Objectives:To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research.Design:An appointed Task Force followed a standard, systematic, and evidence-

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

Catastrophic disasters occurring in 2011 in the United States and worldwide--from the tornado in Joplin, Missouri, to the earthquake and tsunami in Japan, to the earthquake in New Zealand--have demonstrated that even prepared communities can be overwhelmed. In 2009, at the height of the influenza A (H1N1) pandemic, the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, along with the Department of Veterans Affairs and the National Highway Traffic Safety Administration, asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in disaster situations-both naturally occurring and man-made-under conditions of scarce resources. Building on the work of phase one (which is described in IOM's 2009 letter report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations), the committee developed detailed templates enumerating the functions and tasks of the key stakeholder groups involved in crisis standards of care (CSC) planning, implementation, and public engagement-state and local governments, emergency medical services (EMS), hospitals and acute care facilities, and out-of-hospital and alternate care systems. Crisis Standards of Care provides a framework for a systems approach to the development and implementation of CSC plans, and addresses the legal issues and the ethical, palliative care, and mental health issues that agencies and organizations at each level of a disaster response should address. Please note: this report is not intended to be a detailed guide to emergency preparedness or disaster response. What is described in this report is an extrapolation of existing incident management practices and principles. Crisis Standards of Care is a seven-volume set: Volume 1 provides an overview; Volume 2 pertains to state and local governments; Volume 3 pertains to emergency medical services; Volume 4 pertains to hospitals and acute care facilities; Volume 5 pertains to out-of-hospital care and alternate care systems; Volume 6 contains a public engagement toolkit; and Volume 7 contains appendixes with additional resources.

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response

Objectives:We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that requir

Interprofessional Care and Teamwork in the ICU.

Objectives To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. Data sources Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. Study selection Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. Data extraction Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. Data synthesis Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. Conclusions Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.

Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018.

Epidemiological studies have found strong associations between air pollution and respiratory effects including development and/or exacerbation of asthma and chronic obstructive pulmonary disease (COPD) as well as increased occurrence of respiratory infections and lung cancer. It has become increasingly clear that also polycyclic aromatic hydrocarbons (PAHs) may affect processes linked to non-malignant diseases in the airways. The aim of the present paper was to review epidemiological studies on associations between gas phase and particle-bound PAHs in ambient air and non-malignant respiratory diseases or closely related physiological processes, to assess whether PAH-exposure may explain some of the effects associated with air pollution. Based on experimental in vivo and in vitro studies, we also explore possible mechanisms for how different PAHs may contribute to such events. Epidemiological studies show strongest evidence for an association between PAHs and asthma development and respiratory function in children. This is supported by studies on prenatal and postnatal exposure. Exposure to PAHs in adults seems to be linked to respiratory functions, exacerbation of asthma and increased morbidity/mortality of obstructive lung diseases. However, available studies are few and weak. Notably, the PAHs measured in plasma/urine also represent other exposure routes than inhalation. Furthermore, the role of PAHs measured in air is difficult to disentangle from that of other air pollution components originating from combustion processes. Experimental studies show that PAHs may trigger various processes linked to non-malignant respiratory diseases. Physiological- and pathological responses include redox imbalance, oxidative stress, inflammation both from the innate and adaptive immune systems, smooth muscle constriction, epithelial- and endothelial dysfunction and dysregulated lung development. Such biological responses may at the molecular level be initiated by PAH-binding to the aryl hydrocarbon receptor (AhR), but possibly also through interactions with beta-adrenergic receptors. In addition, reactive PAH metabolites or reactive oxygen species (ROS) may interfere directly with ion transporters and enzymes involved in signal transduction. Overall, the reviewed literature shows that respiratory effects of PAH-exposure in ambient air may extend beyond lung cancer. The relative importance of the specific PAHs ability to induce disease may differ between the biological endpoint in question.

/pdf/potential-role-of-polycyclic-aromatic-hydrocarbons-in-air-5b1q12a79n.pdf

Potential role of polycyclic aromatic hydrocarbons in air pollution-induced non-malignant respiratory diseases

Impact of nonphysician staffing on outcomes in a medical ICU.

Incomplete combustion produces a pollutant mixture that includes polycyclic aromatic hydrocarbons (PAHs). Previous work by the Columbia Center for Children's Environmental Health (CCCEH) and others linked exposure to PAH with symptoms of asthma and other adverse health effects in young children. Inhaled β2-adrenergic agonists are mainstays in the treatment of reactive airway diseases. These exogenous catecholamines engage membrane-bound β2-adrenergic receptors (β2AR) on airway epithelial and smooth muscle cells to cause airway dilation. We hypothesized that exposure to PAH might similarly interfere with the function of β2AR in airway epithelial or smooth muscle cells, reducing the efficacy of a medication important for the treatment of asthma symptoms. A PAH mixture was devised, based on ambient levels measured prenatally among a cohort of pregnant women participating at the CCCEH. Primary airway epithelial and smooth muscle cells were exposed to varying concentrations of the PAH mixture, and expression, function, and signaling of β2AR were assessed. Murine tracheal epithelial cells and human airway smooth muscle cells, after exposure to a PAH mixture, exhibited reduced expression and function of β2AR. These findings support our hypothesis that environmentally relevant PAHs can impede β2AR-mediated airway relaxation, and suggest a new paradigm where air pollutants not only contribute to the pathogenesis of childhood asthma, but also diminish responsiveness to standard therapy.

Polycyclic aromatic hydrocarbons impair function of β2-adrenergic receptors in airway epithelial and smooth muscle cells.

Is it the inflammation or the free radicals that cause ischemia/reperfusion lung injury?

A 35-year-old woman with unusual behavior and prolonged respiratory failure

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Impact of nonphysician staffing on outcomes in a medical ICU.

Polycyclic aromatic hydrocarbons impair function of β2-adrenergic receptors in airway epithelial and smooth muscle cells.

Is it the inflammation or the free radicals that cause ischemia/reperfusion lung injury?

A 35-year-old woman with unusual behavior and prolonged respiratory failure