critical thinking in acute care

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Developing critical thinking skills for delivering optimal care

Scott IA, Hubbard RE, Crock C, et al. Developing critical thinking skills for delivering optimal care. Intern Med J. 2021;51(4):488-493. doi: 10.1111/imj.15272

Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.

Medication use and cognitive impairment among residents of aged care facilities. June 23, 2021

COVID-19 pandemic and the tension between the need to act and the need to know. October 14, 2020

Choosing wisely in clinical practice: embracing critical thinking, striving for safer care. April 6, 2022

Scoping review of studies evaluating frailty and its association with medication harm. June 22, 2022

Countering cognitive biases in minimising low value care. June 7, 2017

'More than words' - interpersonal communication, cognitive bias and diagnostic errors. August 11, 2021

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. February 6, 2019

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021

Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA. June 24, 2020

Developing and aligning a safety event taxonomy for inpatient psychiatry. July 13, 2022

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic. September 28, 2022

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics. March 8, 2023

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023

Barriers to accessing nighttime supervisors: a national survey of internal medicine residents. March 17, 2021

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020

Transforming the medication regimen review process using telemedicine to prevent adverse events. December 16, 2020

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial. February 2, 2022

Perceived patient safety culture in a critical care transport program. July 31, 2013

Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory. May 18, 2022

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022

Patient harm from cardiovascular medications. August 25, 2021

Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. June 1, 2022

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population. May 19, 2021

Evaluation of a second victim peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical specialties using the second victim experience and support tool (SVEST). November 3, 2021

Diagnostic errors in hospitalized adults who died or were transferred to intensive care. January 17, 2024

Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort. March 16, 2022

Multiple meanings of resilience: health professionals' experiences of a dual element training intervention designed to help them prepare for coping with error. March 31, 2021

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis. March 10, 2021

TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care? September 15, 2021

An act of performance: exploring residents' decision-making processes to seek help. April 14, 2021

Preventing home medication administration errors. March 14, 2022

A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020

Clinical predictors for unsafe direct discharge home patients from intensive care units. October 21, 2020

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors. July 21, 2021

Standardized assessment of medication reconciliation in post-acute care. April 27, 2022

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. June 16, 2021

Survey of nurses' experiences applying The Joint Commission's medication management titration standards. November 3, 2021

Effectiveness of acute care remote triage systems: a systematic review. February 5, 2020

Physician task load and the risk of burnout among US physicians in a national survey. December 2, 2020

Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers. September 23, 2020

Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study. May 5, 2021

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021

Association between surgeon technical skills and patient outcomes. September 9, 2020

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being. June 8, 2022

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors. October 12, 2022

Comparison of health care worker satisfaction before vs after implementation of a communication and optimal resolution program in acute care hospitals. April 5, 2023

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures. September 21, 2011

Temporal associations between EHR-derived workload, burnout, and errors: a prospective cohort study. July 20, 2022

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022

Deferral of care for serious non-COVID-19 conditions: a hidden harm of COVID-19. November 18, 2020

An observational study of postoperative handoff standardization failures. June 23, 2021

Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients? January 8, 2020

Exploring the impact of employee engagement and patient safety. September 14, 2022

Deprescribing for community-dwelling older adults: a systematic review and meta-analysis. September 16, 2020

The abrupt expansion of ambulatory telemedicine: implications for patient safety. February 9, 2022

Nurse's Achilles Heel: using big data to determine workload factors that impact near misses. April 14, 2021

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain. July 14, 2021

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. October 21, 2020

Expert consensus on currently accepted measures of harm. September 9, 2020

The July Effect in podiatric medicine and surgery residency. July 14, 2021

The calm before the storm: utilizing in situ simulation to evaluate for preparedness of an alternative care hospital during COVID-19 pandemic. June 2, 2021

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study. June 22, 2022

The association between nurse staffing and omissions in nursing care: a systematic review. July 11, 2018

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations. June 22, 2022

Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial. June 8, 2016

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports. October 14, 2020

Pediatric surgical errors: a systematic scoping review. July 20, 2022

Racial bias in pulse oximetry measurement. December 20, 2020

Accuracy of practitioner estimates of probability of diagnosis before and after testing. May 5, 2021

Recommendations for the safe, effective use of adaptive CDS in the US healthcare system: an AMIA position paper. April 21, 2021

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. September 23, 2020

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. September 29, 2021

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022

Second victim experiences of nurses in obstetrics and gynaecology: a Second Victim Experience and Support Tool Survey December 23, 2020

Understanding the second victim experience among multidisciplinary providers in obstetrics and gynecology. May 19, 2021

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. June 16, 2021

Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). May 5, 2021

Organizational safety climate and job enjoyment in hospital surgical teams with and without crew resource management training, January 26, 2022

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial. March 1, 2023

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.  August 24, 2005

Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study. October 21, 2020

Safety II behavior in a pediatric intensive care unit. August 1, 2018

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation. April 20, 2022

The working hours of hospital staff nurses and patient safety. January 9, 2005

Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients. March 2, 2022

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety. December 9, 2020

COVID-19: an emerging threat to antibiotic stewardship in the emergency department. October 21, 2020

Improving self-reported empathy and communication skills through harm in healthcare response training. January 26, 2022

Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study. February 17, 2021

Predicting avoidable hospital events in Maryland. December 1, 2021

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. April 21, 2005

Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. September 2, 2020

COVID-19: patient safety and quality improvement skills to deploy during the surge. June 24, 2020

Patient safety skills in primary care: a national survey of GP educators. February 4, 2015

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error? June 8, 2011

Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors. October 12, 2022

Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. June 20, 2018

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs. March 10, 2021

Racial and ethnic harm in patient care is a patient safety issue. May 15, 2024

All in Her Head. The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today. March 20, 2024

The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature. December 6, 2023

A scoping review exploring the confidence of healthcare professionals in assessing all skin tones. October 4, 2023

Patient safety in palliative care at the end of life from the perspective of complex thinking. August 16, 2023

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds. August 16, 2023

Factors influencing in-hospital prescribing errors: a systematic review. July 19, 2023

Introducing second-year medical students to diagnostic reasoning concepts and skills via a virtual curriculum. June 28, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error. June 21, 2023

The good, the bad, and the ugly: operative staff perspectives of surgeon coping with intraoperative errors. June 14, 2023

Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections. June 7, 2023

The time is now: addressing implicit bias in obstetrics and gynecology education. May 17, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States. May 3, 2023

Annual Perspective

Formalizing the hidden curriculum of performance enhancing errors. March 22, 2023

Implicit racial bias, health care provider attitudes, and perceptions of health care quality among African American college students in Georgia, USA. January 18, 2023

Structural racism and impact on sickle cell disease: sickle cell lives matter. January 11, 2023

The REPAIR Project: a prospectus for change toward racial justice in medical education and health sciences research: REPAIR project steering committee. January 11, 2023

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. January 11, 2023

Exploring the intersection of structural racism and ageism in healthcare. December 7, 2022

Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022

Improved Diagnostic Accuracy Through Probability-Based Diagnosis. September 28, 2022

Medical malpractice lawsuits involving trainees in obstetrics and gynecology in the USA. September 21, 2022

A state-of-the-art review of speaking up in healthcare. August 24, 2022

Skin cancer is a risk no matter the skin tone. But it may be overlooked in people with dark skin. August 17, 2022

Oxford Professional Practice: Handbook of Patient Safety. July 27, 2022

Narrowing the mindware gap in medicine. July 20, 2022

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. June 15, 2022

A call to action: next steps to advance diagnosis education in the health professions. June 8, 2022

Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. April 27, 2022

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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• Nurses' reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. [Int J Nurs Stud. 2007] Nurses' reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. Funkesson KH, Anbäcken EM, Ek AC. Int J Nurs Stud. 2007 Sep; 44(7):1109-19. Epub 2006 Jun 27.
• Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. [Nurse Educ Today. 2016] Registered nurses' clinical reasoning skills and reasoning process: A think-aloud study. Lee J, Lee YJ, Bae J, Seo M. Nurse Educ Today. 2016 Nov; 46:75-80. Epub 2016 Aug 15.
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thinking critical care

a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!

Shifting the Paradigm: Macro to Micro – Grand Rounds for Lennox Hill, April 2024. #FOAMed

Had the honour of being invited to give grand rounds by Dr. Paul Mayo and share some thoughts on fluid tolerance and venous congestion. Starts around the 17min mark – sorry I have no editing capabilities!

HR24: Acute Inpatient Medicine – Next Level

June 15, 2024, 10-4 EST – Online Webinar Only

Preliminary Schedule:

H&R 2024 Outline: Acute Inpatient Medicine – Next Level! 

Date: June 15 10am-4:30pm EST (7am-1:30pm PST) 

Format: 

• one-day, 6.5 hours, online only
• Pre-recorded lectures
• Live Q&A
• 10am-10:15am: Intro and welcome (15min)
• 10:15am-10:35am: POCUS for shock – Ross Prager
• 10:35am-10:55am: VEXUS tips and tricks – Abhilash Koratala
• 10:55am-11:15am: Ventilators 101 – Segun Olusanya
• 11:15am-11:35am: Q&A 
• 11:35am-11:55am: Dysnatremias in cirrhosis – Eduardo Argaiz
• 11:55am-12:15pm: Top 10 diuretic mistakes – Frederik Verbrugge 
• 12:15pm-12:35pm: Physiology of the shock patient – Ashley Miller 
• 12:35-12:55pm: Q&A
• 12:55pm-1:30pm: Break (35min)
• 1:30pm-1:50pm: The sick aortic stenosis patient – Trina Augustin
• 1:50pm-2:10pm: The sick pulmonary HTN patient – Matt Siuba
• 2:10pm-2:30pm: The seizing ward patient – Casey Albin
• 2:30pm-2:50pm: Q&A
• 2:50pm-3:10pm:  Palliative Medicine pointers – Brittany Rance
• 3:10pm-3:30pm:  Top 5 Geriatric Pearls on the ward – Gurmeet Sohi
• 3:30pm-3:50pm: Sepsis: what we should be doing – Sara Crager
• 3:50pm-4:10pm: Q&A
• 4:10-4:30pm: Concluding remarks (20min)

Also some online-only BONUS lectures – How-To VExUS by Dr. Taweevat Assavapokee!

Registration is OPEN! https://ccusinstitute.wixsite.com/ccus/events/hr2024-acute-inpatient-medicine-next-level-online-webinar

Spiegel & Hockstein Crit Lit HR23!

VExUS/POCUS/Resus Mini-Fellowships 2024

In the last couple of years VExUS has seemingly sparked a number of clinicians to focus on right-sided or venous congestion and its deleterious consequences. Many of us feel there is sufficient associative evidence and physiological basis to use VExUS to manage patients on a daily basis and do so routinely. Currently, several studies we know of (and probably many we don’t!) are on track to show that a VExUS-based approach is likely to be superior to a highly variable traditional approach. In teaching it at the bedside, however, we emphasize the fact that this tool should not be used in a brain-bypass, monosynaptic fashion – all elevated VExUS scores should NOT blindly be diuresed… These ways on how to integrate VExUS in clinical decision-making is what we will emphasize in this part of the Mini-Fellowship.

