Approved: New Antimicrobial Stewardship Standard

The Joint Commission recently announced a new Medication Management (MM)
standard for hospitals, critical access hospitals, and nursing care centers. Stan￾dard MM.09.01.01 addresses antimicrobial stewardship and becomes effective
January 1, 2017.
Current scientific literature emphasizes the need to reduce the use of inap￾propriate antimicrobials in all health care settings due to antimicrobial resistance.
According to the World Health Organization (WHO): “Antimicrobial resistance
threatens the effective prevention and treatment of an ever-increasing range of
infections caused by bacteria, parasites, viruses and fungi.”1
The Centers for Disease
Control and Prevention (CDC) identified that 20%–50% of all antibiotics pre￾scribed in US acute care hospitals are either unnecessary or inappropriate.2
The
CDC has also stated: “Antibiotics are among the most commonly prescribed medi￾cations in nursing homes. Up to 70% of long-term care facilities’ residents receive
an antibiotic every year.”3
On June 2, 2015, The Joint Commission participated in the White House
Forum on Antibiotic Stewardship. The Joint Commission joined representatives
from more than 150 major health care organizations, food companies, retailers, and
animal health organizations at the forum to express commitment for implementing
changes over the next five years to slow the emergence of antibiotic-resistant bacte￾ria, detect resistant strains, preserve the efficacy of existing antibiotics, and prevent
the spread of resistant infections.4
Subsequently, The Joint Commission developed the antimicrobial steward￾ship standard for hospitals, critical access
hospitals, nursing care centers, ambula￾tory care organizations, and office-based
surgery practices and conducted a field
review in November and December
2015. Prior to and during the field
review, Joint Commission staff conducted
stakeholder calls on the proposed antimi￾crobial stewardship standard with several
governmental and professional organiza￾tions, including the Centers for Medicare & Medicaid Services (CMS), the CDC, and the Society for
Healthcare Epidemiology of America (SHEA).
There was significant support for the antimicrobial
stewardship standard for the hospital, critical access hospital,
and nursing care center accreditation programs. Additionally,
CMS is in the process of developing a Condition(s) of Par￾ticipation (CoP) on antimicrobial stewardship for the hospital
and nursing home settings, which therefore aligns the Joint
Commission’s standard with CMS’s plans for a CoP(s) in this
area. In the meantime, the antimicrobial stewardship standard
for Joint Commission–accredited ambulatory care organiza￾tions and office-based surgery practices is still in development.
The approved antimicrobial stewardship standard and
EPs are shown in the box that begins below and will also be
displayed on The Joint Commission website at http://www.
jointcommission.org/standards_information/prepublication_
standards.aspx. In addition, the requirements will be posted
in the fall 2016 E-dition® update and published in the 2017
Comprehensive Accreditation Manual for the Critical Access
Hospital, Hospital, and Nursing Care Center Accreditation
Programs.
Questions regarding the new antimicrobial stewardship
standard may be directed to Kelly Podgorny, DNP, CPHQ, RN,
project director, Department of Standards and Survey Methods,
The Joint Commission, at kpodgorny@jointcommission.org. P
References
1. World Health Organization. Antimicrobial Resistance. (Updated: Apr
2015.) Accessed May 27, 2016. http://www.who.int/mediacentre/
factsheets/fs194/en/#
2. Centers for Disease Control and Prevention. Core Elements of Hospital
Antibiotic Stewardship Programs. Accessed May 27, 2016. http://www.
cdc.gov/getsmart/healthcare/implementation/core-elements.html
3. Centers for Disease Control and Prevention. Antibiotic Use in Nursing
Homes. Nov 5, 2013. Accessed May 27, 2016. http://www.cdc.gov/
getsmart/healthcare/learn-from-others/factsheets/nursing-homes.html
4. The Joint Commission. Joint Commission Joins White House Effort to
Reduce Antibiotic Overuse. Jt Comm Perspect. 2015 Jul;35(7):4, 11.

