BACKGROUND:A minority of Pulmonary and Critical Care Medicine (PCCM) graduates pursue careers in academic medicine. Although compensation is only a portion of the career decision, job negotiations remain shrouded in ambiguity and inconsistency. Additionally, while role-level salary tables exist through the Association of American Medical Colleges (AAMC), to our knowledge there is no resource that includes important non-salary. OBJECTIVE:We sought to describe key components of first PCCM academic job offers for both physician scientists and clinician educators, including salary, start-up packages, non-clinical full-time equivalent (FTE) breakdown, and bonus ranges. METHODS:An electronic survey was distributed via a snowball sampling method between May-June 2025. PCCM graduates between 2020 and 2025 who accepted a job in academic medicine were included. Mann-Whitney Wilcoxon tests were used for ordinal comparisons. Qualitative analysis of free text responses was performed with a social cognitive career theory framework. RESULTS:There were 60 respondents who provided information about 103 job offers, with 50% (14/28) of physician-scientists and 66% (21/32) of clinician-educators reporting more than one job offer. Physician-scientists received lower salary offers compared to clinician-educators (respective median ranges: $150 000-$199 999 vs $250 000-$299 999, P < .001). Only 35.7% of physician-scientists (10/28) received a career development award prior to negotiation, which was associated with a higher start-up package offer (P < .05). For all clinician-educator jobs (n = 59), 42.4% had non-clinical FTE in the initial offer. Many respondents commented on the lack of negotiating power. CONCLUSION:PCCM physician-scientists and clinician-educators experience wide variability in their initial job offers. Recognizing differences is essential to improve transparency in job negotiations in academic medicine.

Rationale Communication errors during transitions of care between the intensive care unit (ICU) and the hospital wards threaten care quality and patient safety. In 2019, we developed a structured ICU-to-ward transfer tool (ICU-PAUSE) to improve handoff communication during this transition of care; ICU-PAUSE has since been implemented at 23 medical centers in the United States and one in India. To develop best practices for continued implementation efforts, we sought to understand how local modifications to the ICU-PAUSE template and its implementation strategies enhanced fit, acceptance, and uptake. Methods We conducted semi-structured post-implementation interviews and surveys with intensivist ICU-PAUSE implementation champions at each site to identify and describe implementation strategy modifications that were successful at their institutions. Concurrently, we analyzed content modifications to the ICU-PAUSE template embedded into each site's electronic health record. We used the Framework for Reporting Adaptations and Modifications-Enhanced to Implementation Strategies (FRAME-IS) to characterize the site-specific modifications. We then developed a set of best practices to guide ongoing scale-up efforts. Results The majority of the site-specific modifications were content changes to the template (Figure 1); prominent examples included a checkbox to indicate if a referral to a post-ICU clinic is needed and a section listing any operations performed during a patient's ICU course with the surgeon's information. Per FRAME-IS, most remaining modifications to the implementation strategies were context-informed personnel and format adjustments, such as adding regular information sessions regarding ICU-PAUSE for rotating trainees. Overall, interviews identified four key implementation strategies for the successful adoption and sustainability of ICU-PAUSE: 1) build a coalition, 2) distribute educational materials, 3) promote adaptability, and 4) conduct ongoing training. Important local partnerships included collaboration with hospitalists, administrators, technical support, and more. Conclusion The identified best practices for implementation will now be incorporated into the ICU-PAUSE bundled intervention for future sites participating in rolling implementation. Next steps include evaluating the impact of the intervention on key care processes and patient outcomes, including readmissions, length of ICU stay and total hospitalization, and mortality. Multisite center-level patient data analyses are underway in partnership with Vizient, Inc., the national quality improvement data organization, and will be available for review at the time of ATS 2025. Figure 1. Best practices for ICU-PAUSE implementation and site-specific template modifications.