So due to demand, we have added this specific skill to our Mini-Fellowships which have been going strong for over a decade. The idea (just like in resuscitation!) is to tailor these days to what you need the most. Whether you want to focus on advanced POCUS, looking at coupling parameters and TDI or whether you want to learn to integrate these findings into a resuscitation approach, we will do our best to fill the gaps you may have.

We’ve been organizing mini-fellowships now for over a decade (obviously slowed by the whole pandemic business), because while learning the technical aspect of scanning is one thing, the translation into clinical application and decision-making is altogether another step that, for many, is achieved more readily by witnessing live clinical management.

This year, for the first time, we are adding a specific VExUS element. Participants will be able to pre-emptively watch the online VExUS Course, and then follow a senior instructor for 2-5 days of clinical practice (avg 4-6h/day) where they will be able to observe live scanning and management of real patients both in outpatient, inpatient, ED and ICU settings.

Tuition – Montreal Mini-Fellowships: 600$ CAN / 500$ USD per day for 1 physician, 400$ CAN / 350$ USD per person per day for additional days, and 400$ CAN / 350$ USD per person per day for a 2 to maximum 3 physician group. For physicians who are not from high income countries, do let us know, we will try to help get some industry sponsorship to make it possible.

CME : For Canadians, from the Royal College of Physicians standpoint, the Mini-Fellowships qualify for 25 Section 2 credits (regardless of the length) and 3 hours of Section 3 credits (per day of fellowship). For you Americans:

Through an agreement between the Royal College of Physicians and Surgeons of Canada and the American Medical Association, physicians may convert Royal College MOC credits to AMA PRA Category 1 Credits™. 

Please see the prior posts for participant feedback ( https://thinkingcriticalcare.com/2018/05/09/ccus-institute-pocus-resuscitationist-mini-fellowship-evolution/ ), and if interested, please email [email protected] and we will put you in touch with one of the senior instructors whose time matches your availability.

The H&R Team

H&R’s Advanced Airway & Basic Airway Endoscopy Workshop 2024

The H&R Advanced Airway Workshop 

Santa Cabrini Hospital, Feb 9th, 2024, 1200pm-4pm

Airway/Intubation

Advanced airway skills are a key element of the resuscitationist’s arsenal. In this workshop, participants will be able to tailor their experience and spend as much or as little time as they want in each station to maximize their learning. We will cover basic direct and video laryngoscopy and intubation with and without the use of the bougie as well as bronchoscopic assistance. Emergency surgical airways – both percutaneous and scalper-finger-bougie techniques – will be reviewed and practiced until participants can perform both rapidly and adequately. 

Basic Upper Airway Endoscopy

Endoscopy for basic diagnostic and procedural purposes will be reviewed for obstructive and airway toilet. This will include rhino-pharyngo-laryngoscopy for foreign body/lesion assessment and stridor management in the ER.

Critical Care Endoscopy

Basic bronchoscopy for rapid diagnosis and airway toilet will be covered. This will pertain to most critical care cases where removal of mucus plugs and broncho-alveolar lavage is the bread and butter. Following instruction, each participant will be asked to demonstrate the ability to identify basic anatomy and be able to orient themselves successfully.

Bedside Percutaneous Tracheostomy Course

Participants will spend the last 90 minutes in a separate track focused on the technique and will be asked to perform 5 unassisted techniques to obtain a certificate of adequate completion. {Note that, since this is not an emergency life-saving procedure, this does not qualify the participant to perform the technique independently in clinical practice and will require supervision by an experienced colleague until sufficient experience is attained.}

Participants & Registration

There will be 15 complimentary trainee registration slots and 20 spots for practicing physicians (249$/199$ for CEMTL MDs) and 5 spots including the percutaneous tracheostomy course (349$). Participants will receive a link to pre-course material to watch prior to the workshops. Lunch will be included. There is no formal CME accreditation for this event.

Registration link: https://ccusinstitute.wixsite.com/ccus/events/hsco-hr-airway-course-2024

The Faculty : Dr. Joe Nemeth (ER), Dr. Philippe St-Arnaud – (ER/Critical Care) Dr. Lawrence Leroux (ER/Anaesthesia), Dr. Andy Nguyen (Respirology), Dr. Olivier Abboud (Otolaryngology), Dr. Ian Ajmo (Critical Care), Dr. Philippe Rola (Critical Care).

Welcome and Lunch – 1230-1300

Stations A: 1300-1400

– Basic DL/VL station (St-Arnaud, Ajmo)

– The Art of the Bougie (Rola)

– Bronchoscopy-guided intubation (Leroux, Nemeth)

– Rhino/pharyngo/laryngoscopy – (Abboud)

Stations B: 1400-1500

– Emergency percutaneous cricothyrotomy (St-Arnaud/Rola)

– Emergency Surgical Airway (Scalpel-Finger-Bougie) (St-Arnaud/Rola)

– Emergency Tracheostomy (Nemeth)

– Bronchoscopy for toilet/foreign body extraction (Nguyen)

Percutaneous Tracheostomy w/ Bronchoscopy Assistance (Ajmo/Rola) 1430-1600

Open Practice and Q&A: 1500-1600

HR2023 Highlights: Matt Siuba on a Practical Approach to VA Coupling!

So HR2023 was awesome. So many good talks and workshops, as well as some fantastic hallway discussions with both faculty and participants!

I will be sharing several of the talks on #FOAMed and wanted to start with what I think is hands-down the best practical clinical talk on VA coupling. Matt, as a true clinician and bedside physiologist, finds a way to take a complex topic and make it understandable and usable. Kudos!

For those interested in the rest of the #HR23 lectures, they can be found here, with CME to come in the next weeks.

Super excited for this. No issues with travel this year, the H&R family all keen on getting together again, the lineup is awesome, most of the OGs able to make it, lots of new additions, and the programme is looking really sweet. Am totally amped to have Katie Wiskar as the Chair of The Hospitalist as she’s putting together a great group with sharp lectures and super interesting workshops. With help from the usual suspects (Rory Spiegel, Andre Denault, Korbin Haycock) we are focusing on some core areas in acute and critical care – sepsis, arrest and respiratory failure are perennials, but this year we are also adding neurocrit as a core component, which I think is a bit underserved and certainly deserving of more.

A message from Katie Wiskar: I cannot express how excited I am to be a part of H&R 2023, and to finally get to experience the magic in person. Building on the energy and ethos that Philippe has curated in the Resuscitation side, I’m thrilled to bring a killer set of on-demand lectures and in-person content delivered by a top-notch, multi-disciplinary faculty. The program is full of hot topics, evidence-based medicine updates, and practical ward pearls. I can’t wait to learn from this group of incredible educators; and I hope to see you all there! 

When? September 27-30 with the core being 28-29 and the pre/post stuff on either side.

Where? Montreal – both at the Heart Institute (core days) and my shop, Santa Cabrini Hospital (pre/post courses).

CME? Of course, should be over 40 credits, watch this space in the next weeks.

What? So you get a bunch (about 50) lectures to watch prior to the conference, then during the in-person part, you get some live lectures followed by group discussions around those topics, as well as hands-on workshops. You can hop between the Hospitalist and the Resuscitationist tracks depending on your interest or mood. Most importantly, there’s plenty of hallway time where you get to hunt down the universally open minded and available faculty members to pick their brains, share ideas, start collaborations and who knows what else you might come up with. This is gold. There’s going to be a buffet of workshops to pick and choose from that we are still putting together, from airway management to bedside procedures, ekg workshops, neuro exam workshop, wound dressing, and of course all kinds of POCUS.

Oh yeah, and the pre/post stuff is pretty fantastic. If you’ve been following acute care and POCUS, you’ve noticed the beginning of an ear where we will focus on fluid tolerance rather than responsiveness, and VExUS is a pretty important part of it. Learn from the originators and other pioneers of the score in this VExUS course with real patients and pathology. If you struggle with refractory hypoxia in acute lung injury, add APRV-TCAV to your armamentarium. Understand the mode, shake off the myths and learn knobology on a couple of ventilators with simulated lungs. You do trauma or medical resus? REBOA is growing in use. Familiarize yourself with the technique using the different available aortic occlusion catheters with the REBOA course . The Resuscitative TEE Course , run by none other than Felipe Teran is back again! If you’re not personalizing your CPR, here’s the place to learn!

The Hospitalist POCUS Course will be split in Basic (AM) and Advanced (PM) and the focus will be on all core skills required at the inpatient level. The faculty is absolutely top notch.

A newcomer this year is the Jr. Doc Procedure Course , aimed at trainees but truly good for anyone entering the hospital arena, regardless of age or training status. Go over and practice intubation and basic airway management, central and arterial line placement, thoracic and abdominal pigtail insertion and more!

And of course, the Introduction to Brazilian Jiu Jitsu workshop is always a blast. Last year, participants were treated to a short philosophical discussion on breathing with guru coach Firas Zahabi followed by a hands-on training session. In previous years we had reviewed basic concepts to stay safe in volatile situations. Always a lot of fun! We are fortunate to have some pretty seriously BJJ-skilled faculty members such as Ashley Miller and Rory Spiegel! Can’t wait!

Who? So the H&R family keeps growing!

On the H side, Katie has assembled an impressive lot that I am really looking forward to meeting and exchanging with, such as Gigi Liu, Michael Fralick, Elaine Kilabuk, Ria Dancel and more to be confirmed!

On the R side, we have many of the usual (awesome) suspects, Korbin Haycock, Rory Spiegel, Matt Siuba, Segun Olusanya, Felipe Teran, Jeff Scott.

Some young guns like Ben Daxon, Trina Augustin, Max Hockstein, Eduardo Argaiz, Vimal Bhardwaj, Frederick Verbrugge and Jay Chatterjee.

Some who joined us virtually last year but whom I am totally psyched about meeting some in person such as Katie Wiskar, Abhilash Koratala, Casey Albin, Neha Dangayach, Ashley Miller, Hatem Soliman, Mourad Senussi and Sara Crager.

Not to mention some icons of emergency and critical care like Scott Weingart, Ognen Gajic, Sheldon Magder, Andre Denault, Ashish Khanna, Jan Bakker and Glenn Hernandez who have contributed so much to the literature.

…and we keep adding talks and faculty! Bookmark this to keep up!

For the preliminary programme and more information , https://hr2023.sched.com/

Registration is open! https://ccusinstitute.wixsite.com/ccus/events/the-hospitalist-the-resuscitationist-2023

See you there!!!

Etomidate: a perspective on a current controversy.

Personally, I’ve never used it, so not really an issue to me. But it seems to generate a fair bit of emotion and debate, and having the pleasure of knowing some really smart and, in this case, highly experienced people, I think we have something good to share here, a story from Thomas Woodcock! This insight may help clinicians currently debating the issue…

Edomidate – A Brief Personal History.

By Thomas Woodcock, MD.

We all want Evidence, good solid peer reviewed communications with verifiable data, ideally randomised and controlled. But we are human, and our practices are also informed by unpublished experience, what used to be cited as “Personal communications”. I acknowledge the dangers of placing too much confidence in such evidence. Our recollections of events may become clouded or unreliable as the years pass. With that caution in mind, I am going to take the final opportunity to offer my unpublished recollections of events surrounding Iain Watt’s fortuitous discovery of the lethality of the intravenous anaesthetic agent etomidate back in 1983; forty years ago, though it only seems like yesterday.