Standard MM.09.01.01
The [critical access] hospital has an antimicrobial stewardship
program based on current scientific literature.
Elements of Performance for MM.09.01.01
1. Leaders establish antimicrobial stewardship as an orga￾nizational priority. (See also LD.01.03.01, EP 5)
Note: Examples of leadership commitment to an antimi￾crobial stewardship program are as follows:
l Accountability documents
l Budget plans
l Infection prevention plans
l Performance improvement plans
l Strategic plans
l Using the electronic health record to collect antimi￾crobial stewardship data
2. The [critical access] hospital educates staff and li￾censed independent practitioners involved in antimicro￾bial ordering, dispensing, administration, and monitor￾ing about antimicrobial resistance and antimicrobial
stewardship practices. Education occurs upon hire or
granting of initial privileges and periodically thereafter,
based on organizational need.
3. The [critical access] hospital educates patients, and
their families as needed, regarding the appropriate use
of antimicrobial medications, including antibiotics. (For
more information on patient education, refer to Stan dard PC.02.03.01)
Note: An example of an educational tool that can be
used for patients and families includes the Centers for
Disease Control and Prevention’s Get Smart docu￾ment, “Viruses or Bacteria—What’s got you sick? at
http://www.cdc.gov/getsmart/community/downloads/
getsmart-chart.pdf.
4. The [critical access] hospital has an antimicrobial stew￾ardship multidisciplinary team that includes the follow￾ing members, when available in the setting:
l Infectious disease physician
l Infection preventionist(s)
l Pharmacist(s)
l Practitioner
Note 1: Part-time or consultant staff are acceptable as
members of the antimicrobial stewardship multidisci￾plinary team.
Note 2: Telehealth staff are acceptable as members of
the antimicrobial stewardship multidisciplinary team.
5. D The [critical access] hospital’s antimicrobial steward￾ship program includes the following core elements:
l Leadership commitment: Dedicating necessary hu￾man, financial, and information technology resources.
l Accountability: Appointing a single leader respon￾sible for program outcomes. Experience with suc￾cessful programs shows that a physician leader is
effective.
l Drug expertise: Appointing a single pharmacist leader
responsible for working to improve antibiotic use.
l Action: Implementing recommended actions, such
as systemic evaluation of ongoing treatment need,
after a set period of initial treatment (for example,
“antibiotic time out” after 48 hours).
l Tracking: Monitoring the antimicrobial stewardship
program, which may include information on antibi￾otic prescribing and resistance patterns.
l Reporting: Regularly reporting information on the
antimicrobial stewardship program, which may
include information on antibiotic use and resistance,
to doctors, nurses, and relevant staff.
l Education: Educating practitioners, staff, and
patients on the antimicrobial program, which may
include information about resistance and optimal
prescribing. (See also IC.02.01.01, EP 1 and
NPSG.07.03.01, EP 5)
Note: These core elements were cited from the Centers
for Disease Control and Prevention’s Core Elements of
Hospital Antibiotic Stewardship Programs (http://www.
cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf).
The Joint Commission recommends that organizations
use this document when designing their antimicrobial
stewardship program.
6. D The [critical access] hospital’s antimicrobial steward￾ship program uses organization-approved multidisci￾plinary protocols (for example, policies and procedures).
Note: Examples of protocols are as follows:
l Antibiotic Formulary Restrictions
l Assessment of Appropriateness of Antibiotics for
Community-Acquired Pneumonia
l Assessment of Appropriateness of Antibiotics for
Skin and Soft Tissue Infections
l Assessment of Appropriateness of Antibiotics for
Urinary Tract Infections
l Care of the Patient with Clostridium difficile (c.-diff)
l Guidelines for Antimicrobial Use in Adults
l Guidelines for Antimicrobial Use in Pediatrics
l Plan for Parenteral to Oral Antibiotic Conversion
l Preauthorization Requirements for Specific
Antimicrobials
l Use of Prophylactic Antibiotics
7. D The [critical access] hospital collects, analyzes, and
reports data on its antimicrobial stewardship program.
Note: Examples of topics to collect and analyze data
on may include evaluation of the antimicrobial steward￾ship program, antimicrobial prescribing patterns, and
antimicrobial resistance patterns.
8. D The [critical access] hospital takes action on im￾provement opportunities identified in its antimicrobial
stewardship program. (See also MM.08.01.01, EP 6)

Applicable to Nursing Care Centers
Effective January 1, 2017
Medication Management (MM)
Standard MM.09.01.01
The organization has an antimicrobial stewardship program
based on current scientific literature.
Elements of Performance for MM.09.01.01
1. Leaders establish antimicrobial stewardship as an orga￾nizational priority. (See also LD.01.03.01, EP 5)
Note: Examples of leadership commitment to an antimi￾crobial stewardship program are as follows:
l Accountability documents
l Budget plans
l Infection prevention plans
l Performance improvement plans
l Strategic plans
l Using the electronic health record to collect antimi￾crobial stewardship data
2. The organization educates staff and licensed inde￾pendent practitioners involved in antimicrobial order￾ing, dispensing, administration, and monitoring about
antimicrobial resistance and antimicrobial stewardship
practices. Education occurs upon hire or granting of
initial privileges and periodically thereafter, based on
organizational need.
3. The organization educates residents, and their families
as needed, regarding the appropriate use of antimi￾crobial medications, including antibiotics. (For more
information on patient and resident education, refer to
Standard PC.02.03.01)
Note: An example of an educational tool that can be
used for patients and families includes the Centers for
Disease Control and Prevention’s Get Smart docu￾ment, “Viruses or Bacteria—What’s got you sick? at
http://www.cdc.gov/getsmart/community/downloads/
getsmart-chart.pdf.
4. The organization has an antimicrobial stewardship mul￾tidisciplinary team that includes the following members,
when available in the setting:
l Infectious disease physician
l Infection preventionist(s)
l Pharmacist(s)
l Practitioner
Note 1: Part-time or consultant staff are acceptable as
members of the antimicrobial stewardship multidisci￾plinary team.
Note 2: Telehealth staff are acceptable as members of
the antimicrobial stewardship multidisciplinary team.
5. D The organization’s antimicrobial stewardship pro￾gram includes the following core elements:
l Leadership commitment: Demonstrate support and
commitment to safe and appropriate antibiotic use
in your facility.
l Accountability: Identify physician, nursing, and phar￾macy leads responsible for promoting and oversee￾ing antibiotic stewardship activities in your facility.
l Drug expertise: Establish access to consultant
pharmacists or other individuals with experience or
training in antibiotic stewardship for your facility.
l Action: Implement policy or practice changes to
improve antibiotic use.
l Tracking: Monitor and measure the use of antibiotic
use and at least one outcome from antibiotic use in
your facility.
l Reporting: Regularly reporting information on the
antimicrobial stewardship program, which may
include antibiotic use and resistance, to physicians
and other practitioners, nurses, and relevant staff.
l Education: Provide resources to physicians and
other practitioners, nursing staff, residents, and
families about antibiotic resistance and opportunities
for improving antibiotic use. (See also IC.02.01.01,
EP 1)
Note: These core elements were cited from the Centers
for Disease Control and Prevention’s The Core Ele￾ments of Antibiotic Stewardship for Nursing Homes
(http://www.cdc.gov/longtermcare/prevention/antibiotic￾stewardship.html). The Joint Commission recommends
that nursing care centers use this document when
designing their antimicrobial stewardship program.
6. D The organization’s antimicrobial stewardship pro￾gram uses organization-approved multidisciplinary
protocols (for example, policies and procedures).
Note: Examples of protocols are as follows:
l Antibiotic Formulary Restrictions
l Assessment of Appropriateness of Antibiotics for
Community-Acquired Pneumonia
l Assessment of Appropriateness of Antibiotics for
Skin and Soft Tissue Infections
l Care of the Long Term Care Patient with a Urinary
Tract Infection
l Care of the Patient with Clostridium difficile (c.-diff)
l Facility Guidelines for Antimicrobial Use in Adults
l Plan for Parenteral to Oral Antibiotic Conversion
l Preauthorization Requirements for Specific
Antimicrobials
7. D The organization collects, analyzes, and reports data
on its antimicrobial stewardship program.
Note: Examples of topics to collect and analyze data
on may include evaluation of the antimicrobial steward￾ship program, antimicrobial prescribing patterns, and
antimicrobial resistance patterns.
8. D The organization takes action on improvement op￾portunities identified in its antimicrobial stewardship
program. (See also MM.08.01.01, EP 6)

