SCCM Resource Library-Super Women: A Highlight of Women's Contributions to Critical Care Medicine in 2020

Video Transcription

Hi, everyone, and welcome to our panel discussion today, entitled Superwomen, a Highlight of Women's Contributions to Critical Care Medicine in 2020.  This is a panel that was co-sponsored by the Women in Critical Care Knowledge and Education Group, and we're so pleased you could join us.  My name is Talia Van Jacob, and I'm an Assistant Professor of Anesthesiology at Cooper University  Hospital in Camden, New Jersey, and I'm also the Division Chief of Critical Care Medicine in the Department of Anesthesiology.  The objectives of our panel today are to describe key findings from pivotal contributions to the field of critical care literature made by women in 2020.  We're going to analyze the women's contributions to the field of critical care using an evidence-based  approach, and we're going to apply these findings from women's contributions to critical  care literature to improve outcomes in critical care medicine, nursing, and pharmacy practice.  Our first speaker is Dr. Shala Siddiqui, and she'll be talking about women's contributions to critical care medicine practice.  Dr. Siddiqui is currently an anesthesiologist and intensivist at Beth Israel Deaconess Medical in Boston, Massachusetts.  She graduated from Aga Khan University Medical College in 1994, and then completed many research years followed by critical care fellowship training at Columbia University.  She is the recipient of peer-reviewed grants and author on multiple critical care publications.  Our next speaker is Maralia Diaz-Perea, and she'll be talking to us about women's contributions to critical care nursing practice in 2020.  Maralia is a fellow of critical care medicine and received her master's degree in education management of critical care from the University of Puerto Rico Medical Science campus.  She's currently a nursing professor at the Sacred Heart University in San Juan, Puerto Rico. She is also a past president and secretary of the Puerto Rican Society of Critical Care  and is currently a member of the membership committee of the Neurocritical Care Society  and a member of the Diversity and Inclusion Committee of the Society of Critical Care Medicine. Our final speaker is Dr. Lauren Igneri, and she'll be talking to us about the women's  contributions to critical care pharmacy practice in 2020. Dr. Igneri is a clinical pharmacy specialist in critical care at Cooper University Healthcare in Camden, New Jersey.  She is an active member of SCCM and contributes regularly within the CPP Communications Committee.  In 2019, Dr. Igneri was elected member at large of the Women in Critical Care Knowledge and Education Group.  Additionally, Dr. Igneri has served as faculty creating educational materials for the American Society of Health System Pharmacists for its reputation resources since 2016.  As this is a live session, you can feel free to put your questions in the Q&A box, but we plan on answering them live at the end.  So without further ado, thank you for attending this presentation, and we'll begin with our first speaker. Hi. My name is Shala Siddiqui.  I'm an anesthesiologist and intensivist at the Beth Israel Deaconess Medical Center in Boston.  I've been asked to talk about a highlight of women's contributions to critical care medicine in 2020.  My disclosures are that I am a teaching faculty for Merck module on COVID Next Wave for American Society of Anesthesiology, and the outline of today's talk includes challenges faced  by women clinicians and academics in 2020, academic achievements by women in critical care, multiple roles played and hurdles overcome, and finally, an equitable solution to ensure  fairness and balance. So when we talk about the challenges in 2020, where does one begin? As you can see in this diagram, the first and the second surge are different because  in the second surge, physicians in the forefront or at the front lines are getting worn out, and they require much more support and sort of a lending hand by society and by other  people who are around them to help them overcome the stresses of this society. You can see how the women are worn out, and they have suffered during the first and second  surges, and especially women because they're also juggling multiple roles, which we will talk about later on.  Even before the COVID-19 pandemic, physicians have been affected by systemic issues that foster unhealthful work environments with expectations of 24-7 availability and a persistent  life-work imbalance. The COVID-19 pandemic has also highlighted systemic assumptions about women physicians that may cause unintentional disadvantage.  Most often, women physicians make more accommodations and take the risk of being seen as less than fully committed, either personally or professionally.  Historically, more women physicians selected or were encouraged to select modifying career progress or reducing professional work hours so that the proportion of women physicians  who have reduced professional work hours exceeds that of their male peers. Let's look at the academic achievements by women in critical care.  Across the board, there's been increased clinical responsibility during COVID-19 surges.  Women have taken the forefront in ICU responsibilities, managing clinically complex patients. They've taken on leadership roles and surge planning, and they've shared development of  protocols and guidelines for COVID-19. However, overall academic productivity of women academics has fallen in 2020.  In this paper by Anderson et al., we can see that compared to just 2019, the first and the last authorships of women, as well as the overall group, has decreased for women  academics. In another paper by Hilton et al., we can see the flaw of medicine. And in this paper, the authors address racial and gender disparities in critical care.  They say that female physicians and those of minority race remain underrepresented in critical care medicine.  There is a paucity of systemic data pertaining to reasons behind this disparity, alluding  to a need for additional studies targeting the recruitment, training, and retention patterns of the hospital system.  Despite this, there have been some landmark papers in which women authors have led the way. For example, the surviving sepsis campaign guideline on management of COVID-19 patients  was led by a woman. And they talk about how patients with hypoxia should be dealt with, when there is an indication  for endotracheal intubation, when high-flow nasal cannula can be used, et cetera. In another paper, women have talked about the coagulopathy associated with COVID.  And this is a very important complication of the pandemic. And they've given guidelines on how this coagulopathy and DIC should be dealt with.  