This year our friends at San Raffaele Scientific Institute, Milan, Italy published a meta-analysis of studies reporting the use of etomidate to cover tracheal intubation in critically ill patients and concluded as follows;

We included 11 randomized trials comprising 2704 patients. We found that etomidate increased mortality (319/1359 [23%] vs. 267/1345 [20%]; risk ratio (RR) =  1.16; 95% confidence interval (CI), 1.01–1.33; P =  0.03; I2 = 0%; number needed to harm = 31). The probabilities of any increase and a 1% increase (NNH ≤100) in mortality were 98.1% and 92.1%, respectively. [1]

This came as no surprise to me, and was predictably followed by etomidate anaesthetists explaining that the harm (euphemism for lethal effect) could only be proven by enrolling thousands of participants in a blinded RCT. Imagine the Consent form.

We have a broad selection of intravenous anaesthetic agents to offer for your general anaesthetic, but one of them has had serious concerns raised about a lethal effect. With your permission we would like to randomise you to receive a safe drug or etomidate so that we can learn more about the lethal effect.

In 1983 I was an Englishman abroad, the London anaesthetist who was appointed to be the English anaesthetist on the Shock Team only because the outstanding candidate from Oxford had preferred to take up a job doing muscle relaxant research with Kitz and Katz in the USA. The Western Infirmary Glasgow (WIG) was a Victorian red brick building on the Byres Road. The Boss was Professor Iain McAllister Ledingham, Editor of the book series Recent Advances in Critical Care Medicine, a founder of The European Society of Intensive Care Medicine and one of its first Presidents. With many original publications on shock and interhospital transfer, in the clinic and in the laboratory, Iain Ledingham was as reverered as Pope John Paul II who had been granted an audience with the Prof during the first Papal visit to Glasgow in 1982. A photograph recording the event was prominent on Iain’s desk. As an American visitor to the Unit observed, this was surely the best Intensive Care service in England (sic) [2] . Up to 1982, intensive care patients at WIG were being sedated with propofol infusions, opioids and benzodiazepines, but by the time I arrived the preferred hypnotic was etomidate with morphine analgesia. It may be that the change was prompted by a 1982 report from Sheffield entitled “Safer sedation for ventilated patients. A new application for etomidate.” [3] The ICU looked to me like something out of the 1978 movie Coma, based on the novel by Michael Crichton. Most patients were sedated to immobility with the new wonder drug that had no histamine release and a stable haemodynamic profile – except, of course, for the patients who were also receiving dopamine. Nursing tasks were thus greatly simplified, and the staff were able to enjoy a post round morning tea break at which everybody was offered an egg “piece”. [4]

The research agenda at the time was broad. Complement activation and histamine release were blamed for capillary permeability changes in shock, and imbalance between the arachnadonic acid metabolites was blamed for arteriolar dysfunction and microvascular coagulation. Adam Fleck had his own team investigating the transcapillary escape rate of albumin in severe disease and injury. To everybody outside Glasgow glucocorticoids seemed to be the answer and Chicago surgeon William Schumer was their chief flag waver, claiming in 1976 that steroid therapy reduced the mortality of saline-treated sepsis in his service from 33% to around 10%. [5]   We had all witnessed the almost miraculous Shock Reversal that often followed the infusion of 30 mg/kg methylprednisolone (Solumedrone in the UK). Upjohn Pharmaceuticals sent their representatives around the country to ensure that every intensive care physician was aware of this. When I told a London Upjohn Representative that I was heading to Glasgow, he warned me that WIG may be the only UK service refusing to treat sepsis with high dose steroids. He predicted that by the time I returned from Glasgow any lingering doubts about the life-saving power of Solumedrone would have been cast off.

When I arrived in Scotland I was tasked with investigating the effects of the thromboxane synthase inhibitor dazoxiben on prostaglandin production in sepsis patients. [6] Once a week, on Dr Winifred Finlay’s ICU ward round, we would be joined by biochemist Dr McKee and patient adrenal function test results were reviewed. These ladies had published their findings on serum cortisol levels in severely stressed patients the year before. [7] Now, hydrocortisone was being prescribed for patients deemed to need it, targetting a “normal” stressed serum cortisol and this seemed to be reducing mortality. [8] I was bold enough to ask Prof Ledingham why he was opposed to “pharmacological dose” steroid therapy, and he merely pointed out that the research evidence was very poor. More studies were needed. Finlay and McKee’s surprising data had been shared with Joe Stoddart, a respected Intensivist in Newcastle, England. Joe replied that he had looked at twenty consecutive “severely stressed” Geordie ICU patients, and without exception they had appropriately high serum cortisol levels. You are giving them something harmful, he concluded.

The surgical Shock Team Registrar was Ian Watt, a rather reserved chap with an Aberdonian sense of humour [9] . The Shock Team day started with an early morning debrief in the Laboratory. The Team was Ledingham, two anaesthetic Registrars, one Surgical Registrar, Technicians Ian and Morag, Secretary Dianne and, quite often, a greyhound. Our clinical responsibilities included the advanced management of shock patients. Only the Shock Team were allowed to do right heart catheter haemodynamic studies, and I was entrusted with Ed Sivak’s double indicator dilution machine that measured the extravascular thermal volume of the lungs. We Registrars were each On Call for two weeks, with one week off. This meant that we could dispatch two Shock Team members to any hospital in Scotland, to stabilise and if necessary bring shocked patients into WIG, any time of any day or night. One of us would be the designated Ambulance driver. But I digress, let’s talk more about Iain and the greyhound. At the end of the debrief the Registrars would head off to the ICU to join their rounds, but on days when Ian was experimenting on a dog one of us might stay behind to help him anaesthetise, intubate, ventilate and catheterise the animal. [10] He was using the Gurll model to investigate hypovolaemic shock. The stabilised animal was allowed to bleed until the mean arterial pressure was around 45mmHg. This hypovolaemic shock state was to be maintained for one or two hours before the shed blood was retransfused and the effect of experimental drugs on resuscitation could be tested. [11] The problem was that Iain’s greyhounds died during the hypotensive phase. I do not recall one experiment getting as far as the resuscitation stage. We pooled our intellects on the challenge, and decided that maybe the choice of pedigree greyhounds was an issue. Glaswegians, after all, are not easily compared to thoroughbreds and so Iain acquired some mongrel dogs. Unsurprisingly they died during hypotension too. Ian was getting desperate. In need of data for a Master of Surgery degree, he decided to change tack and get stuck into some clinical research. An anaesthetic Senior Registrar called Richard Marsh was our computer geek – he kindly took me to an international Computing In Anaesthesia and Intensive Care meeting in Rotterdam, where I think he presented a paper. Richard was constructing a relational database of severity of illness scores and intensive care outcome at WIG. He was alarmed to observe a big step-wise increase in ICU mortality occurring in 1982, and Watt’s new research brief was to investigate. The Shock Team had an office with three desks, one for each of us. My own desk was untidy, but Ian’s desk grew an ever increasing tower of patient records with his own notes and annotations. Then came his Eureka moment. Focusing on the cohort of major trauma patients, for whom one could calculate an expected mortality, he confirmed a very sharp rise in the observed mortality at the time there was a switch to etomidate sedation. Moreover, he found that almost all of the adrenal insufficient patients in the Finlay & MacKee series were sedated with etomidate. I obtained plates with cultures of human adrenocortical cells from Glasgow Medical researchers and added various anaesthetic agents in concentrations approximating therapetic plasma levels, before adding ACTH to stimulate cortisol release. I was sure I would find all sedative or analgesic medicines could inhibit cortisol release, but I was very wrong. Etomidate was a very powerful adrenocortical inhibitor. Perhaps the mystery was solved. Then one morning an investigation team representing Janssen arrived. They took over the shock team office, poring over the patient records and Ian’s research notes. For several days I could not get to my own desk. We reassessed Ian’s abysmal animal research history, and realised he had decided to anaesthetise the dogs with etomidate, in line with local clinical practice. He rushed back to the Laboratory to anaesthetise dogs with other anaesthetics and was relieved to find he could successfully run a Gurll model experiment. He used etomidate again, and found that a shot of hydrocortisone enabled dogs to survive long enough to reach the resuscitation stage. How could the Sheffield team have claimed that etomidate provided safer sedation for ventilated patients back in 1982? The reason became clear. Their case series was just 6 healthy patients ventilated for 24 hours after major maxillofacial surgery, and each had received dexamethasone to prevent surgical swelling.

Iain knew he had a responsibility to communicate his discovery as rapidly and widely as possible. This is why he chose a Letter to the Lancet. Unfortunately this prior publication caused some Editors of scholarly journals to turn down his more thoroughly considered and detailed manuscripts that should have followed. The Scottish national press reported that deaths had been caused by etomidate at WIG, but the anticipated public outcry did not materialise. We were spared the ignominy of an Inquiry. The number of Glaswegians whose lives were lost to etomidate was never ascertained. Experts came forward to claim that etomidate was still a preferred hypnotic induction agent for patients who would benefit from its haemodynamic stability, even though this claimed superiority was never demonstrated in sick patients. In the UK the Committee for Safety of Medicines merely drew attention to potential hazards of etomidate administration. In Denmark, the license to infuse etomidate was limited to 12 hours,

Silly comments from Experts included “it only happened in trauma patients who stayed ventilated for 5 days or more” and “a shot of hydrocortisone will block the lethal effect”. Should regulatory authorities have done more to prevent the continued use of this poison?

There are post scriptums  to this story. In November 1984 Charles Sprung and colleagues published a landmark trial showing that impressive early shock reversal with high dose corticosteroids was NOT associated with increased survival of patients with severe, late septic shock. [12]   I had been offered a critical care research post for 1985-6 at The Victoria Hospital, London, Ontario but Upjohn withdrew their research funding and so I had to seek alternative employment. I went instead to a Fellowship at The University of Western Ontario (UWO) in London. [13]

When Charles Sprung later devised and led an international multicentric study on Hydrocortisone Therapy for Patients with Septic Shock (CORTICUS) I was pleased to be a contributing investigator. [14]

A final PS that I forgot to add is that my notoriety in the adrenal insufficiency arena got me tasked with a Working Party on the topic back in 2012. We did not achieve a publishable consensus until 2020. 15  I thought it might be impossible. Anaesthetists in the UK severely underestimate the dangers of poor & inconsistent management in critical care. Many accused us of overstating the danger, while the endocrinologists were dismayed at the lack of commitment to do better.

______________________

Co-Published on Osler https://osler.app.link/1uB7SSRwUzb on May 18 th , 2023

[1] J Crit Care 2023 Apr 29. 77:154317. 10.1016/j.jcrc.2023.154317

[2] I asked the distinguished visitor where the best intensive care unit in the world was; The Vic, in London Ontario was his confident answer. Iain agreed. And so I later went on to spend a year in that welcoming town, and met William (Bill) Sibbald).

[3] PMID: 7048991

[4] In Glaswegian, a piece is a toasted slice of bread split into two thin slices. The usual filling was a tiny spread of scrambled egg.

[5] https://doi.org/10.1016/j.jcrc.2023.154317

[6] Dazoxiben almost completely blocked the synthesis of thromboxane A2, but there was no discernable change in the patients shock state.

