Arthur P Wheeler

Vanderbilt University, Нашвилл, Michigan, United States

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Publications (93)1047.1 Total impact

  • Michael J Noto, Arthur P Wheeler
    European Journal of Intensive Care Medicine 06/2015; DOI:10.1007/s00134-015-3846-6
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    ABSTRACT: Recent emphasis has been placed on methods to predict fluid-responsiveness (FR), but the utility of using fluid boluses to increase cardiac index (CI) in critically-ill patients with ineffective circulation or oliguria remains unclear. Retrospective analysis investigating hemodynamic responses of critically ill patients in the ARDS Network Fluid and Catheter Treatment Trial (FACTT) who were given protocol-based fluid boluses. FR was defined as ≥15% increase in CI after a 15ml/kg fluid bolus. A convenience sample of 127 critically-ill patients enrolled in FACTT was analyzed for physiologic responses to 569 protocolized crystalloid or albumin boluses given for shock, low urine output (UOP), or low pulmonary artery occlusion pressure (PAOP). There were significant increases in mean central venous pressure (9.9±4.5 to 11.1±4.8 mmHg, p<0.0001) and mean PAOP (11.6±3.6 to 13.3±4.3 mmHg, p<0.0001) following fluid boluses. However, there were no significant change in UOP, and clinically small changes in heart rate (HR), mean arterial pressure (MAP), and CI. Only 23% of fluid boluses led to a ≥15% change in CI. There was no significant difference in the frequency of fluid responsiveness between boluses given for shock or oliguria versus boluses given only for low PAOP (24.0% vs. 21.8%, p=0.59). There were no significant differences in 90-day survival, need for hemodialysis, or return to unassisted breathing between patients defined as fluid responders and fluid non-responders. In this cohort of critically-ill and previously resuscitated ARDS patients, the rate of fluid responsiveness was low and fluid boluses only led to small hemodynamic changes.
    Chest 05/2015; DOI:10.1378/chest.15-0445
  • Michael J Noto, Todd W Rice, Arthur P Wheeler
    JAMA The Journal of the American Medical Association 05/2015; 313(18):1863-1864. DOI:10.1001/jama.2015.3539
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    ABSTRACT: Coordinating efforts across disciplines in the intensive care unit is a key component of quality improvement (QI) efforts. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are considered key components of guidelines, yet unfortunately are often not done or coordinated properly. To determine if a pharmacist-driven awakening and breathing coordination (ABC) QI program would improve compliance (ie, process measures) as compared with the previous protocol, which did not involve pharmacists. The QI program included pharmacist-led education, daily discussion on rounds, and weekly performance reports to staff. Using a pre-QI versus during-QI versus post-QI intervention design, we compared data from 500 control ventilator-days (pre-QI period) versus 580 prospective ventilator-days (during-QI period). We then evaluated the sustainability of the QI program in 216 ventilator-days in the post-QI period. SAT safety screens were performed on only 20% pre-QI patient-days versus 97% of during-QI patient-days (P < 0.001) and 100% of post-QI patient-days (P = 0.25). The rates of passing the SAT safety screen in pre-QI and during-QI periods were 63% versus 78% (P = 0.03) and 81% in the post-QI period (P = 0.86). The rates of SATs among eligible patients on continuous infusions were only 53% in the pre-QI versus 85% in the during-QI (P = 0.0001) and 87% in the post-QI (P = 1) periods. In this QI initiative, a pharmacist-driven, interdisciplinary ABC protocol significantly improved process measures compliance, comparing the pre-QI versus during-QI rates of screening, performing, and coordinating SAT and SBTs, and these results were sustained in the 8-month follow-up period post-QI program. © The Author(s) 2015.
    Annals of Pharmacotherapy 04/2015; DOI:10.1177/1060028015582050
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    ABSTRACT: To determine whether addition of an electronic sepsis evaluation and management tool to electronic sepsis alerting improves compliance with treatment guidelines and clinical outcomes in septic ICU patients. A pragmatic randomized trial. Medical and surgical ICUs of an academic, tertiary care medical center. Four hundred and seven patients admitted during a 4-month period to the medical or surgical ICU with a diagnosis of sepsis established at the time of admission or in response to an electronic sepsis alert. Patients were randomized to usual care or the availability of an electronic tool capable of importing, synthesizing, and displaying sepsis-related data from the medical record, using logic rules to offer individualized evaluations of sepsis severity and response to therapy, informing users about evidence-based guidelines, and facilitating rapid order entry. There was no difference between the electronic tool (218 patients) and usual care (189 patients) with regard to the primary outcome of time to completion of all indicated Surviving Sepsis Campaign 6-hour Sepsis Resuscitation Bundle elements (hazard ratio, 1.98; 95% CI, 0.75-5.20; p = 0.159) or time to completion of each element individually. ICU mortality, ICU-free days, and ventilator-free days did not differ between intervention and control. Providers used the tool to enter orders in only 28% of available cases. A comprehensive electronic sepsis evaluation and management tool is feasible and safe but did not influence guideline compliance or clinical outcomes, perhaps due to low utilization.