Rationale Patient handoffs between the intensive care unit (ICU) and medical wards are high-risk and prone to communication errors.1-3 ICU-PAUSE is a structured ICU-to-ward handoff tool, previously developed to improve communication during this transition of care by summarizing pertinent information from a patient's ICU course and embedding a diagnostic pause during the transfer process.4 ICU-PAUSE has subsequently been implemented at 23 medical centers across the United States. However, international institutions may face similar challenges as well as unique challenges during ICU-ward transitions of care. This study describes the process and assesses the feasibility of the first international implementation of ICU-PAUSE at a medical center in India. Methods To implement ICU-PAUSE at the KIMS Hospitals in India, an information session was conducted for the intensivist serving as the site champion to introduce ICU-PAUSE and outline the steps for its implementation. The site champion then modified the ICU-PAUSE tool and implementation strategies to fit their specific institutional needs. Template modifications made by the site champion were the addition of blood group, allergies and nutrition in the handover. These parameters were frequently found to be missed and led to significant medical errors. An educational session was held for faculty and trainees at the medical center to increase buy-in and adoption of the tool. Intervention uptake was evaluated by auditing the use of the template in ICU-ward transfer notes. Furthermore, post-implementation surveys regarding user experience were conducted to assess satisfaction with the tool. Results Utilizing the implementation strategies that were successful in the United States, ICU-PAUSE was introduced to its first international institution. The compliance for usage has been found to be 88.7% from the ICU (55/62) since October 1st,2024. the cases missed were found in the initial days of implementation. The feedback from the ICU team has been positive and the tool could be seamlessly integrated into the institutional Electronic Health Record system. Challenges to implementation found were hesitancy in adopting a new format and perceived documentation burden. Conclusions This study describes the international scale-up of a low-resource ICU-to-ward transfer bundled intervention. Close collaboration with local stakeholders and the modifiability of ICU-PAUSE facilitated successful implementation at an international site despite differences in organizational structures and workflows. Next steps will include assessing the sustainability of the tool in an international setting and the long-term impact on patient outcomes.

Background:ICU readmissions are associated with increased morbidity, mortality, and healthcare costs. As ICU patient complexity increases and care practices evolve, the contemporary epidemiology of ICU readmissions remains unclear. We aimed to examine ICU readmission rates and timing across multiple health systems, focusing on unplanned readmissions occurring within 24, 48, and 72 hours after ICU discharge. Methods:We performed a retrospective cohort study using federated data from the Common Longitudinal ICU data Format (CLIF) Consortium, comprising nine healthcare systems between January 2020 and December 2021 and the MIMIC-IV database. The cohort included adult patients (≥18 years) discharged alive from the ICU. Readmissions following planned surgeries or interventional procedures were excluded. Data were analyzed locally at each site without centralizing patient-level data, and analyses focused on patient demographics, discharge disposition, readmission timing, and clinical interventions during ICU stays and readmissions. Statistical comparisons were performed using two-proportion z-tests and chi-squared tests. Results:Among 185,241 hospital admissions across 19 hospitals, 8.6% of ICU discharges were readmitted during the same hospitalization. Unplanned readmissions occurred within 24 hours in 1.9% of cases, 3.4% within 48 hours, and 4.5% within 72 hours. Readmitted patients experienced higher in-hospital mortality (20.6% vs. 2.1%, p<0.001). Compared to the initial ICU stay, ICU readmissions were associated with significantly increased respiratory (42.3% vs. 35.3%, p<0.001) and vasopressor support (26.1% vs. 23.1%, p<0.001). Conclusions:ICU readmissions remain common and are linked to worse outcomes. Readmissions require more respiratory and vasopressor support. Future work should focus on characterizing these subphenotypes and improving ICU discharge processes to reduce preventable readmissions.

