Clinical and Genetic Contributors to New-Onset Atrial Fibrillation in Critically Ill Adults Objectives: New-onset atrial fibrillation during critical illness is an independent risk factor for mortality. The ability to identify patients at high risk for new-onset atrial fibrillation is limited. We hypothesized that genetic susceptibility contributes to risk of new-onset atrial fibrillation in the ICU. Design: Retrospective sub-study of a prospective observational cohort study. Setting: Medical and general surgical ICUs in a tertiary academic medical center. Patients: One-thousand three-hundred sixty-nine critically ill patients admitted to the ICU for at least 2 days with no known history of atrial fibrillation who had DNA available for genotyping. Interventions: None. Measurements and Main Results: We genotyped 21 single-nucleotide polymorphisms associated with atrial fibrillation in ambulatory studies using a Sequenom platform (San Diego, CA). We collected demographics, medical history, and development of new-onset atrial fibrillation during the first four days of ICU admission. New-onset atrial fibrillation occurred in 98 patients (7.2%) and was associated with age, male sex, coronary artery disease, and vasopressor use. Single-nucleotide polymorphisms associated with new-onset atrial fibrillation were rs3853445 (near PITX2, p = 0.0002), rs6838973 (near PITX2, p = 0.01), and rs12415501 (in NEURL, p = 0.03) on univariate testing. When controlling for clinical factors, rs3853445 (odds ratio, 0.47; 95% CI, 0.30–0.73; p = 0.001) and rs12415501 (odds ratio, 1.72; 95% CI, 1.27–2.59; p = 0.01) remained significantly associated with new-onset atrial fibrillation. The addition of genetic variables to clinical factors improved new-onset atrial fibrillation discrimination in a multivariable logistic regression model (C-statistic 0.82 vs 0.78; p = 0.0009). Conclusions: We identified several single-nucleotide polymorphisms associated with new-onset atrial fibrillation in a large cohort of critically ill ICU patients, suggesting there is genetic susceptibility underlying this common clinical condition. This finding may provide new targets for future mechanistic studies and additional insight into the application of genomic information to identify patients at elevated risk for a common and important condition in the ICU. The contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Supported, in part, by grants from the National Institutes of Health (NIH) T32 GM108554 (to Dr. Kerchberger), NIH HL 138737 (to Dr. Darbar), NIH HL 135849 (to Drs. Bastarache and Ware), NIH HL 103836 (to Dr. Ware), NIH HL 136888 (to Dr. Shaver), Parker B. Francis Foundation (to Dr. Shaver), and Vanderbilt Faculty Research Scholars (to Dr. Shaver). The project publication described was supported by Clinical and Translational Science Award award number UL1 TR002243 from the National Center for Advancing Translational Sciences. Drs. Kerchberger, Koyama, Shoemaker, Darbar, Ware, and Shaver received support for article research from the National Institutes of Health (NIH). Dr. Darbar’s institution received funding from NIH R01 HL138737. Dr. Ware’s institution received funding from Boehringer Ingelheim and Global Blood Therapeutics (research grants). Dr. Shaver’s institution received funding from NIH (K08), Parker B Francis Foundation, and Vanderbilt Faculty Research Scholars. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: vern.e.kerchberger@vumc.org Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Allergic Immune Diseases and the Risk of Mortality Among Patients Hospitalized for Acute Infection Objectives: The immune response during sepsis remains poorly understood and is likely influenced by the host’s preexisting immunologic comorbidities. Although more than 20% of the U.S. population has an allergic-atopic disease, the type 2 immune response that is overactive in these diseases can also mediate beneficial pro-resolving, tissue-repair functions. Thus, the presence of allergic immunologic comorbidities may be advantageous for patients suffering from sepsis. The objective of this study was to test the hypothesis that comorbid type 2 immune diseases confer protection against morbidity and mortality due to acute infection. Design: Retrospective cohort study of patients hospitalized with an acute infection between November 2008 and January 2016 using electronic health record data. Setting: Single tertiary-care academic medical center. Patients: Admissions to the hospital through the emergency department with likely infection at the time of admission who may or may not have had a type 2 immune-mediated disease, defined as