Ex vivo culture of human atherosclerotic plaques: A model to study immune cells in atherogenesis

Ex vivo culture of human atherosclerotic plaques: A model to study immune
cells in atherogenesis

Abstract
Background and aims: The mechanisms that drive atherosclerotic plaque progression
and destabilization in humans remain largely unknown. Laboratory models are
needed to study these mechanisms under controlled conditions. The aim of this study
was to establish a new ex vivo model of human atherosclerotic plaques that
preserves the main cell types in plaques and the extracellular components in the
context of native cytoarchitecture.
Methods: Atherosclerotic plaques from carotid arteries of 28 patients undergoing
carotid endarterectomy were dissected and cultured. At various time-points, samples
were collected and analysed histologically. After enzymatic digestion, single cells
were analysed with flow cytometry. Moreover, tissue cytokine production was
evaluated.
Results: We optimised the plaque dissection protocol by cutting plaques into circular
segments that we cultured on collagen rafts at the medium–air interface, thus
keeping them well oxygenated. With this technique, the relative presence of T and B
lymphocytes did not change significantly during culture, and the sizes of lymphocyte
subsets remained stable after day 4 of culture. Macrophages, smooth muscle cells,
and fibroblasts with collagen fibres, as well as both T and B lymphocyte subsets and
CD16 natural killer cells, remained largely preserved for 19 days of culture, with a
continuous production of inflammatory cytokines and chemokines.
Conclusions: Our new model of ex vivo human atherosclerotic plaques, which
preserves the main subsets of immune cells in the context of tissue cytoarchitecture,
may be used to investigate important aspects of atherogenesis, in particular, the
functions of immune cells under controlled laboratory conditions.

Introduction
Atherosclerosis and its cardiac and cerebral complications are the leading
causes of death from cardiovascular diseases. For a long time, accumulation of
modified lipoproteins within the arterial wall was considered to be the main cause of
atherosclerotic disease [1]. More recently, however, cells of various types, such as
smooth muscle cells, macrophages, and T cells, have been found to play an
important role in atherosclerotic plaque formation [2]. Moreover, a currently accepted
theory of atherogenesis emphasizes the role of immune system activation caused by
oxidized lipoproteins, which activate endothelial cells (as do other foreign agents
within the vascular wall) [3,4]. It is thought that immune cells are attracted by
chemokines, which are produced by activated endothelial cells, and migrate into the
subendothelium, where they proliferate, leading to atherosclerotic plaque progression
[2,5–7].
The role of immune cells in the growth of plaques has been confirmed in
experimental models on immunodeficient mice, as well as from the presence of
autologous antibodies against oxidized low density lipoproteins in atherosclerotic
plaques [8,9]. In our earlier work, we demonstrated T lymphocyte activation in human
atherosclerotic plaques in comparison with the blood of the same patients [10], thus
providing further evidence for the involvement of the immune system in
atherogenesis.
Despite plentiful evidence for the critical role of the immune system in
atherosclerosis, many important aspects of this phenomenon remain unknown. The
lack of this knowledge is in part due to limitations on access to human atherosclerotic
plaques in vivo, while animal models are often not adequate because of differences

in structures of arterial walls [11,12]. In vitro laboratory-controlled systems are
required for the study of atherosclerotic plaque formation and rupture. Several such
models with cells of only one or two types cultured together have been suggested
[13,14]; however, none of them faithfully reproduces the whole range of intercellular
interactions within human atherosclerotic plaques [15,16].
Here, we describe a new ex vivo model of human atherosclerotic plaques,
which preserves the main cell types of plaques in vivo, together with the general
tissue cytoarchitecture. We think that this model may prove useful for investigation of
immune cell function in atherogenesis and for development of novel therapeutic
approaches to atherosclerosis treatment.
Materials and methods
For a detailed description of the Materials and methods see Supplementary Data.
Patients
We collected atherosclerotic plaques from carotid arteries of 28 patients with
peripheral artery disease, undergoing carotid endarterectomy because of extended
atherosclerosis (19 men and 9 women; mean age ± standard deviation = 65.4 ± 8.5
years). The degree of carotid artery stenosis varied from 65% to 90% (median
90.0%, interquartile range (IQR) 73.8% to 90.0%). Ten patients suffered from
transient ischemic attack or stroke within 5 years before surgery, and more than half
of all plaque specimens (60.7%) were ruptured, as determined from macroscopic
evaluation. All patients’ characteristics are presented in Supplementary Table1.
This protocol was approved by the A.I. Yevdokimov Moscow State University
of Medicine and Dentistry Ethics Committee. All the participants provided written
informed consent.

