E Wesley Ely

Vanderbilt University, Nashville, Michigan, United States

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Publications (201)1181.02 Total impact

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    ABSTRACT: Rationale: Existing studies of risk factors for physical impairments in acute lung injury (ALI) survivors were potentially limited by single-center design or relatively small sample size. Objectives: To evaluate risk factors for 3 measures of physical impairments commonly experienced by ALI survivors in the first year after hospitalization. Methods: A prospective, longitudinal study of 6- and 12-month physical outcomes (muscle strength, 6-minute walk distance, and SF-36 Physical Function score) for 203 ALI survivors enrolled from 12 hospitals participating in the ARDS Network randomized trials. Multivariable regression analyses evaluated the independent association of critical illness-related variables and intensive care interventions with impairments in each physical outcome measure, after adjusting for patient demographics, comorbidities, and baseline functional status. Measurements and Main Results: At 6- and 12-months, respectively, mean (±SD) values for strength (presented as proportion of maximum strength score evaluated using manual muscle testing) was 92% (±8%) and 93% (±9%), 6-minute walk distance (as percent-predicted) was 64% (±22%) and 67% (±26%), and SF-36 Physical Function score (as percent-predicted) was 61% (±36%) and 67% (±37%). After accounting for patient baseline status, there was significant association and statistical interaction of mean daily dose of corticosteroids and ICU length of stay with impairments in physical outcomes. Conclusions: Patients had substantial impairments, from predicted values, for 6-minute walk distance and SF-36 Physical Function outcome measures. Minimizing corticosteroid dose and implementing existing evidence-based methods to reduce duration of ICU stay and associated patient immobilization may be important interventions for improving ALI survivors' physical outcomes.
    American Journal of Respiratory and Critical Care Medicine 04/2014; · 11.04 Impact Factor
  • Paula L Watson, Beth A Malow, E Wesley Ely
    Critical care medicine 04/2014; 42(4):e313-4. · 6.37 Impact Factor
  • Eduard E Vasilevskis, E Wesley Ely
    The Neurohospitalist. 04/2014; 4(2):58-60.
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    ABSTRACT: To evaluate whether race influences agreement between screening results and documentation of cognitive impairment and delirium. Secondary data analysis. An urban, public hospital and healthcare system. Hospitalized older adults aged 65 and older admitted to general inpatient medical services evaluated for cognitive impairment (n = 851) and evaluated for delirium (n = 424). Cognitive impairment and delirium were measured in each participant using the Short Portable Mental Status Questionnaire (SPMSQ) and the Confusion Assessment Method (CAM), respectively, as the reference identification method. Clinical documentation of cognitive impairment and delirium was defined according to the presence of International Classification of Diseases, Ninth Revision (ICD-9), codes from within 1 year before hospitalization through discharge for cognitive impairment or from hospital admission through discharge for delirium. Two hundred ninety-four participants (34%) had cognitive impairment based on SPMSQ performance, and 163 (38%) had delirium based on CAM results. One hundred seventy-one (20%) of those with cognitive impairment had an ICD-9 code for cognitive impairment, whereas 92 (22%) of those with delirium had an ICD-9 code for delirium. After considering age, sex, education, socioeconomic status, chronic comorbidity, and severity of acute illness, of those who screened positive on the SPMSQ, African Americans had a higher adjusted odds ratio (AOR) than non-African Americans for clinical documentation of cognitive impairment (AOR = 1.66, 95% confidence interval (CI) = 0.95-2.89), and of those who screened negative on the SPMSQ, African Americans had higher odds of clinical documentation of cognitive impairment (AOR = 2.10, 95% CI = 1.17-3.78) than non-African Americans. There were no differences in clinical documentation rates of delirium between African Americans and non-African Americans. Racial differences in coding for cognitive impairment may exist, resulting in higher documentation of cognitive impairment in African Americans screening positive or negative for cognitive impairment.