In my group in the Critical Care Medicine Society and committee in the American Society of Anesthesiology, we did a nationwide survey of anesthesia critical care trained physicians.  And we found that this group of people have a high rate of board certification. They practice in academic settings, mostly.  And there is a high rate of participation in resident education. Areas of dissatisfaction with this kind of practice included burnout, work-life balance, and lack of respect.  These results may increase recruitment of anesthesiologists into critical care and inform  strategies to improve satisfaction with anesthesia critical care practice and fellowship training.  In another landmark paper, women physicians and promotion in academic medicine has been dealt with by Richter et al.  In this paper, the authors write, over a 35-year period, women physicians in academic medical  centers were less likely than men to be promoted to the rank of associate or full professor or to be appointed to department chair.  And there was no apparent narrowing in the gap over time. Let's talk about the multiple roles played and the hurdles overcome by women.  As a group, women physicians spend proportionately more time on home and family care activities.  Child care activities have grown with school closures, making it impossible for women to fulfill academic requirements and barely fulfill their clinical roles.  Some have been infected by the pandemic due to exposures and have to take time off and quarantine from children.  Others have had to juggle challenging single parenting or single wage earner positions during the pandemic and are close to burnout.  Traditionally, women are also caring for elderly parents who may be sick or in quarantine.  In this paper by Metta et al., the authors discuss an important disparity in women representation in committees, societies, panels for meetings, et cetera.  They propose that critical care societies establish diverse policies for populating the panels they commission, sharing this responsibility with panel chairs and members.  Merit-based representation should reflect sex, gender, geography, ethnicity, economy, and discipline.  We propose that authors document and journals report the principles and methods of panel composition for professional document development.  We propose publicly available metrics of women's representation on panels for definition documents, and census statements and practice guidelines.  We propose that gender parity policies be incorporated into relevant bylaws within all areas of academic critical care, containing explicit targets which reflect, at a minimum,  the proportion of women in the specialty. And finally, we propose training on diversity and unconscious bias for all critical care  academics, particularly for those in leadership positions.  Finally, what are the equitable solutions to ensure fairness and balance? The COVID-19 pandemic has made it easier to see this flawed narrative of life-work balance for medicine.  Women physicians do not have trouble balancing competing demands any more than men physicians do.  It is simply a more common expectation that women physicians will adjust their professional lives.  The COVID-19 pandemic is requiring additional adjustments to the professional lives of physicians. Many of these adjustments will be made disproportionately by women physicians.  Finally, women and men physicians should be able to share the joy and the work of their lives equally. The COVID-19 pandemic may just be the catalyst needed to achieve that goal.  In this picture, we can see how women are juggling children, their academic requirements, research, education, and clinical time.  It becomes important that they be able to balance their stresses and the demands of both their home life, their children, their parents, their spouses, as well as their work  commitments. Women have, for the past two or three decades, made amazing strides in reaching an almost equal role.  However, there is a huge disparity between men and women when it comes to academic medicine, and we need to do more studies, research, as well as explore what are the causes of  this and how they can be overcome. COVID-19 pandemic has brought about a magnifying glass on these disparities, mostly because  of the disproportionate stresses placed on both the genders. We need to use this moment to reflect and to find out how we can reach a more equitable  solution where women can be supported during this time where there are demands of their children who will always be at the forefront of their priority list, but at the same time,  the work and the profession that they have striven and driven themselves to reach excellence in. Thank you very much. Hello, everybody. My name is Marilia Diaz.  I will be talking about women's contribution to critical care nursing practice in 2020. I have no conflict of interest for this lecture.  Learning objectives are describe key findings from pivotal contributions to the critical care literature made by women in 2020, analyze women's contribution to critical care using  an evidence-based approach, and apply findings to improve outcomes in critical care nursing practice. So, let's go back in time a little bit from 2020 to 1860.  And we all have heard the name Florence Lightingale, and last year, we had to put into practice her advices more than ever.  In her work, she brought into attention the importance of washing our hands. What a coincidence that on the same year of the 200th birthday, the whole world was talking  about cleaning their hands. Through the years, we had a lot of research on this topic with the same conclusion, you just have to wash your hands.  But this is the SSCM, and that's why I have to include it on my lecture. On 1971, we had the first SSCM president, and by now, three nurses got the privilege  to be president of the society. The first one was Maureen Harvey. She worked on the guidelines for family-centered care in the ICU.  Those guidelines helped to open the doors of the ICU to family members and other significant people in the patient's life. Because of COVID-19, we had to close those doors again.  Now, we have to work to go back to 2019 and learn how to open the ICU to the relatives of the patients, while at the same time, we make sure to keep our patients and healthcare  workers safe from COVID-19. We need to continue doing some research on this topic. Carol Thompson was the second nurse to be SSCM president, and she researched about the  post-ICU syndrome. And one of the importance of that research is for the patient to be out of the ICU as soon as possible.  I hope you all have heard about the ABCDEF bundle, which is a tool intensivists are using to take care of patients in the ICU.  