Rationale: Disparities in unilateral clinician decisions to decline initiating or maintaining life-sustaining treatment (LST) exist. We aimed to determine 1) which US state statutes support unilateral clinician decisions to decline initiating or maintaining LST; 2) what requirements, if any, must be met for these unilateral clinician decisions to occur; and 3) which state statutes address concerns for sociodemographic disparities associated with these decisions. Methods: Between September and October 2024, we used Fastcase, Casetext and official US state government websites to identify statutes for all US states and Washington, DC that addressed clinician decisions to decline to initiate or maintain LST. We defined reason of conscience as explicit mention of conscience, religion, ethics or moral reasons supporting unilateral clinician decision-making. Two reviewers independently analyzed each statute resolving disagreements with consensus adjudication. Results: Almost all (98%, n=50/51) statutes explicitly support unilateral clinician decisions to decline initiating or maintaining at least one form of LST. Reasons supporting these decisions varied across states including medical reasons only (16%), reasons of conscience only (22%), both medical reasons and reasons of conscience (35%), or no medical or conscience reason explicitly provided (25%). Medical reasons supporting unilateral clinician decisions included if LST was “medically ineffective” (24%), “contrary to medical standards” (14%), “medically inappropriate” (10%), or “nonbeneficial” (8%). For states supporting unilateral clinician decisions if LST was medically ineffective, 75% also supported LST to be declined for reason of conscience while 25% did not. When using medical reasons to support unilateral clinician decisions to decline LST, many statutes require that clinicians must first inform patient/surrogate of this decision (37%) and cooperate with transferring the patient to another clinician or institution (75%). Statutes rarely directly required clinicians to obtain a second medical opinion (8%), pursue a medical ethics committee review (6%), or address conflict (2%) in these situations. Although no state statutes explicitly acknowledged the existence of sociodemographic disparities associated with unilateral clinician decisions to initiate or maintain LST, 27% included guidance that addressed decisions to withhold or withdraw LST in specific marginalized groups. Conclusions: While almost all US state statutes allowed clinicians to decline to initiate or maintain LST, the reasons supporting and actions required to pursue these decisions varied. No statute explicitly addressed sociodemographic disparities associated with these decisions, which may perpetuate these disparities across the US.

BACKGROUND:There is considerable variation in clinicians' approaches to decisions to withhold or withdraw life-sustaining treatment (LST) across US hospitals. These differences are not explained by patient preferences alone and are likely influenced by other factors (eg, hospital policies, hospital culture, state laws, medical society guidelines). RESEARCH QUESTION:How do hospital policies influence clinician approaches to decisions to withhold or withdraw LST among patients admitted to an ICU? STUDY DESIGN AND METHODS:We conducted semistructured interviews with ICU nurses and physicians at 3 geographically diverse hospital systems across the United States between July and October 2024. We asked clinicians about their experiences with, and perceptions of, hospital policies on withholding or withdrawing LST and the relationship between these policies and clinician decision-making in ethically challenging scenarios. RESULTS:We interviewed 10 nurses and 8 attending physicians with a median of 5 years (range, 2-36 years) in practice. Clinicians described limited awareness of, and familiarity with, their hospital's policies that addressed withholding or withdrawing LST. Clinicians with knowledge of these policies could identify their location but described barriers to accessing them. Although clinicians perceived hospital policies as helpful in some ways (eg, legal protection, ethical guidance), they viewed them as neither acknowledging nor addressing sociodemographic disparities or clinician value judgments in LST decision-making. Perceptions varied about whether clinicians followed their own hospital policy guidance when making decisions to withhold or withdraw LST. INTERPRETATION:Our results show that clinicians lack detailed understanding about their hospitals' policies that address withholding or withdrawing LST and perceive these policies as having limited applicability to clinical practice. These findings suggest that hospital policies may have little influence on clinician behavior in addressing decisions to withhold or withdraw LST in ethically challenging scenarios.

This cross-sectional study evaluates US state regulation of clinician decisions about life-sustaining treatment for adults, including justifications and regulatory requirements.