asthma, allergic rhinitis, atopic dermatitis, or food allergy, as determined by International Classification of Diseases, 9th Revision, Clinical Modification codes. Interventions: None. Measurements and Main Results: Of 10,789 admissions for infection, 2,578 (24%) had a type 2 disease; these patients were more likely to be female, black, and younger than patients without type 2 diseases. In unadjusted analyses, type 2 patients had decreased odds of dying during the hospitalization (0.47; 95% CI, 0.38–0.59, p < 0.001), while having more than one type 2 disease conferred a dose-dependent reduction in the risk of mortality (p < 0.001). When adjusting for demographics, medications, types of infection, and illness severity, the presence of a type 2 disease remained protective (odds ratio, 0.55; 95% CI, 0.43–0.70; p < 0.001). Similar results were found using a propensity score analysis (odds ratio, 0.57; 95% CI, 0.45–0.71; p < 0.001). Conclusions: Patients with type 2 diseases admitted with acute infections have reduced mortality, implying that the type 2 immune response is protective in sepsis. Drs. Verhoef and Churpek were involved in study concept and design, obtained funding, and supervised the study. Dr. Churpek was involved in acquisition of data. Dr. Verhoef was involved in the first drafting of the article, had full access to all the data in the study, and took responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Carey and Churpek were involved in administrative, technical, and material support. All authors were involved in critical revision of the article for important intellectual content and statistical analysis; analysis and interpretation of data. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Verhoef is supported by a career development award from the National Heart, Lung, and Blood Institute (NHLBI) (K08 HL132109) and was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award number UL1TR002389 that funds the Institute for Translational Medicine. Dr. Bhavani is supported by the Research Training in Respiratory Biology award from NHLBI (T32HL007605). Dr. Churpek is supported by a career development award from the NHLBI (K08 HL121080) and an R01 from National Institute of General Medical Sciences (R01 GM123193). Dr. Churpek has a patent pending (ARCD. P0535US.P2) for risk stratification algorithms for hospitalized patients, and he received research support from EarlySense (Tel Aviv, Israel). Drs. Verhoef and Churpek received support for article research from the NIH. Mr. Carey has disclosed that he does not have any potential conflicts of interest. Address requests for reprints to: Philip A. Verhoef, MD, PhD, FACP, FAAP, Kaiser Permanente Internal Medicine Residency Program, Room 3D04, 2828 Pa'a Street, Honolulu, HI 96819. E-mail: Philip.verhoef@gmail.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Neurocritical Care for Extracorporeal Membrane Oxygenation Patients Objectives: To review the neurocritical care aspects of patients supported by extracorporeal membrane oxygenation, including cerebral physiology, neurologic monitoring, use of sedatives and anti-seizure medications, and prevalence and management of extracorporeal membrane oxygenation associated brain injury. Data Sources: PubMed database search using relevant search terms related to neurologic complications, neurocritical care management, and brain injury management in patients with extracorporeal membrane oxygenation. Study Selection: Articles included original investigations, review articles, consensus statements and guidelines. Data Extraction: A detailed review of publications performed and relevant publications were summarized. Data Synthesis: We found no practice guidelines or management strategies for the neurocritical care of extracorporeal membrane oxygenation patients. Such patients are at high risk for hypoxic-ischemic brain injury, intracranial hemorrhage, cerebral edema, and brain death. Improving clinical outcomes will depend on better defining the neurologic complications and underlying pathophysiology that are specific to extracorporeal membrane oxygenation. Currently, insufficient understanding of the pathophysiology of neurologic complications prevents us from addressing their etiologies with specific, targeted monitoring techniques and interventions. Conclusions: A large knowledge gap exists in our understanding and treatment of extracorporeal membrane oxygenation-related neurologic complications. A systematic and multidisciplinary approach is needed to reduce the prevalence of these complications and to better manage the neurologic sequelae of extracorporeal membrane oxygenation in a way that will improve patient outcomes. Dr. Cho receives a grant from the Extracorporeal Life Support Organization. Dr. Geocadin received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: csmfisher@gmail.