Tissue processing
Our work was based on the pioneer work of Dr. Hoffman [17,18], who
developed the technique of histoculture that makes possible maintenance of blocks
of mammalian tissues for weeks at the air–liquid interface.
According to the protocol, surgical atherosclerotic plaque samples were
dissected and divided into three parts: one part of the material was fixed in 4%
formaldehyde (Pierce, Thermo Fisher Scientific, Waltham, MA, USA, cat. 28908) and
embedded in paraffin for histological examination, the second part was digested with
an enzymatic cocktail into a single-cell suspension for flow cytometry. The third part
was dissected, placed on a wetted collagen sponge raft (Pfizer, New York, NY, USA,
cat. 0315-08) at the medium–air interface, and cultured. After one day of culture, and
then every 3rd day, culture medium was collected and replaced with fresh medium.
Every 3rd day, several tissue blocks were analysed histologically and by means of
flow cytometry.

Histology
Histology, histochemistry, and immunohistochemistry were performed
according to standard techniques. We focused on several cell types that could not be
properly isolated from plaques by enzymatic treatment and thus were not analysed
with flow cytometry. In particular, we assessed fibroblasts and collagen tissue,
macrophages, and smooth muscle cells, using Masson’s Trichrome staining (Agilent
Technologies, Santa Clara, CA, USA, cat. AR17392-2), antibodies against CD68
(clone KP1, Agilent Technologies) and α-smooth muscle actin (α-SMA) (clone 1A4,
Agilent Technologies), respectively


Statistical analyses

The data obtained in the present study were not normally distributed, according
to the Shapiro-Wilk test, and are presented as medians and IQR. Since distributions
were not normal, for comparison of two independent groups we used the Mann￾Whitney rank test, and for dependent groups we used the Wilcoxon matched pair
test, Friedman ANOVA, and Kendall test. To assess between-group effects, we used
a multiple comparisons rank test. For the age distribution, we made the assumption
of its normality. Statistical analysis was performed with Statistica 10.0 (Statsoft,
Tulsa, OK, USA) and SPSS Statistics 21.0 (IBM, Armonk, NY, USA). Values of p
<0.05 were considered statistically significant.


Results
Histology of ex vivo plaques
Initially, we separated atherosclerotic plaques from normal artery tissue and
dissected them into ~2-mm cubic blocks for culture, similarly to what was
successfully used earlier to culture various human tissues ex vivo [17,19]. However,
analysis of stained histological sections showed that the viability of cultured tissue

blocks of this size decreased over 8–12 days, and cultured blocks contained only ~20
live cells per 100 mg of tissue (Supplementary Fig.3).
We thought that the tissues might be damaged during dissection into small
blocks. Therefore, to diminish tissue injury during preparation, we modified our
protocol and instead of dissecting into small blocks, we sliced tissue into ring-shaped
2-mm thick segments, and with a diameter depending of the carotid artery size (Fig.
1). To verify tissue viability, every 3rd day several dissected segments were analysed
histologically and by means of flow cytometry.
Analysis of histological sections showed that the dissection of plaques into
large circular segments significantly increased cell survival: tissues were preserved
for 19 days. For histological evaluation, tissue segments were stained with
hematoxylin and eosin, Masson’s Trichrome, anti-CD68, and anti-α-SMA antibodies
and their morphology was assessed as described in Materials and methods. We
found that these plaque segments retained their gross morphology and appeared
viable for more than 19 days of culture. In particular, the integrity of the endothelium
and internal elastic membrane, which are most sensitive to the culture conditions,
were preserved over 19 days of culture without a significant increase in the necrotic
core area (Fig. 2).
Furthermore, in 6 plaques, we quantified areas reacting with aniline blue, anti￾CD68, and anti-α-SMA at days 0, 4, 7, and 19 (Fig. 3). We identified macrophages,
fibroblasts, and smooth muscle cells, along with the endothelium, until day 19 of
culture. We found no statistically significant changes (p >0.05) in the fraction of these
cells during the entire culture period (Table 1).

In plaque samples from 16 donors, we assessed tissue viability using flow
cytometry by analysing immune cells extracted from plaque tissue. We compared
flow cytometry results at day 0 with those at days 4, 7, and 19. Towards this goal, we
digested plaque segments with an enzymatic cocktail containing collagenase XI and
desoxyribonuclease I, washed isolated cells, and stained them with live/dead staining
and monoclonal antibodies against CD45, CD3, CD19, CD4, CD8, and CD16. Two
plaques were excluded from the analysis because of a low cellularity at day 0 (lower
than 500 live cells per 100 mg of tissue).
Analysis of tissue at day 0 revealed a median of 6,286.0, IQR [3,172.1–
12,918.9] lymphocytes per 100 mg of plaque tissue. The absolute numbers and
percentages of B lymphocytes among all lymphocytes at day 0 were significantly
lower than those of T lymphocytes (24.6 [7.8–55.3] cells/100 mg vs. 5,694.1
[2,226.7–11,726.6] cells/100 mg; 0.4% [0.1%–0.5%] vs. 89.6% [84.3%–91.2%],
p=0.001). At day 0, among T lymphocytes, the fraction of CD4+CD8- cells was larger
than the fraction of CD4-CD8+ cells (51.6% [43.8%–58.9%] vs. 39.9% [30.0%–
45.1%], p=0.041). The median amount of CD16 NK cells at day 0 was 58.6 [18.7–
360.9] per 100 mg of plaque tissue (Fig. 4). Consecutive flow cytometry after day 0
was performed in plaques from 8 patients, four of which were cultured until day 19.
We showed that,after a decrease during the first 4 days of culture (n=8, 4,125.8
[2,771.4–6,286.0] cells/100 mg at day 0 vs. 2,619.3 [1,360.8–3,712.2] cells/100 mg
at day 4, p=0.036), the amounts of lymphocytes stabilized and did not change
significantly until the 7th day of culture (n=8, 1,249.6 [445.5–3,706.0] cells/100 mg;
p=0.161). A similar pattern was found in T cells, with a stabilization of their amounts
after a reduction during the first 4 days of culture (n=8, 3,546.5 [2,194.2–5,694.1]
cells/100 mg at day 0 vs. 2,123.4 [1,210.5–3,280.1] cells/100 mg at day 4, p=0.036
vs. 949.5 [375.1–2,378.3] cells/100 mg at day 7, p=0.124). In addition, we found no