And one of the benefits from this bundle is to get patients back to their lifetime before their ICU stay.  We already know that having a shorter stay in the ICU, staying mobile, and having their family members at the bedside helps the patient to go back home earlier, and for some of them  to go even back to work. But research shows that there is still a lot of work we have to do on this topic. Part of that bundle are the PADIS guidelines.  Before COVID-19, we wanted to have our patients free of sedatives as much as we could. But then early in 2020, we started sedating our COVID-19-intubated patients.  By 2020, nurses are still researching about it, and one of those research is being worked by the chair of the nursing section of the SSCM, Dr. Sheila Alexander.  By putting into practice the ABCDEF bundle, a decrease in the use of physical restraints among ICU patients has been seen.  But the use is still too high, and the evidence shows us that we still need to teach healthcare personnel about it.  During the last year, we have to change the way of taking care of patients because now we have also to take care of each one of us.  We need to take care also of the healthcare personnel. So changes were implemented, and now we are starting to see the results, but it's too  soon to know how this will affect the patients in the long run. Dr. Sandra Goldsworthy researched about the use of simulations with nursing patients,  and because of COVID-19, nursing students had to learn from home. Researches like this one proves that nursing schools are moving in the right way, even before the pandemic.  And certainly, knowledge is what makes us better professionals, so keep on learning. We thought we were tough and that we could do this, but now, 11 months later, we are  tired and mentally and emotionally drained. Burnout is a real thing between healthcare professionals, but not everybody addresses it.  During the pandemic, we learned that we are the ones now who need help. How many of us thought of having a non-ICU nurse working with critical care patients?  Probably none of us, but now we need them more than ever. Now it's the time to do research on how to train them and the outcomes of this decision.  The third and last nurse so far who got the privilege to be president of the SCCM is Dr. Ruth Klinepel.  She worked on the surviving sepsis campaign, and by 2020, it is still an important topic.  Recent research has concluded that the surviving sepsis campaign is still needed to take care of patients with sepsis.  And even the ones who thought they didn't need to learn about it found that getting to know the guidelines is really useful to take care of patients with COVID-19.  2020 was the year of the nurses, and Time Magazine recognized two nurses as part of their 100 most influential people of 2020. We are being recognized worldwide for our work.  It doesn't matter if you're a physician, a pharmacist, a respiratory therapist, or a nurse. There is one special nurse that in some way has changed your life.  Go ahead and thank them for it. To what do you love, and thanks to all of you for your work. True heroes wear scrubs and masks. Thank you. Thank you for that introduction.  I have no relevant financial relationships or disclosures for this activity. At the end of this learning session, you should be able to describe key findings from pivotal  contributions to the critical care literature made by women in the year 2020.  You'll also be able to analyze these contributions to the critical care literature using an evidence-based  approach and then for my section, apply findings from women's contributions to the critical care literature to improve outcomes in critical care medicine and pharmacy practice.  In order to select articles for today's discussion, I reviewed the CPP pharmacy literature updates from January to November of 2020.  This is a monthly review of select medical literature that is distributed amongst the pharmacy colleagues within SCCM.  All abstracts were then personally reviewed for either a primary or senior author by a woman pharmacist or pharmacologist. This yielded over 40 original publications.  This excluded case reports and review articles. There's a lot of super women that contributed to the literature on a broad range of topics.  This range from thrombolysis, infectious disease, anticoagulation, glycemic control, adverse drug reaction and prevention and reporting, pharmacokinetics, sepsis, quantification of  renal function and kidney and liver injury, use of pulmonary vasodilators, and drug-induced neurotoxicity.  Although I would love to talk about all of these papers today, given the time that we  have, we're going to focus on pain, agitation, and delirium as well as anticoagulation reversal.  In 2018, the pain, agitation, delirium, immobility, and sleep guidelines published some recommendations on the use of adjunctive therapies for pain and delirium.  They suggested the use of acetaminophen and ketamine to help reduce opioid consumption and in the case of acetaminophen, pain intensity.  Prior to this guideline, haloperidol and other antipsychotics had been suggested to be used for the treatment of delirium, but in the 2018 update, it was now recommended only to  use haloperidol or antipsychotics to reserve this when there's significant distress from  delirium, such as anxiety, fearfulness, delusions, or extreme agitation causing physical harm to staff or self.  Ultimately, the plan was to use these for the shortest duration possible until symptoms  resolve, and this is based on very low quality of evidence and panel experience.  So this leads us into our first study. This is a study that was published by Matern and colleagues. This was a retrospective observational study of over 54,000 patients.  There were 19 facilities, part of a medical system that found in one year's period, more than 24,000 patients received IV acetaminophen.  They then analyzed these patients and categorized them with the top 100 procedures and 200 diagnoses, and this resulted in more than 15,000 patients receiving IV acetaminophen.  A matched control group of greater than 38,000 patients was then used for comparison. Subgroup analyses for total knee and total hip replacement, coronary artery bypass graft,  and caesarean section and gallbladder resection were performed.  