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Cell Cycle Biomarkers and Soluble Urokinase-Type Plasminogen Activator Receptor for the Prediction of Sepsis-Induced Acute Kidney Injury Requiring Renal Replacement Therapy: A Prospective, Exploratory Study Objectives: Sepsis-induced acute kidney injury is the dominant acute kidney injury etiology in critically ill patients and is often associated with a need for renal replacement therapy. The indication and timing of renal replacement therapy are controversially discussed. We hypothesized that the product of the G1-cell cycle arrest biomarkers tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 ([TIMP-2] × [IGFBP7]), and the soluble urokinase-type plasminogen activator receptor are of diagnostic value for the prediction of septic acute kidney injury courses requiring renal replacement therapy. Design: In this prospective study, critically ill patients were enrolled immediately after the fulfillment of Sepsis-3 criteria. Urinary [TIMP-2] × [IGFBP7] levels over time and serum soluble urokinase-type plasminogen activator receptor levels once at inclusion were measured. The primary endpoint was the development of septic acute kidney injury with the need for renal replacement therapy. Area under the receiver operating characteristic curves, de Long’s tests, and logistic regression models were calculated. Setting: Two ICUs at Heidelberg University Hospital between May 2017 and July 2018. Patients: One-hundred critically ill patients with positive Sepsis-3 criteria. Interventions: None. Measurement and Main Results: Nineteen patients required renal replacement therapy. Diagnostic performance of urinary [TIMP-2] × [IGFBP7] improved over time with the highest area under the receiver operating characteristic curve of 0.89 (95% CI, 0.80–0.98) 24 hours after study inclusion. Soluble urokinase-type plasminogen activator receptor levels at inclusion showed an area under the receiver operating characteristic curve of 0.83 (0.75–0.92). The best discrimination ability for the primary outcome measure was achieved for [TIMP-2] × [IGFBP7] at 24 hours after inclusion by applying a cutoff value of greater than or equal to 0.6 (ng/mL)2/1,000 (sensitivity 90.9, specificity 67.1). Soluble urokinase-type plasminogen activator receptor performed best by using a cutoff value of greater than or equal to 8.53 ng/mL (sensitivity 84.2, specificity 82.7). A combination of newly tested biomarkers with cystatin C resulted in a significantly improved diagnostic accuracy. Cystatin C in combination with [TIMP-2] × [IGFBP7] 24 hours outperformed all standard renal parameters (area under the receiver operating characteristic curve 0.93 [0.86–1.00]). Conclusions: [TIMP-2] × [IGFBP7] and soluble urokinase-type plasminogen activator receptor are promising biomarker candidates for the risk stratification of septic acute kidney injury patients with the need for renal replacement therapy. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Nusshag disclosed that he is funded by the Physician Scientist Programme of Heidelberg Faculty of Medicine. Dr. Reiser received funding from the National Institutes of Health (NIH) (grants), Massachusetts General Hospital (consulting), UptoDate (consulting), TRISAQ (equity/stock owner), NEPHCURE (grant), Thermo BCT (grant), Genentech (consulting), Merck (consulting), and Inceptionsci (consulting), and he received support for article research from the NIH. Dr. Brenner received funding from the German Research Foundation and the Heidelberg Foundation of Surgery. Moreover, he received honoraria for lectures from Biotest AG, Baxter Germany GmbH, Schöchl medical education GmbH, Boehringer Ingelheim Pharma GmbH, CSL Behring GmbH, Astellas Pharma GmbH, B. Braun Melsungen AG, and Merck Sharp & Dohme GmbH. He also disclosed that he is an advisory board member of Baxter Germany GmbH. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Christian.Nusshag@med.uni-heidelberg.de This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Incidence and Outcomes of Sepsis in Korea: A Nationwide Cohort Study From 2007 to 2016 Objectives: This study aimed to estimate the incidence and clinical outcomes of sepsis in Korea from 2007 to 2016. Design: Retrospective observational study. Setting: Nationwide study with population-based healthcare reimbursement claims database. Patients: Using data from the National Health Insurance Service of Korea, patients who were hospitalized with a diagnosis of sepsis from 2007 to 2016 were analyzed. The incidence of sepsis was calculated using mid-year census population and analyzed according to year, age, and sex. The Elixhauser Comorbidity Index score was calculated to adjust for the impact of comorbidities on clinical outcome. In-hospital mortality, hospital length of stay, ICU admission rates, and risk factors for in-hospital mortality were also analyzed. Interventions: None. Measurements and Main Results: The incidence of sepsis increased from 173.8 per 100,000 population in 2007 to 233.6 per 100,000 population in 2016. In-hospital mortality decreased from 30.9% in 2007 to 22.6% in 2016 (p < 0.0001). From 2007 to 2016, hospital length of stay and ICU admission rates associated with sepsis decreased from 26.0 ± 33.5 days to 21.3 ± 24.4 days (p < 0.0001) and from 16.2% to 12.7% (p < 0.0001), respectively. Male sex, age greater than 50 years, Elixhauser Comorbidity Index greater than 10, and mechanical ventilation were identified as risk factors for in-hospital mortality after adjusting for baseline characteristics. Conclusions: The incidence of sepsis in Korea increased from 2007 to 2016, while the associated in-hospital mortality, hospital length of stay, and ICU admission rates decreased. Dr. Ryu is the guarantor of the content of the article. Dr. Oh contributed substantially to the study design, data interpretation, and the writing of the first draft and subsequent revisions of the article. Dr. Cho, Ms. Kim, and Drs. Jang, Choi, and Lee contributed substantially to data analysis and interpretation, and the writing of the article. Dr. Ryu has contributed substantially to the study design, data analysis and interpretation, and the writing of the first draft and subsequent revisions of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: hogeol@gmail.com Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

A Prospective Analysis of Motor and Cognitive Skill Retention in Novice Learners of Point of Care Ultrasound Objectives: To identify the time at which point of care ultrasound static image recognition and image acquisition skills decay in novice learners. Setting: The University of Iowa Hospitals and Clinics. Subjects: Twenty-four subjects (23 first-year medical students and one first-year physician assistant student). Design: The subjects completed an initial didactic and hands-on session with immediate testing of learned image acquisition and static image identification skills. Interventions: Retesting occurred at 1, 4, and 8 weeks after the initial training session with no retraining in between. Image acquisition skills were obtained on the same healthy male volunteers, and the students were given no immediate feedback on their performance. The image identification skills were assessed with a 10 question test at each follow-up session. Measurements and Main Results: For pleural ultrasound by 4 weeks, there was a significant decline of the ability to identify A-lines (p = 0.0065). For pleural image acquisition, there was no significant decline in the ability to demonstrate lung sliding. Conversely, cardiac image recognition did not significantly decline throughout the study, while the ability to demonstrate cardiac images at 4 weeks (parasternal short axis view) did (p = 0.0008). Conclusions: Motor and cognitive skills decay at different times for pleural and cardiac images. Future ultrasound curricula should retrain skills at a maximum of 8 weeks from initial training. They should focus more on didactic sessions related to image identification for pleural images, and more hands-on image acquisition training for cardiac images, which represents a novel finding. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Supported, in part, departmental funds from the Department of Internal Medicine. Dr. Schmidt received funding from McGraw-Hill, UpToDate, and Springer Science. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: charles-rappaport@uiowa.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