significant changes in the amounts of B cells during the first days of culture (n=8,
12.2 [5.3–35.3] cells/100 mg at day 0 vs. 5.6 [3.3–37.2] cells/100 mg at day 4 vs.
7.9 [0.0–11.4] cells/100 mg at day 7, p=0.798). Furthermore, both T and B cells were
also preserved in plaque tissues during 19 days of culture, although their ratio
changed slightly because of the decrease in the number of T lymphocytes (n=4,
7,673.4 [3,789.0–14,813.2] cells/100 mg vs. 2,594.5 [1,926.8–7,569.0] cells/100 mg
for T cells, and 25.8 [5.3–57.9] cells/100 mg vs. 31.0 [12.2–91.2] cells/100 mg for B
cells). CD16 NK cells were found at day 19 as well: the median cell count at the last
day of culture constituted 44.9 [21.9–233.0] cells/100 mg (Fig. 5). We presume that
the initial fall in T cell count may originate from the intense effect of tissue dissection,
while the statistically significant decrease in the amounts of B cells and CD16 NK
cells may not have been revealed because of the small size of these cell subsets.
These changes were followed by a subsequent system stabilization. This was also
evident by the lack of significant changes (p=0.417) in the fraction of dead cells,
which even at day 19 remained at the level of on average 11.2% [10.1%–14.6%].
Importantly, the initial drop in T cell count was not accompanied by significant
changes in the fraction of T cells among all lymphocytes (n=8, 89.6% [76.3%–91.2%]
at day 0 vs. 86.2% [81.1%–90.8%] at day 4, p=0.779; vs. 86.0% [77.5%–86.9%] at
day 7, p=0.674) (Fig. 6A). The decrease in T cell numbers during the first days of
culture was predominantly associated with the reduction of the fraction of CD4 T cells
(n=7, 58.0% [43.8%–63.6%] at day 0 vs. 42.0% [31.4%–49.2%] at day 4, p=0.018;
vs. 40.8% [21.6%–48.7%] at day 7, p=0.018), accompanied by a minor rise in the
fraction of CD8 T cells (n=7, 36.0% [30.0%–47.5%] at day 0 vs. 45.2% [35.3%–
48.6%] at day 4, p=0.063; vs 44.4% [37.9%–55.1%] at day 7, p=0.018) (Figure 6B).
As a result of these changes, the CD4+CD8-/CD4-CD8+ ratio decreased slightly
during culture. As of the 19th day of culture, the fraction of CD4 T cells was reduced

with a concurrent increase in the fraction of CD8 T cells (49.7% [40.2%–57.6%] vs.
42.3% [27.8%–51.9%] for CD4 T cells, and 43.6% [36.1%–53.8%] vs. 50.8%
[40.9%–61.9%] for CD8 T cells) (Figure 7). Nevertheless, both CD4 and CD8 T cells
were also preserved in culture for at least 19 days.
Cytokine production by plaques ex vivo
We analysed the concentrations of cytokines and chemokines released by six
cultured plaques and accumulated in the culture medium from day 1 to day 4 and
from day 16 to day 19 when the medium was changed. We found that in our system
plaques produce substantial amounts of interleukin (IL)-1α, IL-6, IL-8, IL-16, IL-18, IL-
21, IL-22, eotaxin, interferon-λ, granulocyte macrophage colony-stimulating factor
(GM-CSF), macrophage-CSF, tumor necrosis factor (TNF)-α, transforming growth
factor (TGF)-β, growth related oncogene (GRO)-α, interferon gamma-inducible
protein-10, monocyte chemoattractant protein-1, monokine induced by gamma
interferon, macrophage inflammatory protein (MIP)-1α, MIP-1β, and RANTES. In
contrast, the concentrations of the other measured cytokines and chemokines were
lower than the detection limit of the Luminex platform for these analytes.
Within the panel of cytokines and chemokines that were detectable in the
culture medium, we found no significant changes during culture in most of the
cytokines, except for IL-16 and several cytokines whose concentration decreased, in
particular IL-8 (n=6, from 25,698.7 [14,817.3–52,553.3] pg/ml on day 4 to 4,273.1
[2,695.6–6,274.2] pg/ml on day 19), and to a lesser extent GM-CSF, TNF-α, and
GRO-α. At the same time, the concentrations of other cytokines (including eotaxin,
TGF-β, and MIP-1β) increased during culture (Supplementary Table 2).


DI 

Sinau

http://pionas.pom.go.id/info-bpom

Basic mechanical ventilation

Basic Mechanical Ventilation
Jairo I. Santanilla, MD Clinical Assistant Professor of Medicine Section of Emergency Medicine Section of Pulmonary/Critical Care Medicine LSUHSC New Orleans & Section of Critical Care Medicine Ochsner Medical Center

Outline
Outline
Basic Science
Lingo
Initial Settings
Common Intern Mistakes

How do we breath?
Brainstem control
Chemoreceptors
Diaphragm contraction and Chest wall expansion  increased intrathoracic volume
Leads to negative intrathoracic pressure
Air flows from high to low pressure
Negative pressure ventilation

Why do we breath?
Duh
Oxygenation
Ventilation – the exchange of CO2

Important Principles
Ventilation/Perfusion Matching
Ventilation without Perfusion
Dead space ventilation
Perfusion without ventilation
Shunt
Ideal Body Weight (kg)
Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet.
Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.