RATIONALE: Respiratory Syncytial Virus (RSV) causes significant morbidity and mortality among high-risk patients. Ribavirin is an FDA-approved treatment for severe RSV infections, but few guidelines exist as to which patients should receive this medication. We aimed to characterize the patient factors associated with ribavirin use among hospitalized adults with RSV infection. METHODS: We performed a retrospective cohort study of all adult patients hospitalized with RSV infections at two academic hospital systems between 01/01/2019 and 06/30/2023. We included patients with newly-positive polymerase chain reaction tests for RSV in the 7 days before or after the date of admission, restricting the cohort to those with abnormal respiratory physiology (> 20 respirations per minute, new oxygen use, or SpO2 < 92%). We extracted patient characteristics, care processes, and hospital outcomes from the electronic health record. The primary outcome was the composite of death and discharge to hospice. Secondary outcomes were hospital length of stay, respiratory support, vasoactive medications, and concurrent use of antibiotics. RESULTS: We identified 159 patients who were hospitalized with confirmed RSV infections, with 13 (8%) receiving inhaled or oral ribavirin. Patients who received ribavirin had similar ages (median 61 [IQR 54-71] vs 63 years [IQR 60-67]) and nonsignificantly lower comorbidity burdens (median vanWalraven index 8 [IQR 6-30] vs 17 [IQR 8-24]) than patients who did not receive ribavirin. However, patients who received ribavirin were more likely to have active cancer (n=11 [85%] vs n=86 [50%]) -- predominantly hematologic malignancies or hematopoietic cell transplants (n=10 [77%] vs n=19 [13%]). Patients who received ribavirin had lower absolute neutrophil (2.0 [IQR 0.5-3.4] vs 5.2 [IQR 3.2-6.9]) and absolute lymphocyte counts (0.30 [IQR: 0.13-0.60] vs 0.96 [IQR 0.50-1.50]). Patients who received ribavirin were more likely to be neutropenic (n=5 [38%] vs n=3 [2.1%]) or lymphopenic (n=11 [85%] vs n=69 [47%]). The primary outcome occurred at similar rates between treatment groups (ribavirin n=1 [7.7%], no ribavirin n=15 [10%]). Neither hospital length of stay (median 5 [IQR 3-8] vs 5 [IQR 3-11] p>0.9) nor mechanical ventilation (n=2 [15%] vs n=24 [16%], p>0.9) differed between treatment groups. Antibiotic use was more frequent in the ribavirin group (n=12 [92%]) than in patients not receiving ribavirin (n=102 [70%] p=0.03) CONCLUSIONS: Hospitalized patients with RSV infections had severe outcomes. Ribavirin was infrequently used except among patients with hematologic malignancies and neutropenia. Larger studies should investigate the relationship between patient- and hospitalization factors, ribavirin use, and morbidity and mortality.

Critical illness threatens millions of lives annually. Electronic health record (EHR) data are a source of granular information that could generate crucial insights into the nature and optimal treatment of critical illness. Overcome the data management, security, and standardization barriers to large-scale critical illness EHR studies. We developed a Common Longitudinal Intensive Care Unit (ICU) data Format (CLIF), an open-source database format to harmonize EHR data necessary to study critical illness. We conducted proof-of-concept studies with a federated research architecture: (1) an external validation of an in-hospital mortality prediction model for critically ill patients and (2) an assessment of 72-h temperature trajectories and their association with mechanical ventilation and in-hospital mortality using group-based trajectory models. We converted longitudinal data from 111,440 critically ill patient admissions from 2020 to 2021 (mean age 60.7 years [standard deviation 17.1], 28

Background: Early mobilization (EM) engages critically ill patients in out-of-bed activity within 72 hours of intubation and may prevent disability. Unfortunately, less than 10% of mechanically ventilated patients ever get out-of-bed. If mobilization occurs, it is typically delayed to beyond 72 hours, when the benefits are less clear. Physiologic instability is the most commonly cited barrier to EM. However, objective application of eligibility criteria from EM clinical trials and consensus guidelines are needed to determine if physiologic instability leads to delays in mobilization. Methods: We identified adult patients (≥ 18 years) requiring invasive mechanical ventilation for >2 hours in the MIMIC-IV dataset and at eight healthcare systems from the Common Longitudinal Intensive Care Unit (CLIF) Consortium between March 2020 and March 2022. In the first 72 hours after intubation, we identified hourly windows during business hours (8am-5pm) for which patients were eligible to initiate EM based on physiologic criteria defined in 2 EM clinical trials (Chicago and TEAM) and Consensus Guidelines (Figure-1a). Patients with a tracheostomy or requiring paralytics for >4 hours were excluded. We employed Kaplan-Meier survival analysis to evaluate the cumulative incidence of eligibility between 8am-5pm across different criteria. LLMs were used to assist coding and drafting, with all output reviewed by authors. Results: The study cohort included 64,824 patients (mean age 61.5 years, 40.6% Female, 21.7% Black) admitted to 31 hospitals. Within 72 hours after intubation, 98.2% of the cohort met Chicago, 45.1% met TEAM, and 97.5% met Consensus Guidelines criteria (p<0.001) during business hours. The median time to first eligibility from intubation was 1 hour for Chicago and Consensus Guidelines criteria. Cumulative incidence probabilities at one hour were 74.3% for Chicago, 75.3% for Consensus Guidelines, and 27.9% for TEAM criteria (Figure-1b). Overall, the Chicago and Consensus Guidelines criteria were met in 81.5% and 84.95% of the total business hours, while the TEAM criteria were met for 35.75% of the total number of business hours. The most common reason for TEAM criteria failure was vasopressor dose. Conclusions: Eligibility criteria for EM protocols can influence the timing of out-of-bed activity. Chicago and Consensus Guidelines criteria provided more opportunity for EM, while TEAM criteria were more stringent and met beyond the 72-hour window. Perceived physiologic instability precluding EM implementation was not supported after objective assessment using defined physiologic criteria. Future work should focus on comparing these eligibility windows with actual implementation of EM.