For outcomes associated with the use of IV acetaminophen, these authors found that IV acetaminophen had no impact on length of stay for the total hip and total knee replacement  patients as well as C-section patients. And then when evaluating all patients overall in the 8,506 patient cohort, they found that  there was actually an increased length of stay with the use of IV acetaminophen. Additionally, IV acetaminophen patients had increased opioid requirements and were more  likely to be discharged with opioids. So while this seems to be a bit contradictory to the theory behind using adjunctive IV acetaminophen,  the thought that the authors proposed about this patient population is that it was likely patients who were experiencing uncontrolled pain post-surgery were using IV acetaminophen  as a way to sort of catch up on their pain requirements. So although we found some contradictory findings with this study, certainly more research is  needed with the use of oral and rectal acetaminophen as an adjunct to pain.  IV acetaminophen has a bit of a controversial history due to its high cost associated with the route.  So certainly, if more studies in the future are done with alternative routes, we may find a purpose for using IV acetaminophen adjunctive therapy.  Agitation and agitated delirium are often very challenging to control because they're typically managed with benzodiazepines, which can increase delirium and length of stay,  and atypical antipsychotics, as well as first-generation antipsychotics. And these often have cardiovascular complications.  Chlorpromazine for agitation is a first-generation antipsychotic, and it's thought to have  potentially an increased efficacy for agitation due to its higher affinity for serotonergic, muscarinic, adrenergic, and histamine receptors.  These authors evaluated the use of chlorpromazine in a mixed ICU population. Notably, the median dose of chlorpromazine administered was 25 milligrams.  The authors in this study stated that chlorpromazine was administered at 1 milligram per minute  infusion, and notably, most patients who received chlorpromazine were, or at least a third of those patients were requiring vasopressors.  Psychiatric history was significant in this population as well. The primary outcome was to identify any hemodynamic changes after administration of  chlorpromazine, and although they did not find significant changes in systolic blood pressure or heart rate, there was a significant reduction in MAP in patients that received  the chlorpromazine for agitation.  Although there was a reduction in MAP, there was not an increased need for vasopressors  or changes in doses of vasopressors, so they concluded that it might be administered significantly  safely in this population.  Additionally, they did not find that it resulted in significant differences in the adjunctive  sedative, opioid, or antipsychotic medications pre- and post-chlorpromazine administration,  and ultimately didn't change the rascal achievement after chlorpromazine was administered. So the authors concluded that although for long-term outcomes in delirium, it may not  have an agitation, it may not have an impact, it may be an alternative to other first-generation  antipsychotics and may not have as many hemodynamic compromise challenges as originally thought.  In the paper by Shurtleff and colleagues, this group decided to characterize ketamine versus non-ketamine based sedation regimens on delirium in the ICU.  Admittedly, they did not have a consistent use of delirium in their ICU, and it was generally added on for challenging patients.  And this dose could be anywhere between 5 and 25 mic per kilo per minute.  Notable baseline characteristics is that the ketamine group generally had a significantly lower P to F ratio at baseline and higher use of vasopressors.  Although they found that there was no difference in delirium-free days, they did find that patients receiving ketamine had an increased ICU and hospital length of stay.  So this probably coincides with how they were using ketamine, kind of reserving it for the sickest patients, those that were refractory to other therapies.  As previously mentioned, benzodiazepines may predispose to development of delirium. In this study, flumazenil was used to treat hypoactive delirium.  Patients who had a RAS score of negative 3 to 0 with a positive CAM ICU, and that delirium was thought to be associated with benzodiazepines,  they were randomized to receive either flumazenil test dose plus infusion versus placebo.  Ultimately, the reason that these patients were getting benzodiazepines were primarily for ventilator asynchrony, as well as alcohol withdrawal syndrome.  The time since the last dose of benzodiazepine on average was between two and two and a half days. And then patients were randomized to flumazenil or placebo.  And ultimately, they did not see a significant difference in median delirium-free days alive.  But patients who received the flumazenil were more likely to have delirium resolution on day one than those who received placebo.  So although this is a small study, it's certainly hypothesis generating and warrants study in a larger population.  Now we're going to talk about the effects of analgesia and sedation on ECMO patients.  We know that lipophilic drugs are sequestered by the ECMO circuit and this results in altered drug absorption.  This means that higher than usual doses may be required to achieve the desired effects.  Ex vivo models have demonstrated substantial drug loss in post-oxygenator blood with midazolam and fentanyl in particular.  And within 24 hours of ECMO run, there is 87 and 97 percent drug loss with midazolam and fentanyl respectively. Additionally, obese patients are not well represented in PK studies.  And due to their higher amount of adipose tissue, their volume of distribution is increased. And this may increase the dosing requirements of lipophilic drugs.  The following two studies evaluated analgesia and sedation in ECMO patients.  The first by Landolph and colleagues retrospectively evaluated the use of fentanyl or hydromorphone in 148 patients who required ECMO.  And what they found is that at day seven, patients who were using hydromorphone for their opioid requirement more than 75 percent of the time while they were on sedation had increased delirium-free coma-free days at day seven.  This did lose statistical significance at day 14.  But this may point to hydromorphone being a more preferable agent due to its pharmacokinetic properties. The second study that we'll discuss is by Verkerk and colleagues.  This was a single-center retrospective cohort study evaluating the use of opioid and midazolam requirements in obese and non-obese patients. And the BMI cutoff for this was 30.  They found that overall, there was no significant difference in daily opioid or midazolam requirements up to day seven, even after adjusting for weight.  But the patients who were obese tended to have a lower RAS score at day six and day seven. So this may indicate that these patients are accumulating drug.  Additionally, opioid prescribing at discharge was described in the literature.  