Why do people need ventilators?
Loss of airway anatomy
Edema, direct/indirect trauma, burns, infection
Loss of protective airway mechanisms
Intoxicants, brain injury, strokes
Inability to oxygenate appropriately
Shunt, alveoli filled with stuff
Inability to ventilate appropriately
Expected clinical course

Basic Ventilator Lingo
Control breath
Vent initiates the breath
Assist breath
the patient initiates the breath

What can I set?
Ventilator Target
Ventilator Mode
Respiratory Rate
PEEP
FiO2
Flow Rate
Other stuff… more later

Step 1: What is the target?
You pick what the ventilator is trying to attain
If the vent is trying to reach a Volume goal, its called Volume-Targeted
AKA volume-cycled, volume-assist, volume- control, volume-limited.
If the vent is trying to reach a Pressure goal, its called Pressure-Targeted
AKA pressure-cycled, pressure-assist, pressure- control, pressure-limited
Most adult ICUs use Volume-Targeted and most PICUs use Pressure-Targeted

Associations of the Emergency Severity Index triage categories with patients’ vital signs at triage: a prospective observational study

Associations of the Emergency Severity Index triage categories with patients’ vital signs at triage:
a prospective observational study

Ineke van der Wulp, Hebe A A Rullmann, Luke P H Leenen, Henk F van Stel

ABSTRACT
Study objective Previous studies on the construct validity of the Emergency Severity Index (ESI) were focused on outcome measures which could not be obtained directly at triage. A study was conducted to the construct validity of the ESI by measuring the association between the ESI triage categories and patients’ vital signs at triage.
Methods A prospective observational study was conducted at an emergency department (ED) in the Netherlands. All patients who entered the ED between 20 July 2009 and 21 August 2009 were eligible for inclusion in the study. Patients’ vital signs, triage category, age, gender, referrer and main complaint were registered. Vital signs were scored according to the Worthing Physiological Scoring System (WPSS) and the numerical pain rating scale. The data were analysed using ordinal logistic regression analyses.
Results An association was found between ESI triage categories and patients’ vital signs at triage. Patients in WPSS categories ‘urgent’ and ‘alert’ were more likely triaged into the urgent triage categories (ESI triage categories 1 and 2) than patients with normal WPSS scores. However, no associations were found between pain scores and ESI triage categories.
Conclusion This study supports the validity of the ESI as it showed that patients’ vital signs are associated with the ESI triage categories. However, a revision of the ESI guidelines concerning pain assessments is necessary.
INTRODUCTION
To sort the increasing number of patients presenting to emergency departments (EDs) on the urgency of their complaints, several triage systems have been developed and implemented.1e8 Frequently mentioned triage systems in the literature are: the Australasian Triage Scale, the Manchester Triage System, the Canadian Triage and Acuity Scale and the Emergency Severity Index (ESI).7910 Compared to other triage systems, the ESI is different in that, as well as the level of urgency, it estimates the number of resources that patients need. ESI resources are defined as laboratory tests, radiology, intravenous fluids, specialty consultation, a simple or complex procedure and intravenous, intramuscular or nebulised medications. Patients can be allocated into five urgency categories. ESI categories 1 and 2 represent patients who need immediate life saving interventions (eg, defibrillation), or patients at an increased risk for deterioration (eg, patients with severe pain). When ESI
categories 1 or 2 criteria are not met, the triage nurse estimates the number of ESI resources that patients need. In case more than one resource is needed, or when vital signs are in a predefined danger zone, patients are triaged into ESI category 3. Moreover, the triage nurse can decide to triage a patient in ESI category 2 on the basis of disturbed vital signs, even though initially the criteria for ESI category 2 were not met. Patients are triaged in ESI categories 4 and 5 when one or no resources are required respectively.11
For reasons of patient safety, it is important that ED triage systems are reliable and valid. Previous studies of the reliability of the ESI reported
k scores12 representing moderate to almost perfect reliability.3481013e16 The reliability places an upper limit on the validity of triage systems, that is, a triage system which produces different urgency scores when used in the same patient cannot be valid.17 The validity of the ESI has mainly been studied by means of construct validity because a gold standard to measure criterion validity is absent. The construct validity has been studied by measuring associations between the ESI triage categories and factors related to urgency. Previous studies have reported such associations of the ESI with actual ED resource usage, ED and hospital length of stay, hospital admission, mortality, survival after an ED visit and physiological measurements.124e81014e16 18 19 However, a limitation of these studies is the focus on outcomes of care because of the time lag between the moment of triage and the reported outcomes. As a result, other factors could have influenced the associations since the patient’s condition could have been changed between arrival in, and departure from the ED. To reduce this bias in triage validity studies, one could focus on measures that can be obtained directly at triage. Furthermore, because of the focus on construct validity in the validation of ED triage systems, it is important to keep studying different constructs, as construct validity is a process of making and testing inferences.17 Although vital signs play an important role in the ESI, no studies have assessed if vital signs are associated with urgency categories. Therefore, a study was conducted to the construct validity of the ESI by measuring the associations between the ESI triage categories and patients’ vital signs at triage. We hypothesised that patients triaged in the urgent triage categories of the ESI were more likely to have disturbed vital signs, and therefore at increased risk for dying in the ED, than patients triaged in less urgent triage categories.
METHODS
Study design
The study was conducted in a prospective observational design. The protocol was reviewed and approved by the medical ethics committee of the University Medical Center Utrecht. Informed consent was obtained from patients before inclusion in the study.
Study setting and population
The study was conducted at the ED of the University Medical Center Utrecht, which is a designated level one trauma centre in the Netherlands. Severely injured patients in the designated trauma region are transported to this ED. The ED is staffed 24 h a day by six full time attending physicians and has an annual census of 21000 patients. The ESI was implemented in 2008 and nurses received a 1-day training course on how to triage with the ESI before implementation. All patients over 16 years of age who entered the ED of the University Medical Center Utrecht on weekdays between 20 July 2009 and 21 August 2009 were included in the study.
Data collection
The data were prospectively collected by one researcher (HR) from Monday to Friday, 09:00 to 17:00 (4 days a week) and from 12:00 to 20:00 (1 day a week). A sample size calculation for regression analysis20 estimated a minimum required sample size of 445 patients. A drop out rate of 10% due to unforeseen circumstances was taken into account in this calculation. Each patient was triaged by the triage nurse on duty and assigned a triage category using standard procedures. Immediately after the triage nurse finished the triage assessment and reported the ESI triage category, the researcher registered patients’ gender, referrer, main complaint, age and measured vital signs that were not measured by the triage nurse. The following vital signs were registered: blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature, the Alert, Voice, Pain and Unconsciousness score, and pain. They were measured using an automated vital signs monitor, a tympanic thermometer and the numerical pain rating scale. The numerical pain rating scale was scored by asking patients to allocate a score between 0 and 10, with 0 indicating no pain and 10 the worst pain imaginable. The researcher was trained in the use of these instruments by a triage nurse during a 1 day training in the ED prior to data collection. In case a patient needed to be seen by a doctor immediately, the patient’s data were collected by the triage nurse. All the data were registered on a form.
Interpretation of vital signs
The ESI guidelines state that the interpretation of vital signs for allocating a patient to ESI categories 2 or 3 is up to the triage nurse, for example, a patient with disturbed vital signs does not automatically meet ESI level 2 criteria.11 For example, a patient who has a history of COPD and presents with an oxygen saturation of 89% might not meet ESI level 2 criteria. However, another patient with the same complaints but no such history does require ESI level 2 criteria when presenting with such an oxygen saturation level. Interpreting vital signs separately is not useful in this study as disturbed vital signs are not necessarily related to higher urgency or life threatening situations. Therefore, a prognostic scoring system in which vital signs were interpreted in relation to short term mortality was applied in this study. The Worthing Physiological Scoring System (WPSS) is such a prognostic scoring system (table 1). The WPSS is based upon identifying physiological markers for mortality at an early stage to undertake timely action. The system has been derived