[7] Lancet 1982 Jun 19. 1:1414-5. 10.1016/s0140-6736(82)92531-4

[8] Lancet 1983 Feb 26. 1:484. 10.1016/s0140-6736(83)91489-7

[9] Humour was important in Glasgow at that time, as a young Billy Connolly was making national headlines as an outstanding comedian. I was told that Winifred was the daughter of Scotland’s most famous comedian Alec Finlay.

[10] We each had a Home Office License to conduct terminal animal experiments under anaesthesia. An Inspector called from time to time to ensure our work was humane.

[11] It is an under appreciated fact that much of the post haemorrhagic shock fatality occurs during resuscitation.

[12] N Engl J Med 1984 Nov 01. 311:1137-43. 10.1056/NEJM198411013111801

[13]  I became the first researcher to report measurements of cerebral blood flow and cerebral metabolic rate for oxygen during cardiac surgery with induced hypothermia on cardiopulmonary bypass. I was allowed to spend occasional days at the Vic when my contractual commitments at UWO allowed.

[14] N Engl J Med 2008; 358:111-124 DOI: 10.1056/NEJMoa071366

15 Anaesthesia 2020 May. 75:654-663. 10.1111/anae.14963

Fluid Tolerance: A Concept. #FOAMed

Here is a lecture I gave for the International Fluid Academy annual meeting which is truly a terrific event. Many of us have been working hard at ushering in this concept, which we feel is vastly more important than that of fluid responsiveness.

And for those interested, here is our paper: https://pubmed.ncbi.nlm.nih.gov/35660844/

Venous Congestion Spanish Style: Dr. Curro Miralles-Aguiar! #FOAMED, #FOAMCC, #VEXUS

So I’ve been meaning to put this up for a while, along with many other #FOAMed lectures I want to share and get out there in our neverending quest to cut down on the KT on bedside physiological management. For years now I have enjoyed collaborating with my friend Curro Miralles, who is a fantastic clinician on top of being the latin leading man heir apparent to Antonio Banderas who somehow ended up as a physician instead. Well, medicine should be greateful! Enjoy!

The best is yet to come.

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Mayo Clinic School of Continuous Professional Development

You are here, foundations of critical care nursing online cne course: connecting patient diagnosis to medication therapy.

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Caring for the critical care patient includes understanding common medication therapies for complex diagnosis.  This course will review common medications and nursing considerations for administration.  Concept review and case scenarios include patients with heart failure, acute coronary syndrome and frequently seen therapies including anticoagulation.

Course Director  Denise Rismeyer, DNP, MSN, RN, NPD-BC  Director of Continuing Nursing Education  Mayo Clinic 

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This CNE course is designed for RNs, LPNs, and healthcare professionals providing care for progressive and critical care patients.

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• Identify common drug classes of medications administered in the inpatient setting
• Describe side effects of common medications
• Discuss nursing considerations related to medication administration for complex patient diagnoses
• Apply knowledge of medications to patient scenarios that may be encountered in the critical care setting

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Faculty Tiffany Schoenfelder, MSN, RN Nursing Education Specialist – Interventional Cardiovascular Instructor in Nursing – Mayo Clinic College of Medicine and Science Nursing Professional Development Division Department of Nursing Mayo Clinic, Rochester, MN

Course Director Denise Rismeyer, MSN, RN, NPD-BC Director Continuing Nursing Education Program Assistant Professor of Nursing, Mayo Clinic College of Medicine and Science Department of Nursing Mayo Clinic, Rochester, MN

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Mayo Clinic School of Continuous Professional Development (MCSCPD) strives to foster a learning environment in which individual differences are valued, allowing all to achieve their fullest potential. 

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A, Adjusted odds ratios and 95% CIs for the outcome of any in-hospital PT or OT were derived from logistic regression models. B, Adjusted rate ratios and 95% CIs for the outcome of rate of in-hospital PT or OT were derived from Poisson regression models. All models were constructed separately for each exposure and adjusted for the same set of covariates (age, sex, pre–intensive care unit count of disabilities in activities of daily living, use of mechanical ventilation, and count of organ dysfunction as a surrogate for severity of illness).

Estimates were derived from the multivariable logistic regression model adjusting for covariates of age, sex, pre–intensive care unit count of disabilities in activities of daily living, use of mechanical ventilation, and count of organ dysfunction as a surrogate for severity of illness.

Estimates were derived from the multivariable Poisson regression model adjusting for covariates of age, sex, pre–intensive care unit count of disabilities in activities of daily living, use of mechanical ventilation, and count of organ dysfunction as a surrogate for severity of illness, as described in the methods.

eFigure. Assembly of the Analytic Sample

eTable 1. ICD-9 and ICD-10 Codes Used to Identify Mechanical Ventilation and Organ Dysfunction

eTable 2. Sensitivity Analysis for the Outcome of Any In-Hospital Physical and/or Occupational Therapy Excluding ICU Hospitalizations From NHATS Participants Who Were Admitted From a Nursing Home or Had a Stay in a Nursing Home of ≥100 Days Between Pre-ICU NHATS Interview and Index ICU Hospitalization

eTable 3. Sensitivity Analysis for the Outcome of Rate of In-Hospital Physical and/or Occupational Therapy Excluding ICU Hospitalizations From NHATS Participants Who Were Admitted From a Nursing Home or Had a Stay in a Nursing Home of ≥100 Days Between Pre-ICU NHATS Interview and Index ICU Hospitalization

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Jain S , Murphy TE , Falvey JR, et al. Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization. JAMA Netw Open. 2024;7(5):e2410713. doi:10.1001/jamanetworkopen.2024.10713

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Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization

• 1 Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
• 2 Department of Public Health Sciences, Pennsylvania State University, State College
• 3 Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
• 4 Program on Aging, Yale School of Medicine, New Haven, Connecticut
• 5 Department of Sociology, Yale University, New Haven, Connecticut
• 6 Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut

Question   Are social determinants associated with differential delivery of skilled rehabilitation services to older adults during hospitalization with a critical illness?

Findings   In this cohort study of 1618 hospitalizations in older adults, after accounting for prehospitalization disability and acute illness characteristics, dual Medicare and Medicaid eligibility and rural residence were associated with a lower likelihood of delivery of any rehabilitation, whereas limited English proficiency was associated with reduced amount of rehabilitation services delivered during a critical illness hospitalization.

Meaning   These findings suggest social determinants of health should be taken into consideration in efforts to enhance equitable delivery of skilled rehabilitation to older adults who are critically ill.

Importance   Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known.

Objective   To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults.

Design, Setting, and Participants   This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023.

Exposures   Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence.

Main Outcome and Measures   The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay.

Results   In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]).

Conclusions and Relevance   These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.

Surviving a critical illness, an increasingly common occurrence among older adults, 1 - 3 is frequently accompanied by new or worsening disability. 4 , 5 Skilled rehabilitation with physical therapy (PT) and occupational therapy (OT) during hospitalization facilitates mobilization of patients recovering from critical illness and is known to prevent functional decline 6 - 8 and help to identify post-acute care needs. 9 Therefore, inequitable delivery of rehabilitation services to older adults with social or economic disadvantage may contribute to downstream disparities in disability. 10 Whether social determinants of health (SDOH) are associated with differences in delivery of skilled rehabilitation during a critical illness hospitalization is unknown.

Prior studies have described wide variation in clinician-reported delivery of rehabilitation services to patients who are critically ill. 11 - 13 Cross-sectional studies of hospitals participating in trial networks or quality improvement collaboratives have yielded similar results. 14 - 16 However, these studies did not investigate associations between SDOH and delivery of in-hospital rehabilitation. Many patient- and hospital-level factors known to be associated with prescription of skilled rehabilitation to patients who are critically ill can be affected by SDOH. 11 , 17 - 19 For example, limited English proficiency (LEP) could be associated with lower rehabilitation delivery due to perceived barriers to engagement with therapy services or differences in management of sedation and delirium by clinicians. 20 Furthermore, variation in resources and practices at hospitals caring for a higher proportion of patients with socioeconomic disadvantage could lead to reduced delivery of skilled rehabilitation services, as has been observed for other care processes. 21 , 22 A common challenge in evaluation of health care disparities is the absence of granular information on SDOH, such as LEP, income, and education, and preexisting health status, that could influence in-hospital treatment needs, such as prehospitalization disability in the case of rehabilitation services. We leveraged a nationally representative longitudinal study of aging with detailed information on SDOH and prehospitalization geriatric risk factors, linked with administrative claims, to investigate whether SDOH are associated with differences in the delivery of skilled rehabilitation to older adults during hospitalization in an intensive care units (ICU).

The protocol for the National Health and Aging Trends Study (NHATS) was approved by the Johns Hopkins University institutional review board, and our cohort study using these data was approved by the Yale University institutional review board. All participants provided informed consent. We followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

Data were drawn from the National Health and Aging Trends Study (NHATS), a longitudinal, nationally representative survey of community-dwelling Medicare beneficiaries ages 65 years and older living in the contiguous United States. 23 The initial sample was drawn from the Medicare enrollment database on September 30, 2010. 24 The survey collected information on sociodemographics, including race and ethnicity, insurance, education, income, English proficiency, rural residence, and clinical characteristics, through annual in-person interviews starting in 2011. If a participant was unavailable for interview, a proxy knowledgeable about their health was interviewed. Race and ethnicity were categorized as Hispanic, non-Hispanic Black, non-Hispanic White, and other (including participants reporting race as American Indian, Alaska Native, Asian, Native Hawaiian, Pacific Islander, or other race). Race and ethnicity were included in descriptive analyses because they are key SDOH.

ICU admissions were identified through linked inpatient claims files for Medicare fee-for-service and Medicare Advantage participants using critical care revenue codes indicating admission to general, specialty, or coronary care units but excluding psychiatric and intermediate care units. 25 Information on mechanical ventilation and organ dysfunction was obtained using International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification ( ICD-10-CM ) diagnosis and procedure codes (eTable 1 in Supplement 1 ). 26 , 27 ICU length of stay was determined based on days with a critical care revenue code.

Our primary outcomes were delivery of any PT or OT, as determined by revenue center codes 042.X and 043.X respectively, and amount of PT or OT, determined as number of units of evaluation or treatment delivered during ICU hospitalization. In general, PT and OT are billed in 15-minute increments; therefore, 1 billed unit represents 15 minutes of intervention by a therapist. These units were modeled as units per day to account for differences in hospital length of stay. Since services between 8 and 22 minutes are aggregated as a single unit, the observed rate of therapy is a rounded assessment of the actual delivered amount of therapy.