    Journal of the American Geriatrics Society 02/2014; · 3.98 Impact Factor
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    ABSTRACT: Objectives In the emergency department (ED), health care providers miss delirium approximately 75% of the time, because they do not routinely screen for this syndrome. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a brief (
    Academic Emergency Medicine 02/2014; 21(2). · 1.76 Impact Factor
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    ABSTRACT: Delirium and coma are a frequent source of morbidity for ICU patients. Several factors are associated with the prognosis of mechanically ventilated (MV) cancer patients, but no studies evaluated delirium and coma (acute brain dysfunction). The present study evaluated the frequency and impact of acute brain dysfunction on mortality. The study was performed at National Cancer Institute, Rio de Janeiro, Brazil. We prospectively enrolled patients ventilated >48 h with a diagnosis of cancer. Acute brain dysfunction was assessed during the first 14 days of ICU using RASS/CAM-ICU. Patients were followed until hospital discharge. Univariate and multivariable analysis were performed to evaluate factors associated with hospital mortality. 170 patients were included. 73% had solid tumors, age 65 [53-72 (median, IQR 25%-75%)] years. SAPS II score was 54[46-63] points and SOFA score was (7 [6]-[9]) points. Median duration of MV was 13 (6-21) days and ICU stay was 14 (7.5-22) days. ICU mortality was 54% and hospital mortality was 66%. Acute brain dysfunction was diagnosed in 161 patients (95%). Survivors had more delirium/coma-free days [4(1,5-6) vs 1(0-2), p<0.001]. In multivariable analysis the number of days of delirium/coma-free days were associated with better outcomes as they were independent predictors of lower hospital mortality [0.771 (0.681 to 0.873), p<0.001]. Acute brain dysfunction in MV cancer patients is frequent and independently associated with increased hospital mortality. Future studies should investigate means of preventing or mitigating acute brain dysfunction as they may have a significant impact on clinical outcomes.
    PLoS ONE 01/2014; 9(1):e85332. · 3.73 Impact Factor
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    ABSTRACT: Rationale Delirium is common in intensive care unit (ICU) patients and is a predictor of worse outcomes and neuroinflammation is a possible mechanism. The anti-inflammatory actions of statins may reduce delirium. Objectives To determine whether critically ill patients receiving statin therapy had a reduced risk of delirium than those not on statins. Methods A prospective cohort analysis of data from consecutive ICU patients admitted to a UK mixed medical and surgical critical care unit between August 2011 and February 2012; the Confusion Assessment Method for ICU (CAM-ICU) was used to determine the days each patient was assessed as being free of delirium during ICU admission. Measurements Delirium free days, daily administration of statins and serum C-reactive protein (CRP) were recorded. Main results Four hundred and seventy consecutive critical care patients were followed from August 2011 to February 2012 of whom 151 patients received statins. Using random-effects multivariable logistic regression, statin administration the previous evening was associated with the patient being assessed as free of delirium (OR = 2.28, (CI 1.01 to 5.13) p < 0.05) and with lower CRP (β = -0.52, p <0.01) the following day. When the association between statin and being assessed as free of delirium was controlled for CRP, the effect size became non-significant (OR = 1.56, (CI 0.64 to 3.79) p=0.32). Conclusions Ongoing statin therapy is associated with a lower daily risk of delirium in critically ill patients. An ongoing clinical trial, informed by this study, is investigating if statins are a potential therapy for delirium in the critically ill.
    American Journal of Respiratory and Critical Care Medicine 01/2014; · 11.04 Impact Factor
  • New England Journal of Medicine 01/2014; 370(2):185-6. · 51.66 Impact Factor
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    ABSTRACT: The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice. Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012. Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center. Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service. Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle. For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates. Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.
    Critical care medicine 01/2014; · 6.37 Impact Factor
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    ABSTRACT: Background Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations of age and duration of delirium with mental health and functional disabilities in this group. Methods In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist—Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795. Findings We enrolled 821 patients with a median age of 61 years (IQR 51–71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive–affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes. Interpretation Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care. Funding National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.
