Jay Steingrub - Academia.edu (original) (raw)

Papers by Jay Steingrub

New England Journal of Medicine, 2006

The members of the Writing Committee

Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy

Journal of the American Medical Informatics Association

How to deliver best care in various clinical settings remains a vexing problem. All pertinent hea... more How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data cur...

JAMA Network Open

ImportanceIndividuals who survived COVID-19 often report persistent symptoms, disabilities, and f... more ImportanceIndividuals who survived COVID-19 often report persistent symptoms, disabilities, and financial consequences. However, national longitudinal estimates of symptom burden remain limited.ObjectiveTo measure the incidence and changes over time in symptoms, disability, and financial status after COVID-19–related hospitalization.Design, Setting, and ParticipantsA national US multicenter prospective cohort study with 1-, 3-, and 6-month postdischarge visits was conducted at 44 sites participating in the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network's Biology and Longitudinal Epidemiology: COVID-19 Observational (BLUE CORAL) study. Participants included hospitalized English- or Spanish-speaking adults without severe prehospitalization disabilities or cognitive impairment. Participants were enrolled between August 24, 2020, and July 20, 2021, with follow-up occurring through March 30, 2022.ExposureHospitalization for COVID...

Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19

Annals of Internal Medicine

Chest, 2017

PURPOSE: For patients with selected etiologies of respiratory failure, non-invasive ventilation m... more PURPOSE: For patients with selected etiologies of respiratory failure, non-invasive ventilation may be an important option to prevent intubation and mechanical ventilation, or post-extubation failure. Recent studies (Patel, et al., JAMA 2016) suggested that a helmet interface for NIPPV is better tolerated with better clinical outcomes than a mask interface. Helmet NIPPV is rarely used in the US. We describe our own experience with a helmet interface prior to clinical use. METHODS: Users wore a helmet or a mask for non-invasive positive pressure. NIPPV was delivered by an AVEA ventilator in the PSV mode via a Helmet, or a non-vented full face mask. During and after at least 10 minutes of NIPPV, users scored their subjective experience of several variables on a 0-10 visual analog scale (VAS), where 0 is intolerable and 10 is equivalent to breathing without an interface. Items of interest included: comfort, claustrophobia, noise, temperature, pressure related discomfort (ears, eyes and airway), and ease of triggering inspiration and expiration. RESULTS: Evaluations by VAS scores were completed by 2 female and 3 male healthy clinicians; height range 58-73 inches, and neck size 14-16 inches. All completed more than 30 minutes of helmet ventilation and 10 minutes of mask ventilation. At all pressures, all clinicians reported better VAS scores for overall comfort with a helmet than with a mask (8.2AE1.1 vs. 4.8AE1.5 mask). The helmet was subjectively better for several items scored. The VAS scores for helmet included: claustrophobia (9.6AE0.5 vs. 7.2AE1.1 mask), noise (8.6AE0.9 vs. 7.8AE2.3 mask), temperature (7.4AE1.9 vs. 8.2AE1.9 mask), eye pressure (9.2AE1.1 vs. 8.4AE2.1 mask), and ear pressure (6.6AE1.8 vs. 8.6AE1.1 mask). Users reported better tolerance to the helmet for PEEP up to 10 cm H 2 O and inspiratory pressure up to 15 cm H 2 O (8.0AE0.9 vs. 4.9AE1.5 mask). Users noted better inspiratory synchrony with the helmet (8.4AE0.8 vs 6.0AE2.0 mask), better anticipated long-term tolerance (8.8AE1.6 vs. 3.8AE1.5 mask) and ability to communicate by speaking (9.0AE1.0 vs. 1.4AE0.5 mask). CONCLUSIONS: Healthy volunteers rated the helmet for delivery of NIPPV as more comfortable and better tolerated than a full face mask. Notable subjective complaints with mask NIPPV were: pressure on the face, and inability to communicate be speaking. Discomforts of the Helmet were, at high applied pressures, inner ear pressure and anterior neck pressure. Inspiratory and Expiratory triggering were better with the helmet, particularly at higher pressures. CLINICAL IMPLICATIONS: Application of NIPPV via a helmet interface was better tolerated than via a mask in normal persons. Our observations are consistent with prior descriptions and suggest specific reasons for better tolerance of the Helmet. These data support a possible role of the helmet interface with NIPPV in patients with respiratory failure.

Geographical location and outcome in a multi-center clinical trial of ALI/ARDS

Validation of a model that uses enhanced administrative data to predict mortality in critically ill patients with sepsis

Blood glucose control with three different QI strategies

529: An Analysis of Homeless Patients in the United States Requiring Icu Admission

Critical Care Medicine, 2016

Is there a role for low tidal volume ventilation to prevent ALI/ARDS? Survey of tidal volumes and incidence of ALI/ARDS in ventilated patients

eProtocol-insulin development and refinement in teo research networks

Development of a model that uses enhanced administrative data to predict mortality among patients with sepsis

Fluid management strategy in patients with pulmonary and extra-pulmonary causes of ALI/ARDS

Chest, 2021

BACKGROUND: Although specific interventions previously demonstrated benefit in patients with ARDS... more BACKGROUND: Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION: What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS: We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO 2 to FIO 2 ratio of # 150 with positive endexpiratory pressure of $ 5 cm H 2 O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. RESULTS: A total of 2,466 patients were enrolled. Median baseline PaO 2 to FIO 2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, # 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, # 30 mm H 2 O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR.