    Critical care medicine 04/2015; DOI:10.1097/CCM.0000000000001020
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    ABSTRACT: Rationale Effective teamwork is fundamental to the management of medical emergencies and yet the best method to teach teamwork skills to trainees remains unknown. Objectives In a cohort of incoming internal medicine interns, we tested the hypothesis that expert demonstration of teamwork principles and participation in high-fidelity simulation would each result in objectively-assessed teamwork behavior superior to traditional didactics. Methods This was a randomized, controlled, parallel-group trial comparing three teamwork teaching modalities for incoming internal medicine interns. Participants in a single-day orientation at the Vanderbilt University Center for Experiential Learning and Assessment were randomized 1:1:1 to didactic, demonstration-based, or simulation-based instruction and then evaluated in their management of a simulated crisis by five independent, blinded observers using the Team Behavior Rater score. Clinical performance was assessed using the American Heart Association Advanced Cardiac Life Support algorithm and a novel "Recognize, Respond, Reassess" (3R) score. Measurements and Main Results Participants randomized to didactics (n=18), demonstration (n=17), and simulation (n=17) were similar at baseline. The primary outcome of average overall Team Behavior Rater score for those who received demonstration-based training was similar to simulation participation (4.40 ± 1.15 vs. 4.10 ± 0.95, p=0.917) and significantly higher than didactic instruction (4.40 ± 1.15 versus 3.10 ± 0.51, p=0.045). Clinical performance scores were similar between the three groups and correlated only weakly with teamwork behavior (Rs2=0.267, p < 0.001). Conclusions Among incoming internal medicine interns, teamwork training by expert demonstration resulted in similar teamwork behavior to participation in high-fidelity simulation and was more effective than traditional didactics. Clinical performance was largely independent of teamwork behavior and did not differ between training modalities.
    03/2015; 12(4). DOI:10.1513/AnnalsATS.201501-030OC
  • Annals of Pharmacotherapy 03/2015; 49(3):366-7. DOI:10.1177/1060028014564395
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    ABSTRACT: Daily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care-associated infections. To determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care-associated infections. A pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013. Units performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study. The primary prespecified outcome was a composite of central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care-associated bloodstream infections, and rates of the primary outcome by ICU. During the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, -0.04; 95% CI, -1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit. In this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care-associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine. clinicaltrials.gov Identifier: NCT02033187.
    JAMA The Journal of the American Medical Association 01/2015; 313(4). DOI:10.1001/jama.2014.18400
  • Matthew W Semler, Arthur P Wheeler
    Chest 06/2014; 145(6):1181-2. DOI:10.1378/chest.14-0438
  • Janna S Landsperger, Arthur P Wheeler
    Critical care medicine 03/2014; 42(3):731-2. DOI:10.1097/01.ccm.0000435683.06554.b0
  • April N Kapu, Arthur P Wheeler, Byron Lee
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    ABSTRACT: Background Vanderbilt University Hospital's original rapid response team included a critical care charge nurse and a respiratory therapist. A frequently identified barrier to care was the time delay between arrival of the rapid response team and arrival of the primary health care team. Objective To assess the impact of adding an acute care nurse practitioner to the rapid response team. Methods Acute care nurse practitioners were added to surgical and medical rapid response teams in January 2011 to diagnose and order treatments on rapid response calls. Results In 2011, the new teams responded to 898 calls, averaging 31.8 minutes per call. The most frequent diagnoses were respiratory distress (18%), postoperative pain (13%), hypotension (12%), and tachyarrhythmia (10%). The teams facilitated 360 transfers to intensive care and provided 3056 diagnostic and therapeutic interventions. Communication with the primary team was documented on 97% of the calls. Opportunities for process improvement were identified on 18% of the calls. After implementation, charge nurses were surveyed, with 96% expressing high satisfaction associated with enhanced service and quality. Conclusions Teams led by nurse practitioners provide diagnostic expertise and treatment, facilitation of transfers, team communication, and education.