One-Year Prognosis of Kidney Injury at Discharge From the ICU: A Multicenter Observational Study Objectives: The association between outcome and kidney injury detected at discharge from the ICU using different biomarkers remains unknown. The objective was to evaluate the association between 1-year survival and kidney injury at ICU discharge. Design: Ancillary investigation of a prospective observational study. Setting: Twenty-one ICUs with 1-year follow-up. Patients: Critically ill patients receiving mechanical ventilation and/or hemodynamic support for at least 24 hours were included. Interventions: Serum creatinine, plasma Cystatin C, plasma neutrophil gelatinase-associated lipocalin, urinary neutrophil gelatinase-associated lipocalin, plasma Proenkephalin A 119-159, and estimated glomerular filtration rate (on serum creatinine and plasma Cystatin C) were measured at ICU discharge among ICU survivors. Measurements and Main Results: The association between kidney biomarkers at discharge and mortality was estimated using logistic model with and without adjustment for prognostic factors previously identified in this cohort. Subgroup analyses were performed in patients with discharge serum creatinine less than 1.5-fold baseline at ICU discharge. Among 1,207 ICU survivors included, 231 died during the year following ICU discharge (19.2%). Estimated glomerular filtration rate was significantly lower and kidney injury biomarkers higher at discharge in nonsurvivors. The association between biomarker levels or estimated glomerular filtration rate and mortality remained after adjustment to potential cofounding factors influencing outcome. In patients with low serum creatinine at ICU discharge, 25–47% of patients were classified as subclinical kidney injury depending on the biomarker. The association between kidney biomarkers and mortality remained and mortality was higher than patients without subclinical kidney injury. The majority of patients who developed acute kidney injury during ICU stay had elevated biomarkers of kidney injury at discharge even with apparent recovery based on serum creatinine (i.e., subclinical acute kidney disease). Conclusions: Elevated kidney biomarkers measured at ICU discharge are associated with poor 1-year outcome, including in patients with low serum creatinine at ICU discharge. The complete list of French and euRopean Outcome reGistry in ICUs (FROG-ICU) Investigators is: Etienne Gayat, Alain Cariou, Nicolas Deye, Antoine Vieillard-Baron, Samir Jaber, Charles Damoisel, Qin Lu, Xavier Monnet, Isabelle Rennuit, Elie Azoulay, Marc Léone, Heikel Oueslati, Bertrand Guidet, Diane Friedman, Antoine Tesnière, Romain Sonneville, Philippe Montravers, Sébastien Pili-Floury, Jean-Yves Lefrant, Jacques Duranteau, Pierre-François Laterre, Nicolas Brechot, Karine Chevreul, Morgane Michel, Bernard Cholley, Matthieu Legrand, Jean-Marie Launay, Eric Vicaut, Mervyn Singer, Matthieu Resche-Rigon, and Alexandre Mebazaa. This work was performed at Hôpital Lariboisière, Paris, France; Hôpital Saint-Louis, Paris, France; Hôpital Bichat, Paris, France; Hôpital Beaujon, Paris, France; Hôpital Cochin, Paris, France; Hôpital Bicêtre, Le Kremlin Bicêtre, France; Hôpital Raymond Poincaré, Garches, France; Hôpital Saint-Antoine, Paris, France; Hôpital Nord, Marseille, France; Hôpital de la Pitié-Salpêtrière, Paris, France; Hôpital Saint-Eloi, Montpellier, France; Hôpital Ambroise Paré, Boulogne, France; Hôpital Caremeau, Nîmes, France; Hôpital Jean Minjoz, Besançon, France; Hôpital Saint-Luc, Bruxelles, Belgique. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). French and euRopean Outcome reGistry in ICU (ClinicalTrials.gov Identifier NCT01367093) was funded by the Programme Hospitalier de la Recherche Clinique (AON 10-216) and by a research grant from the Société Française d’Anesthésie Réanimation. Abbott, Sphingotec, Roche Diagnostics, and Critical Diagnostics provided unrestricted free kits to Assistance Publique-Hôpitaux de Paris to conduct biomarker analyses. Dr. Legrand disclosed French and euRopean Outcome reGistry in ICU (ClinicalTrials.gov Identifier NCT01367093) was funded by the Programme Hospitalier de la Recherche Clinique (AON 10-216) and by a research grant from the Société Française d’Anesthésie Réanimation; he received lecture fees from Alere, Fresenius, and Gilead and Consulting fees from Adrenomed. Dr. Deye’s institution received funding from Zoll and Bard for travel and lecture fees. Dr. Fournier’s institution received funding from Programme Hospitalier de la Recherche Clinique (AON 10-216) and a research grant from the Société Française d’Anesthésie Réanimation. Dr. Monnet received funding from Pulsion Medical Systems, and he received support for article research from Assistance publique hôpitaux de Paris. Dr. Darmon received consulting fees from Sanofi and Gilead-Kite, research support from Astute Medical and Merck Sharp & Dohme, (MSD), and speaker fees from MSD, Gilead-Kite, and Astellas. Dr. Zafrani received funding from Jazz Pharmaceuticals (research grant). Dr. Leone received funding from MSD, Pfizer, Amomed, Aguettant (consulting), Octapharma (lecture), Aspen (lecture), and Orion (lecture). Dr. Pili-Floury received funding from Pfizer. Dr. Sato disclosed work for hire. Dr. Mebazaa