from and prospectively validated in ED patients and is therefore suitable for use in this study.21 Except for pain, the system consists of the vital signs used in the ESI as well as systolic blood pressure.
Data analysis
The data were analysed by means of ordinal logistic regression analyses.22 Ordinal logistic regression analysis is an extension of binary logistic regression analysis and used in case the dependent variable is ordinal. The effects of the independent variables are interpreted by assuming that they are constant over the categories of the dependent variable, that is the assumption of parallel lines. This is an important assumption and was checked in the analysis. Because of this assumption the analyses were performed using the complementary log-log link function. This link function is used when the higher categories of the dependent variable (eg, the lower urgency categories) are more common. As a result, the associations should be interpreted as rate ratios instead of ORs.23
In these analyses, the ESI category was the dependent variable. ESI categories 4 and 5 were merged because of the small number of patients triaged in ESI category 5 and used as a reference category (n¼237). Besides WPSS and pain scores, other independent variables were gender, referrer, main complaint and age. The latter four variables were used in the analyses because in a previous study these appeared to be related to the ESI triage categories.24 The variable referrer consisted of patients referred by ambulance, a specialist, a general practitioner or patients who referred themselves to the ED. The variable main complaint was coded in accordance with the chapters of the International Classification of Diseases 10th edition (ICD 10), immediately after triage.25 It was decided to code main complaints this way to decrease the variability in ICD 10 codes, which was needed for the analyses. Univariate ordinal logistic regression analyses were performed and all variables which significantly (p#0.05) predicted urgency were selected for multivariate analysis. All analyses were performed using SPSS for Mac V.17.0.
RESULTS
In total, 929 patients presented at the ED during the study hours. Of these, 584 patients (62.9%) consented for participation and were included in the study. Of these, 40 patients had missing data (WPSS score (6.0%), pain score (1.0%) or age (0.3%)) and were excluded from the study, leaving 544 patients for further analyses. No significant differences (p¼0.53) were found between included and excluded patients, based on age and

The APACHE II

The APACHE II model was originally published in 1985 based on data from the US (Knaus et al,1985). It has been recalibrated twice for use in the UK, first following the Intensive Care Society’s APACHE II study in Britain and Ireland (Rowan, 1992; Rowan et al, 1993) and subsequently using data from the Case Mix Programme Database (Harrison et al, 2006). We regularly recalibrate the model using Case Mix Programme data to ensure that each critical care unit is being compared with current data. Coefficients from the most recent recalibration are used in the eDAR.

Risk predictions in APACHE II are based on:


 The APACHE II score – a score from 0 to 71 consisting of weights for age at admission to your unit (0 to 6 points) and severe conditions in the past medical history (0 to 5 points) plus an Acute Physiology Score (0 to 60 points) based on weightings for deviations from normal in the following twelve physiological parameters during the first 24 hours in the unit

o  temperature
o mean arterial pressure o heart rate
o  respiratory rate
o  A-aDO2 (if FiO2 ≥ 0.5) or PaO2 (if FiO2 < 0.5)
o arterial pH (or serum bicarbonate if no arterial blood gas recorded) o serum sodium

o  serum potassium
o serum creatinine (with double weighting for acute renal failure) o haematocrit (estimated from haemoglobin)
o  white blood cell count
o Glasgow Coma Score (assumed to be normal for patients sedated or paralysed and sedated for the whole of the first 24 hours in the unit, or for the entire stay if less than 24 hours)
 Admission directly from theatre following emergency surgery
 Diagnostic category (weightings for 58 non-surgical diagnoses and 50 surgical diagnoses, plus seven body systems, and a weighting for CPR within 24 hours prior to admission that overrides any other diagnostic category)

Exclusions


Admissions are excluded from the calculation of the APACHE II score if:
a. age at admission to your unit is less than 16 years; or
b. length of stay in your unit is less than 8 hours.