Rationale Deep sedation in the first 48 hours of invasive mechanical ventilation (IMV) is associated with increased IMV duration and mortality. Language barriers may lead to suboptimal assessments of patient sedation needs and culminate in increased restraint use. However, the relationship between EHR-documented preferred language and sedation depth is unknown. Methods We analyzed data from the Common Longitudinal Intensive Care Unit (CLIF) consortium, where independent, geographically diverse health systems use electronic health record data to study critical illness through a federated architecture. We identified all adult patients admitted to an intensive care unit who underwent at least 24 hours of IMV between July 1, 2017, to September 30, 2024, excluding patients with a tracheostomy. The primary outcome was the percent of time spent in deep sedation (defined as Richmond Agitation Sedation Score -3 or lower) in the first 48 hours of IMV. The secondary outcome was total IMV duration. The exposure was the patient's EHR-documented preferred language, categorized as English, Spanish, or other language. Linear regression models were fit at each site to estimate the association between the exposure and outcome adjusted for age, sex, race, ethnicity, body mass index, administration of continuous paralytics, Sequential Organ Failure Assessment score, primary sedative medication, and a hospital fixed effect. Random effects meta-analysis was conducted using maximum likelihood estimation to aggregate results across health systems. LLMs assisted coding, with all output reviewed by authors. Results The cohort included 50,404 mechanically ventilated adults (median age 62 [IQR 21.5], 21,270 (42.2%) female, 11,929 (23.7%) Black, 1,952 (3.9%) Asian, and 3,166 (6.3%) Hispanic) across 7 healthcare systems and 32 hospitals. Patients with EHR-documented English preference (n = 46,926) made up 92.7% of the cohort, while patients with Spanish preference (n = 1,515) were 3%, and other language preference (n = 1,968) were 3.9%. Patients with Spanish language preference experienced a 2.69% (95% CI -0.06, 5.46) absolute increase in deep sedation time relative to English preference patients with significant study site variation (Figure 1). No statistically significant difference in total IMV time between language groups was found. Conclusions Analysis of patients with a Spanish-language preference demonstrates a trend towards increased deep sedation. The significant heterogeneity observed among health systems suggests further research is needed to explore the underlying mechanisms of preferred language on sedation practices and mitigate related disparities.

Objectives:Large language models (LLMs) have demonstrated high levels of performance in clinical information extraction compared to rule-based systems and traditional machine-learning approaches, offering scalability, contextualization, and easier deployment. However, most studies rely on proprietary models with privacy concerns and high costs, limiting accessibility. We aim to evaluate 14 publicly available open-source LLMs for extracting clinically relevant findings from free-text echocardiogram reports and examine the feasibility of their implementation in information extraction workflows. Materials and Methods:We used 14 open-source LLM models to extract clinically relevant entities from echocardiogram reports (n = 507). Each report was manually annotated by 2 independent health-care professionals and adjudicated by a third. Lexical variance and length of each echocardiogram report were collected. Precision, recall, and F1 scores were calculated for the 9 extracted entities via multiclass classification. Results:In aggregate, Gemma2:9b-instruct had the highest precision, recall, and F1 scores at 0.973 (0.962-0.983), 0.959 (0.947-0.973), and 0.965 (0.951-0.975), respectively. In comparison, Phi3:3.8b-mini-instruct had the lowest precision score at 0.831 (0.804-0.856), while Gemma:7b-instruct had the lowest recall and F1 scores at 0.382 (0.356-0.408) and 0.392 (0.356-0.428), respectively. Discussion and Conclusion:Using LLMs for entity extraction for echocardiogram reports has the potential to support both clinical research and health-care delivery. Our work demonstrates the feasibility of using open-source models for more efficient computation and extraction.