Given its previously reported associations with increased risk for functional decline following critical illness and reduced delivery of in-hospital rehabilitation to older adults, our primary exposure was dual eligibility for Medicare and Medicaid. 10 , 28 We additionally explored associations of other SDOH that have been linked to rehabilitation delivery in other populations or settings 29 - 31 and were available in NHATS or Medicare claims data. SDOH assessed in this study included income, education, LEP, and rurality. Dual-eligibility for Medicare and Medicaid was assessed using the dual Medicare-Medicaid status indicator in the Medicare Master Beneficiary Summary File at any time during the year preceding the ICU hospitalization. Information on other SDOH was derived from the participant’s NHATS survey immediately preceding ICU hospitalization. Income and assets were assessed using a composite of income from Social Security; Department of Veterans Affairs; pension; retirement plans; funds, stocks, and bonds; and checking and savings accounts and operationalized as quartiles in our sample. 23 The only missing data were on household income; missing data were imputed using values provided by NHATS. 32 Education was characterized as less than high school vs more. LEP was operationalized as a response of not well or not at all, as opposed to well or very well, to questions about how well respondents understand or speak English. 23 , 33 Residence was classified as rural (nonmetropolitan) vs urban (metropolitan), as assigned by NHATS based on the Office of Management and Budget classification of county of residence. We considered but did not evaluate the exposure of race and ethnicity because of small proportions of participants who identified as a race other than Black or White in our sample.

We selected covariates that could be potential confounders in rehabilitation delivery based on prior research and clinical relevance. We included age categorized into intervals based on proportions in our sample (65-74, 75-79, 80-84, 85-89, and ≥90 years), sex, count of disabilities in the NHATS interview preceding ICU hospitalization (defined as need for help or inability to perform activities of daily living, including 4 self-care activities [eating, bathing, using the toilet, and dressing] and 3 mobility activities [getting outside, getting around inside one’s home, and getting out of bed]), 10 , 34 use of mechanical ventilation (eTable 1 in Supplement 1 ), and severity of illness (determined as count of organ dysfunction). 27

Assembly of the analytic sample is presented in the eFigure in Supplement 1 . We identified 2832 NHATS participants from 2011 to 2018 who had a hospitalization with an ICU admission for at least 1 day. Participants could contribute multiple observations; however, we restricted our sample to 2299 first ICU hospitalizations in the interval between consecutive annual NHATS interviews to allow updating model covariates. After excluding hospitalization from 681 participants who were not community-dwelling at the pre-ICU NHATS interview, our sample included 1618 ICU hospitalizations.

We describe demographic and clinical characteristics of our sample using means and SDs or medians and IQRs for continuous variables and counts and weighted percentages for categorical variables, as appropriate. For each person-year of NHATS data, we used specific analytic weights that adjust for differential probabilities of selection and nonresponse within each strata (region) and cluster (zip code within county); this allows generalization to the 2011 Medicare population. 35 , 36 For income, NHATS provided 5 imputed data sets that were used only in the models testing this exposure. 32 Among other exposures considered in the models, only education had any missing data (0.7%). Hence, our models were based on complete case data. We separately fit multivariable logistic regression models for the binary outcome of delivery of any in-hospital PT or OT on each of the 5 exposures with adjustment for covariates. For exposures with a significant association with this outcome, we calculated risk differences. For the rate of PT or OT delivered per day of hospital stay, we fit multivariable Poisson regression models on each of the exposures with adjustment for the same covariates. We calculated least square means of the outcomes significantly associated with this outcome. Because the provision of PT or OT could be prioritized to patients presumed to be discharging to a facility, we conducted sensitivity analyses excluding participants admitted from a nursing home or with a stay 100 days or more between pre-ICU NHATS interview and index ICU hospitalization. We used SAS software version 9.4 (SAS Institute) for descriptive analyses and SAS-callable SUDAAN software version 11 (RTI International) for all models. To account for the small number of participants who contributed multiple hospitalizations, we used generalized estimating equations with an exchangeable covariance structure based on its minimization of quasilikelihood under the independence model criterion. In all analyses, significance was defined as a 2-tailed P  < .05. Data were analyzed from August 2022 to September 2023.

Our sample included 1618 ICU hospitalizations across 569 hospitals ( Table ). Patients had a median (IQR) age of 81.0 (75.0-86.0) years, and 842 (52.0%) were female. The sample included 371 patients (22.9%) with dual Medicare and Medicaid eligibility, 523 patients (32.6%) with less than high school education, 320 patients (19.8%) with rural residence, and 56 patients (3.5%) with LEP. Median (IQR) income was $22 000 ($12 000-$41 000).

A total of 1076 patients (68.5%) received any PT or OT during ICU hospitalizations. We observed decreased receipt of any PT or OT for hospitalizations among patients with Medicare and Medicaid dual eligibility (228 hospitalizations [62.7%] vs 848 hospitalizations among patients without dual eligibility [69.9%]), rural residence (185 hospitalizations [60.1%] vs 891 hospitalizations among patients from urban areas [70.3%]), and below-median income (520 hospitalizations [65.5%] vs 586 hospitalizations among patients with above-median income [70.8%]). A mean of 0.94 (95% CI, 0.86-1.02) units/d was delivered. Patients with LEP received a lower rate of PT or OT (0.79 [95% CI, 0.76- 0.82] units/d vs 0.95 [95% CI, 0.90-0.99] units/d for those without LEP), as did patients with income above the median (0.84 [95% CI, 0.73-0.96] units/d vs 1.02 [95% CI, 0.91-1.03] units/d for those below median income).

Figure 1 presents the results of our multivariable models. Dual Medicare and Medicaid eligibility (adjusted odds ratio [aOR], 0.70 [95% CI, 0.50-0.97]) and rural residence (aOR, 0.65 [95% CI, 0.48-0.87]) were associated with lower odds of delivery of any PT or OT ( Figure 1 A). For risk differences, the percentage of ICU hospitalizations in which any PT or OT was delivered was 7.8% lower for dual-eligible older adults than for non-dual-eligible older adults and 9.5% lower for residents of rural vs urban areas ( Figure 2 ). For the rate of total therapy, LEP was associated with lower rates of in-hospital PT or OT compared with not having LEP (adjusted rate ratio [aRR], 0.55 [95% CI, 0.32-0.94]) ( Figure 1 B). On the absolute scale, a mean rate of 0.7 (95% CI, 0.4-1.2) units/d of PT or OT was delivered to participants with LEP, compared with 1.3 (95% CI, 1.1-1.5) units/d to those proficient in English ( Figure 3 ). Over a 5-day hospital stay, this would translate into 24 to 66 fewer minutes of therapy for patients with LEP compared with those proficient in English. Having an income between $12 000 and $22 000 was also significantly associated with a lower rate of therapy delivered (aRR, 0.71 [95% CI, 0.52-0.95]) compared with the highest quartile of income; the other income categories did not demonstrate significant associations ( Figure 1 B).

In sensitivity analyses excluding hospitalization for participants who were admitted from a nursing home or had a nursing home stay of at least 100 days between their pre-ICU NHATS interview and the index ICU hospitalization, the magnitude and direction of association between the exposures and both outcomes were similar, albeit with wider CIs (eTable 2 and eTable 3 in Supplement 1 ).

In this nationally representative cohort study of older adults, we found that select SDOH were associated with reduced delivery of skilled rehabilitation services during hospitalization for critical illness. After accounting for prehospitalization disability and severity of acute illness, older adults who were dually eligible for Medicare and Medicaid and those who resided in rural areas had 30% to 35% lower odds of receiving any PT or OT during an ICU hospitalization than patients who were not dually eligible or who were proficient in English. Patients with LEP received lower amounts of therapy than patients proficient in English. Given the well-documented value of in-hospital rehabilitative PT and OT in preventing functional decline and identifying care needs at discharge following critical illness, 6 - 9 our findings of reduced delivery of these services to older adults by dual eligibility status, rural residence, and LEP warrant consideration of targeted efforts to mitigate inequities.

The prevalence of in-hospital rehabilitation delivery in our study was comparable with estimates from contemporary studies of acutely hospitalized patients. 28 , 37 , 38 Among patients who are critically ill, clinician surveys 11 , 12 , 39 and cohort studies of hospitals participating in trials or quality reporting initiatives 14 , 16 have reported wide variability in the use of PT and OT. Despite this known variability, to our knowledge, prior work has not evaluated the role of SDOH in the delivery of skilled rehabilitation services among Medicare beneficiaries. The availability of patient-level information on SDOH in NHATS, beyond those usually available in administrative data, allowed us to evaluate this important question.

Our findings of reduced delivery of skilled rehabilitation to older adults who are dually eligible for Medicare and Medicaid, live in rural areas, or have LEP may have explanations rooted in structural- and individual-level factors underlying in-hospital care delivery. First, factors related to resources and organization of rehabilitation services at hospitals deserve consideration. Staffing by physical therapists and nurses is associated with rehabilitation among patients who are critically ill. 11 , 18 Hospitals serving more dually eligible patients and those located in rural areas are generally more underresourced and may not be adequately staffed by professionals essential to delivering rehabilitation. 40 Similar to our findings, dual Medicare and Medicaid eligibility was associated with a lower likelihood of skilled rehabilitation among patients with acute stroke. 28 Second, percolation of evidence-based strategies, such as the ABCDEF bundle (assess, prevent, and manage pain; both spontaneous awakening and spontaneous breathing trials; choice of analgesia and sedation; assess, prevent, and manage delirium; early mobility and exercise; and family engagement and empowerment), 6 , 41 to promote rehabilitation may be lower at these hospitals. Study collaboratives promoting adoption of the bundle have typically engaged urban, academic hospitals 15 ; whether and how this guidance is translated into practice in rural hospitals should be explored. Third, the association between LEP and reduced PT and OT suggests that interpersonal communication barriers or implicit biases can underlie suboptimal delivery of rehabilitation, as described for other care processes. 20 , 42 Consistent with our observations, in a 2020 study at a safety-net hospital in Texas, speaking a language other than English or Spanish was associated with fewer minutes of therapy delivered to older adults hospitalized with prolonged acute illness. 29 Among patients who are critically ill, the reduced amount of rehabilitation services delivered to those with LEP could be due to differential prescription of rehabilitation services by physicians because of perceived barriers to engagement or differences in management of sedation and delirium that might influence a patient’s ability to participate in rehabilitation. 17 , 19 , 20

Our findings have important implications. First, immobility, a common occurrence during ICU hospitalization, is an important and modifiable risk factor for post-ICU disability. 6 - 8 While mobilizing hospitalized patients who are acutely ill can be achieved by personnel other than rehabilitation therapists, the complex feasibility and safety considerations for older adults who are critically ill usually warrant an interdisciplinary approach. 13 , 43 , 44 Evaluation by physical or occupational therapists is a part of recommended ICU mobilization protocols 6 , 7 , 45 and associated with its delivery in observational studies. 13 , 14 Therefore, while not equivalent to it, the lower delivery of PT or OT services by SDOH in our study likely represents underlying differences in ICU mobilization. Second, evaluation by physical and occupational therapists, usually on the wards, is important to identify postacute rehabilitation needs before hospital discharge. Reduced delivery of any PT or OT during hospitalization suggests that postacute rehabilitation needs are assessed less frequently among older adults with Medicaid and those in rural areas. In-hospital skilled rehabilitation is associated not only with higher mobility at discharge 9 , 46 , 47 but also improved long-term function among adults recovering from critical illness. 48 Therefore, reduced delivery of any rehabilitation during ICU hospitalization may represent a missed opportunity to improve long-term functional outcomes after critical illness and inequities in this practice can be a mechanism underlying disparities in post-ICU disability. 10

Our study has several strengths. First, we used a nationally representative sample of older adults with ICU hospitalization. Second, we included granular assessment of prehospitalization disability that could influence in-hospital rehabilitation needs. Third, we had information on SDOH using instruments specifically tailored for older adults, 23 Fourth, we used rigorous methods to determine delivery of PT and OT using claims data. 28 , 49 , 50

Our findings should be interpreted in the context of a few limitations. First, we could not distinguish the contribution of hospital-level effects or evaluate hospital factors, such as supply of physical therapists, due to the limited number of observations per hospital and hospital-level information in our claims-linked NHATS data. This should be investigated in future work to understand the role of structural factors in driving differences in rehabilitation delivery. Second, we could not distinguish the delivery of PT and OT in the ICU from that delivered elsewhere in the hospital; future studies evaluating this could guide efforts to mitigate differences. Third, we could not evaluate nurse-driven mobility. While this practice exists, an interdisciplinary approach, including at least an evaluation by rehabilitation therapists, remains usual practice in most US ICUs, 13 , 44 suggesting that in-hospital skilled rehabilitation, although not a surrogate for ICU mobilization, is likely associated with differences in this practice. Fourth, we did not have information on severity of illness scores, such as the SOFA score and Acute Physiology and Chronic Health Evaluation scale score, which are known to be associated with rehabilitation in the ICU. 51 Nevertheless we used a validated claims-based organ dysfunction algorithm to account for severity of illness. 27 Fifth, because of the small number of participants with self-reported race and ethnicity other than non-Hispanic Black or non-Hispanic White in our sample, we could not evaluate it as an exposure; future work should investigate this. Furthermore, because LEP and rurality were evaluated as exploratory exposures in our study, the observed associations should be further investigated in future studies.