Additionally, admissions are excluded from the calculation of an APACHE II risk prediction if:
c. the admission is for primary burns;
d. the admission is following coronary artery bypass graft (CABG) surgery;
e. the admission is transferred in from another ICU; or
f. all twelve physiological variables are missing.

Readmissions of the same patient within the same hospital stay and admissions missing ultimate hospital outcome are excluded from comparisons of observed and expected mortality.

Guideline on The Management Of Acute Respiratory Distress Syndrome (ARDS) in Adult ICU

Aim and Scope
1)To ensure that all patients in ICU with ARDS are correctly identified and receive   the best evidence based treatment.
Definition
Onset of ARDS (diagnosis) must be acute, within 7 days of some defined event,  which may be sepsis, pneumonia, or simply a patient’s recognition of worsening  respiratory symptoms. (Most cases of ARDS occur within 72 hours of recognition of  the presumed trigger.)
Bilateral opacities consistent with pulmonary edema must be present but may be
detected on CT or chest X-ray. Ultrasound may also be used to define lung  pathology and the presence of non cardiogenic extra vascular lung water
Respiratory failure can be “not fully explained by cardiac failure or fluid overload,”
in the physician’s best estimation using available information.
ARDS Severity  PaO2/FiO2*  Mortality
()kpa
Mild 200 – 300 27%
(27 – 40)
Moderate 100 – 200 32%
(13-27)
Severe < 100 45%
(<13)
*on PEEP 5+ 
General Measures
1 All patients should have 100% compliance with the Ventilator Care  bundle
2 No chest physiotherapy unless as a trial to improve lobar collapse
3 Minimal suctioning via ETT
4 Normal feed as per protocol
5 Fluids. All patients will have a liberal fluid strategy during the initial resuscitation  phase (usually 0-48hours). If patients are then still vasopressor dependent, we will  aim to maintain a neutral fluid balance. Once inotropes are discontinued or are  being used in low doses to compensate for sedation, then we will aim to remove  the excess fluid that has been given. This will initially be performed using diuretics  but may require CVVHF if the fluid balance remains positive. Vasopressor may be  required to support the BP and  allow diuresis
6.     Ventilation
Mode: 1)VC SIMV  ( Volume control, synchronized mandatory ventilation)
           2) Volume assured PC SIMV (Pressure control, volume assured,  synchronized mandatory ventilation) This is not available on all ventilators
Settings: Peep 5-10cmH2O
               TV 6ml/kg ideal body weight.
               Plateau pressure < 30cmH20
               Rate: titrated to control PaCO2
Ideal body weight is calculated as follows:
Males        Length (in cm) – 100
Females   Length (in cm) – 105
The tidal volume required must be written every day at the top on the ICU  observation chart in red. It is the responsibility of the ICU consultant 1 to ensure that  this is done
7   All patients will have subglottic suction
The following patient group will be managed with an
extended ARDS care bundle
Diagnosis of ARDS as per above criteria
Ventilated for <36hours
A PaO2/FiO2 ratio<20kpa(150mmHg) for 12-24 hours on an FiO2 >0.6. 
NDMR
All patients who meet the above criteria  will be given a cisatracurium infusion. This  will be titrated to a train of four (TOF of 2 twitches). Paralyses will continue for as  long as they meet prone ventilation criteria.
Prone ventilation
All patients who do not have specific contraindications to prone ventilation will be  prone ventilated. They will be placed prone as per unit guidelines. They will remain  prone ventilated for at least 16 hours.

Prone ventilation will be stopped when any of the following criteria are met:
1) Improvement in oxygenation. This is defined as a Pao2:Fio2 ratio of ≥20, with a  PEEP of ≤10 cm of water and an Fio2 of ≤0.6. These criteria have to be sustained in  the supine position at least 4 hours after the end of the last prone session
2) A patient deteriorates compared to their PaO2:FiO2 ratio when supine
3) > 96 hours since first episode of prone ventilation
Management of a raised PaCO2
1) pH> 7.2 secondary to a respiratory acidosis will be tolerated
     The respiratory rate and not the tidal volume should be adjusted to help maintain  a    pH >7.2
2) If the pH remains less than 7.2  for >24 hours then consideration should be given  to using extra corporeal CO2 clearance
3) If the pH is < 7.1 for 4 hours or more with no other therapy (nebulisers etc)  available to reduce it, then extra corporeal CO2 clearance should be considered.
4) All patients being considered for extra corporeal CO2 clearance should initially  be discussed with our regional ECMO centre.
Management of a persistently low PaO2 (<8kpa)
1) Increase FiO2
2) Add nebulised prostacycline as per guideline
3) Maintain TV and peep
4) Discuss with regional ECMO centre
Recruitment maneuvers
1) All patients will have ‘inspiratory hold’ recruitment. This will be performed by  using the inspiratory hold function on the ventilators.
2) This will be 30cm H2O for 30 seconds
3) It should be performed after each disconnection or suctioning episode
4) It should be repeated as required when clinically it is felt that recruitment is  required.
5) It may be used as a trial to improve the PaO2

Steroids
All patients will be given methylprednisolone 0,5mg/kg/day (or equivalent) for 14  days unless contraindicated for standard reasons.
Documentation Control
Development of Policy: Consultation with: Approved by: Signature:
Print name and position: Date of Approval: Review Date:
References
            Dr James Low
Dr. Craig Morris, Dr. Nick Reynolds
ICU  Clinical Group
Nov 2013
Nov 2016
1) JAMA, June 2012 – Vol 307, No. 23
2) NEJM  June 2013 – Vol 368, No 23
3) NEJM  August 2001- Vol 345, No. 8
4) Crit Care Med. 2009 37(9):2680.