    Critical Care Nurse 02/2014; 34(1):51-9. DOI:10.4037/ccn2014847
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    ABSTRACT: Barriers to executing large-scale randomized controlled trials include costs, complexity, and regulatory requirements. We hypothesized that source document verification (SDV) via remote electronic monitoring is feasible. Five hospitals from two NIH sponsored networks provided remote electronic access to study monitors. We evaluated pre-visit remote SDV compared to traditional on-site SDV using a randomized convenience sample of all study subjects due for a monitoring visit. The number of data values verified and the time to perform remote and on-site SDV was collected. Thirty-two study subjects were randomized to either remote SDV (N=16) or traditional on-site SDV (N=16). Technical capabilities, remote access policies and regulatory requirements varied widely across sites. In the adult network, only 14 of 2965 data values (0.47%) could not be located remotely. In the traditional on-site SDV arm, 3 of 2608 data values (0.12%) required coordinator help. In the pediatric network, all 198 data values in the remote SDV arm and all 183 data values in the on-site SDV arm were located. Although not statistically significant there was a consistent trend for more time consumed per data value (minutes +/- SD): Adult 0.50 +/- 0.17 min vs. 0.39 +/- 0.10 min (two-tailed t-test p=0.11); Pediatric 0.99 +/- 1.07 min vs. 0.56 +/- 0.61 min (p=0.37) and time per case report form: Adult: 4.60 +/- 1.42 min vs. 3.60 +/- 0.96 min (p=0.10); Pediatric: 11.64 +/- 7.54 min vs. 6.07 +/- 3.18 min (p=0.10) using remote SDV. Because each site had different policies, requirements, and technologies, a common approach to assimilating monitors into the access management system could not be implemented. Despite substantial technology differences, more than 99% of data values were successfully monitored remotely. This pilot study demonstrates the feasibility of remote monitoring and the need to develop consistent access policies for remote study monitoring.
    PLoS ONE 12/2013; 8(12):e81890. DOI:10.1371/journal.pone.0081890
  • Supriya Srinivasa Gowda, Arthur Wheeler
    43rd Annual Critical Care Congress; 12/2013
  • 43rd Annual Critical Care Congress; 12/2013
  • 43rd Annual Critical Care Congress; 12/2013
  • 43rd Annual Critical Care Congress; 12/2013
  • 43rd Annual Critical Care Congress; 12/2013
  • 43rd Annual Critical Care Congress; 12/2013
  • Michael J Noto, Arthur P Wheeler
    American Journal of Respiratory and Critical Care Medicine 07/2013; 188(2):128-30. DOI:10.1164/rccm.201304-0802ED
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    ABSTRACT: Introduction The role of nitric oxide synthase (NOS) in the pathophysiology of acute respiratory distress syndrome (ARDS) is not well understood. Inducible NOS is upregulated during physiologic stress; however, if NOS substrate is insufficient then NOS can uncouple and switch from NO generation to production of damaging peroxynitrites. We hypothesized that NOS substrate levels are low in patients with severe sepsis and that low levels of the NOS substrate citrulline would be associated with end organ damage including ARDS in severe sepsis. Methods Plasma citrulline, arginine and ornithine levels and nitrate/nitrite were measured at baseline in 135 patients with severe sepsis. ARDS was diagnosed by consensus definitions. Results Plasma citrulline levels were below normal in all patients (median 9.2 uM, IQR 5.2 - 14.4) and were significantly lower in ARDS compared to the no ARDS group (6.0 (3.3 - 10.4) vs. 10.1 (6.2 - 16.6), P = 0.002). The rate of ARDS was 50% in the lowest citrulline quartile compared to 15% in the highest citrulline quartile (P = 0.002). In multivariable analyses, citrulline levels were associated with ARDS even after adjustment for covariates including severity of illness. Conclusions In severe sepsis, levels of the NOS substrate citrulline are low and are associated with ARDS. Low NOS substrate levels have been shown in other disease states to lead to NOS uncoupling and oxidative injury suggesting a potential mechanism for the association between low citrulline and ARDS. Further studies are needed to determine whether citrulline supplementation could prevent the development of ARDS in patients with severe sepsis and to determine its role in NOS coupling and function.
    Critical care (London, England) 01/2013; 17(1):R10. DOI:10.1186/cc11934

Publication Stats

6k Citations
1,047.10 Total Impact Points

Institutions

  • 1990–2015
    • Vanderbilt University
      • • Department of Medicine
      • • Division of Allergy, Pulmonary and Critical Care
      • • Center for Health Services Research
      • • Department of Biostatistics
      • • Department of Biomedical Engineering
      Нашвилл, Michigan, United States
  • 2007
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, CA, United States
  • 2005
    • University of Vermont
      • Department of Medicine
      Burlington, VT, United States
  • 2002–2005
    • Emory University
      • • Division of Pulmonary, Allergy and Critical Care Medicine
      • • School of Medicine
      Atlanta, GA, United States
  • 1995
    • University of Kentucky
      Lexington, Kentucky, United States