In this nationally representative cohort study of older adults, dual eligibility for Medicare and Medicaid and rural residency were associated with lower likelihood and LEP was associated with reduced rate of delivery of skilled rehabilitation therapy during hospitalization with critical illness. Our findings highlight the need to consider these SDOH in efforts to enhance equitable delivery of skilled rehabilitation services during hospitalization. Future research is needed to distinguish individual- vs structural-level factors underlying differences in in-hospital rehabilitation delivery by SDOH.

Accepted for Publication: March 9, 2024.

Published: May 10, 2024. doi:10.1001/jamanetworkopen.2024.10713

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Jain S et al. JAMA Network Open .

Corresponding Author: Snigdha Jain, MD, MHS, Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, 15 York St, New Haven, CT 06510 ( [email protected] ).

Author Contributions: Drs Jain and Ferrante had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jain, Murphy, Zang, Ferrante.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Jain, Murphy.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Jain, Murphy.

Obtained funding: Jain.

Administrative, technical, or material support: Jain, Leo-Summers, O'Leary, Zang.

Supervision: Jain, Falvey, Ferrante.

Conflict of Interest Disclosures: Dr Krumholz reported receiving grants from American Heart Association, Agency for Healthcare Research and Quality, National Institutes of Health (NIH), Johnson & Johnson, Janssen, Centers for Disease Control and Prevention, and Pfizer (paid to institution); personal fees from Massachusetts Medical Society Completed, Identifeye, F-Prime, UpToDate, Ensight, and Element Science; and serving as cofounder of ENSIGHT-AI, Refactor Health, and Hugo Health outside the submitted work. No other disclosures were reported.

Funding/Support: Drs Jain, Ferrante, Zang, and Gill received support from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (award No. P30AG021342). Dr Jain was supported by the Parker B. Francis Family Foundation Fellowship Award, Yale Physician-Scientist Development Award (award No. KL2 TR001862) from the National Center for Advancing Translational Science of the NIH, and National Institute On Aging (NIA) of the NIH (award No. R03AG078942). Dr Ferrante is supported by the NIA (award No. K76 AG057023. Falvey is supported by the University of Maryland Claude D. Pepper Center and the NIA (award No. K76AG074926). Dr Zang is supported by the NIA (award No. R21AG074238-01).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Enhancing critical thinking in clinical practice: implications for critical and acute care nurses

Affiliation.

• 1 Bridget Shoulders, MS, ACNP-BC, CCRN-CMC, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida. Corrinne Follett, MS, FNP-BC, CCRN, RN-BC, RCIS, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida. Joyce Eason, MS, ANP-BC, RN-BC, is a nurse practitioner in the cardiology department at the James A. Haley VA Hospital in Tampa, Florida.
• PMID: 24895950
• DOI: 10.1097/DCC.0000000000000053

The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. Nurses caring for these complex patients are expected to use astute critical thinking in their decision making. The purposes of this article were to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.

Publication types

• Clinical Competence
• Critical Care Nursing*
• Decision Making*
• Evidence-Based Nursing
• Nursing Process*

• Open access
• Published: 14 May 2024

Causes and attributable fraction of death from ARDS in inflammatory phenotypes of sepsis

• Bruno Evrard   ORCID: orcid.org/0000-0003-1829-4927 1 , 2 ,
• Pratik Sinha 3 , 4 ,
• Kevin Delucchi 5 ,
• Carolyn M. Hendrickson 6 ,
• Kirsten N. Kangelaris 7 ,
• Kathleen D. Liu 8 , 9 ,
• Andrew Willmore 10 ,
• Nelson Wu 10 ,
• Lucile Neyton 1 ,
• Emma Schmiege 10 ,
• Antonio Gomez 6 ,
• V. Eric Kerchberger 11 , 12 ,
• Ann Zalucky 1 ,
• Michael A. Matthay 1 , 9 , 10 ,
• Lorraine B. Ware 11 , 13 &
• Carolyn S. Calfee 1 , 9 , 10  

Critical Care volume  28 , Article number:  164 ( 2024 ) Cite this article

Metrics details

Hypoinflammatory and hyperinflammatory phenotypes have been identified in both Acute Respiratory Distress Syndrome (ARDS) and sepsis. Attributable mortality of ARDS in each phenotype of sepsis is yet to be determined. We aimed to estimate the population attributable fraction of death from ARDS (PAF ARDS ) in hypoinflammatory and hyperinflammatory sepsis, and to determine the primary cause of death within each phenotype.

We studied 1737 patients with sepsis from two prospective cohorts. Patients were previously assigned to the hyperinflammatory or hypoinflammatory phenotype using latent class analysis. The PAF ARDS in patients with sepsis was estimated separately in the hypo and hyperinflammatory phenotypes. Organ dysfunction, severe comorbidities, and withdrawal of life support were abstracted from the medical record in a subset of patients from the EARLI cohort who died (n = 130/179). Primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support.

The PAF ARDS was 19% (95%CI 10,28%) in hypoinflammatory sepsis and, 14% (95%CI 6,20%) in hyperinflammatory sepsis. Cause of death differed between the two phenotypes (p < 0.001). Respiratory failure was the most common cause of death in hypoinflammatory sepsis, whereas circulatory shock was the most common cause in hyperinflammatory sepsis. Death with severe underlying comorbidities was more frequent in hypoinflammatory sepsis (81% vs. 67%, p = 0.004).

Conclusions

The PAF ARDS is modest in both phenotypes whereas primary cause of death among patients with sepsis differed substantially by phenotype. This study identifies challenges in powering future clinical trials to detect changes in mortality outcomes among patients with sepsis and ARDS.

Acute respiratory distress syndrome (ARDS) is characterized by mortality of 35–45% [ 1 ] and considerable heterogeneity, contributing to the current challenge of developing effective treatment [ 2 ]. Two molecular phenotypes of ARDS, hypo- and hyperinflammatory, have been identified based largely on plasma levels of biomarkers reflecting inflammation, epithelial and endothelial injury and coagulation abnormalities [ 2 , 3 , 4 ]. Specifically, the hyperinflammatory phenotype, which represents about one-third of ARDS cases, is associated with high levels of inflammatory biomarkers, increased use of vasopressors, and higher mortality rates [ 2 , 3 , 4 ]. In contrast, the hypoinflammatory phenotype, representing approximately two-thirds of ARDS cases, is associated with lower levels of inflammatory biomarkers and reduced mortality rates [ 2 , 3 , 4 ]. These phenotypes have also been identified in sepsis, with similar characteristics, prognosis and differential response to activated protein C, suggesting this schema captures phenotypes of critical illness overall and not only ARDS [ 5 , 6 ].

The attributable fraction and population attributable fraction are epidemiological tools useful for estimating the potential impact of an exposure on an outcome. Population attributable fraction describes the reduction in the rate of the outcome if the exposure could be completely removed, assuming the exposure is causal. These metrics have been used in other fields to inform feasibility and design of trials [ 7 ]; for example, if population AF ARDS is low, sample size requirements for clinical trials in ARDS with primary outcome of mortality will be quite high [ 8 ]. The attributable fraction of death from sepsis-associated ARDS (AF ARDS ) is the proportion of deaths attributable to ARDS among all deaths in patients who developed sepsis-associated ARDS. The population AF ARDS (PAF ARDS ) in this context is the proportion of deaths that would be prevented following elimination of ARDS in patients with sepsis [ 9 ]. In a previous study, Auriemma et al. reported the PAF ARDS to be 16% and 18% in two independent cohorts of septic adults, with mortality mainly driven by severe ARDS (P/F ratio < 100) [ 10 ]. However, this study encompassed both hypo- and hyperinflammatory phenotypes and used sepsis patients without ARDS as the reference population. More recently, Saha et al. estimated the attributable mortality of ARDS phenotypes using a completely different reference population (either critically ill patients without acute respiratory failure or patients with a unilateral radiographic infiltrate), and without estimating the PAF ARDS [ 11 ]. The PAF ARDS for hyper- and hypoinflammatory phenotypes using a referent population of sepsis patients remains unknown. Moreover, whether causes of death differ in sepsis based on molecular phenotypes is also unknown and may inform the proportions of mortality that may be modifiable in each phenotype. In this study, we aimed to (1) estimate 60 days in hospital PAF ARDS in patients with hypo-inflammatory versus hyperinflammatory sepsis, and (2) to determine causes of death in hypo-inflammatory versus hyper-inflammatory sepsis to further contextualize our PAF ARDS analyses.

Participants

We studied patients from two prospectively enrolled cohorts of critically ill adults: (1) the Early Assessment of Renal and Lung Injury (EARLI) study, which enrolls adults admitted from the emergency department to the intensive care unit (ICU) at either an academic medical center or safety net hospital in San Francisco, California, and (2) the Validating Acute Lung Injury markers for Diagnosis (VALID) study which enrolls critically ill adults from an academic medical center in Nashville, Tennessee.

Sepsis and ARDS definition

We selected patients admitted to the ICU for sepsis [ 12 ]. Because data collection started prior to publication of the Sepsis 3 definition [ 13 ], sepsis was defined as documented or suspected infection in the presence of two or more characteristics of the systemic inflammatory response syndrome within the first two days of ICU admission [ 12 ]. Presence or absence of sepsis, and pulmonary or non-pulmonary origin of sepsis if present, was meticulously assessed by a participating study physician using all the data available from the patient’s hospitalization. Patients were defined as having ARDS if they met Berlin criteria for ARDS on at least one of the first five hospital days for EARLI and between ICU days one through four in VALID [ 14 ]. Day one was defined as the admission date in the emergency department in EARLI, whereas it was defined as the day of ICU admission in VALID. Development of ARDS was adjudicated by at least two study physicians and by review of all chest radiographs during the first 5 days of enrollment, using criteria set forth by the AECC or Berlin criteria [ 14 , 15 ]. When patients met chest radiograph and oxygenation criteria for ARDS, then the medical record was thoroughly reviewed for any evidence of a primary or contributory cardiogenic cause of pulmonary edema. We additionally identified patients who were not receiving mechanical ventilation but who met the American-European Consensus Conference (AECC) criteria for acute lung injury (ALI) during the same time frame [ 15 ]. Further information on exclusions criteria is provided in Additional file 1 : E-methods. Latent class assignments for included patients were determined in a previous study [ 6 ]. Briefly, latent class analysis (LCA) is a statistical technique that uses mixture modelling to find the best fitting model for a set of data, based on the hypothesis that the data contain several unobserved groups or classes [ 16 ].