Journal of the American Medical Informatics Association, 2021

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approvi... more Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention—the starting point for delivery of “All the right care, but only the right care,” an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must prov...

ICU Clinical Staff Assessment of Patient Frailty Is Neither Accurate Nor Precise

B104. POST-ICU SURVIVORSHIP, 2020

Reliable Delivery of Pressure Within the Clinically Relevant Range Via a Helmet Interface for Non-Invasive Ventilation

B24. CRITICAL CARE: GONE WITH THE WIND - MECHANICAL VENTILATION: HFNC, NIV AND INVASIVE, 2019

Journal of Critical Care, 2019

To assess how homelessness impacts mortality and length of stay (LOS) among select the intensive ... more To assess how homelessness impacts mortality and length of stay (LOS) among select the intensive care unit (ICU) patients. Methods: We used ICD-9 code V60.0 to identify homeless patients using the Premier Perspective Database from January 2010 to June 2011. We identified three subpopulations who received critical care services using ICD-9 and Medicare Severity Diagnosis Related Groups (MS-DRG) codes: patients with a diagnosis of sepsis who were treated with antibiotics by Day 2, patients with an alcohol or drug related MS-DRG, and patients with a diabetes related MS-DRG. We used multivariable logistic regression to predict mortality and multivariable generalized estimating equations to predict hospital and ICU LOS. Results: 781,540 hospitalizations met inclusion criteria; 2278 (0.3%) were homeless. We found homelessness had no significant adjusted association with mortality among sepsis patients, but was associated with substantially longer hospital LOS: (3.7 days longer; 95% CI (1.7, 5.7, p b .001). LOS did not differ in the Diabetes or Alcohol and Drug related DRG groups. Conclusions: Critically ill homeless patients with sepsis had longer hospital LOS but similar ICU LOS and mortality risk compared to non-homeless patients. Homelessness was not associated with increased LOS in the diabetes or alcohol and drug related groups.

Journal of Vascular Surgery, 2006

A conservative strategy of fluid management in patients with acute lung injury shortens duration ... more A conservative strategy of fluid management in patients with acute lung injury shortens duration of mechanical ventilation without increasing nonpulmonary organ failure. Summary: There is debate about optimal fluid management of patients with acute lung injury. Limiting fluids or inducing diuresis may improve lung function but at the expense of impaired perfusion of other organs. In this randomized study, a conservative or liberal strategy of fluid management in patients with acute lung injuries was used. The protocol was applied for 7 days in 1000 patients with acute lung injury. The primary end point was death at 60 days. Ventilator-free days and organ-failure-free days and measures of lung physiology were secondary end points. There was no difference between the two groups in the primary end point at 60 days. In the conservative strategy group, 25.5% of the patients died, and 28.4% of the patients died in the liberal strategy group (P Ͻ .30; 95% confidence interval for a difference, Ϫ2.6% to 8.4%). The cumulative fluid balance in the first 7 days in the conservative strategy group was Ϫ136 Ϯ 491 mL. The cumulative fluid balance in the first 7 days in the liberal strategy group was ϩ6992 Ϯ 502 mL (P Ͻ .001). The conservative strategy group had an improved oxygenation index, lung injury score, and an increased number of ventilatorfree days (14.6 Ϯ 0.5 vs 12.1 Ϯ 0.5, P Ͻ .001) vs the liberal strategy group. The conservative strategy group also had more days not spent in the intensive care unit (13.4 Ϯ 0.4 vs 11.2 Ϯ 0.4, P Ͻ .001) during the first 28 days. There was no difference between the conservative and liberal strategy groups with respect to prevalence of shock during the course of the study or the use of dialysis during the first 60 days (10% vs 14%, P Ͻ .06). Comment: A conservative fluid management strategy did not decrease death at 60 days vs a liberal fluid management strategy in patients with acute respiratory distress syndrome. However, intensive care unit days were reduced and lung function was improved with the conservative fluid management posture. The results are consistent with other recent reports suggesting improved overall patient outcome with conservative fluid management in acute respiratory distress syndrome. The days of essentially drowning patients with acute lung injury to preserve distal organ perfusion should be over. Chlamydia pneumoniae in foci of "early" calcification of the tunica media in atherosclerotic arteries; an incidental presence?

Drotrecogin Alfa (Activated) in Sepsis: Initial Experience With Patient Selection, Cost, and Clinical Outcomes

Journal of Intensive Care Medicine, 2005

During a 1-year period, the authors examined clinical experience with drotrecogin alfa, activated... more During a 1-year period, the authors examined clinical experience with drotrecogin alfa, activated for sepsis in a 24-bed medical-surgical intensive care unit. Drotrecogin alfa, activated was administered 46 times to 44 patients (3% of all intensive care unit admissions). Eighty-six percent of patients were on vasopressors; 95% were mechanically ventilated. Mean Acute Physiology and Chronic Health Evaluation II score was 22.0 at admission and 21.9 during the 24 hours before drug administration. The 28-day all-cause mortality was 36.4% and hospital mortality was 43.2%, trending higher (P = .10) than in the PROWESS study, which can be attributed to clinical use in patients who would not have met PROWESS study inclusion criteria. Failure to complete a 96-hour infusion of drotrecogin alfa, activated and transfer from another hospital or nursing home before treatment were associated with poor outcome. Total cost of hospital care, including mean drotrecogin alfa, activated drug cost of 7,312 US dollars, exceeded reimbursement by a mean of 18,227 US dollars.