    The Lancet Respiratory Medicine. 01/2014;
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    ABSTRACT: The Intensive Care Unit is not only a place where lives are saved; it is also a site of harm and iatrogenic injury for millions of people treated in this setting globally every year. Increasingly, hospitals admit only the sickest patients, and, while the overall number of hospital beds remains stable in the U.S., the percentage of that total devoted to ICU beds is rising. These two realities engender a demographic imperative to address patient safety in the critical care setting. This manuscript addresses the medical community’s resistance to adopting a culture of safety in critical care with regard to issues surrounding sedation, delirium, and early mobility. Although there is currently much research and quality improvement in this area, most of what we know from these data and published guidelines has not become reality in the day-to-day management of ICU patients. This manuscript is not intended to provide a comprehensive review of the literature, but rather a framework to rethink our currently outdated culture of critical care by employing Maslow’s Hierarchy of Needs, along with a few novel analogies. Application of Maslow’s Hierarchy will help propel healthcare professionals toward comprehensive care of the whole person, not merely for survival, but toward restoration of pre-illness function of mind, body, and spirit.
    Journal of critical care 01/2014; · 2.13 Impact Factor
  • S Jean Hsieh, E Wesley Ely, Michelle N Gong
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    ABSTRACT: Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. These poor outcomes are not only independently associated with the development of delirium but are also associated with increasing delirium duration. Therefore, interventions should strive both to prevent the occurrence of ICU delirium and to limit its persistence. Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.
    Annals of the American Thoracic Society. 12/2013; 10(6):648-56.
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    ABSTRACT: Survivors of critical illness are frequently left with long-lasting disability. The association between delirium and disability in critically ill patients has not been described. We hypothesized that the duration of delirium in the ICU would be associated with subsequent disability and worse physical health status following a critical illness. Prospective cohort study nested within a randomized controlled trial of a paired sedation and ventilator weaning strategy. A single-center tertiary-care hospital. One hundred twenty-six survivors of a critical illness. Confusion Assessment Method for the ICU, Katz activities of daily living, Functional Activities Questionnaire (measuring instrumental activities of daily living), Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score, and Awareness Questionnaire were used. Associations between delirium duration and outcomes were determined via proportional odds logistic regression with generalized estimating equations (for Katz activities of daily living and Functional Activities Questionnaire scores) or via generalized least squares regression (for Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score and Awareness Questionnaire scores). Excluding patients who died prior to follow-up but including those who withdrew or were lost to follow-up, we assessed 80 of 99 patients (81%) at 3 months and 63 of 87 patients (72%) at 12 months. After adjusting for covariates, delirium duration was associated with worse activities of daily living scores (p = 0.002) over the course of the 12-month study period but was not associated with worse instrumental activities of daily living scores (p = 0.15) or worse Medical Outcomes Study 36-item Short Form General Health Survey Physical Components Score (p = 0.58). Duration of delirium was also associated with lower Awareness Questionnaire Motor/Sensory Factors scores (p 0.02). In the setting of critical illness, longer delirium duration is independently associated with increased odds of disability in activities of daily living and worse motor-sensory function in the following year. These data point to a need for further study into the determinants of functional outcomes in ICU survivors.