EARLI was approved by the University of California, San Francisco Institutional Review Board (IRB) and VALID by the Vanderbilt IRB. Consent was obtained from patients or their surrogates when possible, as previously described [ 10 ].

Determination of the cause of the death

We determined cause of death in patients who died in the EARLI cohort for whom electronic health records (EHR) were available. Patients’ data were reviewed by one trained intensivist who did not participate in ARDS adjudication and was blinded to ARDS and phenotype status. Rigorous inspection of the temporal relationship of laboratory data, imaging data, hemodynamic, respiratory parameters and physician’s notes, using a standardized case ascertainment template (Additional file 1 : E-methods) [ 17 ], was carried out to define cause of death. If determination of cause was challenging, adjudication was done with a second trained intensivist (CSC). 25% of randomly patients were assessed by a third intensivist (AZ) to determine inter-rater reliability.

For each patient, we reviewed the medical record for evidence of dysfunction of eight organ systems during the 72 h prior to death (Additional file 1 : Table E1). We classified organ dysfunction as severe or irreversible using modified definitions from prior studies (Additional file 1 : Table E1) [ 17 , 18 ]. The primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support (Additional file 1 : Figure E1). Further information regarding determination of cause of death is provided in the E-methods.

Flow chart of the study

Statistical analysis

Sample size estimation is provided in the E-methods (Additional file 1 : E-methods) and was used to support the decision to combine EARLI and VALID for most analyses. Pearson’s chi square and Wilcoxon rank sum test were used to compare baseline variables stratified by phenotypes of sepsis. The primary outcome was in-hospital 60-day mortality. AF ARDS and PAF ARDS were estimated within each phenotype separately; specifically, the mortality of hypoinflammatory sepsis with ARDS was compared to the mortality of hypoinflammatory sepsis without ARDS, without considering hyperinflammatory patients, and vice versa. To estimate the AF ARDS and the PAF ARDS within each phenotype of sepsis, we used methods outlined previously [ 9 , 10 , 19 ]. Estimates were based on indirect standardization, which computes the weighted average of stratum-specific estimates in the reference population, using weights from the study population [ 10 , 19 ]. Strata were defined by modified APACHE II quartiles; the oxygenation component of APACHE II was removed for this analysis. We also conducted multiple sensitivity analyses, one of which involved a matching approach using propensity scores, for which we used a directed acyclic graph to determine the variables to include in the model (Additional file 1 : Figure E2). Details of the sensitivity analysis are provided in the E-methods (Additional file 1 : E-methods). Pearson’s Chi Square was used to compare cause of death between patients with hypoinflammatory vs hyperinflammatory sepsis and with or without ARDS. A p-value less than 0.05 was considered statistically significant. Analyses were performed using the STDRATE procedure in SAS (Version 3.81) for the calculation of AF ARDS and the PAF ARDS using strata method and using R (Version 4.2.2) for all other analysis.

A Estimation with 95% confidence interval and sensitivity analysis of the population attributable fraction of death from ARDS in each phenotype of sepsis. B Estimation with 95% confidence interval and sensitivity analysis of the attributable fraction of death from ARDS in each phenotype of sepsis. ARDS Acute respiratory distress syndrome, LCA Latent class analysis

Patient characteristics

Overall, 1737 patients were included, 675 from EARLI and 1062 from VALID (Fig.  1 ). Patients from EARLI were significantly older (Median: 66 years, IQR [55,78] vs. 58 years, IQR [47,67], p < 0.001), more frequently required vasopressors (58% vs. 47%, p < 0.001), and less frequently required invasive mechanical ventilation (45% vs. 61%, p < 0.001) (Additional file 1 : Table E2) compared to patients from VALID. The proportion of patients who developed ARDS within five days of enrollment was also higher in EARLI (47% vs. 37%, p < 0.001). In-hospital overall mortality was similar in both cohorts (27% vs. 25%, p = 0.5) and also comparable within the ARDS subgroup in both cohorts (37% vs. 34%, p = 0.5). In both cohorts, more than 85% patients who developed ARDS did so on day 1 or day 2 of study enrollment (Additional file 1 : Figure E3A).

A Barplot showing the comparison of the cause of death between hypoinflammatory and hyperinflammatory sepsis in EARLI overall population. B Barplot showing the comparison of the cause of death between hypoinflammatory and hyperinflammatory sepsis in the subgroup of patients who developed ARDS. ARDS Acute respiratory distress syndrome, CNS Central nervous system, GI Gastro-intestinal

Considering both cohorts together, 1168 patients (67%) were allocated to the hypoinflammatory group, and 440 of these (37%) developed ARDS during their study observation period (Table  1 , Additional file 1 : Figure E4). Age and sex were similar between patients developing ARDS and those who did not, whereas proportion requiring vasopressors, pulmonary sepsis, modified APACHE II and in-hospital mortality were higher in those who developed ARDS (Table  1 ). Albumin levels and hematocrit were similar in patients who developed ARDS and those who did not, whereas patients without ARDS received more fluids in the emergency department (Table  1 ). Among hypoinflammatory patients who died, 41 (20%) died before the end of the ARDS ascertainment time frame (5 days) without having developed ARDS (Additional file 1 : Figure E3B).

In the combined cohorts, 569 patients (33%) were allocated to the hyperinflammatory phenotype, and 272 of these (48%) developed ARDS in the five days following their ICU admission (Table  1 and Additional file 1 : Figure E4). As in the hypoinflammatory phenotype, proportion of pulmonary sepsis, modified APACHE II and in-hospital mortality were higher in patients who developed ARDS. The proportion of patients requiring vasopressors was similar between those who developed ARDS and those who did not. Albumin levels were slightly lower in patients who developed ARDS, while the volume of fluids received in the emergency department and hematocrit did not differ (Table  1 ). Among hyperinflammatory patients who died, 55 (23%) died before the end of the ARDS ascertainment time frame (5 days) without having developed ARDS (Additional file 1 : Figure E3B).

AFARDS and population AFARDS

In hypoinflammatory sepsis, the AF ARDS was 36% (95%CI: 24,45%), and the PAF ARDS was 19% (95%CI: 10,28%) (Fig.  2 ). This finding indicates that eliminating ARDS in hypoinflammatory sepsis would provide a relative mortality reduction of 19%. Sensitivity analyses excluding older patients, those with intermediate probability of phenotype membership, and using propensity scores did not meaningfully alter the results (Additional file 1 : Tables E3 and E4).

In hyperinflammatory sepsis, the AF ARDS was 23% (95%CI: 14,31%) and the PAF ARDS was 14% (95% CI: 1,23%), indicating that eliminating ARDS would provide a relative mortality reduction of 14% in hyperinflammatory sepsis (Fig.  2 ). Similar to hypoinflammatory sepsis, sensitivity analyses did not meaningfully alter the results (Additional file 1 : Tables E3 and E4).

• Cause of death

Among the 179 patients who died in EARLI, 49 (27%) were excluded from analysis because no electronic medical record data was available to determine cause of death (mainly patients enrolled from 2008 to 2011). Of the 130 studied, 54 were hypoinflammatory and 76 were hyperinflammatory. Inter-rater reliability for cause of death was excellent (Kappa = 0.94, p < 0.001).

Cause of death differed by phenotype (p < 0.001) (Additional file 1 : Figs. 3A-B and E5; Table  2 ). In hypoinflammatory sepsis, patients died mainly from respiratory failure (59%) (Fig.  3 A), which was primarily characterized by failure to wean from respiratory support rather than refractory hypoxemia (Additional file 1 : Figure E6). In contrast, patients who died in the hyperinflammatory group died mainly from circulatory failure (63%) (Fig.  3 A and Additional file 1 : Figure E7). When considering only patients who developed ARDS, these proportions and differences remained similar (Fig.  3 B). Among patients who died, 53% of patients with hypoinflammatory sepsis died in the ICU versus 73% in the hyperinflammatory phenotype (p = 0.018). Underlying severe comorbidities were present in most patients but were more pronounced in hypoinflammatory sepsis: 33% of hyperinflammatory sepsis patients who died had no underlying severe comorbidities, versus 19% in hypoinflammatory sepsis (p = 0.004) (Table  2 ; Additional file 1 : Figure E5). In the overall sepsis population and in the ARDS subgroup, modified SOFA score collected on day of death or day of withdrawal of life support was significantly lower in patients with hypoinflammatory sepsis compared to patients with hyperinflammatory sepsis (Table  2 and Additional file 1 : Table E5). Further details comparing cause of death of patients who developed ARDS and those who did not in each phenotype are provided in the Additional file 1 .

To our knowledge, this study estimates for the first time the AF ARDS and PAF ARDS in inflammatory phenotypes of sepsis. While the PAF ARDS was relatively similar in hyper- and hypo-inflammatory sepsis, cause of death differed substantially between the phenotypes. Death in hypoinflammatory sepsis was mainly driven by respiratory causes, most commonly failure to wean from respiratory support, and death in hyperinflammatory sepsis was mainly driven by circulatory failure/shock.

Our analyses of cause of death in each phenotype identified several patterns of interest. First, we found that patients in the hyperinflammatory phenotype died mainly because of circulatory failure (refractory shock). We could not determine if circulatory failure was caused directly by effects of sepsis on the peripheral vasculature (e.g. vasoplegia, hypovolemia) or by pulmonary vascular dysfunction leading to right ventricular failure, which is frequently present in patients who die from ARDS [ 20 , 21 , 22 ], or a combination of the two. Second, we found that patients with hypoinflammatory sepsis died mainly because of respiratory failure, regardless of the presence of ARDS. Respiratory failure in these cases was not driven by irreversible hypoxemia but by failure to wean from ventilatory or oxygenation support. Third, more than 80% of patients with hypoinflammatory sepsis who died had severe comorbidities which contributed to the decision to withdraw or not escalate life support. Thus, deaths in hypoinflammatory sepsis may reflect at least in part a population with severe comorbidities that limit functional recovery from critical illness. Numerous studies have reported that patients with ARDS frequently die because of extrapulmonary organ failure [ 17 , 18 , 23 ], but to our knowledge, the finding that patients with hypoinflammatory sepsis died mainly because of failure to wean from respiratory support is novel.