Patients who were previously opioid naive and received more than 24 hours of IV opioid analgesia while facilitating mechanical ventilation were included in this study.  Essentially, their opioid requirements 24 hours prior to discharge were compared against a previously published algorithm for what appropriate discharge opioid prescribing should look like.  And overall, they found that patients who were appropriately prescribed opioids at discharge had a significantly shorter length of stay for both ICU and hospital.  And they were more likely to have lower 24-hour morphine milligram equivalents prior to discharge.  Post-ICU syndrome is also not well described in the literature, but more literature is emerging.  And one study by Janssen and colleagues described the association of post-intensive care syndrome with the initiation and use of psychotropic medications for patients who were in the ICU for more than 48 hours and were able to participate in a one-year follow-up survey.  In general, patients with mental health problems were more likely to use antidepressants, antipsychotics, and benzodiazepines prior to admission than those without mental health problems.  This cohort of patients was relatively sick in that nearly all patients were mechanically ventilated, 98% in both groups, and they had a very high SAPS-2 score, which correlated to around a 25% mortality.  Overall, these authors found that patients with mental health problems were more likely to use psychotropic medications at the one-year mark from discharge.  Specifically, they were three to four times more likely to be using psychotropic medications.  And in patients with mental health problems, they were more likely to initiate therapy at one year if they had not already been on prior to that point in time.  These patients also had significantly reduced quality of life and cognitive scores one year from ICU discharge, and they were less likely to return to work.  Now we're going to shift gears and talk about anticoagulation and bleeding.  Certainly, we understand that anticoagulation prescribing practices have changed significantly in the last five to 10 years, especially for venous thromboembolism and atrial fibrillation.  We know that DOACs in general are preferred over warfarin for these indications, but despite this, there is still a continued role for warfarin in the anticoagulation armamentarium.  Four-factor PCC is indicated for warfarin reversal with doses ranging 25 to 50 units per kilo based on the baseline INR, but alternative dosing strategies have been proposed, and we'll briefly discuss those today.  Prior to indexamate alpha being approved by the FDA, we used four-factor PCC off-label for direct oral anticoagulant reversal.  So I have two studies to quickly highlight here, the first by Jansman and colleagues.  This was a multi-center retrospective observational study in that numerous centers participated with their patient data, and these patients were all receiving fixed-dose four-factor PCC of 1,500 units for their warfarin reversal.  They had to have a repeat INR within eight hours in order to be included in the study, and ultimately they found that four-factor PCC INR achievement of less than 1.5 and less than 2 was well achieved amongst all groups.  However, pretreatment INR significantly affected the ability to achieve the target INR, and this was noted that when the patient's baseline INR was above four, the use of fixed-dose impacted the ability to make these goals.  They also noted that there were zero thrombotic events within seven days of evaluating these patients.  The second study by Berger and colleagues was a multi-center retrospective observational study evaluating use of low-dose four-factor PCC at 25 units per kilo compared to what we traditionally think of 50 units per kilo being the dose for DOAC reversal.  And they found that 94.7% achieved hemostatic efficacy, and notably the hospital mortality for these patients was 18.2%, which is relatively high, but not unexpected.  There were two thrombotic complications, and one was attributed to a stroke, and this patient received two doses of the four-factor PCC.  After patients bleed, we often are presented with questions as to when to restart anticoagulation.  This retrospective single-system study included patients on DOAC therapy prior to admission, and they were hospitalized for gastrointestinal bleeding.  They characterized patients as whether their DOAC was either held, meaning it was not resumed within seven days of the indexed GI bleed, or it was resumed within seven days of the GI bleed.  And then there were a couple patients switched to warfarin.  Notably, patients who had their DOAC held were more likely to have severe GI bleeding, and generally this was upper GI bleeding.  They also required a significant number of blood transfusions compared to those that resumed their DOAC within seven days.  Overall, 90-day readmission for a GI bleed was not different between groups, as well as mortality at 12 months.  So what we learned from this is that anticoagulation resumption within seven days following a GI bleed did not affect the 90-day readmission rate.  So it's possible that in some cases we may be able to resume anticoagulation sooner in patients with upper GI bleeding associated from DOACs.  So in summary, women pharmacists have contributed to a broad range of topics in the medical literature.  As we discussed, there was numerous areas, but we focused today on pain, agitation, delirium, anticoagulation, and anticoagulation reversal.  Moving forward, support is continued to be needed to increase the authorship by women pharmacists.  Thank you very much for this presentation.  Thank you to our wonderful panelists, Dr. Igneri, Dr. Siddiqui, and Ms. Diaz for their wonderful talks.  We've learned so much.  We now have a live Q&A stream that will take place for the next 20 minutes.  Before we do that, I'd like to thank all of our panelists for joining us today. Thank you to our panelists, Dr. Igneri, Dr. Siddiqui, and Ms. Diaz for their wonderful talks.  Before we begin the Q&As, I just wanted to announce that today is National Women's Physicians Day on Elizabeth Blackwell's birthday.  So happy National Women's Physicians Day to all our critical care medicine female physicians. So please feel free to type your questions for any of the panelists within the Q&A box,  and we're more than happy to answer your questions. While we wait for questions, my first question is for Dr. Siddiqui.  So you recently published a study with regards to burnout and ICU syndrome in healthcare practice, and specifically critical care anesthesiologists.  