Rationale Low tidal volume ventilation (LTVV) reduces death rates in patients with severe respiratory failure on mechanical ventilation, however, previous work has described how ICU clinicians are less likely to treat female patients with this life-saving treatment. We aimed to determine the extent of this LTTV disparity in a large multi-center database. Methods We identified adult patients who received >24 hours of invasive mechanical ventilation between January 2018-December 2023 from nine healthcare systems in the Common Longitudinal Intensive Care Unit (CLIF) Consortium and the MIMIC-IV dataset. Mixed-effects linear regression models were fit to estimate the association between patient sex and set tidal volume per ideal body weight (Vt/IBW). Baseline models were adjusted for age, LAPS2 score, PaO2/FiO2 ratio, pH, PCO2, and hospital. Patients were included as a random effect. We performed a mediation analysis with patient height by including it as a fixed effect. Results The study cohort consisted of 98,935 critically ill adults receiving mechanical ventilation at 43 hospitals (mean age 62.4 years [sd 3.3], 40.2% female). Figure 1 shows the distribution of LTVV stratified by patient sex. The mean LTVV rate in females was 78.9% (78.7 – 79.0) and 94.3% (94.2 – 94.3) for males. Females were predicted to have a tidal Vt of 0.62 ml/kg IBW higher than males (6.98 vs. 6.36). Significant differences in tidal volume between males and females were observed in 7 hospitals (−0.9 to −0.2 mL/kg IBW) in the baseline model without height adjustment. In the mediation analysis, height explained 81-100% of the female sex disparity across health systems. Additionally, after adjustment for height, female sex was still significantly associated with a lower rate of LTVV in 2 out of 9 health systems. (p<0.05). Conclusion After adjustment for important confounders, female patients received an average of 0.62 Vt/IBW higher than male patients and were 15% less likely to receive LTVV across nine healthcare systems nationwide. The disparity is mainly mediated by differences in height; however, a persistent disparity was observed in some hospitals. Interventions to improve ICU clinician performance in setting LTVV for women are urgently needed.

Rationale: While guidelines exist for approaching ethically controversial scenarios involving decisions to withhold or withdraw life sustaining treatment (LST), there is limited understanding about how clinicians approach these specific scenarios in clinical practice. This study aimed to understand how clinicians approach decisions in the intensive care unit to withhold or withdraw LST for cases of 1) physiologic futility, 2) “potentially inappropriate” treatment, and 3) unrepresented patients without a surrogate decision-maker. Methods: We conducted semi-structured interviews with critical care physicians and nurses at three geographically diverse hospitals across the United States between July to October 2024. We asked clinicians about how they approach decisions to withhold or withdraw LST in three ethically controversial scenarios: 1) caring for patients where life support was deemed physiologically futile, 2) deemed “potentially inappropriate”, or 3) where patients were unrepresented without a surrogate decision-maker. Two trained research members developed a codebook using inductive and deductive approaches, double coding 25% of interviews. Discrepancies between reviewers was resolved with consensus adjudication. Results: Sixteen eligible physicians (n=8) and nurses (n=8) with median 5 years (range 2-36 years) in practice participated. Clinician approaches to all three cases varied. Clinicians shared that for a patient in whom cardiopulmonary resuscitation (CPR) is physiologically futile, they may provide full CPR, provide a limited trial of CPR, or withhold CPR. They also shared they may bring family to watch CPR and have repeated conversations with surrogates to encourage them to choose do-not-resuscitate status. Clinician approaches to “potentially inappropriate” treatment included providing “potentially inappropriate” treatment, withholding this treatment, finding a middle ground, going to court, and consulting ethics and palliative care. For unrepresented patients without a surrogate decision-maker, clinicians often engaged multiple approaches. These approaches included treating these patients as full code, seeking information about patient values and preferences, trying to find a decision-maker aided by social work and the police, and/or pursuing a court appointed guardian if no decision-maker is found. Conclusion: Clinicians varied in their approaches to providing treatments they judged to be physiologically futile or “potentially inappropriate.” Further study to needed to identify reasons why clinicians choose to pursue these varying approaches.