    Critical care medicine 10/2013; · 6.37 Impact Factor
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    ABSTRACT: Rationale: The prognostic significance of delirium symptoms in ICU patients with focal neurological injury is unclear. Objectives: To determine the relationship between delirium symptoms and subsequent functional outcomes and quality of life after intracerebral hemorrhage (ICH). Methods. We prospectively enrolled 114 patients. Delirium symptoms were routinely assessed twice daily using the Confusion Assessment Method for the ICU by trained nurses. Functional outcomes were recorded with modified Rankin Scale (scored from 0, no symptoms to 6, dead), and quality of life outcomes with Neuro-QOL at 28 days, three months and 12 months. Measurements and Main Results: Thirty-one (27%) patients had delirium symptoms ("ever delirious"), 67 (59%) were never delirious, and the remainder (14%) had persistent coma. Delirium symptoms were nearly always hypoactive, were detected mean 6 days following ICH presentation and were associated with longer ICU length of stay (mean 3.5 days longer in ever vs. never delirious patients, 95%CI 1.5 - 8.3, P=0.004) after correction for age, admit NIH Stroke Scale and any benzodiazepine exposure. Delirium symptoms were associated with increased odds of poor outcome at 28 days (OR 8.7, 95%CI 1.4 - 52.5, P=0.018) after correction for admission NIH Stroke Scale and age, and with worse QOL in the domains of applied cognition - executive function and fatigue after correcting for the NIH Stroke Scale, age, benzodiazepine exposure, and time of follow-up. Conclusions: After focal neurologic injury, delirium symptoms were common despite low rates of infection and sedation exposure, and were predictive of subsequent worse functional outcomes and lower QOL.
    American Journal of Respiratory and Critical Care Medicine 10/2013; · 11.04 Impact Factor
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    ABSTRACT: Delirium is frequently diagnosed in critically ill patients and is associated with poor clinical outcomes. Haloperidol is the most commonly used drug for delirium despite little evidence of its effectiveness. The aim of this study was to establish whether early treatment with haloperidol would decrease the time that survivors of critical illness spent in delirium or coma. We did this double-blind, placebo-controlled randomised trial in a general adult intensive care unit (ICU). Critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission were enrolled. Patients were randomised (by an independent nurse, in 1:1 ratio, with permuted block size of four and six, using a centralised, secure web-based randomisation service) to receive haloperidol 2·5 mg or 0·9% saline placebo intravenously every 8 h, irrespective of coma or delirium status. Study drug was discontinued on ICU discharge, once delirium-free and coma-free for 2 consecutive days, or after a maximum of 14 days of treatment, whichever came first. Delirium was assessed using the confusion assessment method for the ICU (CAM-ICU). The primary outcome was delirium-free and coma-free days, defined as the number of days in the first 14 days after randomisation during which the patient was alive without delirium and not in coma from any cause. Patients who died within the 14 day study period were recorded as having 0 days free of delirium and coma. ICU clinical and research staff and patients were masked to treatment throughout the study. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN83567338. 142 patients were randomised, 141 were included in the final analysis (71 haloperidol, 70 placebo). Patients in the haloperidol group spent about the same number of days alive, without delirium, and without coma as did patients in the placebo group (median 5 days [IQR 0-10] vs 6 days [0-11] days; p=0·53). The most common adverse events were oversedation (11 patients in the haloperidol group vs six in the placebo group) and QTc prolongation (seven patients in the haloperidol group vs six in the placebo group). No patient had a serious adverse event related to the study drug. These results do not support the hypothesis that haloperidol modifies duration of delirium in critically ill patients. Although haloperidol can be used safely in this population of patients, pending the results of trials in progress, the use of intravenous haloperidol should be reserved for short-term management of acute agitation. National Institute for Health Research.
    The lancet. Respiratory medicine. 09/2013; 1(7):515-23.
  • Critical care medicine 09/2013; 41(9):e237. · 6.37 Impact Factor
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    Nathan E Brummel, E Wesley Ely
    European Journal of Intensive Care Medicine 08/2013; · 5.17 Impact Factor
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    ABSTRACT: Intensive care unit admissions are ever increasing across the US. Following critical illness, physical functioning (PF) may be impaired for up to 5 years. We performed a systematic review of randomized controlled trials (RCT) evaluating the efficacy of interventions targeting PF among ICU survivors. To identify effective interventions that improve long-term PF in ICU survivors. MEDLINE, EMBASE, CINAHL and PEDro were searched between 1990 and 2012. Two reviewers independently evaluated studies for eligibility; critically appraised the included studies; and extracted data into standardized evidence tables. Fourteen studies met the inclusion criteria. Interventions included exercise/physical therapy (PT), parenteral nutrition, nurse-led follow-up, spontaneous awakening trials, absence of sedation during mechanical ventilation, and early tracheotomy. Ten studies failed to demonstrate efficacy on PF of the ICU survivors. However, early physical exercise and PT based interventions had a positive effect on long-term PF. The only effective intervention to improve long-term PF in critically ill patients is exercise/PT; its benefit may be higher if started earlier. Further research in this area comparing different interventions and timing is needed.