But overall, from your research, what have you learned or ways to prevent this from happening, specifically like where you mentioned that women require the majority to shoulder most  of the burden? And so how have you found ways and mechanisms to cope with all the added pressures with regards to COVID research and family life? Thank you, Thalia.  I think a lot of speakers today have touched on this topic, especially Dr. Cook. I found her talk extremely motivating and inspiring, as always.  I think one thing that's really important is that we should try and cultivate more peer compassion, and my study that I'm trying to work on to publish shows that peer compassion  has a great place in the critical care environment and other high-stress environments. And there are ways of doing this, incorporating emotional intelligence and emotional awareness  and support from leadership will really help in that kind of compassionate environment that we have.  Just kindness, just being kind to each other, trying to understand the perspective of the other person and the pressures that they are under goes a long way, as we know.  While we wait for more questions in the chat box, I have a question for Professor Diaz. So my question for you is, you mentioned a lot about the caring and compassion and  thanking a nurse, but there's been such great research and a lot of data and more academic that has come out of the nursing profession.  So how do you steer away from the stereotypical nurse's caring, compassion, and help guide a nursing student or even someone new in their nursing career to realize that there's more  that they can achieve? Well, it is a task. It is definitely something that we have to do, especially with the new nurses.  We have to take into consideration not only our knowledge, but also how to take care of our patients. The caring is so important. They need the caring now more than ever.  2020 was a really tough year for all of us, not only for nurses and physicians, but also for the general public. So they need us to be compassionate about them.  We also closed our ICUs. Again, we don't allow the family members as we did in 2019. So now we are the sole caregivers of those patients.  We need to help the new nurses to how to manage doing both things at the same time, because it is the most important for the patients.  Dr. Aguirre, you talked a lot about anticoagulation and anticoagulation reversal. If you had three take-home pearls from the studies that you reviewed, what would they be?  Going back to the anticoagulation reversal slides, I think what we are finding here is that we can probably use fixed-dose four-factor PCC for warfarin reversal.  However, we have to acknowledge that it may not be enough to achieve INR goals, depending on what that patient's baseline INR is.  So we might need to develop protocols surrounding the use of sort of a mixed model, maybe using more traditional dosing for patients that present with very elevated INRs in the case  of warfarin reversal. And then those who have almost therapeutic or a little above therapeutic INRs at admission might be able to benefit from the fixed-dose PCC. Okay. All right.  So this is a question for all three panelists. If you were to pick a quote from one of your superwomen, what would it be?  And then to coordinate that, being a junior Girl Scout troop leader, what message would you like me to convey to my troop? Dr. Siddiqui, do you want to go first?  I love Dr. Cook's slide. There was one slide where she talked about in her journey, and that's something that's so inspiring.  She talked about being humble, being kind, and going out and being brave. I think those are the pillars of what we should base our way forward.  Dr. Gneri? I would say that... I apologize. I didn't get to see a lot of the sessions today since I was also at work, but I think  that we are at a point in our lives where we can impact the generation under us. So as a new leader of a young Girl Scout troop, I think I would just encourage these  young girls to follow their dreams, to know that anything can be achievable. We have so many women in the medicine profession, and that's an all-encompassing term, and we  can all achieve greatness if we help each other. And Professor Diaz? Well, I think that just to let them know that they can achieve anything they want.  When I was learning about nursing, there weren't a lot of women as physicians as it is now. So it's been different from before.  So how many women we have in different leadership positions. So just to let them know that they can achieve it if they want it.  Dr. Ben-Jacob, I'd like to add one more thing. As a plug for one of the programs for a mentor-mentee within the Women in Critical Care group, we  now have that service within our CAG. And I think that's a nice way to be able to take some of the younger or less experienced  individuals within critical care medicine and pair them up with a more experienced mentor and then have them open some doors for them as well with research, other networking events,  and then also potentially with jobs.  I'm going to combine the next two questions because they seem to go together. And it looks like they're directed towards Professor Diaz, but everyone should feel free to weigh in.  So nurses have been hit badly during this pandemic. Rate of burnout is extremely high and many are developing PTSD.  What are the tools that have been implemented at your institution and that others can mirror? Are there ways that nursing can be supported as we all heal from this pandemic?  That's a really tough question because that is something I'm trying to change in my hospital. We need to take care of the nurses. We need to take care of the caregivers.  And we haven't been able to do it in my hospital as of today as much as I wanted. For now, we are just giving each other the help we can.  And physicians are helping us to get through every single day because it is tough. It is not as tough as in the States. So we are kind of lucky in that way because of COVID-19.  I know that in the States, it's really bad.  I am in Puerto Rico, and here it's not as bad as in the States. So as of today, we are just taking care of each other, being with family members because,  yes, it is really difficult. And PTSD is something that we're going to see in the next few years.  The next question is for all three panelists. What would be some strategies that you would propose to increase the involvement of women  in medical pharmacy nursing practice literature? We'll start with Dr. Igneri. So some of the things that are offered through Society of Critical Care Medicine or the CPP  Research Committee, I think that we can encourage more women to get involved within that committee and then hopefully partner them with maybe more senior or more experienced  researchers so that they can have the chance to participate in that process, learn from the process, and then be able to implement their own research in the future.  