has received speaker’s honoraria from Novartis, Orion, Servier, and fee as member of advisory board and/or Steering Committee from Cardiorentis, Adrenomed, Sphingotec, Sanofi, Roche, Abbott, and Bristol-Myers Squibb. Dr. Gayat’s institution received funding from programme hospitalier de recherche clinique 2011, Retia Medical, and Société Française d’Anesthésie Réanimation; he received funding from Adrenomed, Roche Diagnostics and Magnisense, lecture fees from Edwards LifeScience. The remaining authors have disclosed that they do not have any potential conflicts of interest. Trial registration: ClinicalTrials.gov NCT01367093; registered on June 6, 2011. For information regarding this article, E-mail: matthieu.legrand@aphp.fr Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Toward Increased Understanding of the Steroid Controversy in Septic Shock No abstract available

Promoting Family Engagement in the ICU: Experience From a National Collaborative of 63 ICUs Objectives: As part of an improvement program targeting ICU, a national collaborative was launched to help hospitals implement patient- and family-centered care engagement initiatives. Design: Ten-month quality improvement collaborative. Setting: Guided by a national patient and family advisory group, participating teams implemented an individual project including open visitation; integrating families on rounds; establishing a patient and family advisory committee; using patient and family diaries, among others. Subjects: Sixty-three adult and PICU teams from both academic and community hospitals in 34 states participated. Interventions: Monthly team calls, quarterly webinars, newsletters, an online eCommunity, and team reporting assignments were used to facilitate project implementation. Measurements and Main Results: The Family Satisfaction with Care in the ICU 24 was used to assess family satisfaction. Clinician perceptions were assessed with the Institute for Patient- and Family-Centered Care Self-Assessment Inventory. Thematic analysis was used to explore narrative data captured from team reports of project barriers, facilitators, and the experience of participating in the collaborative. A total of 2,530 family member and 3,999 clinician surveys were completed. Postimplementation, family members reported statistically significant increases in overall family satisfaction, satisfaction with decision-making, and satisfaction with quality of care (Family Satisfaction with Care in the ICU mean score change range 0.83–1.24; p ≤ 0.027). Clinicians reported that opportunities for families to participate as members of the care team increased. Major barriers included lack of buy-in and ability to promote change in the clinical setting, managing the workload of implementation, and funding to support initiatives. Conclusions: A national collaborative format was useful to assist ICU teams to implement patient- and family-engagement initiatives. Enlisting stakeholder support, engaging unit-based champions, and highlighting benefits of family engagement can help ICU teams to promote family member involvement and engagement. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Kleinpell disclosed that this article reports on the work of a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award (6262-SCCM), and disclosed that she served as Society of Critical Care Medicine (SCCM) President-Elect and President during the time of the project. Drs. Kleinpell and Ms. Harmon received support for article research from PCORI. Dr. Zimmerman’s institution received funding from the National Institutes of Health and Immunexpress (research funding), and he received funding from Elsevier Publishing (royalties for co-editing Pediatric Critical Care) and SCCM (travel reimbursement to attend board meetings). Ms. Harmon’s institution received funding from PCORI. Mr. Hanson received funding from Eugene Washington PCORI Engagement Award for the “Improving Care for Critically Ill Patients and Families Through Research Dissemination and Implementation” SCCM Collaborative. Dr. Hwang received funding from SCCM. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Ruth Kleinpell, PhD, RN, Vanderbilt University School of Nursing, 461 21st Avenue South 407 GH, Nashville, TN 37240. E-mail: ruth.kleinpell@vanderbilt.