p < 0.001). Volume-controlled ventilation declined from 29.4 to 14.0% (p < 0.01). Use of corticosteroids increased (baseline: 7.7 to 30.3%; on study: 32.6 to 61.2%; both p < 0.001), as did neuromuscular blockade (baseline: 12.3 to 24.5%; on study: 55.5 to 70.0%; both p < 0.01). Inhaled nitric oxide use increased (24.9 to 65.8%, p < 0.05). We observed no significant change in prone positioning (16.2 to 18.9%, p = 0.70). CONCLUSIONS: Clear trends were apparent in tidal volume, airway pressures, ventilator modes, adjuncts and rescue therapies. With the exception of prone positioning, and outside the context of rescue therapy, these trends appear consistent with the evolving literature on ARDS management.

Howell, A., Havens, L., Swinford, W. and Arroliga, A. (2021). “PPE Effectiveness – Yes, the Buck and Virus can Stop Here.” Infect Control Hosp Epidemiol Feb 19;1-3. [Epub ahead of print].

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We conducted an observational study of a multi-center healthcare system to determine the effectiveness of our infection control/PPE program during the care of COVID-19 patients. The COVID-19 conversion rate in the patient care setting was 0.70%. Comparatively, the conversion rate noted in the non-patient care/community setting was 15.17%.

Danesh, V., Hecht, J., Hao, R., Boehm, L., Jimenez, E.J., Arroliga, A.C., Sanghi, S. and Stevens, A. (2021). “Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS): Study protocol for peer mentor training.” J Adv Nurs Jan 11. [Epub ahead of print].

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AIMS: The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life. DESIGN: Prospective clinical feasibility trial. METHODS: This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours. DISCUSSION: Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors. IMPACT: Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae.

McGraw, M., White, H.D., Boethel, C., Zolfaghari, K., Hochhalter, A. and Arroliga, A. (2020). “Corticosteroid Dosing and Glucose Levels in COPD Patients Are Not Associated with Increased Readmissions.” Chronic Obstr Pulm Dis Nov 25. [Epub ahead of print.].

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INTRODUCTION: Hospital admissions and readmissions for chronic obstructive pulmonary disease (COPD) exacerbations are associated with increased mortality and higher cost. The management of exacerbations with a shortened course of systemic corticosteroids has similar efficacy as compared to longer steroid courses, but actual overall steroid dose given is still variable. The outcomes associated with steroid side effects, such as hyperglycemia, need further evaluation. We hypothesize that the use of higher doses of corticosteroids, and the subsequent hyperglycemia, contributes to readmission. METHODS: This is an retrospective study at a tertiary care referral center in Central Texas between February 2014 and July 2016. Daily corticosteroid dose, blood glucose levels, and readmission rates at 30 and 31-90 days were recorded. Sample characteristics are described using descriptive statistics. A chi-square test or student’s t-test were used to test for associations in bivariate comparisons. Multivariable logistic regression assessed the association between readmission rate and demographic and clinical characteristics. RESULTS: There were 1,120 patients admitted for COPD exacerbation between February 2014 and July 2016. Fifty seven percent were female, mean age was 69 (SD 12), and average BMI was 29.4 (SD 9.8). Of the total, 349 (31%) had diabetes prior to admission. The 30 days readmission rate was 16%, and the readmission rate from 31-90 days was 14%. The average prednisone equivalent dose per day during hospitalization was 86 mg (SD 52). A multivariable logistic regression model did not show any significant association between readmission and average daily glucose, high maximum glucose (>180 mg/dL on any reading), or prednisone equivalent administered per day. CONCLUSION: Corticosteroid dose and hyperglycemia were not associated with an increased 30 or 31-90 days readmission rate after COPD exacerbation discharge. In addition, using higher doses of corticosteroids instead of standard-of-care (Prednisone 40 mg per day for a 5-day period) did not appear to affect the readmission rate in this cohort.

White, B.A.A., White, H.D., Bledsoe, C., Hendricks, R. and Arroliga, A.C. (2020). “Conflict Management Education in the Intensive Care Unit.” Am J Crit Care 29(6): e135-e138.

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BACKGROUND: Conflicts in medical settings affect both team function and patient care, yet a standardized curriculum for conflict management in clinical teams does not exist. OBJECTIVES: To evaluate the effects of an educational intervention for conflict management on knowledge and perceptions and to identify trends in preferred conflict management style among intensive care unit workers. METHODS: A conflict management education intervention was created for an intensive care team. The intervention was 1 hour long and incorporated the Thomas-Kilmann Conflict Mode Instrument as well as conflict management concepts, self-reflection, and active learning through discussion and reviewing clinical cases. Descriptive statistics were prepared on the participants’ preferred conflict management modes. A pretest/posttest was analyzed to evaluate knowledge and perceptions of conflict before and after the intervention, and 3 open-ended questions on the posttest were reviewed for categories. RESULTS: Forty-nine intensive care providers participated in the intervention. The largest portion of participants had an avoiding conflict management mode (32%), followed by compromising (30%), accommodating (25%), collaborating (9%), and competing (5%). Pretest/posttest data were collected for 31 participants and showed that knowledge (P < .001) and perception (P = .004) scores increased significantly after the conflict management intervention. CONCLUSIONS: The conflict management educational intervention improved the participants' knowledge and affected perceptions. Categorization of open-ended questions suggested that intensive care providers are interested in concrete information that will help with conflict resolution, and some participants understood that mindfulness and awareness would improve professional interactions or reduce conflict.