Objective:Use of prone positioning increased among mechanically ventilated patients during the COVID-19 pandemic, but it is unknown whether implementation of this life-saving intervention was sustained. Thus, we aimed to evaluate peri-pandemic trends in proning use. Design:We conducted a retrospective cohort study of proning use among mechanically ventilated adults, with proning rates compared across pre-pandemic (1/2018-2/2020), pandemic (3/2020-2/2022), and post-pandemic (3/2022-12/2024) periods. Setting:37 North American hospitals. Patients:Mechanically ventilated patients with persistent moderate-to-severe hypoxemia (PaO2/FiO2 ≤150 mmHg, FiO2 ≥0.6, and positive end-expiratory pressure ≥5 cmH2O). Intervention:Proning within 12 hours of meeting study hypoxemia criteria. Measurements and Main Results:Among 5,760 proning-eligible patients, 1,737 (30.2%) received proning: 8.0% pre-pandemic, 44.6% pandemic, and 19.9% post-pandemic. The adjusted odds ratio (OR) for proning during pandemic versus pre-pandemic periods was 8.25 (95% Confidence Interval (CI): 6.35-10.70) and pandemic versus post-pandemic, 2.76 (95% CI: 1.83-4.17). Proning varied widely by hospital and was quantified with the median odds ratio (median change in odds of proning an identical patient admitted at a lower versus higher proning hospital) of 2.54 (95% Credible Interval (CrI): 1.75-4.58) pre-pandemic, 2.33 (95% CrI: 1.92-3.04) pandemic, and 2.58 (95% CrI: 1.99-3.73) post-pandemic. Pandemic-period patients with SARS-CoV2 were proned more than those without (OR: 4.55, [95% CI: 3.85-5.56]), but pandemic-period patients without SARS-CoV2 were still proned more than pre-pandemic (OR: 3.87, [95% CI: 2.92-5.13]) or post-pandemic patients (OR: 1.37, [95% CI: 1.03-1.83]). Conclusions:In a North American cohort of proning-eligible patients, proning increased during the pandemic and then declined. Interventions that improve implementation of this life-saving treatment are urgently needed.

Rationale: Different sepsis definitions capture heterogeneous patient populations, which has implications for clinical care, quality improvement, and research. The CDC adapted the Sepsis-3 definition to facilitate sepsis surveillance using EHR data. The effect of serum lactate ≥2 mmol/L as an “optional” organ dysfunction criterion is poorly characterized because it was excluded in the primary analysis by Rhee et al. Therefore, we conducted a retrospective study evaluating sepsis incidence and patient characteristics identified with and without use of this criterion. Methods: The Common Longitudinal Intensive Care Unit consortium is composed of US academic health systems that use a standardized EHRs data format to facilitate federated studies of critical illness. Sites contributed different duration of data based on availability between 12/2019 and 03/2022. Using CDC Adults Sepsis Events (ASE), defined as presumed infection (blood culture obtained and at least four qualifying antimicrobial days) and organ dysfunction, sepsis incidence and patient demographics were compared between sepsis cohorts including and excluding lactate as a criterion for organ dysfunction at four health systems. Organ dysfunction (vasopressor infusion, invasive mechanical ventilation [IMV], acute kidney injury [AKI], hyperbilirubinemia, and thrombocytopenia) were defined per ASE criteria. Results: Of the 252,448 hospitalized patients across 4 health systems and 9 hospitals, 22,704 (8.99%) and 16,069 (6.37%) met sepsis criteria with and without lactate ≥2 mmol/L as an organ dysfunction criterion, respectively. Sepsis patients identified including the lactate criterion were older (mean 61.3 vs 60.2 years), less likely to receive vasopressors (41.1% vs 58.0%) and IMV (44.4% vs 62.7%), and had lower rates of AKI (12.4% vs 17.6), hyperbilirubinemia (9.2% vs 13.1%), thrombocytopenia (22.4% vs 31.6%), hospital length of stay (17.8 vs 20.7 days), and mortality (21.6% vs 28.2%) compared to patients identified excluding it (all p<0.001). Elevated serum lactate was the first organ dysfunction in 52.6% of sepsis patients identified including the lactate criterion. Compared to sepsis patients identified without lactate, the first organ dysfunction was less likely to be IMV (22.0% vs 42.6%), vasopressor infusion (12.2% vs 31.5%), AKI (3.2% vs 6.5%), hyperbilirubinemia (1.7% vs 3.5%), and thrombocytopenia (8.5% vs 15.9%) (all p< 0.001). The median number of lactate orders before sepsis criteria were met was 1 (IQR 1 – 2). Conclusions: The inclusion of lactate ≥2 mmol/L as an organ dysfunction criterion in the CDC ASE definition resulted in a higher estimate of sepsis incidence and identified a cohort of patients with less organ dysfunction and lower mortality.