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes Objectives: To evaluate racial and ethnic disparities in postcardiac arrest outcomes in patients undergoing targeted temperature management. Design: Retrospective study. Setting: ICUs in a single tertiary care hospital. Patients: Three-hundred sixty-seven patients undergoing postcardiac arrest targeted temperature management, including continuous electroencephalogram monitoring. Interventions: None. Measurements and Main Results: Clinical variables examined in our clinical cohort included race/ethnicity, age, time to return of spontaneous circulation, cardiac rhythm at time of arrest, insurance status, Charlson Comorbidity Index, and time to withdrawal of life-sustaining therapy. CT at admission and continuous electroencephalogram monitoring during the first 24 hours were used as markers of early injury. Outcome was assessed as good (Cerebral Performance Category 1–2) versus poor (Cerebral Performance Category 3–5) at hospital discharge. White non-Hispanic (“White”) patients were more likely to have good outcomes than white Hispanic/nonwhite (“Non-white”) patients (34.4 vs 21.7%; p = 0.015). In a multivariate model that included age, time to return of spontaneous circulation, initial rhythm, combined electroencephalogram/CT findings, Charlson Comorbidity Index, and insurance status, race/ethnicity was still independently associated with poor outcome (odds ratio, 3.32; p = 0.003). Comorbidities were lower in white patients but did not fully explain outcomes differences. Nonwhite patients were more likely to exhibit signs of early severe anoxic changes on CT or electroencephalogram, higher creatinine levels and receive dialysis, but had longer duration to withdrawal of lifesustaining therapy. There was no significant difference in catheterizations or MRI scans. Subgroup analysis performed with patients without early electroencephalogram or CT changes still revealed better outcome in white patients. Conclusions: Racial/ethnic disparity in outcome persists despite a strictly protocoled targeted temperature management. Nonwhite patients are more likely to arrive with more severe anoxic brain injury, but this does not account for all the disparity. This work was performed at Brigham and Women’s Hospital. Dr. Jacobs contributed to acquisition of data, analysis of the data, and drafting the article. Mr. Beers and Ms. Park contributed to acquisition of data. Drs. Scirica and Hsu contributed to acquisition of data and revising the article for intellectual content. Dr. Henderson contributed to revising the article for intellectual content. Dr. Bevers contributed to analysis of the data and revising the article for intellectual content. Dr. Dworetzky contributed to analysis of the data and writing of the article. Dr. Lee contributed to design of the study, acquisition of data, analysis of the data, and drafting the article. Dr. Jacobs is partially supported (80%) by the National Institutes of Health (NIH) National Institute of Neurological Disorders and Stroke (NINDS) R25NS065743, principal investigator (PI), 2017–2019 (ongoing), she performs contract work (electroencephalogram [EEG] reading) for Carle Foundation Hospital, and she disclosed that she is an inventor on two (unlicensed) patents relating to work she performed during graduate school (United States Patent US 7,935,530 B2. November 28, 2007; United States Patent US 9,630,950. April 25, 2017); she has not received any compensation related to these patents. Drs. Jacobs and Lee received support for article research from the NIH. Ms. Park disclosed work for hire. Dr. Scirica received research grants via Brigham and Women’s Hospital from AstraZeneca, Eisai, Novartis, and Merck, and he has received consulting fees from AbbVie, Allergan, AstraZeneca, Boehringer Ingelheim, Covance, Eisai, Elsevier Practice Update Cardiology, GlaxoSmithKline, Lexicon, Medtronic, Merck, NovoNordisk, Sanofi, and equity in Health [at] Scale, outside the submitted work. Dr. Bevers receives research support from the American Academy of Neurology and David Heitman Neurovascular Research Fund (unrelated to the current work), outside the scope of the submitted work; he reports grants and personal fees from Biogen and EBSCO Health, outside the scope of the submitted work; and he reports personal fees for editorial work from Dynamed, LCC, outside the scope of the submitted work. Dr. Dworetzky reads EEGs in her clinical practice (25% effort) and bills for this, performs contract work with SleepMed/DigiTrace, is a consultant for SleepMed (EEG interpretation) and for Best Doctors (clinical consults) & Oxford University Press (royalties). Dr. Lee reads EEGs in his clinical practice (25% effort) and bills for this, performs contract work with SleepMed/DigiTrace and Advance Medical; he was supported by the NIH (NINDS R03NS091864 02, PI, 2015–2018). The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jlee38@bwh.harvard.edu Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.