Dr. Siddiqui?  I agree with that. I think an important message is that women can be encouraged to just put up their hand.  And if you're in a committee, it's an easy place where there's some low-hanging fruit research topics that can be discussed.  And if you just put up your hand and offer to do something for that project, your name will be recognized and you can be chosen to do more after that.  So you have to do the hard work. There's no excuse not to do that. So there has to be hard work, but there also has to be a willingness to try and to be brave  and to just put up your hand and volunteer for things. And then the roads will open up, the doors will open up for you if you try very hard  and if you deliver what you promise to do.  And Professor Diaz?  I think that researchers can help new ones by letting them be in their research, helping them, because we need someone to lead us.  Nursing, even though it's doing some research, is not doing as much as other professions. So we definitely need someone who can help us get through it and start from the beginning  because that first step is the really tough one.  And one more thing, if you don't mind, just sharing. No, no, please go ahead.  I think it's like most of our panelists today and the other speakers, it's a long road for research and it's a tough road.  Some people will consider that they have not arrived and get discouraged. But the important thing is not to be discouraged.  For every project that I'm able to do and complete and publish, there are about 25 others which just fell flat on their face or were not, you know, didn't go anywhere.  So, you know, you have to try and not be discouraged, just persevere. That's very important.  And I'm sure people who are more experienced than myself in research will say that that's the actual important part of being a researcher is not to be discouraged.  I'll add one more thing, too, for those listening in that are new to critical care or maybe still in their training programs.  I think the most important thing that I did when I was in college was decide to get involved in the honors research program at my university.  And I knew I was very scared about what might happen. How am I going to manage this with a heavy workload with school or in later years of residency training?  But sometimes you just have to take the leap and then it will lead to other things down the road. You make connections with other people who will get you involved in different  projects. And I think a quote, I think of a quote from many years ago that I heard while at SCCM, and it was that many projects lead to many successes.  And of course, there will be some that are not so successful, but you have to at least try. So I think taking that first leap is the most important step.  And to follow up for that, this question is directed to Professor Diaz. Thank you for your excellent presentation.  You highlighted high profile research by many of our nurse leaders. Do you have any suggestions for nurses that are interested in research or getting  involved in guidelines on a local or national level?  Oh, sure. Get involved as much as you can. Start from putting into practice the guidelines. Not everybody has guidelines at their hospitals, you know.  So start with that and you'll get in love with the guidelines and then you will be in love with research. So start, you know, start low and then go all the way up.  So I don't really have any more questions in the chat box, but we do have six minutes left. So I didn't know if you guys each wanted to share a heartening message to our  membership, especially to the women in critical care, as well as any of the men out there, too, who are here supporting us today.  Because as we know that, you know, it takes both genders or granted, gender is not binary, but it takes support from everyone for everyone to achieve.  So I just wanted to ask you guys if you had a heartening message before we concluded our panel discussion today.  If I may, I just wanted to end this session with thanking everybody and also just a little bit of reflection on this long journey that women have accomplished today in  critical care medicine. If you look back at the previous Congresses, the representation is very good today.  But we have ways to go. And one thing I would say is that there's never enough time. You feel that, OK, I'm overwhelmed. Research always takes a back seat in your life.  But any question that you have, always be curious.  Use research as something which is second nature to you. So, you know, you're grounding, you're taking care of patients.  It should not be mutually exclusive from research questions or burning desire to find out the cause of something. And that cause may have been answered in previous work or not.  But if you can ask questions constantly, I think that's one way of coming up with research questions, which is the first step in any kind of research.  And I'll dovetail on that. So I think I also am faced with challenges of a busy work life balance and also just busy rounding requirements here at Cooper.  Some of the things that I did at my during my at my last job was try to get creative in how I can accomplish some research.  So I used to precept for many pharmacy schools in the area and would often be able to find very motivated students that were looking to also get involved in research so  that they would have something to present at midyear when they were looking for residency. So a lot of times you can find motivated students to help with some of the  lifting of the data collection. And then you can kind of, you know, create numerous projects within a data set and then, you know, help the student out.  But also, you know, long term, some of that lower hanging fruit will help you with your own projects down the road.  Well, I think that even that we are super women, we do need help, we need help from others, not only in research, but in our every day in the ICU.  So feel free to ask somebody for help. Feel free to be part of a team.  Don't don't work by yourself.  You know, be part of a team.  Team is what get us through the day.  I'm going to check one more time. Okay. Well, it looks like that's about it. I want to thank our panelists and our speakers once again for an excellent presentation and  an excellent job. I know I learned a lot. I want to thank SCCM for giving us the opportunity to have this presentation and for supporting us here at Critical Care Congress 50.  And I also wanted to thank our Congress coordinators, Dr. Jose Diaz-Gomez, Dr. Lillian Emlett, and Beth Taylor for allowing us to present today. So thank you guys once again.  It's been a real pleasure.