    Chest 08/2013; · 5.85 Impact Factor
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    ABSTRACT: Standard sleep scoring criteria may be unreliable when applied to critically ill patients. We sought to quantify typical and atypical polysomnographic findings in critically ill patients and to begin development and reliability testing of methodology to characterize the atypical polysomnographic tracings that confound standard sleep scoring criteria. Prospective convenience sample. Two academic, tertiary care medical centers. Thirty-seven critically ill, mechanically ventilated, medical ICU patients. None. Mechanically ventilated subjects were monitored by continuous polysomnography. After noting frequent atypical polysomnographic findings (i.e., lack of stage N2 markers, the presence of polymorphic delta, burst suppression, or isoelectric electroencephalography), attempts to use standard sleep scoring criteria alone were abandoned. Atypical polysomnographic findings were characterized and used to develop a modified scoring system. Polysomnographic data were scored manually via this revised scoring scheme. Of 37 medical ICU patients enrolled, 36 experienced atypical sleep, which accounted for 85% of all recorded data, with 5.1% normal sleep and 9.4% wake. Coupling observed patient arousal levels with polysomnographic characteristics revealed that standard polysomnographic staging criteria did not reliably determine the presence or absence of sleep. Rapid eye movement occurred in only five patients (14%). The revised scoring system incorporating frequently seen atypical characteristics yielded very high interrater reliability (weighted κ = 0.80; bootstrapped 95% CI, [0.48, 0.89]). Analysis of polysomnographic data revealed profound deficiencies in standard scoring criteria due to a predominance of atypical polysomnographic findings in ventilated patients. The revised scoring scheme proved reliable in sleep staging and may serve as a building block in future work.
    Critical care medicine 08/2013; 41(8):1958-1967. · 6.37 Impact Factor

Publication Stats

6k Citations
1,181.02 Total Impact Points


  • 2000–2014
    • Vanderbilt University
      • • Department of Internal Medicine
      • • Department of Anesthesiology
      • • Center for Health Services Research
      • • Department of Medicine
      • • Department of Biostatistics
      • • Division of Allergy, Pulmonary and Critical Care
      Nashville, Michigan, United States
  • 2013
    • Northwestern University
      Evanston, Illinois, United States
    • Regenstrief Institute, Inc.
      Indianapolis, Indiana, United States
  • 2012
    • University of Nebraska at Omaha
      • College of Nursing
      Omaha, NE, United States
  • 2011
    • Imperial College London
      • Section of Anaesthetics, Pain Medicine, and Intensive Care (APMIC)
      London, ENG, United Kingdom
    • American Economic Association
      United States
  • 2010
    • Prince of Wales Hospital and Community Health Services
      Sydney, New South Wales, Australia
  • 2009
    • Hospital Clínico Universidad de Chile
      CiudadSantiago, Santiago, Chile
    • Brigham and Women's Hospital
      • Division of Pulmonary and Critical Care Medicine
      Boston, MA, United States
  • 2007
    • Baylor Health Care System
      Dallas, Texas, United States
  • 2005
    • Brown University
      • Division of Infectious Diseases
      Providence, RI, United States
  • 2004–2005
    • Yale University
      • Department of Internal Medicine
      New Haven, CT, United States
    • University of Pittsburgh
      • Department of Critical Care Medicine
      Pittsburgh, PA, United States
  • 2002
    • Emory University
      • Division of Pulmonary, Allergy and Critical Care Medicine
      Atlanta, GA, United States
    • University of Minnesota Twin Cities
      • Department of Medicine
      Minneapolis, MN, United States