The PAF ARDS can be defined as the proportion of death over a specified time that would be prevented following elimination of the exposure (i.e., ARDS) in the sepsis population, assuming the exposure is causal [ 9 ]. Following this definition, 19% of deaths could be avoided during hospitalization if ARDS were eliminated in hypoinflammatory sepsis, and 14% of deaths in hyperinflammatory sepsis. Surprisingly, the AF ARDS and PAF ARDS seemed relatively similar and perhaps even lower in hyperinflammatory sepsis compared to hypoinflammatory sepsis. One possible explanation for this finding is that in hyperinflammatory sepsis, the lung is only one of many failing organs; thus, treating respiratory failure is less likely to eliminate risk of death. Another explanation could be that more patients with hyperinflammatory sepsis die before they can develop ARDS. However, as ARDS occurred mainly in the first 48 h, and because only a small proportion of patients died without ARDS within the five first days, this explanation seems less likely. As a result of this low PAF ARDS , therapies that target lung-specific pathways in hyperinflammatory sepsis may require dramatic efficacy to identify a mortality benefit, while therapies that have less organ-specific effects may be more fruitful [ 8 , 10 ].

The AF ARDS and PAF ARDS in hypoinflammatory sepsis were modestly higher, with a lower prevalence of multi-system organ failure, which might imply that ARDS plays a larger role in short-term mortality in this phenotype. However, the proportion of hypoinflammatory patients who died with a high burden of severe comorbidities was very high. If confirmed by other studies, these findings may limit the utility of mortality as an endpoint for future studies in hypoinflammatory sepsis, especially when severe comorbidities persist and contribute to a short life expectancy. Using severe comorbidities as a surrogate for frailty, we speculate that the modifiable proportion of death in this phenotype may be lower. It is important to emphasize that we did not explore other important endpoints such as morbidity, quality of life and other patient-centered outcomes, or the financial impact of ARDS in patients who survived [ 24 ]. Taken together, these findings highlight challenges to achieving mortality reduction in ARDS clinical trials. Designs for future trials in both phenotypes should take account of these findings, which could indicate that a large number of patients would need to be treated in order to identify a survival benefit, or that the trial population must be more strictly selected [ 7 , 10 , 23 ]. Cooperative multinational trials may be required in order to generate studies adequately powered for mortality endpoints.

With recent data suggesting that hypoinflammatory and hyperinflammatory phenotypes are generalizable to sepsis [ 5 , 6 ], we chose to study the AF ARDS and PAF ARDS within each sepsis phenotype. This approach considers ARDS as a complication of each phenotype of sepsis, rather than considering each phenotype of ARDS as a complication of overall sepsis or more broadly of critical illness. Analyses that assess the PAF of hyperinflammatory ARDS and hypoinflammatory ARDS relative to an unselected control group (i.e., unselected patients, or ventilated controls) will likely find quite different results. In a previous study, Saha et al. estimated the attributable fraction of mortality from hyperinflammatory ARDS using a different control population (either critically ill patients without acute respiratory failure or patients with a unilateral radiographic infiltrate) [ 11 ]. In contrast with our results, they found that the AF of death from hyperinflammatory ARDS was higher than from hypoinflammatory ARDS. The observed difference may be explained by the presence of both inflammatory phenotypes within their control population.

This study has several strengths. First unlike some prior studies [ 11 ], phenotypes were assigned by LCA, a robust method [ 16 ] with consistent and well-replicated findings [ 2 , 5 , 25 , 26 , 27 ]. Moreover, sensitivity analysis provided similar results, even when using another approach (propensity scoring) to estimate attributable mortality. Second, we strictly followed established methodological guidelines for estimation and interpretation of PAF ARDS [ 28 ]. Third, it included two large, diverse prospective cohorts from distinct centers which provide a generalizable population with external validity to estimate PAF ARDS . Fourth, all patients were meticulously assessed for both sepsis and ARDS. Fifth, inter-rater reliability for cause of death was excellent.

This study also has limitations. First, we only explored cause of death in EARLI, and some patients had missing data due to timing of EHR implementation. Second, we used the Sepsis-2 criteria to define sepsis, since studies started before the Sepsis-3 definition. However, as we enrolled only critically ill patients, it is unlikely that our patients would not fulfill the more recent criteria for sepsis [ 13 ]. Third, we were not able to assess if LCA class assignment changed over time, although a previous analysis showed that ARDS phenotypes were stable over the first 3 days [ 29 ]. Fourth, while the high burden of comorbidities in hypoinflammatory patients may imply a higher prevalence of frailty, we do not have formal measures of frailty, which might shed further light on causes of death in patients with multi-comorbidity [ 30 ]. Fifth, we assumed that no ARDS patients were misclassified for the analysis. However, our systematic prospective approach to determine presence of ARDS by at least two specialists limits the risk of classification bias, and we explicitly excluded patients whose ARDS diagnosis was unclear or equivocal in one cohort. Sixth, we did not treat ARDS as a time-varying exposure, which could theoretically lead to an overestimation of the population AF ARDS [ 31 , 32 ]. However, this potential bias is limited by the fact that the vast majority of ARDS occurred on Day 1 or 2 of study enrollment. Finally, we focused here only on sepsis patients admitted in ICU, and findings may not be generalizable to patients with other risk factors for ARDS.

This study provides important new findings about PAF ARDS in each inflammatory phenotype of sepsis. The PAF ARDS was modest (< 20%) in both phenotypes and relatively similar. Patients with ARDS in hypoinflammatory sepsis died primarily from respiratory failure with a high burden of severe comorbidities contributing to decisions around end-of-life. Conversely, patients with ARDS in hyperinflammatory sepsis died primarily from circulatory failure. These findings suggest that identifying effective therapies to reduce mortality from sepsis-induced ARDS may be challenging in both phenotypes but for different reasons—namely, the higher prevalence of multiorgan failure in hyperinflammatory sepsis which may decrease the impact of treating only one organ, and the burden of comorbidities which may impact short-term prognosis for patients with hypoinflammatory sepsis.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Acute respiratory distress syndrome

Attributable fraction of death from ARDS

Population attributable fraction of death from ARDS

Intensive care unit

Acute Physiology and Chronic Health Evaluation II

Early Assessment of Renal and Lung Injury cohort

Validating Acute Lung Injury markers for Diagnosis cohort

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BE is supported by « La Société de Réanimation de Langue Française», « Association Limousine d’Aide aux Insuffisants Respiratoires», « Philippe Fondation», « L’institut Servier» and « Fondation Monahan». CSC is supported by R35 HL140026. LBW is supported by NIH HL158906 and NIH HL164937. PS is supported by NIH GM142992.

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Pratik Sinha

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Contributions

BE, PS, KD, LBW and CSC designed the study. BE, NW, LN and AW performed the analysis. BE and CSC drafted the manuscript. AZ performed the inter-rater reliability. CMH, KNK, ES, AG, VEK, MAM, LBW and CSC enrolled the patients. All the authors critically reviewed the manuscript and approved the final version of the manuscript.

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Correspondence to Bruno Evrard .

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Ethics approval and consent to participate.

EARLI was approved by the University of California, San Francisco Institutional Review Board (IRB) and VALID by the Vanderbilt IRB.

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Consent was obtained from patients or their surrogates when possible, as previously described.

Competing interests

BE received Grants for the present work from la Société de Réanimation de la langue Française, la Fondation Monohan, L’institut Servier and L’Association Limousine d’Aide aux Insuffisants Respiratoires. VEK declares a grant from the National Heart Lung and Blood Institute to his institution for the present manuscript; grants from the American Thoracic Society and Parker B. Francis Fellowship outside the present work; being part of DSMB of MODE Trial. CSC declares a grant from NIH to her institution for the present manuscript; grants from Roche Genentech, Quantum Leap Healthcare Collaborative and NIH outside the present work; consulting fees from Vasomune, Gen1e Life Science, NGM Bio, Cellenkos, Calcimedica, Arrowhead; being a co-recipient of a patent; being a council member of the International Sepsis Forum. CMH declares a grant from NIH for the present manuscript; support from DOD, NIH-NIAID and FDA to her institution outside the present work; consulting fees from Spring Discovery; being a DSMB member for regARDS Trial. KD declares being part of the University of Vermont DSBB. KDL declares grants from NIH and Quantum Leap Healthecare collaborative; consulting fees from AM Pharma, Biomerieux, Seastar Biomedical, UpToDate, Baxter; Honoraria and support from the American Society of Nephrology; and being part of advisory Boards for BOA Medical and Novartis; being an Associate Journal Editor for the American Thoracic Society. LBW declares a grant from NIH for the present manuscript; research contracts with Department of Defense, Genentech, Boehringer Ingelheim and CSL Behring; consulting fees from Arrowhead, Akebia, Santhera, Global Blood Therapeutics and Boehringer Ingelheim; being part of DSMB for CHILL Trial and SIGNET Trial; stock in Virtuoso Surgical. MAM declares grants paid to his institution outside the present work from NHLBI, NIAID, Department of Defense, Calif Institute if Regeneration, Roche Genentec and Quantum Health; consulting fees from Citius Pharmaceuticals, Gen1LifeScience, Gilead Pharmaceuticals, Novartis, Johnson and Johnson and Pilant Therapeutics. PS declares a Grant from NIGMS/NIH for the present manuscript and consulting fees from AstraZeneca and Prenosis Inc. AG, AZ, LN, NW, KNK, ES and AW declare no conflict of interests.

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Additional file 1. e-methods:.

Participants, exclusion criteria, determination of the cause of the death and statistical analysis. E-results . Table E1: Definition of severe and irreversible organ system dysfunction derived from Stapleton et al. and Ketcham et al. Table E2: Characteristics on ICU admission between EARLI and VALID cohort. Table E3: Estimation of population attributable fraction of death from ARDS in each subphenotype of sepsis. Table E4: Estimation of attributable fraction of death from ARDS in each subphenotype of sepsis. Table E5: Details of the SOFA score without neurologic component before the day of death or at the time of withdrawal of life support, stratified by phenotype. Table E6: Characteristics of patients before the day of death or at the time of the withdrawal of life support, stratified by subphenotype and presence or not of ARDS. Figure E1: Algorithm from Ketcham et al. to determinate the primary cause of death. Figure E2: Directed Acyclic graph used for propensity score matching. Figure E3: Barplot showing the day of diagnosis of ARDS from ICU admission (Day 1) in each subphenotype of sepsis, and showing the proportion of patient who died in each phenotype and stratified by the timing of death. Figure E4: Overview of the study. Figure E5: Alluvial plot showing the relation between severe comorbidities, the origin of sepsis the phenotype of sepsis, the presence or not of ARDS and the cause of death, stratified by the subphenotype of sepsis. Figure E6: Upset plot showing the number of patients with one or multiple irreversible or severe organ dysfunction collected at the time of death or the withdrawal of life support in hypoinflammatory sepsis using the standardized case ascertainment template. Figure E7: Upset plot showing the number of patients with one or multiple irreversible or severe organ dysfunction collected at the time of death or the withdrawal of life support in hyperinflammatory sepsis using the standardized case ascertainment template. Figure E8: Results for the matching using propensity score in the hypoinflammatory sepsis. Figure E9: Results for the matching using propensity score in the hyperinflammatory sepsis. E-references . STROBE Statement .

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Evrard, B., Sinha, P., Delucchi, K. et al. Causes and attributable fraction of death from ARDS in inflammatory phenotypes of sepsis. Crit Care 28 , 164 (2024). https://doi.org/10.1186/s13054-024-04943-x

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