Video Summary

Women in critical care medicine have made significant contributions to the field in 2020. Key findings from their research include the impact of IV acetaminophen on patient outcomes, the use of chlorpromazine for agitation in the ICU, the role of hydromorphone in analgesia in ECMO patients, and the resumption of anticoagulation after gastrointestinal bleeding. These studies provide important insights and can help improve patient care in critical care medicine. However, despite these contributions, there is still a need for more research and greater involvement of women in critical care literature. Strategies to increase involvement include mentorship programs, peer compassion, and a willingness to put oneself out there and volunteer for research projects. It is important to support and encourage women in critical care medicine, as they have the potential to make a significant impact in the field. By creating a more inclusive and supportive environment, we can ensure more equitable representation and recognition of women's contributions in critical care medicine.

Asset Subtitle

Professional Development and Education, Quality and Patient Safety, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Describe key findings from pivotal contributions to the critical care literature made by women in 2020
Analyze women's contributions to the critical care literature using an evidence-based approach
Apply findings from women's contributions to the critical care literature to improve outcomes in critical care medicine, nursing, and pharmacy practice

Women's Contributions to Critical Care Medicine Practice in 2020
Shahla Siddiqui

Women's Contributions to Critical Care Nursing Practice in 2020
Marilia I. Diaz Correa

Women's Contributions to Critical Care Pharmacy Practice in 2020
Lauren A. Igneri

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Team Leadership

Tag Evidence Based Medicine

Year 2021

Keywords

women in critical care medicine

IV acetaminophen

patient outcomes

chlorpromazine

agitation in the ICU

hydromorphone

analgesia

ECMO patients

anticoagulation

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